ECG, HOLTER, and STRESS Treadmill TESTS

Electrocardiography(ECG) provides a graphic recording of the heart’s electrical activity.electrodes

placed on the skin transmit the electrical impulses to an oscillope or graphic recorder. With the wave
forms recorded, the ECG can then be examined to detect dysrythmias and alterations in conduction
indicative of myocardial damage, enlargement of the heart or drug effects. (Kozier’s Fundamentals of
Nursing, 2007)

It a diagnostic tool that measures and records the electrical activity of the heart in exquisite detail.
Interpretation of these details allows diagnosis of a wide range of heart conditions. These conditions can
vary from minor to life threatening.

The term electrocardiogram was introduced by Willem Einthoven in 1893 at a meeting of the Dutch
Medical Society. In 1924, Einthoven received the Nobel Prize for his life's work in developing the ECG.

The ECG has evolved over the years.

• The standard 12-lead ECG that is used throughout the world was introduced in 1942.
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 • It is called a 12-lead ECG because it examines the electrical activity of the heart from 12 points
of view.

• This is necessary because no single point (or even 2 or 3 points of view) provides a complete
picture of what is going on.

• To fully understand how an ECG reveals useful information about the condition of your heart
requires a basic understanding of the anatomy (that is, the structure) and physiology (that is, the
function) of the heart.

As the heart undergoes depolarization and repolarization, the electrical currents that are generated spread
not only within the heart, but also throughout the body. This electrical activity generated by the heart can
be measured by an array of electrodes placed on the body surface. The recorded tracing is called an
electrocardiogram (ECG, or EKG). A "typical" ECG tracing is shown to the right. The different waves
that comprise the ECG represent the sequence of depolarization and repolarization of the atria and
ventricles. The ECG is recorded at a speed of 25 mm/sec, and the voltages are calibrated so that 1 mV =
10 mm in the vertical direction. Therefore, each small 1-mm square represents 0.04 sec (40 msec) in time
and 0.1 mV in voltage. Because the recording speed is standardized, one can calculate the heart rate from
the intervals between different waves.

Heart Function and the ECG

The heart normally beats between 60 and 100 times per minute, with many normal variations. For
example, athletes at rest have slower heart rates than most people. This rate is set by a small collection of
specialized heart cells called the sinoatrial (SA) or sinus node.
Located in the right atrium, the sinus node is the heart's "natural pacemaker."
• It has "automaticity," meaning it discharges all by itself without control from the brain.

• Two events occur with each discharge: (1) both atria contract, and (2) an electrical impulse
travels through the atria to reach another area of the heart called theatrioventricular (AV) node,
which lies in the wall between the 2 ventricles.
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 • The AV node serves as a relay point to further propagate the electrical impulse.

• From the AV node, an electrical wave travels to both ventricles, causing them to contract and
pump blood.

• The normal delay between the contraction of the atria and of the ventricles is 0.12 to 0.20
seconds. This delay is perfectly timed to account for the physical passage of the blood from the
atrium to the ventricle. Intervals shorter or longer than this range indicate possible problems.
The ECG records the electrical activity that results when the heart muscle cells in the atria and ventricles
contract.

• Atrial contractions (both right and left) show up as the P wave.

• Ventricular contractions (both right and left) show as a series of 3 waves, Q-R-S, known as
the QRS complex.

• The third and last common wave in an ECG is the T wave. This reflects the electrical activity
produced when the ventricles are recharging for the next contraction (repolarizing).

• Interestingly, the letters P, Q, R, S, and T are not abbreviations for any actual words but were
chosen many years ago for their position in the middle of the alphabet.

• The electrical activity results in P, QRS, and T waves that have a myriad of sizes and shapes.
When viewed from multiple anatomic-electric perspectives (that is, leads), these waves can show a
wide range of abnormalities of both the electrical conduction system and the muscle tissue of the
heart's 4 pumping chambers.

Some of the ECG leads are bipolar leads (e.g., standard limb leads) that utilize a single positive and a
single negative electrode between which electrical potentials are measured. Unipolar leads (augmented
leads and chest leads) have a single positive recording electrode and utilize a combination of the other
electrodes to serve as a composite negative electrode. Normally, when an ECG is recorded, all leads are

BIPOLAR LEADS

recorded simultaneously, giving rise to what is called a 12-lead ECG.

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Lead I has the positive electrode on the left arm, and the negative electrode on the right arm, and therefore
measures the potential difference between the two arms. In this and the other two limb leads, an electrode
on the right leg serves as a reference electrode for recording purposes. In the lead II configuration, the
positive electrode is on the left leg and the negative electrode is on the right arm. Lead III has the
positive electrode on the left leg and the negative electrode on the left arm. These three bipolar limb
leads roughly form an equilateral triangle (with the heart at the center) that is called Einthoven's triangle
in honor of Willem Einthoven who developed the electrocardiogram in 1901. Whether the limb leads are
attached to the end of the limb (wrists and ankles) or at the origin of the limb (shoulder or upper thigh)
makes no difference in the recording because the limb can simply be viewed as a long wire conductor
originating from a point on the trunk of the body.

if the three limbs of Einthoven's triangle (assumed to be equilateral) are broken apart, collapsed, and
superimposed over the heart, then the positive electrode for lead I is said to be at zero degrees relative to
the heart (along the horizontal axis) (see figure at right). Similarly, the positive electrode for lead II will
be +60º relative to the heart, and the positive electrode for lead III will be +120º relative to the heart as
shown to the right. This new construction of the electrical axis is called the axial reference system.
With this system, a wave of depolarization traveling at +60º produces the greatest positive deflection in
lead II. A wave of depolarization oriented +90º relative to the heart produces equally positive deflections
in both lead II and III. In this latter example, lead I shows no net deflection because the wave of
depolarization is heading perpendicular to the 0º, or lead I, axis

UNIPOLAR LEADS

These are termed unipolar leads because there is a single positive electrode that is referenced against a
combination of the other limb electrodes. The positive electrodes for these augmented leads are located
on the left arm (aVL), the right arm (aVR), and the left leg (aVF). In practice, these are the same electrodes
used for leads I, II and III. (The ECG machine does the actual switching and rearranging of the electrode
designations). The three augmented leads, along with the threestandard bipolar limb leads, are depicted
as shown to the right using the axial reference system. The aVL lead is at -30° relative to the lead I axis;
aVR is at -150° and aVF is at +90°. It is very important to learn which lead is associated with each axis.

The three augmented unipolar leads, coupled with the three bipolar leads, constitute the six limb leads of
the ECG. These leads record electrical activity along a single plane, termed the frontal plane relative to
the heart. Using the axial reference system and these six leads, it is simple to define the direction of an
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electrical vector at any given instant in time. If a wave of depolarization is spreading from right-to-left
along the 0° axis, then lead I will show the greatest positive amplitude. If the direction of the electrical
vector for depolarization is directed downwards (+90°), then aVF will show the greatest positive
deflection. If a wave of depolarization is moving from left-to-right at +150°, then aVL will show the
greatest negative deflection

CHEST LEADS

figuration places six positive electrodes on the surface of the chest over different regions of the heart in
order to record electrical activity in a plane perpendicular to the frontal plane (see figure at right). These
six leads are named V1 - V6. The rules of interpretation are the same as for the limb leads. For example, a
wave of depolarization traveling toward a particular electrode on the chest surface will elicit a positive
deflection.

Because initial ventricular depolarization is from left to right across the septum, there is an initial R-wave
in V1 followed by an S-wave as the anterior and lateral walls of the left ventricle depolarize. Leads V5 and
V6 show a large net positive QRS because these leads overlie the anterolateral wall of the left ventricle,
which has a large muscle mass undergoing depolarization. Tracings from leads V5 and V6 are almost
opposite in polarity from V1because they are viewing opposite sides of the heart. Leads V2-V4 are
intermediate owing to their electrode placement.

In summary, the chest leads provide a different view of the electrical activity within the heart. Therefore,
the waveform recorded is different for each lead compared to the limb leads.

Reasons of Having ECG

• Chest pain

• Syncope (fainting)

• Palpitations(abnormal feeling of heart beat)

• Nausea

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 • Shortness of breath

• Weakness

• Abdominal pain

Nursing Management/s:

1. Advise the client to wear Wear light, comfortable clothes and shoes.

2. Instruct the client to avoid having a heavy meal a few hours before the test.

3. Sometimes your doctor may advise you to stop taking certain heart medications for one or two days
before the test.

It uses ECGs to assess the client’s response to an increased cardiac workload during exercise. As the
body’s demand for oxygen increases with exercising, the cardiac workload increases, as does the oxygen
demand of the heart muscle itself. Clients with coronary artery disease may develop chest pain and
characteristic ECG changes during exercise.

It’s an ECG that is recorded while you are walking on a treadmill or cycling on an exercise bike. The idea
of this test is to see how your heart works when you are more active.

Electrodes will be put on your chest and you’ll be asked to walk on a treadmill or cycle on an exercise
bike. The test starts off at an easy rate, and is gradually made harder either by increasing the speed and
slope of the treadmill or by putting a break on the bike. A doctor or technician will carefully monitor your
ECG at regular intervals throughout the test. Make sure you let staff know if you have any symptoms such
as chest pain or discomfort or if you get very tired or short of breath during the test. The test usually lasts
from a few minutes up to 15 minutes.

Your heart needs more blood and oxygen when you are active, so the exercise ECG can show whether
your heart is getting enough blood from the coronary arteries during physical activity. This can help
doctors find out if you have coronary heart disease and, if so, how severe it is.

An exercise ECG is also helpful for looking at how well the heart is working after angioplasty or bypass
surgery.

A regular stress test is considered in the following circumstances:

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 • Patients with symptoms or signs that are suggestive of coronary artery diseases (CAD).
• Patients with significant risk factors for CAD.
• To evaluate exercise tolerance when patients have unexplained fatigue and shortness of breath.
• To evaluate blood pressure response to exercise in patients with borderline hypertension.
• To look for exercise-induced serious irregular heart beats.

A 12-lead EKG is recorded on paper. Each lead of the EKG represents a different portion of the heart,
with adjacent leads representing a single wall. For example:

• Leads 2, 3, and aVF = bottom or inferior portion of the heart.

• Leads V1 and V2 = septum or partition of the heart.
• Leads V3, V4, V5 and V6 = anterior or front portion of the heart.
• Leads 1 and aVL = superior or top and outer left portion of the heart.
• Lead aVR looks at the cavity of the heart and has almost no clinical value in identifying coronary
disease.

The treadmill is then started at a relatively slow "warm-up" speed. The treadmill speed and it's slope or
inclination are increased every three minutes according to a preprogrammed protocol (Bruce is the
commonest protocol in the USA, but several other protocols are perfectly acceptable). The protocol
dictates the precise speed and slope. Each three minute interval is known as a Stage (Stage 1, Stage 2,
Stage 3, etc. Thus a patient completing Stage 3 has exercised for 3 x 3 = 9 minutes). The patient's blood
pressure is usually recorded during the second minute of each Stage. However, it may be recorded more
frequently if the readings are too high or too low.

Nursing Management/s:

• Do not eat or drink for three hours prior to the procedure. This reduces the likelihood of nausea
that may accompany strenuous exercise after a heavy meal. Diabetics, particularly those who use
insulin, will need special instructions from the physician's office.
• Specific heart medicines may need to be stopped one or two days prior to the test. Such
instructions are generally provided when the test is scheduled.
• Wear comfortable clothing and shoes that are suitable for exercise.
• An explanation of the test is provided and the patient is asked to sign a consent form.
• How long does the entire test take? A patient should allow approximately one hour for the entire
test, including the preparation.

Alternative name/s: Ambulatory Electrocardiography(ECG)

The Holter monitor is named for Dr. Norman J. Holter who invented telemetric cardiac monitoring in
1949

Procedure:

Electrodes (small conducting patches) are stuck onto your chest and attached to a small recording
monitor. You carry the Holter monitor in a pocket or small pouch worn around your neck or waist. The
monitor is battery operated.
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While you wear the monitor, it records your heart's electrical activity. You should keep a diary of what
activities you do while wearing the monitor. After 24 - 48 hours, you return the monitor to your doctor's
office. The doctor will look at the records and see if there have been any irregular heart rhythms.

It is very important that you accurately record your symptoms and activities so that the doctor can match
them with your Holter monitor findings.

Purposes:

It may be used to determine how the heart responds to normal activity. The monitor may also be used:

• After a heart attack

• To diagnose heart rhythm problems
• When starting a new heart medicine

Used to diagnose:

• Atrial fibrillation/flutter
• Multifocal atrial tachycardia
• Palpitations
• Paroxysmal supraventricular tachycardia
• Reasons for fainting
• Slow heart rate (bradycardia)
• Ventricular tachycardia

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