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\DIAGNOSTIC ELECTROCARDIOGRAPHY SLECTROCARDIOGRAPHIE DIAGNOSTIQUE

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When and why should I do an electrocardiogram?

Rocky DiFruscia, Michael O'Grady, Brian Hill

Electrocardiography has been used in the evaluation Table 1. Common uses of the of cardiovascular disease in animals for many electrocardiogram years. Although interpreting an electrocardiogram (ECG) may seem to be, at first glance, a complicated 1. Evaluation of primary cardiac diseases and time-consuming task, there is a logical, simple and - Changes in atrial or ventricular mass - Cardiac dysrhythmias easy approach that will be reviewed in this series of - Pericardial effusion articles. The final interpretation, and consequently the 2. Monitoring drug response (antidysrhythmic, digoxin) clinical utility of the ECG data, must always be eval3. Identification of changes reflecting hyperkalemia uated in the context of other data related to the clinical 4. Monitoring during pericardiocentesis 5. Evaluation of extra-cardiac disease (pleural effusion, cardiac problem. The clinician, who has recorded a hypothyroidism) good history, performed a complete physical examina6. Monitoring during anesthesia, after trauma, or during tion and interpreted thoracic radiographs of good severe systemic diseases. quality, is the best person to accurately interpret the significance of the electrocardiographic data. It is therefore important to use this diagnostic tool with assessed properly as to their type and etiology by the knowledge of its usefulness and limitations. electrocardiogram. Since the therapeutic approach to any type of cardiac rhythm disturbance is dependent on the proper identification and classification of the dysrhythmia, it becomes obvious that ECG recording The clinician, who has recorded a good and interpretation is essential. history, performed a complete physical The second most useful indication for performing examination and interpreted thoracic an ECG is to assess cardiac chamber enlargement. radiographs of good quality, is the best However, the ability to assess cardiac chamber enlargement using electrocardiography in domestic animals person to accurately interpret the significance will depend on the type of Purkinje network in the of the electrocardiographic data species under consideration. There are important species differences in the intracardiac conduction system that should be understood. These differences Conventional electrocardiography represents the explain why the ECG can be useful to detect chamber measurements, both in amplitude and duration, of enlargement in certain animals while it is generally not action potential differences at the body surface, of an in others. electrical current generated during depolarization and In all animals, the sinoatrial node is the normal, repolarization of the heart muscle. Standard position- dominant pacemaker that is responsible, under the ing of the patient and proper placement of the elec- influence of the autonomic nervous system, for maintrodes ensures reproducible results. The reader is taining a cardiac rate and rhythm that correspond to referred to excellent textbooks and articles describing the physiologic demands of the body. The impulse the proper technique for recording the ECG in small originates in the specialized cells of the sinus node, and large animals (1-5). spreads throughout the atrial muscle and eventually Indications for electrocardiography are numerous reaches the atrioventricular node (AVN) which (Table 1) and some of them are more important than represents the only normal pathway to activate the others. The most important indication is the identifica- ventricles. Only in rare instances do abnormal tion of cardiac dysrhythmias, which can only be pathways exist that bypass the AVN and give rise to Faculte de medecine veterinaire de l'Universite de Montreal, ventricular activation (the so-called pre-excitation Departement de Medecine, P.O. Box 5000, St. Hyacinthe, syndromes). The AVN can be viewed as a filter which Quebec J2S 7C6 (DiFruscia); Ontario Veterinary College, prevents too frequent activation of the ventricles if Department of Clinical Studies, University of Guelph, atrial depolarization becomes too rapid (e.g. atrial Guelph, Ontario NIG 2W1. (O'Grady); Atlantic Veteri- fibrillation, atrial flutter, supraventricular tachynary College, University of Prince Edward Island, 550 Unicardia). It thus ensures coordination of atrial and venversity Avenue, Charlottetown, P.E.I. CIA 4P3 (Hill). tricular contraction. After passing through the AVN,
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Can Vet J Volume 32, March 1991

PV

Py

AVC

A
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RA
PVC

LA
14444, y PVC344*

,It

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CLASS I

CLASS II

Figure 1. A schematic diagram of the conduction system of the heart. RA = right atrium, LA = left atrium, RV = right ventricle, LV = left ventricle, PVC = caudal vena cava, AVC = cranial vena cava, PV - pulmonary veins. In class I animals, the ECG is generally of no value in assessing ventricular enlargement. In class II animals, the ECG is often very useful in assessing ventricular enlargement. [Reproduced with permission and modified from Hamlin RL, Smith CR. Electrophysiology of the heart. In: Duke's Physiology of Domestic Animals. Swenson MJ, ed. 9th ed. Ithaca, New York: Comstock Publishing Assoc, 1977: 73.1

the impulse will next activate the bundle of His. From there, the impulse will enter the bundle branches (left and right) en route to the Purkinje network. The major difference between animals that has important clinical implications in the interpretation of cardiac chamber enlargement lies in the final distribution of Purkinje fibers within the ventricular muscle (Figure 1). In the first group of animals (class I), which includes ruminants, pigs, and horses, the Purkinje network penetrates the whole thickness of the ventricular wall, thus allowing much more rapid ventricular activation (6,7). This has two important effects on the generation of the QRS complex: first, the deep penetration and very rich arborization and anastomosis of the Purkinje network within the ventricular myocardium fails to generate a united wavefront of depolarization across the bulk of the ventricular muscle, which results in many very small vector wavefronts directed in all directions which cancel each other; and second, the QRS that is recorded in the ECG results almost exclusively from the depolarization of the base of the interventricular septum and base of the ventricular walls. The orientation of the average QRS vector that occurs in this group of animals is directed from the apex to the base of the heart (6,7). In the second group of animals (class II), which includes man, primates, carnivores and rodents, the Purkinje network penetrates only a small part of the endocardial-epicardial distance (Figure 1) (6,7). In this

group the electrical impulse leaves the Purkinje fibers along the ventricular endocardium and is disseminated from myocyte to myocyte creating a united wavefront of activation, or mean cardiac vector, oriented radially (from endocardium to epicardium) and an average QRS vector in a direction from the base of the heart to the apex. This major difference in the degree of penetration and arborization of the Purkinje fibers in the ventricular myocardium is not only responsible for the differences in the general pathways of ventricular activation but also explains why the ECG is helpful in the identification of cardiac chamber enlargement in class II animals and of little or no use in class I animals. In the latter species, the major masses of both ventricles are excited with a burst of depolarization that contributes little, if at all, to the QRS complex recorded at the body surface (6,7). Therefore, the utility of the ECG in class I animals is limited, but nevertheless of great value, for the evaluation of dysrhythmias, conduction disturbances, and monitoring cardiac rhythm. In both classes of animals, there is no doubt that electrocardiography is an indispensable tool in numerous emergency situations to monitor cardiac rate and rhythm such as cardiac arrest, myocardial trauma in hit-by-car accidents, acute malignant cardiac dysrhythmias, and intensive care or anesthetic monitoring for high-risk patients. As for identifying electrolyte and acid-base disorders, changes in the ECG (PR interval, ST segment, QRS duration, QT interval) are usually relatively nonspecific and very vague to the point that the value of this diagnostic aid is very low. Hyperkalemia, though, can frequently by suspected by carefully examining the ECG and, for those cases with characteristic ECG findings of hyperkalemia, the ECG diagnosis may enable early treatment of this abnormality. In the following issues, we will review a simple approach to the electrocardiographic interpretation of different cardiac conditions as well as their causes in both small and large animals illustrated with typical tracings.

References
1. Tilley LP. Essentials of Canine and Feline Electrocardiography. 2nd ed. Philadelphia: Lea & Febiger, 1985: 1-37. 2. Edwards NJ. Bolton's Handbook of Canine and Feline Electrocardiography. 2nd ed. Toronto: W.B. Saunders, 1987: 1-30. 3. Fregin GF. The equine electrocardiogram with standardized body and limb positions. Cornell Vet 1982; 72: 304-324. 4. Fregin GF. Electrocardiography. Symposium on cardiology. Vet Clin North Am (Equine Pract) 1985; 1: 419-432. 5. DeRoth L. Electrocardiographic parameters in the normal lactating Holstein cow. Can Vet J 1980; 21: 271-277. 6. O'Callaghan MW. Regulation of heart beat. In: Philipson AT et al., ed. Veterinary Medicine. Oxford: William Heinemann Medical Books, 1980: 303-311. 7. Hamlin RL, Smith CR. Categorization of common domestic mammals based upon their ventricular activation process. Ann NY Acad Sci 1965; 127: 195-203.

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