Electrocardiogram
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Transcript of Electrocardiogram
ElectrocardiogramElectrocardiogram
Wendy Blount, DVMNacogdoches TXWendy Blount, DVMNacogdoches TX
ECG – What it DetectsECG – What it Detects
Heart chamber enlargement• Eccentric hypertrophy
– Dilation and growth of heart chambers– Due to volume overload
• Concentric hypertrophy– Wall thickening of heart chambers– Due to pressure overload
Conduction Disturbances
ECG – What Doesn’t DetectECG – What Doesn’t Detect
Type of Heart chamber enlargement• Eccentric vs. Concentric hypertrophy• Congestive Heart Failure
A Short ECG won’t detect many arrhythmias
• Arrhythmias can be intermittent• 10 minutes is <1% of the day
ECG – When to DoECG – When to Do
• Pulse deficits detected on exam• Chaotic heart sounds (arrhythmia)
detected on exam• Tachycardia• Bradycardia• Episodes of weakness or collapse• Pre-anesthetic in sick or geriatric animal
– Abdominal mass (especially spleen)– Heart murmur
ECG – When to DoECG – When to Do
Event Recorders• Owner/witness starts recording during an event
Holter Monitors• Continuously record ECG for 24 hours• Can rent for Dr. Kate Meurs at Washington State
Vet School
http://www.vetmed.wsu.edu/deptsVCGL/holter/requestform.aspx
ECG – Helpful HintsECG – Helpful Hints
• Always in right lateral recumbency • Patient on a towel or rubber mat• Metal tables are more problematic• Limbs perpendicular to body• Place leads at the elbow and knee• No one moves while the ECG is being
recorded• Enhance lead contact with gel or alcohol
Alcohol is FLAMMABLE!!
ECG – Helpful HintsECG – Helpful Hints
Which lead goes where• “Snow and Grass are on the ground”
– White and green leads are on the bottom (R)
• “Christmas comes at the end of the year”– Red and green are on the back legs
• “Read the newspaper with your hands”– White and black are on front legs
White – RF Green – RR (ground) Black – LF Red – LR
ECG – The Cardiac CycleECG – The Cardiac Cycle
P wave• SA node fires
1. Atrial depolarization (contraction)
• HS42. Iternodal tracts (shortcut to AV node)
ECG – The Cardiac CycleECG – The Cardiac Cycle
PR interval • Beginning of P wave to beginning of QRS• AV node
– *most of the PR interval is here*
• Bundle of HIS• bundle branches (R&L)• Purkinje fiber network
ECG – The Cardiac CycleECG – The Cardiac Cycle
QRS complex• ventricular depolarization (systole)• Q wave 1st negative deflection• R wave 1st positive deflection• S wave 2nd negative deflection
ECG – The Cardiac CycleECG – The Cardiac Cycle
QRS complex• HS1
– AV valves closing– beginning of QRS
• HS2 – Semilunar valves closing (AoV, PV)– end of QRS
• Pulse is generated
ECG – The Cardiac CycleECG – The Cardiac Cycle
T wave• Ventricular repolarization (diastole)• HS3
– Ventricular filling– if myocardium is stiff
ECG – The Cardiac CycleECG – The Cardiac Cycle
QT interval• beginning of QRS to end of T wave• ventricular depolari- zation & repolarization• HS1, HS2, HS3• Pulse generated
ECG – The Cardiac CycleECG – The Cardiac Cycle
ST segment• Between S & T waves• Between ventricular contraction (depolarization – systole) and ventricular relaxation (repolarization – diastole)• Isn’t measured per se• But it’s relationship with baseline is noted
ECG – 6 LeadsECG – 6 Leads
Bipolar leads• I – LF+ RF-• II – LR+ RF-• III – RR+ LF-Unipolar leads• aVR – RF+ (summation lead III)-• aVL – LF+ (summation lead II)-• aVF - LR+ (summation lead I)-
ECG – Systematic Interpretation
ECG – Systematic Interpretation
1. Heart Rate and Rhythm2. Measurements of the parts
• P wave - width and height• PR interval - length• QRS - width and height• QT interval – length
• ST segment – relative to PR interval• T wave - width and height
3. Mean Electrical Axis
Form
ECG – MeasurementsECG – Measurements
• Take 3-5 measurements and average• All measurements done in lead II• Use calipers• Measure from the center of the line
ECG – Heart RateECG – Heart Rate
At 25 mm/sec, 150mm = 6 sec• “Bic Pen Times Ten”• Accurate within 10 beats per minute
At 50 mm/sec, 300mm = 6 sec• A Bic Pen times Twenty• Accurate within 20 beats per minute
ECG – Heart RateECG – Heart Rate
Normals• Giant dogs 60-140 Med-Lg dogs 70-
160• Toy dogs 80-180 Puppies 70-220• Cats 100-240
Get Baseline heart rates for individuals on every visit
ECG – RhythmECG – Rhythm
Normal Sinus rhythm• Regular heart rate
– Measure from one P wave to the next with calipers
• P, QRS and T waves in each complex
Respiratory Sinus Arrhythmia• heart rate regularly irregular
– Speeds up with inhale, slows with exhale (vagal tone variance, in a regular cycle)
• P, QRS and T waves in each complex• Variable P wave – wandering pacemaker• Heart rate less than 200
Arrhythmia
ECG – RhythmECG – Rhythm
Respiratory Sinus Arrhythmia
• Atrial depolarization (contraction)• Normal Dog: <0.4 mV x <0.04 sec <0.5 sec in giant breeds
– 4 boxes tall– 25 mm/sec 1-1.25 boxes wide– 50 mm/sec 2-2.5 boxes wide
• Normal Cat: <0.2 mV x <0.04 sec
– 2 boxes tall
ECG – P Wave MeasurementsECG – P Wave
Measurements
ECG – P Wave MeasurementsECG – P Wave
Measurements
• Wide P wave (Sometimes Notched)– 25 mm/sec > 1 box wide– 50 mm/sec > 2 boxes wide– LA enlargement
• Tall P wave (often spiked)– Dog > 4 boxes tall, cat > 2 boxes tall– RA enlargement
• Variable P wave – normal variation– “wandering pacemaker” – increased vagal tone
• Lack of P wave– Atrial standstill
ECG – P Wave MeasurementsECG – P Wave
Measurements
Wandering pacemaker
ECG – PR IntervalECG – PR Interval
ECG – PR IntervalECG – PR Interval
Conduction from atria to ventricles (AV node)
Establishes the ECG baseline
Normal Dog: 0.06-0.13 sec
Normal Cat: 0.05-0.09 sec
ECG – PR IntervalECG – PR Interval
Conduction from atria to ventricles (AV node)
Establishes the ECG baseline
Normal Dog: 0.06-0.13 sec
Normal Cat: 0.05-0.09 sec
ECG – PR IntervalECG – PR Interval
• Short PR Interval (tachycardia)– AV node is bypassed– “Accessory pathway” (Wolff-Parkinson-White)– Congenital or acquired– Treated in people by radioablation of the pathway– Sudden onset of tachycardia in a dog– Can try calcium channel blockers
• Diltiazem SR (Plumb dose)– If you don’t treat right away, the myocardium will
poop out & rapidly progressive CHF will ensue
ECG – PR IntervalECG – PR Interval
Normal Dog: 0.06-0.13 sec
Normal Cat: 0.05-0.09 sec
• Long PR Interval– Slow conduction through abnormal AV node– AV Blocks
ECG – PR IntervalECG – PR Interval
Normal Dog: 0.06-0.13 sec
Normal Cat: 0.05-0.09 sec
1st degree AV Block• Every P wave is followed
by a QRS• Due to increased vagal tone• Non-pathogenic
50 mm/sec50 mm/sec
ECG – PR IntervalECG – PR Interval
ECG – PR IntervalECG – PR Interval
2nd degree AV Block
Some P waves not followed by a QRS• Mobitz type I – PR progressively longer until QRS
dropped (Wenkebach Phenomenon)
ECG – PR IntervalECG – PR Interval
2nd degree AV Block
Some P waves not followed by a QRS• Mobitz type 2 – no pattern• PR interval does not change• P-P interval is consistent, so SA node is working fine• PR interval may be prolonged and may be normal• Occasionally, a P wave is not followed by a QRS• Not necessarily pathogenic
Physiology - Cardiac Pacemakers
Physiology - Cardiac Pacemakers
Automatic cells in the heart• Depolarize on their own during phase 4 of
the cardiac cycle• Rate of depolarization affected by
autonomic nervous system– SA node (60-180 beats/min dog) (100-240 cat)– AV node (40-60 beats/min dog) (80-130 cat)– Purkinje fibers (20-40 beats/min)– Bundle of HIS (20-40 beats/min)– Ventricular myocytes (20-40 beats/min)
Physiology - Cardiac Pacemakers
Physiology - Cardiac Pacemakers
Automatic cells in the heart• The fastest functioning pacemaker in the
heart takes over, by default• The closer to the AV node, the more the
escape beat will resemble normal QRS• The closer to the ventricle, the more wide
and bizarre the QRS will appear• Escape rhythm – pacemaker other than
SA node takes over, because SA node fails to fire
ECG – PR IntervalECG – PR Interval
3rd degree AV Block (complete AV block)
No relationship between P waves and QRS• P waves have their own rate (faster), determined by the
normal SA node• QRS has its own rate (slower), determined by the
automaticity of the fastest remaining functioning pacemaker
• Treatment– pacemaker
• Prognosis– Cats – without anesthesia, potentially very good– Dogs – eventual asystole is likely, if no pacemaker implanted
ECG – PR IntervalECG – PR Interval
3rd degree AV Block (complete AV block)
•Pacemaker above bifurcation of bundle of His
•Pacemaker left ventricle
ECG – QRS Complex Measurements
ECG – QRS Complex Measurements
Normal Dog:
<40 lbs: <0.05sec x <3.0 mV• 30 boxes tall
• 25 mm/sec 1.25 boxes wide
• 50 mm/sec 2.5 boxes wide
>40 lbs: <0.06sec x <3.0 mV• 25 mm/ sec 1.5 boxes wide
• 50 mm/sec 3 boxes wide
Normal Cat:
<0.04sec x <0.9 mV• 9 boxes tall
• 25 mm/sec 1 box wide
• 50 mm/sec 2 boxes wide
ECG – QRS Complex Measurements
ECG – QRS Complex Measurements
R wave measured from
baseline to top• Tall R wave, wide QRS
– LV enlargement– Left Bundle branch block
• Deep S wave in leads
I, II & III– RV enlargement
ECG – Bundle Branch BlocksECG – Bundle Branch Blocks
• Depolarization wave through myocardium rather than through Purkinje network on affected side– takes longer– “appears bigger” on ECG
• Can be persistent or intermittent– Intermittent often precipitated by increased heart
rate (delayed refractory period)
• Left side, right side or both– Bilateral BBB looks like 3rd degree AV block
ECG – Bundle Branch BlocksECG – Bundle Branch Blocks
Right Bundle Branch Block (RBBB)• Causes:
– primary conduction system disease– Disruption of moderator band– RV enlargement– Congenital (especially beagles)
• ECG– Deep S wave leads I, II, III, aVF– Wide QRS
• May cause a split S2
ECG – Bundle Branch BlocksECG – Bundle Branch Blocks
Left Bundle Branch Block (RBBB)• Causes:
– primary conduction system disease– Widespread LV myocardial disease– Unlike RBBB, not usually benign
• ECG– Tall R wave– Wide QRS– Looks like a VPC, but follows
normal PR interval
Ventricular Premature Complexes
Ventricular Premature Complexes
• Depolarization wave through myocardium rather than through Purkinje network on affected side– takes longer– “appears bigger” on ECG
Ventricular Premature Complexes
Ventricular Premature Complexes
• VPCs are like escape beats in that they both originate from the ventricular myocardium
• VPCs are abnormal due to primary LV pathology or secondary to metabolic disease
• Escape beats are the normal life saving response to a failure of upline pacemaker
• VPCs can be persistent or intermittent– Intermittent often precipitated by increased heart
rate (delayed refractory period)
• Multiform VPCs are more serious– Multifocal areas of LV pathology
ECG – ST SegmentECG – ST Segment
ST segment depression orelevation • >0.2mV between baseline and ST• hypothermia• hypokalemia• Digitalis toxicity• Bundle branch block• Myocardial infarction
– Rare in dogs– Can be seen in feline HCM
ECG – Mean Electrical Axis (MEA)
ECG – Mean Electrical Axis (MEA)
• when a wavefront spreads toward an electrode, the largest possible deflection will occur
• When a wavefront spreads perpendicular to a lead, the smallest or no deflection occurs
• ECG shows the sum of all wavefronts relative to the lead being used to measure (MEA)
• Isoelectric lead– lead with the smallest deflection– Perpendicular to the MEA
ECG – Mean Electrical Axis (MEA)
ECG – Mean Electrical Axis (MEA)
• The normal MEA is 40o to 100o
in the dog• Lead II is most perpendicular
to the normal MEA– largest deflections– best for measurements
• aVL is most often the
isoelectric lead– Approximates MEA in normal
dogs
ECG – Mean Electrical Axis (MEA)
ECG – Mean Electrical Axis (MEA)
Calculating MEA by graph• Calculate the net deflection in lead I
– Graph on “x axis”
• Calculate net deflection in head aVF– Graph on “y axis”
• Draw the vector between the two (MEA)
ECG – Mean Electrical Axis (MEA)
ECG – Mean Electrical Axis (MEA)
+3 - 5 = -2
+10 -1.5 = +8.5
MEA = 105MEA = 105oo
+-
ECG – Mean Electrical Axis (MEA)
ECG – Mean Electrical Axis (MEA)
Estimating MEA• Find the isoelectric lead
– NOT the lead with smallest deflections– Lead with smallest NET DEFLECTION
• MEA is perpendicular to that, in the direction of net deflection
ECG – Mean Electrical Axis (MEA)
ECG – Mean Electrical Axis (MEA)
Estimating MEA
+3
-5
-2
+8
-0
+8
+13
-2
+11
+2
-2
0
+1
-8
-7
+9.5
-1
+8.5
Isoelectric lead = aVR
MEA = +120o
Right Axis Shift
ECG – Mean Electrical Axis (MEA)
ECG – Mean Electrical Axis (MEA)
Normal Canine MEA
40-110o
Normal Feline MEA
0-160o
ECG – Mean Electrical Axis (MEA)
ECG – Mean Electrical Axis (MEA)
Right Axis Shift• Right ventricular enlargement
– RV hypertrophy or dilation
• Right bundle branch block
Left Axis Shift• HCM in cats• hyperkalemia