Definition

An electrocardiogram is used to monitor the heart. Each beat of the heart is triggered by
an electrical impulse normally generated from special cells in the upper right chamber of
the heart. An electrocardiogram also called an ECG or EKG records these
electrical signals as they travel through the heart.

The doctor will look for a consistent, even heart rhythm and a heart rate between 50 and
100 beats a minute. Having a faster, slower or irregular heartbeat provides clues about
heart health, including:

Heart rate. Normally, heart rate can be measured by checking the pulse rate. But an
ECG may be helpful if the pulse rate is difficult to feel or too fast or too irregular to
count accurately.
Heart rhythm. An ECG can help doctors identify an unusually fast heartbeat
(tachycardia), unusually slow heartbeat (bradycardia) or other heart rhythm
irregularities (arrhythmias). These conditions may occur when any part of the heart's
electrical system malfunctions. In other cases, medications, such as beta blockers,
psychotropic drugs or amphetamines, can trigger arrhythmias.
Heart attack. An ECG can often show evidence of a previous heart attack or one
that's in progress. The patterns on the ECG may indicate which part of the heart has
been damaged, as well as the extent of the damage.
Inadequate blood and oxygen supply to the heart. An ECG done while having
symptoms can help doctors determine whether chest pain is caused by reduced
blood flow to the heart muscle, such as with the chest pain of unstable angina.
Structural abnormalities. An ECG can provide clues about enlargement of the
chambers or walls of the heart, heart defects and other heart problems.
EKG Paper

ECG tracings are recorded on grid paper.

The horizontal axis of the EKG paper records time, with black marks at the top
indicating 3 second intervals.

Each second is marked by 5 large grid blocks. Thus each large block equals 0.2
second. The vertical axis records EKG amplitude (voltage).
Two large blocks equal 1 millivolt (mV). Each small block equals 0.1 mV.

Within the large blocks are 5 small blocks, each representing 0.04 seconds.
EKG Nomenclature
Normal EKG tracings consist of waveform components that indicate electrical events
during one heartbeat. These waveforms are labeled P, Q, R, S, T and U. The following
descriptions are with respect to Lead II.

P wave is the first deflection and is normally a positive (upward) waveform. It indicates
atrial depolarization.

QRS complex follows the P wave. It normally begins with a downward deflection, Q; a
larger upward deflection, R; and then a downward S wave. The QRS complex
represents ventricular depolarization and contraction.

T wave is normally a modest upward waveform, representing ventricular repolarization.

U wave indicates the recovery of the Purkinje conduction fibers. This wave component
may not be observable.
EKG Interpretation

EKG interpretation should be performed using a standard procedure. An eight step

procedure is usually used:

Rhythm : For ventricular rhythms, examine the R to R intervals on the EKG strip.
Calipers or paper marks can be used to fix the distance for one R-R interval and
then this distance can be compared to other R-R pairs.

Rate: There are several methods for determining heart rate. The first method is
simple. Count the number of QRS complexes over a 6 second interval. Multiply
by 10 to determine heart rate. This method works well for both regular and
irregular rhythms. In the first image, we can count 7 QRS complexes, so the
heart rate is 70.

The second method uses small boxes. Count the number of small boxes for a
typical R-R interval. Divide this number into 1500 to determine heart rate. In the
second image, the number of small boxes for the R-R interval is 22.5. The heart
rate is 1500/21.5, which is 69.8.
 P Wave: The P wave represents atrial depolarization. In a normal EKG, the P-
wave precedes the QRS complex. It looks like a small bump upwards from the
baseline. The amplitude is normally 0.05 to 0.25mV (0.5 to 2.5 small boxes).
Normal duration is 0.06-0.11 seconds (1.5 to 2.75 small boxes). The shape of a
P-wave is usually smooth and rounded.

P-wave questions:

o Are they present?

o Do they occur regularly?

o Is there one P-wave for each QRS complex?

o Are the P-Waves smooth, rounded, and upright?

o Do all P-Waves have similar shapes?

PR Interval: The PR Interval indicates AV conduction time.

In this step one should measure the interval from where the P wave begins until
the beginning of the QRS complex. Calipers, marked paper or counting small
boxes methods can be used to determine PR Intervals. Normally this interval is
0.12 to 0.20 seconds (3 to 5 small boxes) in adults, longer in elderly people. This
interval shortens with increased heart rate.

Also evaluate if PR Intervals are constant or varying across the EKG strip. If they
vary, determine if the variations are a steady lengthening until the point where an
expected QRS does not appear.
PR Interval questions to address:

o Does the PR-Interval fall within the norm of 0.12-0.20 seconds?

o Is the PR-Interval constant across the ECG tracing?

QRS Complex/ Interval: The QRS complex indicates ventricular depolarization.

Depolarization triggers contraction of the ventricles.

Because of the larger tissue mass, the QRS complex is larger than the P wave.
While the prototypical QRS complex consists of three wave components, one or
two of these components may be missing.

In this step, measure the QRS interval from the end of the PR interval to the end
of the S wave. Use calipers, marking paper or by counting small boxes. Normally
this interval is 0.06 to 0.12 seconds (1.5 to 3 boxes).

QRS questions:

o Does the QRS interval fall within the range of 0.08-0.12 seconds?

o Are the QRS complexes similar in appearance across the ECG tracing?
 T Wave: The T wave indicates the repolarization of the ventricles. It is a slightly
asymmetrical waveform that follows (after a pause), the QRS complex. Take note
of T waves that have a downward (negative) deflection or of T waves with tall,
pointed peaks.

The U-wave is a small upright, rounded bump. When observed, it follows the T-
wave.

QT Interval: The QT interval represents the time of ventricular activity including

both depolarization and repolarization.

It is measured from the beginning of the QRS complex to the end of the T wave.
Normally, the QT interval is 0.36 to 0.44 seconds (9-11 boxes). The QT interval
will vary with patient gender, age and heart rate. Another guideline is that normal
QT Intervals is less than half of the R-R Interval for heart rates below 100 bpm.
 ST Segment: The ST segment represents the early part of ventricular
repolarization.

The ST segment is the line that from the end of the QRS complex to beginning of
the T wave. Normally the ST segment is flat relative to the baseline.
 Conduction system

The Cardiac Conduction System

The pumping action of the heart (heartbeat) is controlled by the hearts electrical
system or the cardiac conduction system. This is a group of specialized
cells located in the wall of the heart which send electrical impulses to the cardiac
muscle causing it to contract.

The cardiac conduction system comprises of the:

1. Sinoatrial (SA) node

2. Atrioventricular (AV) node
3. Bundle of His
4. Bundle branches
5. Purkinje fibres

Contractions in the heart begin when electrical impulses are sent from the SA
node (also known as the natural pacemaker) which is located in the right atrium. The
impulse from the SA node causes the atria to contract, pushing blood through the open
valves into the ventricles. The electric signal arrives at the AV node which is located
between the two atria. From here it travels through the bundle of His, divides into the left
and right bundle branches and through the Purkinje fibres. This causes the ventricles to
contract. Both ventricles do not contract at precisely the same time, the left ventricle
contracts slightly before the right. When the ventricles contract blood from the right
ventricle is pumped through the pulmonary valves and onto the lungs, blood from the
left ventricle is pumped through the aortic valves and onto the rest of the body. After
contraction the ventricles relax, and wait for the next electric impulse. The atria fill with
blood and an impulse from the SA node starts the cycle over again.

The electrical impulses caused by the hearts activity can be observed on a graph called
an electrocardiogram (ECG), this is a good way to monitor the hearts cardiac
conduction system and is especially used to detect any abnormalities.