Introduction

The nurse’s ability to recognize normal and abnormal heart rhythms is an essential skill (Wesley, 2011). The nurse should
understand the conduction system of the heart, the process associated with rhythm monitoring through ECG
interpretation, patient preparation for the 12-lead ECG, ECG findings, interpretation, and patient management with
specific heart rhythm conditions.
Upon completion of this lesson the learner will be able to:
• Discuss components of basic ECG interpretation.
Overview
The nurse needs to understand how the electrical activity of the heart functions inside the body in order to evaluate the
results that are seen in patient ECG rhythm strips. The ECG uses electrodes attached to the patient’s skin to record
physiologic heart changes. The nurse should be able to equate certain heart activity with a designated ECG strip and
resulting patient
Four Properties of the Cardiac Cells
Four properties of heart cells, automaticity, excitability, conductivity, and contractility, allow the conduction system to
start an electrical impulse, send it through the heart tissue, and stimulate muscle contraction.
Property Definition
Automaticity Ability to initiate an impulse spontaneously and continuously
Excitability Ability to be electrically stimulated
Conductivity Ability to transmit an impulse along a membrane in an orderly manner
Contractility Ability to respond mechanically to an impulse
Path of the Normal Cardiac Impulse

A normal cardiac impulse begins in the

sinoatrial (SA) node in the upper right atrium. It
spreads over the atrial myocardium via
interatrial and internodal pathways, causing
atrial contraction, pumping blood into the left
and right ventricles. The impulse then travels to
the atrioventricular (AV) node, through the
bundle of His, and down the left and right
bundle branches. It ends in the Purkinje fibers,
which transmit the impulse to the ventricles.
Nervous Control of the Heart

The components of the autonomic

nervous system that affect the heart are
the vagus nerve fibers of
the parasympathetic nervous system and
nerve fibers of the sympathetic nervous
system.
• Stimulation of the vagus nerve causes a
decreased rate of firing of the SA node
and slowed impulse conduction of the AV
node.
• Stimulation of the sympathetic
nerves increases SA node firing, AV node
impulse conduction, and cardiac
contractility (Patton, 2013).
Depolarization and Repolarization

The membrane of a heart cell

is semipermeable. This allows it to
maintain a high concentration of potassium
and a low concentration of sodium inside
the cell. Outside the cell a high
concentration of sodium and a low
concentration of potassium exist. The
inside of the cell, when at rest, or in the
polarized state, is negative compared with
the outside. When a cell or groups of cells
are stimulated, the cell membrane changes
its permeability. This allows sodium to
move rapidly into the cell, making the
inside of the cell positive compared with
the outside (depolarization). A slower
movement of ions across the membrane restores the cell to the polarized state, called repolarization.
The depolarization and repolarization of the myocardial cells allows for the electrical impulses to be measured using an
electrocardiogram to evaluate heart function.
Nursing Care Pearl
Remember to always monitor potassium levels in your patients—even small variances above or below normal levels can
cause problems with cardiac muscle conduction, causing dysrhythmias.
Key Points
• Heart cells possess four properties that allow for initiation of an impulse and contraction of the heart muscle:
automaticity, excitability, conductivity, and contractility.
• The electrical impulse begins in the sinoatrial node and travels through the heart to stimulate the ventricles.
• Both the parasympathetic and sympathetic nervous systems affect the firing of impulse.
• The semipermeable nature of the myocardial membrane is responsible for the ability of the cells to depolarize
and repolarize and allows for the electrical impulses to be measured by an electrocardiogram to evaluate heart
function.
Quiz me
1. Match:
Property of the cell that allows it to accept initiation of stimulation
Excitability

Property that moves electrical impulse along a membrane

Conductivity

Ability of heart muscle to respond mechanically to an impulse

Contractility

Ability of heart muscle to initiate an impulse, begin stimulation

Automaticity
2. List in order the pathway of a normal cardiac impulse:
The impulse causes the atria to contract.
The impulse travels from the AV node through the bundle of His.
The impulse divides into the left and right bundle branches.
The impulse reaches the Purkinje fibers.
The ventricles contract.
The SA node begins the normal cardiac cycle. The impulse travels from the SA node in the upper right atrium to the
interatrial and intermodal pathways. The atrium contracts. The impulse continues to the AV node following the bundle
of His to the bundle branches. The impulse ends in the Purkinje fibers that send the impulse to the ventricles. The
ventricles then contract.
3. An increase in the rate of cardiac impulse initiation is linked to stimulation of which component?

Purkinje system
Electrolyte system
Sympathetic nervous system
Parasympathetic nervous system
Sympathetic nervous system
The sympathetic nervous system is responsible for increasing the rate of cardiac impulse initiation at the SA node. It also
assists with node impulse conduction and cardiac contractility.
4. Which electrolytes play key roles in polarization of the heart cells?

Sodium and potassium

Potassium and calcium
Potassium and glucose
Sodium and magnesium
Sodium and potassium. The electrolytes sodium and potassium are partners in cardiac function. A higher sodium level
outside the cell allows for a high potassium and low sodium level inside the cell. Potassium inside the cell is required for
the conduction of impulses to achieve a polarized state.
The 12-Lead ECG
The electrocardiogram (ECG) is a graphic tracing of the electrical impulses produced in the heart. The waveforms on the
ECG represent electrical activity produced by the movement of ions across the membranes of heart cells, representing
depolarization and repolarization. Each waveform has an expected shape, length, and height. Variations in these
measurements can indicate problems with cardiac conductivity or damage to cardiac muscle.
P wave Atrial depolarization
PR segment Electrical impulse traveling through atrioventricular (AV) node
QRS complex Ventricular depolarization
QT interval Represents total time required for ventricular depolarization and repolarization
T wave Ventricular repolarization
The main segments of the electrocardiogram are the P wave (depolarization of atria), the QRS complex (depolarization
of ventricles and repolarization of atria), and the T wave (repolarization of ventricles).
The ECG has 12 recording leads. Six of the leads measure electrical forces in the frontal plane. The remaining six unipolar
leads measure the electrical forces in the horizontal plane (precordial leads).

A, Limb leads I, II, and

III. These bipolar leads
are located on the
extremities. Illustrated
are the angles from
which these leads view
the heart. B, Limb leads
aVR, aVL, and aVF.
These unipolar leads use
the center of the heart
as their negative
electrode. C, Placement
for the unipolar chest
leads: V1, fourth
intercostal space at the
right sternal border; V2,
fourth intercostal space
at the left sternal
border; V3, halfway
between V2 and V4; V4,
fifth intercostal space at the left midclavicular line; V5, fifth intercostal space at the left anterior axillary line; V6, fifth
intercostal space at the left midaxillary line.
One or more ECG leads can be used to continuously monitor a patient. A modified chest lead (MCL1) is used when only
three leads are available for monitoring. Accurate interpretation of an ECG depends on the correct placement of the
leads on the patient. The monitoring leads selected are determined by the patient’s clinical status. The monitor
continuously displays the heart rhythm. ECG paper attached to the monitor records the ECG (i.e., rhythm strip). This
provides a record of the patient’s rhythm. It also allows for measurement of complexes and intervals and for assessment
of dysrhythmias.
The 12-lead ECG may show changes suggesting structural changes, conduction disturbances, damage (e.g., ischemia,
infarction), electrolyte imbalance, or drug toxicity. Obtaining 12-lead ECG views of the heart is also helpful in the
assessment of dysrhythmias.
Measuring Time and Voltage
To correctly interpret an ECG, measure time and voltage on the ECG paper. ECG paper consists of large (heavy lines) and
small (light lines) squares. Each large square consists of 25 smaller squares (five horizontal and five vertical).
Horizontally, each small square (1 mm) represents 0.04 second. This means that one large square equals 0.20 second
and that 300 large squares equal 1 minute. Vertically, each small square (1 mm) represents 0.1 millivolt (mV).
This means that one large square equals 0.5 mV. Use these squares to calculate the heart rate (HR) and measure time
intervals for the different ECG complexes.
A variety of methods can be used to calculate the HR from an ECG.
Counting methods
• Count the number of QRS complexes in 1 minute (most accurate, most time consuming).
• Count the number of R-R intervals in 6 seconds and multiply that number by 10. (An R wave is the first upward
[or positive] wave of the QRS complex.)
• Count the number of small squares between one R-R interval and divide this number into 1500.
• Count the number of large squares between one R-R interval and divide this number into 300.
Use of calipers
Many times a P or an R wave will not fall directly on a light or heavy line. Place the fine points of the calipers exactly on
the parts you need to measure and then move to another part of the strip for a more precise time measurement.
Assessing the Heart Rhythm
When assessing the heart rhythm, make an accurate interpretation and immediately assess the patient’s clinical status.
Assess the patient’s hemodynamic response to any change in rhythm. This information will guide the selection of your
interventions. Determination of the cause of dysrhythmias is a priority. For example, tachycardia may be the result of
fever and may cause a decrease in cardiac output (CO) and hypotension. Electrolyte disturbances can cause
dysrhythmias and, if not treated, can lead to life-threatening dysrhythmias. At all times, assess and treat the patient,
rather than just “monitoring” when a dysrhythmia is noted.
When assessing a heart rhythm, use a consistent and systematic approach. One such approach includes the following:
• Look for P wave. Is it upright or inverted? Is there one for every QRS complex or more than one?
• Evaluate atrial rhythm. Is it regular or irregular?
• Calculate atrial rate.
• Measure duration of the PR interval. Is it normal duration or prolonged? Is duration consistent before each QRS?
• Evaluate ventricular rhythm. Is it regular or irregular?
• Calculate ventricular rate.
• Measure duration of the QRS complex. Is it normal duration or prolonged?
• Assess ST segment. Is it isoelectric (flat), elevated, or depressed?
• Measure duration of QT interval. QT interval varies with age, gender, and changes in heart rate. Slower heart
rates cause a lengthening of QT interval and faster rates cause QT interval to shorten.
• Note T wave. Is it upright or inverted?
Additional questions to consider include the following:
• What is dominant or underlying rhythm and/or dysrhythmia?
• What is clinical significance of your findings?
• What is treatment for particular rhythm?
Proper application of ECG leads

ECG leads consist of an electrode pad fixed with electrical conductive gel. Before placing these on the patient, properly
prepare the skin.
To properly place the ECG leads, the nurse should:
Clip excessive hair on chest wall with scissors.
Gently rub skin with dry gauze until slightly pink.
Wipe with alcohol if skin is oily.
Apply a skin protectant before placing electrode if patient is diaphoretic.
You will see artifact on the monitor when leads and electrodes are not secure, the conductive gel is becoming dry, or
there is muscle activity (e.g., shivering) or electrical interference. Artifact is a distortion of the baseline and waveforms
seen on the ECG. Accurate interpretation of heart rhythm is difficult when artifact is present. If artifact occurs, check the
connections in the equipment. Replace the electrodes if the conductive gel has dried out.

ECG artifacts.
A, Muscle tremor.
B, Loose electrodes.

Key Points

• The electrocardiogram (ECG) is a graphic tracing of the electrical activity of the heart that can provide
information on the function of the heart and, in some cases, the causes of certain dysfunction.
• Accurate ECG information is dependent on accurate placement of the leads and preparation of the patient.
• Assessing the heart rhythm should be approached using a systematic method to ensure all possible information
is obtained from the ECG tracing.
• There are a number of methods to determine the heart rhythm from an ECG tracing.
Quiz me
1. Which wave on the ECG tracing will provide the nurse more information about atrial depolarization?
QRS Complex
P wave
T wave
U wave

P wave. The P wave demonstrates the initial firing of the SA node. The P wave can display as positive
(upright), negative (inverted), or biphasic (both positive and negative).

2. A patient asks the nurse, "Why do I need a 12-lead ECG if my heart rate is within normal limits?" The nurse responds
by explaining that which heart conditions may be identified by the 12-lead ECG?

Cardiotoxicity
Cardiac murmur
Irregular rhythm
Myocardial infarction
Heart valve deformation

3. Which ECG component would the nurse measure to identify the total time needed for ventricular depolarization and
repolarization of a patient's heart?

PR segment
P wave
QT interval
QRS complex

The QT interval is the time it takes for ventricular depolarization and then repolarization. It is calculated by measuring
the distance between the QRS complex and the T wave.

4. The nurse is assessing heart rate from a patient's ECG and counts 80 R-R intervals in a 60-second stretch. The patient's
heart rate is how many beats per minute?

80

Heart rate can be calculated by counting the number of R-R intervals in a 6 second strip and multiplying by 10. In this
instance a 60-second strip notes 80 R-R intervals meaning the heart rate is 80 beats per minute.

Overview

When assessing patients with cardiac conditions, it is important for the nurse to note the expected and unexpected
findings. A 12-lead ECG should show a normal sinus rhythm in a patient with a healthy heart.

Normal sinus rhythm refers to a rhythm that starts in the SA node at a rate of 60 to 100 times per minute and follows
the normal conduction pathway (one P wave for each QRS complex, PR interval of 0.12 - 0.20, a QRS duration of 0.04 to
0.10 second).

Any rhythm that does not meet these criteria would be considered a dysrhythmia and may require intervention.
Sinus Tachycardia

Sinus tachycardia: The conduction pathway is the same as that in normal sinus rhythm. The discharge rate from the
sinus node increases because of vagal inhibition or sympathetic stimulation. The sinus rate is 101 to 200 beats/minute.

Clinical Sinus tachycardia is associated with physiologic and It can also be an effect of drugs such as
Associations psychologic stressors such as exercise, fever, pain, epinephrine, norepinephrine, atropine,
hypotension, hypovolemia, anemia, hypoxia, caffeine, theophylline, or hydralazine. In
hypoglycemia, myocardial ischemia, heart failure (HF), addition, many over-the-counter cold
hyperthyroidism, anxiety, and fear. remedies have active ingredients (e.g.,
pseudoephedrine) that can cause tachycardia.

ECG HR is 101 to 200 beats/minute and rhythm is regular. The

Characteristics P wave is normal, precedes each QRS complex, and has a
normal shape and duration. The PR interval is normal
and the QRS complex has a normal shape and duration.

Clinical The patient may have dizziness, dyspnea, and

Significance hypotension because of decreased cardiac output (CO).
Increased myocardial O2 consumption is associated with
an increased HR. Angina or an increase in infarction size
may accompany sinus tachycardia in patients with
coronary artery disease (CAD) or an acute myocardial
infarction (MI).
Sinus Bradycardia

Sinus bradycardia is characterized by a conduction pathway that is the same as that in normal sinus rhythm, but the SA
node fires at a rate <60 beats/minute.

Symptomatic bradycardia refers to a HR that is <60 beats/minute and is inadequate for the patient’s condition. This
causes the patient to experience symptoms (e.g., fatigue, dizziness, chest pain, syncope).

Clinical Associations

• Sinus bradycardia may be a normal sinus rhythm in aerobically trained athletes and in some people during
sleep. It also occurs in response to:
• Carotid sinus massage
• Valsalva maneuver
• Hypothermia
• Increased intraocular pressure
• Vagal stimulation
• Certain drugs (e.g., β-blockers, calcium channel blockers)

ECG Characteristics

• HR <60 beats/minute and rhythm is regular. P wave precedes each QRS complex and has a normal shape and
duration. PR interval is normal and QRS complex has normal shape and duration.

Clinical Significance

• Manifestations of symptomatic bradycardia include pale, cool skin; hypotension; weakness; angina; dizziness or
syncope; confusion or disorientation; and shortness of breath.

Treatment for Sinus Tachycardia

A priority in assessing a patient with tachycardia is to identify the underlying cause as the guide the to treatment. For
example, if the patient is experiencing tachycardia from pain, effective pain management is important to treat the
tachycardia. In clinically stable patients, vagal maneuvers can be attempted. In addition, IV β-blockers (e.g., metoprolol
[Lopressor]), adenosine (Adenocard), or calcium channel blockers (e.g., diltiazem [Cardizem]) can be given to reduce HR
and decrease myocardial O2 consumption. In clinically unstable patients, synchronized cardioversion is used.
Synchronized cardioversion uses low voltage electricity to correct the abnormal cardiac impulses that lead to extreme
tachycardia.

Treatment for Sinus Bradycardia

For the patient with symptoms, treatment consists of giving IV atropine (anticholinergic drug). If atropine (AtroPen) is
ineffective, transcutaneous pacing or a dopamine (Intropin) or epinephrine (Adrenalin) infusion is considered.
Permanent pacemaker therapy may be needed. If bradycardia is due to drugs, these may have to be held, discontinued,
or reduced.

Key Points

• Normal sinus rhythm refers to a rhythm that starts in the SA node at a rate of 60 to 100 times per minute and
follows the normal conduction pathway.
• Heart rates that are slower than normal are called bradycardia, and those that are faster are called tachycardia.
• Each type of abnormal rhythm is associated with clinical manifestations and characteristic ECG tracings.
 • A first line treatment for sinus bradycardia is atropine, whereas the main treatment for sinus tachycardia is
treatment of the underlying cause.

Quiz Me

1. A review of a patient's 12-lead ECG reveals sinus bradycardia. Which information should the nurse expect to
find in the patient history?

Hypoglycemia
Hyperthyroidism
Marathon training
Excessive caffeine intake
Increased intracranial pressure
Prolonged exposure to extreme cold

2. A nurse is gathering the history for a patient with sinus tachycardia. Which information should be expected based on
the patient's condition?

Fatigue (brady not tachy)

Anemia – sinus tachycardia is associated w anemia
Hypothyroidism (sinus brady)
Increased intraocular pressure (sinus brady)

3. A patient presents with fatigue, dizziness and chest pain. On assessment, the patient's heart rate is 55 beats per
minute and blood pressure is 85/60. A dopamine infusion is ineffective at reducing symptoms and returning vital signs to
normal. The nurse should expect the health care provider to schedule the patient for which procedure?

Echocardiogram
IV atropine administration
Synchronized cardioversion
Placement of a permanent pacemaker - Permanent pacemaker therapy may be necessary for a patient who does not
respond to atropine or dopamine. atropine would have been administered before dopamine.

4. A patient presents with a sinus rate of 150 beats per minute and body temperature of 103 °F; the patient is otherwise
clinically stable. How should the nurse prepare to manage the patient's sinus tachycardia?

Prepare to administer antipyretics. The underlying cause of tachycardia guides the treatment. Sinus tachycardia may be
caused by a high fever. Treating the patient's fever would be the first step to treating the tachycardia.
Prepare to administer IV atropine.
Provide the patient information on epinephrine infusion.
Provide the patient information on synchronized cardioversion.

Summary

The heart possesses certain qualities that allow it to function in a very precise way to support blood exchange
throughout the body. It is important for the nurse to have a basic understanding of these properties and the workings of
the heart to properly evaluate heart function in a patient. The electrocardiogram is a visual tracing of the electrical
activity of the heart and can be used to identify certain heart conditions. Sinus tachycardia and bradycardia are two such
conditions that are characterized by clinical manifestations, specific ECG abnormalities, and treatments.
Key Points

• Heart cells possess four properties that allow for initiation of an impulse and contraction of the heart muscle:
automaticity, excitability, conductivity, and contractility.
• The electrical impulse begins in the sinoatrial node and travels through the heart to stimulate the ventricles.
• Both the parasympathetic and sympathetic nervous systems affect the firing of impulse.
• The semipermeable nature of the myocardial membrane is responsible for the ability of the cells to depolarize
and repolarize, and allows for the electrical impulses to be measured by an electrocardiogram to evaluate heart
function.
• The electrocardiogram (ECG) is a graphic tracing of the electrical activity of the heart that can provide
information on the function of the heart and, in some cases, the causes of certain dysfunction.
• Accurate ECG information is dependent on accurate placement of the leads and preparation of the patient.
• Assessing the heart rhythm should be approached using a systematic method to ensure all possible information
is obtained from the ECG tracing.
• There are a number of methods to determine the heart rhythm from an ECG tracing.
• Normal sinus rhythm refers to a rhythm that starts in the SA node at a rate of 60 to 100 times per minute and
follows the normal conduction pathway.
• Heart rates that are slower than normal are called bradycardia, and those that are faster are called tachycardia.
• Each type of abnormal rhythm is associated with clinical manifestations and characteristic ECG tracings.
• A first line treatment for sinus bradycardia is atropine, whereas the main treatment for sinus tachycardia is
treatment of the underlying cause.

FINAL QUIZ

1. Which statement describes the role of the Purkinje fibers in the pathway of the normal cardiac cycle?

Origination of normal impulses

Conduction of impulses from the atria to the ventricles
Transmits electrical impulses from the AV node to the ventricles
Conduction of impulses through the ventricles leading to ventricular muscle contraction

2. Which action results in the atria after firing of the sinoatrial (SA) node?

Repolarization of cardiac muscle

Depolarization of cardiac muscle
Contraction of the atria to move blood to the ventricles
Contraction of the ventricle moving blood out to the body

3. Which physiologic process is responsible for repolarization of heart cells?

Movement of sodium into the cell

Movement of sodium out of the cell - When a cell or groups of cells is stimulated, the cell membrane changes its
permeability. This allows sodium to move rapidly into the cell, making the inside of the cell positive compared with the
outside (depolarization). A slower movement of sodium ions across the membrane restores the cell to the polarized
state, called repolarization.
Movement of potassium into the cell
Movement of magnesium out of the cell
4. The nurse is reviewing a patient's ECG reading and notices artifact on the monitor. Which action should the nurse
perform to identify the cause of the artifact?

Ask the patient about any medications taken prior to the ECG
Ensure that the patient's cell phone is turned off during the ECG
Ask the patient about the amount of caffeine ingested prior to the ECG
Determine the condition of the conductive gel on the electrodes

5. A nursing student is discussing a rhythm strip with the faculty member. Which rationale explains a shortened QT
interval?

A faster heart rate

A slower heart rate
Atrial Repolarization
Firing of the sinoatrial (SA) node

6. Using the R-R interval formula, the heart rate in the 6-second strip shown measures how many beats per minute? nine
QRS segments shown

90

7. The nurse obtains an ECG for a 53-year-old patient with chest pain. The nurse palpates a heart rate of 106. Which
alteration in waveform should the nurse expect to see on the ECG tracing?

Inverted T wave
Flattened P wave
Short QT interval
Narrow QRS complex

8. The nurse is caring for a patient with chest tightness and shortness of breath. The ECG tracing reports sinus
tachycardia. Which additional finding should be expected?

QRS duration 0.07 seconds

Heart rate is 50 beats per minute
Heart rate is 114 beats per minute
Two P waves for each QRS complex

9. The nurse is teaching a cardiac seminar for a local community center. The nurse knows further teaching is needed if a
member makes which comment about bradycardia?

"If I strain with a bowel movement my heart rate may go down."

"Bradycardia means my heart rate is routinely <60 beats per minute."
"My heart rate may be slower if I discontinue my calcium channel blockers."
"I should stop my speed walking sessions since my heart rate is 50 beats per minute."
10. Match

Patient reports no clinical signs or symptoms; HR is 80 bpm

Sinus rhythm

Patient reports exhaustion and episodes of fainting; HR is 50 bpm

Sinus bradycardia

Patient reports being in extreme emotional stress; HR is 102 bpm

Sinus tachycardia

11. A patient calls the health care provider's office reporting dizziness and fatigue. The patient started taking a beta
blocker one week ago. The patient's radial pulse is 52 bpm. Which instruction should the nurse give the patient?

"Consult your health care provider about stopping the beta blocker."
"Continue taking the beta blocker. Your symptoms will resolve in a week or so."
"You will need to make an appointment to have a permanent pacemaker implanted."
"Ask your health care provider about doubling up on your beta blocker. You need a higher dose to treat your
symptoms."

12. A patient reports dizziness and dyspnea. On assessment, the patient's heart rate is 130 bpm. An ECG indicates
normal P-wave, PR interval, and QRS complex. The patient reports that the symptoms began shortly after an injury
causing acute back pain. What is the priority intervention for this patient?

Repeat the ECG.

Administer pain medications as prescribed.
Encourage the patient to listen to the radio to help with relaxation.
Obtain cardiac enzymes for evaluation of a myocardial infarction (MI).

13. A patient presents with sinus tachycardia with a heart rate of 122. The patient also has pneumonia. Which
assessment question should the nurse ask the patient first to identify the cause of the patient's symptoms?

"Are you coughing up any secretions?"

"What have you eaten in the last 24 hours?"
"Do you find yourself sleeping in a chair at night?"
"Have you taken any over-the-counter medications since you became sick?"

14. A patient presents during a normal well-visit with a heart rate of 58 beats per minute. The patient is an avid runner
and is currently training for a triathlon. All other vital signs are normal. Which statement indicates to the nurse the
patient teaching is understood?

"I need to return in 48 hours. If my heart rate is still low, I need a pacemaker."
"I am sad that I have to stop running. My heart does not tolerate it anymore."
"I should stop drinking coffee in the morning. This will help my heart rate increase."
"I do not need to take any medications. My heart rate is expected because of my triathlon training."