Electrocardiography

Electrocardiography
Electrocardiogram (ECG or EKG): a graphic recording of electric potentials generated by the heart. The signals are detected by means of metal electrodes attached to the extremities and chest wall and then are amplified and recorded by the electrocardiograph. ECG leads actually display the instantaneous differences in potential between the electrodes.

clinical utility of the ECG

Immediately available, noninvasive, inexpensive Highly versatile test: detecting arrhythmias, conduction disturbances, and myocardial ischemia,

lmetabolic disturbances (e.g., hyperkalemia) increased susceptibility to sudden cardiac death (e.g., QT prolongation syndromes).

Electrophysiology
Initiating event for cardiac contraction- Depolarization. Source of electric currents in the heart cardiac pacemaker cells, specialized conduction tissue, and the heart muscle itself. ECG, records only the depolarization (stimulation) and repolarization (recovery) potentials generated by the atrial and ventricular myocardium. Origin of depolarization stimulus for the normal heartbeat sinoatrial (SA) node a collection of pacemaker cells. These cells exhibit automaticity.

 The first phase of cardiac activation is spread of depolarization wave through right and left atria, followed by atrial contraction. Next, the impulse stimulates pacemaker and specialized conduction tissues in the atrioventricular (AV) nodal and His-bundle areas (AV junction). Two main branches of the bundle of His: right and left bundles, transmit depolarization wavefronts to the right and left ventricular myocardium via Purkinje fibers.

 Main left bundle bifurcates into two primary subdivisions: a left anterior fascicle and a left posterior fascicle. The depolarization wavefronts then spread through the ventricular wall, from endocardium to epicardium, triggering ventricular contraction.

 Cardiac depolarization and repolarization can be represented by vectors. Vector analysis illustrates a central concept of electrocardiography:
The ECG records the complex spatial and temporal summation of electrical potentials From multiple myocardial fibers conducted to the surface of the body.

Thus there are limitations in both ECG sensitivity (activity from certain cardiac regions may be canceled out or may be too weak to be recorded) and specificity (the same vectorial sum can result from either a selective gain or a loss of forces in opposite directions).

ECG Waveforms and Intervals

P wave = atrial depolarization The QRS complex = ventricular depolarization ST-T-U complex = ventricular repolarization. The J point = junction between end of QRS complex and beginning of ST segment. Atrial repolarization is usually too low in amplitude to be detected, but it may become apparent in conditions such as acute pericarditis and atrial infarction.

The QRS-T waveforms correspond in a general way with the different phases of simultaneously obtained ventricular action potentials
The rapid upstroke (phase 0) = onset of QRS. The plateau (phase 2) = ST segment Active repolarization (phase 3) = T wave. Factors that decrease the slope of phase 0 by impairing the influx of Na+ (e.g., hyperkalemia and drugs such as flecainide) tend to increase QRS duration. Conditions that prolong phase 2 (amiodarone, hypocalcemia) increase the QT interval. In contrast, shortening of ventricular repolarization (phase 2), such as by digitalis administration or hypercalcemia, abbreviates the ST segment.

electrocardiogram
Recorded on special graph paper divided into 1-mm2 gridlike boxes. 1 mm horizontal divisions = 0.04 (40 ms), Heavier lines = intervals of 0.20 s (200 ms). Vertically 1 mV = 10 mm Four major ECG intervals: R-R, PR, QRS, and QT The heart rate can be computed readily from the interbeat (R-R)
number of large (0.20 s) time units between consecutive R waves divided by 300 or the number of small (0.04 s) units divided by 1500.

 PR interval measures the time between atrial and ventricular depolarization, (normally 120200 ms)

QRS interval reflects the duration of ventricular depolarization. (normally 100110 ms or less) The QT interval includes both ventricular depolarization and repolarization times and varies inversely with the heart rate.

 A rate-related ("corrected") QT interval, QTc, can be calculated as:

QT/R-R and normally is 0.44 s.

(Some references give QTc upper normal limits as 0.43 s in men and 0.45 s in women.

The QRS complex is subdivided into specific deflections or waves.

Q wave = A negative initial QRS deflection in a particular lead R wave = The first positive deflection is termed an S wave = A negative deflection after an R wave is an. R' and S = Subsequent positive or negative waves respectively. Lowercase letters (qrs) are used for waves of relatively small amplitude. QS wave = An entirely negative QRS complex

ECG Leads
The 12 conventional ECG leads record the difference in potential between electrodes placed on the surface of the body. These leads are divided into two groups:
six limb (extremity) leads record potentials transmitted onto the frontal plane six chest (precordial) leads record potentials transmitted onto the horizontal plane

The six chest leads are unipolar recordings obtained by electrodes in the following positions:

lead V1, fourth intercostal space, just to the right of the sternum; lead V2, fourth intercostal space, just to the left of the sternum; lead V3, midway between V2 and V4; lead V4, midclavicular line, fifth intercostal space; lead V5, anterior axillary line, same level as V4; and lead V6, midaxillary line, same level as V4 and V5 .

 frontal and horizontal plane electrodes provide a three-dimensional representation of cardiac electrical activity. The conventional 12-lead ECG can be supplemented with additional leads in special circumstances. For example, right precordial leads V3R, V4R, etc., are useful in detecting evidence of acute right ventricular ischemia.

ECG configuration
Positive (upright) deflection is recorded in a lead if a wave of depolarization spreads toward the positive pole of that lead, A negative deflection is recorded if the wave spreads toward the negative pole. If the mean orientation of the depolarization vector is at right angles to a particular lead axis, a biphasic (equally positive and negative) deflection will be recorded.

Genesis of the Normal ECG

P Wave Normal atrial depolarization vector is oriented downward and toward the subject's left, reflecting the spread of depolarization from the sinus node to the right and then the left atrial myocardium. Since this vector points toward the positive pole of lead II and toward the negative pole of lead aVR, the normal P wave will be positive in lead II and negative in lead aVR. By contrast, activation of the atria from an ectopic pacemaker in the lower part of either atrium or in the AV junction region may produce retrograde P waves (negative in lead II, positive in lead aVR). The normal P wave in lead V1 may be biphasic with a positive component reflecting right atrial depolarization, followed by a small (<1 mm2) negative component reflecting left atrial depolarization.

QRS Complex

Can be divided into two major sequential phases, and each phase can be represented by a mean vector First phase = depolarization of the interventricular septum from the left to the right and anteriorly (vector 1). Second results = simultaneous depolarization of the right and left ventricles; it normally is dominated by the more massive left ventricle, so that vector 2 points leftward and posteriorly. Therefore, a right precordial lead (V1) will record this biphasic depolarization process with a small positive deflection (septal r wave) followed by a larger negative deflection (S wave). A left precordial lead, e.g., V6, will record the same sequence with a small negative deflection (septal q wave) followed by a relatively tall positive deflection (R wave). Intermediate leads show a relative increase in R-wave amplitude (normal R-wave progression) and a decrease in S-wave amplitude progressing across the chest from right to left. The precordial lead where the R and S waves are of approximately equal amplitude is referred to as the transition zone (usually V3 or V4)

 The QRS pattern in extremity leads may vary from one normal subject to another depending on the electrical axis of the QRS, which describes the mean orientation of the QRS vector with reference to the six frontal plane leads. Normal QRS axis = 30 to +100 Axis more negative than 30 = left axis deviation, Axis more positive than +100 = right axis deviation. Left axis deviation = normal or more commonly left ventricular hypertrophy, a block in the anterior fascicle of the left bundle system (left anterior fascicular block or hemiblock), or inferior myocardial infarction. Right axis deviation = normal (particularly in children and young adults), a spurious finding due to reversal of the left and right arm electrodes, or in conditions such as right ventricular overload (acute or chronic), infarction of the lateral wall of the left ventricle, dextrocardia, left pneumothorax, and left posterior fascicular block.

T Wave and U Wave

Normally, the mean T-wave vector is oriented roughly concordant with the mean QRS vector (within about 45 in the frontal plane). Since depolarization and repolarization are electrically opposite processes, this normal QRST-wave vector concordance indicates that repolarization normally must proceed in the reverse direction from depolarization (i.e., from ventricular epicardium to endocardium). The normal U wave is a small, rounded deflection (1 mm) that follows the T wave and usually has the same polarity as the T wave. An abnormal increase in U-wave amplitude
drugs (e.g., dofetilide, amiodarone, sotalol, quinidine, procainamide, disopyramide) hypokalemia.

Very prominent U waves = a marker of increased susceptibility to the torsades de pointes type of ventricular tachycardia Inversion of the U wave in the precordial leads = abnormal and may be a subtle sign of ischemia.