Beruflich Dokumente
Kultur Dokumente
Electrocardiography
FromWikipedia,thefreeencyclopedia
Electrocardiography(ECGorEKG[a])istheprocessof
recordingtheelectricalactivityoftheheartoveraperiodoftime Electrocardiography
usingelectrodesplacedontheskin.Theseelectrodesdetectthe Intervention
tinyelectricalchangesontheskinthatarisefromtheheart
muscle'selectrophysiologicpatternofdepolarizingand
repolarizingduringeachheartbeat.Itisaverycommonly
performedcardiologytest.
Inaconventional12leadECG,10electrodesareplacedonthe
patient'slimbsandonthesurfaceofthechest.Theoverall
magnitudeoftheheart'selectricalpotentialisthenmeasured
from12differentangles("leads")andisrecordedoveraperiod
oftime(usually10seconds).Inthisway,theoverallmagnitude
anddirectionoftheheart'selectricaldepolarizationiscaptured
ateachmomentthroughoutthecardiaccycle.[4]Thegraphof
voltageversustimeproducedbythisnoninvasivemedical
procedureisreferredtoasanelectrocardiogram.
Duringeachheartbeat,ahealthyhearthasanorderly ECGofaheartinnormalsinusrhythm.
progressionofdepolarizationthatstartswithpacemakercellsin ICD9CM 89.52
thesinoatrialnode,spreadsoutthroughtheatrium,passes
throughtheatrioventricularnodedownintothebundleofHis MeSH D004562
andintothePurkinjefibers,spreadingdownandtotheleft MedlinePlus 003868
throughouttheventricles.Thisorderlypatternofdepolarization
givesrisetothecharacteristicECGtracing.Tothetrainedclinician,anECGconveysalargeamountof
informationaboutthestructureoftheheartandthefunctionofitselectricalconductionsystem.[5]Amongother
things,anECGcanbeusedtomeasuretherateandrhythmofheartbeats,thesizeandpositionoftheheart
chambers,thepresenceofanydamagetotheheart'smusclecellsorconductionsystem,theeffectsofcardiac
drugs,andthefunctionofimplantedpacemakers.[6]
Contents
1 History
2 Medicaluses
3 Electrocardiographs
4 Electrodesandleads
4.1 Limbleads
4.2 Augmentedlimbleads
4.3 Precordialleads
4.4 Specializedleads
4.5 LeadlocationsonanECGreport
4.6 Contiguityofleads
5 Electrophysiology
6 Interpretation
6.1 Theory
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6.2 Electrocardiogramgrid
6.3 Rateandrhythm
6.4 Axis
6.5 Amplitudesandintervals
6.6 Ischemiaandinfarction
6.7 Artifacts
7 Diagnosis
8 Seealso
9 Notes
10 References
11 Externallinks
History
TheetymologyofthewordisderivedfromtheGreekelectro,becauseitis
relatedtoelectricalactivity,kardio,Greekforheart,andgraph,aGreek
rootmeaning"towrite".
AlexanderMuirheadisreportedtohaveattachedwirestoafeverish
patient'swristtoobtainarecordofthepatient'sheartbeatin1872atSt
Bartholomew'sHospital.[7]AnotherearlypioneerwasAugustusWaller,of
StMary'sHospitalinLondon.[8]Hiselectrocardiographmachineconsisted
ofaLippmanncapillaryelectrometerfixedtoaprojector.Thetracefrom
theheartbeatwasprojectedontoaphotographicplatethatwasitselffixed
toatoytrain.Thisallowedaheartbeattoberecordedinrealtime. AnearlycommercialECGdevice
(1911)
AninitialbreakthroughcamewhenWillemEinthoven,workinginLeiden,
theNetherlands,usedthestringgalvanometer(thefirstpractical
electrocardiograph)heinventedin1901.[9]Thisdevicewasmuchmore
sensitivethanboththecapillaryelectrometerWallerusedandthestring
galvanometerthathadbeeninventedseparatelyin1897bytheFrench Electrocardiography(1957)
[10]
engineerClmentAder. Einthovenhadpreviously,in1895,assignedthe
lettersP,Q,R,S,andTtothedeflectionsinthetheoreticalwaveformhecreatedusingequationswhichcorrected
theactualwaveformobtainedbythecapillaryelectrometertocompensatefortheimprecisionofthatinstrument.
UsinglettersdifferentfromA,B,C,andD(thelettersusedforthecapillaryelectrometer'swaveform)facilitated
comparisonwhentheuncorrectedandcorrectedlinesweredrawnonthesamegraph.[11]Einthovenprobablychose
theinitialletterPtofollowtheexamplesetbyDescartesingeometry.[11]Whenamoreprecisewaveformwas
obtainedusingthestringgalvanometer,whichmatchedthecorrectedcapillaryelectrometerwaveform,he
continuedtousethelettersP,Q,R,S,andT,[11]andtheselettersarestillinusetoday.Einthovenalsodescribedthe
electrocardiographicfeaturesofanumberofcardiovasculardisorders.In1924,hewasawardedtheNobelPrizein
Medicineforhisdiscovery.[12]
In1937,TaroTakemiinventedthefirstportableelectrocardiographmachine.[13]
Thoughthebasicprinciplesofthateraarestillinusetoday,manyadvancesinelectrocardiographyhavebeen
madeovertheyears.Instrumentationhasevolvedfromacumbersomelaboratoryapparatustocompactelectronic
systemsthatoftenincludecomputerizedinterpretationoftheelectrocardiogram.[14]
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Medicaluses
Theoverallgoalofperformingelectrocardiographyisto
obtaininformationaboutthestructureandfunctionofthe
heart.Medicalusesforthisinformationarevariedand
generallyrelatetohavinganeedforknowledgeofthe
structureand/orfunction.Someindicationsforperforming
electrocardiographyinclude:
Suspectedmyocardialinfarction(heartattack)or
newchestpain A12leadECGofa26yearoldmalewithan
Suspectedpulmonaryembolismornewshortnessof incompleteRBBB
breath
Athirdheartsound,fourthheartsound,acardiac
murmur[15]orotherfindingstosuggeststructuralheartdisease
Perceivedcardiacdysrhythmias[15]eitherbypulseorpalpitations
Monitoringofknowncardiacdysrhythmias
Faintingorcollapse[15]
Seizures[15]
Monitoringtheeffectsofaheartmedication(e.g.druginducedQTprolongation)
Assessingseverityofelectrolyteabnormalities,suchashyperkalemia
Hypertrophiccardiomyopathyscreeninginadolescentsaspartofasportsphysicaloutofconcernforsudden
cardiacdeath(variesbycountry)
Perioperativemonitoringinwhichanyformofanesthesiaisinvolved(e.g.monitoredanesthesiacare,
generalanesthesia)typicallybothintraoperativeandpostoperative
Asapartofapreoperativeassessmentsometimebeforeasurgicalprocedure(especiallyforthosewith
knowncardiovasculardiseaseorwhoareundergoinginvasiveorcardiac,vascularorpulmonaryprocedures,
orwhowillreceivegeneralanesthesia)
Cardiacstresstesting
Computedtomographyangiography(CTA)andMagneticresonanceangiography(MRA)oftheheart(ECG
isusedto"gate"thescanningsothattheanatomicalpositionoftheheartissteady)
Biotelemetryofpatientsforanyoftheabovereasonsandsuchmonitoringcanincludeinternalandexternal
defibrillatorsandpacemakers
TheUnitedStatesPreventiveServicesTaskForcedoesnotrecommendelectrocardiographyforroutinescreening
procedureinpatientswithoutsymptomsandthoseatlowriskforcoronaryheartdisease.[16][17]Thisisbecausean
ECGmayfalselyindicatetheexistenceofaproblem,leadingtomisdiagnosis,therecommendationofinvasive
procedures,orovertreatment.However,personsemployedincertaincriticaloccupations,suchasaircraftpilots,[18]
mayberequiredtohaveanECGaspartoftheirroutinehealthevaluations.
ContinuousECGmonitoringisusedtomonitorcriticallyillpatients,patientsundergoinggeneralanesthesia,[15]
andpatientswhohaveaninfrequentlyoccurringcardiacdysrhythmiathatwouldbeunlikelytobeseenona
conventionaltensecondECG.
Performinga12leadECGintheUnitedStatesiscommonlyperformedbyspecializedtechniciansthatmaybe
certifiedelectrocardiogramtechnicians.ECGinterpretationisacomponentofmanyhealthcarefields(nursesand
physiciansandcardiacsurgeonsbeingthemostobvious)butanyonetrainedtointerpretanECGisfreetodoso.
However,"official"interpretationisperformedbyacardiologist.Certainfieldssuchasanesthesiautilize
continuousECGmonitoringandknowledgeofinterpretingECGsiscrucialtotheirjobs.
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Oneadditionalformofelectrocardiographyisusedinclinicalcardiacelectrophysiologyinwhichacatheterisused
tomeasuretheelectricalactivity.Thecatheterisinsertedthroughthefemoralveinandcanhaveseveralelectrodes
alongitslengthtorecordthedirectionofelectricalactivityfromwithintheheart..
Electrocardiographs
Anelectrocardiographisamachinethatisusedtoperform
electrocardiography,andproducestheelectrocardiogram.The
firstelectrocardiographsarediscussedaboveandare
electricallyprimitivecomparedtotoday'smachines.
Thefundamentalcomponenttoelectrocardiographisthe
Instrumentationamplifier,whichisresponsiblefortakingthe
voltagedifferencebetweenleads(seebelow)andamplifying
thesignal.ECGvoltagesmeasuredacrossthebodyareonthe
orderofhundredsofmicrovoltsupto1millivolt(thesmall
squareonastandardECGis100microvolts).Thislowvoltage
necessitatesalownoisecircuitandinstrumentationamplifiers
arekey.
Earlyelectrocardiographswereconstructedwithanalog
electronicsandthesignalcoulddriveamotortoprintthe
signalonpaper.Today,electrocardiographsuseanalogto
digitalconverterstoconverttoadigitalsignalthatcanthenbe
manipulatedwithdigitalelectronics.Thispermitsdigital
recordingofECGsanduseoncomputers.
Anelectrocardiographwithintegrateddisplayand
Thereareothercomponentstotheelectrocardiograph:[19] keyboardonawheeledcart
Safetyfeaturesthatincludevoltageprotectionforthe
patientandoperator.Sincethemachinesarepoweredbymainspower,itisconceivablethateitherperson
couldbesubjectedtovoltagecapableofcausingdeath.Additionally,theheartissensitivetotheAC
frequenciestypicallyusedformainspower(50or60Hz).
Defibrillationprotection.AnyECGusedinhealthcaremaybeattachedtoapersonwhorequires
defibrillationandtheelectrocardiographneedstoprotectitselffromthissourceofenergy.
Electrostaticdischargeissimilartodefibrillationdischargeandrequiresvoltageprotectionupto18,000
volts.
Additionallycircuitrycalledtherightlegdrivercanbeusedtoreducecommonmodeinterference(typically
the50/60Hzmainspower).
Typicaldesignforaportableelectrocardiographisacombinedunitthatincludesascreen,keyboard,andprinteron
asmallwheeledcart.Theunitconnectstoalongcablethatbranchestoeachleadwhichattachestoaconductive
padonthepatient.
Lastly,theelectrocardiographmayincludearhythmanalysisalgorithmthatproducesacomputerizedinterpretation
oftheelectrocardiogram.Theresultsfromthesealgorithmsareconsidered"preliminary"untilverifiedand/or
modifiedbysomeonetrainedininterpretingelectrocardiograms.Includedinthisanalysisiscomputationof
commonparametersthatincludePRinterval,QTduration,correctedQT(QTc)duration,PRaxis,QRSaxis,and
more.Earlierdesignsrecordedeachleadsequentiallybutcurrentdesignsemploycircuitsthatcanrecordallleads
simultaneously.Theformerintroducesproblemsininterpretationsincetheremaybebeattobeatchangesinthe
rhythmthatmakesitunwisetocompareacrossbeats.
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Electrodesandleads
A"lead"isnotthesameasan"electrode".Whereasanelectrodeisa
conductivepadincontactwiththebodythatmakesanelectricalcircuit
withtheelectrocardiograph,aleadisaconnectortoanelectrode.Since
leadscansharethesameelectrode,astandard12leadEKGhappensto
needonly10electrodes(aslistedinthetablebelow).
Aleadisslightlymoreabstractandisthesourceofmeasurementofa
vector.Forthelimbleads,theyare"bipolar"andarethecomparison
betweentwoelectrodes.Fortheprecordialleads,theyare"unipolar"and
comparedtoacommonlead(commonlytheWilson'scentralterminal),as Properplacementofthelimb
electrodes.Thelimbelectrodescanbe
describedbelow.[21]
fardownonthelimbsorclosetothe
Leadsarebrokendownintothreesets:limbaugmentedlimband hips/shouldersaslongastheyare
precordial.The12leadEKGhasatotalofthreelimbleadsandthree placedsymmetrically. [20]
augmentedlimbleadsarrangedlikespokesofawheelinthecoronalplane
(vertical)andsixprecordialleadsthatlieontheperpendiculartransverse
plane(horizontal).
Inmedicalsettings,thetermleadsisalsosometimesusedtorefertothe
electrodesthemselves,althoughthisisnottechnicallyacorrectusageofthe
term,whichcomplicatestheunderstandingofdifferencebetweenthetwo.
The10electrodesina12leadEKGarelistedbelow.
Electrode
Electrodeplacement
name
RA Ontherightarm,avoidingthickmuscle.
InthesamelocationwhereRAwasplaced,butontheleft
LA
arm.
Ontherightleg,lowerendofmedialaspectofcalfmuscle.
RL
(Avoidbonyprominences)
Placementoftheprecordial
LL InthesamelocationwhereRLwasplaced,butontheleftleg.
electrodes.
V1 Inthefourthintercostalspace(betweenribs4and5)justto
therightofthesternum(breastbone).
V2 Inthefourthintercostalspace(betweenribs4and5)justto
theleftofthesternum.
V3 BetweenleadsV2andV4.
V4 Inthefifthintercostalspace(betweenribs5and6)inthemid
clavicularline.
V5 HorizontallyevenwithV4,intheleftanterioraxillaryline.
V6 HorizontallyevenwithV4andV5inthemidaxillaryline.
Twocommonelectrodesusedareaflatpaperthinstickerandaselfadhesivecircularpad.Theformeraretypically
usedinasingleECGrecordingwhilethelatterareforcontinuousrecordingsastheysticklonger.Eachelectrode
consistsofanelectricallyconductiveelectrolytegelandasilver/silverchlorideconductor.[22]Thegeltypically
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containspotassiumchloridesometimessilverchlorideaswelltopermitelectronconductionfromtheskinto
thewireandtotheelectrocardiogram.
Thecommonlead,Wilson'scentralterminalVW,isproducedbyaveragingthemeasurementsfromtheelectrodes
RA,LA,andLLtogiveanaveragepotentialacrossthebody:
Ina12leadECG,allleadsexceptthelimbleadsareunipolar(aVR,aVL,aVF,V1,V2,V3,V4,V5,andV6).The
measurementofavoltagerequirestwocontactsandso,electrically,theunipolarleadsaremeasuredfromthe
commonlead(negative)andtheunipolarlead(positive).Thisaveragingforthecommonleadandtheabstract
unipolarleadconceptmakesforamorechallengingunderstandingandiscomplicatedbysloppyusageof"lead"
and"electrode".
Limbleads
LeadsI,IIand
IIIarecalledthe
limbleads.The
electrodesthat
formthese
signalsare
locatedonthe
limbsoneon
eacharmand
oneontheleft
leg.[23][24][25]
Thelimbleads
formthepoints
ofwhatis
knownas
Einthoven's
triangle.[26]
LeadIis
the
voltage
between
the Thelimbleadsandaugmentedlimbleads
(positive)
leftarm
(LA)electrodeandrightarm(RA)electrode:
LeadIIisthevoltagebetweenthe(positive)leftleg(LL)electrodeandtherightarm(RA)electrode:
LeadIIIisthevoltagebetweenthe(positive)leftleg(LL)electrodeandtheleftarm(LA)electrode:
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Augmentedlimbleads
LeadsaVR,aVL,andaVFaretheaugmentedlimbleads.They
arederivedfromthesamethreeelectrodesasleadsI,II,and
III,buttheyuseGoldberger'scentralterminalastheirnegative
pole.Goldberger'scentralterminalisacombinationofinputs
fromtwolimbelectrodes,withadifferentcombinationfor
eachaugmentedlead.Itisreferredtoimmediatelybelowas
"thenegativepole".
Leadaugmentedvectorright(aVR)'hasthepositive
electrodeontherightarm.Thenegativepoleisa
combinationoftheleftarmelectrodeandtheleftleg
electrode:
Leadaugmentedvectorleft(aVL)hasthepositiveelectrodeontheleftarm.Thenegativepoleisa
combinationoftherightarmelectrodeandtheleftlegelectrode:
Leadaugmentedvectorfoot(aVF)hasthepositiveelectrodeontheleftleg.Thenegativepoleisa
combinationoftherightarmelectrodeandtheleftarmelectrode:
TogetherwithleadsI,II,andIII,augmentedlimbleadsaVR,aVL,andaVFformthebasisofthehexaxial
referencesystem,whichisusedtocalculatetheheart'selectricalaxisinthefrontalplane.
Precordialleads
Theprecordialleadslieinthetransverse(horizontal)plane,perpendiculartotheothersixleads.Thesixprecordial
electrodesactasthepositivepolesforthesixcorrespondingprecordialleads:(V1,V2,V3,V4,V5andV6).
Wilson'scentralterminalisusedasthenegativepole.
Specializedleads
Additionalelectrodesmayrarelybeplacedtogenerateotherleadsforspecificdiagnosticpurposes.Rightsided
precordialleadsmaybeusedtobetterstudypathologyoftherightventricleorfordextrocardia(andaredenoted
withanR(e.g.,V5R)).Posteriorleads(V7toV9)maybeusedtodemonstratethepresenceofaposterior
myocardialinfarction.ALewislead(requiringanelectrodeattherightsternalborderinthesecondintercostal
space)canbeusedtostudypathologicalrhythmsarisingintherightatrium.
Anesophogealleadcanbeinsertedtoapartoftheesophaguswherethedistancetotheposteriorwalloftheleft
atriumisonlyapproximately56mm(remainingconstantinpeopleofdifferentageandweight).[27]An
esophagealleadavailsforamoreaccuratedifferentiationbetweencertaincardiacarrhythmias,particularlyatrial
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flutter,AVnodalreentranttachycardiaandorthodromicatrioventricularreentranttachycardia.[28]Itcanalso
evaluatetheriskinpeoplewithWolffParkinsonWhitesyndrome,aswellasterminatesupraventricular
tachycardiacausedbyreentry.[28]
Anintracardiacelectrogram(ICEG)isessentiallyanECGwithsomeaddedintracardiacleads(thatis,insidethe
heart).ThestandardECGleads(externalleads)areI,II,III,aVL,V1,andV6.Twotofourintracardiacleadsare
addedviacardiaccatheterization.Theword"electrogram"(EGM)withoutfurtherspecificationusuallymeansan
intracardiacelectrogram.
LeadlocationsonanECGreport
Astandard12leadECGreport(anelectrocardiograph)showsa2.5secondtracingofeachofthetwelveleads.The
tracingsaremostcommonlyarrangedinagridoffourcolumnsandthreerows.thefirstcolumnisthelimbleads
(I,II,andIII),thesecondcolumnistheaugmentedlimbleads(aVR,aVL,andaVF),andthelasttwocolumnsare
theprecordialleads(V1V6).Additionally,arhythmstripmaybeincludedasafourthorfifthrow.
Thetimingacrossthepageiscontinuousandnottracingsofthe12leadsforthesametimeperiod.Inotherwords,
iftheoutputweretracedbyneedlesonpaper,eachrowwouldswitchwhichleadsasthepaperispulledunderthe
needle.Forexample,thetoprowwouldfirsttraceleadI,thenswitchtoleadaVR,thenswitchtoV1,andthen
switchtoV4andsononeofthesefourtracingsoftheleadsarefromthesametimeperiodastheyaretracedin
sequencethroughtime.
Contiguityofleads
Eachofthe12ECGleadsrecordstheelectricalactivityofthe
heartfromadifferentangle,andthereforealignwithdifferent
anatomicalareasoftheheart.Twoleadsthatlookat
neighboringanatomicalareasaresaidtobecontiguous.
V3 Lookatelectricalactivityfromthevantage
Anterior pointoftheanteriorwalloftherightand
and
leads leftventricles(Sternocostalsurfaceof
V4
heart)
Inaddition,anytwoprecordialleadsnexttooneanotherareconsideredtobecontiguous.Forexample,thoughV4
isananteriorleadandV5isalaterallead,theyarecontiguousbecausetheyarenexttooneanother.
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Electrophysiology
Theformalstudyoftheelectricalconductionsystemoftheheartiscalledcardiacelectrophysiology(EP).An
electrophysiologystudyinvolvesaformalstudyoftheconductionsystemandcanbedoneforvariousreasons.
Duringsuchastudy,cathetersareusedtoaccesstheheartandsomeofthesecathetersincludeelectrodesthatcan
beplacedanywhereinthehearttorecordtheelectricalactivityfromwithintheheart.Somecatheterscontain
severalelectrodesandcanrecordthepropagationofelectricalactivity.
Interpretation
InterpretationoftheECGisfundamentallyaboutunderstandingtheelectricalconductionsystemoftheheart.
Normalconductionstartsandpropagatesinapredictablepattern,anddeviationfromthispatterncanbeanormal
variationorbepathological.AnECGdoesnotequatewithmechanicalpumpingactivityoftheheart,forexample,
pulselesselectricalactivityproducesanECGthatshouldpumpbloodbutnopulsesarefelt(andconstitutesa
medicalemergencyandCPRshouldbeperformed).VentricularfibrillationproducesanECGbutistoo
dysfunctionaltoproducealifesustainingcardiacoutput.Certainrhythmsareknowntohavegoodcardiacoutput
andsomeareknowntohavebadcardiacoutput.Ultimately,anechocardiogramorotheranatomicalimaging
modalityisusefulinassessingthemechanicalfunctionoftheheart.
Likeallmedicaltests,whatconstitutes"normal"isbasedonpopulationstudies.Theheartraterangeofbetween60
and100isconsiderednormalsincedatashowsthistobetheusualrestingheartrate.
Theory
InterpretationoftheECGisultimatelythatofpatternrecognition.In
ordertounderstandthepatternsfound,itishelpfultounderstandthe
theoryofwhatECGsrepresent.Thetheoryisrootedinelectromagnetics
andboilsdowntothefourfollowingpoints:
depolarizationofthehearttowardthepositiveelectrodeproducesa
positivedeflection
depolarizationoftheheartawayfromthepositiveelectrode
producesanegativedeflection
repolarizationofthehearttowardthepositiveelectrodeproducesa
negativedeflection
repolarizationoftheheartawayfromthepositiveelectrode
producesapositivedeflection
Thus,theoveralldirectionofdepolarizationandrepolarizationproducesa QRSisuprightinaleadwhenitsaxis
vectorthatproducespositiveornegativedeflectionontheECG isalignedwiththatlead'svector
dependingonwhichleaditpointsto.Forexample,depolarizingfrom
righttoleftwouldproduceapositivedeflectioninleadIbecausethetwovectorspointinthesamedirection.In
contrast,thatsamedepolarizationwouldproduceminimaldeflectioninV1andV2becausethevectorsare
perpendicularandthisphenomenoniscalledisoelectric.
NormalrhythmproducesfourentitiesaPwave,aQRScomplex,aTwave,andaUwavethateachhavea
fairlyuniquepattern.
ThePwaverepresentsatrialdepolarization.
TheQRScomplexrepresentsventriculardepolarization.
TheTwaverepresentsventricularrepolarization.
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TheUwaverepresentspapillarymusclerepolarization.
However,theUwaveisnottypicallyseenanditsabsenceis
generallyignored.Changesinthestructureoftheheartandits
surroundings(includingbloodcomposition)changethepatterns
ofthesefourentities.
Electrocardiogramgrid
ECG'sarenormallyprintedonagrid.Thehorizontalaxis
representstimeandtheverticalaxisrepresentsvoltage.The
standardvaluesonthisgridareshownintheadjacentimage:
Asmallboxis1mmx1mmbigandrepresents0.1mVx SchematicrepresentationofnormalECG
0.04seconds.
Alargeboxis5mmx5mmbigandrepresents0.5mVx0.2secondswide.
The"large"boxisrepresentedbyaheavierlineweightthanthesmallboxes.
NotallaspectsofanECGrelyonpreciserecordingsorhavingaknownscalingofamplitudeortime.Forexample,
determiningifthetracingisasinusrhythmonlyrequiresfeaturerecognitionandmatching,andnotmeasurement
ofamplitudesortimes(i.e.,thescaleofthegridsareirrelevant).Anexampletothecontrary,thevoltage
requirementsofleftventricularhypertrophyrequireknowingthegridscale.
Rateandrhythm
Inanormalheart,theheartrateistherateinwhichthesinoatrialnodedepolarizesasitisthesourceof
depolarizationoftheheart.Heartrate,likeothervitalsignslikebloodpressureandrespiratoryrate,changewith
age.Inadults,anormalheartrateisbetween60and100beatsperminute(normocardic)whereinchildrenitis
higher.Aheartratelessthannormaliscalledbradycardia(<60inadults)andhigherthannormalistachycardia
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(>100inadults).Acomplicationofthisiswhentheatriaandventriclesarenotinsynchronyandthe"heartrate"
mustbespecifiedasatrialorventricular(e.g.,atrialrateinatrialfibrillationis300600bpm,whereasventricular
ratecanbenormal(60100)orfaster(100150)).
Innormalrestinghearts,thephysiologicrhythmoftheheartisnormalsinusrhythm(NSR).Normalsinusrhythm
producestheprototypicalpatternofPwave,QRScomplex,andTwave.Generally,deviationfromnormalsinus
rhythmisconsideredacardiacarrhythmia.Thus,thefirstquestionininterpretinganECGiswhetherornotthereis
asinusrhythm.AcriterionforsinusrhythmisthatPwavesandQRScomplexesappear1to1,thusimplyingthat
thePwavecausestheQRScomplex.
Oncesinusrhythm,ornot,isestablishedthesecondquestionistherate.Forasinusrhythmthisiseithertherateof
PwavesorQRScomplexessincetheyare1to1.Iftherateistoofastthenitissinustachycardiaandifitistoo
slowthenitissinusbradycardia.
Ifitisnotasinusrhythm,thendeterminingtherhythmisnecessarybeforeproceedingwithfurtherinterpretation.
Somearrhythmiaswithcharacteristicfindings:
AbsentPwaveswith"irregularlyirregular"QRScomplexesisthehallmarkofatrialfibrillation
A"sawtooth"patternwithQRScomplexesisthehallmarkofatrialflutter
Sinewavepatternisthehallmarkofventricularflutter
AbsentPwaveswithwideQRScomplexeswithfastrateisventriculartachycardia
Determinationofrateandrhythmisnecessaryinordertomakesenseoffurtherinterpretation.
Axis
Thehearthasseveralaxes,butthemostcommonbyfaristheaxisoftheQRScomplex(referencesto"theaxis"
implicitlymeanstheQRSaxis).Eachaxiscanbecomputationallydeterminedtoresultinanumberrepresenting
degreesofdeviationfromzero,oritcanbecategorizedintoafewtypes.
TheQRSaxisisthegeneraldirectionoftheventriculardepolarizationwavefront(ormeanelectricalvector)inthe
frontalplane.Itisoftensufficienttoclassifytheaxisasoneofthreetypes:normal,leftdeviated,orrightdeviated.
PopulationdatashowsthatnormalQRSaxisisfrom30to105with0beingalongleadIandpositivebeing
inferiorandnegativebeingsuperior(bestunderstoodgraphicallyasthehexaxialreferencesystem).[29]Beyond
+105isrightaxisdeviationandbeyond30isleftaxisdeviation(thethirdquadrantof90to180isvery
rareandisanindeterminateaxis).AshortcutfordeterminingiftheQRSaxisisnormalisiftheQRScomplexis
mostlypositiveinleadIandleadII(orleadIandaVFif+90istheupperlimitofnormal).
ThenormalQRSaxisisgenerallydownandtotheleft,followingtheanatomicalorientationoftheheartwithinthe
chest.Anabnormalaxissuggestsachangeinthephysicalshapeandorientationoftheheart,oradefectinits
conductionsystemthatcausestheventriclestodepolarizeinanabnormalway.
Theextentofnormalaxiscanbe+90or105dependingonthesource.
Amplitudesandintervals
AllofthewavesonanEKGtracingandtheintervalsbetweenthemhavea
predictabletimeduration,arangeofacceptableamplitudes(voltages),and
atypicalmorphology.Anydeviationfromthenormaltracingispotentially
pathologicalandthereforeofclinicalsignificance.
Foreaseofmeasuringtheamplitudesandintervals,anEKGisprintedon
graphpaperatastandardscale:each1mm(onesmallboxonthestandard
EKGpaper)represents40millisecondsoftimeonthexaxis,and0.1
millivoltsontheyaxis.
AnimationofanormalECGwave
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interventricularseptum.It
normallyhasalow
amplitude,andevenmore
ofteniscompletelyabsent.
Ischemiaandinfarction
IschemiaornonSTelevationmyocardialinfarctionsmaymanifestasSTdepressionorinversionofTwaves.It
mayalsoaffectthehighfrequencybandoftheQRS.
STelevationmyocardialinfarctionshavedifferentcharacteristicECGfindingsbasedontheamountoftime
elapsedsincetheMIfirstoccurred.TheearliestsignishyperacuteTwaves,peakedTwavesduetolocal
hyperkalemiainischemicmyocardium.ThisthenprogressesoveraperiodofminutestoelevationsoftheST
segmentbyatleast1mm.Overaperiodofhours,apathologicQwavemayappearandtheTwavewillinvert.
OveraperiodofdaystheSTelevationwillresolve.Pathologicqwavesgenerallywillremainpermanently.[32]
ThecoronaryarterythathasbeenoccludedcanbeidentifiedinanSTelevationmyocardialinfarctionbasedonthe
locationofSTelevation.TheLADsuppliestheanteriorwalloftheheart,andthereforecausesSTelevationsin
anteriorleads(V1andV2).TheLCxsuppliesthelateralaspectoftheheartandthereforecausesSTelevationsin
lateralleads(I,aVLandV6).TheRCAusuallysuppliestheinferioraspectoftheheart,andthereforecausesST
elevationsininferiorleads(II,IIIandaVF).
Artifacts
AnEKGtracingisaffectedbypatientmotion.Somerhythmicmotions(suchasshiveringortremors)cancreate
theillusionofcardiacdysrhythmia.[33]Artifactsaredistortedsignalscausedbyasecondaryinternalorexternal
sources,suchasmusclemovementorinterferencefromanelectricaldevice.[34][35]
Distortionposessignificantchallengestohealthcareproviders,[34]whoemployvarioustechniques[36]and
strategiestosafelyrecognize[37]thesefalsesignals.AccuratelyseparatingtheECGartifactfromthetrueECG
signalcanhaveasignificantimpactonpatientoutcomesandlegalliabilities.[38]
Improperleadplacement(forexample,reversingtwoofthelimbleads)hasbeenestimatedtooccurin0.4%to4%
ofallEKGrecordings,[39]andhasresultedinimproperdiagnosisandtreatmentincludingunnecessaryuseof
thrombolytictherapy.[40][41]
Diagnosis
Numerousdiagnosisandfindingscanbemadebaseduponelectrocardiographyandmanyarediscussedabove.The
followingisanorganizedlistoftheseandmore.
Rhythmdisturbances/Arrhythmias:
Atrialfibrillation&atrialflutterwithoutrapidventricularresponse
Prematureatrialcontraction(PACs)&Prematureventricularcontraction(PVCs)
Sinusarrhythmia
Sinusbradycardia&sinustachycardia
Sinuspause&sinoatrialarrest
Sicksinussyndrome:bradycardiatachycardiasyndrome
Supraventriculartachycardia
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Atrialfibrillation(afib)withrapidventricularresponse
Atrialflutterwithrapidventricularresponse
AVnodalreentranttachycardia
Atrioventricularreentranttachycardia
Junctionalectopictachycardia
Atrialtachycardia
Ectopicatrialtachycardia(unicentric)
Multifocalatrialtachycardia
Paroxysmalatrialtachycardia
Sinoatrialnodalreentranttachycardia
Torsadesdepointes(polymorphicventriculartachycardia)
Widecomplextachycardia
Ventricularflutter
Ventricularfibrillation
Ventriculartachycardia(monomorphicventriculartachycardia)
Preexcitationsyndrome
WolffParkinsonWhitesyndrome
Heartblockandconductionproblems:
Aberration
Brugadasyndrome
FirstdegreeAVblock,SeconddegreeAVblock(MobitzI&II),ThirddegreeAVblock
Leftanterior&leftposteriorfascicularblockbifasciularblockandtrifasciularblocks
Incompleteandcompleterightbundlebranchblock(RBBB)
IncompleteandcompleteLeftbundlebranchblock(LBBB)
LongQTsyndrome
Rightandleftatrialabnormality
Electrolytesdisturbances&intoxication:
Digitalisintoxication
Calcium:hypocalcemiaandhypercalcemia
Potassium:hypokalemiaandhyperkalemia
Ischemiaandinfarction:
STelevationandSTdepression
HighFrequencyQRSchanges
Myocardialinfarction(heartattack)
NonQwavemyocardialinfarction
NSTEMI
STEMI
Structural:
Acutepericarditis
Rightandleftventricularhypertrophy
Rightventricularstrain/S1Q3T3
Seealso
Electricalconductionsystemoftheheart
Electrogastrogram
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Electropalatography
Electroretinography
Heartratemonitor
Emergencymedicine
Notes
a.TheversionwithK,whichisrarerinBritishEnglishthaninAmericanEnglish,isanearly20thcenturyloanwordfrom
theGermanacronymEKGforElektrokardiogramm(electrocardiogram),[1]whichreflectsthatGermanphysicianswere
pioneersinthefieldatthetime.TodayAMAstyleand,underitsstylisticinfluence,mostAmericanmedicalpublications
useECGinsteadofEKG.[2]TheGermantermElektrokardiogrammaswellastheEnglishequivalentelectrocardiogram
consistoftheNewLatin/internationalscientificvocabularyelementselektro(cognateelectro)andkardi(cognate
cardi),thelatterfromGreekkardia(heart).[3]TheKversionismoreoftenretainedundercircumstanceswherethere
maybeverbalconfusionbetweenECGandEEG(electroencephalography)duetosimilarpronunciation.
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2.AmericanMedicalAssociation,"15.3.1ElectrocardiographicTerms",AMAManualofStyle
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5.Walraven,G.(2011).Basicarrhythmias(7thed.),pp.111
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ed.).Philadelphia,PA:Saunders/Elsevier.p.12.ISBN1416037748.
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JointEuropeanSocietyofCardiology/AmericanCollegeofCardiologyCommitteefortheredefinitionofmyocardial
infarction".JAmCollCardiol.36(3):95969.doi:10.1016/S07351097(00)008044.PMID10987628.
33.SeguraSampedro,JuanJosParraLpez,LoretoSampedroAbascal,ConsueloMuozRodrguez,JuanCarlos(2015).
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Herpen,GerardKors,JanA.Macfarlane,Peter(20070313)."Recommendationsforthestandardizationand
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Externallinks
ThewholeECGcourseon1A4paper(http://www.ecgpedia.org/A4/
ECGpedia_on_1_A4En.pdf)fromECGpedia(http://en.ecgpedia.org/ WikimediaCommonshas
mediarelatedtoECG.
wiki/Main_Page),awikiencyclopediaforacourseoninterpretation
ofECG(http://en.ecgpedia.org/wiki/ECG_course)
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WaveMavenalargedatabaseofpracticeECGquestions(http://ecg.bidmc.harvard.edu/maven/mavenmain.
asp)providedbyBethIsraelDeaconessMedicalCenter
PysioBankafreescientificdatabasewithphysiologicsignals(hereecg)(http://www.physionet.org/physiob
ank/database/#ecg)
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