1. Instrumental methods of examination of cardiovascular system
Prof. S.M. Andreychyn

2. Electrocardiography Is a method of graphic
recording of electric currents
generated in the working heart.
Electrocardiography

3. Conducting system

4. I bipolar limb leads – right arm (R+) – left leg (Y-).
II bipolar limb leads – right arm (R+) – left leg (G-).
III bipolar limb leads – left arm (Y+) – left leg (G-).
Ground (black electrode on the right leg)
Bipolar limb leads

5. Bipolar limb leads

6. Ground

7. aVR – the active electrode, is placed successively on the right arm.
aVL – the active electrode, is placed successively on the left arm.
aVF - the active electrode, is placed successively on the left leg.
Unipolar limb leads

8. Unipolar limb leads

9. Bipolar and Unipolar limb leads

10. Chest leads V1 – right sternal border, the 4th intercostal space.
V2 – left sternal border, the 4th interspace.
V3 – left parasternal line, between the 4th and 5th interspace.
V4 – left midclavicular line, the 5th interspace.
V5 – left anterior axillary line, the 5th interspace.
V6 – left midaxillary line, the 5th interspace.
Chest leads

11. Chest leads

12. Normal ECG

13. Normal ECG

14. The scheme of ECG interpretation
1. Is heart rrhythm sinus or ectopic, regular or irregular.
2. Heart rate = 60/R-R (when paper speed is 50 mm/sec R-R=N×0,02).
3. Amplitude of ECG voltage (amplitude of R in standard leads ≥5 mm or their summation in I,II and III leads ≥15 mm.
4. Electrical axis deviation.
5. Assessment of all components of ECG.
The scheme of ECG interpretation

16. Normal ECG

17. ECG interpretation Interval R-R Interval P-Q Segment S-T Interval Q-T
Segment P-Q
ECG interpretation

18. ECG interpretation

19. Determination of inner deviation of atriums and ventricles

20. ECG in standard limb leads

21. ECG unipolar limb leads

22. Chest leads in norm

23. Causes of electrical axis deviation
causes of right axis deviation
normal finding in children and tall thin adults
right ventricular hypertrophy
chronic lung disease even without pulmonary hypertension
anterolateral myocardial infarction
left posterior hemiblock
pulmonary embolus
Wolff-Parkinson-White syndrome - left sided accessory pathway
atrial septal defect
ventricular septal defect
causes of left axis deviation
left anterior hemiblock
Q waves of inferior myocardial infarction
artificial cardiac pacing
emphysema
hyperkalaemia
Wolff-Parkinson-White syndrome - right sided accessory pathway
tricuspid atresia
ostium primum ASD
injection of contrast into left coronary artery

24. Electrical axis

25. Hypertrophies of heart chambers
Left atrial hypertrophy:
- broad biphasic P in I, AVL, V5-V6
Right atrial hypertrophy:
- high acute P in III, AVF, V1
Left ventricular hypertrophy:
- high R in I, AVL, V5-V6
Discordant displacement of ST segment opposite to the lagest wave in QRS complex
Broad QRS (more than 0,1 sec)
Right ventricular hypertrophy:
- high R in III, AVF, V1
Discordant displacement of ST segment opposite to the lagest wave in QRS complex

27. Right atrial hypertrophy

28. Left atrial hypertrophy

29. Hyperthrophy of the left ventricle

30. Hyperthrophy of the right ventricle

31. Hyperthrophy of the right ventricle

32. Disorders of heart rrhythm:
I. Disorders of excitation (arrhythmias):
1. Sinus arrhythmia
sinus tachycardia,
sinus bradycardia
sinus arrhythmia
2. Ectopic arrhythmias:
extrasystole (sinus, atrial, atrioventricular, ventricular)
Paroxismal tachycardia (atrial, ventricular).
II. Disorders of heart conduction:
sinus, atrial,atrioventricular and ventricular blocks,
III. Combined disorders of excitation and conduction:
flutter (atrial and ventricular)
fibrillation (atrial and ventricular)

33. SINUS ARRHYTHMIA
Sinus arrhythmia is a cyclic increase in normal heart rate with inspiration and decrease with expiration. It results from reflex changes in vagal influence on the normal pacemaker and disappears with breath-holding or increase of heart rate due to any cause. The arrhythmia has no significance except in older persons, when it may be associated with coronary artery disease.

34. SINUS ARRHYTHMIA

35. SINUS TACHYCARDIA Sinus tachycardia is a heart rate faster than
90 beats/min that is caused by rapid impulse formation by the normal pacemaker secondary to fever, exercise, emotion, anemia, shock, thyrotoxicosis, or drug effect. The rate may reach 180/min in young persons but rarely exceeds 160/min.
In quick heart rate the patient feels palpitation.

36. SINUS BRADYCARDIA
Sinus bradycardia is a heart rate slower than 60/min due to increased vagal influence on the normal pacemaker. The rate increases after exercise or administration of atropine. Slight degrees have no significance, especially in youth, unless there is underlying heart disease, especially coronary heart disease or acute myocardial infarction.
Elderly patients may develop weakness, confusion, or even syncope with slow heart rates. Arrhythmia disappears to use ephedrine or atropine in some patients to speed the heart rate. Rarely, artificial pacemakers are necсessary.

37. а-normal sinus rrhythm
б- sinus tachycardia
в- sinus bradycardia
г- sinus arrhythmia

38. The most common mechanisms of ectopic arrhythmia are:
1) reentry mechanism. The depolarization wave front proceeds antegradely through the fiber whose conduction is slowed and returns retrogradely in a nearly fiber that had unidirectional antegrade block.When this returning echo reaches the site of its origin, it may then reexcite the fiber, which is now no longer refractory.
Alternative mechanisms are:
2) abnormal automaticity,
3) triggered activity (more rarely).
Repetitive reentry may result paroxysmal tachycardia, if the atrial premature beat is appropriately timed. Similarly, a single atrial premature beat may terminate atrial tachycardia by making the reentry pathway refractory. Recent evidence indicates that about one-third of patients have aberrant pathways to the ventricles.

39. Ectopic arrhythmias I. Extrasystole - atrial - atrioventricular
II. Paroxismal tachycardia
Ectopic arrhythmias

40. ATRIAL PREMATURE BEATS (Atrial Extrasystoles)
Atrial premature beats occur when an ectopic focus in the atria fires off before the next expected impulse from the sinus node. Ventricular systole occurs prematurely, and the compensatory pause following this is only slightly longer than the normal interval between beats. P wave is byphasic.
ECG signs: 1) premature appearance of cardiac complex of ECG,
2) non-complete compensatory pause,
3) P wave is biphasic or negative,
4) P is always recorded before QRS.

41. Atrial extrasystole

42. Atrial extrasystoly

43. Atrial bigeminy

44. ATRIO-VENTRICULAR PREMATURE BEATS (AV extrasystoles)
ECG signs:
1) premature appearance of cardiac
complex on ECG,
2) non-complete compensatory pause,
3) Depending on the location of focus
of excitation P wave occurs before
or after QRS complex or can be
superimposed on the last one.
ATRIO-VENTRICULAR PREMATURE BEATS (AV extrasystoles)

45. Ventricular Extrasystoles
Main features:
premature appearance of heart complex;
P wave is abcent;
QRS complex is disfigured depending on the location of pathological focus (right or left His bundlebranch) and broadened;
Discordant displacement of ST segment opposite to the largest wave in the QRS complex;
complete compensatory pause.

46. а- extrasystole from the left ventricle
б- extrasystole from the right ventricle

47. Ventricular extrasystole

48. Ventricular bigeminy and quadrigeminy

49. Dangerous extrasystoles by Lawn

51. Paroxismal tachycardia
This is a sudden acceleration of the cardiac rhythm
ECG signs:
1) Acceleration of heart rate more than 150 per min;
2) The same shape of all cardiac complexes;
3) Sudden start and stop;
4) Equal R-R intervals.
Paroxismal tachycardia

52. PAROXYSMAL ATRIAL TACHYCARDIA
It occurs more often in young patients with normal hearts. Attacks begin and end abruptly and usually last several hours. The heart rate may be /min(usually /min) and is perfectly regular, therate will not vary more than 1-2 beats per minute.Exercise, change of position, breath-holding, carotid sinus massage, or induced gagging or vomiting either has no effect or promptly abolishes the attack. Patient sare asymptomatic except for awareness of rapid heart action unless there is underlying heart disease, especially mitral stenosis and coronary heart disease. Inprolonged attacks with rapid rates, dyspnea or tight-ness in the chest may be felt as palpitation, discomfort in heart region, dizziness.
PAROXYSMAL ATRIAL TACHYCARDIA

53. а- atrial paroxismal tachycardia
б- atrioventricular (nodal) tachycardia with premature excitation of ventricles
в- atrioventricular (nodal) tachycardia with simultaneous excitation of ventricles and atriums

54. Atrial PT

55. Ventricular paroxismal tachycardia

56. Ventricular PT

57. ATRIAL FIBRILLATION
Atrial fibrillation is the commonest chronic arrhythmia. It occurs most frequently in rheumatic heart disease, especially mitral stenosis, and arteriosclerotic heart disease. It is the only common arrhythmia in which the ventricular rate is rapid and the rhythm irregular. An ectopic atrial pacemaker fires times per minute.

58. Atrial fibrillation

59. ATRIAL FLUTTER
Atrial flutter is uncommon and usually occurs inpatients with rheumatic or coronary heart disease, cor pulmonale, or atrial septal defect or as a result of quinidine effect on atrial fibrillation. Ectopic impulse formation occurs at rates of , with transmission of every second, third, or fourth impulse through the atrioventricular node to the ventricles. The ventricular rate is usually one-half the atrial rate (2:1conduction), or 150/min. Carotid sinus massage causes sudden slowing or standstill, with rapid return of the rate to the original level on release of pressure.When the ventricular rate is 75 (4:1 block), exercise may cause sudden doubling of the rate to 150 (2:1block). The first heart sound varies slightly in intensity from beat to beat (but not when the patient is in aconstant 2:1 flutter).

60. Atrial flutter

61. Ventricular flutter and fibrillation

62. Ventricular fibrillation

63. а- ventricular flutter
б- ventricular fibrillation

64. Disorders of heart conduction:
Atrial block
Atrioventricular block:
I degree
II degree (Mobitz I, II and III)
III degree
Hiss bundlebranch block (right, left).
Disorders of heart conduction:

65. ECG signs: broad P wave
Atrial block

66. Intraatrial block

67. AV block I degree: Prolongation of PQ
II degree: Prolongation of PQ and periodical missing of QRS,
- Mobitz I: Venkebach’s periods (gradual PQ prolongation)
- Mobitz II: PQ il longer but equal in all complexes, periodical missing of QRS
Mobitz III: long PQ, many missed QRS (more P waves on ECG than QRS complexes but P is recorded before QRS)
III degree or complete AV block: more P waves on ECG than QRS complexes and P is recorded independently of QRS
AV block

68. AV block I degree Permanent prologation of PQ more than 0,20с
а- atrial form
б- nodal form
в- distal (trifascicular) form

69. I degree AV block

70. II degree AV block

71. III degree AV block

72. Left bundle branch block (LBBB)

73. Left HBBB

74. Right HBBB

75. LBBB

76. Right bundle branch block (RBBB)

77. Holter ECG monitoring

78. Heart sonohraphy (B-mode)

79. B- and M-mode ultrasound of a heart

80. X-ray of a heart. Aortic heart configuration

81. Mitral heart configuration

82. Thank you