Electrocardiography - Wikipedia, The Free Encyclopedia

1/7/2015
ElectrocardiographyWikipedia,thefreeencyclopedia
Electrocardiography
FromWikipedia,thefreeencyclopedia
Electrocardiography(ECGorEKG[1]fromGreek:
kardia,meaningheart[2])istherecordingofthe
electricalactivityoftheheart.Traditionallythisisin
theformofatransthoracic(acrossthethoraxorchest)
interpretationoftheelectricalactivityoftheheart
overaperiodoftime,asdetectedbyelectrodes
attachedtothesurfaceoftheskinandrecordedor
displayedbyadeviceexternaltothebody.[3]The
recordingproducedbythisnoninvasiveprocedureis
termedanelectrocardiogram(alsoECGorEKG).It
ispossibletorecordECGsinvasivelyusingan
implantablelooprecorder.
AnECGisusedtomeasuretheheartselectrical
conductionsystem.[4]Itpicksupelectricalimpulses
generatedbythepolarizationanddepolarizationof
cardiactissueandtranslatesintoawaveform.The
waveformisthenusedtomeasuretherateand
regularityofheartbeats,aswellasthesizeand
positionofthechambers,thepresenceofanydamage
totheheart,andtheeffectsofdrugsordevicesusedto
regulatetheheart,suchasapacemaker.
MostECGsareperformedfordiagnosticorresearch
purposesonhumanhearts,butmayalsobeperformed
onanimals,usuallyfordiagnosisofheart
abnormalitiesorresearch.
Electrocardiography
Intervention
Imageshowingapatientconnectedtothe10
electrodesnecessaryfora12leadECG
ICD9CM
89.52
MeSH
D004562
MedlinePlus
003868
Contents
1Medicaluses
1.1Screeningforcoronaryheart
disease
1.2Myocardialinfarction
1.3Pulmonaryembolism
1.4Otherpatternsofdisease
2Function
3Principles
4ECGgraphpaper
4.1Layout
4.2Artifacts
http://en.wikipedia.org/wiki/Electrocardiography
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5Leads
5.1Placementofelectrodes
5.1.1Additionalelectrodes
5.2Limbleads
5.3Unipolarvs.bipolarleads
5.4Augmentedlimbleads
5.5Precordialleads
5.6Esophageallead
6Wavesandintervals
7Vectorsandviews
7.1Axis
7.2Leadgroups
8Filterselection
9Electrocardiogramheterogeneity
10Rhythmstrip
11History
12Fetalelectrocardiography
13Seealso
14References
15Externallinks
Medicaluses
Generalsymptomsindicatinguseof
electrocardiographyinclude:
Symptomsofmyocardialinfarction
Symptomsofpulmonaryembolism
Cardiacmurmurs[5]
Syncopeorcollapse[5]
Seizures[5]
TwelveleadECGofa26yearoldmalewithan
incompleteRBBB
Perceivedcardiacdysrhythmias[5]
Itisalsousedtoassesspatientswithsystemicdisease,aswellasmonitoringduringanesthesiaand
criticallyillpatients.[5]
Screeningforcoronaryheartdisease
PreventativeServicesTaskForcedonotrecommendeithertheECGoranyothercardiacimaging
procedureasaroutinescreeningprocedureinpatientswithoutsymptomsandthoseatlowriskfor
coronaryheartdisease.[6][7]Thisisbecauseoveruseoftheprocedureismorelikelytosupplyincorrect
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supportingevidenceforanonexistentproblemthantodetectatrueproblem.[7]Teststhatfalselyindicate
theexistenceofaproblemarelikelytoleadtomisdiagnosis,therecommendationofinvasive
procedures,orovertreatment,andtherisksassociatedwithmanagingfalseinformationareusuallymore
troublesomethannotusingECGresultstomakeahealthrecommendationinlowriskindividuals.[7]
Personsemployedincertaincriticaloccupations,suchasaircraftpilots,[8]orincertainenvironments,
suchashighaltitudes,[9]mayberequiredtohaveanECGaspartofaregulatoryregime.
Myocardialinfarction
CharacteristicchangesseenonelectrocardiographyinmyocardialinfarctionisincludedintheWHO
criteriaasrevisedin2000.[10]Accordingtothese,acardiactroponinriseaccompaniedbyeithertypical
symptoms,pathologicalQwaves,STelevationordepressionorcoronaryinterventionarediagnosticof
myocardialinfarction.
Pulmonaryembolism
Inpulmonaryembolism,anECGmayshowsignsofrightheart
strainoracutecorpulmonaleincasesoflargePEstheclassic
signsarealargeSwaveinleadI,alargeQwaveinleadIIIand
aninvertedTwaveinleadIII(S1Q3T3).[11]Thisisoccasionally
(upto20%)present,butmayalsooccurinotheracutelung
conditionsandhas,therefore,limiteddiagnosticvalue.This
S1Q3T3patternfromacuterightheartstrainistermedthe
"McGinnWhitesign"aftertheinitialdescribers.Themost
commonlyseensignsintheECGissinustachycardia,rightaxis
deviation,andrightbundlebranchblock.[12]Sinustachycardia
washoweverstillonlyfoundin869%ofpeoplewithPE.[13]
Otherpatternsofdisease
Electrocardiogramofapatientwith
pulmonaryembolismshowingsinus
tachycardiaofapproximately150
beatsperminuteandrightbundle
branchblock.
Thefollowingtablementionssomepathologicalpatternsthatcan
beseenonelectrocardiography,followedbypossiblecauses.
ShortenedQTinterval
Hypercalcemia,somedrugs,certaingeneticabnormalities,
hyperkalemia
ProlongedQTinterval
Hypocalcemia,somedrugs,certaingeneticabnormalities
FlattenedorinvertedT
waves
Coronaryischemia,hypokalemia,leftventricularhypertrophy,digoxin
effect,somedrugs
HyperacuteTwaves
Possiblythefirstmanifestationofacutemyocardialinfarction,whereT
wavesbecomemoreprominent,symmetrical,andpointed
PeakedTwave,QRSwide, Hyperkalemia,treatwithcalciumchloride,glucoseandinsulinor
prolongedPR,QTshort dialysis
ProminentUwaves
Hypokalemia
Function
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AnECGproducesapatternreflectingtheelectricalactivityoftheheartandusuallyrequiresatrained
cliniciantointerpretitinthecontextofthesignsandsymptomsthepatientpresentswith.Itcangive
informationregardingtherhythmoftheheart[14](whetherornottheelectricalimpulseconsistently
arisesfromthepartoftheheartwhereitshouldandatwhatrate),whetherthatimpulseisconducted
normallythroughouttheheart,orwhetheranypartoftheheartiscontributingmoreorlessthanexpected
totheelectricalactivityoftheheart.Itcanalsogiveinformationregardingthebalanceofsalts
(electrolytes)intheblood(e.g.hyperkalaemia)orevenrevealproblemswithsodiumchannelswithinthe
heartmusclecells(Brugadasyndrome).[15]ModernECGmachinesoftenincludeanalysissoftwarethat
attemptstointerpretthepatternbutthediagnosesthisproducesmaynotalwaysbeaccurate.[16]
Itisoneofthekeytestsperformedwhenaheartattack(myocardialinfarctionorMI)issuspectedthe
ECGcanidentifywhethertheheartmusclehasbeendamagedinspecificareas,thoughnotallareasof
theheartarecovered.[17]TheECGcannotreliablymeasurethepumpingabilityoftheheart,forwhich
ultrasoundbased(echocardiography)ornuclearmedicinetestsareused.Itispossibleforahumanor
otheranimaltobeincardiacarrest,butstillhaveanormalECGsignal(aconditionknownaspulseless
electricalactivity).
Principles
TheECGdevicedetectsandamplifiesthetinyelectricalchanges
ontheskinthatarecausedwhentheheartmuscledepolarizes
duringeachheartbeat.Atrest,eachheartmusclecellhasa
negativecharge,calledthemembranepotential,acrossitscell
membrane.Decreasingthisnegativechargetowardzero,viathe
influxofthepositivecations,Na+andCa++,iscalled
depolarization,whichactivatesthemechanismsinthecellthat
causeittocontract.Duringeachheartbeat,ahealthyheartwill
haveanorderlyprogressionofawaveofdepolarisationthatis
triggeredbythecellsinthesinoatrialnode,spreadsoutthrough
Tabelectrodeusingsilver/silver
theatrium,passesthroughtheatrioventricularnodeandthen
chloridesensingtodetectatraceof
spreadsallovertheventricles.Thisisdetectedastinyrisesand
voltage. [18]
fallsinthevoltagebetweentwoelectrodesplacedeithersideof
theheart,whichisdisplayedasawavylineeitheronascreenor
onpaper.Thisdisplayindicatestheoverallrhythmoftheheartandweaknessesindifferentpartsofthe
heartmuscle.
Usually,morethantwoelectrodesareused,andtheycanbecombinedintoanumberofpairs(For
example:leftarm(LA),rightarm(RA),andleftleg(LL)electrodesformthethreepairsLA+RA,
LA+LL,andRA+LL).Theoutputfromeachpairisknownasalead.Eachleadlooksattheheartfroma
differentangle.DifferenttypesofECGscanbereferredtobythenumberofleadsthatarerecorded,for
example3lead,5lead,or12leadECGs(sometimessimply"a12lead").A12leadECGisonein
which12differentelectricalsignalsarerecordedatapproximatelythesametimeandwilloftenbeused
asaoneoffrecordingofanECG,traditionallyprintedoutasapapercopy.Threeand5leadECGstend
tobemonitoredcontinuouslyandviewedonlyonthescreenofanappropriatemonitoringdevice,for
exampleduringanoperationorwhilstbeingtransportedinanambulance.Theremayormaynotbeany
permanentrecordofa3or5leadECG,dependingontheequipmentused.
ECGgraphpaper
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TheoutputofanECGrecorderisagraph(orsometimesseveral
graphs,representingeachoftheleads)withtimerepresentedon
thexaxisandvoltagerepresentedontheyaxis.Adedicated
ECGmachinewouldusuallyprintontographpaperthathasa
backgroundpatternof1millimetersquares(ofteninredor
green),withbolddivisionsevery5mminbothverticaland
horizontaldirections.
ItispossibletochangetheoutputofmostECGdevicesbutitis
standardtorepresenteachmVontheyaxisas1cmandeach
OnesecondofECGgraphpaper
secondas25mmonthexaxis(thatisapaperspeedof
25mm/s).Fasterpaperspeedscanbeused,forexample,to
resolvefinerdetailintheECG.Atapaperspeedof25mm/s,onesmallblockofECGpapertranslates
into40ms.Fivesmallblocksmakeuponelargeblock,whichtranslatesinto200ms.Hence,thereare
fivelargeblockspersecond.Acalibrationsignalmaybeincludedwitharecord.Astandardsignalof
1mVmustmovethestylusvertically1cm,thatis,twolargesquaresonECGpaper.
Layout
Bydefinition,a12leadECGwillshowashortsegmentoftherecordingofeachofthetwelveleads.
Thisisoftenarrangedinagridoffourcolumnsbythreerows,thefirstcolumnbeingthelimbleads(I,II,
andIII),thesecondcolumntheaugmentedlimbleads(aVR,aVL,andaVF),andthelasttwocolumns
beingthechestleads(V1V6).Itisusuallypossibletochangethislayout,soitisvitaltocheckthelabels
toseewhichleadisrepresented.Eachcolumnwillusuallyrecordthesamemomentintimeforthethree
leadsandthentherecordingwillswitchtothenextcolumn,whichwillrecordtheheartbeatsafterthat
point.Itispossiblefortheheartrhythmtochangebetweenthecolumnsofleads.
Eachofthesesegmentsisshort,perhapsonetothreeheartbeatsonly,dependingontheheartrate,andit
canbedifficulttoanalyseanyheartrhythmthatshowschangesbetweenheartbeats.Tohelpwiththe
analysis,someECGmachineswillprintoneortwo"rhythmstrips"aswellalongthebottomoftheECG
paper.ThiswillusuallybeleadII(whichshowstheelectricalsignalfromtheatrium,thePwave,well)
andshowstherhythmforthewholetimetheECGwasrecorded(usually56sec).Itisusuallypossible
tosetthemachinetoprintanumberofleadscontinuouslyiffurtherinformationregardingtherhythmis
required.
Theterm"rhythmstrip"mayalsorefertothewholeprintoutfromacontinuousmonitoringsystem,
whichmayshowonlyoneleadandiseitherinitiatedbyaclinicianorinresponsetoanalarmorevent.
Artifacts
Theelectrocardiogram,animportantandbasicdiagnosticproofcanevenconfuseadiagnosisduetoa
wronginterpretation.IthasbeenpreviouslyreviewedthemechanismsbehindequipmentrelatedECG
artifacts.AgoodknowledgeaboutthebasicprinciplesofECGcanbeveryvaluabletosolvethesecases.
ForexampleduetoParkinsondisease.[19]
Leads
Theterm"lead"inelectrocardiographycausesmuchconfusionbecauseitisusedtorefertotwodifferent
things.Inaccordancewithcommonparlance,thewordleadmaybeusedtorefertotheelectricalcable
attachingtheelectrodestotheECGrecorder.Assuch,itmaybeacceptabletorefertothe"leftarmlead"
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astheelectrode(anditscable)thatshouldbeattachedatorneartheleftarm.Usually,10ofthese
electrodesarestandardina"12lead"ECG.
Alternatively(andsomewouldsayproperly,inthecontextof
electrocardiography),thewordleadmayrefertothetracingof
thevoltagedifferencebetweentwooftheelectrodesandiswhat
isactuallyproducedbytheECGrecorder.Eachwillhavea
specificname.Forexample"leadI"isthevoltagebetweenthe
rightarmelectrodeandtheleftarmelectrode,whereas"LeadII"
isthevoltagebetweentherightarmandtheleftleg.(Thisrapidly
becomesmorecomplexasoneofthe"electrodes"mayinfactbe
acompositeoftheelectricalsignalfromacombinationofthe
otherelectrodes).Twelveofthistypeofleadforma"12lead"
ECG.
Tocauseadditionalconfusion,theterm"limbleads"usually
referstothetracingsfromleadsI,II,andIIIratherthanthe
electrodesattachedtothelimbs.
Illustrationdepictingleadplacement
duringelectrocardiography
Placementofelectrodes
Tenelectrodesareusedfora12leadECG.Theelectrodesusuallyconsistofaconductinggel,
embeddedinthemiddleofaselfadhesivepadontowhichcablesclip.Sometimesthegelalsoformsthe
adhesive.[20]Theyarelabeledandplacedonthepatient'sbodyasfollows:[21][22]
Electrode
label(inthe
USA)
Electrodeplacement
RA
Ontherightarm,avoidingthickmuscle.
LA
InthesamelocationwhereRAwasplaced,but
ontheleftarm.
RL
Ontherightleg,lateralcalfmuscle.
LL
InthesamelocationwhereRLwasplaced,but
ontheleftleg.
V1
Inthefourthintercostalspace(betweenribs4
and5)justtotherightofthesternum
(breastbone).
V2
Inthefourthintercostalspace(betweenribs4
and5)justtotheleftofthesternum.
V3
BetweenleadsV2andV4.
V4
Inthefifthintercostalspace(betweenribs5and
6)inthemidclavicularline.
V5
HorizontallyevenwithV4,intheleftanterior
axillaryline.
V6
HorizontallyevenwithV4andV5inthe
midaxillaryline.
Properplacementofthelimb
electrodes,colorcodedas
recommendedbytheAmericanHeart
Association(adifferentcolour
schemeisusedinEurope):Thelimb
electrodescanbefardownonthe
limbsorclosetothehips/shoulders,
buttheymustbeeven(leftvs
right). [23]
*Whenexercisestresstestsare
performed,limbleadsmaybeplaced
onthetrunktoavoidartifactswhile
ambulatory(armleadsmoved
subclavicularlyandlegleadsmedial
toandabovetheiliaccrest).
Additionalelectrodes
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Theclassical12leadECGcanbeextendedinanumberofwaysinanattempttoimproveitssensitivity
indetectingmyocardialinfarctioninvolvingterritoriesnot
normally"seen"well.ThisincludesanrV4lead,whichusesthe
equivalentlandmarkstotheV4butontherightsideofthechest
wall(usedinpaediatricpatientsunder5yearsofageduetothe
dominanceoftherightventricleinthisagegroup[24])and
extendingthechestleadsontothebackwithaV7,V8andV9.
TheLewisleadorS5hastheLAelectrodeplacedinthesecond
intercostalspacetotherightofthesternumwiththeRAatthe
fourthintercostalspace.ItisreadasleadIandissupposedto
demonstrateatrialactivitymuchbettertoaidinidentificationof
atrialflutterorbroadcomplextachycardia.
AposteriorECGcanaidinthediagnosisofaposterior
myocardialinfarction.Thisisperformedbytheadditionofleads
V7,V8andV9extendingaroundtheleftchestwalltowardthe
back.
Placementoftheprecordialleads
Limbleads
Inboththe5and12leadconfigurations,leadsI,IIandIIIare
calledlimbleads.Theelectrodesthatformthesesignalsare
locatedonthelimbsoneoneacharmandoneontheleft
leg.[25][26][27]Thelimbleadsformthepointsofwhatisknownas
Einthoven'striangle.[28]
12leads
LeadIisthevoltagebetweenthe(positive)leftarm(LA)electrodeandrightarm(RA)electrode:
LeadIIisthevoltagebetweenthe(positive)leftleg(LL)electrodeandtherightarm(RA)
electrode:
LeadIIIisthevoltagebetweenthe(positive)leftleg(LL)electrodeandtheleftarm(LA)
electrode:
Simplifiedelectrocardiographsensorsdesignedforteachingpurposes,e.g.athighschoollevel,arein
generallimitedtothreearmelectrodesservingsimilarpurposes.[29]
Unipolarvs.bipolarleads
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Thetwotypesofleadsareunipolarandbipolar.Bipolarleadshaveonepositiveandonenegative
pole.[30]Ina12leadECG,thelimbleads(I,IIandIII)arebipolarleads.Unipolarleadsalsohavetwo
poles,asavoltageismeasuredhowever,thenegativepoleisacompositepole(Wilson'scentral
terminal,orWCT)madeupofsignalsfrommultipleotherelectrodes.[31]Ina12leadECG,allleads
exceptthelimbleadsareunipolar(aVR,aVL,aVF,V1,V2,V3,V4,V5,andV6).
Wilson'scentralterminalVWisproducedbyconnectingtheelectrodesRA,LA,andLLtogether,viaa
simpleresistivenetwork,togiveanaveragepotentialacrossthebody,whichapproximatesthepotential
atinfinity(i.e.zero):
Augmentedlimbleads
LeadsaVR,aVL,andaVFareaugmentedlimbleads(aftertheirinventorDr.EmanuelGoldberger
knowncollectivelyastheGoldberger'sleads).Theyarederivedfromthesamethreeelectrodesasleads
I,II,andIII.However,theyviewtheheartfromdifferentangles(orvectors)becausethenegative
electrodefortheseleadsisamodificationofWilson'scentralterminal.Thiszeroesoutthenegative
electrodeandallowsthepositiveelectrodetobecomethe"exploringelectrode".Thisispossiblebecause
Einthoven'sLawstatesthatI+(II)+III=0.TheequationcanalsobewrittenI+III=II.Itiswritten
thisway(insteadofIII+III=0)becauseEinthovenreversedthepolarityofleadIIinEinthoven's
triangle,possiblybecausehelikedtoviewuprightQRScomplexes.Wilson'scentralterminalpavedthe
wayforthedevelopmentoftheaugmentedlimbleadsaVR,aVL,aVFandtheprecordialleadsV1,V2,
V3,V4,V5andV6.
Leadaugmentedvectorright(aVR)'hasthepositiveelectrode(white)ontherightarm.The
negativeelectrodeisacombinationoftheleftarm(black)electrodeandtheleftleg(red)
electrode,which"augments"thesignalstrengthofthepositiveelectrodeontherightarm:
Leadaugmentedvectorleft(aVL)hasthepositive(black)electrodeontheleftarm.Thenegative
electrodeisacombinationoftherightarm(white)electrodeandtheleftleg(red)electrode,which
"augments"thesignalstrengthofthepositiveelectrodeontheleftarm:
Leadaugmentedvectorfoot(aVF)hasthepositive(red)electrodeontheleftleg.Thenegative
electrodeisacombinationoftherightarm(white)electrodeandtheleftarm(black)electrode,
which"augments"thesignalofthepositiveelectrodeontheleftleg:
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TheaugmentedlimbleadsaVR,aVL,andaVFareamplifiedinthiswaybecausethesignalistoosmall
tobeusefulwhenthenegativeelectrodeisWilson'scentralterminal.TogetherwithleadsI,II,andIII,
augmentedlimbleadsaVR,aVL,andaVFformthebasisofthehexaxialreferencesystem,whichis
usedtocalculatetheheart'selectricalaxisinthefrontalplane.TheaVR,aVL,andaVFleadscanalsobe
representedusingtheIandIIlimbleads:
Precordialleads
Theelectrodesfortheprecordialleads(V1,V2,V3,V4,V5andV6)areplaceddirectlyonthechest.
Becauseoftheircloseproximitytotheheart,theydonotrequireaugmentation.Wilson'scentralterminal
isusedforthenegativeelectrode,andtheseleadsareconsideredtobeunipolar(recallthatWilson's
centralterminalistheaverageofthethreelimbleads.Thisapproximatescommon,oraverage,potential
overthebody).Theprecordialleadsviewtheheart'selectricalactivityinthesocalledhorizontalplane.
Theheart'selectricalaxisinthehorizontalplaneisreferredtoastheZaxis.
Esophageallead
leadstory:Filteredesophagealleftheartelectrogram.
Thefilteredesophagealleftheartelectrogramisasemiinvasivemethod.Thistechniqueisableto
provideadditionalmarkerfromtheleftatriumandtheleftventricle.
Thefilteredbipolaresophagealleftatrialelectrogram(LAE)recording,incombinationwiththesurface
ECGcanbeofadvantageinallsituationsrequiringdoubtlessrecognitionoftheatrialactivities.With
thisadditionalleftatrialmarkerchanneltheatrialactivitiescaneasilyberecognizedeveniftheyare
superimposedbytheQRScomplex.Thus,LAErecordingcanbeutilized,forexample,toquickly
differentiatetachycardiasandextrasystoliesandtodiagnoseDDDpacemakermalfunctions.Asaspecial
advantageinatriobiventricularandconventionalAVblockpacing,theesophagealleftatrial
electrogramrecodingenablesmeasurementofinteratrialconductionintervals,whicharethemajor
determinantsoftheoptimalAVdelaysinVDDandDDDpacing.
ComparedtothesurfaceECG,thefilteredbipolaresophagealleftventricularelectrogramallowsamore
directdeterminationoftheextentofcardiacdesynchronizationinheartfailurepatients.Thus,the
esophagealleftventricularconductiondelay(LVCDE)couldbeusedasanadditionalmarkerof
interventriculardyssynchronytojustifyimplantationofbiventricularpacingsystemsandtoguidethe
positioningoftheleftventricularelectrode.
Therecordingoftheesophagealleftheartelectrogramsrequiresabipolaresophagealelectrode.For
example,theTOslim(OsypkaAG,Rheinfelden,Germany)canbeused.Ithastobeappliedperorallyor
transnasallyeitherwithorwithoutanymildsedation.Toeliminateartifactsintheesophagealleftatrial
electrogramandtoimprovethedifferentiationbetweentheleftatrialdeflectionandtheventricular
complex,highpassfilteringisrecommended.BestresultscanbeobtainedusingButterworthhighpass
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filtertechnique(forexample:throughtheDCinputofastandardECGrecorderincombinationwiththe
Rostockfilter(OsypkaAG,Rheinfelden,Germany)orbyusingtheesophagealelectrogramoptionofthe
BiotronikICS3000programmer.Inthiscase,nofurtherequipmentisneeded.[32]
Wavesandintervals
AtypicalECGtracingofthecardiaccycle
(heartbeat)consistsofaPwave,aQRScomplex,a
Twave,andaUwave,whichisnormallyinvisible
in50to75%ofECGsbecauseitishiddenbytheT
waveandupcomingnewPwave.[36]Thebaselineof
theelectrocardiogram(theflathorizontalsegments)
ismeasuredastheportionofthetracingfollowing
theTwaveandprecedingthenextPwaveandthe
segmentbetweenthePwaveandthefollowingQRS
complex(PRsegment).Inanormalhealthyheart,
thebaselineisequivalenttotheisoelectricline
(0mV)andrepresentstheperiodsinthecardiac
cyclewhentherearenocurrentstowardseitherthe
positiveornegativeendsoftheECGleads.
SchematicrepresentationofnormalECG
However,inadiseasedheart,thebaselinemaybe
depressed(e.g.,cardiacischaemia)orelevated(e.g.,
myocardialinfarction)relativetotheisoelectriclineduetoinjury
currentsduringtheTPandPRintervalswhentheventriclesare
atrest.TheSTsegmenttypicallyremainsclosetotheisoelectric
lineasthisistheperiodwhentheventriclesarefullydepolarised
andthusnocurrentscanbeintheECGleads.SincemostECG
recordingsdonotindicatewherethe0mVlineis,baseline
depressionoftengivestheappearanceofanelevationoftheST
segmentandconverselybaselineelevationgivestheappearance
ofdepressionoftheSTsegment.[37]
Feature
Description
TheintervalbetweenanRwaveandthe
RR
nextRwavenormalrestingheartrateis
interval
between60and100bpm.
Pwave
Duration
0.6to
1.2s
AnimationofanormalECGwave
Duringnormalatrialdepolarization,the
mainelectricalvectorisdirectedfromthe
SAnodetowardstheAVnodeandspreads 80ms
fromtherightatriumtotheleftatrium.
ThisturnsintothePwaveontheECG.
ThePRintervalismeasuredfromthe
beginningofthePwavetothebeginning
oftheQRScomplex.ThePRinterval
PR
reflectsthetimetheelectricalimpulse
120to
interval takestotravelfromthesinusnodethrough 200ms
theAVnodeandenteringtheventricles.
ThePRintervalis,therefore,agood
estimateofAVnodefunction.
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ThePRsegmentconnectsthePwaveand
theQRScomplex.Theimpulsevectoris
fromtheAVnodetotheBundleofHisto
thebundlebranchesandthentothe
PR
50to
Purkinjefibers.Thiselectricalactivity
segment
120ms
doesnotproduceacontractiondirectlyand
ismerelytravelingdowntowardsthe
ventricles,andthisshowsupflatonthe
ECG.ThePRintervalismoreclinically
relevant.
TheQRScomplexreflectstherapid
depolarizationoftherightandleft
QRS
ventricles.Theventricleshavealarge
complex musclemasscomparedtotheatria,sothe
QRScomplexusuallyhasamuchlarger
amplitudethanthePwave.
Jpoint
80to
100ms
ThepointatwhichtheQRScomplex
finishesandtheSTsegmentbegins.Itis
N/A
usedtomeasurethedegreeofSTelevation
ordepressionpresent.
TheSTsegmentconnectstheQRS
ST
complexandtheTwave.TheSTsegment 80to
segment representstheperiodwhentheventricles
120ms
aredepolarized.Itisisoelectric.
TheTwaverepresentstherepolarization
(orrecovery)oftheventricles.Theinterval
fromthebeginningoftheQRScomplexto
Twave theapexoftheTwaveisreferredtoasthe 160ms
absoluterefractoryperiod.Thelasthalfof
theTwaveisreferredtoastherelative
refractoryperiod(orvulnerableperiod).
ST
TheSTintervalismeasuredfromtheJ
interval pointtotheendoftheTwave.
320ms
TheQTintervalismeasuredfromthe
beginningoftheQRScomplextotheend
oftheTwave.AprolongedQTintervalis
QT
ariskfactorforventricular
interval tachyarrhythmiasandsuddendeath.It
varieswithheartrateand,forclinical
relevance,requiresacorrectionforthis,
givingtheQTc.
Upto
420ms
inheart
rateof
60bpm
DetailoftheQRScomplex,showing
ventricularactivationtime(VAT)and
amplitude
TheUwaveishypothesizedtobecaused
bytherepolarizationoftheinterventricular
septum.Itnormallyhasalowamplitude,
andevenmoreofteniscompletelyabsent.
Uwave ItalwaysfollowstheTwave,andalso
followsthesamedirectioninamplitude.If
itistooprominent,suspecthypokalemia,
hypercalcemiaorhyperthyroidism.[38]
TheJwave,elevatedJpointorOsborn
waveappearsasalatedeltawave
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Jwave
followingtheQRSorasasmallsecondary
Rwave.Itisconsideredpathognomonicof
hypothermiaorhypercalcemia.[39]
Originally,fourdeflectionswerenoted,butafterthe
mathematicalcorrectionforartifactsintroducedbyearly
amplifiers,afifthdeflectionwasdiscovered.Einthovenchosethe
lettersP,Q,R,S,andTtoidentifythetracingthatwas
superimposedovertheuncorrectedlabeledA,B,C,andD.[40]
Inintracardiacelectrocardiograms,suchascanbeacquiredfrom
pacemakersensors,anadditionalwavecanbeseen,theH
deflection,whichreflectsthedepolarizationofthebundleof
His.[41]TheHVinterval,inturn,isthedurationfromthe
beginningoftheHdeflectiontotheearliestonsetofventricular
depolarizationrecordedinanylead.[42]
Vectorsandviews
Graphicshowingtherelationship
betweenpositiveelectrodes,
depolarizationwavefronts(ormean
electricalvectors),andcomplexes
displayedontheECG
UpperlimitofnormalQTinterval,
correctedforheartrateaccordingto
Bazett'sformula, [33]Fridericia's
formula[34]andsubtracting0.02s
fromQTforevery10bpmincrease
inheartrate. [35]Upto0.42s(
420ms)ischosenasnormalQTcof
QTB andQTFinthisdiagram.
InterpretationoftheECGreliesontheideathatdifferentleads
(meaningtheECGleadsI,II,III,aVR,aVL,aVFandthechest
leads)"view"theheartfromdifferentangles.Thishastwo
benefits.First,leadsthatareshowingproblems(forexampleST
segmentelevation)canbeusedtoinferwhichregionoftheheart
isaffected.Second,theoveralldirectionoftravelofthewaveof
depolarisationcanalsobeinferred,whichcanrevealother
problems.Thisistermedthecardiacaxis.Determinationofthe
cardiacaxisreliesontheconceptofavector,whichdescribesthe
motionofthedepolarisationwave.Thisvectorcanthenbe
describedintermsofitscomponentsinrelationtothedirection
oftheleadconsidered.Onecomponentwillbeinthedirectionof
theleadandthiswillberevealedinthebehaviouroftheQRS
complexandonecomponentwillbeat90tothis(whichwill
not).AnynetpositivedeflectionoftheQRScomplex(i.e.,height
oftheRwaveminusdepthoftheSwave)suggeststhewaveof
depolarisationisspreadingthroughtheheartinadirectionthat
hassomecomponent(ofthevector)inthesamedirectionasthe
leadinquestion.
Axis
Theheart'selectricalaxisreferstothegeneraldirectionoftheheart'sdepolarizationwavefront(ormean
electricalvector)inthefrontalplane.Withahealthyconductingsystem,thecardiacaxisisrelatedto
wherethemajormusclebulkoftheheartlies.Undernormalcircumstances,thisistheleftventricle,with
somecontributionfromtherightventricle.Itisusuallyorientedinarightshouldertoleftlegdirection,
whichcorrespondstotheleftinferiorquadrantofthehexaxialreferencesystem,although30to+90
isconsideredtobenormal.Iftheleftventricleincreasesitsactivityorbulk,thenthereissaidtobe"left
axisdeviation"astheaxisswingsaroundtotheleftbeyond30however,inconditionswhereinthe
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rightventricleisstrainedorhypertrophied,thentheaxisswings
aroundbeyond+90and"rightaxisdeviation"issaidtoexist.
Disordersoftheconductionsystemoftheheartcandisturbthe
electricalaxiswithoutnecessarilyreflectingchangesinmuscle
bulk.
Normal
30
Normal
to90
Normal
Leftaxisdeviation
Mayindicateleft
30
isconsidered
Leftaxis
anteriorfascicularblock
to
normalinpregnant
deviation
orQwavesfrominferior
90
womenandthose
MI.
withemphysema.
Mayindicateleft
posteriorfascicular
Right
+90
block,Qwavesfrom
axis
to
highlateralMI,ora
deviation +180
rightventricularstrain
pattern
Diagramshowinghowthepolarityof
theQRScomplexinleadsI,II,and
IIIcanbeusedtoestimatetheheart's
electricalaxisinthefrontalplane
Rightdeviationis
considerednormal
inchildrenandisa
standardeffectof
dextrocardia.
Extreme +180 Israre,andconsidered

rightaxis to
an'electricalnoman's
deviation 90 land'
Inthesettingofrightbundlebranchblock,right
orleftaxisdeviationmayindicatebifascicular
block.
Leadgroups
Ofthe12leadsintotal,eachrecordsthe
electricalactivityoftheheartfromadifferent
perspective,whichalsocorrelatestodifferent
anatomicalareasoftheheartforthepurposeof
identifyingacutecoronaryischemiaorinjury.
Twoleadsthatlookatneighbouringanatomical
areasoftheheartaresaidtobecontiguous.The
relevanceofthisisindeterminingwhetheran
abnormalityontheECGislikelytorepresent
truediseaseoraspuriousfinding.
Thehexaxialreferencesystemshowingtheorientation
ofeachlead:Forexample,ifthebulkofheartmuscleis
orientedat+60degreeswithrespecttotheSAnode,
leadIIwillshowthegreatestdeflectionandaVLthe
least.
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Color
Category on Leads
chart
Inferior
leads'
Activity
Leads
Lookatelectricalactivityfromthe
II,III
Yellow
vantagepointoftheinferiorsurface
and
(diaphragmaticsurfaceofheart)
aVF
Lookattheelectricalactivityfrom
thevantagepointofthelateralwall
ofleftventricle
Diagramshowingthecontiguous
leadsinthesamecolor
Thepositiveelectrodefor
leadsIandaVLshouldbe
locateddistallyontheleftarm
Lateral
leads
I,
aVL,
Green V5
and
V6
and,becauseofwhich,leadsI
andaVLaresometimes
referredtoasthehighlateral
leads.
Becausethepositive
electrodesforleadsV5and
V6areonthepatient'schest,
theyaresometimesreferredto
asthelowlateralleads.
Septal
leads
Anterior
leads
V1
Orange and
V2
Blue
V3
and
V4
vantagepointoftheseptalsurfaceof
theheart(interventricularseptum)
vantagepointoftheanteriorwallof
therightandleftventricles
(Sternocostalsurfaceofheart)
Inaddition,anytwoprecordialleadsnexttooneanotherareconsideredtobecontiguous.Forexample,
thoughV4isananteriorleadandV5isalaterallead,theyarecontiguousbecausetheyarenexttoone
another.Acommonsayingtorememberthecontiguousleadsis"Iseeallleads"(inferior,septal,anterior
andlateral).
LeadaVRoffersnospecificviewoftheleftventricle.Rather,itviewstheinsideoftheendocardialwall
tothesurfaceoftherightatrium,fromitsperspectiveontherightshoulder.
Filterselection
ModernECGmonitorsoffermultiplefiltersforsignalprocessing.Themostcommonsettingsare
monitormodeanddiagnosticmode.Inmonitormode,thelowfrequencyfilter(alsocalledthehighpass
filterbecausesignalsabovethethresholdareallowedtopass)issetateither0.5Hzor1Hzandthe
highfrequencyfilter(alsocalledthelowpassfilterbecausesignalsbelowthethresholdareallowedto
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pass)issetat40Hz.Thislimitsartifactsforroutinecardiac
rhythmmonitoring.Thehighpassfilterhelpsreducewandering
baselineandthelowpassfilterhelpsreduce50or60Hzpower
linenoise(thepowerlinenetworkfrequencydiffersbetween50
and60Hzindifferentcountries).Indiagnosticmode,thehigh
passfilterissetat0.05Hz,whichallowsaccurateSTsegments
toberecorded.Thelowpassfilterissetto40,100,or150Hz.
Asaconsequence,themonitormodeECGdisplayismore
filteredthandiagnosticmode,becauseitspassbandis
narrower.[43]
Electrocardiogramheterogeneity
Wiggersdiagram,showinganormal
ECGcurvesynchronizedwithother
majoreventsduringthecardiaccycle
ECGheterogeneityisameasurementoftheamountofvariance
betweenoneECGwaveformandthenext.ThisheterogeneitycanbemeasuredbyplacingmultipleECG
electrodesonthechestandthencomputingthevarianceinwaveformmorphologyacrossthesignals
obtainedfromtheseelectrodes.RecentresearchsuggestsECGheterogeneityoftenprecedesdangerous
cardiacarrhythmias.
Inthefuture,implantabledevicesmaybeprogrammedtomeasureandtrackheterogeneity.These
deviceshavepotentialtohelpwardoffarrhythmiasbystimulatingnervessuchasthevagusnerve,
deliveringdrugssuchasbetablockersand,ifnecessary,defibrillatingtheheart.[44]
Rhythmstrip
Althoughmultipleleads,andthusmultipleelectricalvectors,arecommonlyusedinunisontogain
diagnosticandtherapeuticinsightintocardiacstatus,monitoringonelead,referredtoasarhythmstrip,
canbeusefultotrendcardiacfunctionintermsofheartrate,regularity,pauses,andbasicrhythm.
History
TheetymologyofthewordisderivedfromtheGreekelectro,becauseitisrelatedtoelectricalactivity,
kardio,Greekforheart,andgraph,aGreekrootmeaning"towrite".
AlexanderMuirheadisreportedtohaveattachedwirestoafeverishpatient'swristtoobtainarecordof
thepatient'sheartbeatwhilestudyingforhisDoctorofScience(inelectricity)in1872atSt
Bartholomew'sHospital.[45]ThisactivitywasdirectlyrecordedandvisualizedusingaLippmann
capillaryelectrometerbytheBritishphysiologistJohnBurdonSanderson.[46]Thefirsttosystematically
approachtheheartfromanelectricalpointofviewwasAugustusWaller,workinginStMary'sHospital
inPaddington,London.[47]HiselectrocardiographmachineconsistedofaLippmanncapillary
electrometerfixedtoaprojector.Thetracefromtheheartbeatwasprojectedontoaphotographicplate
thatwasitselffixedtoatoytrain.Thisallowedaheartbeattoberecordedinrealtime.In1911hestill
sawlittleclinicalapplicationforhiswork.
AninitialbreakthroughcamewhenWillemEinthoven,workinginLeiden,theNetherlands,usedthe
stringgalvanometerheinventedin1901.[48]Thisdevicewasmuchmoresensitivethanboththe
capillaryelectrometerWallerusedandthestringgalvanometerthathadbeeninventedseparatelyin1897
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bytheFrenchengineerClmentAder.[49]Ratherthanusingtoday'sselfadhesiveelectrodesEinthoven's
subjectswouldimmerseeachoftheirlimbsintocontainersofsaltsolutionsfromwhichtheECGwas
recorded.
EinthovenassignedthelettersP,Q,R,S,andTtothevariousdeflections,[40]anddescribedthe
electrocardiographicfeaturesofanumberofcardiovascular
disorders.In1924,hewasawardedtheNobelPrizeinMedicine
forhisdiscovery.[50]
Thoughthebasicprinciplesofthateraarestillinusetoday,
manyadvancesinelectrocardiographyhavebeenmadeoverthe
years.Theinstrumentation,forexample,hasevolvedfroma
cumbersomelaboratoryapparatustocompactelectronicsystems
thatoftenincludecomputerizedinterpretationofthe
electrocardiogram.[51]
Fetalelectrocardiography
AnearlycommercialECGdevice
(1911)
Fetalelectrocardiographyrecordstheelectricalactivityofafetus,andwhenperformedasapartof
monitoringinchildbirth,involvesasingleelectrodebeingpassedthroughthewoman'scervixand
attachedtothebaby'sscalp.[52]AccordingtoaCochranereview,monitoringthefetususingECGplus
cardiotocography(CTG)resultedinfewerinstancesoffetalscalpbloodtestingandlesssurgical
assistancewiththebirth,comparedtoCTGalone.[52]Therewasnodifferenceinthenumberof
Caesareandeliveriesandlittletosuggestthebabieswereinbetterconditionatbirth.[52]
Seealso
Advancedcardiaclifesupport(ACLS)
Angiography
AutomatedECGinterpretation
Ballistocardiography
Bundlebranchblock
Cardiacstresstest
Cardiovasculartechnologist
EdgarHull
Electricalconductionsystemoftheheart
Electrogastrogram
Electropalatography
Electroretinography
Heartratemonitor
HEARTscan
Holtermonitor
Intrinsicoiddeflection
Magneticfieldimaging
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Magnetocardiography
RapidInterpretationofEKG's
Vectorcardiography
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Externallinks
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(https://www.dmoz.org/Health/Medicine/Medical_Specialties/Cardiology/Diagnostic_Tests/Electr
ocardiograms/)atDMOZ
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fromECGpedia(http://en.ecgpedia.org/wiki/Main_Page),awikiencyclopediaforacourseon
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