See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/254738601

ECG interpretation in small animals : 3. Practical guidelines

Article  in  In practice · May 2002

DOI: 10.1136/inpract.24.5.250

CITATIONS READS

9 718

1 author:

Mike Martin
Independent Consultant Veterinary Cardiologist
64 PUBLICATIONS   1,011 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Ape Heart Project View project

Ape Heart Project https://twycrosszoo.org/conservation/research-at-twycross-zoo/current-research/ape-heart-project/ View project

All content following this page was uploaded by Mike Martin on 09 March 2017.

The user has requested enhancement of the downloaded file.

 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

A reliable connection, with

minimal animal movement,
is crucial in obtaining a good
quality, artefact-free ECG

ECG interpretation in smnall animmals

3. Practical guidelines MIKE MARTIN

THIS final article in the series outlines a step-by-step approach to interpreting electrocardiograms (ECGs)
and describes the significance of the various P-QRS-T morphologies which may be seen on a trace. It
concludes by providing practical guidance on recording an ECG and outlines the measures that can be
taken to reduce artefacts on ECG traces. The first two articles in this series reviewed the electrical activity
of the heart (Martin 2002a) and described the abnormalities associated with the conduction system of the
heart (Martin 2002b).

PRELIMINARY CONSIDERATIONS ECG interpretation essentially involves four main

Mike Martin
graduated from
Dublin in 1986. In
1997, he founded his
own cardiorespiratory
referral practice,
the Veterinary
Cardiorespiratory
Centre, in Kenilworth,
Warwickshire. He
holds the certificate
and diploma in
veterinary cardiology
and is an RCVS
Specialist in
Cardiology. He is the
current chairman
of the Veterinary
Cardiorespiratory
Society and is a past
recipient of the
BSAVA's Dunkin and
Melton Awards.
It is important not to overinterpret, or depend too
much on, ECG findings. Surface limb ECGs only show
a small percentage of the electrical activity of the heart
and this limits the information that can be gained
from them. Such ECGs are often poorly related to the
mechanical function of the heart and do not provide
information about the aetiology or severity of organic
heart disease. Therefore, a normal ECG does not neces-
sarily infer that the heart is normal and, likewise, an
abnormal ECG is not always indicative of heart disease.
If an ECG is abnormal, it is essential to determine its
clinical significance, and whether treatment is indicated
or not.
A good history and clinical examination is a prerequi-
site to an ECG recording - just as it is before choosing,
or interpreting the results of, any diagnostic tool. Parts I
and 2 of this series described the clinical findings in
animals with arrhythmias; from that discussion, it can
be seen, for instance, that atrial fibrillation and com-
plete heart block are good examples of arrhythmias
that can be strongly suspected from a thorough clinical
examination.
A STEP-BY-STEP APPROACH
When reading ECGs, it is useful to develop and apply a
set routine. ECGs should always be read from the begin-
ning (ie, from left to right). If an ECG is difficult to read,
start from the easiest (ie, most recognisable) part of the
tracing and then continue reading from left to right from
that point.
steps:
* Calculation of the heart rate;
* Determination of the heart rhythm;
* Measurement of the complex amplitudes and intervals;
* Measurement of the mean electrical axis.
CALCULATION OF THE HEART RATE
Once the animal has been examined and the heart rate
determined on auscultation, calculation of the heart rate
in terms of beats per minute should be fairly easy. The
simplest way to calculate the rate from an ECG is to
mark a six second strip on a representative part of the
tracing, count the number of complexes which appear
within this time frame and multiply this figure by 10. If
the P wave rate and QRS-T complex rate differ, these
should be recorded separately.
DETERMINATION OF THE HEART RHYTHM
Check if the complexes are complete (ie, whether there
is a P wave for every QRS-T complex, and a QRS-T
complex for every P wave).
Identifying parts of the ECG complex
In some instances, it can be difficult to identify P waves
or determine which features are the P waves and which
are the T waves (especially at fast heart rates). There are
a few general tips which can help with this:
* It is often useful to mark the position of each P wave
and QRS-T complex. These can be plotted on a separate
piece of paper placed below the ECG tracing (see Part 2).
This can help to establish if there is a pattern, or if there
are hidden complexes, and if a complex has occurred
before or after it was due, or expected, to occur.

250 In Practice * MAY 2002

 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

1 mm = 0-02 second
FL] * R wave amplitude and QRS duration;
* P-R interval - the time from the start of a P wave to
the start of the following QRS complex (strictly speak-
ing, this is a P-Q interval);
* Q-T interval - the time from the start of a QRS com-
plex to the end of the following T wave;
* T wave morphology;
* S-T segment elevation or depression.
These measurements can then be compared to the
normal values for a particular type or breed of animal to
check whether or not they are within the normal range
(see table below).

MEASUREMENT OF THE MEAN

Measurement of ECG
complex amplitudes and
intervals (calibration
I cm/mV, 50 mm/second).
From Martin and Corcoran
(1997). Reproduced with
permission from Blackwell
Science
* As the heart must always repolarise (to be depolarised
again), a T wave should always follow every QRS
complex.
* Using callipers, note the P-R interval and Q-T inter-
val for a run of beats. This will often reveal the identity
of each deflection, as the P-R and Q-T intervals will
generally remain fairly constant. This method is most
usefully performed on a stretch of the ECG in which
there is a variation in rate.
MEASUREMENT OF THE COMPLEX
AMPLITUDES AND INTERVALS
Complexes are usually measured on a lead II rhythm
strip at 50 mm/second (100 mm/second on a machine
with a computer-type printout) and on an unfiltered sec-
tion. At 50 mm/second, a 1 mm box is equivalent to 0-02
second (see diagram above). The calibration should be
noted and the following measurements recorded:
* P wave amplitude and duration;
ELECTRICAL AXIS
Measurement of the mean electrical axis (MEA) is of
limited value in small animals, partly because the vector
in the frontal plane (ie, the plane which is measured from
limb leads) is less representative of the true direction of
the vector in three dimensions than it is in humans. The
MEA is mainly used to assist in the assessment of
ventricular enlargement and in the recognition of intra-
ventricular conduction defects. Therefore, the benefit of
accurately measuring the MEA in every case is question-
able, as a rough estimate of whether it is orientated
towards the right or left is usually sufficient. Arguably,
however, an understanding of the MEA provides a better
understanding of the electricity of the heart.
Estimating the MEA
The MEA can be measured using a number of methods.
However, it is usually sufficient to gauge by eye whether
the MEA is normal or abnormal (see Part 2). The follow-
ing two options may be used:
* Using all six limb leads and the hexaxial lead system,
find the tallest QRS complexes - the MEA is approxi-
mately in this direction. Similarly, find the most negative
complexes, the MEA is opposite in direction to these;
* Alternatively, find the lead in which the QRS com-
plex is equally positive and negative (and usually small)
- this is called the isoelectric lead. The MEA will be per-
pendicular to this. Find which of the six limb leads is
perpendicular to the isoelectric lead. If the perpendicular
lead is positive, then the MEA is in that direction. If the
perpendicular lead is negative, then the MEA is in the
opposite direction to that lead.

CHANGES IN P-QRS-T MORPHOLOGY

0 .'Lei I V SI. SI
Dog Cat Changes in the P-QRS-T morphology are associated with
a change in the shape, size or duration of the P wave,
Heart rate Adult 70-160 beats per minute 120-240 beats per minute QRS complex or T wave.
Puppy 70-220 beats per minute
P wave duration < 0-04 second < 0 04 second
Giant breeds < 0-05 second P WAVE
P wave amplitude < 0-4 mV < 0.2 mV Wandering pacemaker
P-R interval 0.06-0 13 second 0-05-0 09 second A wandering pacemaker occurs as a result of the dominant
QRS duration < 0-05 second < 0-04 second pacemaker shifting from the sinoatrial node to other pace-
Giant breeds < 0-06 second
maker cells with a high intrinsic rate within the atria. This
R wave amplitude < 2-0 mV < 0.9 mV
Giant breeds <25 mV is sometimes referred to as a wandering atrial pacemaker.
S-T segment Depression < 0-2 mV No depression
Elevation < 0-15 mV No elevation ECG FEATURES
T wave amplitude < One quarter of the < 0-3 mV P waves can vary in morphology (ie, there is a variation
normal R wave amplitude
in amplitude) and can be positive, negative or biphasic,
Q-T interval 0 15-0 25 second 0-12-0-18 second
or even isoelectric. In addition, they can be so small that
Mean electrical axis +40 to +1 00' 0 to +1600
they are difficult to identify.

252 In Practice 0 M AY 2 0 0 2
 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

QRS COMPLEX Notching in the R wave

Low voltage QRS complexes
QRS complexes will be smaller the further the electrodes
are from the heart and depending on the resistance to
electrical conduction between the heart and the elec-
trodes. For example, the ECG complexes are larger in
precordial chest leads (because the electrodes are close
to the heart). However, complexes can be small in limb
leads in obese animals. Heavy filtering on the ECG
machine can also significantly reduce the amplitude of
the ECG complexes.
ECG FEATURES
An R wave amplitude of less than 0 5 mV in the limb
leads is considered small in dogs. QRS complexes are
usually small in normal cats.
Electrical alternans
Electrical altemans refers to an alternation in the size of
the QRS amplitude that occurs nearly every other beat.
Although abnormalities associated with notching in the
R wave are seen commonly in small animals with heart
disease, the significance of the notches is debatable -
recognition of the 'heart disease' is of greater impor-
tance than trying to analyse every minutiae. Notches in
the QRS complex are reported to occur with microscopic
intramural myocardial infarction or may be associated
with areas of myocardial fibrosis. Notches in the QRS
complex can be seen with intraventricular conduction
defects and a slight notch is sometimes also seen with
ventricular pre-excitation in the upstroke of the R wave
(delta wave). In addition, notches can be produced arte-
factually in tracings in which there is excessive muscle
tremor or electrical interference (see later).
S-T segment abnormalities
S-T elevation is seen in animals with:
* Pericarditis;
* Severe ischaemia/infarction (eg, full wall thickness).

ECG (lead 11) from a dog showing a normal sinus rhythm. The P wave morphology varies considerably this is termed
- a
wandering pacemaker

ECG from a dog showing a normal sinus rhythm but with small QRS complexes

.
- R -R- R

Io R

_le iA I

_~~mu m

ECG from a dog showing a normal sinus rhythm but with an alternation in the size of the QRS amplitude - this is termed
electrical alternans and is sometimes seen in dogs with severe pericardial effusion

ECG from a cat with dilated cardiomyopathy showing a normal sinus rhythm but with a notch (arrows) in the downstroke
of the QRS complex

In Practice 0 M AY 2 0 0 2 253
 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

ECG from a dog showing

a normal sinus rhythm "
but the S-T segment is
depressed (arrows)

Changes assoaed wiUm chamber elarg nt

The ECG should not be viewed as a means of diagnosing heart
enlargement in small animals, but rather as a diagnostic aid that
might help to support such a clinical suspicion. Chest radiographs
are often considered a more reliable indicator of heart enlarge-
ment, while echocardiography offers probably the best means of
assessing chamber size and morphology.
In 'ECG speak', the term enlargement is commonly used to
encompass either hypertrophy or dilation, as these conditions can
rarely be distinguished reliably on an ECG. Parameters are usually
measured in lead 11 at 50 mm/second, unfiltered.
Left atrial enlargement
When there is left atrial enlargement (or dilation), the P wave is
often prolonged and sometimes also notched. A prolonged and
notched P wave is referred to as P-mitrale (as left atrial enlarge-
ment is often associated with mitral valve disease). The notching
occurs as a result of asynchronous depolarisation of the atria, with
the dilated left atrium depolarising fractionally later than the right
atrium. It should be noted that in giant breeds a slightly prolonged
P wave is often a normal finding.
Right atrial enlargement
When there is right atrial enlargement (or dilation), the P wave
is increased in amplitude. These tall P waves are referred to as
P-pulmonale (as right atrial enlargement may be associated with
cor pulmonale). P-pulmonale is also commonly seen in breeds which
are predisposed to chronic airway disease.
Left ventricular enlargement
Tall R waves are suggestive of left ventricular enlargement. An R wave
in lead I which is greater than that in leads 11 or aVF may be associated
with hypertrophy. An increase in the amplitude of the R waves in leads
1, 11 and III may be associated with dilation. Other ECG features which
may be suggestive of left ventricular enlargement are a prolonged QRS
duration, S-T segment sagging/coving, or a shift in the MEA to the left.
Right ventricular enlargement
Deep S waves (in lead 11) are suggestive of right ventricular enlarge-
ment. Other ECG features which may be associated with right
ventricular enlargement are a prolonged QRS duration or a shift
in the MEA to the right.

p p
p p
.%10
_.- il,P _. K rI ~,% h
ECG (lead 11, I cm/mV, 50 mm/seond) from a dog
showing a normal sinus rhythm but with prolonged and
notched P waves ('M' shaped). This P wave morphology
is termed 'P-mitrale' and is considered to be suggestive
of left atrial enlargement, and Is commonly seen in
association with mitral valve disease
\4 '\(

P P P
p p
P p P

ECG (lead 11, I cm/mV) from a dog showing a normal Al F 0!

SPPt VI-
> 'S_
sinus rhythm but with tall P waves. This P wave
morphology is termed 'P-pulmonale' and is considered 0w
t~~~~~~~~~~~~~~~#V fb,F -lt
11.41.

to be suggestive of right atrial enlargement, and is

commonly seen in association with cor pulmonale

254 In Practice C M AY 2 0 0 2
 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

S-T depression is seen in animals with:

* Endomyocardial ischaemia (eg, cardiomyopathy, HyperI kalaemia
trauma); Hyperkaleaemia is a well known cause of ECG abnormalities, but it must be
* Potassium imbalance; remembei?red that a normal ECG would not exclude hyperkalaemia (or Addison's
E Digitalis toxicity. disease) and serum electrolyte levels should always be measured (and, where
a

T WAVE appropriaate, an adrenocorticotropic hormone test performed) if this is suspected.

Unlike in humans, the morphology of T waves in small
animals is very variable and the diagnostic value of
T wave changes is therefore limited. More value might
be placed on comparing T wave changes with a previous
recording in the same animal. The most common abnor-
mality is the development of large T waves. This can be
associated with hyperkalaemia (see box on the right) or
myocardial hypoxia.
The EC:G changes vary with increasing severity of the hyperkalaemia and include:
A proggressive bradycardia;
* Progrea sed amplitude of the T wave, producing a narrow and spiked appearance;
0Por ~ssive
decrease in amplitude of the R wave;
Progre ?ssive decrease in amplitude of the P wave;
E Disa pp :)earance of the P wave (ie, atrial standstill) with a sinoventricular
rhythm (si;ee Part 2);
U Ventri(icular fibrillation or asystole.

Abnormal MEA
A right axis deviation may suggest right ventricular enlargement, but
may be due to displacement of the heart within the chest to the right
side, or may even be a normal variation. A conduction disturbance
such as right bundle branch block also produces a right axis deviation.
A left axis deviation may indicate left ventricular enlargement,
but may be due to displacement of the heart within the chest to
the left, or may be a normal variation. A conduction disturbance
such as left anterior fascicular block also produces a left axis
deviation.

QRS

ECG (lead II, 0.5 cmi/mV, 50 mmlsecond)

from a dog showing a normal sinus rhythm
but the QRS complexes are very tall and
slightly prolonged. This QRS morphology is
suggestive of left ventricular enlargement

iaVR

II
t

aVL

......

aVF

ECG (leads I to aVF) from

a dog showing a normal
sinus rhythm. In lead II
there are deep S waves
and the cardiac axis is
towards aVK - this
indicates a right axis shift
which is suggestive of
right ventricular
enlargement

In Practice * M AY 2 0 0225 255

 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

RECORDING AN ECG MAKING THE CONNECTION

ELECTRODES
An ECG machine is connected to an animal's skin with a
connector which is known as an electrode. As animals
have a coat of hair, the sticky adhesive electrodes com-
monly used in human medicine are not practical for
everyday use, as a patch of hair would have to be shaved
in order to attach the adhesive electrode and, despite this,
the electrode is still not likely to stick properly to the
animal's skin! Such electrodes therefore require a ban-
dage or tape to be wrapped around the limb and elec-
trode to hold them in place.
The most commonly used electrode to connect an
ECG cable to an animal's skin is a crocodile clip. While
these provide an excellent electrical connection, their
bite can be painful to less stoic animals. To minimise
this pain, the teeth of a crocodile clip can be filed down a
little and the clips bent outwvards (until they are atrau-
matic but still stay in place). Alternatively, a small con-
ductive plate can be soldered onto the tip of the teeth.
Small metal plate electrodes (paediatric limb elec-
trodes) can be used instead of crocodile clips, but require
tape, bandage or an elastic rubber band to hold them in
place on the limb.
Making a reliable connection to obtain a good diagnos-
tic-quality tracing is the single most important part of
ECG recording. The following discussion relates to the
use of crocodile clips, as these are the most commonly
used type of electrode. However-, the same general prin-
ciples apply, irrespective of the type of electrode being
used, and so the description below can be adapted
accordingly.
Using spirit
When using crocodile clips, an adequate connection
is often achieved simply by pinching a told of skin
between finuer and thumb (rolling the skin to feel its
edge through a hairy coat) and, with the other hand,
opening the crocodile clip fully, parting the hair and
attaching the clip to the skin. Good conduction between
the skin and crocodile clip may be enhanced with the use
of a conducting medium. A little spirit (or alcohol),
sprayed just enough to wet the crocodile clip and the
skin through the hair, is usually adequate. However, spir-
it evaporates after five to 10 minutes and, if the ECG
recording takes longer than this (such as during anaes-
thetic monitoring), this method will not suffice. In such
cases, or where spirit does not produce a good quality
artefact-free recording, gel should be used (ECG gel is
ideal, but ultrasound gel or K-Y Jelly are cheaper alter-
natives). The gel can be applied after the clips have been
attached, which is usually easier than applying the gel
first and then trying to open the crocodile clips with slip-
pery fingers!

Crocodile clips are commonly WHERE TO PLACE THE ELECTRODES

used in small animal practice. Electrodes are attached to each of the four limbs, using
The middle and lower ones in
this picture have had their a
the correct ECG cable for each corresponding limb
'teeth' filed down and the (see Part 2). The precise location on the leg is not
lower one has also been bent
outwards; this helps to reduce too critical. Essentially, a good loose fold of skin, prefer-
the severity of the clip's bite ably with little hair, is required. Pinching the skin at
various sites on the limbs of the animal will identify
the best site.
OlAr r,l-",-
Forelimbs
In the author's experience, the flexor angle of the elbow
is a useful site. An alternative site is caudal and just dor-
Paediatric limb electrodes sal to the elbow; however, since this is close to the chest,
(Callatec) may be used in
-less stoic animals and are respiratory movement can cause the cable and clip to
especially useful for cats. move, resulting in movement artefact on the ECG trace.
They are held in place with Another possible site is halfway between the elbow and
sticky tape such as Micropore
(3M) carpus, on the palmar aspect of the leg.

',IIi
,',*
JB)

A crocodile clip can be attached to the skin at, for example, the flexor angle of a dog's hock. (A) Pinch a good piece of skin, rolling the skin to feel its edge
through a hairy coat. (B) Position the crocodile clip with its jaws fully open and over the skin as far as possible. This ensures maximum skin-to-clip contact (C)

256 In Practice * M AY 2 002

 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

POSITIONING THE ECG CABLES

In addition to the above, it is prudent not to place the
crocodile clips so that the ECG cable runs over the ani-
mal, as this can lead to respiratory movement artefact.
Also, take care not to twist the cable and ultimately the
clip and skin - even the most stoic animals may not
tolerate this. When applying the crocodile clip, position
the ECG cable so that it is away from the animal and
resting on the table (or ground).

POSITIONING THE ANIMAL

Gel can be applied after the clips have been attached by
rubbing the gel over the clips and the surrounding skin
Hindlimbs
In the author's experience, the flexor angle of the hock
(or sometimes just above this) is a useful site. Alternative
sites are either above or below the knee, on the dorsal
aspect of the limb.
ISOLATING THE ELECTRODES
Once all the electrodes have been attached, it vital to
ensure that none of the electrodes, the skin to which they
are attached or the conducting medium (ie, the spirit or
gel) is touching any other part of the animal, the handler
or the table. Such contact can potentially cause electrical
shorting and introduce artefacts into the ECG recording.
To minimise the electrical activity of the skeletal
muscles, the animal must be relaxed and resting. Any
trembling, shaking, panting or purring will show up
as baseline artefact on the ECG trace. This may obscure
small ECG complexes such as P waves, especially in
cats, or mimic ECG activity. A good quality ECG should
have minimal movement, with a nice steady baseline in-
between each ECG complex. If an animal would be put
at risk (for example, if it was in respiratory distress) by
making it adopt a particular position for ECG recording,
then the ECG should be obtained in whatever position is
achievable.
* DOGS. Dogs should preferably be placed in right lat-
eral recumbency. A recumbent position will, in many
dogs, reduce skeletal muscle electrical activity, and nor-
mal ECG values for the dog have been determined based
on this position. If measurement of amplitudes is not
critical, such as when examining an animal primarily for
an arrhythmia, then recording the ECG while the dog

Setting up and preparation of the ECG machine

The setting up and preparation of an ECG
machine will vary a little between different
models and adjustments to the guidelines
outlined below (which are based on a stan-
dard ECG machirw) should be allowed.
Paper speed
Select the paper speed. Options usually
include 25 or 50 mm/second and sometimes
100 mm/second. The paper speed selection
is partly dependent on the animal's heart
rate. As a guide, for normal heart rates in
dogs, set the speed at 25 mm/second, but if
there is a fast heart rate (and routinely for
cats) set the pVer speed at 50 mm/second.
For ECG machines with a computer-type
printout, which produces a 'stepped' effect
in the lines (ie, pixel effect), measurement
of ECG complex durations is best achieved
at 100 mm/second.
Calibration
Calibration is usually set at 1 cm/mV. How-
ever, if the complexes are very small this
can be increased to 2 cm/mV; alternatively,
if they are very large, it can be reduced to
0.5 cm/mV. The calibration should be mark-
ed on the ECG paper by briefly running the
ECG paper and pressing the 1 mV marker
button - found on most standard ECG
machines.
Filter setting
In an ideal situation, if good connections
have been made, this function can usually
be left off (ie, no filter). Measurement of
amplitudes should always be performed on
an unfiltered tracing, as the dampening
effect of the filter will reduce the ampli-
tude of the complexes by a variable (albeit
small) amount. If an animal is being exam-
Clipping
ined primarily for an arrhythmia and there
is baseline artefact that appears to be diffi-
cult to avoid, filtering can reduce this arte-
fact and make reading of the ECG tracing
easier.
Positioning the stylus
During the recording, the stylus should be
positioned so that the whole of the ECG
complex appears within the graph lines of
the ECG paper (and does not extend into the
white margins). When the complexes are so
large that they run off the graph paper (or
outside the limits of the stylus), this is
referred to as clipping. In such cases, the sty-
lus should be moved up or down, so that the
whole of the ECG trace moves to within the
limits of the graph paper or, alternatively,
the calibration may be reduced, whichever is
more appropriate.

U i

I
ECC shwing the effect
-_-_w
j -.. : of dcljppin f ths went
unnotki, the R wave
amplitude could be
misakenlymsurd as
~~ ~~ &4~~~ IS-8mV. Hw ver wen
42>-"32\u"~~ths8tylsI repostioed
I- it is found to be 2-4 mV
Stylus repositioned
In Practice e M AY 2 0 0 2 257
 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

Suggested routine for recording an ECG

Physical examination
Perform a routine cardiovascular examina-
tion. In particular, note the heart and pulse
rates, and heart rhythm and determine
whether there are any pulse deficits. Ensure
that the ECG recorded is representative of
any clinical findings.
10 seconds of all six limb leads
Run the ECG on all of the six leads (I, II, III,
aVR, aVL and aVF) for approximately 10 sec-
onds each. Ensure that each lead is well
centred within the graph lines of the ECG
paper, briefly pause the ECG paper (with the
stylus still moving) when switching the ECG
machine from one lead to the next, until the
stylus can be repositioned as described in
the box on page 257.
A rhythm strip
Switch back to lead 11 and record a long
rhythm strip for 30 to 60 seconds, depend-
ing on the requirements of the individual
case. If an occasional abnormal beat was
heard on auscultation, the ECG rhythm strip
will need to be run until that abnormal
beat is repeated. If lead 11 does not produce
a good quality tracing with satisfactorily
large complexes, run the rhythm strip on a
lead that does. When searching for P waves
(which can often be small and hard to see)
run the ECG on the limb lead in which these
are best shown.
A representative rhythm strip
If an arrhythmia was heard on auscultation,
but is not revealed on the ECG rhythm strip,
simultaneously auscultate the animal while
continuing to run the ECG recording. It is
possible that the abnormality is only pre-
sent intermittently, in which case continue
to auscultate the animal until the arrhyth-
mia is heard and hopefully captured on the
ECG. If the arrhythmia is still audible on
auscultation, but not recognised on the
ECG, the ECG tracing should be sent to
a cardiologist for interpretation. It should
be noted that the abnormal heart sounds
heard may not be an arrhythmia but, for
example, could be a gallop sound. In
summary, ensure that the ECG recording
obtained is representative of any physical
examination findings.
Label the tracing
Ensure the ECG recording is well labelled
(unless the ECG machine does this automat-
ically) so that it can be used for future ref-
erence, or in case other colleagues within
the practice need to examine the recording,
or the tracing has to be submitted to a car-
diologist for interpretation.
The following information should be
clearly labelled on an ECG trace:
* The position in which the animal was
restrained;
* Whether any chemical restraint was used;
* The paper speed and if, and where, it
was changed;
* The calibration and if, and where, it was
changed;
* The filter level and when, and where, it
was used;
* Each lead at the beginning of the corre-
sponding trace.

lies, sits or (2\5(1 staids is aIcccptablc. prosided a tood air(2 the author s pi-ctct-rct ehloiee 10lol- ts). halhkvcd inI
c uqal1ity trac in sw ith minimal baseClin 1mo emIcnlt arCteClaet plae. with Mictopore tapc. ial- .asici esCen th1on-ch thleilt
c.an be obt(aincd. 115( isIsn)r( tilinc eonSmI-11ni11.
* C ATS. Tthinormal VI adlIes lot- eats 11hasVe no0t beeCn deCtCt--
mIinedI inl aI laItCrall teColmbenlht position, Cand so recumblllncll- CHEMICAL RESTRAINT
cx is Icss im1portant ill cats. Many ea.ts sw ill otten sit qluite \ll sedlatisc and t -inqUillisel Ci nLI has 11e
\ a a ableC Ctt

Recording an ECG in a dog.
Note that the forelimb clips
are positioned at the flexor
angle of the elbows and the
hindlimb clips are placed at
the flexor angle of the
hocks. The ECG cables run
away from the dog
Still in a holnchetd position. htIt C'ICh Cat is dttierenit and
the sveterlinatN- silI 2(1)1
C muLIst dleter-mllinle hos thic inclisid-
ital animal prtctCIs to kcc) still. In friactions cats, a usetul
imiethod (.tssuLmIine,> the electrodes ccan be plavedl is to
put the animai.ll back in a basket. together sith the clcc-
trodes atnd ECG caibles attached:l shen. or if. the cat sct-
tles. the ECG can he r-eci)-ded s hile the cat sits in the
basket. This imlethodi sholId, of CoUisc, bc (aborted it' the
cat starts to hite the ECG cables. Cats ottcln rcsclt the
uSe Of) cr-ocodilc clips and so pauledi atric clecti-odes (wshich
oni thi heart and/or antonIomIiC tonie. D[)il-Is Can1 tlCe-CtoreC
chan ,c thc llttc aInd rwhsthin ot the. 11cairt dir etlt o0-
th l-oneh-(211Cects mi aLltaitolno iC tonIC.
Il an ECG is bein' pertfor1med to cIharatctlisc an
at rh- thin a hcard oni aLnsICntlati)tOl. the.C', is a possi it\
tlht thlis ill C1ehaneC it C11chiclCt1 I-CStl-Milt is LIseCd andI a
rep-cseniltatise ECG sill n1ot bc obtaitiel. Idcally. tlhel-e-
tote. anW lol-ilm t eh emiciC"Al Irsntlainit shoUld be asooidlc
prior to i-ecording- (an ECG. It is bette- to obtain an ECG
i-ccortdino iln ax11v positiol (ic. do1 not sot-i ahbont I-Ceo-d-

Recording an ECG in a cat. Paediatric electrodes are being

used instead of crocodile clips and are tolerated very well
- the cat is more concerned about the photographer!

258 2In Plractice * MAD 2002

 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

ing in the 'official' right lateral position in difficult ani-
mals) rather than resort to sedation. If crocodile clips are
a little too painful to be tolerated by cats or sensitive
breeds of dog then paediatric limb electrodes can be
used, as described above.
If chemical restraint cannot be avoided, then the heart
and pulse rates, and heart rhythm should be determined
by physical examination before and after the use of
restraining drugs, and any differences taken into account
when interpreting the ECG.
The problem of electrical interference can be correct-
ed by:
* Ensuring that the skin-to-clip connections are good
and that they are insulated (isolated);
* Ensuring that the animal is insulated from the surface
of the table or floor by placing a rug under it;
* Ensuring that the ECG machine is earthed (to the
building); alternatively, run the ECG machine using a
battery instead of the mains electricity supply;
* Insulating the handler from the dog by ensuring they
wear gloves.

ARTEFACTS MUSCLE TREMOR ARTEFACT

Artefacts are abnormal deflections reproduced on an
ECG recording which are not associated with the
electrical activity of the heart. They have the potential
to either mask the ECG or mimic ECG activity and,
therefore, the production of an artefact-free tracing is of
paramount importance.
ELECTRICAL INTERFERENCE
Electrical interference produces fine, rapid and regular
movements on the baseline of the ECG recording. Such
movements are often associated with interference due
to electrical lines (ie, electromagnetic interference) within
the room in which the recording is being made. Interfer-
ence may be transmitted by the person restraining the ani-
mal, who acts as an aerial, or through the power line of
the ECG machine. The fine deflections usually occur at a
rate of 50/second (60/second in the USA) which corre-
sponds to the frequency of the mains electricity.
A muscle tremor artefact can look a little similar to
electrical interference, but the fine deflections in this
instance are not regular, but fairly random. This type of
artefact can be produced by the animal trembling or
shaking, or by recording an ECG in a standing animal.
Purring in a cat will also result in baseline 'trembling'!
The problem of muscle tremor artefact can be correct-
ed by:
* Ensuring that the limbs are relaxed and supported;
* Placing the animal in the position in which it will
relax best, preferably not standing;
* Holding the limbs to minimise the tremor;
* Dabbing a little spirit on a cat's nose using cotton
wool to stop it from purring.
MOVEMENT ARTEFACT
Movement artefact is a more exaggerated form of tremor
artefact and deflections are variable and large as a result
of the stylus moving up and down the paper. This type of

ECG showing a 50-cycle

alternating current (AC)
interference for the first
half of the trace, making it
FHIPIj , , ,,,,ji',wI q.W difficult to identify any
~~~~~~~~6P waves. When the filter is
~~~~~~'
, t ,j i switched on, the P waves
Filter turned on are unmasked

__y!\ .s E - 9 -< , ,
ECG showing mild muscle
tremor artefact for the first
half of the trace, after which
the filter is turned on
t Filter turned on

ECG from a cat showing an

intermittent artefact due to
purring (as indicated)

ECG showing excessive

baseline movement
associated with limb
PS 50-3
movement

In Practice * M AY 2 002 2
259
 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

A r
; d' vi#S~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~'
l~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
i
:;"*
k.-v
*. 1-1-11
ECG showing the baseline moving up and down - this is associated with movement of a forelimb in time with breathing

II
iI
I
'IH
11
.k.
i;\ 'I

II I.'l'li
'1 * I'
/\. Ifs (A. .
Acknowledgement
it This article is based on material
* Il published in the author's book
.;
entitled 'Small Animal ECGs: An
'. IN
1%
1
Introductory Guide' (2000),
i*AV,
l ., Oxford, Blackwell Science, and
Ill is reproduced with permission
*II %sy "..''.
of the publisher.
.
; 9 il
0,;
>t.
;. Further reading
~ I~ ~ ~ ~~~~~~~~~~~~~~~~~~~~~~~~ ;
~ , ,, DARKE,P., BONAGURA, J. D.
.I .l iI
t I 4. : & KELLY, D. F. (1996) Color
I
l ,~ i i Atlas of Veterinary Cardiology.
London, Mosby-Wolfe
ECG (leads 1, 11 and 111) showing movement in leads 11 and Ill but not lead 1. The interference is therefore due to movement FOX, P. R., SISSON, D. & MOISE,
N. S. (1999) Textbook of Canine
of the left hindlimb and Feline Cardiology.
Philadelphia, W. B. Saunders
KITTLESON, M. D. & KIENLE,
artefact may be caused by respiratory movements, or the SUMMARY
- - - - - - - --- - -
R. D. (1998) Small Animal
Cardiovascular Medicine.
animal moving or struggling. St Louis, Mosby
The problem of movement artefact can be corrected ECG interpretation relies on a good unders,tanding of the LUIS FUENTES, V. & SWIFT, S.
by the various ways discussed above for tremor artefact, electrical activity of the heart which relates directly to the (1998) Manual of Small Animal
Cardiorespiratory Medicine and
as well as by: complexes seen on an ECG trace. Howeverr, it is essential Surgery. Cheltenham, BSAVA
* Trying to get the animal to relax and remain still; that the results of any diagnostic tool such as electrocar- MARTIN, M. (2000) Small
Animal ECGs: An Introductory
* Ensuring that the ECG cables are not moving with diography are always evaluated with a sounid appreciation Guide. Oxford, Blackwell
movement of the animal (eg, respiratory movement), or of the history and clinical findings. Varrious types of Science
.
..ical findins MARTIN, M. (2002a) ECG
because the clips are not stable and secure. arrhythmia may be seen in practice; the cl ini11cal fin1d1ings interpretation in small animals.
of the most important ones are summarised below. 1. Understanding the electricity
of the heart. In Practice 24,
WHICH LEG MOVED? 114-123
By identifying the appropriate electrode connections for 1&11117mIJI _0
KO3
MARTIN, M. (2002b) ECG
interpretation in small animals.
a given lead (see Part 2), it is possible to determine 2. Abnormalities in the
which leg is moving or causing connection problems. Rhythm Pulse deficit conduction system. In Practice
For example, if interference is seen in leads I and II, the 24, 194-203
Regular MARTIN, M. & CORCORAN, B.
connection that is common to these leads - that is, the Sinus rhythm No (1997) Cardiorespiratory Disease
Sinus tachycardia No of the Dog and Cat. Oxford,
right forelimb - needs to be checked and improved or Sinus bradycardia No Blackwell Science
the leg held still. If interference is seen in leads I and III, Ventricular tachycardia ?No (weak) SMITH, F. W. R. & TILLEY, L. P.
the left forelimb needs to be checked, and if interference Supraventricular tachycardia ?No (weak) (1992) Rapid Interpretation of
Heart block (A sounds) No Heart Sounds, Murmurs, and
is seen in leads II and III, then the left hindlimb needs to Arrhythmias. Philadelphia,
Regularly irregular
be checked. Sinus arrhythmia No Lea & Febiger
TILLEY, L. P. (1992) Essentials
Tripping in the rhythm of Canine and Feline
INCORRECTLY PLACED ELECTRODES Ventricular premature complexes Yes Electrocardiography:
Supraventricular premature complexes Yes Interpretation and Treatment,
Incorrectly placed electrodes may result in inverted com- Sinus arrest or block No 3rd edn. Philadelphia, Lea &
plexes or a bizarre mean electrical axis. It is worth not- Chaotic Febiger
ing that P waves are nearly always positive in leads I, II Atrial fibrillation Yes (>50%) TILLEY, L. P. (1992) Self
Frequent ventricular premature complexes Yes Assessment: Small Animal
and III. If this is not the case, double-check the position Frequent supraventricular premature complexes Yes Arrhythmias. Philadelphia,
of the ECG cables. Lea & Febiger

In Practice I M AY 2 0 0 2 261
 Downloaded from http://inpractice.bmj.com/ on November 6, 2014 - Published by group.bmj.com

ECG interpretation in small animals: 3.

Practical guidelines

Mike Martin

In Practice 2002 24: 250-261

doi: 10.1136/inpract.24.5.250

Updated information and services can be found at:

http://inpractice.bmj.com/content/24/5/250

Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/

View publication stats