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Wrappin’ Up Rhythm – ECG that is…. Degrees of Dysrrhytmias. Minor: Does not significantly reduce Cardiac Output Major: Significant reduction in Cardiac Output and coronary blood flow Lethal: Cardiac Output is negligible. Examples of “Minor” Dysrrythmias:. Atrial Fibrillation

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degrees of dysrrhytmias
Degrees of Dysrrhytmias
  • Minor: Does not significantly reduce Cardiac Output
  • Major: Significant reduction in Cardiac Output and coronary blood flow
  • Lethal: Cardiac Output is negligible
examples of minor dysrrythmias
Examples of “Minor” Dysrrythmias:
  • Atrial Fibrillation
    • Atrial output is negligible but only contributes 20-30% to total CO
  • Occassional to frequent PVC’s*
  • Atrial Flutter
  • PJC, PAC

* In otherwise uncompromised heart

examples of major dysrrythmias
Examples of Major Dysrrythmias:
  • Supraventricular Tachycardia:
    • Sinus Tachycardia*
    • Paroxysmal Atrial Tachy (PAT)
    • Paroxysmal Junctional Tachy (PJT)
  • Atrioventricular Block: R- R rate is between 20-40
  • Extreme Bradycardia
  • *Coronaries fill between T- P waves (Diastole)
examples of lethal arryhthmias
Examples of Lethal Arryhthmias:
  • Cardiac Output is negligible
  • Sustained V-Tach
  • V-Fib
  • Ventricular Standstill/Asystole: “Flat Line”
more on pvc s
More on PVC’s
  • PVC’s are “ubiquitous” and usually “innocuous”
  • Easy to Spot: No P wave and wide and bizarre QRS complex
  • Generally followed by Compensatory Pause:Impulse doesn’t pass retrograde back to AV node, must “wait” for SA node to reset
  • 80-90% of Infarcting patients have them: Some are more “ominous” than others:
    • Multiform (focus)
    • 2+ consecutive PVC’s
    • “R - on – T”
      • PVC is so early it initiates V-Fib
the prognostic strength of pvc s
The Prognostic Strength of PVC’s
  • Not “Independent” predictors
  • BUT when accompanied by
    • Infarction
    • Ischemia
    • LV dysfunction
    • PVC’s of LV Foci (+ in V1)
  • Should Not Be Ignored!
conduction arrhythmias


Springhouse: Chapter 8

ectopic focus or conduction disturbance
Ectopic Focus or Conduction Disturbance?
  • Ectopic Beats:
    • Premature and/or wide QRS complexes
    • Absent and / or abnormal P waves
  • AV Blocks:
    • Prolonged P-R intervals
    • Irregular P:R ratios
  • Ventricular blocks: Bundle Branch Blocks
    • Wide QRS / Normal P-R
bottom line
Bottom Line:
  • The Speed of conduction in the Atria and ventricles is similar (Very Fast)
  • The AV Node Necessarily slows down conduction to allow time for the ventricles to fill before contraction
  • About 50% of the cardiac cycle is “held up” at the AV-Node
  • Conduction is slowed or interrupted
  • A-V Blocks occur in the conduction between the atria and ventricles
  • Ventricular Blocks: Occur in the Bundle Branches
12 lead ecg clinical exercise electrocardiography

12 Lead ECGClinical Exercise Electrocardiography

Springhouse: Chapter 11


Brubaker et. al: Chapter 6

clinical indications for exercise testing
Clinical Indications for Exercise Testing:
  • Diagnosis: Reproduce symptoms
    • CP, SOB, Poor work tolerance
    • ECG changes?
  • Functional Testing:
    • Work Capacity, BP response to exercise, Exercise duration
  • Prognosis:
    • AHA, AACVPR, ACP: Risk Stratification, Duke’s 5-Year Mortality prognosis

(Brubaker Chapter 7)

  • Indications:
    • Confirm or rule out suspected myocardial ischemia
    • Mechanisms for syncope (LOC)
    • Suspected arrhythmias (palpitations with symptoms) during exercise
functional capacity
Functional Capacity:
  • Indications:
    • Assessing work capacity for return to work/leisure activites
    • Used in determining risk/prognostic stratification
    • Used in determining therapy choices
    • Exercise Prescription: Phase II Entrance requirements
prognostic benchmarks
Prognostic Benchmarks
  • <5 METs: poor prognosis especially under 65 years old
  • 10 METs: considered normal fitness: survival good – regardless of intervention
  • 13 METs: good prognosis even with CAD present
  • ACSM Guidelines
    • Co-existing conditions or unstable cardiovascular status
      • Recent AMI
      • Unstable angina
      • CHF
      • RBP >200/120
      • Active infections
      • Uncontrolled Diabetes, other endocrine disorders
stress test protocols
Stress Test Protocols
  • ACSM
  • AHA
  • Modalities
    • Bicycle Ergometer
    • Treadmill
bike vs treadmill
Less expensive

Less space


Less ECG artifact

Easier BP’s

Non-Weight dependent

More flexibility in protocols

More reproducible (not-patient dependent)

More accurate work determinations

Bike vs. Treadmill
disadvantages homework due tuesday
Disadvantages? Homework – Due Tuesday
  • Brubaker: Chapter 6
  • List the disadvantages of each modality
  • Describe the variables monitored and the recommended intervals for monitoring them before, during and after the test
treadmill protocols
Treadmill Protocols:
  • Treadmill Speed: Individualize
  • Increment Size: Age, condition
    • Larger incremental increases for younger, more fit patients
    • Smaller incremental increases for elderly, de-conditioned
  • Test Length:
    • Between 8-12 minutes
estimating work capacity selecting protocols
Estimating Work Capacity: Selecting Protocols
  • Healthy Men >40 years old
    • 75% have 12.5 MET capacity
    • 50% ~ 10 METs
  • Healthy Women >40 years old
    • 75% have 10 MET capacity
    • 50% ~8-9 METs
  • Choose a protocol that achieves the estimated MET capacity between 8-12 minutes
commonly used clinical protocols
Commonly Used Clinical Protocols:
  • Naughton: 2.0 mph X 3.5% increases every 2 minutes
    • Max METs = 9 /16 minutes
  • Balke: 3.3 mph X 3% increases every 3 minutes
    • Max METs = 12 /18 minutes
  • McHenry: Similar to Balke but Stage I is 2.0 mph/3% grade
critical measurements
Critical Measurements:
  • Work Loads: MET calculations
  • ECG: Clean ST-Segment changes
  • BP: Accurate work SBP/DBP
  • RPP: MVO2 eliciting CP
  • Elicited Symptoms: CP, SOB, Syncope, RPE
rating anginal symptoms
Rating Anginal Symptoms:
  • 1+: Light, barely noticeable
  • 2+: Moderate, bothersome
  • 3+: Severe, very uncomfortable
  • 4+: Most severe pain ever experienced
exercise test endpoints
Exercise Test Endpoints:
  • Pre-determined HR achieved
  • Pre-determined Workload achieved
  • Patient c/o CP, SOB, leg pains, fatigue
  • ECG changes:
    • Significant ST changes
    • New Bundle branch or AV block
    • Increasing PVC frequency, VT or Fib
post exercise period
Post Exercise Period:
  • For Maximal Diagnostic Sensitivity:
    • No Cool Down
    • 10-sec ECG immediately
    • 6-8 minutes of supine monitoring* - record ECG every minute or after any irregularity

*Unless patient is severely dyspneic – then sitting preferred

testing competencies
Testing Competencies:
  • Know Absolute and Relative indications for test termination:
    • 3+ to 4+ angina
    • Suspected MI
    • Drop in SBP with increased work
    • Serious arrhythmias
    • Signs of poor perfusion
    • Patient request
why a 12 lead ecg
Why a 12-Lead ECG?
  • Gives a “3-D” view of the heart
  • Especially important in revealing ischemia / infarct
  • Is more sensitive in assessing LV function
prepping the patient
Prepping the Patient:
  • Electrode Sites:
    • Flat, Fleshy (not over bone/large muscles
    • Shave excess hair
    • Clean excess oil – alcohol scrub
  • Respect Modesty!
    • Use a drape
    • Explain procedure
12 lead ecg electrode placement
12-Lead ECG: Electrode Placement
  • RA/LA:
    • On Shoulders at distal ends of clavicles: (Not over large muscle masses or directly over bone)
  • RL/LL:
    • Base of Torso: Just medial to the iliac crests
  • Chest Leads: V1-V6
    • Traditional pre-cordial positioning

V1-V2: 4th intercostal space –R/L of sternum

V4: 5th intercostal space – midclavicle line

V3: Between V2 and V4

V5: At horizontal level of V4, anterior to axilla

V6: Midaxillary at horizontal level of V4

  • Lead: Recording the wave of depolarization between negative and positive electrodes
  • Einthoven Triangle: An equilateral triangle depicting the leads of the frontal plane (I-III and aVR – aVL)
  • Frontal Plane: Vertical plane of the body, separating the front from back
  • Transverse Plane: Horizontal plane separating the top from the bottom
frontal plane leads
Frontal Plane Leads:
  • Standard (bipolar) Leads:
    • I: RA- to LA+
    • II: RA- to LL+
    • III: LA- to LL+
  • Augmented Vector (Unipolar) Leads
    • aVR: to RA+
    • aVL: to LA+
    • aVF: to LL+
qrs axis
QRS Axis?
  • Used to determine right or left heart hypertrophy or other anatomical anomalies
  • But How do we Determine Axis?
the heart is situated in the chest at an angle from right arm to left hip
The heart is situated in the chest at an angle from right arm to left hip:

Waves of


Travel from the

Right shoulder

To the left hip.

The ECG deflection (-/+) is determined by the direction of the depolarization wave relative to the “reading” or POSITIVE electrode
like so
Like So:


Depolarization wave



Lead I






Normal QRS


(ve = + / -)

Check Leads:

I and aVF

Positive: Leads I-III, aVL, aVF, V4-V6

Negative: avR, V1-V2

Both Negative and Positive: V3

interpreting axis deviation
Interpreting Axis Deviation:
  • Normal Electrical Axis:
    • (Lead I + / aVF +)
  • Left Axis Deviation:
    • Lead I + / aVF –
    • Pregnancy, LV hypertrophy etc
  • Right Axis Deviation:
    • Lead I - / aVF +
    • Emphysema, RV hypertrophy etc.
nw axis no man s land
NW Axis (No Man’s Land)
  • Both I and aVF are –
  • Check to see if leads are transposed (Did you reverse the RA and LL electrodes?)
  • Indicates:
    • Emphysema
    • Hyperkalemia
    • VTach

“Seeing” the heart in the

Transverse plane: The Chest














st segment analysis ischemia diagnosis
ST Segment Analysis: Ischemia Diagnosis
  • Key Reference Points:
    • Isoelectric line: Use the PR segment as reference
    • J-Point: Point at which QRS complex ends and ST segment begins
  • Most Common Measurement:
    • .06-.08 sec (>1-2 mm) past J-Point
    • ST Slope: Downsloping > Horizontal > Upsloping (questionable/angina)
st depression49
  • >1.0 mm depression:
    • Downsloping: Very predictive
    • Horizontal: Very predictive
    • Upsloping: Predictive if angina present
  • >2.0 mm depression
    • Usually indicative of ischemia
positive co conditions signals more severe cad
Positive Co-Conditions – Signals More Severe CAD:
  • Exertional Hypotension
  • Angina that limits exercise
  • Exercise capacity < 6 METs
  • ST changes at RPP < 15,000
  • ST changes persist into recovery
determining regions of cad st changes in leads
Determining Regions of CAD: ST-changes in leads…
  • RCA: Inferior myocardium
    • II, III, aVF
  • LCA: Lateral myocardium
    • I, aVL, V5, V6
  • LAD: Anterior/Septal myocardium
    • V1-V4
regions of the myocardium
Regions of the Myocardium:




Anterior /