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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of
Health.
Ashley EA, Niebauer J. Cardioloy E!"lained. London# $e%edica& '(().
Chapter 3Conquering the ECG
Besides the stethosco"e, the electrocardiora% *EC+ is the oldest and %ost endurin tool of
the cardioloist. A basic kno-lede of the EC+ -ill enhance the understandin of cardioloy
*not to %ention this book.
Electrocardiography
At every beat, the heart is de"olaried to trier its contraction. /his electrical activity istrans%itted throuhout the body and can be "icked u" on the skin. /his is the "rinci"le
behind the EC+. An EC+ %achine records this activity via electrodes on the skin and
dis"lays it ra"hically. An EC+ involves attachin 0( electrical cables to the body# one to
each li%b and si! across the chest.
EC+ ter%inoloy has t-o %eanins for the -ord 1lead1#
the cable used to connect an electrode to the EC+ recorder
the electrical vie- of the heart obtained fro% any one co%bination of electrodes
Carrying out an ECG
0. Ask the "atient to undress do-n to the -aist and lie do-n
'. $e%ove e!cess hair -here necessary
2. Attach li%b leads *any-here on the li%b
). Attach the chest leads *see 3iure 0 as follo-s#
o 40 and 4'# either side of the sternu% on the fourth rib *count do-n fro% the
sternal anle, the second rib insertion
o 4)# on the a"e! of the heart *feel for it
o 42# half-ay bet-een 4' and 4)
o 45 and 46# horiontally laterally fro% 4) *not u" to-ards the a!illa
5. Ask the "atient to rela!
6. 7ress record
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/he standard EC+ uses 0( cables to obtain 0' electrical vie-s of the heart. /he different
vie-s reflect the anles at -hich electrodes 1look1 at the heart and the direction of the heart8s
electrical de"olariation.
Limb leads
/hree bi"olar leads and three uni"olar leads are obtained fro% three electrodes attached to the
left ar%, the riht ar%, and the left le, res"ectively. *An electrode is also attached to the riht
le, but this is an earth electrode. /he bi"olar li%b leads reflect the "otential difference
bet-een t-o of the three li%b electrodes#
lead I# riht ar%9left ar%
lead II# riht ar%9left le
lead III# left le9left ar%
/he uni"olar leads reflect the "otential difference bet-een one of the three li%b electrodes
and an esti%ate of ero "otential 9 derived fro% the re%ainin t-o li%b electrodes. /hese
leads are kno-n as au%ented leads. /he au%ented leads and their res"ective li%b
electrodes are#
aVR lead# riht ar%
aVL lead# left ar%
aVF lead# left le
Chest leads
Another si! electrodes, "laced in standard "ositions on the chest -all, ive rise to a further
si! uni"olar leads 9 the chest leads *also kno-n as "recordial leads, 40946. /he "otential
difference of a chest lead is recorded bet-een the relevant chest electrode and an esti%ate of
ero "otential 9 derived fro% the averae "otential recorded fro% the three li%b leads.
Planes of ie!
/he li%b leads look at the heart in a vertical "lane *see 3iure ', -hereas the chest leads
look at the heart in a horiontal "lane. In this -ay, a three:di%ensional electrical "icture of
the heart is built u" *see /able 0.
Performing "ogs
British physiologist Augustus D Waller of St Mary's Medical School, London, published thefirst human electrocardiogram in theBritish Medical Journalin 1888 !t "as recorded from#homas $os"ell, a technician in the laboratory, using a capillary electrometer After that,Waller used a more a%ailable sub&ect for his demonstrations his dog (immy, "ho "ould
patiently stand "ith his pa"s in glass &ars of saline
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"epolari#ation of the heart
/he route that the de"olariation -ave takes across the heart is outlined in 3iure 2./he
sinoatrial node *;AN is the heart8s "ace%aker. 3ro% the ;AN, the -ave of de"olariation
s"reads across the atria to the atrioventricular node *A4N. /he i%"ulse is delayed briefly at
the A4N and atrial contraction is co%"leted.
/he -ave of de"olariation then "roceeds ra"idly to the bundle of His -here it s"lits into t-o
"ath-ays and travels alon the riht and left bundle branches. /he i%"ulse travels the lenth
of the bundles alon the interventricular se"tu% to the base of the heart, -here the bundles
divide into the 7urkin
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the $ -ave reflects de"olariation of the %ain %ass of the ventricles 9hence it is the
larest -ave
the ; -ave sinifies the final de"olariation of the ventricles, at the base of the heart
&$ segment
/he ;/ se%ent, -hich is also kno-n as the ;/ interval, is the ti%e bet-een the end of the
=$; co%"le! and the start of the / -ave. It reflects the "eriod of ero "otential bet-een
ventricular de"olariation and re"olariation.
$ !ae
/ -aves re"resent ventricular re"olariation *atrial re"olariation is obscured by the lare
=$; co%"le!.
(ae direction and si#e
;ince the direction of a deflection, u"-ard or do-n-ard, is de"endent on -hether the
electrical activity is oin to-ards or a-ay fro% a lead, it differs accordin to the orientation
of the lead -ith res"ect to the heart *see 3iure 5.
/he EC+ trace reflects the net electrical activity at a iven %o%ent. Conse>uently, activity in
one direction is %asked if there is %ore activity, e, by a larer %ass, in the other direction.
3or e!a%"le, the left ventricle %uscle %ass is %uch reater than the riht, and therefore its
de"olariation accounts for the direction of the biest -ave.
Interpreting the ECG
A nor%al EC+ tracin is "rovided in 3iure 6. /he only -ay to beco%e confident at readin
EC+s is to "ractice. It is i%"ortant to be %ethodical 9 every EC+ readin should start -ith
an assess%ent of the rate, rhyth%, and a!is. /his a""roach al-ays reveals so%ethin about an
EC+, reardless of ho- unusual it is.
Rate
Identify the =$; co%"le! *this is enerally the biest -ave& count the nu%ber of lares>uares bet-een one =$; -ave and the ne!t& divide 2(( by this nu%ber to deter%ine the rate
*see /able '.
Rhythm
7 -aves are the key to deter%inin -hether a "atient is in sinus rhyth% or not. If 7 -aves are
not clearly visible in the chest leads, look for the% in the other leads. /he "resence of 7
-aves i%%ediately before every =$; co%"le! indicates sinus rhyth%. If there are no 7
-aves, note -hether the =$; co%"le!es are -ide or narro-, reular or irreular.
)o P !aes and irregular narro! %R& comple'es
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/his is the hall%ark of atrial fibrillation *see 3iure ?. ;o%eti%es the baseline a""ears
1noisy1 and so%eti%es it a""ears entirely flat. Ho-ever, if there are no 7 -aves and the =$;
co%"le!es a""ear at rando%ly irreular intervals, the dianosis is atrial fibrillation.
&a!tooth P !aes
A sa-tooth -avefor% sinifies atrial flutter *see 3iure @. /he nu%ber of atrial contractions
to one ventricular contraction should be s"ecified.
*'is
/he a!is is the net direction of electrical activity durin de"olariation. It is altered by left
ventricular or riht ventricular hy"ertro"hy or by bundle branch blocks. It is a very
straihtfor-ard %easure%ent that, once it has been ras"ed, can be calculated
instantaneously#
find the =$; co%"le! in the I and a43 leads *because these look at the heart at (
and (, res"ectively
deter%ine the net "ositivity of the =$; -ave fro% each of the t-o leads by
subtractin the ; -ave heiht *the nu%ber of s%all s>uares that it crosses as it di"s
belo- the baseline 9 if it does fro% the $ -ave heiht *the nu%ber of s%all s>uares
that it crosses as it rises *see 3iure a and b
"lot out the net sies of these =$; -aves aainst each other on a vector diara% *see
3iure c. 3or the I lead, "lot net "ositives to the riht and net neatives to the left&
for the a43 lead, "lot "ositive do-n-ards and neative u"-ards
the direction of the end"oint fro% the startin "oint re"resents the a!is or "redo%inant
direction of electrical de"olariation *deter%ined "ri%arily by the %uscle %ass of the
left ventricle. It is e!"ressed as an anle and can be esti%ated >uite easily *nor%al is
(90'(
+uman Resuscitation
#he first electrical resuscitation of a human too) place *almost certainly+ in 18- #he
resuscitation of a dro"ned girl "ith electricity is described by $uillaume Ben&amin AmandDuchenne de Boulogne, a pioneering neurophysiologist, in the third edition of his te.tboo)on the medical uses of electricity Although it is sometimes described as the first artificial
pacing, the stimulation "as of the phrenic ner%e and not the myocardium
ECG abnormalities
/his section discusses the %ost i%"ortant and %ost fre>uently encountered EC+
abnor%alities.
)ormal ariations
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;%all = -aves and inverted / -aves in lead III often disa""ear on dee" ins"iration.
Dccasional se"tal = -aves can be seen in other leads.
;/ elevation follo-in an ; -ave *1hih take off1 is co%%on in leads 4'94) and is
>uite nor%al. ifferentiatin this fro% "atholoical ;/ elevation can be difficult and
relies on the "atient8s history and the availability of a "revious EC+. /hese1re"olariation abnor%alities1 are %ore co%%on in the youn and in athletes.
/:-ave inversion is co%%on in Afro:Caribbean blacks.
F -aves 9 s%all e!tra -aves follo-in / -aves 9 are seen in hy"okale%ic "atients,
but can also re"resent a nor%al variant.
4entricular e!trasystoles 9 no 7 -aves, broad and abnor%al =$; co%"le!es, and /
-aves inters"ersed bet-een nor%al sinus rhyth% 9 so%eti%es occur and do not
re>uire further investiation unless they are associated -ith sy%"to%s *such asdiiness, "al"itations, e!ercise intolerance, chest "ain, shortness of breath or occur
several ti%es every %inute.
Pathological ariations
Long PR interal
A distance of %ore than five s%all s>uares fro% the start of the 7 -ave to the start of the $
-ave *or = -ave if there is one constitutes first:deree heart block *see3iure 0(. It rarely
re>uires action, but in the "resence of other abnor%alities %iht be a sin of hy"erkale%ia,
dio!in to!icity, or cardio%yo"athy.
E,G or ECG-
#here is some debate o%er e.actly "ho in%ented the electrocardiogram #he Dutch /0/*ele)tro)ardiogram+ is often used as a tribute to the !ndonesianborn physician Wilhelm
2intho%en "ho, "hile "or)ing in #he 3etherlands in 14-5, recei%ed the 3obel pri6e for /thedisco%ery of the mechanism of the electrocardiogram/ !n fact, it "as Augustus D7sir7 Waller,a physician trained in 2dinburgh, "ho presented to the students of St Mary's ospitalmedical school, London, at the introductory lecture of the 1888 academic year his
/cardiograph/, the first e%er 29$ recording in man !t "as some years later, in 14:1, thatWilhelm 2intho%en reported his string gal%anometer "ith the limb leads labeled !, !!, and!!! and the "a%es labeled ;,
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Large %R& comple'es
Left ventricular hy"ertro"hy *L4H is one of the easiest and %ost useful dianoses to %ake
*see 3iure 0'. /he ;okolo-9Lyon inde! is the %ost co%%only calculated inde! of
esti%ation. oes the su% of the ; -ave in lead 40 *;40 and the $ -ave in 46 *$46 add u"
to %ore than 2.5 %4, ie, 25 s%all or seven bi s>uaresG If so, the "atient has L4H by voltaecriterion. $iht ventricular hy"ertro"hy is indicated by a do%inant $ -ave in 40 *ie, $ -ave
bier than follo-in ; -ave& ;okolo-9Lyon inde!# $ in 40 ; in 45 or 46 0.(5 %4
and riht a!is deviation.
.road %R& comple'es and strange/loo0ing ECGs
A -ide =$; co%"le! des"ite sinus rhyth% is the hall%ark of bundle branch block. Left
bundle branch block *LBBB can cause the EC+ to look e!tre%ely abnor%al *see3iure 02.
hen faced -ith such an EC+ 9 after calculatin rate, rhyth%, and a!is 9 check the -idth of
the =$; co%"le!. If it is %ore than three s%all s>uares -ide, it is abnor%al. Bundle branch
block can then be dianosed by "attern reconition of the =$; co%"le!es in the 40 and 46leads *see 3iure 0). Ne- LBBB can be dianostic of %yocardial infarction *MI.
&$ segment changes
/he ;/ se%ent e!tends fro% the end of the ; -ave to the start of the / -ave. It should be
flat or slihtly u"slo"in and level -ith the baseline. Elevation of %ore than t-o s%all
s>uares in the chest leads or one s%all s>uare in the li%b leads, co%bined -ith a
characteristic history, indicates the "ossibility of MI *see 3iure 05, "revious "ae. ;/
de"ression is dianostic of ische%ia *see3iure 06. It is -orth notin that althouh ;/
elevation can localie the lesion *e, anterior MI, inferior MI, ;/ de"ression cannot.
Concave u"-ards ;/ elevation in all 0' leads is dianostic of "ericarditis.
$ !aes
In a nor%al EC+, / -aves are u"riht in every lead e!ce"t a4$. /:-ave inversion can
re"resent current ische%ia or "revious infarction *see 3iure 0?. In co%bination -ith L4H
and ;/ de"ression, it can re"resent 1strain1. /his for% of L4H carries a "oor "ronosis.
Long %$ interal
/he =/ interval should be less than half of the $9$ interval. Calculation of the corrected =/*=/c is enerally not necessary and usually -ill have been done by the EC+ %achine *but
be-are of blindly believin any auto%ated dianostic syste%. Conditions associated -ith a
lon =/ interval are outlined in /able 2*see 3iure 0@.
Lon =/ syndro%e %ay also be dru:induced *see /able ), ". 2'. Dnce this occurs, the
res"onsible dru needs to be discontinued.
Pattern combinations
"igo'in
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A reverse tick ;/ de"ression is characteristic and does not indicate to!icity. io!in to!icity
can result in dysrhyth%ia.
Pulmonary embolism
;inus tachycardia is seen in %any "atients -ith "ul%onary e%bolis%. Ne- riht bundlebranch block *$BBB or riht a!is deviation -ith 1strain1 can also indicate 7E. /he classic
;I=III/IIIis less co%%on.
+yper0alemia
/he absolute "otassiu% level is less i%"ortant than its rate of rise. EC+ chanes reflectin a
ra"id rise de%and i%%ediate action *see 3iures 09'0. /he level of daner increases as the
EC+ chanes "roress. /he se>uence enerally follo-s the order#
tall, tented / -aves *see 3iure 0
lenthenin of the 7$ interval
reduction in the 7:-ave heiht
-idenin of the =$; co%"le! *see 3iure '(
1sinus1 -ave =$; "attern *see 3iure '0
A sinus:-ave =$; should be treated i%%ediately -ith calciu% chloride, -hilst hy"erkale%ia
associated -ith lesser EC+ chanes can be treated -ith insulinlucose infusion.
P%R&$-
3obody )no"s for sure "hy these letters became standard 9ertainly, mathematicians used tostart lettering systems from the middle of the alphabet to a%oid confusion "ith the freuentlyused letters at the beginning 2intho%en used the letters C to to mar) the timeline on his
29$ diagrams and, of course, ; is the letter that follo"s C !f the image of the ;
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Figures
Figure 1
;tandard attach%ent sites for chest leads.
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Figure 2
/he li%b leads lookin at the heart in a vertical "lane.
Figure 3
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/he cardiac de"olariation route. A4N# atrioventricular node& ;AN# sinoatrial node.
$e"roduced -ith "er%ission fro% B ;aunders *+uyton A, Hall J. #e.tboo) of Medical;hysiology. 7hiladel"hia# B ;aunders, 06.
Figure
/he basic "attern of electrical activity across the heart.
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Figure 4
*a A horiontal section throuh the chest sho-in the orientation of the chest leads -ith
res"ect to the cha%bers of the heart. *b In lead 40, de"olariation of the interventricular
se"tu% occurs to-ards the lead, thus creatin an u"-ard deflection *$ -ave on the EC+. It
is follo-ed by de"olariation of the %ain %ass of the L4, -hich occurs a-ay fro% the lead,
thus creatin a do-n-ard deflection *; -ave. /his "attern is reversed for lead 46,
e!"lainin the different sha"es of the =$; co%"le!. /his "attern should be checked in every
EC+. LA# left atriu%& L4# left ventricle& $A# riht atriu%& $4# riht ventricle.
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Figure 5
E!a%"le of a nor%al EC+.
Figure 6
EC+ de%onstratin atrial fibrillation.
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Figure 7
EC+ de%onstratin atrial flutter 9 note the characteristic sa-tooth -avefor%.
Figure 8
4ector diara% to deter%ine the =$; a!is.
Figure 19
EC+ de%onstratin first:deree heart block.
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Figure 11
EC+ de%onstratin abnor%al = -aves in 4094). /his is indicative of a "revious infarction.
Figure 12
EC+ de%onstratin left ventricular hy"ertro"hy. Note also the /:-ave inversion in leads 4)9
46. /his is often labeled 1strain1.
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Figure 13
EC+ de%onstratin left bundle branch block.
Figure 1
/he sha"es of 40 and 46 =$; co%"le!es in left and riht bundle branch block.
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Figure 14
EC+ de%onstratin anterose"tal %yocardial infarction. Note the ;/:se%ent elevation.
Figure 15
EC+ de%onstratin ;/:se%ent de"ression *I, 42946.
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Figure 16
EC+ de%onstratin /:-ave inversion.
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Figure 17
EC+ de%onstratin a lon =/ interval.
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Figure 18
Hy"erkale%ia. Note the tall, tented / -aves.
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Figure 29
EC+ de%onstratin a -idenin of the =$; co%"le!.
Figure 21
EC+ de%onstratin a sinus:-ave =$; "attern.
$ables
$able 1ECG leads and their respectie ie!s of the heart
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Vie! Lead
Inferior II, III, a43
Anterior I, a4L, 40942
;e"tal 42, 4)
Lateral 4)946
$able 2&ome common heart rates as determined by analysis of the %R&
comple'
)umber of large squares bet!een %R& comple'es +eart rate :bpm;
5 6(
) ?5
2 0((
' 05(
$able 3Causes of a long %$ interal
Congenital *cquired
Jervell and Lane9Nielsen syndro%e A%iodarone, sotalol
$o%ano9ard syndro%e 3lecainide
Hy"ocalce%ia
Hy"okale%ia
Hy"o%anese%ia
7henothiaines
/ricyclic antide"ressants
$able "rug/induced increase in the %$ interal and torsade de pointes
Generic name
%$
interal
$orsade de
pointes Generic name
%$
interal
$orsade de
pointes
*ntiarrhythmics &electie serotonin re/upta0e inhibitors
A
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Generic name
%$
interal
$orsade de
pointes Generic name
%$
interal
$orsade de
pointes
Lithiu%
Clinda%ycin
Naratri"tan
Erythro%ycin
;u%atri"tan
$o!ithro%ycin
;"ira%ycin 4enlafa!ine
*ntibiotics :quinolones; ol%itri"tan
+atiflo!acin *nti/Par0inson=s
+re"aflo!acina
A%antadine
Levoflo!acin
Budi"inec
Mo!iflo!acin
;"arflo!acin *ntimalarials
uine
Halofantrine
/ri%etho"ri%:
sulfa%etho!aole
Meflo>uine
*ntihistamines
Aste%iolea "iuretics
Cle%astine Inda"a%ide
i"henhydra%ine
Hydro!yine Lipid/lo!ering agents
/erfenadine 7robucol
*ntidepressants
>otility enhancers
A%itri"tyline
Cisa"ridea
Clo%i"ra%ine
esi"ra%ine )ootropic geriatrics
o!e"ine 4inca%ine
I%i"ra%ine
Chemotherapeutics
Ma"rotiline
/a%o!ifen
)euroleptics
7enta%idine
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Generic name
%$
interal
$orsade de
pointes Generic name
%$
interal
$orsade de
pointes
A%isul"ride
Cloa"ine Immunosuppressants
Chlor"ro%aine
/acroli%us
ro"eridola
3lu"henaine Peptides
Halo"eridol
Dctreotide
Mel"erone
Dlana"ine Virostatics
7i%oide 3oscarnet
=uetia"ine
>uscle rela'ants;ul"iride
/hioridaine /ianidine
$is"eridone
?/ray contrast agents
;ertindoleb
/ia"ride Io!alate
%elu%ine
/raodone
A "roloned =/ interval can occur or torsade de "ointes -as observed
a
/aken off the %arket.
b
;us"ended fro% the %arket, final decision by the reulatory authorities still a-aited.
c
Indication li%itations have been e!"ressed.
I%"ortant ti"s on the use of the table# infor%ation is based on the latest scientific
kno-lede as far as it is enerally available fro% "ublished studies *Medline
research, case re"orts, internet "ublications, s"ecialist infor%ation, the $ed List, and
infor%ation fro% the reulatory authorities. In the case re"orts available about torsade
de "ointes, the causal relationshi" to the inestion of the "articular %edication is no
loner a""arent& "ure coincidence cannot be e!cluded in individual cases.
Co"yrihtO '((), $e%edica.
Bookshelf I# NBK''0)
http://www.ncbi.nlm.nih.gov/books/about/copyright/http://www.ncbi.nlm.nih.gov/books/about/copyright/7/23/2019 Conquering the ECG
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