National Center for Competency Testing 7007 College Boulevard, Suite 705 Overland Park, KS 66211

COURSE DESCRIPTION
This CE course will review cardiovascular anatomy and physiology, ECG machine components, ECG paper, electrodes, lead wires Performance of ECG, Common ECG technical issues and resolution, and ECG abnormalities in common cardiology disorders. A glossary of commonly used terms in the cardiovascular system, performance of ECG, and cardiac disorders is included.

Rev 2.0 August 2009

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COURSE TITLE: A Review of the Cardiovascular System and ECG Performance, Troubleshooting, & Interpretation Author: Lucia Johnson, MA Ed, CLS(NCA), MT(ASCP)SBB Director, Continuing Education NCCT Number of Clock Hours Credit: 6 CH Course # 1220909 P.A.C.E. Approved: Yes X No

OBJECTIVES Upon successful completion of this course student will be able to:
1. Describe the anatomy and physiology of the cardiovascular system. 2. Identify the critical characteristics of an ECG tracing and their relationship to the cardiac cycle. 3. Define terms related to the cardiovascular system and ECG. 4. Explain how the heart generates electrical signals. 5. Describe the cardiac cycle and electrical conduction system. 6. Identify measurements found on ECG paper. 7. Identify the placement of limb and chest electrodes/lead wires. 8. Correlate lead wire color-coding with placement on limbs/chest. 9. List the 12 leads recorded on the ECG tracing. 10. Describe the characteristics of the ECG machine. 11. Describe components of normal ECG waveform. 12. Identify causes of ECG tracing technical issues and methods used to correct them. 13. Identify and recognize ECG waveform abnormalities in common cardiovascular disorders. 14. Define commonly used terms in the cardiovascular system, performance of ECG, and cardiac disorders.

Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions.

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INTRODUCTION
This continuing education course consists of a review of cardiovascular anatomy and physiology, ECG theory, performance, troubleshooting, and interpretation. A glossary of terms is included at the end of the course.

CARDIOVASCULAR ANATOMY AND PHYSIOLOGY

The Circulatory System The circulatory system consists of the heart and blood vessels. Together, these provide a continuous flow of blood to the body, supplying the tissues with oxygen and nutrients. 1. Blood Vessels: There are four types of blood vessels: arteries, veins, capillaries, and sinusoids. A. Arteries Arteries carry blood away from the heart and distribute it to all parts of the body. Oxygenated blood is pumped out of the heart through the aorta, the body's main artery. Arteries that branch off the aorta transport blood throughout the body, supplying tissues with oxygen and nutrients. Arteries have thicker and stronger walls and are under higher pressure than veins. Arterioles are the smallest branches of the arteries and are the sites of highest resistance in the cardiovascular system. B. Veins Veins carry blood back towards the heart. Capillaries, tiny vessels in the organs and tissues, deliver deoxygenated blood into small veins called venules, which join to form veins. Blood flows through the veins to the body's two main veins, the superior and inferior vena cava. These veins carry the blood back into the heart. Veins have the lower pressure than arteries. Veins contain valves that prevent backflow. C. Capillaries Capillaries are exchange sites where oxygen and nutritive materials from the oxygenated blood diffuse across the wall of the arteriolar end of the capillary into tissue spaces, and the waste products and carbon dioxide diffuse from the tissue spaces into the blood through the wall of the venous end. Capillaries are thin-walled, which allows for the delivery of oxygen and the removal of waste products.

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Capillaries Source: United States Federal Government, public domain

Capillaries are not found in the corneas, epidermis, and hyaline cartilage, and other areas where arterioles and venules have direct connections (arteriovenous anastomoses). Capillaries are present in the skin, nose, lips, fingers, ears, where they also function to conserve body heat.

D. Sinusoids Sinusoids are wider than capillaries. Sinusoids serve as a substitute for capillaries in the spleen, red bone marrow, liver, parathyroid glands, adenohypophysis, and suprarenal cortex. 2. Circulatory Loops A. Pulmonary circulation: Blood pumps from the right ventricle of the heart to the lungs through the pulmonary arteries and returns it to the left atrium of the heart through the pulmonary veins.

Pulmonary Circulation Source: United States Federal Government, public domain

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B. Systemic circulation: Pumps blood from the left ventricle of the heart through the aorta to all parts of the body and returns it to the right atrium of the heart through the superior and inferior vena cava and the cardiac veins. C. Blood Pressure The pressure exerted on the walls of blood vessels by the flowing blood varies during different phases of the cardiac cycle. Arterial blood pressure is pulsatile and it is not constant during a cardiac cycle. It is highest during systole, when the ventricles are contracting and lowest during diastole, as the heart is relaxed and blood is being returned to the heart. Blood pressure is measured in millimeters (mm) of mercury (Hg) using a sphygmomanometer, an instrument that consists of a pressure recording device and an inflatable cuff that is usually placed around the upper arm. Normal blood pressure in an adult is about 120 mm of mercury during systole, and about 80 mm of mercury during diastole. Blood pressure is usually noted as a ratio of systolic pressure to diastolic pressure; i.e.,120/80. Pulse pressure is the difference between systolic and diastolic pressures. A person's blood pressure may increase for a short time during moments of stress or strong emotions. However, a prolonged or constant elevation of blood pressure, a condition known as hypertension, can increase a person's risk for heart attack, stroke, heart failure, kidney failure, and other health problems.

Sphygmomanometer & stethoscope Source: CDC, public domain

Electronic Sphygmomanometer Source: Julo, public domain

The Heart 1. Anatomy A. General The heart is a hollow muscular organ located inside the chest cavity (thorax) that pumps blood through the body. It weight about one pound and is about the size of a closed fist. The heart is the circulatory system's power supply.

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The Human Heart Source: Wapcaplet, public domain

B. Heart chambers The heart has four chambers. The upper two chambers, the right and left atria, are receiving chambers for blood. They collect blood from veins. The atria have relatively thin walls compared to the ventricles. The heart's lower two chambers, the right and left ventricles, are the powerful pumping chambers. The ventricles pump blood into arteries. C. Heart wall The heart wall consists of three layers: epicardium (outer area), the myocardium (middle layer), and the endocardium (inner layer). The lining of endocardium helps blood flow smoothly and prevents blood clots from forming inside the circulatory system. D. Pericardial sac The pericardial sac is a double-layered fibrous membrane that surrounds the heart. The outer layer of the pericardium is attached to the sternum (breastbone) and other structures in the chest cavity and helps hold the heart in place. Between the two layers of the pericardium is a thin space filled with pericardial fluid, a watery fluid that helps prevent these layers from rubbing against each other when the heart beats. E. Septum: The heart is separated by the septum (a wall of tissue) into right and left sides. Each side pumps blood through a different circuit of blood vessels. 2. Coronary blood supply The heart is nourished not by the blood passing through its chambers but by a specialized network of blood vessels, the coronary arteries, which encircle the heart like a crown.
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Three main coronary arteries, the right circumflex, the left circumflex, and the left anterior descending, nourish different regions of the heart muscle. The veins running through the heart muscle converge to form a large channel called the coronary sinus, which returns blood to the right atrium.

3. Heart Valves The heart has four valves, which help prevent blood from flowing backward in the heart. The valves open easily in the direction of blood flow. Two valves, known as the atrioventricular valves, are located between the atria and ventricles. o The right atrioventricular valve is formed from three flaps of tissue and is called the tricuspid valve, while the left atrioventricular valve has two flaps and is called the bicuspid or mitral valve. o The tricuspid is most audible over the right lower part of the body of the sternum. The mitral valve is most audible over the left fifth intercostal space at the midclavicular line. The other two valves, called semilunar valves, are located between the ventricles and arteries. They are called semilunar valves because they each consist of three half-moon-shaped flaps of tissue. o The right semilunar valve, between the right ventricle and pulmonary artery, is also called the pulmonary valve. o The left semilunar valve, between the left ventricle and aorta, is also called the aortic valve. o The pulmonary valve is most audible over the left second intercostal space. Although the right and left halves of the heart are separate, they both contract in unison, producing a single heartbeat. A stethoscope is used to detect internal body sounds, including the sounds produced by the heart as it is beating. The characteristic heartbeat sounds are made by the valves in the heart and not by the contraction of the heart muscle itself. The sound comes from the leaflets of the valves slapping together. The closing of the atrioventricular valves, just before the ventricles contract, makes the first heart sound. The second heart sound is made when the semilunar valves close. The first heart sound is generally longer and lower than the second, producing a heartbeat that sounds like lub-dub, lub-dub, lub-dub.

Stethoscope Source: HujiStat; public domain Page 7 of 47

4. The Cardiac Cycle The cardiac cycle is the sequence of events from the beginning of one heartbeat to the beginning of the next one. The cardiac cycle has two phases: diastole, when the hearts chambers are relaxed, and systole, when the chambers contract to move blood. o During systole, the atria contract first, followed by contraction of the ventricles. o During diastole, both atria and ventricles are relaxed, and the atrioventricular valves are open. o Blood pours from the veins into the atria, and then into the ventricles. o Systole then begins as the atria contract to complete the filling of the ventricles. o The ventricles contract next, forcing blood through the semilunar valves and into the arteries, and then the atrioventricular valves close to prevent blood from flowing back into the atria. o As pressure rises in the arteries, the semilunar valves snap shut to prevent blood from flowing back into the ventricles. o Diastole then begins again as the heart muscle relaxes, first the atria, then the ventricles, and blood begins to pour into the heart once more. 5. Properties and Characteristics of Cardiac Cells Two cell types are found in the heart: myocardial cells and pacemaker cells. Myocardial cells, found in the hearts muscular layer, contract when stimulated electrically. Specialized pacemaker cells in the sinoatrial node determine the overall rate of contractions. An average resting pulse of 70-80 beats per minute.

The hearts rhythmic contractions occur spontaneously, although the rate of contraction can be changed by nervous or hormonal influences, exercise and emotions. 6. Electrical conduction system of the heart The heartbeat begins with the pacemaker muscle cells in the sinoatrial (SA) node located in the upper right-hand corner of the right atrium. These cells generate electrical signals that synchronize with other electrical signals traveling to the rest of the heart. Impulses generated by the SA node spread rapidly throughout the atria, so that all the muscle cells of the atria essentially contract in unison. Electrical impulses cannot be conducted through the partition between the atria and ventricles, which is primarily made of fibrous connective tissue rather than muscle cells. The impulses from the SA node are carried across this connective tissue partition by a small bridge of muscle called the atrioventricular conduction system. The first part of this system is a group of cells at the lower margin of the right atrium, known as the atrioventricular (AV) node. Cells in the AV node conduct impulses relatively slowly, introducing a delay of about two-tenths of a second before an

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impulse reaches the ventricles. This delay allows time for the blood in the atria to empty into the ventricles before the ventricles begin contracting. After making its way through the AV node, the impulse passes along a group of muscle fibers called the bundle of His, which span the connective tissue wall separating the atria from the ventricles. Once on the other side of that wall, the impulse spreads rapidly to the muscle cells that make up the ventricles. The impulse travels to all parts of the ventricles with the help of a network of fastconducting fibers called Purkinje fibers. These fibers are necessary because the ventricular walls are thick and massive. If the impulse had to spread directly from one muscle cell to another, different parts of the ventricles would not contract together, and the heart would not pump blood efficiently. Although this complicated circuit has many steps, an electrical impulse spreads from the SA node throughout the heart in less than one second. Transmission of the impulse from the SA node to the ventricles called depolarization, which is followed by repolarization or electric recovery, and after that, the heart is resting in the polarization phase of cardiac cycle. Then, the entire cycle starts again. The cardiac cycle consists of depolarization, repolarization, and polarization (or atrial contraction, ventricular contraction, recovery and rest). Normal heart beat rhythm is 70-80 BPM (beats per minute). Some factors may increase or decrease heart rate, depending on different regulatory mechanisms. For example, when a person moves to a standing position, blood suddenly pools in the leg veins, causing a decrease in venous return to the heart, decreasing cardiac output and arterial blood pressure.

ELECTROCARDIOGRAPHY
1. The Cardiac Cycle and Electrocardiography The electrocardiogram (ECG) is a commonly performed cardiac test. It is used to diagnose and monitor various cardiac disorders. ECG is sometimes abbreviated EKG from the German word Elektrokardiogramm. EKG is often considered the better abbreviation for electrocardiogram, as ECG could be mistaken for EEG (electroencephalography) on a handwritten test order. An ECG is a recording of the electrical activity of the heart. Electrodes are placed on specific areas of the skin and then attached to an ECG machine; the machine records either an upward or a downward deflection (movement) from a baseline on a specifically designed paper printout. Upward movements from the baseline are considered positive; downward movements are considered negative. The strength or voltage of the electrical impulse determines the size of the deflection; i.e., large voltages cause larger deflections and smaller voltages cause smaller deflections. The deflections are called waves and are given specific names.

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Specific medical conditions that may cause changes in the ECG pattern, include, but are not limited to: enlarged heart (congenital defects, high blood pressure, congestive heart failure, heart valve disorders); conduction disorders (conditions that make the heart beat too fast, too slow, or at an irregular rate); electrolyte disturbances (imbalances in the bodys chemical substances like sodium, potassium, calcium, magnesium, etc.); pericarditis (inflammation or infection of the pericardium, the sac that surrounds the heart); valve disease (obstruction of blood flow through the valves into the chambers); and chest trauma.

ECG tests may also be ordered as part of a routine examination, as part of a pre-surgical workup to make sure there are no abnormalities, to check pacemaker function, to check the effectiveness of certain heart medications, and to check the status of heart function following cardiac procedures such as cardiac catheterization, open heart surgery, etc. The accuracy of the ECG varies with the condition being tested. Some heart conditions are not detectable all the time, and others may never produce any specific ECG changes. 2. Electrocardiograph (ECG) Machines There are many types of ECG machines in use today. Most incorporate computer hardware and software that allow for data entry of pertinent patient information. The main components of a basic ECG machine are: a cable that splits into individual wires called leads and collects the electrical signals from the skin and transfers them to the machine, an amplifier to increase the strength of the received electrical signals (galvanometer), electronics that gather the electrical information and translate it into a readable form, strip recorder with paper, and a stylus.

The stylus reacts to electrical signals from the galvanometer and traces the ECG pattern on the paper. The tracing is made via pen/ink, heat transfer, or laser. For ECG machines that contain computer hardware and software, there is a visual view of the tracing on a monitor, interpretation of tracings, storage of patient data and test results, and interfaces to transfer information to the patients electronic medical record.

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3. Electrocardiograph Paper Electrocardiograph paper is graph paper that is heat and pressure sensitive. Each small square measures 1 mm by 1 mm. Every fifth horizontal or vertical line is thicker and divides paper in to squares that are 5 mm by 5 mm.

A 5 mm by 5 mm square of ECG paper

ECG paper with tracing; source RMGH, Glendale, CA

4. Electrodes (Sensors) The electrodes are small plastic tabs that attach to the skin much like an adhesive bandage. Each electrode is made up of a very thin metal layer (usually stainless steel or silver wire) and a thin layer of gel which is an electrolyte. The electrolyte assists with the transfer of the electrical current from the heart to the ECG machine. Electrodes are placed in specific areas as described in the following section and are attached to the lead wires via mini-alligator (or similar) clips. 5. Lead Wires The word lead in electrocardiography can be confusing as it has two meanings. It can mean: 1. the wire that connects an electrode to the electrocardiograph machine OR 2. a combination of electrodes that form imaginary lines in the body along which the electrical signals are measured.
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This section will discuss leads as defined in #1. Lead wires are color-coded and, in the United States, the color-coding is standardized among manufacturers. Each lead is attached to a different electrode and each lead will provide different view of the heart (front to back, side to side, etc.). A standard ECG has 10 electrodes and 10 lead wires, resulting in 12 different views or electronic pictures of the heart. This is the origin of the term 12 Lead EKG. Electrode/Lead Wire Placements Limb Leads Four electrodes are placed on the inner portions of the arms and legs as indicated in the following graphic. The electrode placements should be parallel. For example, if a patient has a cast on the left arm, both of the arm electrodes are placed on the shoulders, not one on the right wrist and one on the left shoulder. The leads that are attached to the electrodes are abbreviated LA (left arm), RA (right arm), LL (left leg), and RL (right leg). The lead placement should be one or the other as indicated; i.e., if the RA and LA leads are placed on the wrists, the RL and LL should not be placed on the upper thighs. However, patient conditions such as amputations and cast placements may require alterations in the electrode/lead placements. The leads are color coded as indicated in the following graphic.

OR

Source: Wikipedia; released into the public domain

Chest Leads Six electrodes are placed in specific areas of the chest. Lead wires attached to these electrodes are named V1, V2, V3, V4, V5, and V6. As with the limb leads, the leads are color coded. The electrodes and the lead wires attached to them are indicated on the graphic on the following page. The table following the graphic describes the exact placement of the electrodes and lead wires.
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V2 V3 V4 V5 V6

V1

Chest Lead Placement;

Source: Microsoft Office Clip Art; lead graphics added by author

Lead Names and Color-Coding

Lead Name & Abbreviation Left Arm (LA) Right Arm (RA) Left Leg (LL) Right Leg (RL) V1 V2 V3 V4 V5 V6 Also Known As Electrode/Lead Placement Lead Color Code Black White Red Green

extremity or limb lead extremity or limb lead extremity or limb lead extremity or limb lead; also known as neutral or ground lead right precordial or chest lead right precordial or chest lead right precordial or chest lead left precordial or chest lead left precordial or chest lead left precordial or chest lead

left arm right arm left leg right leg 4th intercostal space, right border of sternum 4th intercostal space, left border of sternum midpoint between V 2 and V4 5th intercostal space, left mid-clavicular line anterior axillary line, parallel to V4 mid-axillary line, same level with V4 and V5

Red Yellow Green Blue Orange Purple

The leads are generally inscribed with the name abbreviation. Therefore, the colors of the limb and chest leads are not confused. Alternately, a letter L for limb or C for chest may precede the lead number. Some chest leads may be brown in color while limb leads may be white with the pertinent abbreviations inscribed on them.

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6. Lead Views This section will briefly describe the second definition of the term lead (as mentioned in the previous section), i.e., combinations of electrodes that form imaginary lines in the body along which the electrical signals are measured There are three types of leads that provide views of the heart: standard limb leads, augmented leads, and precordial leads. Standard limb leads The first three limb lead wires are bipolar as they measure electrical activity of the heart on the axis between two limbs. These leads provide a view of the hearts frontal plane. The lead views are designated Lead I, Lead II, and Lead III. Lead I: Lead I records electrical activity between the RA and LA lead wires. Lead I is helpful for monitoring of atrial rhythms and hemiblocks. Lead II: Lead II records electrical activity between the RA and LL lead wires. Lead II is useful to monitor sinus node and atrial arrhythmias. Lead III: Lead III records the electric activity between the LA and LL lead wires. Lead III is helpful for detecting changes associated with an inferior wall myocardial infarction.

The axes of the three standard bipolar limb leads form a triangle around the heart and provide a frontal plane view of the heart. Augmented Leads The augmented leads are unipolar and also provide a view of the hearts frontal plane. The leads are named aVR, aVL, and aVF. Lead aVR (augmented voltage right arm): Lead aVR records the electric activity from the midpoint between the left arm and the left leg to the right arm. Lead aVL (augmented voltage left arm): Lead aVL records the electric activity from the midpoint between the right arm and the left leg to the left arm. Lead aVF (augmented voltage foot): Lead aVF records the electric activity from the midpoint between the right arm and the left arm to the left leg, despite the name aVF.

Precordial Leads The precordial leads are the six chest leads V1-V6. These leads are unipolar and record the electrical activity of the heart in two dimensions - from top to bottom and from left to right. The precordial leads record from front to rear, or the hearts horizontal plane.
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7. Performing an ECG a. Identify the patient following your facilitys standard operating procedures. b. Ensure patient privacy and explain the procedure. c. Have the patient undress from the waist up. Women should remove their bras. Provide the patient with a drape or hospital gown. d. Have the patient lie down on a flat surface (exam table or bed). If the patient is uncomfortable lying flat, the head of the bed or table may be elevated to 30-45. e. The patients legs should be uncrossed and the arms should lie at the sides. f. Place the chest and limb electrodes in the appropriate locations. Ensure the electrodes are not outdated. 1) Alcohol wipes and gauze pads should be used to remove skin oils, lotions, etc. from the patients skin before applying the electrodes. This will assure good contact between the patients skin and the adhesive of the electrodes. 2) It may be necessary to shave body hair to assure the electrodes will adhere sufficiently to the skin. 3) Electrodes should be placed under womens breasts and not on top of them. To maintain patient modesty, have the patient lift her breast or lift the breast yourself using the patients drape, gown, or clothing to touch the breast. 4) Pantyhose should be removed. However, electrodes can be placed on the lower abdomen but not on top of the pantyhose. g. Attach the lead wires to the electrodes, assuring the lead wires are attached correctly. h. Turn the ECG machine on. Ensure the proper calibration and speed are set. Standard settings are generally as follows. 1) Proper calibration is generally 10 mm to 1 mV (a standard signal of 1 mV should move the stylus vertically 1 cm or 2 large squares of the ECG paper). 2) Speed is generally set to 25 mm per second (stylus moves 5 large blocks every second). 3) Frequency response for screening ECG is 0.5 Hz to 20-50 Hz; for diagnostic ECG, the frequency response is 0.05 Hz to 150 Hz. i. Ask the patient to be still and relax as much as possible. j. Press the appropriate button to start the ECG. k. Run the ECG for one complete cardiac cycle in each lead. Before discontinuing the procedure, ensure a technically correct tracing has been obtained. l. Inform the patient when the procedure is completed, disconnect the lead wires, and remove the electrodes from the patient. Count the electrodes to ensure all have been removed. m. Have the patient get dressed. n. Follow your facilitys standard operating procedures with regards to labeling the ECG tracing and distributing it for interpretation. o. Release the patient from the ECG location. The ECG tracing will be labeled with the leads as follows: I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, and V6. Refer to the tracing on the following page.

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Normal 12 Lead ECG Tracing

Source: Wikimedia Commons; public domain

8. ECG Waves and Intervals The ECG recording consists of two key components- waves (deflections above and below the baseline) and intervals (distances between waves). Each ECG cycle consists of P, Q, R, S, T, and (rarely) U waves. Intervals between the wave that may be measured include QRS complex, QT interval, PR interval, ST segment, and PR segment. Other intervals may be measured. Intervals may sometimes be written as P-R, S-T, etc.

Normal ECG Tracing (normal sinus rhythm) Source: Wikimedia Commons; public domain

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Waves P wave Caused by atrial depolarization Normally lasts less than 0.12 seconds Amplitude is normally less than 0.25 mV An abnormally tall P was may be seen in hypertrophy of the right atrium; decreased P wave height may be seen in hyperkalemia Q wave Represents activation of intraventricular septum Normally 0.04 second or less Abnormal Q waves may indicate myocardial infarction or obstructive septal hypertrophy R wave Represents early ventricular depolarization R waves greater than 25 mm may indicate ventricular hypertrophy Tall R waves are also seen in athletes and young thin individuals S wave Represents late ventricular depolarization Abnormally large S waves indicate ventricular hypertrophy T wave Represents ventricular repolarization Normally less than 5 mm Inverted T waves may be seen in myocardial infarction and ischemia; inverted T waves may also be seen in late stages of cerebral disease, ventricular hypertrophy, pericarditis, and bundle branch heart blocks Hyperkalemia and very early myocardial infarction may cause tall T waves Flat T waves are seen in many conditions U wave Appears in about 50-75% of individuals immediately following the T wave as a small upward movement Not much known about physiology leading up to development of U waves; most experts correlate the U wave with electrophysiologic events called after depolarizations in the ventricles An abnormal prominent upright wave may be seen in hypokalemia, CNS disease, mitral valve prolapse, hyperthyroidism; negative wave may be seen in acute ischemia, myocardial infarction, and coronary artery spasm Intervals QRS complex Represents the time it takes for depolarization of the ventricles Normal duration is from 0.04 sec to 0.12 sec Prolonged QRS duration indicates a block in either the right or left bundle branches

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PR interval Time from the start of atrial depolarization to the start of ventricular depolarization Normally between 0.12 and 0.20 seconds Shortened PR intervals seen in Wolff-Parkinson-White (WPW) Syndrome; WPW syndrome may result in fainting, sudden cardiac arrest and death Long PR intervals usually are not significant QT interval Represents period of depolarization and repolarization of the ventricles Normal interval generally 0.20 0.40 seconds Shortened QT intervals usually are not significant unless heart beat is greater than 100 BPM Prolonged QT interval seen in CNS disease, patients taking antiarrhythmia drugs, hypokalemia, hypocalcemia, hypomagnesiumemia Romano-Ward Syndrome is an genetic form of prolonged QT that may result in fainting, sudden cardiac arrest, and death PR Segment Represents the time from the end of atrial depolarization to the onset of ventricular depolarization Normal is about 0.1 sec Shortened in atrial injury and pericarditis ST segment Represents the period between the end of ventricular depolarization to the beginning of ventricular repolarization Usually flat and even with the baseline (isoelectric); if depressed, may be flat, sagging, or down sloping; may be elevated, concave, or arched Normally between 0.08 0.12 seconds May be elevated in myocardial infarction, severe hypercalcemia, pericarditis Depressed ST segments are abnormal but nonspecific Normal ECG segments in each of 12 leads

Lead I

Lead II

Lead III

Lead aVR

Lead aVL

Lead aVF

Lead V1 Page 18 of 47

Lead V2

Lead V3

Lead V4

Lead V5

Lead V6

ECG segment tracings provided by RMGH, Glendale, CA

9. Heart Rate Heart rate can be both estimated and exactly calculated from an ECG tracing. Some physicians may request an estimate or calculation be provided with the ECG tracing, if it is not part of an ECG computer analysis. 6 Second Method: Estimation Begin at one 3-second marker on the ECG paper and go to right for two additional markers, which is 6 seconds. Count the number of QRS complexes in the six second interval and add a zero. The result is the heart rate in beats per minute. Heart Rate Exact Calculation The ECG paper moves at a standard speed of 25 mm per second, which is 1500 mm per minute. Count the number of mm markers between two QRS complexes and divide 1500 by that number. This will equal the number of heartbeats per minute. For example, if there are 25 mm boxes between two QRS complexes, 1500 divided by 25 equals 60 BPM (1500/25 = 60). 10. Heart Rhythm Heart rhythm originates in SA node, so the normal heart rhythm called sinus rhythm. Rhythm may be either regular or irregular. Heart rhythms that are not sinus rhythm are called arrhythmias (sometimes called dysrhythmias). Criteria used to determine if a heart rate is regular include: Heart rate must be between 60 and 100 BPM Atrial contractions (P waves) must precede QRS complexes Measure the PP intervals in several patterns. Intervals between P waves must be the same over the ECG tracing P waves are not higher than 2.5 mm in Lead II and Lead III, and are positive in Lead I and II

Irregular rhythm may be regularly irregular or irregularly irregular.

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11. ECG Accuracy Accuracy of an ECG is dependent upon correct lead placement, assuring one complete cardiac cycle in each lead has been recorded, use of the diagnostic frequency response, correct calibration of 10 mm to 1 mV, and correct paper speed of 25 mm per second.

ECG TROUBLESHOOTING & PREVENTATIVE MEASURES ECG tracing may not always be reliable due to interferences that result from the performance of the procedure. It is important to recognize and correct the interferences, and identify ways to prevent recurrence. Causes of interferences include artifacts from patient movement and/or improperly functioning or placed equipment. NOTE: Unless otherwise noted, ECG tracings are provided by RMGH, Glendale, CA. 1. Unwanted movement of the stylus: Results in artifact/waveform interference 2. Error in placement of the bipolar leads: Results in artifact/waveform interference

Waveform Interference

Causes Interference in leads I and II - poor RA and/or LA connection Interference in leads II and III - poor LL connection Intervention Check all electrodes/lead placements, replace/reconnect as needed

3. Baseline (no waveforms)

Baseline Page 20 of 47

Possible causes Electrode disconnection Poor connection or failure of wires Improper electrode placement Intervention If electrodes have loosened, replace with new ones Reposition electrodes if needed Reattach lead wires Replace lead wires or wire cable if failure suspected

4. Wandering Baseline (gradual shifting of the stylus away from the center of paper)

Wandering Baseline

Possible causes Movement of the patient, including chest wall movement during respiration Electrode positioned over the bone or applied too loosely Intervention Ask the patient to remain still Ensure tension from the lead wires or cable has not pulled electrodes away

5. Weak signals (incomplete waveforms)

Weak Signal

Possible causes QRS complex too small Wire failure Incorrect electrode placement
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Intervention Replace cable if failure suspected Reapply electrodes

6. Somatic Tremor (additional stylus movement resulting in jagged peaks of irregular height and possibly a spacing/shifting baseline)

Somatic Tremor

Possible cause Uncomfortable positioning of patient Patient condition (fever, chills) Patient talking and/or moving Intervention Reposition the patient Ask patient to take deep breaths Lower thermostat if the room temperature is chilly Use sedatives if necessary

7. Alternating Current/Fuzzy Baseline (series of small spiked lines on tracing)

Alternating Current or Fuzzy Baseline

Possible cause Electrical interference from other equipment in the room Improper grounding or electrode malfunction
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Intervention Check electrodes and make sure that all equipment is properly grounded and that no prongs are loose on the electrical plug Wires are attached to electrodes should be placed as close together as possible Twist lead wires them rather than looping them Unplug equipment in the room including electrical beds and lighting Assure X-ray equipment in adjacent rooms is not in use Move the table away from walls Remove cell phones from room

8. Baseline Interruption (stylus moves onto the margin of the paper)

Baseline Interruption

Possible cause Sudden movement of patient Broken wire or sudden loosening of connection between electrode and wire Intervention Assure patient stays still Check connection between electrodes and wires

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ECG INTERPRETATION FOR COMMON CARDIAC PROBLEMS Unless otherwise indicated, ECG rhythm strips are from RMGH, Glendale, CA. 1. Acute Myocardial Infarction ECG confirmation of an acute myocardial infarction (AMI) is challenging. Even having a normal ECG does not rule out AMI. An insufficient flow of blood to the heart muscle can result in myocardial ischemia, injury, or infarction. ECG results will vary based on where the heart muscle is damaged and whether ischemia, injury, or infarction occurred. A typical AMI shows increased ST intervals pathologic Q waves (Q waves that are higher than the R waves by 25% or more AND greater than 0.04 seconds in length) ST segment elevation over the area of damage ST segment depression in leads opposite the area of damage reduced R waves inverted T waves

Anterior wall AMI

Source: Wikimedia Commons; public domain

2. Asystole No cardiac activity detected Indicates death If patient is conscious yet no cardiac activity is being recorded, a technical problem such as loose wires should be suspected

Asystole Page 24 of 47

3. Atrial Flutter Narrow QRS complexes Ventricular rate generally 150 BPM Atrial rate can be 250 - 300 BPM

Atrial Flutter

4. Atrial Fibrillation (A fib) No P wave Atrial rate can be 400 - 700 BPM Ventricular rate can be 160 180 BPM QRS complexes generally normal

Atrial Fibrillation

5. Ventricular Fibrillation (V fib) Heart Rate: 250-500/min No P Wave, PR interval, or RR intervals QRS Complexes are irregularly shaped, pointed or rounded

Ventricular Fibrillation

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6. Ventricular Tachycardia Erratic rhythm with no P wave and odd QRS complexes

Ventricular Tachycardia

7. Sinus Tachycardia P waves of more than 100 BPM Shortened PR intervals

Sinus Tachycardia

8. Sinus Bradycardia P waves of less than 60 BPM Shortened PR interval

Sinus Bradycardia

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GLOSSARY OF CARDIOVASCULAR TERMINOLOGY

A
abdominal aorta - the portion of the aorta in the abdomen ablation - elimination or removal ACE (angiotensin converting enzyme) inhibitor - a medication that lowers blood pressure acetylcholine - a type of chemical (called a neurotransmitter) that transmits messages among nerve cells and muscle cells alveoli - air sacs in the lungs where oxygen and carbon dioxide are exchanged aneurysm - a sac-like protrusion from a blood vessel or the heart angina pectoris (also called angina) - recurring chest pain or discomfort that happens when some part of the heart does not receive enough blood angiography - an x-ray that uses dye injected into the coronary arteries so that blood circulation can be studied angioplasty - a minimally invasive surgical procedure for treating diseased arteries anticoagulant - a medication that keeps blood from clotting antihypertensive - a medication or other therapy that lowers blood pressure aorta - the largest artery in the body and the primary blood vessel leading from the heart to the body aortic valve - the valve that regulates blood flow from the heart into the aorta apex - the pointed part of the heart's left lower chamber (ventricle) arrhythmia (or dysrhythmia) - an abnormal heartbeat arterioles - small branches of arteries artery - a blood vessel that carries oxygenated blood away from the heart to the body arteriosclerosis - commonly called "hardening of the arteries;" a variety of conditions caused by fatty or calcium deposits in the artery walls causing them to thicken atherectomy - a non-surgical procedure that involves removing plaque from the walls of arteries with a rotating blade

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atherosclerosis - a type of arteriosclerosis caused by a build-up of plaque in the inner lining of an artery atrium (atria pl.) - one of two upper chambers in the heart atrioventricular block - an interruption of the electrical signal between the atria and the ventricles atrioventricular (AV) node - a cluster of cells between the atria and ventricles that regulate the electrical current

B
bacterial endocarditis - a bacterial infection of the lining of the heart's chambers (called the endocardium) or the heart's valves balloon catheter - a long tube-like device with a small balloon on the end that can be threaded through an artery. Used in angioplasty or valvuloplasty balloon valvuloplasty - a procedure to repair a heart valve that is not working properly. A balloon-tipped catheter is threaded through an artery and into the heart. The balloon is inflated to open and separate any narrowed or stiffened flaps (called leaflets) of a valve. The catheter and deflated balloon are removed after the procedure beta blocker - an antihypertensive medication that limits the activity of epinephrine (a hormone that increases blood pressure) blood pressure - the force or pressure exerted by the heart when pumping blood; also, the pressure of blood in the arteries blood pressure cuff - a device usually placed around the upper of the arm to measure blood pressure; also called sphygmomanometer brady - suffix meaning slow bradycardia - abnormally slow heartbeat bundle-branch block - a condition in which the heart's electrical system is unable to normally conduct the electrical signal

C
calcium channel blocker (or calcium blocker) - a medication that lowers blood pressure capillaries - tiny blood vessels between arteries and veins that distribute oxygen-rich blood to the body cardiac - pertaining to the heart
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cardiac arrest - stopping of the heartbeat cardiac catheterization - a diagnostic procedure in which a tiny, hollow tube (catheter) is inserted into an artery, guided to the heart in order to image the heart and blood vessels cardiac output - the amount of blood that goes through the circulatory system in one minute cardiology - the clinical study and practice of treating the heart cardiovascular (CV) - pertaining to the heart and blood vessel (circulatory) system cardiopulmonary resuscitation (CPR) - an emergency measure that can maintain a person's breathing and heartbeat. The person performing CPR helps the patient's circulatory system by breathing into the patient's mouth to give them oxygen and by giving chest compressions to circulate the patient's blood cardioversion - the procedure of applying electrical shock to the chest to change an abnormal heartbeat into a normal one cardiomyopathy - a disease of the heart muscle that causes it to lose its pumping strength carotid artery - the major arteries in the neck that supply blood to the brain cholesterol soft waxy substance found in all parts of the body; some is endogenous (made in the body) and some is exogenous (from the food we eat) cineangiography - the procedure of taking moving pictures to show the passage of dye through blood vessels circulatory system - pertaining to the heart, blood vessels, and the circulation of blood claudication - pain or fatigue in arms and legs due to poor supply of oxygen to the muscles computed tomography (CT or CAT scan) - a non-invasive procedure that takes crosssectional images of the brain or other internal organs; to detect any abnormalities that may not show up on an ordinary x-ray congenital - present at birth congenital heart defects - malformation of the heart or of its major blood vessels present at birth congestive heart failure - a condition in which the heart cannot pump out all of the blood that enters it, which leads to an accumulation of blood in the vessels and fluid in the body tissues
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coronary arteries - two arteries that come from the aorta to provide blood to the heart muscle coronary artery bypass graft (CAB or CABG) - a surgical procedure in which a healthy blood vessel is transplanted from another part of the body into the heart to replace or bypass a diseased vessel coronary artery spasm - a sudden closing of an artery, which cuts off blood flow to the heart and causes symptom of angina or heart attack coronary heart disease - a condition in which the coronary arteries narrow from an accumulation of plaque (atherosclerosis) and cause a decrease in blood flow coronary occlusion - an obstruction of one of the coronary arteries that decreases flow to the heart muscle coronary thrombosis - the formation of a clot in one of the arteries that carry blood to the heart muscle cyanosis blue coloration of the skin due to insufficient oxygen in the blood

D
deep vein thrombosis - a blood clot in a deep vein in the calf defibrillator - an electronic device used to establish normal heartbeat diastolic blood pressure - the lowest blood pressure measure in the arteries, which occurs between heartbeats diuretic - a medication that lowers blood pressure Doppler ultrasound - A procedure that uses sound waves to evaluate heart, blood vessels, and valves dyspnea - shortness of breath dysrhythmia - an abnormal heart rhythm

E
echocardiography - a computer procedure that studies or evaluates of the heart's function by using sound waves recorded on an electronic sensor that produces a moving picture of the heart and heart valves edema - swelling caused by fluid accumulation in body tissues ejection fraction - the measurement of the blood pumped out of the ventricles
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electrocardiogram (ECG or EKG) - a test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage electrophysiological study (EPS) - a cardiac catheterization to study electrical current in patients who have arrhythmias endarterectomy - the surgical removal of plaque or blood clots in an artery endocardium - the membrane that covers the inside surface of the heart endocarditis - a bacterial infection of the heart lining enlarged heart - a condition of the heart in which it is abnormally larger than normal epicardium - the membrane that covers the outside of the heart

F
familial hypercholesterolemia - a genetic predisposition to dangerously high cholesterol levels fatty acids (fats) - substances that occur in several forms in foods; different fatty acids have different effects on lipid profiles fibrillation - rapid contractions of the heart muscles first-degree heart block - when electrical impulse from the heart's upper chambers (the atria) are slowed as it moves through the atria and atrioventricular (AV) node flutter - ineffective contractions of the heart muscles fusiform aneurysm -a tube-shaped aneurysm that causes the artery to bulge outward; involves the entire circumference (outside wall) of the artery

G
gated blood pool scan - a nuclear scan which shows heart wall movements and measures the quantity of blood expelled with each heart beat, just after the patient has walked on a treadmill or ridden on a stationary bike guide wire - a small, bendable wire that is threaded through an artery; it helps doctors position a catheter so they can perform angioplasty or stent procedures. The guidewire is small enough that it can be inserted into the vessel through a needle, but it is also stiff enough to be threaded "up" the artery

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H
heart attack - also called myocardial infarction; damage to the heart muscle due to insufficient blood supply heart block - interrupted electrical impulse to heart muscles heart-lung machine - a machine that performs for the heart during open heart surgery. heart valve prolapse - a condition of the heart valve in which it is partially open when it should be closed high blood pressure - blood pressure that is above the normal range high density lipoprotein (HDL) - the "good" cholesterol that promotes breakdown and removal from the body of cholesterol Holter monitor - A small recording monitor that is generally worn for 24-48 hours during normal activity and continuously records the hearts rhythms hypertension - high blood pressure hypertrophy obstructive cardiomyopathy (HOCM) - a bulge in the ventricle that causes impeded blood flow hypoxia - abnormal oxygen content in the organs and tissues of the body

I
inferior vena cava - the large blood vessel (vein) that returns blood from the legs and abdomen to the heart inotropic medications - medications that increase strength of the contractions in the heart intravascular echocardiography - echocardiography and cardiac catheterization ischemia - decreased flow of oxygenated blood to an organ due to obstruction in an artery ischemic heart disease - coronary artery disease or coronary heart disease caused by narrowing of the coronary arteries and decreased blood flow to the heart

J
jugular veins - veins that carry blood from the head back to the heart

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L
lipid - a fatty substance in the blood lipoproteins - transporters of fatty substances in the blood low density lipoprotein (LDL) - the primary protein in the blood that carries cholesterol

M
mitral valve - the valve that controls blood flow between the left atrium and left ventricle in the heart mitral valve prolapse - a bulge in the valve between the left atrium and left ventricle of the heart that causes backward flow of blood into the atrium monounsaturated fats - dietary fats, such as olive oil or canola oil, that don't seem to have any affect on blood cholesterol murmur - a blowing or rasping sound heard while listening to the heart that may or may not indicate problems within the heart or circulatory system myocardial infarction (heart attack) - occurs when one of more regions of the heart muscle experience a severe or prolonged decrease in oxygen supply caused by a blocked blood flow to the heart muscle myocardial ischemia - insufficient blood flow to part of the heart myocardium - the muscle wall of the heart

N
nitroglycerin - a medication used to relax or dilate arteries; often given to individuals who suffer from angina

O
occluded artery - an artery that is narrowed by plaque that impedes blood flow open heart surgery - surgery that involves opening the chest and heart while a heartlung machine performs for the heart

P
pacemaker - an electronic device that is surgically implanted into the patient's heart and chest to regulate heartbeat palpitation - irregular heartbeat
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percutaneous transluminal coronary angioplasty (PTCA) - angioplasty pericarditis - inflammation of the membrane that surrounds the heart pericardiocentesis - a diagnostic procedure that uses a needle to draw fluid from the pericardium pericardium - the membrane that surrounds the heart plaque - deposits of fat and other substances attached to the artery wall platelets - cells found in the blood polyunsaturated fat - a type of fat found in vegetable oils and margarines that doesn't appear to raise blood cholesterol levels positron emission tomography (PET) - a nuclear scanning device that gives a threedimensional picture of the heart to provide information about the flow of blood through the coronary arteries to the heart muscle pulmonary - pertains to lungs and respiratory system pulmonary edema - a condition in which there is a fluid accumulation in the lungs caused by an incorrectly functioning heart pulmonary valve - the heart valve located between the right ventricle and the pulmonary artery that controls blood flow to the lungs pulmonary vein - the vessel that carries newly oxygenated blood to the heart from the lungs pulse oximeter - a small device placed on a finger that measures the amount of oxygen in the blood R radioisotope - a radioactive material injected into the body so that a nuclear scanner can make pictures radionuclide ventriculography - a diagnostic procedure used to determine the shape and size of the heart's chambers regurgitation - backward flow of blood caused by a defective heart valve rheumatic fever - a childhood disease that may damage the heart valves or the outer lining of the heart risk factor - a condition, element, or activity that may adversely affect the heart

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S
saturated fat - fat that is found in foods from animal meats and skin, dairy products and some vegetables septal defect - a hole in the wall of the heart septum - the muscle wall that divides the heart chambers shock - impaired body function due to severe blood loss or a disturbance in the circulatory system shunt - a connector to allow blood flow between two locations silent ischemia - ischemia not accompanied by chest pain sinus node - the cells that produce the electrical impulses that cause the heart to contract sphygmomanometer - the instrument used to measure blood pressure stent - a device implanted in a vessel used to help keep it open stenosis - the narrowing or constriction of a blood vessel or valve in the heart stethoscope - the instrument used to listen to the heart and other sounds in the body streptokinase - a clot-dissolving medication sternum - the breastbone stress test - any of various tests that assess cardiovascular health and function after application of a stress to the heart, usually exercise but sometimes others such as atrial pacing (regulation of the heartbeat by means of an electrode inserted in the atrium of the heart) or specific drugs. superior vena cava - the large vein that returns blood to the heart from the head and arms syncope - light-headedness or fainting caused by insufficient blood supply to the brain systolic blood pressure - the highest blood pressure measured in the arteries

T
tachycardia - rapid heartbeat tachypnea - rapid breathing

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telemetry unit - a small transmitter with wires that attach ECG patches to the chest that is used to send information about the heart via radio transmission to healthcare professionals for evaluation thallium stress test - a study in which radioactive potassium is carried by the blood and the progress is followed by x-ray pictures thrombolysis - the breaking up of a blood clot thrombosis - a blood clot formed in the blood vessel or in the heart thrombolytic therapy - a medication that dissolves blood clots tissue plasminogen activator (TPA) - a medication used to dissolves blood clots trans fat - an unhealthy substance, also known as trans fatty acid, made through the chemical process of hydrogenation of oils. Hydrogenation solidifies liquid oils and increases the shelf life and the flavor stability of oils and foods that contain them. Trans fats drive up levels of LDL ("bad") cholesterol, which increases the risk of heart attack and stroke. transesophageal echocardiography (TEE) - a diagnostic test that is used to measure the sound waves that bounce off the heart tricuspid valve - the heart valve that controls blood flow from the right atrium into the right ventricle triglyceride - the major form of fat. Triglycerides serve as the backbone of many types of lipids (fats). Triglycerides come from foods but are also produced by the body. Triglyceride levels do not provide clinically significant information about the risk of coronary heart disease (CHD) beyond that provided by levels of HDL and LDL cholesterol

U
ultrasound - a diagnostic tool used to measure high-frequency sound vibrations

V
valves (the heart valves are tricuspid, pulmonic, mitral, and aortic) - the "doors" between the chambers of the heart valvuloplasty - repairing a heart valve vascular - pertaining to blood vessels vasodilator - a medication that dilates or widens the opening in a blood vessel vasodepressors - a medication that raises blood pressure
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vein - a blood vessel that carries blood from the body back into the heart ventricle - one of the two lower chambers of the heart ventricular fibrillation - a condition in which the ventricles contract in rapid and unsynchronized rhythms and cannot pump blood into the body ventricular tachycardia - a condition in which the ventricles cause a very fast heartbeat vertigo a feeling of dizziness or spinning

W
Wolff-Parkinson-White syndrome a disorder caused by an extra electrical pathway that connects the atria and ventricles and causes rapid heartbeat

REFERENCES
Clinical Electrocardiography, Lipman, 8th Edition, Year Book Medical Publishers Incorporated, 1989. Clinical Electrocardiography, The Spatial Vector Approach, Robert P. Grant, M.D., McGraw-Hill Book Company, 1957 Clinical Vectorcardiography, 2nd edition, Te-Chuan Chow, M.D., Robert A. Helm, M.D., & Samuel Kaplan, M.D., Grune & Stratton, 1974 New Antiarrhythmic Drugs for Atrial Flutter and Atrial Fibrillation: A Conceptual Breakthrough at last?- F.G, Cosio and E. Delpon, Circulation 105 (3): 276-78, January 2002 Diagnostic Electrocardiography & Vectorcardiography, H. Harold Friedman, M.D., FACP, FACC, McGraw-Hill Book Company, 1971 ECG cards, 3rd ed. Springhouse, Pa.: Springhouse Corp., 2000 ECG Interpretation Made Increadebly Easy, 2nd ed. Springhouse, Pa.: Springhouse Corp., 2002 Electrocardiography - E.K. Chung, 3rd Edition, Appleton-Century-Crofts, Norwalk, Connecticut, 1985. Electrocardiography, Third Edition, E. Grey Dimond, M.D., Paul Schlesinger, M.D., Rafael L. Luna, M.D., The Corinth Press, 1961 Experimental results relating to the rhythmical and excitatory motions of the ventricle of the frog heart. - Burdon Sanderson J Proc Roy Soc Lond 27: 41014, 1878
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Expert ECG Interpretation- N J. Bekken, C. Clayton, J. Kruithhof and others, Lippincott Williams & Wilkins Co., 2002 Gross Anatomy, 3rd edition- Kyung Won Chung, Williams & Wilkins, 1995 Heart Disease: A Textbook of Cardiovascular Medicine- Braunwald E., Fifth Edition, p. 108, Philadelphia, W.B. Saunders Co., 1997. Heart Disease: A Textbook of Cardiovascular Medicine- Braunwald E., Fifth Edition, p. 119-123, Philadelphia, W.B. Saunders Co., 1997. Heart Disease: A Textbook of Cardiovascular Medicine- Braunwald E., Fifth Edition, p. 153-176, Philadelphia, W.B. Saunders Co., 1997. How to Quickly and Accurately Master ECG Interpretation - Dale Davis, 2nd Edition, Lippincott Company, Philadelphia, 1991 How to Quickly and Accurately Master Arrhythmia Interpretation - Dale Davis, Lippincott Company, Philadelphia, 1989 Introduction to Electrocardiography, 2nd edition, J. Willis Hurst & Robert J. Myerburg, McGraw-Hill Book Company, 1973 Mastering ACLS. Springhouse, Pa.: Springhouse Corp., 2002 Physiology, 2nd edition- L. S. Costanzo, PhD., Williams & Wilkins, 1995 Pocket Guide to Basic Dysrhythmias- R. J. Huszar, MD., Mosby Lifeline, 1995 Practical Electrocardiography - H.J.L. Marriott, 8th Edition, Williams Wilkins, Baltimore, 1988. Practical Electrocardiography, Fourth Edition, Henry J.L. Marriott, M.D., The Williams & Wilkins Co., 1968 Srikureja W, Darbar D, Reeder GS. Tremor-induced ECG artifact mimicking ventricular tachycardia. Circulation. 000;102:13371338. Structure And Function Of The Cardiovascular System, Second Edition, Robert F. Rushmer, M.D., W.B. Saunders Company, 1976 The Cardiac Rhythms, Raymond E. Phillips, M.D., F.A.C.P. & Mary K. Feeney, R.N., B.S.N., W.B. Saunders Company, 1973 The clinical value of the ECG in noncardiac conditions. Chest 2004; 125(4): 1561-76. The Hemiblocks, Mauricio B. Rosenbaum, M.D., Marcelo V. Elizari, M.D., Julio O. Lazzari, M.D., Tampa Tracings, 1970

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The Rapid Interpretation of ECGs Programmed Course - D. Dubin, 4th Edition, Cover Publishing Co., Tampa, Florida 1989. The Disorders of Cardiac Rhythm, Leo Schamroth, Blackwell Scientific Publications, 1971 The Medical Assistant, 7th edition, M. E. Kinn, M.A. Woods, E. Derge, W.B. Saunders Co, 1993 Value of normal electrocardiographic findings in predicting resting left ventricular function in patients with chest pain and suspected coronary artery disease- O'Keefe J, Zinsmeister A, Gibbons R, Am J Med 86 (6 Pt 1): 658-62. 1989. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 8: Stabilization of the Patient With Acute Coronary Syndromes." Circulation 2005; 112: IV-89 - IV-110. Internet Websites http://www.cma.com http://www.ecglibrary.com http://www.ginagagua.com http://en.ecgpedia.org/wiki/Main_Page http://medstat.med.utah.edu/kw/ecg/ http://omni.ac.uk/browse/mesh/D004562.html http://www.rmgh.net http://sprojects.mmi.mcgill.ca/heart/egcyhome.html

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TEST QUESTIONS A Review of the CV System & ECG Performance, Troubleshooting & Interpretation Course #1220909 Directions: Before taking this test, read the instructions on how to correctly complete the answer sheet. Select the response that best completes each sentence or answers each question from the information presented in the module. If you are having great difficulty answering a question, go to www.ncctinc.com and select Recertification/CE, then select Updates/Revisions to see if course content and/or a test question have been revised. If you do not have internet access, call Customer Service at 800-874-4404. 1. Which one of the following is a characteristic of arteries? a. b. c. d. Carry blood back toward the heart Deliver deoxygenated blood into venules via arterioles Have lower pressure than veins Supply tissues with oxygen and nutrients

2. Which one of the following is a characteristic of veins? a. b. c. d. Carry blood away from the heart Contain valves to prevent backflow of blood Deliver oxygenated blood into venules via capillaries Have thicker and stronger wall than arteries

3. Capillaries are absent from which one of the following anatomic locations? a. b. c. d. Corneas Ears Fingers Lips

4. Which chamber of the heart pumps blood to the lungs? a. b. c. d. Left atrium Left ventricle Right atrium Right ventricle

5. Based on information provided in this course, which of the following is considered a normal blood pressure? a. b. c. d. 114/78 132/70 113/96 148/90

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6. When listening to the heart with a stethoscope, the lub-dub sound heard is from __________. a. b. c. d. blood entering the aorta from the left ventricle blood rushing left to right across the septum leaflets of the heart valves slapping together ventricles pumping blood into the pulmonary vein

7. Which one of the following statements is TRUE regarding the cardiac cycle? a. b. c. d. Diastole begins when the heart chambers contract. Systole begins when the atria contract to move blood. As systole begins, blood pours from the veins into the ventricles. The semilunar valves close to prevent blood from flowing into the atria.

8. Which one of the following statements is FALSE regarding electrical conduction of the heart? a. Myocardial cells contract when stimulated by electrical signals from the pacemaker cells. b. Pacemaker cells in the sinoatrial node generate electrical signals that cause the heart to contract. c. The bundle of His allows electrical signals from the atria to move to the ventricles. d. Transmission of the electrical impulse from the SA nodes to the ventricles is called repolarization. 9. Which of the following is NOT part of an electrocardiograph machine? a. b. c. d. Recorder that graphically records the electrical signals Electrodes that transmit electrical signals from the heart to the cables Cable that splits into individual lead wires Amplifier to increase electrical signal strength

10. The smallest square on electrocardiograph paper is __________. a. b. c. d. 1 mm X 1 mm square 1 cm X 1 cm square 5 mm X 5 mm square 5 cm X 5 cm square

11. A 12 lead ECG is called this because __________. a. b. c. d. electrodes can be attached in twelve different locations it results in twelve electronic views of the heart the procedure takes twelve seconds twelve leads are attached to the patient

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12. What is the color code for the left leg lead? a. b. c. d. Black Green Red White

13. What is the color code for the right arm lead? a. b. c. d. Black Green Red White

14. Where is a blue color-coded chest lead placed? a. b. c. d. 4th intercostal space, right border of sternum 5th intercostal space, left mid-clavicular line Anterior axillary line, parallel to V2 Mid-axillary line, same level as V4 and V5

15. What is the color code for a V6 chest lead? a. b. c. d. Green Orange Purple Yellow

16. Which of the following lead views is useful for diagnosing inferior wall myocardial infarction? a. b. c. d. Lead I Lead II Leads I and II Lead III

17. Which of the following leads are bipolar? a. b. c. d. Standard limb leads Augmented leads Precordial leads All leads are bipolar

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18. Which of the following is a FALSE statement regarding patient preparation for an ECG procedure? a. Before applying electrodes, alcohol wipes should be used to remove skin oils, lotions, soaps, etc. from the patients skin. b. It may be necessary to shave body hair to assure good adherence of the electrodes. c. Electrodes should be placed under a womans breasts and not on top of them. d. Electrodes should be placed on the top of pantyhose and not underneath them. 19. Standard ECG speed is __________. a. b. c. d. 5 mm per minute 25 mm per second 25 mm per minute 5 mm per second

20. Standard ECG calibration is __________. a. b. c. d. 1 mm to 1 mV 1 mm to 1 Hz 10 mm to 1 mV 10 mm to 1 Hz

21. In a normal ECG, which one of the following waves is a negative deflection? a. b. c. d. P R S T

22. The Q wave represents the __________. a. b. c. d. activation of the intraventricular septum depolarization and repolarization of the ventricle normal depolarization of the right and left atria ventricular repolarization stage

23. The PR interval is the time between __________. a. b. c. d. the beginning of the P wave to the end of the R wave the end of the P wave to the end of the R wave the beginning of the P wave to the beginning of the QRS complex the end of the P wave to the end of the Q wave

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24. Which of the following are associated with Wolff-Parkinson-White Syndrome? a. b. c. d. Fainting Shortened PR intervals Sudden cardiac arrest and death All of the above

25. There are 18 1-mm boxes between two QRS complexes. What is the heart rate in BPM? a. b. c. d. 12 52 83 97

26. Which of the following is a criteria used to determine if a heart rate is regular? a. b. c. d. Intervals between P waves must be the same Heart rate must be between 60 and 80 BPM P waves must follow the QRS complexes P waves must be higher than 2.5 mm in Leads II and III

27. Which of the following would negatively affect the accuracy of an ECG? a. b. c. d. Calibration of 15 mm to 1 mV Correct lead placement Paper speed of 25 mm per second Use of diagnostic frequency response

28. Incorrect placement of electrodes may result in __________ on the ECG tracing. a. b. c. d. baseline interruption somatic tremor waveform interference weak signal

29. A loose prong on the ECG machine electrical plug could result in which of the following artifacts? a. b. c. d. Alternating current Baseline interruption Somatic tremor Weak signals

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30. The ECG tracing you have just performed appears as follows. What is this called and what could be a cause of its occurrence?

a. Alternating current; electrical interference from other equipment in the room b. Baseline interruption; loosening of a connection between an electrode and lead wire c. Somatic tremor; patient has fever and chills d. Waveform interference; poor electrode/lead wire connection 31. While performing an ECG, you notice that the baseline is wandering. What should you do to assure you obtain an accurate tracing? a. b. c. d. Check for loose prongs on the electrical plug Ask the patient to remain still Reapply the electrodes Turn off other machines in the area

32. Which of the following ECG abnormalities may be seen in acute myocardial infarction? a. b. c. d. Pathologic Q waves Increased R waves Decreased ST intervals All of the above

33. Very narrow QRS complexes are seen in which of the following? a. b. c. d. Asystole Atrial flutter Atrial fibrillation Ventricular fibrillation

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34. Review the following ECG tracings. The top ECG is abnormal; the bottom is a normal ECG. What is the probable diagnosis of the patient with the abnormal ECG? (Notethe arrows should provide assistance.)

a. b. c. d.

Sinus bradycardia Sinus tachycardia Atrial fibrillation Atrial flutter

35. The absence of P waves and odd QRS complexes are seen in which of the following? a. b. c. d. Sinus tachycardia Ventricular tachycardia Atrial flutter Asystole

36. Which of the following is the definition of ischemia? a. b. c. d. Bacterial infection of the membrane that surrounds the heart Backward flow of blood caused by a defective heart valve Narrowing or constriction of a cardiac blood vessel or valve Decreased flow of oxygenated blood due to an arterial obstruction

37. The condition in which the hearts electrical system is unable to normally conduct an electrical signal is called a/an __________. a. b. c. d. aneurysm bundle-branch block claudication mitral valve prolapse

38. Which of the following is a drug that dissolves blood clots? a. b. c. d. Angiotensin converting enzyme Calcium channel blocker Nitroglycerin Streptokinase
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39. Which of the following is the term for rapid heartbeat? a. b. c. d. Angina Dyspnea Tachycardia Syncope

40. Which of the following is responsible for regulating the cardiac electrical current? a. b. c. d. AV node Blood pressure Endocardium Myocardium

*end of test*

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