Welcome to the first of two ECG review sessions that are being offered as part of your

PCE course.

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The goal of the next two sessions is to provide you with a series of tools that will help
you interpret ECGs in a rapid, systematic manner.

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This topics covered in the two ECG sessions are included on this slide.

This list of topics is not an exhaustive list of all aspects of electrocardiography.

Rather, this is a list that is intended to give you the information you will need to
perform basic ECG reading as part of your clinical activities.

Today, we will review the basic physiologic concepts you need to understand in order
to review ECG recordings. This will be followed by an introduction to a systematic
method for ECG interpretation.

We will then discuss ECG manifestations of two particular types of cardiac

pathophysiology: heart block and atrial arrhythmias.

In next weeks session, we will discuss axis deviation/bundle branch block, ventricular
hypertrophy, and myocardial infarction.

For each individual topic, the structure of the discussion will be the same. We will
start with some didactic materials, and will follow up with an interactive review of
ECG tracings that highlight that topic.

At the end of next weeks session, we will engage in an interactive review of ECGs

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that represent all of the types of cardiac pathophysiology reviewed as part of this
mini-course.

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These sessions build upon material that you have already seen as part of the
Homeostasis I course. You will therefore see some familiar material, especially during
todays session.

These sessions are but an introduction to ECG analysis. We know that your study of
the topic will continue throughout your training.

In order to facilitate future study, these sessions reference other resources available
at HMS, including:

The Wave Maven site, organized by Dr. Ary Goldberger. This site contains a
searchable list of ECGs and explanations, and will be an excellent reference for future
study.

The Medical Explorer site, ordanized by Drs. Parker and Peralta, is another ECG
learning site. This site will require that you establish a username and password.
Once your are established as a user, you will be able to utilize reference materials and
also ask questions regarding specific tracings.

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This is an example of the Wave Maven site both of the sites referenced by todays
talk are very user-friendly, and can help you learn in a time-efficient manner.

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The first section in todays session with be a review of basic ECG physiology.

The learning objectives for this first block are the following.

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The electrocardiogram, often referred to as the acronym ECG (or historically EKG
based on the German spelling of cardio), is a measurement of the electrical activity of
the heart as detected using electrodes placed on the surface of the body.

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The ECG, as originally recorded using a device created by Einthoven at the beginning
of the 20th century, is collected in the following manner.

A wire filament affixed to two points the body (in order to establish electrical contact)
is passed through a magnet. Electrical current generated by the heart passes through
the wire. The current passing through the wire leads to physical displacement of the
wire in proportion to the current.

Movement of the wire can be transcribed onto a substrate that moves with time,
leading to a recording of cardiac electrical currents as a function of time.

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The earliest versions of ECG recording systems established electrical contact with the
human body through use of jars of salt solution.

Both arms and the left leg were used for recording, creating a series of measured
vectors in the body call Einthovens triangle, a concept still in use.

This was a large machine weighing several hundred pounds and requiring five
operators.

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Modern ECG systems use contact electrodes (stickers). A standard set of electrode
positions was developed, including Einthovens limb lead positions, as well as six
electrodes on the chest.

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The standard electrode positions facilitate measurement of cardiac electrical vectors
in standard positions.

Electrodes placed on the arms and legs allow for measurement of vectors within the
frontal/coronal plane of the body. The positions of these leads create what is called
Einthovens triangle.

These include bipolar leads (I, II, and III) as well as unipolar leads (aVR, aVL, aVF).

Electrodes placed on the chest allow for measurement of vectors in the transverse
plane of the body. All of these precordial leads are unipolar.

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Current is reflected by the amplitude of the signal in the Y axis the standard scale is
typically 0.1mV/mm

X axis reflects time paper speed is typically 25mm/second

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This scoring pattern leads to the standard appearance of ECG readouts that you have
seen before.

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This is a diagram of the cardiac electrical conduction system, as viewed in the coronal
plane. This diagram has been included in order to review the sequence of
depolarization events that occurred during the cardiac cycle.

We will focus for now on the depolarization of the atrium, following the spontaneous
depolarization of the sinoatrial node (depicted by the dashed
line).

Propagation of the depolarization wave front leads to a deflection in the ECG.

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Repolarization is also associated with electrical currents. Atrial repolarization
typically occurs during the QRS complex and is therefore obscured. Ventricular
repolarization (shown here as an action potential overlying surface ECG signals) is
most obvious during phase III of the action potential, which overlies the observed T
wave in the surface ECG.

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The ECG gives far more information than just signal amplitude and time.

If the depolarization wavefront is traveling toward a surface ECG lead, the deflection
will be positive in that lead.(negative if away)

By measuring voltage amplitudes from multiple electrodes it is possible to determine

the direction in which the depolarization wavefront is propagating.

For the sake of simplicity, we will start with the example of right atrial depolarization.

This four-chamber view of the heart includes some key components of the cardiac
conduction system, including the SA node, the AV node, and the His-Purkinje system.
In sinus rhythm, electrical signals emanate from the SA node and propagate toward
the AV node (dashed line).

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Atrial depolarization leads to a characteristic deflection on the surface ECG (P wave).

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Direction of the P wave depolarization can be determined from the orientation of the
P waves seen in the surface leads.

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This slide is a summary of the basic information included in an ECG tracing.

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Due to the complexity of ECG findings, you will be well-served to utilize a standard
sequence of analyses for each tracing. This will help you improve your proficiency
and will reduce the likelihood that you miss findings.

This slide contains a basic strategy in common use.

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We will start with calculation of heart rate from the ECG.

Because the paper speed is 25mm/sec, each large box will correspond to 0.2 sec.
Heart rate can be calculated either from the rate (measured as timing between QRS
complexes) in msec or by a more simple box counting technique.

Note that rate calculation may be challenging with irregular rhythms, in which case a
more simple strategy may be utilized.

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When determining the rhythm, you will be well served to ask a brief sequence of
questions to assess if sinus rhythm is present or not.

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Axis of depolarization can be determined from the ECG as well.

This is a diagrammatic representation of the standard system for recording the

average vector (axis) for depolarization. 0 degrees is at 3 oclock on the dial by
convention, and degrees increase in a clockwise direction.

Normal axis of the P wave is between 0 and 90 degrees, and normal axis of the QRS
complex is between -30 and 90 degrees.

We will spend more time on this simple technique for determining if the axis is
normal later in this session.

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This slide illustrates tha standards for normal conduction intervals.

Note that PR and QRS duration are standard irrespective of heart rate. QT interval
can be considerably more variable with different heart rates, and a sliding scale for
normal QT interval was therefore devised.

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This is a table that defines normal QT intervals, as determined from population
studies.

This table includes normal QT intervals as a function of both heart rate and patient
age.

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In a given patient, a normal QT interval can be calculated for heart rates in normal
range. This heart rate corrected QT interval is defined in the following manner.

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We will now proceed with a description of measurement of block in the cardiac
conduction system using the surface ECG.

The learning objectives for this block are the following.

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This is a diagram of the cardiac electrical conduction system, as viewed in the coronal
plane. This diagram has been included in order to review the sequence of
depolarization events that occur during the cardiac cycle.

P wave duration is the time taken for electrical signals to propagate through the atria.

PR interval is the time taken for signals to go from the atrial tissue surrounding the SA
node to the ventricle (including time taken to transit the atrium as well as the AV
node).

QRS interval is the time taken for depolarization of the ventricles.

QT interval is a reflection of the time taken for the ventricles to repolarize.

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Reference table for the different types of heart block and the anatomic location of
the block for each type.

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Determining the level of block is clinically relevant, as this will determine the need for
pacemaker support.

Block in the proximal conduction system is generally less ominous than block in the
conduction system distal to the AV node.

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Permanent pacemaker implant indicated if no reversible etiology can be indicated.
May also need to consider short-term support with a temporary pacing wire.

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Do not know if this is (Mobitz I) Wenckebach block or Mobitz II block

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The last block in this session is devoted to atrial arrhythmias.

The learning objectives are listed on this slide.

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This is a diagram of the cardiac electrical conduction system, as viewed in the coronal
plane. This diagram has been included in order to review the sequence of
depolarization events that occurred during the cardiac cycle.

In sinus rhythm, firing of the SA node (asterisk) is followed by depolarization of the

atria and propagation of the wavefront toward the AV node (arrow).

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Atrial fibrillation, the most common sustained arrhythmia in adults, is the
consequence of nearly continuous, chaotic electrical activiies that emanates from the
LA (generally the pulmonary veins). This electrical activity overdrive suppresses the
SA node.

In addition, the AV node is continuously bombarded by irregular signals leading to an

irregularly irregular cadence of ventricular depolarization.

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This ECG demonstrates key ECG features of AF.

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Atrial flutter is an arrhythmia closely associated with AF.

There are several mechanisms for atrial flutter, which are reviewed in the following
slides.

This slide reviews the mechanism for counterclockwise, isthmus-dependent flutter

(or what was previously called typical atrial flutter).

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This is an ECG demonstrating classic features of isthmus dependent flutter, including
regular R-R intervals (result of single, organized atrial activation sequence) and a
sawtooth pattern reflecting the flutter circuit.

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Not all atrial flutters are dependent on the cavotricuspid isthmus. AFL can also
emanate from the LA, as demonstrated in this slide.

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Atrail tachycardia is the third variety of atrial arrhythmia. This is typically the result of
a single focus of tissue in the atrium (outside the SA node) that fires spontaneously.

This slide reviews several key features of ATs.

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Atrial tachycardia that is the result of multiple foci has also been well-described.
MAT, which is often associated with ither disease states such as pulmonary illness or
other acute illness states, is depicted in this slide.

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