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Electrocardiogram and
arrhythmias
Learning objectives
After reading this article, you should be able to:
C
recognize two common variations of each of the normal P, QRS
and T waves
C
distinguish the three atrioventricular blocks
C
describe three common tachyarrhythmias.
Rajender Singh
Jeremy J Murphy
Abstract
Introduced by Einthoven, electrocardiography remains the most common
diagnostic procedure readily available to the physician in primary and
secondary care. It is a graphical display of the electrical potential difference as it spreads through the heart and is recorded at the body surface.
The electrocardiogram (ECG) is an indispensable tool to screen and
monitor cardiac patients. Exercise ECG is used to diagnose coronary artery
disease and ambulatory ECG to assess arrhythmias.
beneath the electrode because the heart is close to the chest wall.
(For detailed discussion about lead position and cardiac depolarization please refer to Anaesthesia and Intensive Care Medicine 2006; 7: 264e6.)
ECG waves
P wave
P waves result from atrial activation by the sinoatrial (SA) node.
Because the SA node is situated in the right atrium, right atrial
activation begins first and is reflected by the proximal
(ascending) limb of the P wave. Left atrial activation begins 0.03
seconds later and is represented by the descending limb of the P
wave. Because of the orientation of the leads, this is best seen in
standard lead II and lead V1. The P wave in these leads is usually
positive, pyramidal and with a slightly rounded apex. It is normally inverted in aVR, and upright in aVF plus the left chest leads
(V4e6). Amplitude does not usually exceed 2e3 mm in any lead.
cardia; ECG waves and their variations; electrical impulse of the heart;
tachycardia; ventricular tachycardia
Royal College of Anaesthetists CPD matrix: 1A01
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PHYSIOLOGY
In the chest leads, as a consequence of this normal depolarization process, the right-oriented leads (V1 and V2) show a small
upward deflection (septal R wave), followed by a deep S wave.
The same sequence in the left-sided chest leads (V6, aVL, lead I)
causes a small downward deflection (physiological Q wave)
followed by a tall R wave. In the intermediate chest leads, there is
a relative increase in the R wave and a reduction in the S wave
amplitude (normal R wave progression) from left to right. R and
S waves are approximately equal in the mid-chest leads (V3 and
V4); this is called the transition zone.
The QRS pattern in the limb leads varies and depends on the
mean QRS axis. Lead aVR, which records from the right shoulder, effectively looks from the cavity of the heart with all the
vectors directed away and thus has all negative deflections. The
normal duration of the QRS complex is 0.05e0.10 seconds.
Bradycardia
This is normally present during sleep and in fit athletes (athletes
heart syndrome). Pressure receptors (baroceptors) in the aorta
and carotid arteries respond to arterial pressure, altering vagal
tone through acetylcholine release. In carotid sinus syndrome,
there is increased sensitivity of the baroceptors located in the
carotid sinus region of the carotid artery. Therefore, pressure on
the neck can result in extreme bradycardia, dizziness and syncope. Sometimes, it can trigger asystole for up to 10 seconds.
Heart rate also varies with the phase of respiration; this is called
sinus arrhythmia (For further description, please refer to
Anaesthesia and Intensive Care Medicine 2006; 7: 264e6.)
Second-degree block: type 1 second-degree AV block (Wenckebach, Mobitz type I); there is progressive prolongation of the PR
interval, before a QRS complex fails to appear after a P wave. The
block is usually in the AV node and the QRS is of normal duration. Causes are inferior wall myocardial infarction, drug intoxication with beta blockers, digoxin and calcium channel blockers.
Type 1 block can be present in normal individuals with increased
vagal tone, generally at night. If the ventricular rate is adequate
and the patient is asymptomatic, observation is sufficient.
Third-degree block (complete heart block): this is characterized by complete cessation of the electrical impulses from the
atrium to the ventricle. P waves are dissociated from the ventricular complex and the two are asynchronously controlled by
independent pacemakers. This is the most advanced form of AV
block. It is mostly due to chronic degenerative changes in the
bundle branches due to Levs and Lenegres disease. It can also
occur with cardiomyopathy and inferior myocardial infarction.
Complete heart block can be congenital owing to maternal
Arrhythmias
It is beyond the scope of this article to discuss arrhythmias in
detail, but a brief overview is provided. The heart normally beats
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PHYSIOLOGY
Figure 1 Bradycardia: type II second-degree (Mobitz type II) atrioventricular block. There are two P waves for one QRS complex (2:1 block).
SVT in origin, whereas regular broad complex tachycardia usually originates from the ventricle.
Atrial fibrillation
Atrial fibrillation (AF) can be paroxysmal or persistent and is
characterized by disorganized atrial activity with no discrete P
waves on the ECG. The mechanism of AF is unclear, but it is
believed that there are numerous micro-re-entry circuits or
stimuli that excite the atria, usually from where the pulmonary
veins enter the left atrium. The atrial rate is between 350 and 600
beats per minute (bpm), and this activity causes an undulating
baseline. Impulses reach the AV node through multiple paths at
frequent and irregular intervals. Rapidly entering atrial impulses
render the AV node partially refractory to subsequent impulses,
so the ventricular rate is somewhat slower and irregularly
irregular. Acute AF can be precipitated by infection, alcohol,
Tachycardia
Normally, myocardial cells do not discharge spontaneously.
Tachyarrhythmias can arise from any part of the heart. These can
be disorders of impulse formation (enhanced automaticity)
owing to exogenous catecholamines, hyperkalaemia, hypoxia
and digitalis; they can also arise from disorders of impulse spread
(re-entry), such as in sustained supraventricular tachycardias.
Tachyarrythmias can be further classified as (1) regular or
irregular and (2) narrow or broad complex, depending on the
QRS morphology. An irregular arrhythmia is usually atrial
fibrillation (or flutter with variable block), whether narrow or
broad complex. Regular narrow complex tachycardia is generally
Figure 2 Atrial flutter: regular narrow complex tachycardia showing 2:1 physiological block. P waves (arrows) are best seen in leads V1 and V2.
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PHYSIOLOGY
dehydration, congestive cardiac failure and pulmonary embolism. In acute AF, treating the primary cause usually resolves the
arrhythmia. If the patient is compromised, electrical or chemical
cardioversion can be performed.
Atrial flutter
Atrial flutter (Figure 2) is characterized by rapid and regular atrial
activity, causing a saw-tooth or picket-fence appearance, typically
in the inferior leads. The mechanism is generally a macro-re-entry
circuit in the right atrium. The atrial rate is 250e350 bpm; the
ventricular rate is typically half the atrial rate, usually around 150
bpm. Atrial flutter, when it lasts for more than a week, frequently
converts to AF. Although the risk of systematic emobolization is
less than for AF, management is the same for both.
Ventricular tachycardia
Ventricular tachycardia (VT) (Figure 3) is defined as three or
more consecutive ectopic ventricular QRS complexes occurring at
a rate of >100 bpm. It is called sustained VT if it lasts for more
than 30 seconds or needs intervention. It is broad complex and
quite regular, arising as a result of abnormal automaticity or
(more commonly) re-entry distal to the His bundle. Broad complex tachycardia is most commonly VT, particularly if structural
heart disease is present. Certain ECG criteria support VT as
opposed to SVT with aberrant conduction.
ECG features that favour VT are:1
1 atrioventricular dissociation
2 QRS width:
>0.14 seconds with RBBB configuration
>0.16 seconds with LBBB configuration
3 QRS axis:
left axis with RBBB morphology
extreme left axis with LBBB morphology
4 concordance of QRS in precordial leads
REFERENCE
1 Josephson ME, Zimetbaum P. The tachyarrhythmias. In: Braunwald E,
Fauci AS, Kasper DL, et al., eds. Harrisons principle of internal medicine. 15th edn, vol. 1. New York: McGraw-Hill, 2001; 1303.
FURTHER READING
Marriott HJL. Practical electrocardiography. 8th edn. Baltimore, USA:
Williams & Wilkins, 1988.
Schamroth L. An introduction to electrocardiography. 7th edn. Oxford:
Blackwell Science, 1990.
Acknowledgement
This is an update of the original article by Emrys Kirkman (Kirkman E.
The electrocardiogram. Anaesthesia and Intensive Care Medicine
2006; 7: 264e6), which discusses some basic principles of the ECG.
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