electrocardiography electrocardiography electrocardiography is the process of producing an electrocardiogram (ecg or ekg ), a recording of the heart's electrical activity through repeated cardiac cycles. it is an electrogram of the heart which is a graph of voltage versus time of the electrical activity of the heart using electrodes placed on the skin. these electrodes detect the small electrical changes that are a consequence of cardiac muscle depolarization followed by repolarization during each cardiac cycle (heartbeat). changes in the normal ecg pattern occur in numerous cardiac abnormalities, including cardiac rhythm disturbances (such as atrial fibrillation and ventricular tachycardia), inadequate coronary artery blood flow (such as myocardial ischemia and myocardial infarction), and electrolyte disturbances (such as hypokalemia and hyperkalemia). not to be confused with other types of electrography or with echocardiography. electrocardiographyecg of a heart in normal sinus rhythmicd-10-pcsr94.31icd-9-cm89.52meshd004562medlineplus003868 use of real time monitoring of the heart in an intensive care unit in a german hospital (2015), the monitoring screen above the patient displaying an electrocardiogram and various values of parameters of the heart like heart rate and blood pressure traditionally, "ecg" usually means a 12-lead ecg taken while lying down as discussed below. however, other devices can record the electrical activity of the heart such as a holter monitor but also some models of smartwatch are capable of recording an ecg. ecg signals can be recorded in other contexts with other devices. in a conventional 12-lead ecg, ten electrodes are placed on the patient's limbs and on the surface of the chest. the overall magnitude of the heart's electrical potential is then measured from twelve different angles ("leads") and is recorded over a period of time (usually ten seconds). in this way, the overall magnitude and direction of the heart's electrical depolarization is captured at each moment throughout the cardiac cycle. there are three main components to an ecg: the p wave, which represents depolarization of the atria; the qrs complex, which represents depolarization of the ventricles; and the t wave, which represents repolarization of the ventricles. during each heartbeat, a healthy heart has an orderly progression of depolarization that starts with pacemaker cells in the sinoatrial node, spreads throughout the atrium, and passes through the atrioventricular node down into the bundle of his and into the purkinje fibers, spreading down and to the left throughout the ventricles. this orderly pattern of depolarization gives rise to the characteristic ecg tracing. to the trained clinician, an ecg conveys a large amount of information about the structure of the heart and the function of its electrical conduction system. among other things, an ecg can be used to measure the rate and rhythm of heartbeats, the size and position of the heart chambers, the presence of any damage to the heart's muscle cells or conduction system, the effects of heart drugs, and the function of implanted pacemakers. medical uses normal 12-lead ecg a 12-lead ecg of a 26-year-old male with an incomplete right bundle branch block (rbbb) the overall goal of performing an ecg is to obtain information about the electrical functioning of the heart. medical uses for this information are varied and often need to be combined with knowledge of the structure of the heart and physical examination signs to be interpreted. some indications for performing an ecg include the following: chest pain or suspected myocardial infarction (heart attack), such as st elevated myocardial infarction (stemi) or non-st elevated myocardial infarction (nstemi) symptoms such as shortness of breath, murmurs, fainting, seizures, funny turns, or arrhythmias including new onset palpitations or monitoring of known cardiac arrhythmias medication monitoring (e.g., drug-induced qt prolongation, digoxin toxicity) and management of overdose (e.g., tricyclic overdose) electrolyte abnormalities, such as hyperkalemia perioperative monitoring in which any form of anesthesia is involved (e.g., monitored anesthesia care, general anesthesia). this includes preoperative assessment and intraoperative and postoperative monitoring. cardiac stress testing computed tomography angiography (cta) and magnetic resonance angiography (mra) of the heart (ecg is used to "gate" the scanning so that the anatomical position of the heart is steady) clinical cardiac electrophysiology, in which a catheter is inserted through the femoral vein and can have several electrodes along its length to record the direction of electrical activity from within the heart. ecgs can be recorded as short intermittent tracings or continuous ecg monitoring. continuous monitoring is used for critically ill patients, patients undergoing general anesthesia, and patients who have an infrequently occurring cardiac arrhythmia that would unlikely be seen on a conventional ten-second ecg. continuous monitoring can be conducted by using holter monitors, internal and external defibrillators and pacemakers, and/or biotelemetry. screening a patient undergoing an ecg for adults, evidence does not support the use of ecgs among those without symptoms or at low risk of cardiovascular disease as an effort for prevention. this is because an ecg may falsely indicate the existence of a problem, leading to misdiagnosis, the recommendation of invasive procedures, and overtreatment. however, persons employed in certain critical occupations, such as aircraft pilots, may be required to have an ecg as part of their routine health evaluations. hypertrophic cardiomyopathy screening may also be considered in adolescents as part of a sports physical out of concern for sudden cardiac death. electrocardiograph machines an ekg electrode electrocardiograms are recorded by machines that consist of a set of electrodes connected to a central unit. early ecg machines were constructed with analog electronics, where the signal drove a motor to print out the signal onto paper. today, electrocardiographs use analog-to-digital converters to convert the electrical activity of the heart to a digital signal. many ecg machines are now portable and commonly include a screen, keyboard, and printer on a small wheeled cart. recent advancements in electrocardiography include developing even smaller devices for inclusion in fitness trackers and smart watches. these smaller devices often rely on only two electrodes to deliver a single lead i. portable twelve-lead devices powered by batteries are also available. recording an ecg is a safe and painless procedure. the machines are powered by mains power but they are designed with several safety features including an earthed (ground) lead. other features include: defibrillation protection: any ecg used in healthcare may be attached to a person who requires defibrillation and the ecg needs to protect itself from this source of energy. electrostatic discharge is similar to defibrillation discharge and requires voltage protection up to 18,000 volts. additionally, circuitry called the right leg driver can be used to reduce common-mode interference (typically the 50 or 60 hz mains power). ecg voltages measured across the body are very small. this low voltage necessitates a low noise circuit, instrumentation amplifiers, and electromagnetic shielding. simultaneous lead recordings: earlier designs recorded each lead sequentially, but current models record multiple leads simultaneously. most modern ecg machines include automated interpretation algorithms. this analysis calculates features such as the pr interval, qt interval, corrected qt (qtc) interval, pr axis, qrs axis, rhythm and more. the results from these automated algorithms are considered "preliminary" until verified and/or modified by expert interpretation. despite recent advances, computer misinterpretation remains a significant problem and can result in clinical mismanagement. cardiac monitors besides the standard electrocardiograph machine, there are other devices capable of recording ecg signals. portable devices have existed since the holter monitor was produced in 1962. traditionally, these monitors have used electrodes with patches on the skin to record the ecg, but new devices can stick to the chest as a single patch without need for wires, developed by zio (zio xt), tz medical (trident), philips (biotel) and bardydx (cam) among many others. implantable devices such as the artificial cardiac pacemaker and implantable cardioverter-defibrillator are capable of measuring a "far field" signal between the leads in the heart and the implanted battery/generator that resembles an ecg signal (technically, the signal recorded in the heart is called an electrogram, which is interpreted differently). advancement of the holter monitor became the implantable loop recorder that performs the same function but in an implantable device with batteries that last on the order of years. additionally, there are available various arduino kits with ecg sensor modules and smartwatch devices that are capable of recording an ecg signal as well, such as with the 4th generation apple watch, samsung galaxy watch 4 and newer devices. electrodes and leads proper placement of the limb electrodes. the limb electrodes can be far down on the limbs or close to the hips/shoulders as long as they are placed symmetrically. placement of the precordial electrodes electrodes are the actual conductive pads attached to the body surface. any pair of electrodes can measure the electrical potential difference between the two corresponding locations of attachment. such a pair forms a lead. however, "leads" can also be formed between a physical electrode and a virtual electrode, known as wilson's central terminal (wct), whose potential is defined as the average potential measured by three limb electrodes that are attached to the right arm, the left arm, and the left foot, respectively. commonly, 10 electrodes attached to the body are used to form 12 ecg leads, with each lead measuring a specific electrical potential difference (as listed in the table below). leads are broken down into three types: limb; augmented limb; and precordial or chest. the 12-lead ecg has a total of three limb leads and three augmented limb leads arranged like spokes of a wheel in the coronal plane (vertical), and six precordial leads or chest leads that lie on the perpendicular transverse plane (horizontal). in medical settings, the term leads is also sometimes used to refer to the electrodes themselves, although this is technically incorrect. the 10 electrodes in a 12-lead ecg are listed below. electrode name electrode placement ra on the right arm, avoiding thick muscle. la in the same location where ra was placed, but on the left arm. rl on the right leg, lower end of inner aspect of calf muscle. (avoid bony prominences) ll in the same location where rl was placed, but on the left leg. v1 in the fourth intercostal space (between ribs 4 and 5) just to the right of the sternum (breastbone) v2 in the fourth intercostal space (between ribs 4 and 5) just to the left of the sternum. v3 between leads v2 and v4. v4 in the fifth intercostal space (between ribs 5 and 6) in the mid-clavicular line. v5 horizontally even with v4, in the left anterior axillary line. v6 horizontally even with v4 and v5 in the mid-axillary line. two types of electrodes in common use are a flat paper-thin sticker and a self-adhesive circular pad. the former are typically used in a single ecg recording while the latter are for continuous recordings as they stick longer. each electrode consists of an electrically conductive electrolyte gel and a silver/silver chloride conductor. the gel typically contains potassium chloride – sometimes silver chloride as well – to permit electron conduction from the skin to the wire and to the electrocardiogram. the common virtual electrode, known as wilson's central terminal (vw), is produced by averaging the measurements from the electrodes ra, la, and ll to give an average potential of the body: v w = 1 3 ( r a + l a + l l ) =(ra+la+ll)} in a 12-lead ecg, all leads except the limb leads are assumed to be unipolar (avr, avl, avf, v1, v2, v3, v4, v5, and v6). the measurement of a voltage requires two contacts and so, electrically, the unipolar leads are measured from the common lead (negative) and the unipolar lead (positive). this averaging for the common lead and the abstract unipolar lead concept makes for a more challenging understanding and is complicated by sloppy usage of "lead" and "electrode". in fact, instead of being a constant reference, vw has a value that fluctuates throughout the heart cycle. it also does not truly represent the center-of-heart potential due to the body parts the signals travel through. limb leads the limb leads and augmented limb leads (wilson's central terminal is used as the negative pole for the latter in this representation) leads i, ii and iii are called the limb leads. the electrodes that form these signals are located on the limbs – one on each arm and one on the left leg. the limb leads form the points of what is known