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ELECTROCARDIOGRAPHY AND ECHOCARDIOGRAPHY

Fadillah Nur Herbuono 030.06.085

Medical Faculty of Trisakti University Jakarta 2010

PREFACE

This paper, titled Electrocardiography And Echocardiography, I arranged in order to complete my English assignment for subject medical English 3 in the faculty of medicine, trisakti university. I arrange this paper so simple in order to make these topics easier. I hope this papers topics is compatible and can give the information which needed by friends or everybody as medical student and physicians both here and abroad. I realized that this paper is too far from perfect, but I have tried to arrange this paper to be good enough for us as medical student. I hope all the readers who had read this paper will continue to find all of things about these topics. So their knowledge didnt come only from this paper, but all the information from the other sources. With this time, I would like to say thank you to my teacher, DR. Dr. H. Ardiyan Boer, Sm. Hk. who taught and helped, my friends, and everybody who helped and inspiring me during the process of making this paper so I can finished this paper. Finally I hope this paper can be useable for us.

Thank you

ABSTRACT

Electrocardiography and Echocardiography are diagnostic tool that very useful for determining whether a person has heart disease. The electrocardiogram (ECG or EKG) is a diagnostic tool that measures and records the electrical activity of the heart in exquisite detail, gives a graphic recording of the electric forces generated by the heart during depolarization and repolarization. Interpretation of these details allows diagnosis of a wide range of heart conditions. These conditions can vary from minor to life threatening. And Echocardiography is a unique noninvasive method for imaging the living heart, to create a moving picture of the heart, to make images of the heart chambers, valves and surrounding structures. It is based on detection of echoes produced by a beam of ultrasound (very high frequency sound) pulses transmitted into the heart.

INTRODUCTION
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The electrocardiogram (ECG or EKG) is a diagnostic tool that measures and records the electrical activity of the heart in exquisite detail. Interpretation of these details allows diagnosis of a wide range of heart conditions. These conditions can vary from minor to life threatening. The term electrocardiogram was introduced by Willem Einthoven in 1893 at a meeting of the Dutch Medical Society. In 1924, Einthoven received the Nobel Prize for his life's work in developing the ECG. The ECG has evolved over the years.

The standard 12-lead ECG that is used throughout the world was introduced in 1942. It is called a 12-lead ECG because it examines the electrical activity of the heart from 12 points of view.

This is necessary because no single point (or even 2 or 3 points of view) provides a complete picture of what is going on.

To fully understand how an ECG reveals useful information about the condition of your heart requires a basic understanding of the anatomy (that is, the structure) and physiology (that is, the function) of the heart.

And Echocardiography is a unique non-invasive method for imaging the living heart. It is based on detection of echoes produced by a beam of ultrasound (very high frequency sound) pulses transmitted into the heart. From its introduction in 1954 to the mid 1970's, most echocardiographic studies employed a technique called M-mode, in which the ultrasound beam is aimed manually at selected cardiac structures to give a graphic recording of their positions and movements. M-mode recordings
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permit measurement of cardiac dimensions and detailed analysis of complex motion patterns depending on transducer angulation. They also facilitate analysis of time relationships with other physiological variables such as ECG, heart sounds, and pulse tracings, which can be recorded simultaneously. A more recent development uses electromechanical or electronic techniques to scan the ultrasound beam rapidly across the heart to produce two-dimensional tomographic images of selected cardiac sections. This gives more information than M-mode about the shape of the heart and also shows the spatial relationships of its structures during the cardiac cycle. A comprehensive echocardiographic examination, utilizing both M-mode and two dimensional recordings, therefore provides a great deal of information about cardiac anatomy and physiology, the clinical value of which has established echocardiography as a major diagnostic tool. This unit covers the principles of two-dimensional echocardiography in more detail; it explains the normal two-dimensional recordings in terms of the anatomy of the cardiac sections scanned by the ultrasound beam. Some supplementary M-mode recordings are included. Subsequent units will discuss applications of both M-mode and two-dimensional echocardiography in acquired and congenital disease.

References Review

I. ELECTROCARDIOGRAPHY (ECG)

Definition(1) A galvanometer and electrodes with six limb leads and six chest leads. Gives a graphic recording of the electric forces generated by the heart during depolarization and repolarization. The electrocardiogram is recorded on graph paper with divisions.

Terminology(1) - Depolarization: Electrical activation of the myocardium. - Repolarization: Restoration of the electrical potential of the myocardial cell. - P wave: ECG deflection representing atrial depolarization. Atrial repolarization occurs during ventricular depolarization and is obscured. - QRS wave: ECG deflection representing ventricular depolarization. - T wave: ECG defection representing ventricular repolarization.
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- Normal R Wave Progression: Vl Consists of a small R wave and a large S wave, whereas V6 consists of a small Q wave and a large R wave. Since V3 and V4 are located midway between Vl and V6, the QRS complex would be expected to be nearly isoelectric in one of these leads; i.e., the positive and negative deflections will be about equal.

Sequence Depolarization occurs in the sinoatrial (SA) node. Current travels through internodal tracts of the atria to the atrioventricular (AV) node. Then through Bundle of His, which divides into right and left bundle branches. Left bundle branch divides into left anterior and posterior fascicles.

ECG Electrodes(1) Two arrangements, bipolar and unipolar leads.


1. Bipolar Lead:

One in which the electrical activity at one electrode is compared with that of another. By convention, a positive electrode is one in which the ECG records a positive (upward) deflection when the electrical impulse flows toward it and a negative (downward) deflection when it flows away from it.
2. Unipolar Lead:

One in which the electrical potential at an exploring electrode is compared to a reference point that averages electrical activity, rather than to that of another electrode. This single electrode, termed the exploring electrode, is the positive electrode. Limb Leads: I, II, III, aVR, aVL, aVF explore the electrical activity in the heart in a frontal plane; i.e., the orientation of the heart seen when looking directly at the anterior chest. Standard Limb Leads: I, II, III; bipolar, form a set of axes 60 apart Lead I: Composed of negative electrode on the right arm and positive electrode on the left arm. Lead II: Composed of negative electrode on the right arm and positive electrode on the left leg. Lead III: Composed of negative electrode on the left arm and positive electrode on the left leg. Augmented Voltage Leads: aVR, aVL aVF; unipolar ; form a set of axes 60 apart but are rotated 30 from the axes of the standard limb leads. aVR: Exploring electrode located at the right shoulder.

aVL: Exploring electrode located at the left shoulder. aVF: Exploring electrode located at the left foot. Reference Point for Augmented Leads: The opposing standard limb lead; i.e., that standard limb lead whose axis is perpendicular to the particular augmented lead. Chest Leads: Vl, V2, V3, V4, V5, V6, explore the electrical activity of the heart in the horizontal plane; i.e., as if looking down on a cross section of the body at the level of the heart. These are exploring leads. Reference Point for Chest Leads: The point obtained by connecting the left arm, right arm, and left leg electrodes together. Vl: Positioned in the 4th intercostal space just to the right of the sternum. V2: Positioned in the 4th intercostal space just to the left of the sternum. V3: Positioned halfway between V2 and V4. V4: Positioned at the 5th intercostal space in the mid-clavicular line. V5: Positioned in the anterior axillary line at the same level as V4. V6: Positioned in the mid axillary line at the same level as V4 and V5.

Vl and V2*: Monitor electrical activity of the heart from the anterior aspect, septum, and right ventricle. V3 and V4*: Monitor electrical activity of the heart from the anterior aspect. V5 and V6*: Monitor electrical activity of the heart from the left ventricle and lateral aspect.

Rhythms(8) The normal rhythms of the heart known as Sinus Rhythm. The criteria for a Normal Sinus Rhythm is:

P-wave before each QRS with an interval of 0.12 to 0.20 seconds in duration. A QRS width of 0.04 to 0.12 seconds Q-T interval of less the 0.40 seconds. The rate for a normal sinus rhythm is 60 to 100 beats a minute

If the rate is below 60 beats a minute but the rest is the same it is a Sinus Bradycardia. If the rate is between 100 to 150 beats a minute with the same intervals it is a Sinus Tachycardia. When the pattern becomes irregular with normal intervals it is a Sinus Arrhythmia

Normal ECG(1)

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Pulse rate lies between 60 and 100 beats/minute Rhythm is regular except for minor variations with respiration. P-R interval is the time required for completion of aerial depolarization; conduction through the AV note, bundle of His, and bundle branches; and arrival at the ventricular myocardial cells. The normal P-R interval is 0 12 to 0.20 seconds.

The QRS interval represents the time required for ventricular cells to depolarize. The normal duration is 0.06 to 0.10 seconds.

The Q-T interval is the time required for depolarization and repolarization of the ventricles.

The time required is proportional to the heart rate. The faster the heart rate, the faster the repolarization, and therefore the shorter the Q-T interval. With slow heart rates, the Q-T interval is longer. The Q-T interval represents about 40% of the total time between the QRS

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complexes (the R-R interval). In most cases, the Q-T interval lasts between 0.34 and 0.42 seconds. Dimensions of Grids on ECG Paper: Horizontal axis represents time. Large blocks are 0.2 seconds in duration, while small blocks are 0.04 seconds in duration. Vertical axis represents voltage. Large blocks are 5mm, while small blocks represent 1mm.

Indication(6) An ECG is used to measure:


Any damage to the heart How fast your heart is beating and whether it is beating normally The effects of drugs or devices used to control the heart (such as a pacemaker) The size and position of your heart chambers

An ECG is a very useful tool for determining whether a person has heart disease. Your doctor may order this test if you have chest pain or palpitations. An ECG may be included as part of a routine examination in patients over age 40.

Caution(6) Make sure your health care provider knows about all the medications you are taking, as some can interfere with test results.
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Exercising or drinking cold water immediately before an ECG may cause false results.

Risks(6) There are no risks. No electricity is sent through the body, so there is no risk of shock.

Preparation(6) You will be asked to remove your clothes, then you will be asked to lie down. The health care provider will clean several areas on your arms, legs, and chest, and then attach small patches called electrodes to the areas. It may be necessary to shave or clip some hair so the electrodes stick to the skin. The electrodes may feel cold when first applied. In rare cases, some people may develop a rash or irritation where the patches were placed. The number of patches used may vary. You usually need to remain still, and you may be asked to hold your breath for short periods during the procedure. It is important to be relaxed and relatively warm during ECG recording. Any movement, including muscle tremors such as shivering, can alter the results. The electrodes are connected by wires to a machine that converts the electrical signals from the heart into wavy lines, which are printed on paper and reviewed by the doctor. Sometimes this test is done while you are exercising or under minimal stress to monitor changes in the heart. This type of ECG is often called a stress test.
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Results on ECG(6) - Normal Results


Heart rate: 50 to 100 beats per minute Heart rhythm: consistent and even

- Abnormal Results Abnormal ECG results may be a sign of


Abnormal heart rhythms (arrhythmias) Cardiac muscle defect Congenital heart defect Coronary artery disease Ectopic heartbeat Enlargement of the heart Faster-than-normal heart rate (tachycardia) Heart valve disease Inflammation of the heart (myocarditis) Changes in the amount of electrolytes (chemicals in the blood) Past heart attack Present or impending heart attack Slower-than-normal heart rate (bradycardia)

Additional conditions under which the test may be performed include the following:

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Alcoholic cardiomyopathy Anorexia nervosa Aortic dissection Aortic insufficiency Aortic stenosis Atrial fibrillation/flutter Atrial myxoma Atrial septal defect Cardiac tamponade Coarctation of the aorta Complicated alcohol abstinence (delirium tremens)

Insomnia Ischemic cardiomyopathy Left-sided heart failure Lyme disease Mitral regurgitation; acute Mitral regurgitation; chronic Mitral stenosis Mitral valve prolapse Multifocal atrial tachycardia Narcolepsy Obstructive sleep apnea Paroxysmal supraventricular tachycardia

Coronary artery spasm Digitalis toxicity Dilated cardiomyopathy Drug-induced lupus erythematosus Familial periodic paralysis Guillain-Barre Heart failure Hyperkalemia Hypertensive heart disease Hypertrophic cardiomyopathy Hypoparathyroidism Idiopathic cardiomyopathy Infective endocarditis

Patent ductus arteriosus Pericarditis


o o o

Bacterial pericarditis Constrictive pericarditis Post-MI pericarditis

Peripartum cardiomyopathy Primary amyloid Primary hyperaldosteronism Primary hyperparathyroidism Primary pulmonary hypertension Pulmonary embolus Pulmonary valve stenosis
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Restrictive cardiomyopathy Right-sided heart failure Sick sinus syndrome Stable angina Stroke Systemic lupus erythematosus Tetralogy of Fallot Thyrotoxic periodic paralysis Transient ischemic attack (TIA)

Transposition of the great vessels Tricuspid regurgitation Type 1 diabetes Type 2 diabetes Unstable angina Ventricular septal defect Ventricular tachycardia Wolff-Parkinson-White syndrome

II. ECHOCARDIOGRAPHY Definition(10,11) Echocardiography is a diagnostic test which uses ultrasound waves to create a moving picture of the heart, to make images of the heart chambers, valves and surrounding structures. It can measure cardiac output and is a sensitive test for inflammation around the heart (pericarditis). It can also be used to detect abnormal anatomy or infections of the heart valves. The picture is much more detailed than a plain x-ray image and involves no radiation exposure. Echo can be used as part of a stress test and with an electrocardiogram (ECG) to help your doctor learn more about your heart.

Types(13)

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The different types of echocardiograms are:

Transthoracic echocardiogram (TTE). This is the most common type. Views of the heart are obtained by moving the transducer to different locations on your chest or abdominal wall.

Stress echocardiogram. During this test, an echocardiogram is done both before and after your heart is stressed either by having you exercise or by injecting a medicine that makes your heart beat harder and faster. A stress echocardiogram is usually done to find out if you might have decreased blood flow to your heart (coronary artery disease, or CAD).

Doppler echocardiogram. This test is used to look at how blood flows through the heart chambers, heart valves, and blood vessels. The movement of the blood reflects sound waves to a transducer. The ultrasound computer then measures the direction and speed of the blood flowing through your heart and blood vessels. Doppler measurements may be displayed in black and white or in color.

Transesophageal echocardiogram (TEE). For this test, the probe is passed down the esophagus instead of being moved over the outside of the chest wall. TEE shows clearer pictures of your heart, because the probe is located closer to the heart and because the lungs and bones of the chest wall do not block the sound waves produced by the probe. A sedative and an anesthetic applied to the throat are used to make you comfortable during this test.

Indication(11) This test is performed to evaluate the valves and chambers of the heart in a noninvasive way. The echocardiogram allows doctors to diagnose, evaluate, and monitor:
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Heart murmurs Abnormal heart valves The pumping function of the heart for people with heart failure Damage to the heart muscle in patients who have had heart attacks Infection in the sac around the heart (pericarditis) Infection on or around the heart valves (infectious endocarditis) The source of a blood clot or emboli after a stroke or TIA Congenital heart disease Atrial fibrillation Pulmonary hypertension

Risks(11) There are no known risks associated with this test.

Preparation(11) You will be asked to remove your clothes from the waist up and lie on an examination table on your back. Electrodes will be placed on your chest to allow for an echo to be done. A gel will be spread on your chest and then the transducer will be applied. You will feel a slight pressure on your chest from the transducer. You may be asked to breathe in a certain way or to roll over onto your left side. A trained sonographer performs the test, then your heart doctor interprets the results. An instrument called a transducer that transmits high-frequency sound waves is placed on your ribs near the breast bone and directed toward the heart. Additional images will be taken underneath and slightly to the left of your nipple (at the apex of your heart). The transducer picks up the echoes of the sound waves and transmits them as

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electrical impulses. The echocardiography machine converts these impulses into moving pictures of the heart. The Doppler probe records the motion of the blood through the heart. An echocardiogram allows doctors to see the heart beating, and to see many of the structures of the heart. Occasionally, your lungs, ribs, or body tissue may prevent the sound waves and echoes from providing a clear picture of heart function. If so, the sonographer may inject a small amount of liquid (contrast) through an IV to better see the inside of the heart. Very rarely, more invasive testing using special echocardiography probes may be necessary. Your health care provider may choose to perform a TEE:

If the regular or transthoracic echocardiogram is unclear due to a barrel chest, lung disease, or obesity

If a much clearer picture is needed of a certain area

With TEE, the back of your throat is numbed and a scope is inserted down your throat. On the end of the scope is an ultrasonic device that an experienced technician will guide down to the lower part of the esophagus. It is used to obtain a more clear two-dimensional echocardiogram of your heart.

Results on Echocardiography(11) - Normal Results A normal echocardiogram reveals normal heart valves and chambers and normal heart wall movement.

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- Abnormal Results An abnormal echocardiogram can mean many things. Some abnormalities are very minor and do not pose significant risks. Other abnormalities are signs of very serious heart disease that will require further evaluation by a specialist. Therefore, it is very important to discuss the results of your echocardiogram in depth with your health care provider. Abnormal results may indicate heart valve disease, cardiomyopathy, pericardial effusion, or other heart abnormalities. This test may also be performed for the following conditions:

Alcoholic cardiomyopathy Aortic dissection Aortic insufficiency Aortic stenosis Arrhythmias Arterial embolism Atrial fibrillation/flutter Atrial myxoma Atrial septal defect Cardiac tamponade Cardiomyopathy Coarctation of the aorta Heart attack Heart failure Hypertensive heart disease Mitral regurgitation; acute Mitral regurgitation; chronic Mitral stenosis Mitral valve prolapse

Patent ductus arteriosus Pericarditis; bacterial Pericarditis; constrictive Pericarditis; post-MI Peripartum cardiomyopathy Primary amyloidosis Pulmonary arterial hypertension Pulmonary valve stenosis Restrictive cardiomyopathy Right-sided heart failure Secondary systemic amyloidosis Senile cardiac amyloidosis Stroke Tetralogy of Fallot Transient ischemic attack (TIA) Transposition of the great vessels Tricuspid regurgitation Ventricular septal defect

Conclusion Both electrocardiography and echocardiography are very useful to help the doctors diagnose problems on their patients heart. Its use for each indication. Altough both of them
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already passed many year but those two are still very often used to help to diagnose besides interview, physical examination and the, laboratory finding.

References

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1. R. Richter, MD. Basic Electrocardiography. Available at :

http://www.sh.lsuhsc.edu/fammed/OutpatientManual/BasicECG.htm . Accessed July 3, 2010. 2. Dubin, Dale: Rapid Interpretation of EKGs, Third Edition. Cover Publishing Company, Tampa, FL, 1981. 3. Grauer, Ken: 12 Lead EKGs A Pocket Brain for Easy Interpretation. KG/EKG Press, Gainsville, FL. 4. Marriott, Henry JL: Practical Electrocardiography, Sixth Edition. Waverly Press, Inc, Baltimore, MD. 1981. 5. Milhorn, Jr., HT: Electrocardiology for the Family Physician: Parts 1-5. Family Practice Recertification. Vol 5, Nos 2,3,4,5 & 6. Months Feb, Mar, Apr, May & June, respectively, 1983. 6. Basic ECG. Available at www.nlm.nih.gov/medlineplus/ency/article/003868.htm . Accessed July 11, 2010. 7. Ganz L, Curtiss E. Electrocardiography. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 52. 8. Aaron Segel. Sinus Rhythms. Available at http://www.drsegal.com/medstud/ecg/Sinus.htm . Accessed July 11, 2010. 9. Definition of Echocardiography. Available at http://www.emedicinehealth.com/script/main/art.asp?articlekey=3182 . Accessed July 11, 2010. 10. Echocardiography. Available at

http://www.nhlbi.nih.gov/health/dci/Diseases/echo/echo_whatis.html . Accessed July 11, 2010.

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11.

Echocardiography. Available at

http://www.nlm.nih.gov/medlineplus/ency/article/003869.htm . Accessed July 11, 2010. 12. Connolly HM, Oh JK. Echocardiography. In: Libby P, Bonow RO, Mann DL,

Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, Pa: Saunders Elsevier;2007: chap 14. 13. Echocardiogram. Available at http://www.webmd.com/heart-

disease/echocardiogram . Accessed July 11, 2010.

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