Electrocardiography (ECG)

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 Electrocardiography (ECG)

Table of Content Page

No.
1 INTRODUCTION 2

2 Medical uses 3

3 Heart Function, ECG, and ECG Wave Strips 4

4 Anatomy of the Heart 6

5 What Happens During an ECG? Is It Painful? 8

6 Reasons for an ECG 8

7 ECG Interpretation and Results 8

8 References 10

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 Electrocardiography (ECG)

1. INTRODUCTION
Electrocardiography (ECG or EKG[a]) is the process of recording the electrical activity of the heart
over a period of time using electrodes placed over the skin. These electrodes detect the tiny
electrical changes on the skin that arise from the heart muscle's electrophysiologic pattern of
depolarizing and repolarizing during each heartbeat. It is very commonly performed to detect
any cardiac problems.
In a conventional 12-lead ECG, ten electrodes are placed on the patient's limbs and on the surface
of the chest. The overall magnitude of the heart's electrical potential is then measured from
twelve different angles ("leads") and is recorded over a period of time (usually ten seconds). In
this way, the overall magnitude and direction of the heart's electrical depolarization is captured
at each moment throughout the cardiac cycle. The graph of voltage versus time produced by this
noninvasive medical procedure is an electrocardiogram.

There are three main components to an ECG: the P wave, which represents the depolarization of
the atria; the QRS complex, which represents the depolarization of the ventricles; and the T wave,
which represents the repolarization of the ventricles. It can also be further broken down into the
following:
O is the origin or datum point preceding the cycle

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 Electrocardiography (ECG)
P is the atrial systole contraction pulse
Q is a downward deflection immediately preceding the ventricular contraction
R is the peak of the ventricular contraction
S is the downward deflection immediately after the ventricular contraction
T is the recovery of the ventricles
U is the successor of the T wave but it is small and not always observed
During each heartbeat, a healthy heart has an orderly progression of depolarization that starts
with pacemaker cells in the sinoatrial node, spreads throughout the atrium, passes through the
atrioventricular node down into the bundle of His and into the Purkinje fibers, spreading down
and to the left throughout the ventricles. This orderly pattern of depolarization gives rise to the
characteristic ECG tracing. To the trained clinician, an ECG conveys a large amount of information
about the structure of the heart and the function of its electrical conduction system. Among other
things, an ECG can be used to measure the rate and rhythm of heartbeats, the size and position
of the heart chambers, the presence of any damage to the heart's muscle cells or conduction
system, the effects of heart drugs, and the function of implanted pacemakers. [1]

2. Medical uses
The overall goal of performing an ECG is to obtain information about the structure and function
of the heart. Medical uses for this information are varied and generally need knowledge of the
structure and/or function of the heart to be interpreted. Some indications for performing an ECG
include:

 Suspected myocardial infarction (heart attack) or chest pain

o ST elevated myocardial infarction (STEMI)
o non-ST elevated myocardial infarction (NSTEMI)
 Suspected pulmonary embolism or shortness of breath
 A third heart sound, fourth heart sound, a cardiac murmur or other findings suggestive of
a structural heart disease
 Perceived arrhythmia either by pulse or palpitations
 Monitoring of known cardiac arrhythmias
 Fainting or collapse
 Seizures
 Monitoring the effects of a medication on the heart (e.g. drug-induced QT prolongation)
 Assessing severity of electrolyte abnormalities, such as hyperkalemia
 Hypertrophic cardiomyopathy screening in adolescents as part of a sports physical out of
concern for sudden cardiac death (varies by country)

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 Electrocardiography (ECG)
 Perioperative monitoring in which any form of anesthesia is involved (e.g. monitored
anesthesia care, general anesthesia); typically both intraoperative and postoperative
 As a part of a preoperative assessment some time before a surgical procedure
(especially for those with known cardiovascular disease or who are undergoing invasive,
cardiac, vascular or pulmonary procedures, or who will receive general anesthesia)
 Cardiac stress testing
 Computed tomography angiography (CTA) and magnetic resonance angiography (MRA)
of the heart (ECG is used to "gate" the scanning so that the anatomical position of the
heart is steady)
 Biotelemetry of patients for any of the above reasons and such monitoring can include
internal and external defibrillators and pacemakers. [2]

3. Heart Function, ECG, and ECG Wave Strips

Electrode leads on the chest wall are able to detect electrical impulses that are generated by the
heart. Multiple leads provide many electrical views of the heart. By interpreting the tracing, the
physician can learn about the heart rate and rhythm as well as blood flow to the ventricles
(indirectly).
Rate refers to how fast the heart beats. Normally, the SA node generates an electrical impulse
50-100 times per minute. Bradycardia (brady=slow+cardia=heart) describes a heart rate less than
50 beats per minute. Tachycardia (tachy=fast+cardia=heart) describes a heart rate faster than
100 beats per minute.

Rhythm refers to the type of heartbeat. Normally, the heart beats in a sinus rhythm with each
electrical impulse generated by the SA node resulting in a ventricular contraction, or heartbeat.
There are a variety of abnormal electrical rhythms, some are normal variants and some are
potentially dangerous. Some electrical rhythms do not generate a heartbeat and are the cause
of sudden death.
Examples of heart rhythms include:

 Normal sinus rhythm

 Sinus tachycardia
 Sinus bradycardia
 Atrial fibrillation
 Atrial flutter
 Ventricular tachycardia
 Ventricular fibrillation
There can also be delays in transmission of the electrical impulse anywhere in the system,
including the SA node, the atria, the AV node, or in the ventricles. Some aberrant impulses cause
normal variants of the heart rhythm and others can be potentially life threatening.

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Some examples include:

 1st degree AV block

 2nd degree AV block, type I (Wenckebach)
 2nd degree AV block, type II
 3rd degree AV block or complete heart block
 Right bundle branch block
 Left bundle branch block
There can also be short circuits that can lead to abnormal electrical pathways in the heart causing
abnormalities of rate and rhythm. Wolfe-Parkinson-White (WPW) syndrome is a condition where
an abnormal accessory pathway at the AV node can cause tachycardia.

The ECG tracing can also provide information about whether the heart muscle cells are
conducting electricity appropriately. By analyzing the shape of the electrical waves, the physician
may be able to determine if there is decreased blood flow to parts of the heart muscle. The
presence of an acute blockage associated with a myocardial infarction or heart attack can be
determined as well. That's one of the reasons that an ECG is done as soon as possible when a
patient presents with chest pain.

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 Electrocardiography (ECG)
4. Anatomy of the Heart

The heart has four chambers – the right and left atrium and the right and left ventricle.

The right side of the heart collects blood from the body and pumps it to the lungs while the left
side of the heart receives blood from the lungs and pumps it to the body.
Blood flows through the body in the following way:

 Oxygen-rich blood from the lungs enters the left atrium through the pulmonary veins.
 Blood then flows into the left ventricle where it is pumped into the aorta and is distributed
to the rest of the body. This blood supplies organs and cells with oxygen and nutrients
necessary for metabolism.
 Blood that returns to the heart is depleted of oxygen and carries carbon dioxide, the
waste product of metabolism. The blood enters the right atrium though the vena cava,
where it is collected and pumped to the right ventricle.
 The right ventricle then pumps blood through the pulmonary artery to the lungs where
carbon dioxide is stripped off, oxygen is replaced, and the cycle begins again.

Like any muscle, the heart requires oxygen and nutrients to function. Oxygen and nutrients are
supplied by arteries that originate from the aorta. These vessels branch out to supply all the
regions of the heart with oxygen rich blood.

Electrically, the heart can be divided into upper and lower chambers. An electrical impulse is
generated in the upper chambers of the heart that causes the atria to squeeze and push blood

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 Electrocardiography (ECG)
into the ventricles. There is a short delay to allow the ventricles to fill. The ventricles then contract
to pump blood to the body and the lungs.

Conducting system of the heart: SA means sinoatrial node. AV means atrioventricular node. RB
and LB mean right and left bundle, respectively, and are the nerves that spread the electric
impulse from the AV node into the ventricles.

 The heart has its own automatic pacemaker called the sinaoatrial, or SA node, located in
the right atrium. The SA node acts independently of the brain to generate electricity for
the heart to beat.
 Normally, the impulse generated by the SA node runs through the heart's electrical grid
and signals the muscle cells in the atria to beat simultaneously, allowing for a coordinated
squeeze of the heart. Contraction of the atria pushes blood into the ventricles.
 The electrical signal that was generated in the SA node travels to a junction box between
the atria and ventricles (the AV node) where it is delayed for a few milliseconds to allow
the ventricles to fill.
 The electrical signal then travels through the ventricles, stimulating those heart muscle
cells to contract. Ventricular contraction pumps blood to the body (from the left ventricle)
and the lungs (from the right ventricle).
 There is a short pause to allow blood to return to the heart and fill before the electrical
cycle repeats itself for the next heartbeat.

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 Electrocardiography (ECG)
5. What Happens During an ECG? Is It Painful?
The ECG is a relatively simple test to perform. It is non-invasive and does not hurt. Patches are
placed on the skin to detect electrical impulses that the heart generates. These impulses are
recorded by an ECG machine. Four patches are placed on the limbs. One is placed on each
shoulder or upper arm and one on each leg. These are called the limb leads. There are six patches
that are placed on the chest wall beginning just to the right of the breast bone. Patches are placed
in the shape of a semi-circle ending near the left axilla (underarm). These are called the chest
leads. These patches are connected to an ECG machine that records the tracings and prints them
onto paper.

Newer machines also have video screens that help the technician, nurse, or doctor decide
whether the quality of the tracing is adequate or whether the test should be repeated. ECG
machines are also equipped with computer programs that can help interpret the ECG, although
they are not completely accurate.
In certain situations, the physician may want to look at the heart from different angles after the
initial ECG is done. The chest leads may then be placed across the right chest wall or on the back.

The skin should be clean and dry to prevent electrical interference to get an acceptable tracing
for interpretation. Sometimes that means shaving chest hair or aggressively toweling off the skin.
Shivering or tremors can interfere with the tracing and cause interference that affects the quality
of the ECG tracing. Usually, the patient has to hold still for 5-10 seconds without moving to get
an accurate ECG.

6. Reasons for an ECG

The ECG is used to assess heart function. Patients who complain of chest pain or shortness of
breath will often have an ECG as one of the first tests to help determine if there is an acute
myocardial infarction or heart attack present. Even if there is no heart attack, the ECG can help
decide whether the pain is due to angina or narrowing of blood vessels to the heart muscle
(atherosclerosis). It is important to realize that an initial ECG may be normal even if there is heart
disease present. Serial EKGs may be needed over time to find an abnormality.
ECGs are often performed when a patient complains of lightheadedness, palpitations, or syncope
(passing out) since abnormal heart rate and rhythms may affect the heart's ability to pump blood
and provide the body with oxygen.

7. ECG Interpretation and Results

Interpreting an ECG requires a fair amount of education and experience. Numerous textbooks
are devoted to ECG interpretation. The ECG is just one test to assess the heart. History and
physical examination remain the cornerstones for diagnosing heart disease. The doctor-patient
discussion may uncover the potential for heart problems even if the ECG is normal.

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 Electrocardiography (ECG)

Most often, the ECG assessment includes the following:

 determination of the rate,

 assessment of the rhythm,
 evaluation of the electrical conduction patterns. Heart muscle that is irritated conducts
electricity differently than heart muscle that is normal. Abnormal conduction may be
apparent during ventricular contraction and during ventricular recovery.
The ECG records the heart tracing in12 leads: Six limb leads (I, II, III, AVR, AVL, AVF) and six chest
leads (V1-V6).
The P wave looks at the atria. The QRS complex looks at the ventricles and the T wave evaluates
the recovery stage of the ventricles while they are refilling with blood.
The time it takes for electricity to travel from the SA node to the AV node is measured by the PR
interval. The QRS interval measures electrical travel time through the ventricles and the QT
interval measures how long it takes for the ventricles to recover and prepare to beat again.
Basic P-QRS-T wave sequence: Strip shows a simple sequence where M equals 1.0 millivolts.

The computers imbedded in most ECG machines are able to measure the time it takes for the
electrical impulse to travel from the SA node to the ventricles. These measurements can help the
doctor assess heart rate and some types of heart block.

Computer programs may also try to interpret the ECG. And as artificial intelligence and
programming improves, they are often correct. However, there are enough subtleties in
interpretation that the human element is still a very important part of the assessment. The ECG
machine is not always correct.
The decision to act upon the results of an ECG depends not only upon the ECG tracing, but also
upon the clinical situation. A normal ECG does not exclude heart disease and an abnormal ECG
may be the "normal" baseline for that patient. [3]

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 Electrocardiography (ECG)
8. References
[1] Braunwald E. (ed) (1997), Heart Disease: A Textbook of Cardiovascular Medicine, Fifth Edition,
p. 108, Philadelphia, W.B. Saunders
[2] https://en.wikipedia.org/wiki/Electrocardiography

[3]https://www.emedicinehealth.com/angina_pectoris/article_em.htm#ecg_interpretation_an
d_results

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