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Steps : 1. Heart rate 2. Heart rhythm - check for deviation from normal in terms of origin (automaticity) or sequence (conductivity) of heart action. - check whether it is occasional, frequent, continuous, regular or irregular, repetitive or occurring with many combinations. 3. Measure complexes and intervals. 4. Evaluate the waveform morphology. 5. Determine MEA - vector always point towards hypertrophy but away from infarcted areas. - more reliable in narrow-chested animals/breeds.
ECG : MEA
MEA indicates average direction of the electrical activation signals in the heart during a cardiac cycle. Three methods : 1. Using isoelectric leads. 2. Looking for strongest QRS deflections. 3. Calculating from Lead I and Lead III. - MEA should be interpreted with evidences from other leads or other clinical evidences, can be very tricky in broad-chested animals and cats. - MEA depends on muscle mass and not the thickness of the myocardial wall. A dog with dilated cardiomyopathy may not necessary show abnormal MEA.
ECG : MEA
ECG : MEA
ECG : MEA
ECG : MEA
Biatrial Enlargement
Characterised by Long P duration and very tall P wave. Notching is frequent. Associated with Chronic Tricuspid or Mitral valvular disease or various congenital heart defects
Biatrial Enlargement
Bi-Ventricular Enlargement
This condition is more difficult to determine accurately but oftentimes the diagnosis of left ventricular enlargement is more accurate. This is because left ventricular forces can easily counteract any increased forces from the right (remember ECG is dependent on volume and mass) Characterised by Large QRS complexes, tall S and R waves Deep Q waves quite characteristic of biventricular enlargements Evidences of right and left atrial enlargements Associated with Mitral and tricuspid valve insufficiency, dilated cardiomyopathy, PDA and mitral insufficiency
Bi-Ventricular Enlargement
Bi-Ventricular Enlargement
The following ECG findings are important, but I will leave it to the students to determine their usefulness in routine clinical analysis.
Q-T interval (prolonged or shortened) not so important in vet. med. Prolonged hypocalcemia (hypoparathyroidism, eclampsia), hypokalemia, ethylene
glycol poisoning, hypothermia Shortened hyperkalemia, hepercalcemia
Q-T interval is the summation of ventricular depolarization and repolarization, and represents ventricular systole
Arrhythmias
Classification of rhythms : A.Normal sinus impulse formation - normal sinus rhyhm - sinus arrhythmia B.Disturbances of sinus impulse formation - sinus bradycardia - sinus tachycardia C.Disturbances of ventricular impulse formation - ventricular premature complexes - ventricular tachycardia - ventricular asystole - ventricular fibrillation
Arrhythmias
D.Disturbances of impulse conduction : - sinus arrest or block - sick sinus syndrome - atrial standstill - ventricular pre-excitation - 1st degree AV block - 2nd degree AV block - 3rd degree AV block - Left bundle branch block - Right bundle branch block Arrhythmias = abnormality in rate, regularity or site of origin of the cardiac impulse OR a disturbance in conduction of impulse that the normal sequence of activation of the atria and ventricle is altered.
Arrhythmias
There are three different sites of origin for arrythmias, they can be identified based on the morphology of P wave and QRS complexes : a.)Atrial (sinus) P wave is +ve and present, constant P-R interval and normal duration QRS. b.)Junctional P wave absent or ve, normal or short duration QRS. May occur with BBB which causes poor morphology and prolonged duration on the QRS. c.)Ventricular P waves absent (may even be superimposed on QRS). QRS wide and bizarre and may be +ve (left) of ve (right) depending on which ventricle is the site of origin.
Arrhythmias
The automaticity (ability to initiate impulse) of the site further describe the arrythmia by being : i.too fast (tachycardia) ii.too slow (bradycardia) iii.too irritable (premature) iv.not irritable (block)
Sinus bradycardia
Defined as heart rate < 120 (cats), < 70 (dogs) or < 60 (large dogs). Associated with : physiologic changes intubation, vomiting, hypothermia, elevated intracranial pressure, hypothyroidism, good conditioning. pathological systemic disease with toxicity (renal failure), hyperkalemia, cardiac arrest.
Physiologic sinus arrthymia arise due to waxing and waning of vagal tone during normal respiration. During inspiration the vagal tone of the heart will be suppressed rendering brief s. tachycardia, this becomes s.bradycardia or normal pace when the respiratory system relaxes activation of vagal tone.
Sinus Tachycardia
Defined as heart rate > 240 (cats), > 140 (dogs) or > 120 (large dogs), > 180 (toy breeds), > 220 (puppies). Associated with : physiologic changes exercise, pain or restraint. pathological fever, hyperthyroidism, shock, anaemia, CHF, hypoxia.
Atrial Tachycardia
Rapid regular rhythm arising from atrial sites other than the SA node. 3 or more APC = Atrial tachycardia Characteristics : Tachycardia, prolonged or normal P-R interval (depending on the origins of the ectopic site). QRS = normal, but P wave have unusual configuration.
Atrial Fibrillation
Caused by numerous disorganised atrial impulses bombarding the AV node. Af causes rapid and totally irregular atrial and ventricular rate. Ventricular rate becomes irregular as few fibrillatory waves managed to be condcuted through the AV junction to the ventricles. Hallmark of AF = absence of P waves replaced by oscillations of f waves. A.k.a. saw-tooth waves. In dogs and cats, the QRS may still be evident albeit differing in amplitudes. In ungulate where the Purkinje fibres penetrate deep into the myocardium, the f waves and QRS superimposed on each other. Associated with atrial enlargement, early signs of DCM (dilated cardiomyopathy) or DCM itself. Toxicity. AF may even occur without any evident cardiac disease.
Atrial Fibrillation
This dog had Ventricular Bigeminy a condition where VPCs and normal PQRST complexes are occuring at a fixed interval. In this case it is a Uniform VB as the ectopic pacemaker that gave rise to the VPC is stationary. VB may be seen in PDAs and rarely during thiopentone anaesthesia
Ventricular Tachycardia
The result of 3 or more VPCs. Characterised by ventricular rate > 150 bpm. No relation ship between P and QRS. There will be ventricular fusion and capture complexes (with P waves). Uncommon in cats.
Ventricular Asystole
You see this in dying animals ! A medical emergency because this condition indicates absence of pacemaker impulses. No pulse can be detected and CO may be = 0. Indicated by absence of QRS complex. P waves may be present if the animal has complete AV block.
Ventricular Fibrillation
Occurs when cells of the ventricular myocardium depolarise in a chaotic and uncoordinated manner. No pulse can be felt and Co is 0. Characterised by rapid, irregular rhythm with bizarre waves and oscillations (large = coarse fibrillation easier to treat; small = fine fibrillation req epinephrine to convert them into coarse fibrillation first before attempting any treatment). Associated with shock, anoxia, trauma, myocardial infarction, electrolyte and acid imbalances, anaesthetic reactions, digitalis toxicity, electric shock, myocarditis, hypothermia. Requires agrresive therapy. Electric cardioversion is often instituted immediately (remember the defibrillator ?) , alternatively a precordial thump may be helpful (although it may not work most of the time).
Ventricular Fibrillation
Sinus Block
Occasional failure of SA node to initiate an impulse, as a result no heart beat can be detected. No ventricular escape rhythms ! Prolonged pauses usually results in low CO An incidental finding in brachycephalic breed dogs, hereditory stenosis of the AV bundle (esp in pure breeds). Associated with elctrolyte imbalance, intense vagal stimulation, drug toxicity (digitalis, quinidine).Treatment is not really recommended if animal is asymptomatic.
AV blocks
AV block referred to a delay or interruption in conduction of a supraventricular impulse through the AV junction and AV bundle. Three types : A.)1st degree = delay in conduction. B.)2nd degree = intermittent disruptions of conduction. Further classified according to the location of blocks. Normal in horses and young animals. C.)3rd degree = complete or permanent interruption of conduction. Since P-R = duration taken by the impulse to travel from atria to ventricles. Therefore, this parameter will be most affected. Morphology of QRS will indicate whether the block is at the level of AV node (i.e. above AV bundle normal QRS) or below the AV bundle (bizarre QRS). Due to the dependence of block regions of the ventricle on the aberrant electrical signal from the excited ventricle.