Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD...

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Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD

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Page 1: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Introduction to Clinical Electrocardiography

Gari Clifford, PhDAndrew Reisner, MDRoger Mark, MD PhD

Page 2: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Electrocardiography

The heart is an electrical organ, and its activity can be measured non-invasively

Wealth of information related to: The electrical patterns proper The geometry of the heart tissue The metabolic state of the heart

Standard tool used in a wide-range of medical evaluations

Page 3: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

A heart• Blood circulates, passing near every cell in the body, driven by this pump

• …actually, two pumps…

• Atria = turbochargers

• Myocardium = muscle

• Mechanical systole

• Electrical systole

Page 4: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

To understand the ECG:

Electrophysiology of a single cell How a wave of electrical current

propagates through myocardium Specific structures of the heart

through which the electrical wave travels

How that leads to a measurable signal on the surface of the body

Page 5: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Part I: A little electrophysiology

Page 6: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Once upon a time, there was a cell:

ATPaseATPase

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-90-90

Resting comfortably

a myocyte

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Depolarizing trigger

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Na channels

open, briefly

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In: Na+

Mysterycurrent

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In: Na+

Ca++ is in balancewith K+ out

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In: Na+

Excitation/Contraction Coupling:Ca++ causes the Troponin Complex

(C, I & T) to release inhibitionof Actin & Myosin

Page 13: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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In: Na+

Ca++ in; K+ out

More K+ out;Ca++ flow halts

Page 14: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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In: Na+

In: Ca++; Out: K+

Out: K+

Sodium channels reset

Page 15: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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In: Na+

Higher resting potentialFew sodium channels reset

Slower upstroke

Page 16: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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a pacemaker cell

Slow current of Na+ in;note the resting potential

is less negative in apacemaker cell

-55-55

Page 17: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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a pacemaker cell

Threshold voltage

-40-40

Page 18: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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Ca++ flows in

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. . . and K+ flows out

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. . . and when it is negativeagain, a few Na+

channels open

Page 21: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

How a wave of electrical current propagates through myocardium

Typically, an impulse originating anywhere in the myocardium will propagate throughout the heart

Cells communicate electrically via “gap junctions”

Behaves as a “syncytium” Think of the “wave” at a football

game!

Page 22: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

The dipole field due to current flow in a myocardial cell at the advancing front of depolarization.

Vm is the transmembrane potential.

Page 23: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Cardiac Electrical Activity

Page 24: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Important specific structures

Sino-atrial node = pacemaker (usually) Atria After electrical excitation: contraction Atrioventricular node (a tactical pause) Ventricular conducting fibers (freeways) Ventricular myocardium (surface roads) After electrical excitation: contraction

Page 25: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

The Idealized Spherical Torso with the Centrally Located Cardiac Source (Simple dipole model)

Page 26: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Excitation of the Heart

Page 27: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Excitation of the Heart

Page 28: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Cardiac Electrical Activity

Page 29: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Recording the surface ECG

Page 30: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Clinical Lead Placement

Einthoven Limb Leads:

Page 31: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Precordial leads

Page 32: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

12 Lead ECG

Page 33: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.
Page 34: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

The temporal pattern of the heart vector combined with the geometry of the standard frontal plane limb leads.

Page 35: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Normal features of the electrocardiogram.

Page 36: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Normal sinus rhythm

Page 37: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

What has changed?

Page 38: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Sinus bradycardia

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Neurohumeral factors

Vagal stimulation makes the resting potential

MORE NEGATIVE. . .

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Neurohumeral factors

. . . and the pacemakercurrent SLOWER. . .

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. . . and raise the THRESHOLD

Page 42: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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Catecholamines make the resting potential MORE EXCITED. . .

Page 43: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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. . . and speed the PACEMAKER CURRENT. . .

Page 44: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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. . . and lower the THRESHOLD FOR

DISCHARGE. . .

Page 45: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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Vagal Stimulation:

Page 46: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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Adrenergic Stim.

Page 47: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Sinus arrhythmia

Page 48: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Atrial premature contractions (see arrowheads)

Page 49: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.
Page 50: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Usually just a spark; rarely sufficient for an explosion

“Leakiness” leads to pacemaker-like current

Early after-depolarization Late after-depolarization

Page 51: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

What’s going on here?

Page 52: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Wave-front Trajectory in a Ventricular Premature Contraction.

Page 53: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Is this the same thing?

Page 54: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

What’s going on here?

Page 55: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

What’s going on here?

Page 56: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Non-sustained ventricular tachycardia (3 episodes)

Page 57: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Slow Refractory

Quick Refractory

KeyWords: Heterogeneous, Circus, Self-Perpetuating

Side “A” Side “B”

Page 58: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

No Longer Refractory

KeyWords: Heterogeneous, Circus, Self-Perpetuating

Side “A” Side “B”

Page 59: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

KeyWords: Heterogeneous, Circus, Self-Perpetuating

Side “A” Side “B”

Page 60: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

KeyWords: Heterogeneous, Circus, Self-Perpetuating

Side “A” Side “B”

Page 61: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

KeyWords: Heterogeneous, Circus, Self-Perpetuating

Side “A” Side “B”

Page 62: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

KeyWords: Heterogeneous, Circus, Self-Perpetuating

Side “A” Side “B”

Page 63: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

INCREASEDRefractory

Side “A” Side “B”

Page 64: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

INCREASEDRefractory

Side “A” Side “B”

Page 65: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

INCREASEDRefractory

Side “A” Side “B”

Page 66: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

INCREASEDRefractory

Side “A” Side “B”

Page 67: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

INCREASEDRefractory

Side “A” Side “B”

Page 68: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

INCREASEDRefractory

Side “A” Side “B”

Page 69: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Ventricular Fibrillation

Page 70: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.
Page 71: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.
Page 72: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.
Page 73: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.
Page 74: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Heart attack

Page 75: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Hyperkalemia

Page 76: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

Understanding the ECG: A Cautionary Note

Basic cell electrophysiology, wavefront propagation model, dipole model:

Powerful, but incomplete There will always be electrophysiologic

phenomena which will not conform with these explanatory models

Examples: metabolic disturbances anti-arrhythmic medications need for 12-lead ECG to record a 3-D phenomenon

Page 77: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD.

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