Electrocardiography

Electrocardiography is a commonly used, non-invasive procedure for recording electrical changes in the heart. The record, which is called an electrocardiogram (ECG or EKG), shows the series of waves that relate to the electrical impulses which occur during each beat of the heart. The results are printed on paper or displayed on a monitor. The waves in a normal record are named P, Q, R, S, and T and follow in alphabetical order. The number of waves may vary, and other waves may be present.

Purpose

Electrocardiography is a starting point for detecting many cardiac problems. It is used routinely in physical examinations and for monitoring the patient's condition during and after surgery, as well as during intensive care. It is the basic measurement used for tests such as exercise tolerance. It is used to evaluate causes of symptoms such as chest pain, shortness of breath, and palpitations.

This EKG strip shows evidence of Wolff-Parkinson-White syndrome. (Custom Medical Stock Photo. Reproduced by permission.)

An EKG strip indicting atrial flutter. (Custom Medical Stock Photo. Reproduced by permission.)

Precautions

No special precautions are required.

Description

The patient disrobes from the waist up, and electrodes (tiny wires in adhesive pads) are applied to specific sites on the arms, legs, and chest. When attached, the electrodes are called leads; three to 12 leads may be employed.

Muscle movement may interfere with the recording, which lasts for several beats of the heart. In cases where rhythm disturbances are suspected to be infrequent, the patient may wear a small Holter monitor in order to record continuously over a 24-hour period; this is known as ambulatory monitoring.

Preparation

The skin is cleaned to obtain good electrical contact at the electrode positions.

Aftercare

To avoid skin irritation from the salty gel used to obtain good electrical contact, the skin should be thoroughly cleaned after removal of the electrodes.

Risks

No complications from this procedure have been observed.

Normal results

When the heart is operating normally, each part contracts in a specific order. Contraction of the muscle is

A patient undergoing electrocardiography. (Russell Curtis, Photo Researchers. Reproduced by permission.)

triggered by an electrical impulse. These electrical impulses travel through specialized cells that form a conduction system. Following this pathway ensures that contractions will occur in a coordinated manner.

When the presence of all waves is observed in the electrocardiogram and these waves follow the order defined alphabetically, the heart is said to show a normal sinus rhythm, and impulses may be assumed to be following the regular conduction pathway.

The heart is described as showing arrhythmia or dysrhythmia when time intervals between waves, the order, or the number of waves do not fit this pattern. Other features that may be altered include the direction of wave deflection and wave widths.

In the normal heart, electrical impulses—at a rate of 60–100 times per minute—originate in the sinus node. The sinus node is located in the first chamber, known as the right atrium, where blood re-enters the heart. After traveling down to the junction between the upper and lower chambers, the signal stimulates the atrioventricular node. From here, after a delay, it passes by specialized routes through the lower chambers or ventricles. In many disease states, the passage of the electrical impulse can be interrupted in a variety of ways, causing the heart to perform less efficiently.

Abnormal results

Special training is required for interpretation of the electrocardiogram. To summarize the features used in interpretations in the simplest manner, the P wave of the electrocardiogram is associated with the contraction of the atria. The QRS series of waves, or QRS complex, is associated with ventricular contraction, with the T wave coming after the contraction. Finally, the P-Q or P-R interval gives a value for the time taken for the electrical impulse to travel from the atria to the ventricle (normally less than 0.2 sec).

The cause of dysrhythmia is ectopic beats. Ectopic beats are premature heart beats that arise from a site other than the sinus node—commonly from the atria, atrioventricular node, or the ventricle. When these dysrhythmias are only occasional, they may produce no symptoms, or a feeling of the heart turning over or "flipflopping" may be experienced. These occasional dysrhythmias are common in healthy people, but they also can be an indication of heart disease.

The varied sources of dysrhythmias provide a wide range of alterations in the form of the electrocardiogram. Ectopic beats that start in the ventricle display an abnormal QRS complex. This can indicate disease associated with insufficient blood supply to the muscle (myocardial ischemia). Multiple ectopic sites lead to rapid and uncoordinated contractions of the atria or ventricles. This condition is known as fibrillation. In atrial fibrillation, P waves are absent, and the QRS complex appears at erratic intervals, or "irregularly irregular."

When the atrial impulse fails to reach the ventricle, a condition known as heart block results. If this is partial, the P-R interval (the time for the impulse to reach the ventricle) is prolonged. If complete, the ventricles beat independently of the atria at about 40 beats per minute, and the QRS complex is mostly dissociated from the P wave.