LSM 3212 Practical Session ELECTROCARDIOGRAM (ECG)

NOTE: 1. There will be a Quiz at the end of the practical. 2. PRE-PRAC and POST-PRAC exercises are included for your own private study.

Outline for Practical Day: Briefing: 10 min Graded exercise test: 60 min Practice lead placement: 15 min Discussion and Quiz: 30min You would have learned about cardiovascular response to exercise and electrocardiograph (ECG) monitoring in your lectures. In this practical session you will get to observe and experience the process of a graded exercise test (GXT) with 12-lead ECG monitoring. During the session, you should try to relate what you have learnt in your lectures to the cardiovascular responses that you observed during the GXT and your own experience (i.e. heart and respiratory rates) when you participate in sports and exercise activities. The experience in this session and the exercises in the lab worksheet are designed to complement the lectures to help you understand the relationship between the demands (stress) of physical exertion and the response of the cardiovascular system. By the end of this session, you should: a. Understand the relationship between heart rate and exercise intensity. b. Be able to calculate heart rate using the ECG recordings. c. Be able to determine the components of an ECG wave (PQRST) and the various intervals that are used to interpret ECG readings. d. Experience placing the electrodes for a 12-lead ECG on your peers. GRADED EXERCISE TEST (GXT) GXT is a process where stress is imposed on the cardiovascular system in the form of an exercise activity to induce a response from the cardiovascular system. In the clinical setting GXT is used as part of the diagnosis for heart diseases. For example, men > 40 years of age and women > 50 years of age should undergo a GXT annually for medical clearance if they intend to engage in high intensity activities. In the healthy population, GXT is performed mainly to evaluate aerobic fitness. Generally, any form of physical activity that stresses the heart can be used to conduct a GXT, but because of the need to standardize and regulate workload (exercise intensity), walking / running on the treadmill and cycling on a bicycle ergometer are the most common modes of exercises used in GXT. During a GXT, the subject starts the exercise with a light workload and the workload is increased at a fixed time interval. The changes in heart rate and in the morphology of the ECG waves at the different workloads are used to interpret the condition of the heart. A variety of exercise protocols can be used to conduct a GXT. The key considerations for selecting an exercise protocol are the purpose of the test and the population being tested. For example, an exercise protocol that comprises high intensity work is not suitable for the diagnosis of heart disease in unfit populations. The high work intensity would cause the GXT to stop prematurely due to muscular fatigue before any pathological responses can be observed in the ECG. An exercise protocol comprising more graduated work intensities would be more suitable for such cases. Exercise protocols that use high intensity workloads are more suitable for evaluating aerobic fitness in the active population. More information on GXT exercise protocol can be found at the website for the American College of Sports Medicine (www.acsm.org).
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LAB ACTIVITIES___________________________________________________________________ I. Graded Exercise Test (GXT) We will perform a GXT using a cycle ergometer on one of your peers. Before he / she starts the test, we need to ensure that the subject does not have any pre-existing conditions that are contraindicative to intense exercise (self-declaration) e.g., congenital heart disease, hypertension etc. GXT for those with pre-existing medical conditions that are contraindicative to exercise should be done under medical supervision. For today, we will be going through the following process: a. Place the leads on the subject. b. Subject sits on the cycle ergometer. Hook-up ECG leads to the ECG monitor and take a resting 12-lead ECG is taken. Adjust the sit height so that there is a 15 to 20 flexion at the knee joint at full-extension. Make sure that the subject is comfortable. c. Record resting heart rate (1 min interval) for 3 min (below). d. Subject starts cycling using the following exercise protocol below. i. Rest for 3 min ii. 25 W; 2min iii. 50 W; 2min iv. 75 W; 2min v. 100 W; 2min vi. 125 W; 2min vii. Recover; 5min e. Record the heart rate at the end of each stage. Exercise 1 Record the age of the subject: ___________years Calculate the subjects maximum heart rate (MHR = 220 Age) = _____ bpm Record the heart rate response during the GXT Resting 1 min: ______ bpm Resting 2 min: ______ bpm Resting 3 min: _____ bpm 25 W: _____ bpm 50 W: _____ bpm 75 W: _____ bpm 100 W: _____ bpm 125 W: _____ bpm
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Recovery 1 min:_____ bpm Recovery 2 min: _____ bpm Recovery 3 min: _____ bpm Recovery 4 min: _____ bpm Recovery 5 min: _____ bpm

II. ECG Lead Placement There are 3 sets of leads in a 12-lead ECG: a. Bipolar leads (I, II, III) b. Augmented unipolar leads (AVL, AVR and AVF) c. Unipolar chest leads (V1 to V6)

Figure 1: ECG lead placement. The placement of these leads are described in Figure 1 and demonstrated to you during this session: AVL: Hollow of the chest near the left shoulder joint. AVR: Hollow of the chest near the right shoulder joint. AVF: Left leg, above the ankle joint, above the medial malleolus for resting ECG, or left side of the waist for exercise ECG. V1: 4th intercostal space on the right side of the sternum. V2: 4th intercostal space on the left side of the sternum. V3: Between V2 and V4. V4: Mid-clavicular 5th intercostal space V5: Anterior axillary 4th intercostal space V6: Mid-axillary 5th intercostal space.

Practice Electrode Placement Organize yourselves into groups of 5 to 6, with a mix of males and females. Each student should get 10 ECG electrodes. Practice placing the electrodes on the male students. Female students who wish to practice on each other can use a separate dedicated room.

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PRE-PRAC Reading and Exercises_____________________________________________________ This part should be done before the Lab session for your own private study. Examples of single strip ECG recordings (V5) of a subject undergoing the same GXT protocol that you will do in the practical are shown in the worksheet below. The ECG recordings were taken at and when exercising at 25W, 75W, and 125W and during 5 min of recovery. For each ECG strip: a. Label the components of an ECG wave (PQRST) on ONE wave on the ECG strip. b. Calculate the heart rate per minute (Speed of recording is 25mm/sec) (see below). c. Measure the RR, PR and QT intervals.

P wave: Left and right atrial depolarization. T wave: Left and right ventricular repolarization. PR interval: P wave (atrial depolarization) plus PR segment (represent spread of impulse through the bundle of His, right and left bundle branches, and the Purkinje fibres). Normally shortens as heart rate increases. QRS interval: Ventricular depolarization. ST segment: Time during which ventricles are contracting and emptying. RR interval: Used to determine the rate and regularity of a cardiac (ventricular) rhythm. If the ventricular rhythm is regular, the RR intervals will measure the same. PP intervals determine atrial rhythm. Heart Rate Calculation To determine heart rate from ECG tracings, count the number of 5mm squares between two R intervals and divide 300 by the number of 5mm intervals. For example, if there are 2.5 squares (5mm) between 2 R waves, then the heart rate would be: 300/2.5 = 120 bpm
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PRE-PRAC Exercises__________________________________________________________________

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PRE-PRAC Exercises__________________________________________________________________

POST-PRAC Exercises________________________________________________________________ This part is to be done after the Lab session for your own private study. Using the results you obtained today, a. Graph the heart rate response (Y axis) against time / workload (X axis) using Microsoft Excel. b. Based on the graph in a, describe the relationship between heart rate and work intensity. c. Calculate the percentage (%) of maximum heart rate (MHR) of the subject at each work load using the following formula: MHR = 220 Age %MHR = [HR / (220 Age)] X 100 Answers: %MHR at 25 W: ______ % MHR at 50 W: ______ % MHR at 75 W: ______ % MHR at 100 W: ______ % MHR at 125 W: ______

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