Text Book Reading

Interpretation of the
Electrocardiogram

Delivered By :
M. Dzikrul Haq Karimullah, MD

Supervised :
Cholid Tri Tjahjono, MD, Cardiologist
Consultant of Preventive and Rehabilitative Medicine
Introduction

Electrocardiographic Correlations with Chest Exercise testinduced

(ECG) response to The three ST-segment pain arrhythmias are the
exercise. responses to exercise final ECG response
associated with
ischemiaelevation,
normalization, and
depressionare
presented.
Studies of the Electrocardiographic
Response to Exercise

1928 1953
Einthoven reported the first
attempt to evaluate the
Fiel and Masters Simonson
reported the
response of the Siegel first step test electrocardiogra
electrocardiogram (ECG) to noted ST introduced phic response to
exercise. depression treadmill
with testing of a wide
age range of
1908 exercise.
1930 normal subjects.
Timelines

1979The United States Air

1965Blomqvist the Force Medical Corps (USAFMC)
response of the Frank 1975Simoons and Hugenholtz5
1973Rautaharju and Normal Aircrewmen Study was
reported Frank lead
vector cardiographic leads colleagues4 analyzed P-, ST-, and
vectorcardiographic changes
based on digital data from 40
to bicycle exercise using T-vector functions in the Frank low-risk normal subjects,
during exercise in normal
leads in response to exercise. processed, and analyzed across
computer subjects.
treadmill times on the basis of
Techniques. waveform component and lead.
USAFMC
Normal Air crewmen Study

FIGURE 4-1 The waveforms produced using median

values of the measurements of all 40 subjects for
leads V5, Y, and Z. These figures demonstrate the
specific waveform alterations that occur in response
to maximal treadmill exercise. Supine, exercise to a
heart rate of 120 beats per minute, maximal
exercise, 1-minute recovery, and 5-minute recovery
were chosen as representative times for presentation
of these median-based simulated waveforms.
Q-Wave, R-Wave, and S-Wave Amplitudes

ST Slope, J-Junction Depression, and T-Wave Amplitude

Controversial
ECG Responses to Exercise
R-Wave Changes

S-Wave Changes
Contd
U-Wave Changes
 ST-T Changes
The most common ECG
abnormality seen in the
exercise laboratory is
ST-segment depression,
whereas ST elevation is
relatively rare
Is ST Elevation Caused by Ischemia or Wall Motion Abnormality?
ST-Segment Depression
ST Depression in Recovery
R-Wave Amplitude Adjustment
Resting ST-Segment Displacement
Exercise-Induced ST-Segment Depression Not Caused by
Coronary Artery Disease
Atrial
Repolarization
Atrial Repolarization
Contd
Hyperventilation
Abnormalities

ST Shift Location
and Ischemia
Chest Pain
Do Diabetics Have a Higher Prevalence of Silent Ischemia during
Treadmill Testing Than Non diabetics?
Interpretation of Exercise TestInduced
Arrhythmias
Pathophysiology :
Activation of the sympathetic nervous system and an increase in the
availability of circulating catecholamines
These changes interact with the three major mechanisms involved in
the generation of arrhythmias: enhanced automaticity, triggered
automaticity, and reentry.
Potential proarrhythmic mechanisms include electrolyte shifts,
baroreceptor activation, myocardial stretch, and ischemia.
Atrial arrhythmias may reflect underlying left atrial enlargement and
ventricular dysfunction.
Reproducibility

Prevalence of Exercise TestInduced Ventricular Tachycardia

Clinical Prognostic Studies
Exercise TestInduced Supraventricular Arrhythmias
Few studies have evaluated if exercise testinduced
supraventricular arrhythmias (ETISVAs) (supraventricular or atrial
arrhythmias during exercise testing) are predictive of an increased
risk of cardiac events and death.
Atrial arrhythmias may reflect underlying left atrial enlargement
and ventricular dysfunction, which themselves predict mortality.
 Exercise TestInduced ventricular Arrhythmias
Nonsustained ventricular tachycardia was defined as eight or
more consecutive ventricular ectopic beats at greater than 100
beats per minute.
Detry et all conclude that The 5-year survival rate was 84% in
patients with a short run of VT and only 43% in patients with VF or
sustained VT.
Reproducibility of
Treadmill Test Responses
Sullivan et all studied 14
male patients with
exercise testinduced
angina and ST-segment
depression with
treadmill testing on
three consecutive days
to evaluate the
reproducibility of certain
treadmill variables.
Conclusion

The interpretation of the exercise test requires understanding

exercise physiology and pathophysiology as well as expertise in
electrocardiography.
When properly interpreted, the exercise test is one of the most
important diagnostic and clinically helpful tests in medicine.
Thank you