Chapter 4 Basic ECG Concepts & the Normal ECG
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1 Chapter 4 Basic ECG Concepts & the Normal ECG Introduction Cardiac electrical activity originates in the SA node. Depolarization & repolarization of myocardial cells. Action potential. Electrocardiogram (ECG) Traces waveforms of cardiac electrical potentials, or heart rhythm. EKG (German) = ECG (English). 1
2 ECG Paper Isoelectric, baseline, no electrical activity: Positive or negative deflection from baseline. Biphasic deflection. Waveform amplitude measured vertically (mm). Waveform width measured horizontally (seconds). Figure 4 1 ECG paper. 2
3 ECG Paper & Speed Grid lines are standardized for accuracy. Small light boxes = 1 mm² (1 mm vertical & horizontal) Large dark boxes = 25 mm² Paper speed of the ECG is recorded. 25 mm/s: Actual measurements 50 mm/s: Measurements divided by half Calibration of the ECG Beginning or end of each 12 lead reading 10 mm high (1 mv) & 0.2 second long, or one large box Can be doubled or cut in half to better interpret ECG 2 mv, 20 mm, 0.4 second (half the measurement) 0.5 mv, 5 mm, 0.1 second (double the measurement) 3
4 Figure 4 2 (a) Standard calibration 1 mv = 10 mm. (b) Half calibration 0.5 mv = 5 mm. Wave Amplitudes & Automated bld Pressure Cuffs Clinical Tip: Automatic machines typically use R waves to determine HR. When QRS complex is small, double the calibration signal. Paper speed may be 50 mm/s. If R wave is still insufficient, technician should take BP manually. 4
5 Standard 12 Lead Printouts 12 seconds long, including all 12 leads, printed at 25 mm/s using standard calibration signal. 3 lines of 4 leads horizontally across. Separated by lead dividers (not used in ECG interpretation). Rhythm strip below 12 lead printout, usually lead II, used to determine rate & rhythm. Figure 4 3 Standard 12 lead ECG printout. 5
6 Calculation of HR: Dark Line Method Dark line method (regular rate, determined w/ calipers) Find R wave on dark line. Subsequent R waves on dark lines represent rates of 300, 150, 100, 75, 60, 50, 44, & 38 bpm. R waves on every dark line = 300 bpm. Every other dark line = 150, every 3 rd dark line = 100, etc. Figure 4 4 (A) The dark line method of heart rate determination. (B) The second consecutive R wave falls on the fourth dark line; therefore, HR = 75 b/min Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD. 6
7 Quick Check Method Clinical Tip: During exercise in cardiac rehab, target HR range = bpm. Find R wave on dark line. Second R wave at least 2 little boxes before the 3 rd dark line. HR is faster than 102 bpm. Symptoms may appear. Adjustment of workload may be needed. Second R wave at least 2 little boxes after the 3 rd dark line. HR is slower than 96 bpm. Adjustment of workload may be needed. Calculation of HR: 1500 Method 1500 method (regular rate) most accurate HR from ECG. Count the number of small boxes b/n 2 consecutive R waves. Divide 1,500 (60 sec divided by 0.04 s/small box = 1,500) by the number of small boxes. Example: 17 small boxes b/n consecutive R waves; thus, 1,500/17 = 88 bpm. 7
8 Figure Method of HR Calculation There are 17 small boxes b/n 2 consecutive R waves; therefore, 1,500/17 = 88 beats per minute. Reproduced from Arrhythmia Recognition: The Art of Interpretation, courtesy of Tomas B. Garcia, MD. Calculation of HR: 6 Second Method The 6 second method for irregular HR. 6 seconds = 30 large boxes or the distance b/n three 3 second marks at the top or bottom of the rhythm strip. Count cardiac cycles in 6 second period. Multiply the number of cycles by 10 to estimate HR. 8
9 Figure Second Method of Irregular HR Calculation Development of the 12 Leads Einthoven s triangle 10 electrodes produce 12 leads: 6 limb leads & 6 chest leads. 6 limb leads 3 unipolar & 3 bipolar. Placement of 4 electrodes: (1) right arm (RA), (2) left arm (LA), (3) right leg (RL), (4) & left leg (LL) on extremities (diagnostic) or torso (functional). The right leg electrode serves as a ground; no electrical movement. 9
10 Anterior Chest View 10
11 Mason Likar (modified) electrode placement Precordial (Chest Leads) Arranged across the chest in a horizontal plane Record forces moving anteriorly & posteriorly Each electrode is (+) Whole body is common ground 11
12 Bipolar Limb Leads (3) Einthoven s triangle Mvt of electricity from negative to positive pole as compared to the heart. R wave amplitude in leads I & III must be equal amplitude of R wave in lead II. I = LA RA III = LL LA II = LL RA 12
13 Figure 4 7 Einthoven s triangle. Figure 4 8 Einthoven s Equation I + III = II The R wave in I (4 mm) + the R wave in III (10 mm) = the R wave in II (14 mm). Reproduced from Klabunde, RE. Cardiovascular Physiology Concepts: Electrocardiogram St&ard Limb Leads (Bipolar). Accessed on March 16,
14 Unipolar Limb Leads (3) Augmented vector leads are developed from a combination of leads. RA, LA, or LL electrode as the positive pole & the combination of 2 others as the negative pole, which augments signal strength from the measuring electrode. av F, av L, av R. Hexaxial Reference System Helps to determine heart's electrical axis in the frontal plane. Identify negative & positive poles of each lead. Identify positive poles of different leads located in the same region. Identify angle associated with positive & negative pole of each lead. Helps to determine positive, negative, & biphasic deflections of QRS complex. 14
15 Figure 4 9 Hexaxial reference system. Precordial Leads (6) Negative pole, imaginary center of heart, to positive pole of electrodes Chest or ventral (V) leads, horizontal plane V 1 6 (Table 4 1) 15
16 Figure 4 10 Precordial leads in the horizontal plane. The Normal Cardiac Cycle 1 P wave for every QRS complex (1:1 ratio). The P wave & QRS complex must be positive in lead II. The P wave & QRS complex must be negative in lead av R. HR must be b/n 60 & 99 bpm. Normal axis deviation (NAD) is present. All wave forms must have normal morphology in every cycle. 16
17 Figure 4 11 Basic ECG of the cardiac cycle. The P Wave Electrical activity from the SA node to the AV node; atrial depolarization & atrial kick, ventricular filling. First positive deflection in all leads except av R. Normal height is < 2.5 mm (2.5 small boxes) & length is seconds (2 3 small boxes) at a paper speed of 25 mm/sec. 17
18 The PR Interval Electrical activity from SA node to AV node to Purkinje fibers. Measured from beginning of P wave to beginning of QRS complex. The beginning of atrial depolarization to beginning of ventricular depolarization. Normal PR Interval measures seconds. Figure 4 13 The PR Interval The PR interval is 0.16 seconds measured from the beginning of the P wave to the beginning of the QRS complex. 18
19 Figure 4 12 Wiggers diagram. QRS Complex Complete (left) ventricular depolarization. Measured from the beginning of the complex (Q or R) to the end of the complex (R or S). Normal QRS complex measures seconds ( little boxes). 19
20 QRS Complex Nomenclature After the P wave, if the initial deflection is negative, it is a Q wave. If the initial deflection is positive, or there is any positive deflection after a Q wave, it is an R wave. Any negative deflection after an R wave is an S wave. Lowercase letter signifies a wave of 3 mm or less; uppercase letters identify waves > 3 mm. Figure 4 14 The QRS Complex The QRS complex is 0.10 seconds from the beginning of the QRS complex to the end of the complex. 20
21 QRS Complex in Precordial Leads V 1 : A small positive r wave (septal r) & negative deflection (S wave) occurs = rs. V 6 : A small negative q wave (septal q) & positive deflection (R wave) = qr or qrs. ST Segment On isoelectric line or baseline, no electrical activity. Ventricular volume is ng at the time & just after the aortic valve opens. J point = where the QRS complex ends & the ST segment begins. ST segment deviation (> 1 mm) indicates disease &/or infarction. 21
22 Figure 4 17 ST Segment ST segment variations from baseline greater than 1 mm constitute ST elevation or ST depression. Reproduced from Grauer, K. ECG Interpretation Review #34 (Acute MI vs Nonspecific Changes ST Elevation/Depression). interpretation review 34 acute mi.html. Accessed on March 21, ST Segment Depression Electrical signal is taking longer to move through the myocardium. Potential coronary artery disease or old myocardial injury. During exercise testing, depression is evidence of possible myocardial ischemia. Ventricular hypertrophies & bundle branch blocks. 22
23 ST Segment Elevation Insufficient bld supply to myocardium. Evidence of a recent or impending myocardial infarction. During exercise testing, elevation is cause for immediate concern, especially if patient is symptomatic. Could represent myocardial injury or infarction. T Wave The positive deflection after the S wave (in lead II). End of the T wave to the start of the next QRS complex. Same direction as QRS complex. Ventricles are isoelectrically inactive, repolarization, diastole. Normal T waves are asymmetrical; inverted T wave is clinically significant if seen in more than one lead. 23
24 U Wave Last small, rounded, upward deflection in lead II. Last stages of ventricular repolarization. Typically not seen in a normal ECG. Can be fused with the previous T wave. Figure 4 18 T wave. Reproduced from Introduction to 12 Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD. 24
25 Q T Interval Start of QRS complex to end of T wave. Can be corrected for HR. Bazett sformula, QT C. Normal QTc < 0.44 sec & less than half of R R interval. Elongated Q T intervals increase risk for sudden death. Patients with a history of ventricular tachyarrhythmia. Axis Deviation Can indicate underlying disease or previous cardiac event. Calculate the mean QRS axis (vector). Hexaxial reference system & limb leads (I, II, III, av R, av L, av F ). Two lead method of axis determination (I, av F ) Normal axis deviation (NAD) = 0 90 degrees +/ 15 degrees ( 15 to 105 degrees). 25
26 Figure 4 19 Mean QRS Calculation Example 1: Obviously, lead III is the closest to being equiphasic, so lead av R is the 90 lead. Because lead avr is negative, the direction of ventricular depolarization is toward the negative pole of lead av R & the mean QRS axis is determined to be 30. Example 2: There are no perfectly equiphasic leads. Two leads can be considered to be the most equiphasic. The R wave in lead II is 3 mm positive & the S wave is 6 mm negative. The R wave in lead av R is 3 mm positive, & the S wave is 4 mm negative. Therefore, avr is the most equiphasic & lead III is the 90 lead. Because lead III is negative, the direction of ventricular depolarization is toward the negative pole of lead III, & the mean QRS axis is determined to be 60. Example 3: Again, there are no exactly equiphasic leads. Leads II & av R are both 1.5 mm positive & 0 mm negative. Following rule 3, leads avl & III are the 90 leads. av L is negative & III is positive. Therefore, the mean QRS axis is b/n 120 & 150. Reproduced from Introduction to 12 Lead ECG: The Art of Interpretation, courtesy of Tomas B. Garcia, MD. 26
27 Left Axis Deviation (LAD) Nonpathologic LAD (0 & 30 degrees) Athletic heart or an individual who is endurance trained Pathologic LAD ( 30 & 90 degrees) Left anterior hemiblock, Q waves of inferior MI, pacemaker, hyperkalemia, Wolff Parkinson White right sided bypass, tricuspid atresia, or atrial septal defect 27
28 Right Axis Deviation (RAD) 105 & 180 RAD can be caused by right ventricular hypertrophy, left posterior hemiblock, COPD, anterior lateral MI, pulmonary embolism, Wolff Parkinson White left sided bypass, AJD, Marfan syndrome. Typically normal in children & tall, thin adults. Indeterminate Axis No man s land. 180 & 90 Can be caused by emphysema, hyperkalemia, lead transposition, pacemaker, & ventricular tachycardia. 28
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