ECG : Analysis & Interpretation

Steps : 1. Heart rate 2. Heart rhythm - check for deviation from normal in terms of origin (automaticity) or sequence (conductivity) of heart action. - check whether it is occasional, frequent, continuous, regular or irregular, repetitive or occurring with many combinations. 3. Measure complexes and intervals. 4. Evaluate the waveform morphology. 5. Determine MEA - vector always point towards hypertrophy but away from infarcted areas. - more reliable in narrow-chested animals/breeds.

ECG : Normal Canine Parameters

ECG : Normal Feline Parameters

ECG : MEA
MEA indicates average direction of the electrical activation signals in the heart during a cardiac cycle. Three methods : 1. Using isoelectric leads. 2. Looking for strongest QRS deflections. 3. Calculating from Lead I and Lead III. - MEA should be interpreted with evidences from other leads or other clinical evidences, can be very tricky in broad-chested animals and cats. - MEA depends on muscle mass and not the thickness of the myocardial wall. A dog with dilated cardiomyopathy may not necessary show abnormal MEA.

ECG : MEA

ECG : MEA

ECG : MEA

ECG : MEA

Waveforms and PQRST deflections

Abnormalities of the atrium, ventricle and their associated conduction systems will be evident on the ECG. Atrial abnomalities look at P wave (morphology, amplitude + duration) Ventricular abnormalities QRS complexes (esp S and Q), precordial leads, deviation from normal MEA Conduction abnormalities delayed or oddly defined intervals, abnormal amplitudes, abnormal wave patterns seen in precordial leads, e.g. W wave (Lead V10) in right bundle branch block is quite diagnostic.

Waveforms and PQRST deflections

As a general rule (AGAIN).a quick but not absolutely reliable guide !
P relates to atrial problems QRS ventricular or conduction problems R left ventricular problems S right ventricular problems PR conduction through the AV bundle ST period during the repolarization of the ventricles. Typically associated with electrolytes

Students MUST KNOW the following ECG signatures

-Atrial enlargements -Ventricular enlargements -AV Blocks (1st , 2nd and 3rd degree)

Right Atrial Enlargement

Characterised by Tall P waves (>0.4mv dogs / 0.2 mv in cats) P wave can be very tall, slender and peaked (P pulmonale) especially in chronic pulmonary disease. Associated with Chronic respiratory disease (blockade/collapsed trachea) or congenital defects (Interatrial SD)

Right Atrial Enlargement

Left Atrial Enlargement

Characterised by Long P duration Notched and wide P wave. Notching itself is not necessarily abnormal. Associated with Mitral valvular disease or congenital defects (aortic stenosis, also seen in VSD and PDA)

Left Atrial Enlargement

Biatrial Enlargement
Characterised by Long P duration and very tall P wave. Notching is frequent. Associated with Chronic Tricuspid or Mitral valvular disease or various congenital heart defects

Biatrial Enlargement

Right Ventricular Enlargement

Characterised by Right axis deviation Large S waves in I, II, III and aVF and probably Q waves as well. Positive T wave in lead V10 Associated with Congestive Heart Failure (as in severe dirofilariasis), mitral or tricuspid valve insufficiency, acute cor pulmonale due to pulmonary embolism (as a result of heartworm treatment) and various congenital heart defects (Tetralogy of Fallot)

Right Ventricular Enlargement

Right Ventricular Enlargement

Left Ventricular Enlargement

Characterised by Left axis deviation Large QRS complexes in lead II and aVF, tall R and T (25 %) waves Coving or depressed S-T segment (aka endocardial ischaemic change) Associated with Eccentric hypertrophy secondary to volume overload (mitral insufficiency, VSD, PDA), Concentric hypertrophy secondary to pressure overload (aortic stenosis), dilated cardiomyopathy

Left Ventricular Enlargement

Left Ventricular Enlargement

Bi-Ventricular Enlargement
This condition is more difficult to determine accurately but oftentimes the diagnosis of left ventricular enlargement is more accurate. This is because left ventricular forces can easily counteract any increased forces from the right (remember ECG is dependent on volume and mass) Characterised by Large QRS complexes, tall S and R waves Deep Q waves quite characteristic of biventricular enlargements Evidences of right and left atrial enlargements Associated with Mitral and tricuspid valve insufficiency, dilated cardiomyopathy, PDA and mitral insufficiency

Bi-Ventricular Enlargement

Bi-Ventricular Enlargement

The following ECG findings are important, but I will leave it to the students to determine their usefulness in routine clinical analysis.

Low Voltage QRS complexes

The amplitude and voltage of a normal QRS complex is dependent on breed, age and size of the dog. Generally low voltage QRS is suggestive of the following conditions : artifact (signal/response calibration required ?) obesity ? pericardial effusion severe myocardial damage severe MI, loss of muscle mass pulmonary disease (pulmonary edema, pneumonia) pleural effusion pneumothorax ALWAYS CONSIDER THEM AS ARTIFACTS FIRST BEFORE DECIDING ANYTHING FURTHER!

Low Voltage QRS complexes

Intervals and segments

S-T segment (depressed or elevated)
Normally the ST segment is isoelectric because the cells are almost equally depolarised and there is no driving force for current to flow from one region of the heart to another. An exception is when part of the heart is ischaemic: then there can be ST segment depression or elevation. wandering baseline ? Pseudodepression due to tachycardia (as a result of prominent Ta wave) depression with prominent R wave indicates myocardial ischaemia, hyperkalemia/hypokalemia, subendocardial MI. elevation with prominent R wave indicates MI of the entire thickness of the left ventricle, pericarditis

Q-T interval (prolonged or shortened) not so important in vet. med. Prolonged hypocalcemia (hypoparathyroidism, eclampsia), hypokalemia, ethylene
glycol poisoning, hypothermia Shortened hyperkalemia, hepercalcemia

Intervals and segments

S-T segment represents the early phase of ventricular repolarisation

Intervals and segments

Q-T interval is the summation of ventricular depolarization and repolarization, and represents ventricular systole

Students MUST KNOW the following ECG signatures

-Sinus Rhythm -Important Sinus Arrhythmias -AV Blocks (1st , 2nd and 3rd degree) -APCs and VPCs - and may be WPW syndrome

Rhythms and Arrhythmias

Rhythms and arrhythmias can be summarised into 4 categories according to their origin (sinus, junctional and ventricular) and causes (impulse formation and conduction): 1.Sinus normal sinus rhythm, sinus tachycardia, sinus bradycardia, wandering sinus pace maker. 2.Abnormalities of impulse formation Sinus arrest, APC, atrial tachycardia, atrial fibrillation, AV junctional escape rhythm, VPC, ventricular tachycardia, ventricular escape rhythm. 3.Abnormalities of impulse conduction SA block, atrial standstill, AV block (first degree, second degree, third degree or complete heart block). 4.Abnormalities of both impulse conduction and formation.
Escape rhythm happens when the pacemaker with the highest automaticity changes its firing pace and had to be rescued by the other pacemaker.

Arrhythmias
Classification of rhythms : A.Normal sinus impulse formation - normal sinus rhyhm - sinus arrhythmia B.Disturbances of sinus impulse formation - sinus bradycardia - sinus tachycardia C.Disturbances of ventricular impulse formation - ventricular premature complexes - ventricular tachycardia - ventricular asystole - ventricular fibrillation

Arrhythmias
D.Disturbances of impulse conduction : - sinus arrest or block - sick sinus syndrome - atrial standstill - ventricular pre-excitation - 1st degree AV block - 2nd degree AV block - 3rd degree AV block - Left bundle branch block - Right bundle branch block Arrhythmias = abnormality in rate, regularity or site of origin of the cardiac impulse OR a disturbance in conduction of impulse that the normal sequence of activation of the atria and ventricle is altered.

Arrhythmias
There are three different sites of origin for arrythmias, they can be identified based on the morphology of P wave and QRS complexes : a.)Atrial (sinus) P wave is +ve and present, constant P-R interval and normal duration QRS. b.)Junctional P wave absent or ve, normal or short duration QRS. May occur with BBB which causes poor morphology and prolonged duration on the QRS. c.)Ventricular P waves absent (may even be superimposed on QRS). QRS wide and bizarre and may be +ve (left) of ve (right) depending on which ventricle is the site of origin.

Arrhythmias
The automaticity (ability to initiate impulse) of the site further describe the arrythmia by being : i.too fast (tachycardia) ii.too slow (bradycardia) iii.too irritable (premature) iv.not irritable (block)

Sinus bradycardia
Defined as heart rate < 120 (cats), < 70 (dogs) or < 60 (large dogs). Associated with : physiologic changes intubation, vomiting, hypothermia, elevated intracranial pressure, hypothyroidism, good conditioning. pathological systemic disease with toxicity (renal failure), hyperkalemia, cardiac arrest.
Physiologic sinus arrthymia arise due to waxing and waning of vagal tone during normal respiration. During inspiration the vagal tone of the heart will be suppressed rendering brief s. tachycardia, this becomes s.bradycardia or normal pace when the respiratory system relaxes activation of vagal tone.

Sinus Tachycardia
Defined as heart rate > 240 (cats), > 140 (dogs) or > 120 (large dogs), > 180 (toy breeds), > 220 (puppies). Associated with : physiologic changes exercise, pain or restraint. pathological fever, hyperthyroidism, shock, anaemia, CHF, hypoxia.

Wandering sinus pacemaker

Characterised by changing gradual change in P wave morphology (gradually appearing or dissapearing), common in dogs. However, both QRS and P-R durations are not affected. No specific treatment is required.

Atrial Premature Complexes

Caused by supraventricular impulses originating from an ectopic atrial site (not SA node). The ectopic site arise as a result of increase automaticity of the atrial myocardial fibres / single reentrant circuit. Important feature P waves touches T waves of previous beat and resets the SA node therefore there should be a brief pause after the APC. Associated with atrial enlargement, cardiomyopathy, mitral insufficiency. APC may be hard to spot, may gives rise to atrial tachycardia or even atrial fibrillation.

Atrial Premature Complexes

Atrial Tachycardia
Rapid regular rhythm arising from atrial sites other than the SA node. 3 or more APC = Atrial tachycardia Characteristics : Tachycardia, prolonged or normal P-R interval (depending on the origins of the ectopic site). QRS = normal, but P wave have unusual configuration.

Atrial Fibrillation
Caused by numerous disorganised atrial impulses bombarding the AV node. Af causes rapid and totally irregular atrial and ventricular rate. Ventricular rate becomes irregular as few fibrillatory waves managed to be condcuted through the AV junction to the ventricles. Hallmark of AF = absence of P waves replaced by oscillations of f waves. A.k.a. saw-tooth waves. In dogs and cats, the QRS may still be evident albeit differing in amplitudes. In ungulate where the Purkinje fibres penetrate deep into the myocardium, the f waves and QRS superimposed on each other. Associated with atrial enlargement, early signs of DCM (dilated cardiomyopathy) or DCM itself. Toxicity. AF may even occur without any evident cardiac disease.

Atrial Fibrillation

Ventricular Premature Complexes (VPC)

Cause by impulses generated within the ventricles, instead of the SA Node. VPC is an important condition associated with weakness, syncope, exercise intolerance and sudden death. Characterised by wide and bizarre QRS, dissociated P waves. VPC usually followed by a quiet compensatory pause. Associated with cardiomyopathies (large dogs / cats), hyperthyroidism (cats), congenital defects (aortic stenosis), chronic valve disease, traumatic myocarditis, digitalis toxicity, myocarditis, cardiac neoplasia.

Ventricular Premature Complexes (VPC)

Ventricular Premature Complexes (VPC)

This dog had Ventricular Bigeminy a condition where VPCs and normal PQRST complexes are occuring at a fixed interval. In this case it is a Uniform VB as the ectopic pacemaker that gave rise to the VPC is stationary. VB may be seen in PDAs and rarely during thiopentone anaesthesia

Ventricular Tachycardia
The result of 3 or more VPCs. Characterised by ventricular rate > 150 bpm. No relation ship between P and QRS. There will be ventricular fusion and capture complexes (with P waves). Uncommon in cats.

Ventricular Asystole
You see this in dying animals ! A medical emergency because this condition indicates absence of pacemaker impulses. No pulse can be detected and CO may be = 0. Indicated by absence of QRS complex. P waves may be present if the animal has complete AV block.

Ventricular Fibrillation
Occurs when cells of the ventricular myocardium depolarise in a chaotic and uncoordinated manner. No pulse can be felt and Co is 0. Characterised by rapid, irregular rhythm with bizarre waves and oscillations (large = coarse fibrillation easier to treat; small = fine fibrillation req epinephrine to convert them into coarse fibrillation first before attempting any treatment). Associated with shock, anoxia, trauma, myocardial infarction, electrolyte and acid imbalances, anaesthetic reactions, digitalis toxicity, electric shock, myocarditis, hypothermia. Requires agrresive therapy. Electric cardioversion is often instituted immediately (remember the defibrillator ?) , alternatively a precordial thump may be helpful (although it may not work most of the time).

Ventricular Fibrillation

Sinus Block
Occasional failure of SA node to initiate an impulse, as a result no heart beat can be detected. No ventricular escape rhythms ! Prolonged pauses usually results in low CO An incidental finding in brachycephalic breed dogs, hereditory stenosis of the AV bundle (esp in pure breeds). Associated with elctrolyte imbalance, intense vagal stimulation, drug toxicity (digitalis, quinidine).Treatment is not really recommended if animal is asymptomatic.

Atrial standstill (associated primarily with Hyperkalemia)

Absence of P waves (in all leads) associated with supraventricular-type QRS. Low heart rate (<60 bpm which is AV nodes rhythm pace) Conditions can be temporary (due to hyperkalemia, drugs) or terminal (severe hyperkalemia (e.g. urethral obstruction in cats), severe atrial myopathy). Atrial myopathy is most common in English Springer spaniels, mostly young animals with skeletal muscle involvement.

Wolff-Parkinson-White Syndrome (WPW)

WPW syndrome consists of ventricular pre-excitation with paroxysmal supraventricular tachycardia. Ventricular pre-excitation occurs when impulses originating from the SA node or atrium activate a portion of ventricle prematurely through the AV node. The remainder of the ventricle is still activated normally through the usual conduction system. Charaterized by normal P waves, normal rhythm, short P-R interval, widened QRS (often with slurring or notching of the upstroke of the R wave = delta wave) or even bizarre looking QRS. Heart rate may be very high (dog > 300 bpm, cats > 400 bpm). Associated with congenital defect of the conduction system, ASD, tricuspid valve dysplasia in dogs, hypertrophic cardiomyopathy in cats. Occular or sinus carotid pressure will slow heart rates down, often treated with direct current shock or drugs (lidocaine, procainamide dogs or propanolol, atenolol in cats).

Wolff-Parkinson-White Syndrome (WPW)

Medical intervention is not required in cases with ventricular pre-excitation only without tachycardia.

AV blocks
AV block referred to a delay or interruption in conduction of a supraventricular impulse through the AV junction and AV bundle. Three types : A.)1st degree = delay in conduction. B.)2nd degree = intermittent disruptions of conduction. Further classified according to the location of blocks. Normal in horses and young animals. C.)3rd degree = complete or permanent interruption of conduction. Since P-R = duration taken by the impulse to travel from atria to ventricles. Therefore, this parameter will be most affected. Morphology of QRS will indicate whether the block is at the level of AV node (i.e. above AV bundle normal QRS) or below the AV bundle (bizarre QRS). Due to the dependence of block regions of the ventricle on the aberrant electrical signal from the excited ventricle.

1st degree AV block

Caused by delay in conduction of a supraventricular impulse through the AV junction and AV bundle. P, QRS are usually normal. Only prolongation of P-R interval (>0.13 s in dogs, >0.09 s in cats). Caused by aging changes in Cocker spaniel and Dachshunds (due to degenerative changes of the conduction system), associated with drug therapy (digoxin, propanolol, quinidine infact 50 % of digitalised dogs have prolonged P-R), potassium imbalance, hypothyroidism or protozoal myocarditis.

2nd degree AV block (Mobitz type I, usually Type A)

Characterised by intermittent failure or disturbance of Av conduction. One or more P waves are not followed by QRS-T complexes. Progressive prolongation of P-R and shortening of R-R until P is blocked. Therefore the ventricular waves become slower compared to atrial waves. QRS duration is often normal. Type I AV block is often due to conduction failure above the bifurcation of AV bundle.

2nd degree AV block (Mobitz type I, usually Type A)

Characterised by intermittent failure or disturbance of AV conduction. One or more P waves are not followed by QRS-T complexes. Progressive prolongation of P-R and shortening of R-R until P is blocked. Therefore the ventricular waves become slower compared to atrial waves. QRS duration is often normal. Type I AV block is often due to conduction failure above the bifurcation of AV bundle.

2nd degree AV block (Mobitz type II, usually Type B)

Characterised by normal P waves and QRS with abnormal configuration (similar to bundle bunch block characteristics). Frequency and the severity of the block is unpredictable. May developed into advanced 2nd degree AV block = when >2 consecutive P waves are blocked. Associated with cardiac neoplasia, myocarditis (Lyme disease), hereditary stenosis of the AV bundle (pugs), hypertophic cardiomyopathy or hyperthyroidism in cats. Electrolyte imbalance and drugs (eg Xylazine, Digoxin).

3rd degree AV block

The cardiac impulse is completely blocked in the region of the AV junction and/or all bundle branches. The atrial rate is normal but idioventricular escape rhythm is slow (therefore more P than QRS syncope). P wave have not constant relationships with QRS. QRS may be normal (pacemaker in the lower AV junction), or bizarre (if pacemaker is in the ventricle or bundle branch blocks are present). Associated with VSD, aortic stenosis, endocarditis, myocarditis, idiopathic fibrosis (in older dogs esp Cocker Spaniels), DCM, cardiac neoplasia.

Left Bundle Branch Block (LBBB)

Due to the delay of block of the conduction in the LBB, either the main branch or anterior/posterior fascicles. The supraventricular impulse activates the right ventricle via the RBB. The left ventricle was activated much later or not at all, causing bizarre QRS. Characterized by prolonged QRS (>0.08 s in dogs, >0.06 s in cats). QRS positive in leads I, II, III, aVF. Rather uncommon in dogs and cats as the LBB is large and extensive. Associated with direct cardiac trauma (e.g. MVA or HBC, cardiac needle puncture), cardiomyopathy, ischaemic cardiomyopathy (ateriosclerosis of the coronary artery, MI), subvalvular aortic stenosis (when septum and LBB are affected). LBB does not cause haemodynamic abnormalities. May give similar features as to that of LVH, please verify with echocardiography or radiography.

Left Bundle Branch Block (LBBB)

Right Bundle Branch Block (RBBB)

Causes are similar to LBBB, but it involved the RBB. Similar to LBBB, RBBB is also an incidental finding that does not cause any heamodynamic abnormality. The block can be complete (prolonged QRS) or incomplete (normal or near normal QRS duration). Associated with chronic valvular fibrosis, heartworm disease, hyperkalemia, cardiomyopathy.

Note the large S waves !