introduction to clinical electrocardiography gari clifford, phd andrew reisner, md roger mark, md...
TRANSCRIPT
![Page 1: Introduction to Clinical Electrocardiography Gari Clifford, PhD Andrew Reisner, MD Roger Mark, MD PhD](https://reader036.vdocument.in/reader036/viewer/2022062308/56649d0c5503460f949e03aa/html5/thumbnails/1.jpg)
Introduction to Clinical Electrocardiography
Gari Clifford, PhDAndrew Reisner, MDRoger Mark, MD PhD
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Electrocardiography
The heart is an electrical organ, and its activity can be measured non-invasively
Wealth of information related to: The electrical patterns proper The geometry of the heart tissue The metabolic state of the heart
Standard tool used in a wide-range of medical evaluations
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A heart• Blood circulates, passing near every cell in the body, driven by this pump
• …actually, two pumps…
• Atria = turbochargers
• Myocardium = muscle
• Mechanical systole
• Electrical systole
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To understand the ECG:
Electrophysiology of a single cell How a wave of electrical current
propagates through myocardium Specific structures of the heart
through which the electrical wave travels
How that leads to a measurable signal on the surface of the body
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Part I: A little electrophysiology
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Once upon a time, there was a cell:
ATPaseATPase
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Intr
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-90-90
Resting comfortably
a myocyte
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Intr
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Depolarizing trigger
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Intr
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Na channels
open, briefly
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Intr
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In: Na+
Mysterycurrent
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timetime
Intr
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Intr
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In: Na+
Ca++ is in balancewith K+ out
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In: Na+
Excitation/Contraction Coupling:Ca++ causes the Troponin Complex
(C, I & T) to release inhibitionof Actin & Myosin
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timetime
Intr
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Intr
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lula
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In: Na+
Ca++ in; K+ out
More K+ out;Ca++ flow halts
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timetime
Intr
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Intr
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In: Na+
In: Ca++; Out: K+
Out: K+
Sodium channels reset
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Intr
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In: Na+
Higher resting potentialFew sodium channels reset
Slower upstroke
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a pacemaker cell
Slow current of Na+ in;note the resting potential
is less negative in apacemaker cell
-55-55
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a pacemaker cell
Threshold voltage
-40-40
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Ca++ flows in
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. . . and K+ flows out
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. . . and when it is negativeagain, a few Na+
channels open
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How a wave of electrical current propagates through myocardium
Typically, an impulse originating anywhere in the myocardium will propagate throughout the heart
Cells communicate electrically via “gap junctions”
Behaves as a “syncytium” Think of the “wave” at a football
game!
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The dipole field due to current flow in a myocardial cell at the advancing front of depolarization.
Vm is the transmembrane potential.
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Cardiac Electrical Activity
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Important specific structures
Sino-atrial node = pacemaker (usually) Atria After electrical excitation: contraction Atrioventricular node (a tactical pause) Ventricular conducting fibers (freeways) Ventricular myocardium (surface roads) After electrical excitation: contraction
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The Idealized Spherical Torso with the Centrally Located Cardiac Source (Simple dipole model)
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Excitation of the Heart
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Excitation of the Heart
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Cardiac Electrical Activity
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Recording the surface ECG
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Clinical Lead Placement
Einthoven Limb Leads:
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Precordial leads
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12 Lead ECG
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The temporal pattern of the heart vector combined with the geometry of the standard frontal plane limb leads.
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Normal features of the electrocardiogram.
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Normal sinus rhythm
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What has changed?
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Sinus bradycardia
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Neurohumeral factors
Vagal stimulation makes the resting potential
MORE NEGATIVE. . .
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Neurohumeral factors
. . . and the pacemakercurrent SLOWER. . .
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. . . and raise the THRESHOLD
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Catecholamines make the resting potential MORE EXCITED. . .
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. . . and speed the PACEMAKER CURRENT. . .
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. . . and lower the THRESHOLD FOR
DISCHARGE. . .
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Vagal Stimulation:
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Adrenergic Stim.
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Sinus arrhythmia
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Atrial premature contractions (see arrowheads)
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Usually just a spark; rarely sufficient for an explosion
“Leakiness” leads to pacemaker-like current
Early after-depolarization Late after-depolarization
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What’s going on here?
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Wave-front Trajectory in a Ventricular Premature Contraction.
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Is this the same thing?
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What’s going on here?
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What’s going on here?
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Non-sustained ventricular tachycardia (3 episodes)
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Slow Refractory
Quick Refractory
KeyWords: Heterogeneous, Circus, Self-Perpetuating
Side “A” Side “B”
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No Longer Refractory
KeyWords: Heterogeneous, Circus, Self-Perpetuating
Side “A” Side “B”
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KeyWords: Heterogeneous, Circus, Self-Perpetuating
Side “A” Side “B”
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KeyWords: Heterogeneous, Circus, Self-Perpetuating
Side “A” Side “B”
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KeyWords: Heterogeneous, Circus, Self-Perpetuating
Side “A” Side “B”
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KeyWords: Heterogeneous, Circus, Self-Perpetuating
Side “A” Side “B”
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INCREASEDRefractory
Side “A” Side “B”
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INCREASEDRefractory
Side “A” Side “B”
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INCREASEDRefractory
Side “A” Side “B”
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INCREASEDRefractory
Side “A” Side “B”
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INCREASEDRefractory
Side “A” Side “B”
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INCREASEDRefractory
Side “A” Side “B”
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Ventricular Fibrillation
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Heart attack
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Hyperkalemia
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Understanding the ECG: A Cautionary Note
Basic cell electrophysiology, wavefront propagation model, dipole model:
Powerful, but incomplete There will always be electrophysiologic
phenomena which will not conform with these explanatory models
Examples: metabolic disturbances anti-arrhythmic medications need for 12-lead ECG to record a 3-D phenomenon
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Questions?