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https://en.ecgpedia.org/index.php?title=Arrhythmogenic_Right_Ventricular_Cardiomyopathy&diff=9999
Arrhythmogenic Right Ventricular Cardiomyopathy
2010-01-28T00:19:00Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|advisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= P.G. Postema, MD<br />
}}<br />
[[Image:epsilon_wave.png|thumb|ECG with an epsilon wave in V1]]<br />
[[Image:arvdhart.png|thumb| A section throughout the heart of an ARVC patient. (A) Transmural fatty replacement of the right ventricular free wall. (B) Myocardial atrophy is confined to the right ventricle and substantially spares the interventricular septum as well as the left ventricular free wall. <cite>Corrado</cite> Reproduced with permission from BMJ Publishing Group Ltd. ]]<br />
'''Arrhytmogenic Right Ventricular Cardiomyopathy''', (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart. Most commonly the right ventricle apex and outflow tract are involved. However the left ventricle can be affected to.<cite>Corr</cite><br />
<br />
As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this disease and can lead to palpitations, syncope and sudden death. At more advanced ages right ventricular pump failure can occur.<br />
<br />
The diagnosis is based on major and minor criteria, as published by the European Society of Cardiology.<cite>McKenna1994</cite><br />
<br />
ARVC is a progressive disease. The '''incidence''' is estimated to be 1:3.000-1:10.000. Manifestations are usually seen in teenagers. Although the diagnosis is more often made in athletes, sports are not thought to have a causative relationship with the disease. ARVD can occur in families; more than 9 different chromosomal defects have been described, most often with autosomal dominant inheritance. <br />
<br />
One unique form of ARVD, called Naxos disease (after the Greek island where it was first diagnosed), has an autosomal recessive pattern of inheritance. <br />
<br />
'''Diagnosis''' ARVC is a difficult diagnosis to make. Therefore, the European Society of Cardiology has created a list of diagnostic criteria for the diagnosis of ARVC<cite>#McKenna1994</cite> (see table).<br />
{| class="wikitable" width="400px"<br />
!Major diagnostic criteria for Arrhythmogenic Right Ventricular Cardiomyopathy<cite>McKenna1994</cite><br />
|-<br />
|<ul><li>Familial disease confirmed at necroscopy or surgery</li><br />
<li>Severe dilatation and reduction of right ventricular ejection fraction with no (or only mild) LV impairment</li><br />
<li>Localized right ventricular aneurysms (akinetic or diskinetic areas with diastolic bulging)</li><br />
<li>Severe segmental dilataion of the right ventricle</li><br />
<li>Fibrofatty replacement of myocardium on endomyocardial biopsy</li><br />
</ul><br />
|-<br />
!Diagnostic criteria that can be diagnosed on the ECG<br />
|-<br />
|<ul><br />
<li>(major) Epsilon wave or localized prolongation (>110ms) of the QRS complex in right precordial leads (V1-V3)</li><br />
<li>(minor) Inverted T waves in right precordial leads (V2 and V3) (people aged more than 12 yr; in absence of [[RBBB]]</li><br />
<li>(minor) [[Late potentials]] ([[SAECG|signal averaged ECG]])</li><br />
<li>(minor) Left bundle branch block type [[Ventricular Tachycardia|ventricular tachycardia]] (sustained and non-sustained) (ECG, [[Holter]], [[Exercise Testing|exercise testing]]</li><br />
<li>(minor) Frequent [[Ventricular Premature Beats|ventricular extrasystoles]] (more than 1000/24h) ([[Holter]])</li><br />
</ul><br />
|}<br />
<br />
'''Treatment''' focuses on avoiding complications.<cite>ACC2006</cite><br />
*Medication: <br />
**Anti-arrhythmics: Sotalol better than Amiodarone.<br />
**ACE-inhibitors to prevent cardiac remodelling<br />
*[[ICD]] implantation is recommended for the prevention of sudden cardiac death in patients with ARVC with documented sustained VT or VF who are receiving chronic optimal medical therapy.<br />
*[[ICD]]] implantation can be considered for the prevention of sudden cardiac death in patients with ARVC with extensive disease, including those with left ventricular involvement, 1 or more affected family member with ICD, or undiagnosed syncope when [[Ventricular Tachycardia|ventricular tachycardia]] or [[Ventricular Fibrillation|ventricular Fibrillation]] has not been excluded as the cause of syncope, who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y.<br />
*Radiofrequency [[ablation]] can be useful as adjunctive therapy in management of patients with ARVC with recurrent [[Ventricular Tachycardia|ventricular tachycardia]], despite optimal antiarrhythmic drug therapy.<br />
<br />
<gallery><br />
Image:arvd_ecg1.png<br />
Image:arvd_ecg2.png<br />
Image:arvd_ecg3.png<br />
</gallery><br />
<br />
==References==<br />
<biblio><br />
#McKenna1994 pmid=8142187<br />
#Corrado pmid=10768917<br />
#ACC2006 pmid=16949478<br />
#Corr pmid=19366719<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Arrhythmogenic_Right_Ventricular_Cardiomyopathy&diff=9998
Arrhythmogenic Right Ventricular Cardiomyopathy
2010-01-28T00:05:18Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|advisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= P.G. Postema, MD<br />
}}<br />
[[Image:epsilon_wave.png|thumb|ECG with an epsilon wave in V1]]<br />
[[Image:arvdhart.png|thumb| A section throughout the heart of an ARVC patient. (A) Transmural fatty replacement of the right ventricular free wall. (B) Myocardial atrophy is confined to the right ventricle and substantially spares the interventricular septum as well as the left ventricular free wall. <cite>Corrado</cite> Reproduced with permission from BMJ Publishing Group Ltd. ]]<br />
'''Arrhytmogenic Right Ventricular Cardiomyopathy''', (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart. Especially the right ventricle apex and outflow tract are involved. However the left ventricle can be affected to.<cite>Corr</cite><br />
<br />
As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this disease and can lead to palpitations, syncope and sudden death. At more advanced ages right ventricular pump failure can occur.<br />
<br />
The diagnosis is based on major and minor criteria, as published by the European Society of Cardiology.<cite>McKenna1994</cite><br />
<br />
ARVC is a progressive disease. The '''incidence''' is estimated to be 1:3.000-1:10.000. Manifestations are usually seen during the teens. Although the diagnosis is more often made in athletes, sports are not thought to have a causative relationship with the disease. ARVD can occur in families; more than 9 different chromosomal defects have been described, most often with autosomal dominant inheritance. <br />
<br />
One unique form of ARVD, called Naxos disease (after the Greek island where it was first diagnosed), has an autosomal recessive pattern of inheritance. <br />
<br />
'''Diagnosis''' ARVC is a difficult diagnosis to make. Therefore, the European Society of Cardiology has created a list of diagnostic criteria for the diagnosis of ARVC<cite>#McKenna1994</cite> (see table).<br />
{| class="wikitable" width="400px"<br />
!Major diagnostic criteria for Arrhythmogenic Right Ventricular Cardiomyopathy<cite>McKenna1994</cite><br />
|-<br />
|<ul><li>Familial disease confirmed at necroscopy or surgery</li><br />
<li>Severe dilatation and reduction of right ventricular ejection fraction with no (or only mild) LV impairment</li><br />
<li>Localized right ventricular aneurysms (akinetic or diskinetic areas with diastolic bulging)</li><br />
<li>Severe segmental dilataion of the right ventricle</li><br />
<li>Fibrofatty replacement of myocardium on endomyocardial biopsy</li><br />
</ul><br />
|-<br />
!Diagnostic criteria that can be diagnosed on the ECG<br />
|-<br />
|<ul><br />
<li>(major) Epsilon wave or localized prolongation (>110ms) of the QRS complex in right precordial leads (V1-V3)</li><br />
<li>(minor) Inverted T waves in right precordial leads (V2 and V3) (people aged more than 12 yr; in absence of [[RBBB]]</li><br />
<li>(minor) [[Late potentials]] ([[SAECG|signal averaged ECG]])</li><br />
<li>(minor) Left bundle branch block type [[Ventricular Tachycardia|ventricular tachycardia]] (sustained and non-sustained) (ECG, [[Holter]], [[Exercise Testing|exercise testing]]</li><br />
<li>(minor) Frequent [[Ventricular Premature Beats|ventricular extrasystoles]] (more than 1000/24h) ([[Holter]])</li><br />
</ul><br />
|}<br />
<br />
'''Treatment''' focuses on avoiding complications.<cite>ACC2006</cite><br />
*Medication: <br />
**Anti-arrhythmics: Sotalol better than Amiodarone.<br />
**ACE-inhibitors to prevent cardiac remodelling<br />
*[[ICD]] implantation is recommended for the prevention of sudden cardiac death in patients with ARVC with documented sustained VT or VF who are receiving chronic optimal medical therapy.<br />
*[[ICD]]] implantation can be considered for the prevention of sudden cardiac death in patients with ARVC with extensive disease, including those with left ventricular involvement, 1 or more affected family member with ICD, or undiagnosed syncope when [[Ventricular Tachycardia|ventricular tachycardia]] or [[Ventricular Fibrillation|ventricular Fibrillation]] has not been excluded as the cause of syncope, who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y.<br />
*Radiofrequency [[ablation]] can be useful as adjunctive therapy in management of patients with ARVC with recurrent [[Ventricular Tachycardia|ventricular tachycardia]], despite optimal antiarrhythmic drug therapy.<br />
<br />
<gallery><br />
Image:arvd_ecg1.png<br />
Image:arvd_ecg2.png<br />
Image:arvd_ecg3.png<br />
</gallery><br />
<br />
==References==<br />
<biblio><br />
#McKenna1994 pmid=8142187<br />
#Corrado pmid=10768917<br />
#ACC2006 pmid=16949478<br />
#Corr pmid=19366719<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Arrhythmogenic_Right_Ventricular_Cardiomyopathy&diff=9997
Arrhythmogenic Right Ventricular Cardiomyopathy
2010-01-28T00:01:53Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|advisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= P.G. Postema, MD<br />
}}<br />
[[Image:epsilon_wave.png|thumb|ECG with an epsilon wave in V1]]<br />
[[Image:arvdhart.png|thumb| A section throughout the heart of an ARVC patient. (A) Transmural fatty replacement of the right ventricular free wall. (B) Myocardial atrophy is confined to the right ventricle and substantially spares the interventricular septum as well as the left ventricular free wall. <cite>Corrado</cite> Reproduced with permission from BMJ Publishing Group Ltd. ]]<br />
'''Arrhytmogenic Right Ventricular Cardiomyopathy''', (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart. Especially the right ventricle apex and outflow tract are involved. However the left ventricle can be affected to.<cite>Corr</cite><br />
<br />
As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this disease and can lead to palpitations, syncope and sudden death. At more advanced ages right ventricular pump failure can occur.<br />
<br />
The diagnosis is based on major and minor criteria, as published by the European Society of Cardiology.<cite>McKenna1994</cite><br />
<br />
ARVC is a progressive disease. The '''incidence''' is estimated to be 1:3.000-1:10.000. Manifestations are usually seen during the teens. Although the diagnosis is more often made in athletes, sports are not thought to have a causative relationship with the disease. ARVD can occur in families; more than 9 different chromosomal defects have been described, most often with autosomal dominant inheritance. <br />
<br />
One unique form of ARVD, called Naxos disease (after the Greek island where it was first diagnosed), has an autosomal recessive pattern of inheritance. <br />
<br />
'''Diagnosis''' ARVC is a difficult diagnosis to make. Therefore, the European Society of Cardiology has created a list of diagnostic criteria for the diagnosis of ARVC<cite>#McKenna1994</cite> (see table).<br />
{| class="wikitable" width="400px"<br />
!Major diagnostic criteria for Arrhythmogenic Right Ventricular Cardiomyopathy<cite>McKenna1994</cite><br />
|-<br />
|<ul><li>Familial disease confirmed at necroscopy or surgery</li><br />
<li>Severe dilatation and reduction of right ventricular ejection fraction with no (or only mild) LV impairment</li><br />
<li>Localized right ventricular aneurysms (akinetic or diskinetic areas with diastolic bulging)</li><br />
<li>Severe segmental dilataion of the right ventricle</li><br />
<li>Fibrofatty replacement of myocardium on endomyocardial biopsy</li><br />
</ul><br />
|-<br />
!Diagnostic criteria that can be diagnosed on the ECG<br />
|-<br />
|<ul><br />
<li>(major) Epsilon wave or localized prolongation (>110ms) of the QRS complex in right precordial leads (V1-V3)</li><br />
<li>(minor) Inverted T waves in right precordial leads (V2 and V3) (people aged more than 12 yr; in absence of [[RBBB]]</li><br />
<li>(minor) [[Late potentials]] ([[SAECG|signal averaged ECG]])</li><br />
<li>(minor) Left bundle branch block type [[Ventricular Tachycardia|ventricular tachycardia]] (sustained and non-sustained) (ECG, [[Holter]], [[Exercise Testing|exercise testing]]</li><br />
<li>(minor) Frequent [[Ventricular Premature Beats|ventricular extrasystoles]] (more than 1000/24h) ([[Holter]])</li><br />
</ul><br />
|}<br />
<br />
'''Treatment''' focuses on avoiding complications.<cite>ACC2006</cite><br />
*Medication: <br />
**anti-arrhythmics: Sotalol better than Amiodarone.<br />
**ACE-inhibitors to prevent cardiac remodelling<br />
*[[ICD]] implantation is recommended for the prevention of sudden cardiac death in patients with ARVC with documented sustained VT or VF who are receiving chronic optimal medical therapy.<br />
*[[ICD]]] implantation can be considered for the prevention of sudden cardiac death in patients with ARVC with extensive disease, including those with left ventricular involvement, 1 or more affected family member with SCD, or undiagnosed syncope when [[Ventricular Tachycardia|ventricular tachycardia]] or [[Ventricular Fibrillation|ventricular Fibrillation]] has not been excluded as the cause of syncope, who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y.<br />
*Radiofrequency [[ablation]] can be useful as adjunctive therapy in management of patients with ARVC with recurrent [[Ventricular Tachycardia|ventricular tachycardia]], despite optimal antiarrhythmic drug therapy.<br />
<br />
<gallery><br />
Image:arvd_ecg1.png<br />
Image:arvd_ecg2.png<br />
Image:arvd_ecg3.png<br />
</gallery><br />
<br />
==References==<br />
<biblio><br />
#McKenna1994 pmid=8142187<br />
#Corrado pmid=10768917<br />
#ACC2006 pmid=16949478<br />
#Corr pmid=19366719<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Arrhythmogenic_Right_Ventricular_Cardiomyopathy&diff=9996
Arrhythmogenic Right Ventricular Cardiomyopathy
2010-01-27T22:59:10Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|advisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= P.G. Postema, MD<br />
}}<br />
[[Image:epsilon_wave.png|thumb|ECG with an epsilon wave in V1]]<br />
[[Image:arvdhart.png|thumb| A section throughout the heart of an ARVC patient. (A) Transmural fatty replacement of the right ventricular free wall. (B) Myocardial atrophy is confined to the right ventricle and substantially spares the interventricular septum as well as the left ventricular free wall. <cite>Corrado</cite> Reproduced with permission from BMJ Publishing Group Ltd. ]]<br />
'''Arrhytmogenic Right Ventricular Cardiomyopathy''', (ARVC, or ARVD: Arrhythmogenic Right Ventricular Disease) is characterized by fatty replacement and fibrosis of the heart. Especially the right ventricle apex and outflow tract are involved. However the left ventricle can be affected to.<cite>Corr</cite><br />
<br />
As a result of the fatty replacement and fibrosis, ventricular arrhythmias are common in this disease and can lead to palpitations, syncope and sudden death. At more advanced ages right ventricular pump failure can occur.<br />
<br />
The diagnosis is based on major and minor criteria, as published by the European Society of Cardiology.<cite>McKenna1994</cite><br />
<br />
ARVC is a progressive disease. The '''incidence''' is estimated to be 1:3.000-1:10.000. Manifestations are usually seen during the teens. Although the diagnosis is more often made in athletes, sports are not thought to have a causative relationship with the disease. ARVD can occur in families; more than 9 different chromosomal defects have been described, most often with autosomal dominant inheritance. <br />
<br />
One unique form of ARVD, called Naxos disease (after the Greek island where it was first diagnosed), has an autosomal recessive pattern of inheritance. <br />
<br />
'''Diagnosis''' ARVC is a difficult diagnosis to make. Therefore, the European Society of Cardiology has created a list of diagnostic criteria for the diagnosis of ARVC<cite>#McKenna1994</cite> (see table).<br />
{| class="wikitable" width="400px"<br />
!Major diagnostic criteria for Arrhythmogenic Right Ventricular Cardiomyopathy<cite>McKenna1994</cite><br />
|-<br />
|<ul><li>Familial disease confirmed at necroscopy or surgery</li><br />
<li>Severe dilatation and reduction of right ventricular ejection fraction with no (or only mild) LV impairment</li><br />
<li>Localized right ventricular aneurysms (akinetic or diskinetic areas with diastolic bulging)</li><br />
<li>Severe segmental dilataion of the right ventricle</li><br />
<li>Fibrofatty replacement of myocardium on endomyocardial biopsy</li><br />
</ul><br />
|-<br />
!Diagnostic criteria that can be diagnosed on the ECG<br />
|-<br />
|<ul><br />
<li>(major) Epsilon wave or localized prolongation (>110ms) of the QRS complex in right precordial leads (V1-V3)</li><br />
<li>(minor) Inverted T waves in right precordial leads (V2 and V3) (people aged more than 12 yr; in absence of [[RBBB]]</li><br />
<li>(minor) [[Late potentials]] ([[SAECG|signal averaged ECG]])</li><br />
<li>(minor) Left bundle branch block type [[Ventricular Tachycardia|ventricular tachycardia]] (sustained and non-sustained) (ECG, [[Holter]], [[Exercise Testing|exercise testing]]</li><br />
<li>(minor) Frequent [[Ventricular Premature Beats|ventricular extrasystoles]] (more than 1000/24h) ([[Holter]])</li><br />
</ul><br />
|}<br />
<br />
'''Treatment''' focuses on avoiding complications.<cite>ACC2006</cite><br />
*Medication: <br />
**anti-arrhythmics: Sotalol better than Amiodarone.<br />
**ACE-inhibitors to prevent cardiac remodelling<br />
*[[ICD]] implantation is recommended for the prevention of sudden cardiac death in patients with ARVC with documented sustained VT or VF who are receiving chronic optimal medical therapy.<br />
*[[ICD]]] implantation can be considered for the prevention of sudden cardiac death in patients with ARVC with extensive disease, including those with left ventricular involvement, 1 or more affected family member with SCD, or undiagnosed syncope when [[Ventricular Tachycardia|ventricular tachycardia]] or [[Ventricular Fibrillation|ventricular Fibrillation]] has not been excluded as the cause of syncope, who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 y.<br />
*Radiofrequency [[ablation]] can be useful as adjunctive therapy in management of patients with ARVC with recurrent [[Ventricular Tachycardia|ventricular tachycardia]], despite optimal antiarrhythmic drug therapy.<br />
<br />
<gallery><br />
Image:arvd_ecg1.png<br />
Image:arvd_ecg2.png<br />
Image:arvd_ecg3.png<br />
</gallery><br />
<br />
==Referenties==<br />
<biblio><br />
#McKenna1994 pmid=8142187<br />
#Corrado pmid=10768917<br />
#ACC2006 pmid=16949478<br />
#Corr pmid=19366719<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Long_QT_Syndrome&diff=9995
Long QT Syndrome
2010-01-27T22:48:20Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|supervisor=<br />
|coauthor= [[user:Pgpostema|P.G. Postema, MD]]<br />
|moderator= [[user:Pgpostema|P.G. Postema, MD]]<br />
|editor= <br />
}}<br />
[[Image:acquired_longQT.jpg|thumb|A 12 lead ECG of a patient with acquired long QT syndrome. Notice the QT prolongation. The QTc is about 640ms.]]<br />
The '''Long QT Syndrome (LQTS)''' is characterized on the ECG by prolongation of the [[Conduction#The_QT_interval|heart rate corrected QT interval]]. This was first recognized by dr. Jervell and dr. Lange-Nielsen in 1957. They described 4 children with a long QT interval which was accompanied by hearing deficits, sudden cardiac death and an autosomal recessive inheritance.<cite>Lang1957</cite><br />
<br />
The Long QT syndrome may be divided into two distinct forms: congenital Long QT syndrome and acquired Long QT syndrome. These forms may however <br />
<br />
===Diagnosis===<br />
*The diagnosis is by measurement of the [[Conduction#The_QT_interval|heart rate-corrected QT interval]] on the ECG, which can be calculated with the [[QTc calculator]].<br />
*Sometimes the QT interval can be difficult to assess. Read the [[Difficult_QT|guidelines for measurement of difficult QT interval]].<br />
*A QTc of > 500ms in patients with Long QT Syndrome is associated with an increased risk for sudden death.<cite>Priori</cite> <br />
*In patients suspected of LQTS (e.g. family members of known LQTS patients) a QTc > 430ms makes it likely that a LQTS gene defect is present.<cite>Hofman</cite><br />
*Because the QTc can change with age, it is best to take the ECG with the longest QTc interval for risk stratification.<cite>Goldenberg</cite><br />
<br />
===Treatment<cite>ACC2006</cite>===<br />
*"Lifestyle modification":<br />
** No competitive sports in all LQTS patients<br />
** No swimming in LQT1 patients<br />
** Avoid nightly noise in LQT2 patients (e.g. no alarm clock)<br />
*Medication: beta-blockers. Beta-blockers even reduce the risk of sudden death in patients in whom a genetic defect has been found, but no QT prolongation is visible on the ECG.<br />
*[[:w:nl:Internal_Cardiac_Defibrillator|ICD]] implantation in combination with beta-blockers in LQTS patients with previous cardiac arrest or [[syncope]] or [[Ventricular Tachycardia|ventricular tachycardia]] while on beta-blockers.<br />
<br />
===Acquired LQTS===<br />
Acquired LQTS is most often caused by drugs that prolong the QT interval. Combined with risk factors (see table) the risk of [[Torsade_de_Pointes|Torsade de Pointes]] increases.<br />
<br />
{| <br />
|-<br />
|valign="top"|<br />
{| class="wikitable" width="400px"<br />
!Common drugs that can cause [[Torsade_de_Pointes|Torsade de Pointes]] include:<cite>Roden</cite><br />
|-<br />
|<br />
<ul><br />
<li>Sotalol</li><br />
<li>Amiodarone</li><br />
<li>Erythromycin</li><br />
<li>Clarithromycin</li><br />
</ul><br />
|-<br />
!Less often used drugs include:<br />
|-<br />
|<br />
<ul><br />
<li>Cisapride</li><br />
<li>antibiotics: halofantrine, pentamidine, sparfloxacin</li><br />
<li>Anti-emetics: domperidon, droperidol</li><br />
<li>Anti-psychotics: chlorpromazine, haloperidol, mesoridazine, thioridazine, pimozide</li><br />
<li>Methadon</li><br />
<li>Disopyramide</li><br />
<li>Dofetilide</li><br />
<li>Ibutilide</li><br />
<li>Procainamide</li><br />
<li>Quinidine</li><br />
<li>Bepridil</li><br />
</ul><br />
|-<br />
|[http://www.torsades.org Torsades.org] has an extensive list of drugs that can TdP<br />
|}<br />
|valign="top"|<br />
{| class="wikitable" align="right" width="400px"<br />
!Concomittant risk factors for medication induced [[Torsade_de_Pointes|Torsade de Pointes]]:<br />
|-<br />
|<br />
<ul><br />
<li>Female sex</li><br />
<li>Hypokalemia</li><br />
<li>Bradycardia</li><br />
<li>Recent conversion of [[Atrial Fibrillation|atrial fibrillation]], especially if QT prolonging drugs were used (sotalol, amiodarone)</li><br />
<li>Cardiac decompensation</li><br />
<li>Digoxin treatment</li><br />
<li>High or overdosing or rapid infusion of a QT prolonging drug</li><br />
<li>Pre-existing QT prolongation</li><br />
<li>Congenital long QT syndrome</li><br />
</ul><br />
|}<br />
|-<br />
|}<br />
<br />
===Congenital LQTS===<br />
[[Image:lqts1-3.png|thumb|The three most common forms of LQTS can be recognized by the '''characteristic ECG abnormalities''']]: <br />
*LQT1 'early onset' broad based T wave<br />
*LQT2 small late T wave<br />
*LQT3 prolonged QT interval with 'late onset' T wave with a normal configuration<br />
In congenital LQTS the ventricular repolarisation is prolonged. '''The prevalence is about 1:3000-5000'''. <br />
<br />
More than 10 different types of congenital LQTS have been described. However, only LQTS 1-3 are relatively common.<cite>ACC2006</cite><br />
<br />
{| border="1" cellpadding="2" cellspacing="0" bordercolor="#6EB4EB" style="font-size:100%;" class="plainlinks" class="wikitable"<br />
|- style="text-align:center;background-color:#6EB4EB;"<br />
| '''Type'''<br />
| '''Chromosome'''<br />
| '''Gene'''<br />
| '''Protein'''<br />
| '''Ionchannel'''<br />
| '''Frequency<cite>priori</cite>'''<br />
| '''SCD incidence<cite>Shah2005</cite>'''<br />
| '''Inheritance'''<br />
| '''ECG characteristics'''<br />
| '''Trigger'''<br />
| '''Eponyme'''<br />
| '''[[w:OMIM|OMIM&trade;]] link'''<br />
|-<br />
! LQTS1<br />
| 11p15<br />
| KCNQ1<br />
| KvLQT1 <br />
| I''ks''<br />
| ~50%<br />
| 0.30%/year<br />
| AD, AR<br />
| broad base 'early onset' T wave<br />
| exercise, especially swimming<br />
| JLN1 if homozygous, LQTS1 if heterozygous<br />
| {{OMIM2|607542}} <br />
|-<br />
! LQTS2<br />
| 7q35<br />
| KCNH2<br />
| hERG<br />
| I''kr''<br />
| 30-40%<br />
| 0.60%/year<br />
| AD<br />
| small late T wave<br />
| adrenergic triggers, especially nightly noise<br />
| JLN2 if homozygous, LQTS2 if heterozygous<br />
| {{OMIM2|152427}}<br />
|-<br />
! LQTS3<br />
| 3p21<br />
| SCN5A<br />
| NA channel<br />
|<br />
| 5-10%<br />
| 0.56%/year<br />
| AD<br />
| 'Late onset' T wave with normal configuration<br />
|<br />
|<br />
| {{OMIM2|600163}}<br />
|-<br />
! LQTS4<br />
| 4q25-q27<br />
| ANK2<br />
| Ankyrin B<br />
| I''Na,K''<br />
| <1%<br />
| <br />
| AD<br />
|<br />
|<br />
|<br />
| {{OMIM2|106410}}<br />
|-<br />
! LQTS5<br />
| 21q22.1<br />
| KCNE1<br />
| minK <br />
| I''ks''<br />
| <1%<br />
| unknown<br />
| AD/AR<br />
|<br />
|<br />
|<br />
| {{OMIM2|176261}}<br />
|-<br />
! LQTS6<br />
| 21q22.1<br />
| KCNE2<br />
| MiRP1<br />
| I''kr''<br />
| <1%<br />
| unknown<br />
| AD<br />
|<br />
|<br />
|<br />
| {{OMIM2|603796}}<br />
|-<br />
! LQTS7 = ATS1<br />
| 17q23<br />
| KCNJ2<br />
| Kir 2.1<br />
| I''K1''<br />
| <1%<br />
| unknown<br />
| AD<br />
|<br />
|<br />
| Anderson-Tawil syndrome<br />
| {{OMIM2|600681}}<br />
|-<br />
! LQTS8 = TS1<br />
| 12p13.3<br />
| CACNA1C<br />
| Ca<sub>v</sub>1.2<br />
| I''Ca-L''<br />
| <1%<br />
| unknown<br />
| <br />
| alternating T waves<br />
|<br />
| Timothy syndrome<br />
| {{OMIM2|601005}}<br />
|-<br />
! LQTS9<br />
| 3p25.3<br />
| CAV3<br />
| Caveolin 3<br />
| I''Na''<br />
| <br />
| unknown<br />
| <br />
| <br />
|<br />
| <br />
| {{OMIM2|601253}}<br />
|-<br />
! LQTS10<br />
| 11q23.3<br />
| SCN4B<br />
| Na<sub>v</sub>1.5 b4<br />
| <br />
| 1 family<br />
| unknown<br />
| <br />
| <br />
|<br />
| <br />
| {{OMIM2|608256}}<br />
|-<br />
! LQTS11<br />
| 7q21-q22<br />
| Akap9<br />
| AKAP<br />
| I''ks''<br />
| 1 family<br />
| unknown<br />
| <br />
| <br />
|<br />
| <br />
| {{OMIM2|611820}}<br />
|}<br />
;LQTS: Long QT syndrome<br />
;JLN: Jervell and Lange-Nielsen syndrome<br />
;SCD: Sudden Cardiac Death<br />
<br />
Long before the genes involved were known, two syndromes associated with a prolonged QT interval on the ECG had been described.<br />
* Anton Jervell and Fred Lange-Nielsen from Oslo described in 1957 an autosomaal recessive syndrome that was associated with QT interval prolongation, deafness and sudden death: the now called '''Jervell-Lange-Nielsen syndrome'''. <cite>Lang1957</cite><br />
* '''Romano-Ward syndrome''' is a long QT syndrome with normal auditory function and autosomal dominant inheritance. <br />
* In a genotype–phenotype study by Moss et al. that studied type-1 LQTS, it was found that mutations located in the transmembrane portion of the ion channel protein and the degree of ion channel dysfunction caused by the mutations are important independent risk factors influencing the clinical course of this disorder.<cite>moss</cite><br />
<br />
==External links==<br />
#[http://www.torsades.org Torsades.org has a list of QT prolonging drugs]<br />
#[http://qtdrugs.org QTdrugs.org, another list of QT prolonging drugs]<br />
#[http://www.sads.org Sudden Arrhythmia Death Syndrome Foundation]. LQTS patient group.<br />
#[http://www.fsm.it/cardmoc/ Inherited Arrhythmias Database]<br />
<br />
==Referenties==<br />
<biblio><br />
#Schwartz2001 pmid=11136691<br />
#Shah2005 pmid=16230503<br />
#Lang1957 pmid=13435203<br />
#ACC2006 pmid=16935995<br />
#Goldenberg pmid=16949500<br />
#Roden pmid=14999113<br />
#moss pmid=17470695<br />
#priori pmid=12736279<br />
#Hofman pmid=17090615<br />
#Roden pmid=18184962<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Ventriculophasic_Reflex&diff=9994
Ventriculophasic Reflex
2010-01-27T22:39:24Z
<p>KGoldin: </p>
<hr />
<div>{{Chapter|Supraventricular Rhythms}}<br />
[[Image:ventrfascreflex.jpg|thumb| Ventriculophasic reflex during second degree AV block type I. The PP interval that follow upon the blocked sinus beat is prolonged.<cite>Rosenbaum</cite>]]<br />
<br />
Ventriculophasic reflex is a phenomenon that can be seen during AV block or during ventricular extrasystoles in bigemini. It describes the sinus arrhythmia that exists during a irregular rhythm. The phenomenon has been described by Erlanger and Blackman in 1910 <cite>Erlanger</cite>. Different theories have been postulated to explain the phenomenon (a.o. by Wenkebach), but the theory published by Rosenbaum and Lepeschkin in 1955 <cite>Rosenbaum</cite> is the most accepted.<br />
<br />
A positive chronotropic (accelerating) effect on the ventricular contraction is probably caused by stretch on the right atrium by contraction of the ventricles. A negative chronotropic effect (slowing) is probably caused by a vagal reflex caused by stimulation of the carotid arterial baroreceptors by the pressure wave. The result of these two effects determines whether the P-P interval that surrounds the extra beat is shorter or longer than the P-P interval that surrounds the missing beat.<br />
<br />
The baroreflex influences both the sinus node and the AV node and thus both sinus rate and atrioventricular conduction can be influenced.<br />
{{clr}}<br />
== References ==<br />
<biblio><br />
#Rosenbaum pmid=13231262<br />
</biblio><br />
<analytics uacct="UA-807577-6"></analytics></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Ventriculophasic_Reflex&diff=9993
Ventriculophasic Reflex
2010-01-27T22:38:15Z
<p>KGoldin: </p>
<hr />
<div>{{Chapter|Supraventricular Rhythms}}<br />
[[Image:ventrfascreflex.jpg|thumb| Ventriculophasic reflex during second degree AV block type I. The PP interval that follow upon the blocked sinus beat is prolonged.<cite>Rosenbaum</cite>]]<br />
<br />
Ventriculophasic reflex is a phenomenon that can be seen during AV block or during ventricular extrasystoles in bigemini. It describes the sinus arrhythmia that exists during a irregular rhythm. The phenomenon has been described by Erlanger and Blackman in 1910 <cite>Erlanger</cite>. Different theories have been postulated to explain the phenomenon (a.o. by Wenkebach), but the theory published by Rosenbaum and Lepeschkin in 1955 <cite>Rosenbaum</cite> is the most accepted.<br />
<br />
A positive chronotropic (accelerating) effect on the ventricular contraction is probably caused by stretch on the right atrium by contraction of the ventricles. A negative chronotropic effect (slow down) is probably caused by a vagal reflex caused by stimulation of the carotid arterial baroreceptors by the pressure wave. The result of these two effects determines whether the P-P interval that surrounds the extra beat is shorter or longer than the P-P interval that surrounds the missing beat.<br />
<br />
The baroreflex influences both the sinus node and the AV node and thus both sinus rate and atrioventricular conduction can be influenced.<br />
{{clr}}<br />
== References ==<br />
<biblio><br />
#Rosenbaum pmid=13231262<br />
</biblio><br />
<analytics uacct="UA-807577-6"></analytics></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Mechanisms_of_Arrhythmias&diff=9992
Mechanisms of Arrhythmias
2010-01-27T22:31:58Z
<p>KGoldin: </p>
<hr />
<div>==Abnormal impulse formation==<br />
Abnormal impulse formation can result in abnormal frequency, as in symptomatic [[#sinus bradycardia|sinus bradycardia]], but often the problem is an abnormal location of impulse formation, as is the cause in an [[#ectopic_pacemaker|ectopic pacemaker]].<br />
<br />
===Abnormal automaticity===<br />
The sinus node contains pacemaker cells that have spontaneous firing capacity. This is called ''normal automaticity''. '''Abnormal automaticity''' occurs when other cells start firing spontaneously, resulting in premature heartbeats. All cardiac cells have spontaneous firing capacity, but at only at a very slow heart rate. Therefore, during a normal heart rate, they will never have the chance to show off their firing capacity. However, in pathologic conditions, such as during extreme bradycardia, other cells can take over and cause for example an [[AV nodal rhythm|AV-nodal heart rate]].<br />
{{clr}}<br />
===Triggered activity===<br />
During '''triggered activity''' heart cells contract twice, although they only have been activated once. This is often caused by so called ''afterdepolarizations'' (early or delayed afterdepolarizations EADs / DADs) caused by electrical instability in the myocardial cell membrane. A typical example of this is [[Torsade de Pointes]].<br />
{{clr}}<br />
<br />
==Abnormal conduction==<br />
===Conduction delay===<br />
Conduction delay can cause a slow heart rate, as happens during [[#AV-block|AV conduction blocks]]. If conduction delay occurs more distally in the heart, i.e. within the ventricles, the QRS complex will widen and a [[Conduction|left or right bundle branch block]] can be seen on the ECG.<br />
<br />
===Re-entry===<br />
[[Image:Re_entry.png|thumb|'''Re-entry'''. A prerequisite for re-entry is the presence of two pathways with differing conduction velocities that connect two points, in this case the atria with the ventricles. The signal splits in two at arrival, but no arrhythmia is initiated as the slow signal becomes extinct when it meets the fast signal. However, after an extrasystole (second image) the fast pathway is still refractory and conduction is by the slow pathway, resulting in a prolongation of the PR interval. The signal that reaches the His by the slow pathway may find the fast pathway conducting and return to the atria (third image), resulting in an '''echo beat'''. This may set in motion a re-entry pathway through the AV node resulting in AV nodal tachycardia (fourth image).]]<br />
<br />
Re-entry is a common cause of arrhythmias. [[#Ventricular tachycardia|Ventricular tachycardia]] and [[#AVNRT|AV-nodal re-entry]] are typical examples. Re-entry can occur when a conduction path is partly slowed down. As a result of this, the signal is conducted by both a fast and a slow pathway. During normal sinus rhythm this generally does not cause problems, but when an extrasystole follows rapidly upon the previous beat, the fast pathway is sometimes still refractory and cannot conduct the signal. Now the following sequence results in re-entry.<br />
<br />
# The atrial signal coming from above is conducted by the slow pathway.<br />
# As the signal, going through the slow pathway, reaches the end of the fast pathway, it finds this pathway able to conduct.<br />
# The signal is conducted through the fast pathway up to the beginning of the slow pathway, which by that time is able to conduct.<br />
# This circle is perpetuated and a signal generator is created. In the case of [[#AVNRT|AV-nodal re-entry]] this will typically generate a signal at a frequency of 180-250 bpm.<br />
<br />
{{clr}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Approach_to_the_Wide_Complex_Tachycardia&diff=9991
Approach to the Wide Complex Tachycardia
2010-01-27T22:23:29Z
<p>KGoldin: </p>
<hr />
<div>During wide complex tachycardia (heart rate > 100/min, QRS > 0.12 sec) the differentiation between supraventricular and ventricular origin of the arrhythmia is important to guide therapy. Several algorithms have been developed to aid in this differentiation (below). It is important to keep in mind that a good estimate of VT ''versus'' SVT can be made based on the clinical vignette:<br />
* 'Horizontal entrance' into the ER. Older patient with previous myocardial infarction = most likely VT<br />
* Younger patient with known paroxysmal tachycardias and who is hemodynamically stable = most like SVT<br />
== The ACC algorithm <cite>ACC</cite>==<br />
[[File:VT_algorithm_en.png|800px|thumb|left|SVT vs VT algorhytm. Adapted from <cite>ACC</cite>]]<br />
{{clr}}<br />
<br />
== Brugada criteria ==<br />
[[File:Brugada_algorithm.png|500px|thumb|left]]<br />
<br />
{| class="wikitable" width="500px"<br />
! colspan="3" | Morphological criteria (if the above criteria are inconclusive)<br />
|-<br />
!colspan="3" |[[LBBB]] pattern<br />
|-<br />
| Initial R more than 40ms? ||Yes => VT || [[Image:Rhythm_RSratio.png|thumb|100px]]<br />
|-<br />
| Slurred or notched downwards leg of S wave in leads V1 or V2 || Yes => [[VT]] ||<br />
|-<br />
| Beginning of Q to nadir QS >60 ms in V1 or V2? || Yes => [[VT]] || LR >50:1<br />
|-<br />
| Q or QS in V6? || Yes => [[VT]] || LR >50:1<br />
|-<br />
| colspan="3" |[[Image:Rhythm_LBTBmorph_nl.png|thumb|300px]]<br />
|-<br />
! colspan="3" |[[RBBB]] pattern<br />
|-<br />
| Monofasic R or qR in V1? ||Yes => [[VT]] ||<br />
|-<br />
| R taller than R' (rabbit-ear sign)?||Yes => [[VT]] || LR >50:1<br />
|-<br />
| rS in V6? || Yes => VT || LR >50:1<br />
|-<br />
| colspan="3" |[[Image:Rhythm_RBTBmorph_nl.png|thumb|300px]]<br />
|-<br />
|}<br />
{{clr}}<br />
<br />
== Vereckei algorithm <cite>Vereckei</cite>==<br />
[[File:Vereckei_algorithm.png|500px|thumb|left]]<br />
[[File:vivt.png|300px|thumb|If the distance traveled on the Y axis in the initial 40ms of the QRS complex is smaller than that traveled in the terminal 40ms of the QRS complex, a VT is much more likely]]<br />
{{clr}}<br />
<br />
==Examples==<br />
<gallery><br />
Image:wide_qrs_tachy_AAM1.jpg|Wide complex tachycardia. No AV dissociation. RBBB. Resembles sinus rhythm from the same patient. Conclusion: SVT with [[RBBB]]<br />
Image:wide_qrs_tachy_AAM2.jpg|ECG from the same patient in sinus rhythm. The QRS complex is very similiar.<br />
Image:wide_qrs_tachy_AAM3.png|Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. [[AV dissociation]] is present. Conclusion: [[VT]]<br />
Image:wide_qrs_tachy_AAM4.png|Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. [[AV dissociation]] is present. Conclusion: [[VT]]<br />
</gallery><br />
== Referenties ==<br />
<biblio><br />
#ACC pmid=14563598<br />
#Brug1 pmid=2022022<br />
#Vereckei pmid=17272358<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Approach_to_the_Wide_Complex_Tachycardia&diff=9990
Approach to the Wide Complex Tachycardia
2010-01-27T22:20:31Z
<p>KGoldin: </p>
<hr />
<div>During wide complex tachycardia (heart rate > 100/min, QRS > 0.12 sec) the differentiation between supraventricular and ventricular origin of the arrhythmia is important to guide therapy. Several algorithms have been developed to aid in this differentiation (below). It is important to keep in mind that a good estimate of VT ''versus'' SVT can be made based on the clinical vignette:<br />
* 'Horizontal entrance' into the ER. Older patient with previous myocardial infarction = most likely VT<br />
* Younger patient with known paroxysmal tachycardias and who is hemodynamically stable = most like SVT<br />
== The ACC algorithm <cite>ACC</cite>==<br />
[[File:VT_algorithm_en.png|800px|thumb|left|SVT vs VT algorhytm. Adapted from <cite>ACC</cite>]]<br />
{{clr}}<br />
<br />
== Brugada criteria ==<br />
[[File:Brugada_algorithm.png|500px|thumb|left]]<br />
<br />
{| class="wikitable" width="500px"<br />
! colspan="3" | Morphological criteria (if the above criteria are inconclusive)<br />
|-<br />
!colspan="3" |[[LBBB]] pattern<br />
|-<br />
| Initial R more than 40ms? ||Yes => VT || [[Image:Rhythm_RSratio.png|thumb|100px]]<br />
|-<br />
| Slurred or notched downwards leg of S wave in leads V1 or V2 || Yes => [[VT]] ||<br />
|-<br />
| Beginning of Q to nadir QS >60 ms in V1 or V2? || Yes => [[VT]] || LR >50:1<br />
|-<br />
| Q or QS in V6? || Yes => [[VT]] || LR >50:1<br />
|-<br />
| colspan="3" |[[Image:Rhythm_LBTBmorph_nl.png|thumb|300px]]<br />
|-<br />
! colspan="3" |[[RBBB]] pattern<br />
|-<br />
| Monofasic R or qR in V1? ||Yes => [[VT]] ||<br />
|-<br />
| R taller than R' (rabbit-ear sign)?||Yes => [[VT]] || LR >50:1<br />
|-<br />
| rS in V6? || Yes => VT || LR >50:1<br />
|-<br />
| colspan="3" |[[Image:Rhythm_RBTBmorph_nl.png|thumb|300px]]<br />
|-<br />
|}<br />
{{clr}}<br />
<br />
== Vereckei algorithm <cite>Vereckei</cite>==<br />
[[File:Vereckei_algorithm.png|500px|thumb|left]]<br />
[[File:vivt.png|300px|thumb|If the distance traveled on the Y axis in the initial 40ms of the QRS complex is smaller than that traveled in the terminal 40ms of the QRS complex, a VT is much more likely]]<br />
{{clr}}<br />
<br />
==Examples==<br />
<gallery><br />
Image:wide_qrs_tachy_AAM1.jpg|Wide complex tachycardia. No AV dissociation. RBBB. Resembles sinus rhythm from the same patient. Conclusio SVT with [[RBBB]]<br />
Image:wide_qrs_tachy_AAM2.jpg|ECG from the same patient in sinus rhythm. The QRS complex is very similiar.<br />
Image:wide_qrs_tachy_AAM3.png|Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. [[AV dissociation]] is present. Conclusion: [[VT]]<br />
Image:wide_qrs_tachy_AAM4.png|Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. [[AV dissociation]] is present. Conclusion: [[VT]]<br />
</gallery><br />
== Referenties ==<br />
<biblio><br />
#ACC pmid=14563598<br />
#Brug1 pmid=2022022<br />
#Vereckei pmid=17272358<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Ventricular_Premature_Beats&diff=9989
Ventricular Premature Beats
2010-01-27T22:16:18Z
<p>KGoldin: </p>
<hr />
<div>{{Chapter|Ventricular Arrhythmias}}<br />
[[Image:Rhythm_ventricular_premature.png|thumb| The arrow indicates a ventricular extrasystole (VES).]]<br />
[[Image:Rhythm_bigemini.png|thumb|Bigemini: every sinus beat is followed by a ventricular extrasystole]]<br />
<br />
A VPB is an [[Ectopic Beats|ectopic beat]] that originates from the ventricles. VPBs are conducted by the specialized conduction system and therefore are broad. The QRS width is at least > 0.12 seconds, but often very broad at around 0.16-0.20 seconds. The VPB is usually followed by a [[Ectopic Beats|compensatory pause]], however this can be absent in the presence of retrograde conduction through the av-node.<br />
<br />
Causes: e.g. ischemia, hypoxia, old scar tissue, idiopathic. Fifty per cent of healthy men have sporadic VPBs.<br />
The origin of the VPB can be derived from its form. An LBTB-configured VPB originates in the right ventricle. An RBTB-configured VPB comes from the left ventricle. The QRS duration of a VPB is > 0.12 seconds and can be as wide as 0.16-0.20 seconds.<br />
<br />
'''A sequence of three or more extrasystoles''' is called a [[Ventricular Tachycardia|non-sustained ventricular tachycardia]].<br />
<br />
If more than one VPB is present on the ECG, they can be:<br />
*'''monomorphic''': all VPBs have the same configuration and thus have a mutual focus of origin.<br />
*'''multiformic''': the complexes have different configurations. <br />
*'''bigemini''': every sinus beat is followed by a ventricular extrasystole.<br />
*'''trigemini''': every second sinus beat is follow by a ventricular extrasystole.<br />
<br />
<br />
VPBs are associated with numerous cardiac diseases (e.g. structural heart disease, ischemia, congenital arrhythmias, pulmonary disease).<br />
However, VPBs are also relatively common in patients without known heart disease. The importance of VPBs for prognosis is controversial. A study by Abdalla et. al <cite>Abdalla</cite> followed 15.637 apparently healthy men aged 35 to 57 years. The prevalence of VPBs was 4.4%. In a subgroup of patients with frequent (2 or more uniform VPCs every 2 minutes) and complex VPBs (multiforms, pairs, runs, R-on-T) the risk of sudden cardiac death was 4.2. In the Framingham study 12% of men and 33% of women without clinically evident coronary heart disease had frequent (>30 VPBs per hour) or complex VPBs. In men, this was associated with a two fold increase of death. However, in another study asymptomatic patients had a good prognosis. <cite>Kennedy</cite> Therefore, probably sporadic VPBs are relatively benign, whereas frequent and complex VPBs are reason for further examination.<br />
==References==<br />
<biblio><br />
#Kennedy pmid=2578212<br />
#Framingham pmid=1280018<br />
#Abdalla pmid=3673904<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Introduction&diff=9988
Introduction
2010-01-27T22:06:31Z
<p>KGoldin: </p>
<hr />
<div>{{nav|<br />
|previouspage=/<br />
|previousname=/<br />
|nextpage=Basics<br />
|nextname=Basics<br />
}}<br />
{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|supervisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= <br />
}}<br />
[[Image:nsr.png|thumb| A short ECG registration of normal heart rhythm (sinus rhythm)]]<br />
The aim of this course is to enable the student to understand and recognize normal ECGs and interpret abnormalities. The course is divided into two different sections. First the '''[[basics]]''' will be presented. This is followed by the interpretation of the normal ECG according to the 7+2 step plan:<br />
==7+2 step plan==<br />
{{box|<br />
* Step 1: [[Rhythm]]<br />
* Step 2: [[Rate]]<br />
* Step 3: [[Conduction]] (PQ,QRS,QT)<br />
* Step 4: [[Heart axis]]<br />
* Step 5: [[P wave morphology]]<br />
* Step 6: [[QRS morphology]]<br />
* Step 7: [[ST morphology]]<br />
* Step 7+1: [[Compare_the_old_and_new_ECG|Compare the current ECG with a previous one]]<br />
* Step 7+2: [[Conclusion]]<br />
}}<br />
<br />
'''Note:''' It is important to realize that not all these steps may be applicable when you encounter ECG abnormalities. If, for example, the rhythm is not sinus in the [[Rhythm|first step]], the algorithm to analyze [[arrhythmias]] should be followed. If a [[LBBB|Left Bundle Branch Block]] is present in [[Conduction|step 3]], [[ST morphology]] will be strongly influenced by this defect.<br />
<br />
Finally the '''real world''' is presented through [[Cases and Examples|'''practice ECGs''']].<br />
<br />
After you have finished the course you are invited to come back to read more about abnormal ECGs in the '''ECG textbook'''.<br />
==ECG textbook==<br />
{{box|<br />
* [[Normal Tracing|Normal Tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus_node_rhythms_and_arrhythmias|Sinus Rhythms]]<br />
** [[Sinus Tachycardia]]<br />
** [[Sinus Bradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|Supraventricular]]<br />
** [[Junctional Tachycardias|Junctional]]<br />
** [[Ventricular Arrhythmias|Ventricular]]<br />
** [[Genetic Arrhythmias|Genetic]]<br />
** [[Ectopic Beats|Ectopic Beats]]<br />
* [[AV Conduction|AV Conduction]]<br />
* [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargement|Chamber Hypertrophy]]<br />
* [[Repolarization (ST-T,U) Abnormalities|Repolarization]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECGs in Athletes]]<br />
* [[Pediatric ECGs|ECGs in Children]]<br />
* [[Accuracy of Computer Interpretation]]<br />
}}<br />
Also read our '''[[Frequently Asked Questions]]''' section.<br />
{{clr}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Brugada_Syndrome&diff=9987
Brugada Syndrome
2010-01-27T20:10:34Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Pgpostema|P.G. Postema, MD]]<br />
|supervisor=<br />
|coauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|moderator= [[user:Pgpostema|P.G. Postema, MD]]<br />
|editor= <br />
}}<br />
[[Image:Brugada.png|thumb|Typical ECG abnormalities in Brugada syndrome: ST elevation in V1-V3, without ischemia.]]<br />
[[Image:Brugada_ecg_characteristics.png|thumb| Typical ECG abnormalities in Brugada syndrome]]<br />
[[Image:brugada.jpg|thumb| Dr. Pedro Brugada. Pedro and Josep Brugada described in 1992 a landmark publication with a case-series of 8 patients with sudden cardiac death. <cite>Brugada</cite> Currently, three brothers of the Brugada family (Pedro, Josep and Ramon Brugada) conduct research in the syndrome that has been named after them.]]<br />
[[Image:scn5a.jpg|thumb| The SCN5a gen is located on the short arm (p) of chromosome 3]]<br />
<br />
<br />
The '''Brugada syndrome is an hereditary disease that is associated with high risk of sudden cardiac death'''. It is characterized by typical ECG abnormalities: '''ST segment elevation in the precordial leads (V1 - V3)'''.<br />
<br />
==Characteristics of the Brugada syndrome:==<br />
*Inheritable arrhythmia syndrome with [[w:Autosomal_dominant|autosomal dominant]] inheritance. If one of the two parents is affected, each child (both males and females) has a 50% chance of inheriting the disease.<br />
*Males are more often symptomatic than females, probably by the influence of sex hormones on cardiac arrhythmias and/or ion channels, and a different distribution of ion channels across the heart in males versus females.<br />
*The arrhythmias usually occur in patients between 30 and 40 years of age. (range 1-77 yrs) and often during rest or while sleeping (high vagal tone).<br />
*In only about 30% of patients, genetic defects can be detected in the ([http://ghr.nlm.nih.gov/gene=scn5a SCN5A]) gene which encodes the cardiac sodium channel (loss-of-function mutation). In much smaller quantities, mutations may be found in the GPD1L gene (which probably influences cardiac sodium channel function) or in cardiac calcium channel encoding genes (CACNxxx). In the remaining patients, the disease is probably multi-genetic or caused by yet unknown genetic defects.<br />
*The right ventricle is most affected in Brugada syndrome, and particularly (but not specifically) the right ventricular outflow tract . <br />
*The prevalence varies between 5-50:10.000, largely depending on geographic location. In some southeast Asian countries the disease is considered endemic and believed to be the second cause of death among young men (after car accidents). In these countries Brugada syndrome is believed to underly (in part) the 'Sudden Unexpected Death Syndrome' (SUDS). This relation has, however, not been thoroughly investigated and there are almost no epidemiological studies into Brugada syndrome ECGs (apart from Japan). In different Asian countries, different names have been given to SUDS: in the Phillipines it is called ''bangungut'' (to rise and moan in sleep) and in Thailand ''lai tai'' (death during sleep). <br />
<br />
The Brugada brothers were the first to describe the characteristic ECG findings and link them to sudden death. Before that, the characteristic ECG findings, were often mistaken for a [[Right_Ventricle_MI|right ventricle myocardial infarction]] and already in 1953, a publication mentions that the ECG findings were not associated with ischemia as people often expected.<cite>osher</cite><br />
<br />
==Diagnosis and treatment==<br />
<br />
*Patients who are symptomatic (unexplained syncopes, ventricular tachycardias or aborted sudden cardiac death) may have a symptom recurrence risk of 2 to 10% per year. In these patients an [[:w:nl:Internal_Cardiac_Defibrillator|ICD]] implant is advisable. Further, life-style advice is given (see below).<br />
*Some groups advise an electrophysiological investigation (inducibility of ventricular fibrillation) for risk assessment in Brugada patients,<cite>brug2</cite><cite>brug3</cite> but others could not reproduce the predictive value of these tests,<cite>priori</cite><cite>eckhardt</cite> so the value of inducibility is controversial.<br />
*In large studies familial sudden death did not appear to be a risk factor for sudden death in siblings.<br />
*In asymptomatic patients in whom the Brugada ECG characteristics are present (either spontaneously or provoked by fever or sodium channel blockers like ajmaline, procainimde or flecainide) life style advice is given. This advice includes:<br />
**A number of medications should not be taken (including sodium channel blockers and certain anti-depressants and anti-arrhythmics, see [http://www.brugadadrugs.org www.BrugadaDrugs.org])<br />
**Rigorous treatment of fever with paracetamol/Tylenol, as fever may elicit a Brugada ECG and arrhythmias in some patients.<br />
* Spontaneous Type I ECGs do appear to be more prevalent in patients who experienced symptoms.<br />
<br />
For a full list of the diagnostic criteria, see <cite>Wilde</cite><br />
<br />
==Electrocardiographic criteria==<br />
[[Image:Brugada_lead_placement.png|thumb|Changed lead positions of leads V3 and V5 to increase the sensitiviy to 'catch' a Brugada pattern on the ECG]]<br />
Three ECG repolarization patterns in the right precordial leads are recognized in the diagnosis of Brugada syndrome.<br />
<br />
'''Type I''' is the only ECG criterion that is diagnostic of Brugada syndrome. The type I ECG is characterized by a J elevation >=2 mm (0.2 mV) a curved type ST segment followed by a negative T wave (see figure). Brugada syndrome is definitively diagnosed when a type 1 ST-segment is observed in >1 right precordial lead (V1 to V3) in the presence or absence of a sodium channel–blocking agent, and in conjunction with one of the following: <br />
*documented ventricular fibrillation (VF)<br />
*polymorphic ventricular tachycardia (VT)<br />
*a family history of sudden cardiac death at <45 years old<br />
*coved-type ECGs in family members<br />
*inducibility of VT with programmed electrical stimulation<br />
*syncope<br />
*nocturnal agonal respiration.<br />
The sensitivity of the ECG for Brugada syndrome can be increased with placement of ECG leads in the intercostal space above V1 and V2 (V1ic3 and V2ic3)<br />
<br />
Electrocardiograms of Brugada patients can change over time from type I to type II and/or normal ECGs and back.<br />
A type III ECG is rather common and is considered a normal variant, but also the Type II is a normal variant (albeit suggestive of Brugada syndrome).<br />
<br />
A recent study suggests that''' fractionation of the QRS complex''' is a marker of a worse prognosis in Brugada syndrome.<cite>Morita</cite><br />
<br />
{| class="wikitable" font-size="90%"<br />
|- style="text-align:center;background-color:#6EB4EB;"<br />
|+'''ST segment abnormalities in the different types of Brugada syndrome'''<cite>Wilde2</cite><br />
|-<br />
!<br />
!Type I<br />
!Type II<br />
!Type III<br />
|- <br />
!J wave amplitude<br />
|>= 2mm<br />
|>= 2mm<br />
|>= 2mm<br />
|-<br />
!T wave<br />
|Negative<br />
|Positive or biphasis<br />
|Positive<br />
|-<br />
!ST-T configuration<br />
|Coved type<br />
|Saddleback<br />
|Saddleback<br />
|-<br />
!ST segment (terminal portion)<br />
|Gradually descending<br />
|Elevated >= 1mm<br />
|Elevated < 1mm<br />
|-<br />
|}<br />
<br />
<br />
<gallery caption="Examples of Brugada syndrome type I"><br />
Image:Brugada_syndrome_type1_example1.png<br />
Image:Brugada_syndrome_type1_example2.png<br />
Image:Brugada_syndrome_type1_example3.png<br />
Image:Brugada_syndrome_type1_example4.png<br />
Image:Brugada_syndrome_type1_example5.png<br />
Image:Brugada_syndrome_type1_example6.jpg|Brugada ECG during ajmaline testing<br />
</gallery><br />
<gallery caption="Examples of Brugada syndrome type II"><br />
Image:Brugada_syndrome_type2_example1.png<br />
Image:Brugada_syndrome_type2_example2.jpg<br />
</gallery><br />
<br />
==External links==<br />
*Cardiogenetics website of the AMC [http://www.cardiogenetica.nl cardiogentica.nl]<br />
*[http://www.brugada.org Brugada.org ]<br />
*[http://www.genereviews.org/servlet/access?id=8888891&key=ghdBRjkdNXE6y&gry=INSERTGRY&fcn=y&fw=E0gK&filename=/profiles/brugada/index.html Genereview Brugada]<br />
*[http://www.brugadadrugs.org Brugada drugs contains lists of medications that should be avoided in patients with Brugada syndrome and medication that can be used to diagnose the syndrome]<br />
<br />
==Referenties==<br />
<biblio><br />
#Wilde pmid=15898165<br />
#Brugada pmid=1309182<br />
#osher pmid=13104407<br />
#brug2 pmid=11772879 <br />
#brug3 pmid=12776858<br />
#priori pmid=11901046<br />
#eckhardt pmid=15642768<br />
#Wilde2 pmid=12417552<br />
#Morita pmid=18838563<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Introduction_to_Arrhythmias&diff=9986
Introduction to Arrhythmias
2010-01-27T19:56:58Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
[[Image:VT_SVT_LBBB_WCT.svg|thumb|300px|Morphologic criteria to differentiate between SVT vs. VT in a wide complex tachycardia. This is part of the [[media:wideQRS_tachycardia_flow.png|wide complex tachycardia flowchart]]]]<br />
Arrhythmias (non-normal heart rhythms) can be a challenge to understand, but with a systematic approach, diagnosis is often less difficult than it may appear at first. <br />
<br />
A good stepwise approach to interpret the heart rhythm is to follow these steps:<br />
*What is the '''ventricular [[Rate|heart rate]]'''?<br />
**>100 bpm = tachycardia<br />
**<60 bpm = bradycardia<br />
**Are there extra beats? -> [[Ectopic Beats]]<br />
* '''Cherchez le P''', French for ''find the P waves''. <br />
** Do you see P waves? Leads II and V1 are often most suitable to find P waves.<br />
** What is the [[rate]] of the P waves?<br />
** What is the [[P wave morphology]]?<br />
* What is the '''relationship between P waves and QRS complexes'''?<br />
** Is there a 1:1 relation between P waves and QRS complexes? If not there may be [[AV dissociation]] due to a [[Ventricular Arrhythmias]] or [[AV Conduction|AV block]]<br />
** Is every P wave followed by a QRS complex? And every QRS preceded by a P wave? <br />
** What is the [[Conduction|PR interval]] and does it change?<br />
* What is the '''[[Conduction|QRS width]]'''?<br />
**If the QRS < 120ms (i.e. a narrow complex), then it is either a [[Sinus node rhythms and arrhythmias|sinus arrhythmia]], [[Supraventricular Rhythms|supraventricular rhythm]] or a [[Junctional Tachycardias|junctional tachycardia]]. In tachycardias, this [[Media:Svt_algorythm_en.png|'''flowchart''']] will lead to the right diagnosis.<cite>ESCnarrowQRS</cite><br />
**If the QRS > 120ms it is either a [[Ventricular Arrhythmias|ventricular tachycardia]] or a [[Supraventricular Rhythms|supraventricular rhythm]] with additional [[Intraventricular Conduction|bundle branch block]]. This is a challenging diagnosis. Therefore a [[media:wideQRS_tachycardia_flow.png|'''flowchart''']] which incoporates the Brugada criteria for VT should be used.<cite>Brugada</cite> Another method to discriminate VT from SVT has been proposed by Vereckei et al.<cite>vereckei</cite>In that paper an excellent review is given on the subject by Dendi and Josephson.<cite>dendi</cite><br />
* What is the '''[[Heart axis|Heart Axis]]''' and did it change?<br />
** If the heart axis turns significantly when compared to the heart axis during sinus rhythm a ventricular origin of the rhythm is more likely.<br />
* What is the '''clinical setting'''?<br />
** A wide complex tachycardia in a hemodynamically unstable 70-year-old man with previous myocardial infarction should be considered a [[ventricular tachycardia]] until proven otherwise<br />
** A wide complex tachycardia in a 24-year-old woman with recurrent spells of tachycardia that respond to vagal maneuvers is most likely an [[AVNRT]] with aberrant conduction.<br />
<br />
{{Box|<br />
==References==<br />
<biblio><br />
#ESCnarrowQRS pmid=14563598<br />
#Brugada pmid=2022022<br />
#vereckei pmid=17272358<br />
#dendi pmid=17317697<br />
</biblio><br />
}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Introduction_to_Arrhythmias&diff=9985
Introduction to Arrhythmias
2010-01-27T19:55:28Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
[[Image:VT_SVT_LBBB_WCT.svg|thumb|300px|Morphologic criteria to differentiate between SVT vs. VT in a wide complex tachycardia. This is part of the [[media:wideQRS_tachycardia_flow.png|wide complex tachycardia flowchart]]]]<br />
Arrhythmias (non-normal heart rhythms) can be a challenge to understand, but with a systematic approach, diagnosis is often less difficult than it may appear at first. <br />
<br />
A good stepwise approach to interpret the heart rhythm is to follow these steps:<br />
*What is the '''ventricular [[Rate|heart rate]]'''?<br />
**>100 bpm = tachycardia<br />
**<60 bpm = bradycardia<br />
**are there extra beats? -> [[Ectopic Beats]]<br />
* '''Cherchez le P''', French for ''find the P waves''. <br />
** Do you see P waves? Leads II and V1 are often most suitable to find P waves.<br />
** What is the [[rate]] of the P waves?<br />
** What is the [[P wave morphology]]?<br />
* What is the '''relationship between P waves and QRS complexes'''?<br />
** Is there a 1:1 relation between P waves and QRS complexes? If not there may be [[AV dissociation]] due to a [[Ventricular Arrhythmias]] or [[AV Conduction|AV block]]<br />
** Is every P wave followed by a QRS complex? And every QRS preceded by a P wave? <br />
** What is the [[Conduction|PR interval]] and does it change?<br />
* What is the '''[[Conduction|QRS width]]'''?<br />
**If the QRS < 120ms (i.e. a narrow complex), then it is either a [[Sinus node rhythms and arrhythmias|sinus arrhythmia]], [[Supraventricular Rhythms|supraventricular rhythm]] or a [[Junctional Tachycardias|junctional tachycardia]]. In tachycardias, this [[Media:Svt_algorythm_en.png|'''flowchart''']] will lead to the right diagnosis.<cite>ESCnarrowQRS</cite><br />
**If the QRS > 120ms it is either a [[Ventricular Arrhythmias|ventricular tachycardia]] or a [[Supraventricular Rhythms|supraventricular rhythm]] with additional [[Intraventricular Conduction|bundle branch block]]. This is a challenging diagnosis. Therefore a [[media:wideQRS_tachycardia_flow.png|'''flowchart''']] which incoporates the Brugada criteria for VT should be used.<cite>Brugada</cite> Another method to discriminate VT from SVT has been proposed by Vereckei et al.<cite>vereckei</cite>In that paper an excellent review is given on the subject by Dendi and Josephson.<cite>dendi</cite><br />
* What is the '''[[Heart axis|Heart Axis]]''' and did it change?<br />
** If the heart axis turns significantly when compared to the heart axis during sinus rhythm a ventricular origin of the rhythm is more likely.<br />
* What is the '''clinical setting'''?<br />
** A wide complex tachycardia in a hemodynamically unstable 70-year-old man with previous myocardial infarction should be considered a [[ventricular tachycardia]] until proven otherwise<br />
** A wide complex tachycardia in a 24-year-old woman with recurrent spells of tachycardia that respond to vagal maneuvers is most likely an [[AVNRT]] with aberrant conduction.<br />
<br />
{{Box|<br />
==References==<br />
<biblio><br />
#ESCnarrowQRS pmid=14563598<br />
#Brugada pmid=2022022<br />
#vereckei pmid=17272358<br />
#dendi pmid=17317697<br />
</biblio><br />
}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Introduction_to_Arrhythmias&diff=9984
Introduction to Arrhythmias
2010-01-27T19:47:35Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
[[Image:VT_SVT_LBBB_WCT.svg|thumb|300px|Morphologic criteria to differentiate between SVT vs. VT in a wide complex tachycardia. This is part of the [[media:wideQRS_tachycardia_flow.png|wide complex tachycardia flowchart]]]]<br />
Arrhythmias (non-normal heart rhythms) can be a challenge to understand, but with a systematic approach, diagnosis is often less difficult than it may appear at first. <br />
<br />
A good stepwise approach to interpret the heart rhythm is to follow these steps:<br />
*What is the '''ventricular [[Rate|heart rate]]'''?<br />
**>100 bpm = tachycardia<br />
**<60 bpm = bradycardia<br />
**are there extra beats? -> [[Ectopic Beats]]<br />
* '''Cherchez le P''', French for ''find the P waves''. <br />
** Do you see P waves? Leads II and V1 are often most suitable to find P waves.<br />
** What is the [[rate]] of the P waves?<br />
** What is the [[P wave morphology]]?<br />
* What is the '''relationship between P waves and QRS complexes'''?<br />
** Is there a 1:1 relation between P waves and QRS complexes? If not there may be [[AV dissociation]] due to a [[Ventricular Arrhythmias]] or [[AV Conduction|AV block]]<br />
** Is every P wave followed by a QRS complex? And every QRS preceded by a P wave? <br />
** What is the [[Conduction|PR interval]] and does it change?<br />
* What is the '''[[Conduction|QRS width]]'''?<br />
**If the QRS < 120ms (i.e. a narrow complex), then it is either a [[Sinus node rhythms and arrhythmias|sinus arrhythmia]], [[Supraventricular Rhythms|supraventricular rhythm]] or a [[Junctional Tachycardias|junctional tachycardia]]. In tachycardias, this [[Media:Svt_algorythm_en.png|'''flowchart''']] will lead to the right diagnosis.<cite>ESCnarrowQRS</cite><br />
**If the QRS > 120ms it is either a [[Ventricular Arrhythmias|ventricular tachycardia]] or a [[Supraventricular Rhythms|supraventricular rhythm]] with additional [[Intraventricular Conduction|bundle branch block]]. This is a challenging difficulty in arrhythmia diagnosis, therefore a [[media:wideQRS_tachycardia_flow.png|'''flowchart''']] might help, which incoporates the Brugada criteria for VT.<cite>Brugada</cite> Another method to discriminate VT from SVT has been proposed by Vereckei et al.<cite>vereckei</cite> In the editorial on that paper an excellent review is given on the subject by Dendi and Josephson.<cite>dendi</cite><br />
* What is the '''[[Heart axis|Heart Axis]]''' and did it change?<br />
** If the heart axis turns significantly when compared to the heart axis during sinus rhythm a ventricular origin of the rhythm is more likely.<br />
* What is the '''clinical setting'''?<br />
** A wide complex tachycardia in a hemodynamically unstable 70-year-old man with previous myocardial infarction should be considered a [[ventricular tachycardia]] until proven otherwise<br />
** A wide complex tachycardia in a 24-year-old woman with recurrent spells of tachycardia that respond to vagal maneuvers is most likely an [[AVNRT]] with aberrant conduction.<br />
<br />
{{Box|<br />
==References==<br />
<biblio><br />
#ESCnarrowQRS pmid=14563598<br />
#Brugada pmid=2022022<br />
#vereckei pmid=17272358<br />
#dendi pmid=17317697<br />
</biblio><br />
}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Conclusion&diff=9983
Conclusion
2010-01-27T19:10:36Z
<p>KGoldin: </p>
<hr />
<div>{{nav|<br />
|previouspage=Compare_the_old_and_new_ECG<br />
|previousname=Step 7+1: Compare with previous ECG<br />
|nextpage=Cases and Examples<br />
|nextname=Cases and Examples<br />
}}<br />
{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|supervisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= <br />
}}<br />
After working through the seven steps, one has to draw a final conclusion. If one gets the question 'what do you see on the ECG?', the questioner probably is not waiting for a summation of the seven steps, but would like to hear your '''interpretation''' of the ECG. This interpretation, or final conclusion, is the starting point for treatment of the patient. <br />
<br />
'''Examples of conclusions are''':<br />
* "Sinus tachycardia with ST elevation, likely caused by acute myocardial infarction"<br />
* "Supraventricular tachycardia of 200 beats per minute caused by an AV nodal re-entry"<br />
* "Previous infarction combined with an acute lateral myocardial infarction with widening of the QRS complexes"<br />
* "Normal ECG"<br />
<br />
Final conclusions should consist of one sentence, which sums up all important aspects of the ECG. It is not necessary to mention all 7 aspects, although one has to look at all of them to find the right conclusion!<br />
<br />
<br />
[[Category:ECG Course]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Accuracy_of_Computer_Interpretation&diff=9982
Accuracy of Computer Interpretation
2010-01-27T19:00:29Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|supervisor=<br />
}}<br />
<br />
Modern ECG equipment often includes some form of algorithm that performs a computer interpretation of the electrocardiogram. It is useful to have some insight into the reliability and pitfalls of computer interpretation so as to be able to assess the value of these interpretations.<br />
<br />
First of all, it is important to realize that the algorithm used often interprets the raw ECG-signal, i.e., the signal before it is filtered. This means that the ECG that is printed by the machine is not the ECG that is interpreted by the machine. Therefore one has to be very careful in making sure that the signal is 'clean' as possible by:<br />
* cleaning the skin with e.g. alcohol before placing the electrodes<br />
* shaving skin when necessary<br />
* using contact spray or electrodes with contact gel<br />
* carefully checking the electrodes position<br />
<br />
Different manufacturers of ECG equipment have produced different algorithms for ECG interpretation. Not surprisingly, the accuracy of algorithms therefore differs. One study comparing nine computer algorithms with eight cardiologists found that overall the per cent of correct classifications of computer programs was 69.7% as compared to 76.3% for the cardiologists.<cite>Willems</cite> However, this study was performed in 1991 and algorithms have developed since. Some 'self learning' algorithms have been developed that improve themselves by learning from adjustments that cardiologists make to their diagnosis.<br />
<br />
Much attention has been aimed at the diagnosis of acute cardiac ischemia. This can be challenging if subtle ST segment shifts are present, and ST segment shifts can also be present in healthy persons. A systematic review on the subject found a sensitivity of 76% (95% CI, 54% to 89%) and a specificity of 88% (95% CI, 67% to 96%) for the correct interpretation of acute cardiac ischemia by a computer algorithm. For acute myocardial infarction the sensitivity was 68% (95% CI, 59% to 76%) and the specificity 97% (95% CI, 89% to 92%).<cite>Ioannidis</cite> One study investigating the Marquette 12SL system in the diagnosis of patients eligible for thrombolytic therapy found a sensitivity of 61.5% and specificity of 100%. The authors conclude that reliance on computer interpretation would result in inappropriate underuse of thromobolytic therapy.<cite>Massel</cite><br />
<br />
A recent scientific statement by a consortium of AHA/ACC and the HRS advises to be prudent when using computer interpretations. The official recommendation reads: "Computer-based interpretation of the ECG is an adjunct to the electrocardiographer, and all computer-based reports require physician overreading. Accurate individual templates should be formed in each lead before final feature extraction and measurement used for diagnostic interpretation." <cite>Kligfield</cite><br />
<br />
==References==<br />
<biblio><br />
#Kudenchuk pmid=2033180<br />
#Massel pmid=10925334<br />
#Ioannidis pmid=11326182<br />
#Willems pmid=1834940<br />
#Kligfield pmid=17322457<br />
#Mason pmid=17322456<br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Compare_the_Old_and_New_ECG&diff=9981
Compare the Old and New ECG
2010-01-27T18:37:15Z
<p>KGoldin: </p>
<hr />
<div>{{nav|<br />
|previouspage=ST_morphology<br />
|previousname=Step 7: ST morphology<br />
|nextpage=Conclusion<br />
|nextname=Step 7+2: Conclusion<br />
}}<br />
{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|supervisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= <br />
}}<br />
__NOTOC__ <br />
An abnormal ECG does not prove acute cardiac disease. And a normal ECG does not exclude cardiac disease. It is necessary therefore to compare new ECG with ECG's made in the past. <br />
<br />
Hallmarks are: <br />
* Is there a [[#ritmeverandering|change in rhythm]]?<br />
* Is there a [[#frequentieverandering| change in frequency]]?<br />
* Is there a change in [[#Geleidingstijden|conduction time]]?<br />
* Is there a change in [[#Hartas|heart axis]]?<br />
* Are there new [[#Pathologische Q's|pathological Q's]]?<br />
* Is there a change in [[#R top hoogte|R wave size]]?<br />
* Is there a change in [[#ST segmenten|ST]]?<br />
* Is there a change in [[#T toppen|T wave]]?<br />
<br />
So, one has to check for changes in all 7 steps.<br />
<br />
==Change in rhythm==<br />
Example: New atrial fibrillation. Atrial fibrillation occurs in ten percent of elderly people (>70 year) without clinical symptoms. Therefore atrial fibrillation in acute dyspneic patients does not prove atrial fibrillation-induced cardiac decompensation. Also other causes (e.g. cardiac ischemia, pneumonia) should be considered. Previous ECGs could provide additional information.<br />
<br />
==Frequency==<br />
Example: Bradycardia. New sinus bradycardia of 50 beats per minute (bpm) may cause dizziness; however, long-existing bradycardias are often without symptoms. Therefore it is important to know the patient's normal frequency.<br />
<br />
==Conduction time==<br />
An increase in PQ time may be seen in elderly patients, but may also be caused by the use of medication or by ischemia. Broadening of the QRS complex may also be caused by medication or ischemia. An increase in QTc time may be caused by medication, but may also be hereditary. Comparison of a previous ECG with new ECG may provide the clue.<br />
<br />
==Heart axis==<br />
Ischemia may cause a change in the heart axis; on the other hand, a deviated heart axis caused by left anterior fascicular block may have already been present for years at the time the ECG was made (and would remain for life). Again, a previous ECG differentiates between old and new changes.<br />
<br />
==Pathological Q's==<br />
Hallmark of the comparison between old and new ECG are pathological Q's. New pathological Q's provide evidence for the occurrence of a myocardial infarction.<br />
<br />
==Increase R wave==<br />
'''Decrease''' of the R wave may be a sign of an infarction. Tamponade, cardiomyopathy and increased body size also decrease the R wave.<br />
<br />
'''Increase''' of the R wave indicates hypertrophy of the left ventricle (leads V5-V6), or a posterior infarction (V2-V3) or a loss of body weight.<br />
<br />
==the ST segment==<br />
New elevation of the ST segment indicates an acute myocardial infarction. Chronic elevation of the ST segment may be caused by cardiac aneurysms or long-standing (several weeks) pericarditis.<br />
<br />
==T wave==<br />
T wave inversion can be caused by ischemia, disturbances in electrolytes or stress. Often no distinction can be made between these causes. T wave inversion indicates that something is possibly wrong and further investigation is needed.<br />
<br />
[[Category:ECG Course]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Compare_the_Old_and_New_ECG&diff=9980
Compare the Old and New ECG
2010-01-27T18:36:00Z
<p>KGoldin: </p>
<hr />
<div>{{nav|<br />
|previouspage=ST_morphology<br />
|previousname=Step 7: ST morphology<br />
|nextpage=Conclusion<br />
|nextname=Step 7+2: Conclusion<br />
}}<br />
{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|supervisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= <br />
}}<br />
__NOTOC__ <br />
An abnormal ECG does not prove acute cardiac disease. And a normal ECG does not exclude cardiac disease. It is necessary therefore to compare new ECG with ECG's made in the past. <br />
<br />
Hallmarks are: <br />
* Is there a [[#ritmeverandering|change in rhythm]]?<br />
* Is there a [[#frequentieverandering| change in frequency]]?<br />
* Is there a change in [[#Geleidingstijden|conduction time]]?<br />
* Is there a change in [[#Hartas|heart axis]]?<br />
* Are there new [[#Pathologische Q's|pathological Q's]]?<br />
* Is there a change in [[#R top hoogte|R wave size]]?<br />
* Is there a change in [[#ST segmenten|ST]]?<br />
* Is there a change in [[#T toppen|T wave]]?<br />
<br />
So, one has to check for changes in all 7 steps.<br />
<br />
==Change in rhythm==<br />
Example: new atrial fibrillation. Atrial fibrillation occurs in ten percent of elderly people (>70 year) without clinical symptoms. Therefore atrial fibrillation in acute dyspneic patients does not prove atrial fibrillation-induced cardiac decompensation. Also other causes (e.g. cardiac ischemia, pneumonia) should be considered. Previous ECGs could provide additional information.<br />
<br />
==Frequency==<br />
Example: bradycardia. New sinus bradycardia of 50 beats per minute (bpm) may cause dizziness; however, long-existing bradycardias are often without symptoms. Therefore it is important to know the patient's normal frequency.<br />
<br />
==Conduction time==<br />
An increase in PQ time may be seen in elderly patients, but may also be caused by the use of medication or by ischemia. Broadening of the QRS complex may also be caused by medication or ischemia. An increase in QTc time may be caused by medication, but may also be hereditary. Comparison of a previous ECG with new ECG may provide the clue.<br />
<br />
==Heart axis==<br />
Ischemia may cause a change in the heart axis; on the other hand, a deviated heart axis caused by left anterior fascicular block may have already been present for years at the time the ECG was made (and would remain for life). Again, a previous ECG differentiates between old and new changes.<br />
<br />
==Pathological Q's==<br />
Hallmark of the comparison between old and new ECG are pathological Q's. New pathological Q's provide evidence for the occurrence of a myocardial infarction.<br />
<br />
==Increase R wave==<br />
'''Decrease''' of the R wave may be a sign of an infarction. Tamponade, cardiomyopathy and increased body size also decrease the R wave.<br />
<br />
'''Increase''' of the R wave indicates hypertrophy of the left ventricle (leads V5-V6), or a posterior infarction (V2-V3) or a loss of body weight.<br />
<br />
==the ST segment==<br />
New elevation of the ST segment indicates an acute myocardial infarction. Chronic elevation of the ST segment may be caused by cardiac aneurysms or long-standing (several weeks) pericarditis.<br />
<br />
==T wave==<br />
T wave inversion can be caused by ischemia, disturbances in electrolytes or stress. Often no distinction can be made between these causes. T wave inversion indicates that something is possibly wrong and further investigation is needed.<br />
<br />
[[Category:ECG Course]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Sinus_Bradycardia&diff=9979
Sinus Bradycardia
2010-01-27T18:17:25Z
<p>KGoldin: </p>
<hr />
<div>{{Chapter|Sinus node rhythms and arrhythmias}}<br />
{{Arrhythmias|<br />
| name = Sinusbradycardia<br />
| locatieImage = <br />
| atrial_frequency = < 60 bpm<br />
| ventricular_frequency = same<br />
| regularity = regular<br />
| origin = sinus node<br />
| p_wave = normal<br />
| adenosine = slows down<br />
| example = Sinusbradycardia of around 40 bpm.[[Image:Rhythm_sinusbradycardia.png|250px|Sinusbradycardia]]<br />
| example2 = <br />
}}<br />
In sinus bradycardia the sinus node fires at a slow (<60 bpm) rate. Causes of sinus bradycardia include:<br />
*Normal physiology in an athelete<br />
*Medication (beta-blockers)<br />
*Ischemia (typically inferior myocardial infarction with involvement of the sinus node artery)<br />
*Hypothermia<br />
*Hypothyroidism. <br />
{{clr}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Sinus_Tachycardia&diff=9978
Sinus Tachycardia
2010-01-27T18:14:50Z
<p>KGoldin: </p>
<hr />
<div>{{Arrhythmias|<br />
| name = Sinustachycardia<br />
| locatieImage = [[Image:Rhythm_tachycardia.png|250px]]<br />
| atrial_frequency = 100-180 bpm<br />
| ventricular_frequency = same<br />
| origin = sinus node<br />
| p_wave = positive in II, AVF<br />
| adenosine = no (can lead to temporary AV block)<br />
| example = <br />
}}<br />
Sinus tachycardia is [[Sinus_node_rhythms_and_arrhythmias|sinus rhythm]] with a rate of > 100bpm. <br />
<br />
Sinus tachycardia is an example of a [[Supraventricular Rhythms|supraventricular rhythm]].<br />
In sinus tachycardia the sinus node fires between 100 and 180 beats per minute, faster than normal. The maximal heart rate decreases with age from around 200 bpm to 140 bpm. The maximal heart rate can be estimated by subtracting the age in years from 210. Sinus tachycardia normally has a gradual start and ending. Most often sinus tachycardia is caused by an increase in the body's demand for oxygen, such as during exercise, stress, infection, blood loss and hyperthyroidism. It can also express an effort of the heart to compensate for a reduced stroke volume, as occurs during cardiomyopathy.<br />
{{clr}}<br />
<br />
The maximal heart rate is considered to be 220/min minus the age (or more precisely 207-0.7xAge <cite>Tanaka</cite><cite>Robergs</cite>). However, this is often exceeded during vigorous exercise and has a large inter-individual variation.<br />
<br />
Appropriate sinus tachycardia can result from: <cite>Surawicz</cite><br />
* Exercise<br />
* Anxiety<br />
* Alcohol / caffeine use<br />
* Drugs (e.g. beta-agonists like dobutamine)<br />
<br />
Inappropriate sinus tachycardia can result from:<br />
* Fever<br />
* Hypotension<br />
* Hypoxia<br />
* Congestive heart failure<br />
* Bleeding<br />
* Anemia<br />
* Hyperthyroidism<br />
* Cardiomyopathy (with reduced left ventricular function and compensatory tachycardia)<br />
* Myocarditis<br />
<br />
Inappropiate sinus tachycardia is rare and characterized by tachycardia at rest and exaggerated acceleration of the heart during physiologic stress. The mechanism leading to an exaggerated response of the sinus node to minimal physiologic stress is incompletely understood.<br />
<br />
==References==<br />
<biblio><br />
#Tanaka pmid=11153730<br />
#Surawicz isbn=9780721686974<br />
#Robergs Robergs and Landwehr. The Surprising History of the “HRmax=220-age” Equation. Journal of Exercise Physiology<br />
online. 2 May 2002<br />
</biblio><br />
{{chapter|Supraventricular Rhythms}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Sinus_Tachycardia&diff=9977
Sinus Tachycardia
2010-01-27T18:13:43Z
<p>KGoldin: </p>
<hr />
<div>{{Arrhythmias|<br />
| name = Sinustachycardia<br />
| locatieImage = [[Image:Rhythm_tachycardia.png|250px]]<br />
| atrial_frequency = 100-180 bpm<br />
| ventricular_frequency = same<br />
| origin = sinus node<br />
| p_wave = positive in II, AVF<br />
| adenosine = no (can lead to temporary AV block)<br />
| example = <br />
}}<br />
Sinus tachycardia is [[Sinus_node_rhythms_and_arrhythmias|sinus rhythm]] with a rate of > 100bpm. <br />
<br />
Sinus tachycardia is an examples of a [[Supraventricular Rhythms|supraventricular rhythm]].<br />
In sinus tachycardia the sinus node fires between 100 and 180 beats per minute, faster than normal. The maximal heart rate decreases with age from around 200 bpm to 140 bpm. The maximal heart rate can be estimated by subtracting the age in years from 210. Sinus tachycardia normally has a gradual start and ending. Most often sinus tachycardia is caused by an increase in the body's demand for oxygen, such as during exercise, stress, infection, blood loss and hyperthyroidism. It can also express an effort of the heart to compensate for a reduced stroke volume, as occurs during cardiomyopathy.<br />
{{clr}}<br />
<br />
The maximal heart rate is considered to be 220/min minus the age (or more precisely 207-0.7xAge <cite>Tanaka</cite><cite>Robergs</cite>). However, this is often exceeded during vigorous exercise and has a large inter-individual variation.<br />
<br />
Appropriate sinus tachycardia can result from: <cite>Surawicz</cite><br />
* Exercise<br />
* Anxiety<br />
* Alcohol / caffeine use<br />
* Drugs (e.g. beta-agonists like dobutamine)<br />
<br />
Inappropriate sinus tachycardia can result from:<br />
* Fever<br />
* Hypotension<br />
* Hypoxia<br />
* Congestive heart failure<br />
* Bleeding<br />
* Anemia<br />
* Hyperthyroidism<br />
* Cardiomyopathy (with reduced left ventricular function and compensatory tachycardia)<br />
* Myocarditis<br />
<br />
Inappropiate sinustachycardia is rare and characterized by tachycardia at rest and exaggerated acceleration of the heart during physiologic stress. The mechanism leading to an exaggerated response of the sinus node to minimal physiologic stress is incompletely understood.<br />
<br />
==References==<br />
<biblio><br />
#Tanaka pmid=11153730<br />
#Surawicz isbn=9780721686974<br />
#Robergs Robergs and Landwehr. The Surprising History of the “HRmax=220-age” Equation. Journal of Exercise Physiology<br />
online. 2 May 2002<br />
</biblio><br />
{{chapter|Supraventricular Rhythms}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=A_Concise_History_of_the_ECG&diff=9976
A Concise History of the ECG
2010-01-27T18:02:02Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= Dr Dean Jenkins & Dr. Stephen Gerred<br />
|moderator= [[user:Drj|J.S.S.G. de Jong]]<br />
|supervisor= <br />
}}<br />
<br />
{| class="wikitable"<br />
|This overview has been adapted from Dean Jenkins's and Stephen Gerred's [http://www.ecglibrary.com ECGlibary.com], for which they are gratefully acknowledged.<br />
|}<br />
<br />
The history of the ECG goes back more than one and a half centuries. <br />
==1600 - 1800==<br />
'''1600.''' William Gilbert, Physician to Queen Elizabeth I, President of the Royal College of Physicians and creator of the 'magnetic philosophy', introduces the term 'electrica' for objects (insulators) that hold static electricity. He derives the word from the Greek for amber (electra). It has been known from ancient times that amber when rubbed could lift light materials. Gilbert adds other examples such as sulphur and describes what will later be known as 'static electricity' to distinguish it from the more noble magnetic force. He sees his ideas as part of a philosophy to replace forever the prevailing Aristotlean view of matter. <cite>Gilbert</cite><br />
<br />
'''1649.''' Sir Thomas Browne, Physician, while writing to dispel popular ignorance in many subjects, is the first to use the word 'electricity'. Browne calls the attractive force "Electricity, that is, a power to attract strawes or light bodies, and convert the needle freely placed". (He is also the first to use the word 'computer' - referring to people who compute calendars.)<cite>Browne</cite><br />
<br />
'''1660'''. Otto Von Guericke builds the first static electricity generator.<br />
<br />
'''1662'''. The work of Rene Descartes, French Philosopher, is published (posthumously) and explains human movement in terms of a complex mechanical interaction of threads, pores, passages and 'animal spirits'. He has worked on his ideas in the 1630s but did not publish because of the persecution of other radical thinkers such as Galileo. William Harvey developed similar ideas but they were never published. <cite>Descartes</cite><br />
<br />
[[Image:Jan_Swammerdam.jpg|thumb|150px|left|Jan Swammerdam]]'''1664'''. Jan Swammerdam, a Dutchman, disproves Descartes' mechanistic theory of animal motion by removing the heart of a living frog and showing that the frog is still able to swim. When the brain is removed all movement stops (which could be in keeping with Descarte's theory) but then, when the frog is dissected and a severed nerve end stimulated with a scalpel, the muscles twitch. This proves that movement of a muscle can occur without any connection to the brain.Therefore the transmission of 'animal spirits' is not necessary.<br />
<br />
Swammerdam's ideas are not widely known and his work is not published until after his death. However, he writes many letters and his friend, Nicolaus Steno, attacks Cartesian ideas in a lecture in Paris in 1665. Boerhaave publishes Swammerdam's 'Book of Nature' in the 1730s.It is translated into English in 1758.<br />
<br />
'''1668''' Swammerdam refines his experiments on muscle contraction and nerve conduction. He demonstrates some of his work to notable figures such as the Grand-Duke Cosimo of Tuscany when the Grand Duke visits Swammerdam's father's house on the Oude Schans in Amsterdam. In one experiment he suspends a muscle on a brass hook inside a glass tube with a water droplet, to detect movement, and 'irritates' the nerve with a silver wire. This produces movement of the muscle, which may be due to the induction of a small electrical charge - although Swammerdam is unaware of this.<br />
<br />
'''1729''' Stephen Gray, English scientist, distinguishes between conductors and insulators of electricity. He demonstrates the transfer of static electrical charge to a cork ball across 150 meters of wet hemp thread. Later he finds that the transfer can be achieved over greater distances through brass wire. <br />
<br />
[[Image:Leyden_Jar.png|thumb|100px|A Leyden Jar]]'''1745''' Dutch physicist Pieter van Musschenbroek discovers that a partly filled jar with a nail projecting from a cork in its neck can store an electrical charge. The jar is named the 'Leyden Jar' after the place of its discovery. Ewald Georg von Kliest of Pomerania invents the same device independently.<br />
<br />
Using a Leyden jar in 1746, Jean-Antoine Nollet, French physicist and tutor to the royal family of France, sends an electrical current through 180 Royal Guards during a demonstration for King Louis XV.<br />
<br />
'''1769''' Edward Bancroft, an American scientist, suggests that the 'shock' from the torpedo fish is electrical rather than mechanical in nature. He shows that the properties of the shock are similar to those from a Leyden jar in that it can be conducted or insulated with appropriate materials. The torpedo fish and other species are widely known to deliver shocks and are often used for therapeutic reasons. However, electrical theory at this time dictates that electricity will always flow through conductors and diffuse away from areas of high charge to areas of low charge. Since living tissues are known to be conductors, it is impossible to imagine how an imbalance of charge can exist within an animal. Therefore animals can not use electricity for nerve conduction - or to deliver shocks. Furthermore, 'water and electricity do not mix' so the idea of an 'electric fish' is generally not accepted. <cite>Bancroft</cite><br />
<br />
'''1773''' John Walsh, Fellow of the Royal Society and Member of Parliament, obtains a visible spark from the electric eel Electrophorus electricus. The eel is out of water, as it is not possible to produce the spark otherwise. Walsh uses thin strips of tin foil to demonstrate his technique to many colleagues and visitors at his house in London. Unfortunately, he never publishes his eel experiment, though he does win the Copley medal in 1774 and 1783 for his work. Walshes observations , and those of Bancroft before him, adds to the argument that some form of animal electricity. <cite>Walsh</cite><br />
<br />
'''1774''' The Rev. Mr Sowdon and Mr Hawes, apothecary, report on the surprising effects of electricity in a case report of recovery from sudden death published in the annual report of the newly founded Humane Society (now the Royal Humane Society). The Society develops from 'The Institution for Affording Immediate Relief to Persons Apparently Dead from Drowning'. It is "instituted in the year 1774, to protect the industrious from the fatal consequences of unforseen accidents; the young and inexperienced from being sacrificed to their recreations; and the unhappy victims of desponding melancholy and deliberate suicide from the miserable consequences of self-destruction."<br />
<br />
A Mr Squires, of Wardour Street, Soho, lives opposite the house from which a three year old girl, Catherine Sophia Greenhill falls from a window on 16th July 1774. After the attending apothecary declares that nothing could be done for the child, Mr Squires, "with the consent of the parents very humanely tried the effects of electricity. At least twenty minutes had elapsed before he could apply the shock, which he gave to various parts of the body without any apparent success; but at length, upon transmitting a few shocks through the thorax, he perceived a small pulsation: soon after the child began to sigh, and to breathe, though with great difficulty. In about ten minutes she vomited: a kind of stupor, occasioned by the depression of the cranium, remained for some days, but proper means being used, the child was restored to perfect health and spirits in about a week.<br />
<br />
"Mr. Squires gave this astonishing case of recovery to the above gentlemen, from no other motive than a desire of promoting the good of mankind; and hopes for the future that no person will be given up for dead, till various means have been used for their recovery."<br />
<br />
Since it is clear she sustained a head injury, the electricity probably stimulated the child out of deep coma rather than providing cardiac defibrillation (see also 1788, Charles Kite). Annual Report 1774: Humane Society, London. pp 31-32 <br />
<br />
'''1775''' Abildgaard shows that hens can be made lifeless with electrical impulses and he can restore a pulse with electrical shocks across the chest. "With a shock to the head, the animal was rendered lifeless, and arose with a second shock to the chest; however, after the experiment was repeated rather often, the hen was completely stunned, walked with some difficulty, and did not eat for a day and night; then later it was very well and even laid an egg." <cite>Abildgaard</cite><br />
<br />
'''1786''' [[Image:Luigi_Galvani_oil-painting.jpg|thumb|150px|left|Italian Anatomist '''Luigi Galvani''']]Italian Anatomist '''Luigi Galvani''' notes that a dissected frog's leg twitches when touched with a metal scalpel. He has been studying the effects of electricity on animal tissues this summer.<br />
<br />
[[Image:Galvani_experiment.jpg|thumb|150px|Luigi Galvani's frog leg]]On 20th September 1786 he wrote, "I had dissected and prepared a frog in the usual way and while I was attending to something else I laid it on a table on which stood an electrical machine at some distance from its conductor and separated from it by a considerable space. Now when one of the persons present touched accidentally and lightly the inner crural nerves of the frog with the point of a scalpel, all the muscles of the legs seemed to contract again and again as if they were affected by powerful cramps."<br />
<br />
He later shows that direct contact with the electrical generator or the ground through an electrical conductor leads to a muscle contraction. Galvani also uses brass hooks attached to the frog's spinal cord and suspended from an iron railing in a part of his garden. He notices that the frogs' legs twitch during lightening storms and when the weather is fine. He interprets these results in terms of "animal electricity" or the preservation in the animal of "nerveo-electrical fluid" similar to that of an electric eel. He later also shows that electrical stimulation of a frog's heart leads to cardiac muscular contraction. Galvani. De viribus Electritatis in motu musculari Commentarius. 1791<br />
<br />
Galvani's name is given to the 'galvanometer', an instrument for measuring (and recording) electricity - this is essentially what an ECG is; a sensitive galvanometer.<br />
<br />
'''1788''' Charles Kite wins the Silver Medal of the Humane Society (awarded at the first prize medal ceremony of the Society, co-judged with the Medical Society of London) with an essay on the use of electricity in the diagnosis and resuscitation of persons apparently dead. This essay is often cited as the first record of cardiac defibrillation, but the use of electricity suggested by Mr Kite is much different. For example, on describing a case of drowning from 1785, in which resuscitation was attempted with artificial respiration, warmth, tobacco, "volatiles thrown into the stomach, frictions, and various lesser stimuli" for nearly an hour, he then recalls the use of electricity. "Electricity was then applied, and shocks sent through in every possible direction; the muscles through which the fluid [electricity] passed were thrown into strong contractions." He concludes that electricity is a valuable tool that can be used to resuscitate a person who appeared dead. Annual Report 1788: Humane Society, London. pp 225-244. Kite C. An Essay on the Recovery of the Apparently Dead. 1788: C. Dilly, London. <br />
<br />
[[Image:Alessandro_Volta.jpg|150px|thumb|left|Alessandro Volta]]'''1792''' Alessandro Volta, Italian Scientist and inventor, attempts to disprove Galvani's theory of "animal electricity'" by showing that electrical current is generated by the combination of two dissimilar metals. [[Image:Voltaic_Pile.jpg|150px|thumb|Voltaic pile]]His assertion is that the electrical current comes from metals and not animal tissues. (We now know that both Galvani and Volta were right.) To prove his theory he develops the voltaic pile in 1800 (a column of alternating metal discs - zinc with copper or silver - separated by paperboard soaked in saline) which can deliver a substantial and steady current of electricity. Enthusiasm in the use of electricity leads to further attempts at reanimation of the dead with experiments on recently hanged criminals. Giovani Aldini (the nephew of Galvani) conducts an experiment at the Royal College of Surgeons in London in 1803. The executed criminal has lain in a temperature of 30 degrees F for one hour and is transported to the College. "On applying the conductors to the ear and to the rectum, such violent muscular contractions were executed, as almost to give the appearance of the reanimation". Aldini, J. Essai: Théorique et expérimental sur le Galvanisme, Paris (1804), Giovani Aldini. General Views on the Application of Galvanism to Medical Purposes Principally in cases of suspended Animation (London: J. Callow, Princes Street and Burgess and Hill, Great Windmill Street, 1819). Mary Shelly's Frankenstein is published in 1818. Louis Figuier, Les merveilles de la Science (Paris, 1867), p.653<br />
<br />
{{clr}}<br />
<br />
==1800 - 1895==<br />
'''1819''' While demonstrating to students the heating of a platinum wire with electricity from a voltaic pile at the University of Copenhagen, Danish physicist Hans Christian Oersted notices that a nearby magnetized compass needle moves each time the electrical current is applied. He discovers electromagnetism, which is given a theoretical basis (with remarkable speed) by André Marie Ampère. <br />
<br />
'''1820''' Johann (Johan) Schweigger of Nuremberg increases the movement of magnetized needles in electromagnetic fields. He finds that wrapping the electric wire into a coil of 100 turns multiplies the effect on the needle. He proposes that a magnetic field revolved around a wire carrying a current. This was later proven by Michael Faraday. Schweigger announces his discovery at the University of Halle on 16th September 1820. <br />
<br />
'''1825''' Leopold Nobili, Professor of Physics at Florence, develops an 'astatic galvanometer'. Using two identical magnetic needles of opposite polarity, either fixed together with a figure of eight arrangement of wire loops (in earlier versions), or one movable needle with a wire loop and one with a scale (in later versions), Nobili is able to compensate for the effects of the earth's magnetic field. In 1827, using this instrument, he manages to detect the flow of current in the body of a frog from muscles to spinal cord. He detects the electricity running along saline-moistened cotton thread joining the dissected frog's legs in one jar to its body in another jar. Nobili feels that this work proves the theory of animal electricity. <br />
<br />
[[Image:Matteucci.jpg|thumb|150px|left|Carlo Matteucci]]'''1838''' Carlo Matteucci, Professor of Physics at the University of Pisa, a student of Nobili, shows that an electric current accompanies each heart beat. He uses a preparation known as a 'rheoscopic frog', in which the cut nerve of a frog's leg is used as the electrical sensor and twitching of the muscle is used as the visual sign of electrical activity. He also uses Nobili's astatic galvanometer for the study of electricity in muscles, typically inserting one galvanometer wire into the open end of the dissected muscle and the other onto the surface of the muscle. He goes on to try to demonstrate conduction in nerve, but is unable to do so (since his galvanometers are not sensitive enough). <cite>Matteucci</cite><br />
<br />
'''1840''' Dr Golding Bird, a physician, accomplished chemist and member of the London Electrical Society, opens an electrical therapy room at Guy's Hospital, London, treating a large range of diseases. Although the application of electricity is popular, it is not considered a subject worthy of serious investigation. Because of Bird's reputation as a researcher, electrical therapy achieves popularity among London physicians, including his mentor, Dr Thomas Addison. <cite>Bird</cite><br />
<br />
[[Image:Emil_Dubois.jpg|thumb|150px|left|Physiologist Emil Du Bois-Reymond]]'''1843''' German physiologist Emil Du Bois-Reymond describes an "action potential" accompanying each muscular contraction. He detects the small voltage potential present in resting muscle and notes that this diminishes with contraction of the muscle. To accomplish this he had develops one of the most sensitive galvanometers of his time. His device has a wire coil with over 24,000 turns - 5 km of wire. Du Bios Reymond devises a notation which he called the 'disturbance curve' for his galvanometer. "O" was the stable equilibrium point of the astatic galvanometer needle and p, q, r and s (and also k and h) were other points in its deflection. Du Bois-Reymond, E. Untersuchungen uber thierische Elektricitat. Reimer, Berlin: 1848.<br />
<br />
'''1850''' Bizarre unregulated actions of the ventricles (later called ventricular fibrillation) is described by Hoffa during experiments with strong electrical currents across the hearts of dogs and cats. He demonstrates that a single electrical pulse can induce fibrillation. <cite>Hoffa</cite><br />
<br />
'''1856''' Rudolph von Koelliker and Heinrich Muller confirm that an electrical current accompanies each heart beat by applying a galvanometer to the base and apex of an exposed ventricle. They also apply a nerve-muscle preparation, similar to Matteucci's, to the ventricle and observe that a twitch of the muscle occurs just prior to ventricular systole, followed by a much smaller twitch after systole. These twitches will later be recognized as caused by the electrical currents of the QRS and T waves. von Koelliker A, Muller H. Nachweis der negativen Schwankung des Muskelstroms am naturlich sich kontrahierenden Herzen. Verhandlungen der Physikalisch-Medizinischen Gesellschaft in Wurzberg. 1856;6:528-33. <br />
<br />
'''1858''' William Thompson (Lord Kelvin), professor of natural philosophy at Glasgow University, invents the 'mirror galvanometer' for the reception of transatlantic telegraph transmissions. A small, freely rotating mirror, with magnets stuck to its back, is suspended in a fine copper coil and a reflected spot of light from this mirror 'amplifies' small movements when electrical current is present. The whole apparatus is suspended in an air chamber and the pressure inside can be adjusted to vary the damping seen on the signals. This galvanometer is sensitive enough for transatlantic telegraphy.<br />
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'''1867''' Thompson improves telegraph transmissions with the 'Siphon Recorder'. Before d'Arsonval (1880), Thompson uses a fine coil suspended in a strong magnetic magnetic field. Attached to the coil but isolated from it by ebonite (an insulator) is a siphon of ink. The siphon is charged with high voltage so that the ink is sprayed onto the paper, which moved over a metal surface. The siphon recorder could therefore not only detect currents; it could also record them onto paper.<br />
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'''1869-70''' Alexander Muirhead, an electrical engineer and pioneer of telegraphy, possibly records a human electrocardiogram at St Bartholomew's Hospital, London but this is disputed. He is thought to have used a Thompson Siphon Recorder. Elizabeth Muirhead, his wife, writes a book of his life, claiming that he refrained from publishing his own work for fear of misleading others. Elizabeth Muirhead. Alexander Muirhead 1848 - 1920. Oxford, Blackwell: privately printed 1926.<br />
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'''1872''' French physicist Gabriel Lippmann invents a capillary electrometer. It is a thin glass tube with a column of mercury beneath sulfuric acid. The mercury meniscus moves with varying electrical potential and is observed through a microscope.<br />
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'''1872''' Mr Green, a surgeon, publishes a paper on the resuscitation of a series of patients who suffered cardiac and/or respiratory arrest during anesthesia with chloroform. He uses a galvanic pile (battery) of 200 cells generating 300 Volts, which he applies to the patient as follows "One pole should be applied to the neck and the other to the lower rib on the left side." Green T. On death from chloroform: its prevention by galvanism. Br Med J 1872 1: 551-3. Although this has been reported as an example of cardiorespiratory resuscitation, it is unclear what the exact mechanism seems to be. It is unlikely to be electric cardioversion or external pacing. It seems to be another example of electrophrenic stimulation (See also Duchenne 1872).<br />
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[[image:Duchenne_de_belogne.jpg|thumb|150px|left|Guillaume Benjamin Amand Duchenne de Boulogne]]'''1872''' Guillaume Benjamin Amand Duchenne de Boulogne, pioneering neurophysiologist, describes the resuscitation of a drowned girl with electricity in the third edition of his textbook on the medical uses of electricity. This episode has sometimes been described as the first 'artificial pacemaker' but he used an electrical current to induce electrophrenic rather than myocardial stimulation. Duchenne GB. De l'electrisation localisee et de son application a la pathologie et la therapeutique par courants induits at par courants galvaniques interrompus et continus. [Localised electricity and its application to pathology and therapy by means of induced and galvanic currents, interrupted and continuous] 3ed. Paris. JB Bailliere et fils; 1872<br />
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'''1874''' A. Vulpian described ''mouvement fibrillaire'' in his article published in 1874, which would be the basis for the name ventricular fibrillation now used for this arrhythmia.<cite>Vulpian</cite><br />
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'''1875''' Richard Caton, a Liverpool physician, presents to the British Medical Association in July 1875 in Edinburgh. Using a Thompson 'mirror galvanometer' in animals he shows it is possible to detect 'feeble currents of varying direction ... when the electrodes are placed on two points of the external surface, or one electrode on the grey matter and one on the surface of the skull'. This is the first report of the EEG (or electroencephalogram). Caton was proving another Physician's hypothesis, John Hughlings Jackson, who suggested in 1873 that epilepsy was due to excessive electrical activity in the grey matter of the brain. Caton R: The electric currents of the brain. BMJ 1875; 2:278, Mumenthaler, Mattle Eds. Neurology. 4th Edition. Stuttgart, Thieme: 2004.<br />
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'''1876''' Marey uses the electrometer to record the electrical activity of an exposed frog's heart. Marey EJ. Des variations electriques des muscles et du couer en particulier etudies au moyen de l'electrometre de M Lippman. Compres Rendus Hebdomadaires des Seances de l'Acadamie des sciences 1876;82:975-977<br />
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'''1878''' British physiologists John Burden Sanderson and Frederick Page record the heart's electrical current with a capillary electrometer and shows it consists of two phases (later called QRS and T). Burdon Sanderson J. Experimental results relating to the rhythmical and excitatory motions of the ventricle of the frog. Proc R Soc Lond 1878;27:410-414<br />
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'''1880''' French physicist Arsène d'Arsonval in association with Marcel Deprez, improves the galvanometer. Instead of a magnetized needle moving when electrical current flows through a surrounding wire coil the Deprez-d'Arsonval galvanometer has a fixed magnet and moveable coil. If a pointer is attached to the coil it can move over a suitably calibrated scale. The d'Arsonval galvanometer is the basis for most modern galvanometers. Comptes rendus de l'Académie des sciences, 1882, 94: 1347-1350 <br />
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'''1884''' John Burden Sanderson and Frederick Page publish some of their recordings. Burdon Sanderson J, Page FJM. On the electrical phenomena of the excitatory process in the heart of the tortoise, as investigated photographically. J Physiol (London) 1884;4:327-338<br />
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[[image:Waller.jpg|thumb|150px|left|A.D. Waller with his famous bulldog Jimmy]]'''1887''' British physiologist Augustus D. Waller of St Mary's Medical School, London publishes the first human electrocardiogram. It is recorded with a capilliary electrometer from Thomas Goswell, a technician in the laboratory. <cite>Waller</cite> This is shortly after the "Cruelty to Animals Act" is accepted in the British parliament, which leads to questions in the House of Commons.<br />
<br />
Q. 'At a converzaione [sic] of the Royal Society at Burlington House on May 12th last, a bulldog was cruelly treated when a leather strap with sharp nails was wound around his neck and his feet were immersed in glass jars containing salts in solution, and the jars in turn were connected with wires to galvanometers. Such a cruel procedure should surely be dealt with under the "Cruelty to Animals Act" of 1876?'<br />
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A. 'The dog in question wore a leather collar ornamented with brass studs, and he was placed to stand in water to which some sodium chloride had been added, or in other words, common salt. If my honourable friend had ever paddled in the sea, he will appreciate fully the sensation obtained thereby from this simple pleasurable experience!'<br />
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'''1887''' McWilliam provides the first detailed description of VF, and demonstrated how VF in man can be terminated by electric shocks applied through a large pair of electrodes; the first description of defibrillation in man.<cite>McWilliam1</cite><cite>McWilliam2</cite><br />
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'''1889''' Dutch physiologist Willem Einthoven sees Waller demonstrate his technique at the First International Congress of Physiologists in Bale. Waller often demonstrated by using his dog "Jimmy" who would patiently stand with paws in glass jars of saline.<br />
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'''1890''' GJ Burch of Oxford devises an arithmetical correction for the observed (sluggish) fluctuations of the electrometer. This allows the true waveform to be seen, but only after tedious calculations. <cite>Burch</cite><br />
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'''1891''' British physiologists William Bayliss and Edward Starling of University College London improve the capillary electrometer. They connect the terminals to the right hand and to the skin over the apex beat and show a "triphasic variation accompanying (or rather preceding) each beat of the heart". These deflections are later called P, QRS and T. <cite>Bayliss1</cite> and <cite>Bayliss2</cite> They also demonstrate a delay of about 0.13 seconds between atrial stimulation and ventricular depolarisation (later called PR interval). On the electromotive phenomena of the mammalian heart. Proc Phys Soc (21st March) in J Physiol (London) 1891;12:xx-xxi <br />
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'''1893''' Willem Einthoven introduces the term 'electrocardiogram' at a meeting of the Dutch Medical Association. (Later he claims that Waller was first to use the term). Einthoven W: Nieuwe methoden voor clinisch onderzoek [New methods for clinical investigation]. Ned T Geneesk 29 II: 263-286, 1893<br />
{{clr}}<br />
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==1895 - 1949==<br />
[[image:Einthoven_portrait.jpg|thumb|150px|left|Willem Einthoven]][[Image:Einthoven_ECG3.jpg|thumb|150px|ECG recordings as registered by Einthoven]][[Image:einthoven.jpg|150px|left|thumb|Willem Einthoven]][[image:Einthoven_ECG2.jpg|thumb|150px|right|Einthoven's ECG recording including putting the patients feet in baths filled with saline to improve electrical conduction]][[Image:Einthoven_ECG.jpg|thumb|150px|An electrocardiograph as used by Einthoven]]<br />
'''1895''' Einthoven, using an improved electrometer and a correction formula developed independently of Burch, distinguishes five deflections which he names P, Q, R, S and T. <cite>Einthoven2</cite><br />
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Why PQRST and not ABCDE? The four deflections prior to the correction formula are labeled ABCD and the 5 derived deflections are labeled PQRST. The choice of P is a mathematical convention (as used also by Du Bois-Reymond in his galvanometer's 'disturbance curve' 50 years previously) by using letters from the second half of the alphabet. N has other meanings in mathematics and O is used for the origin of the Cartesian coordinates. In fact Einthoven uses O ..... X to mark the time line on his diagrams. P is simply the next letter. A lot of work has been undertaken to reveal the true electrical waveform of the ECG by eliminating the damping effect of the moving parts in the amplifiers and using correction formulae. If you look at the diagram in Einthoven's 1895 paper you will see how close it is to the string galvanometer recordings and the electrocardiograms we see today. The image of the PQRST diagram may be striking enough to be adopted by the researchers as a true representation of the underlying form. It would then be logical to continue the same naming convention when the more advanced string galvanometer starts creating electrocardiograms a few years later. <br />
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'''1897''' Clement Ader, a French electrical engineer, reports his amplification system for detecting Morse code signals transmitted along undersea telegraph lines. It is never intended to be used as a galvanometer. Einthoven later quotes Ader's work but seems to have developed his own amplification device independently. <cite>Ader</cite><br />
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'''1899''' Karel Frederik Wenckebach publishes a paper "On the analysis of irregular pulses" describing impairment of AV conduction leading to progressive lengthening and blockage of AV conduction in frogs. This will later be called Wenckebach block (Mobitz type I) or Wenckebach phenomenon.<br />
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'''1899''' Jean-Louis Prevost, Professor of Biochemistry, and Frederic Batelli, Professor of Physiology, both of Geneva, discover that large electrical voltages applied across an animal's heart can stop ventricular fibrillation. <cite>Prevost</cite><br />
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'''1901''' Einthoven invents a new galvanometer for producing electrocardiograms using a fine quartz string coated in silver, based on ideas by Deprez and d'Arsonval (who used a wire coil). His "string galvanometer" weighs 600 pounds. Einthoven acknowledges the similar system by Ader but later (1909) calculates that his galvanometer is in fact many thousands of times more sensitive. <cite>Einthoven3</cite><br />
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'''1902''' Einthoven publishes the first electrocardiogram recorded on a string galvanometer. <cite>Einthoven4</cite><br />
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'''1903''' Einthoven discusses commercial production of a string galvanometer with Max Edelmann of Munich and Horace Darwin of Cambridge Scientific Instruments Company of London. <br />
1905<br />
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Einthoven starts transmitting electrocardiograms from the hospital to his laboratory 1.5 km away via telephone cables. On March 22nd the first 'telecardiogram' is recorded from a healthy and vigorous man and the tall R waves are attributed to his cycling from laboratory to hospital for the recording.<br />
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'''1905''' John Hay, of Liverpool, publishes pressure recordings from a 65 year old man. The recording shows heart block in which AV conduction does not seem to be impaired, since the a-c intervals on the jugular venous waves is unchanged in the conducted beats. This is the first demonstration of what we now call Mobitz type II AV block. <cite>Hay</cite><br />
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'''1906''' Einthoven publishes the first organised presentation of normal and abnormal electrocardiograms recorded with a string galvanometer. Left and right ventricular hypertrophy, left and right atrial hypertrophy, the U wave (for the first time), notching of the QRS, ventricular premature beats, ventricular bigeminy, atrial flutter and complete heart block are all described. Einthoven W. Le telecardiogramme. Arch Int de Physiol 1906;4:132-164 (translated into English. Am Heart J 1957;53:602-615) <br />
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'''1906''' Cremer records the first oesophageal electrocardiogram which he achieved with the help of a professional sword swallower. Oesophageal electrocardiography later developed in the 1970s to help differentiate atrial arrhythmias. He also records the first fetal electrocardiogram from the abdominal surface of a pregnant woman. Cremer. Ueber die direkte Ableitung der Aktionströme des menslichen Herzens vom Oesophagus und über das Elektrokardiogramm des Fötus. Munch. Med. Wochenschr. 1906;53:811 <br />
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'''1907''' Arthur Cushny, professor of pharmacology at University College London, publishes the first case report of atrial fibrillation. His patient was 3 days post-op following surgery on an "ovarian fibroid" when she developed a "very irregular" pulse at a rate of 120 - 160 bpm. Her pulse was recorded with a "Jacques sphygmochronograph" which shows the radial pulse pressure against time - much like the arterial line blood pressure recordings used in Intensive Care today. Cushny AR, Edmunds CW. Paroxysmal irregularity of the heart and auricular fibrillation. Am J Med Sci 1907;133:66-77. <br />
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'''1908''' Edward Schafer of the University of Edinburgh is the first to buy a string galvanometer for clinical use. <br />
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'''1909''' Thomas Lewis, of University College Hospital, London, buys a string galvanometer and so does Alfred Cohn of Mt Sinae Hospital, New York. Thomas Lewis publishes a paper in the BMJ detailing his careful clinical and electrocardiographic observations of atrial fibrillation. At one point Lewis identifies a fibrillating horse's heart using the string galvanometer's electrocardigram recording. He then followed the horse to the slaughterhouse, where he could visually confirm the fibrillating atrium. <cite>Lewis</cite><br />
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'''1909''' Nicolai and Simmons report on the changes to the electrocardiogram during angina pectoris. Nicolai DF, Simons A. (1909) Zur klinik des elektrokardiogramms. Med Kiln 5;160<br />
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'''1910''' Walter James, Columbia University and Horatio Williams, Cornell University Medical College, New York, publish the first American review of electrocardiography. It describes ventricular hypertrophy, atrial and ventricular ectopics, atrial fibrillation and ventricular fibrillation. The recordings were sent from the wards to the electrocardiogram room by a system of cables. There is a great picture of a patient having an electrocardiogram recorded with the caption "The electrodes in use".James WB, Williams HB. The electrocardiogram in clinical medicine. Am J Med Sci 1910;140:408-421, 644-669<br />
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'''1911''' Levy & Lewis demonstrate that when VF occurred during chloroform anesthesia, it was often preceded by the appearance of multiform ventricular premature beats or ventricular tachycardia.<cite>Lewis</cite><br />
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Thomas Lewis publishes a classic textbook. The mechanism of the heart beat. London: Shaw & Sons and dedicates it to Willem Einthoven.<br />
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'''1912''' Einthoven addresses the Chelsea Clinical Society in London and describes an equilateral triangle formed by his standard leads I, II and III later called 'Einthoven's triangle'. This is the first reference in an English article to the abbreviation 'EKG' that I have seen.Einthoven W. The different forms of the human electrocardiogram and their signification. Lancet 1912(1):853-861 <br />
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Hoffman published the first ECG of ventricular fibrillation in man.<cite>Hoffman</cite><br />
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'''1918''' Bousfield describes the spontaneous changes in the electrocardiogram during angina. <cite>Bousfield</cite><br />
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'''1920''' Hubert Mann of the Cardiographic Laboratory, Mount Sinai Hospital, describes the derivation of a 'monocardiogram', later to be called 'vectorcardiogram'. <cite>Mann</cite><br />
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'''1920''' Harold Pardee, New York, publishes the first electrocardiogram of an acute myocardial infarction in a human and describes the T wave as being tall and "starts from a point well up on the descent of the R wave". <cite>Pardee</cite><br />
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'''1924''' Willem Einthoven wins the Nobel prize for inventing the electrocardiograph. <br />
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'''1924''' Woldemar Mobitz publishes his classification of heart blocks (Mobitz type I and type II) based on the electrocardiogram and jugular venous pulse waveform findings in patients with second degree heart block. Mobitz W. Uber die unvollstandige Storung der Erregungsuberleitung zwischen Vorhof und Kammer des menschlichen Herzens. (Concerning partial block of conduction between the atria and ventricles of the human heart). Z Ges Exp Med 1924;41:180-237. <br />
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'''1926''' A doctor from the Crown Street Women's Hospital in Sydney, who wishes to remain anonymous, resuscitates a new-born baby with an electrical device later called a 'pacemaker'. The doctor wants to remain anoymous because of the controversy surrounding research that artificially extends human life. <br />
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'''1928''' Ernstine and Levine report the use of vacuum tubes to amplify the electrocardiogram instead of the mechanical amplification of the string galvanometer. <cite>Ernstine</cite> <br />
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'''1928''' Frank Sanborn's company (founded 1917 and acquired by Hewlett-Packard in 1961 and since 1999, Philips Medical Systems) converts their table model electrocardiogram machine into their first portable version weighing 50 pounds and powered by a 6-volt automobile battery.<br />
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'''1929''' Sydney doctor Mark Lidwill, physician, and Edgar Booth, physicist, report the electrical resuscitation of the heart to a meeting in Sydney. Their portable device uses an electrode on the skin and a transthoracic catheter. Edgar Booth's design could deliver a variable voltage and rate and is employed to deliver 16 volts to the ventricles of a stillborn infant. <br />
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[[image:White_stamp.gif|thumb|150px|left|Dr. Paul Dudley White]]'''1930''' Wolff, Parkinson and White report an electrocardiographic syndrome of short PR interval, wide QRS and paroxysmal tachycardias. Wolff L, Parkinson J, White PD. Bundle branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia. Am Heart J 1930;5:685. Later, when other published case reports are examined for evidence of pre-excitation,earlier examples of 'Wolff Parkinson White' syndrome, which were not recognized as a clinical entity at the time, are identified. The earliest example was published by Hoffmann in 1909. Von Knorre GH. The earliest published electrocardiogram showing ventricular preexcitation. Pacing Clin Electrophysiol. 2005 Mar;28(3):228-30<br />
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'''1930''' Sanders first describes infarction of the right ventricle. <cite>Sanders</cite><br />
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'''1931''' Charles Wolferth and Francis Wood describe the use of exercise to provoke attacks of angina pectoris. They investigate the ECG changes in normal subjects and those with angina, but dismissed the technique as too dangerous "to induce anginal attacks indiscriminately". <cite>Wood</cite><br />
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'''1931''' Dr Albert Hyman patents the first 'artificial cardiac pacemaker', which stimulates the heart by using a transthoracic needle. His aim is to produce a device that is small enough to fit in a doctor's bag and be able to stimulate the right atrial area of the heart with a suitably insulated needle. His experiments are on animals. His original machine was powered by a crankshaft (it is later prototyped by a German company but is never successful). "By March 1, 1932 the artificial pacemaker had been used about 43 times, with a successful outcome in 14 cases." It is not until 1942 that a report of its successful short term use in Stokes-Adams attacks is presented. <cite>Hyman</cite><br />
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'''1932''' Goldhammer and Scherf propose the use of the electrocardiogram after moderate exercise as an aid to the diagnosis of coronary insufficiency. Goldhammer S, Scherf D. Elektrokardiographische untersuchungen bei kranken mit angina pectoris. Z Klin Med 1932;122:134 <br />
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'''1932''' Charles Wolferth and Francis Wood describe the clinical use of chest leads. Wolferth CC, Wood FC. The electrocardiographic diagnosis of coronary occlusion by the use of chest leads. Am J Med Sci 1932;183:30-35 <br />
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'''1934''' By joining the wires from the right arm, left arm and left foot with 5000 Ohm resistors Frank Wilson defines an 'indifferent electrode' later called the 'Wilson Central Terminal'. The combined lead acts as an earth and is attached to the negative terminal of the ECG. An electrode attached to the positive terminal then becomes 'unipolar' and can be placed anywhere on the body. Wilson defines the unipolar limb leads VR, VL and VF where 'V' stands for voltage (the voltage seen at the site of the unipolar electrode). <cite>Wilson</cite> <br />
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'''1935''' McGinn and White describe the changes to the electrocardiogram during acute pulmonary embolism, including the S1 Q3 T3 pattern. <cite>McGinn</cite> <br />
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'''1938''' The American Heart Association and the Cardiac Society of Great Britain define the standard positions and wiring, of the chest leads V1 - V6. The 'V' stands for voltage. Barnes AR, Pardee HEB, White PD. et al. Standardization of precordial leads. Am Heart J 1938;15:235-239 <br />
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'''1938''' Tomaszewski notes changes to the electrocardiogram in a man who died of hypothermia. Tomaszewski W. Changements electrocardiographiques observes chez un homme mort de froid. Arch Mal Coeur 1938;31:525. <br />
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'''1939''' Langendorf reports a case of atrial infarction discovered at autopsy. In retrospect,it could have been diagnosed by changes on the ECG. <cite>Langendorf</cite><br />
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'''1942''' Emanuel Goldberger increases the voltage of Wilson's unipolar leads by 50% and creates the augmented limb leads aVR, aVL and aVF. When they are added to Einthoven's three limb leads and the six chest leads, the 12 lead ECG that we know today emerges.<br />
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'''1942''' Arthur Master standardizes the two step exercise test (now known as the Master two-step) for cardiac function. Master AM, Friedman R, Dack S. The electrocardiogram after standard exercise as a functional test of the heart. Am Heart J. 1942;24:777 <br />
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'''1944''' Young and Koenig report deviation of the P-R segment in a series of patients with atrial infarction. Young EW, Koenig BS. Auricular infarction. Am Heart J. 1944;28:287. <br />
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'''1947''' Gouaux and Ashman describe an observation that helps differentiate aberrant conduction from ventricular tachycardia. The 'Ashman phenomenon' occurs when a stimulus takes place during the relative or absolute refractory period of the ventricles and the aberrancy is more pronounced. In atrial fibrillation with aberrant conduction, this is demonstrated when the broader complexes are seen terminating a relatively short cycle that follows a relatively long one. The QRS terminating the shorter cycle is conducted 'more aberrantly' because it falls in the refractory period. The aberrancy is usually of an RBBB pattern. <cite>Gouaux</cite><br />
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'''1947''' Claude Beck, a pioneering cardiovascular surgeon in Cleveland, successfully defibrillates a human heart during cardiac surgery. The patient is a 14 year old boy - 6 other patients have failed to respond to the defibrillator. His prototype defibrillator follows experiments on defibrillation performed on animals by Carl J. Wiggers, professor of physiology at the Western Reserve University. <cite>Beck</cite><br />
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'''1948''' Rune Elmqvist, Swedish engineer who had trained as a doctor but never practiced, introduces the first ink jet printer for the transcription of analog physiological signals. He demonstrates its use in the recording of ECGs at the First International Congress of Cardiology in Paris in 1950. The machine (the mingograph) was developed by him at the company that later became Siemens. (Luderitz, 2002)<br />
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'''1949''' Montana physician Norman Jeff Holter develops a 75 pound backpack that can record the ECG of the wearer and transmit the signal. His system, the Holter Monitor, is later greatly reduced in size, combined with tape / digital recording and used to record ambulatory ECGs. <cite>Holter</cite><br />
<br />
== 1950 - to date==<br />
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'''1949''' Sokolow and Lyon propose diagnostic criteria for left ventricular hypertrophy i.e. LVH is present if the sum of the size of the S wave in V1 plus the R wave in V6 exceeds 35 mm. <cite>Sokolow</cite><br />
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'''1950''' John Hopps, a Canadian electrical engineer and researcher for the National Research Council, together with two physicians (Wilfred Bigelow, MD of the University of Toronto and his trainee, John C. Callaghan, MD) show that a coordinated heart muscle contraction can be stimulated by an electrical impulse delivered to the sino-atrial node. The apparatus, the first cardiac pacemaker, measures 30cm, runs on vacuum tubes and is powered by household 60Hz electrical current. <cite>Bigelow</cite><br />
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'''1953''' Osborn, while experimenting with hypothermic dogs, describes the prominent J (junctional) wave, often known as the "Osborn wave". He found the dogs were more likely to survive if they had an infusion of bicarbonate and supposed the J wave was due to an injury current caused by acidosis. Osborn JJ. Experimental hypothermia: respiratory and blood pH changes in relation to cardiac function. Am J Physiol 1953;175:389. <br />
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'''1955''' Richard Langendorf publishes the "rule of bigeminy" whereby ventricular bigeminy tends to perpetuate itself. Langendorf R, Pick A, Winternitz M. Mechanisms of intermittent ventricular bigeminy. I. Appearence of ectopic beats dependent upon the length of the ventricular cycle, the "rule of bigeminy." circulation 1955;11:442. <br />
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[[image:Zoll_portrait.jpg|thumb|150px|left|Paul Zoll]]'''1956''' Paul Zoll, a cardiologist, uses a more powerful defibrillator and performs closed-chest defibrillation in a human. <cite>Zoll</cite><br />
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'''1957''' Anton Jervell and Fred Lange-Nielsen of Oslo describe an autosomal recessive syndrome of long-QT interval, deafness and sudden death later known as the Jervell-Lange-Nielsen syndrome. <cite>Jervell</cite><br />
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'''1958''' Professor Ake Senning, of Sweden, places the first implantable cardiac pacemaker designed by Rune Elmqvist into a 43-year-old patient with complete heart block and syncope (Arne Larsson).<br />
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'''1959''' Myron Prinzmetal describes a variant form of angina in which the ST segment is elevated rather than depressed. <cite>Prinzmetal</cite><br />
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'''1960''' Smirk and Palmer highlight the risk of sudden death from ventricular fibrillation; particularly when ventricular premature beats occur at the same time as the T wave. The 'R on T' phenomenon. Smirk FH, Palmer DG. A myocardial syndrome, with particular reference to the occurrence of sudden death and of premature systoles interrupting antecedent T waves. Am J Cardiol 1960;6:620. <br />
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'''1963''' Italian pediatrician C. Romano and Irish pediatrician O. Conor Ward (the following year) independently report an autosomal dominant syndrome of long-QT interval later known as the Romano-Ward syndrome. <cite>Romano</cite><cite>Ward</cite><br />
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[[image:Bruce_portrait.jpg|thumb|150px|left|Robert Bruce]]'''1963''' Robert Bruce and colleages describe their multistage treadmill exercise test, later known as the Bruce Protocol. "You would never buy a used car without taking it out for a drive and seeing how the engine performed while it was running," Bruce says, "and the same is true for evaluating the function of the heart." <cite>Bruce1</cite><cite>Bruce2</cite><br />
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'''1963''' Baule and McFee are the first to detect the magnetocardiogram, the electromagnetic field produced by the electrical activity of the heart. The method can detect the ECG without the use of skin electrodes. Although potentially a useful technique, it has never gained clinical acceptance, partly because of its expense. <cite>Baule</cite><br />
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'''1966''' Mason and Likar modify the 12-lead ECG system for use during exercise testing. The right arm electrode is placed at a point in the infraclavicular fossa medial to the border of the deltoid muscle, 2 cm below the lower border of the clavicle. The left arm electrode is placed similarly on the left side. The left leg electrode is placed at the left iliac crest. Although this system reduces the variability in the ECG recording during exercise, it is not exactly equivalent to the standard lead positions. The Mason-Likar lead system tends to distort the ECG with a rightward QRS axis shift, a reduction in R wave amplitude in lead I and aVL, and a significant increase in R wave amplitude in leads II, III and aVF. <cite>Papouchado</cite><br />
<br />
'''1966''' François Dessertenne of Paris publishes the first case of '[[Torsade de pointes]]' Ventricular Tachycardia. <cite>Dessertenne</cite><br />
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'''1968''' Journal of Electrocardiography, the Official Journal of the International Society for Computerized Electrocardiology and the International Society of Electrocardiology, is founded by Zao and Lepeschkin. <br />
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'''1968''' Henry Marriott introduces the Modified Chest Lead 1 (MCL1) for monitoring patients in Coronary Care. <br />
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'''1969''' Rosenbaum reviews the classification of ventricular premature complexes and adds a benign form that arises from the right ventricle and is not associated with heart disease. This becomes known as the 'Rosenbaum ventricular extrasystole'. <cite>Rosenbaum</cite><br />
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'''1974''' Jay Cohn, of University of Minnesota Medical School, describes the 'syndrome of right ventricular dysfunction in the setting of acute inferior wall myocardial infarction'. <cite>Cohn</cite><br />
<br />
'''1974''' Gozensky and Thorne introduce the term 'Rabbit ears' to electrocardiography. Rabbit ears describe the appearence of the QRS complex in lead V1 with an rSR' pattern (good rabbit) being typical of Right Bundle Branch Block and an RSr' (bad rabbit) suggesting a ventricular origin i.e. ventricular ectopy / tachycardia. <cite>Gozensky</cite><br />
<br />
'''1976''' Erhardt and colleagues describe the use of a right-sided precordial lead in the diagnosis of right ventricular infarction which has previously been thought to be electrocardiographically silent. <cite>Erhardt</cite><br />
<br />
'''1988''' Professor John Pope Boineau of Washington University School of Medicine publishes a 30-year perspective on the modern history of electrocardiography. <cite>Boineau</cite><br />
<br />
[[image:Brugada.jpg|thumb|150px|left|Pedro Brugada]]'''1992''' Pedro Brugada and Joseph Brugada of Barcelona publish a series of 8 cases of sudden death, Right Bundle Branch Block pattern and ST elevation in V1 - V3 in apparently healthy individuals. This 'Brugada Syndrome' may account for 4-12% of unexpected sudden deaths and is the commonest cause of sudden cardiac death in individuals aged under 50 years in South Asia. The technology of the electrocardiogam, which is over 100 years old, can still be used to discover new clinical entities in cardiology. <cite>Brugada</cite><br />
<br />
'''1992''' Cohen and He describe a new non-invasive approach to map cardiac electrical activity accurately by using the surface Laplacian map of the body surface electrical potentials. <cite>He</cite><br />
[[Image:modern_ecg.jpg|thumb|150px|The last generation of ECG equipment. Image courtesy of [http://www.gehealthcare.com/euen/cardiology/ General Electric]]]<br />
'''1993''' Robert Zalenski, Professor of Emergency Medicine, Wayne State University, Detroit, and colleagues publish an influential article on the clinical use of the 15-lead ECG which routinely uses V4R, V8 and V9 in the diagnosis of acute coronary syndromes. Like the addition of the 6 standardised unipolar chest leads in 1938, the addition of the three new leads increases the sensitivity of the electrocardiogram in detecting myocardial infarction. <cite>Zalenski</cite><br />
<br />
'''1999''' Researchers from Texas show that 12-lead ECGs transmitted via wireless technology to hand-held computers is feasible and can be interpreted reliably by cardiologists. <cite>Pettis</cite><br />
<br />
'''2000''' Physicians from the Mayo Clinic describe a new hereditary form of Short QT syndrome associated with syncope and sudden death, that they discovered in 1999. Several genes have since been implicated. <cite>Gussak</cite><br />
<br />
'''2005''' Danish cardiologists report the successful reduction in the time between onset of chest pain and primary angioplasty when the ECG of patients is transmitted wirelessly from ambulance to the cardiologist's handheld PDA (Personal Digital Assistant). The clinician can make an immediate decision to redirect patients to the catheter lab, saving time in transfers between hospital departments. <cite>Clemmensen</cite><br />
<br />
'''2008''' Dr. Haïssaguerre et al. study ECGs from patients with idiopathic ventricular fibrillation and find that patients with early repolarization on their ECG (elevation of the QRS-ST junction of at least 0.1 mV from baseline, which is usually considered a benign finding) is associated with a doubled risk of ICD (implantable cardioverter defibrillator) shock during follow up. <cite>Haiss</cite><br />
<br />
==External Links==<br />
*[http://www.ecglibrary.com/ecghist.html ECG history on ECGlibrary.com]<br />
*[http://www.hrsonline.org/News/ep-history/timeline/ History of electrophysiology on the website of the Heart Rhythm Society]<br />
<br />
==References==<br />
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#Gussak pmid=11173780<br />
#Clemmensen pmid=16226101<br />
#Vulpian Vulpian A. 1874. ''Notes sur les éffets de la faradisation directe des ventricules du coeur chez le chien.'' Arch. Physiol. Norm. Path. 6: 975– 82 <br />
#Abildgaard Abildgaard, Peter Christian. ''Tentamina electrica in animalibus.'' Inst Soc Med Havn. 1775; 2:157-61. <br />
#Ader Ader C. ''Sur un nouvel appareil enregistreur pour cables sous-marins.'' C R Acad Sci (Paris) 1897;124:1440-1442 <br />
#Prevost Prevost JL, Batelli F: ''Sur quelques effets des descharges electriques sur le coeur des mammiferes.'' Acad. Sci. Paris, FR.: 1899; 129:1267-1268. <br />
#Holter Holter NJ, Generelli JA. ''Remote recording of physiologic data by radio.'' Rocky Mountain Med J. 1949;747-751.<br />
#Ernstine Ernstine AC, Levine SA. ''A comparison of records taken with the Einthoven string galvanomter and the amplifier-type electrocardiograph.'' Am Heart J 1928;4:725-731 <br />
#Dubois Du Bois-Reymond, E. ''Untersuchungen über thierische Elektricität''. Reimer, Berlin: 1848.<br />
#Waller Waller AD. ''A demonstration on man of electromotive changes accompanying the heart's beat.'' J Physiol (London) 1887;8:229-234 <br />
#Waller2 Waller AD. ''Introductory Address on The Electromotive Properties of the Human Heart''. Brit. Med J, 1888;2:751-754<br />
#Burch Burch GJ. ''On a method of determining the value of rapid variations of a difference potential by means of a capillary electrometer.'' Proc R Soc Lond (Biol) 1890;48:89-93<br />
#Chauveau Chauveau MA. ''De La Dissociation Du Rythme Auriculaire et du Rythme Ventriculaire.'' Rev. de Méd. Tome V. - Mars 1885: 161-173.<br />
#Hoffa Hoffa M, Ludwig C. 1850. ''Einige neue versuche uber herzbewegung''. Zeitschrift Rationelle Medizin, 9: 107-144<br />
#Waller Waller AD. ''A demonstration on man of electromotive changes accompanying the heart's beat.'' J Physiol (London) 1887;8:229-234<br />
#Wood Wood FC, Wolferth CC, Livezey MM. ''Angina pectoris.'' Archives Internal Medicine 1931;47:339 <br />
#Pardee Pardee HEB. ''An electrocardiographic sign of coronary artery obstruction.'' Arch Int Med 1920;26:244-257 <br />
#Sanders Sanders, A.O. ''Coronary thrombosis with complete heart block and relative ventricular tachycardia: a case report,'' American Heart Journal 1930;6:820-823. <br />
#Einthoven Einthoven W. ''Le telecardiogramme''. Arch Int de Physiol 1906;4:132-164<br />
#Einthoven2 Einthoven W. ''Über die Form des menschlichen Electrocardiogramms''. Pfügers Archiv march 1895, p 101-123<br />
#Einthoven3 Einthoven W. ''Un nouveau galvanometre.'' Arch Neerl Sc Ex Nat 1901;6:625-633 <br />
#Einthoven4 Einthoven W. ''Galvanometrische registratie van het menschilijk electrocardiogram. In: Herinneringsbundel Professor S. S. Rosenstein.'' Leiden: Eduard Ijdo, 1902:101-107 <br />
#Prinzmetal pmid=14434946<br />
#Marey Marey EJ. ''Des variations electriques des muscles et du couer en particulier etudies au moyen de l'electrometre de M <br />
Lippman.'' Compres Rendus Hebdomadaires des Seances de l'Acadamie des sciences 1876;82:975-977 <br />
#Gouaux Gouaux JL, Ashman R. ''Auricular fibrillation with aberration simulating ventricular paroxysmal tachycardia.'' Am Heart J 1947;34:366-73. <br />
#Marquez pmid=12177632<br />
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#Gilbert Gilbert W. ''De Magnete, magneticisique corporibus, et de magno magnete tellure.'' 1600<br />
#Browne Browne, Sir Thomas. Pseudodoxia Epidemica: Or, enquiries Into Very Many Received Tenents, and Commonly Presumed Truths. 1646: Bk II, Ch. 1. London<br />
#Descartes Descartes R. De Homine (Treatise of Man); 1662: Moyardum & leffen, Leiden.<br />
#Bancroft Bancroft, E. ''An essay on the natural history of Guiana'', London:T. Becket and P. A. de Hondt, 1769.<br />
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#Wilson Wilson NF, Johnston FE, Macleod AG, Barker PS. ''Electrocardiograms that represent the potential variations of a single electrode.'' Am Heart J. 1934;9:447-458.<br />
#Sokolow pmid=18107386<br />
#Hyman Hyman AS. ''Resuscitation of the stopped heart by intracardial therapy.'' Arch Intern Med. 1932;50:283<br />
#Lewis Lewis T. ''Auricular fibrillation: a common clinical condition.'' BMJ 1909;42:1528.<br />
#Hay Hay J. ''Bradycardia and cardiac arrhythmias produced by depression of certain functions of the heart.'' Lancet 1906;1:138-143. <br />
#Bousfield Bousfield G. ''Angina pectoris: changes in electrocardiogram during paroxysm.'' Lancet 1918;2:475 <br />
#Mann Mann H. ''A method of analyzing the electrocardiogram.'' Arch Int Med 1920;25:283-294 <br />
#McGinn McGinn S, White PD. ''Acute cor pulmonale resulting from pulmonary embolism: its clinical recognition.'' JAMA 1935;114:1473.<br />
#Bigelow pmid=15433219<br />
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#Beck Beck CS, Pritchard WH, Feil SA: ''Ventricular fibrillation of long duration abolished by electric shock.'' JAMA 1947; 135: 985-989.<br />
#Wiggers Wiggers CJ, Wegria R. ''Ventricular fibrillation due to single localized induction in condenser shock supplied during the vulnerable phase of ventricular systole.'' Am J Physiol 1939;128:500 <br />
#Haiss pmid=1846337<br />
#McWilliam1 pmid=16991467<br />
#McWilliam2 McWilliam JA. ''Electrical stimulation of the heart in man.'' 1889. Br. Med. J. 1: 348 <br />
#Lewis Levy AG, Lewis T. ''Heart irregularities, resulting from the inhalation of low percentages of chloroform vapour, and their relationship to ventricular fibrillation.'' 1911. Heart 3: 99– 112 <br />
#Hoffman Hoffman A. ''Fibrillation of ventricles at the end of an attack of paroxysmal tachycardia in man''. 1912. Heart 3: 213– 18 <br />
#Bayliss1 Bayliss WM, Starling EH. ''On the electrical variations of the heart in man.'' Proc Phys Soc (14th November) in J Physiol (London) 1891;13:lviii-lix <br />
#Bayliss2 Bayliss WM, Starling EH. ''On the electromotive phenomena of the mammalian heart.'' Proc R Soc Lond 1892;50:211-214<br />
#Matteucci Matteucci C. ''Sur un phenomene physiologique produit par les muscles en contraction.'' Ann Chim Phys 1842;6:339-341<br />
#Bird Bird G. ''Lectures on Electricity and Galvanism, in their physiological and therapeutical relations, delivered at the Royal College of Physicians,'' in March, 1847 (Wilson & Ogilvy, London, 1847) <br />
#Walsh Walsh, J. ''On the electric property of torpedo:'' in a letter to Ben. Franklin. Phil. Trans. Royal Soc. 1773;63:478-489<br />
#Hoffa Hoffa M, Ludwig C. 1850. ''Einige neue versuche uber herzbewegung''. Zeitschrift Rationelle Medizin, 9: 107-144 <br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=A_Concise_History_of_the_ECG&diff=9975
A Concise History of the ECG
2010-01-27T01:27:51Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= Dr Dean Jenkins & Dr. Stephen Gerred<br />
|moderator= [[user:Drj|J.S.S.G. de Jong]]<br />
|supervisor= <br />
}}<br />
<br />
{| class="wikitable"<br />
|This overview has been adapted from Dean Jenkins's and Stephen Gerred's [http://www.ecglibrary.com ECGlibary.com], for which they are gratefully acknowledged.<br />
|}<br />
<br />
The history of the ECG goes back more than one and a half centuries. <br />
==1600 - 1800==<br />
'''1600.''' William Gilbert, Physician to Queen Elizabeth I, President of the Royal College of Physicians and creator of the 'magnetic philosophy', introduces the term 'electrica' for objects (insulators) that hold static electricity. He derives the word from the Greek for amber (electra). It has been known from ancient times that amber when rubbed could lift light materials. Gilbert adds other examples such as sulphur and describes what will later be known as 'static electricity' to distinguish it from the more noble magnetic force. He sees his ideas as part of a philosophy to replace forever the prevailing Aristotlean view of matter. <cite>Gilbert</cite><br />
<br />
'''1649.''' Sir Thomas Browne, Physician, while writing to dispel popular ignorance in many subjects, is the first to use the word 'electricity'. Browne calls the attractive force "Electricity, that is, a power to attract strawes or light bodies, and convert the needle freely placed". (He is also the first to use the word 'computer' - referring to people who compute calendars.)<cite>Browne</cite><br />
<br />
'''1660'''. Otto Von Guericke builds the first static electricity generator.<br />
<br />
'''1662'''. The work of Rene Descartes, French Philosopher, is published (posthumously) and explains human movement in terms of a complex mechanical interaction of threads, pores, passages and 'animal spirits'. He has worked on his ideas in the 1630s but did not publish because of the persecution of other radical thinkers such as Galileo. William Harvey developed similar ideas but they were never published. <cite>Descartes</cite><br />
<br />
[[Image:Jan_Swammerdam.jpg|thumb|150px|left|Jan Swammerdam]]'''1664'''. Jan Swammerdam, a Dutchman, disproves Descartes' mechanistic theory of animal motion by removing the heart of a living frog and showing that the frog is still able to swim. When the brain is removed all movement stops (which could be in keeping with Descarte's theory) but then, when the frog is dissected and a severed nerve end stimulated with a scalpel, the muscles twitch. This proves that movement of a muscle can occur without any connection to the brain.Therefore the transmission of 'animal spirits' is not necessary.<br />
<br />
Swammerdam's ideas are not widely known and his work is not published until after his death. However, he writes many letters and his friend, Nicolaus Steno, attacks Cartesian ideas in a lecture in Paris in 1665. Boerhaave publishes Swammerdam's 'Book of Nature' in the 1730s.It is translated into English in 1758.<br />
<br />
'''1668''' Swammerdam refines his experiments on muscle contraction and nerve conduction. He demonstrates some of his work to notable figures such as the Grand-Duke Cosimo of Tuscany when the Grand Duke visits Swammerdam's father's house on the Oude Schans in Amsterdam. In one experiment he suspends a muscle on a brass hook inside a glass tube with a water droplet, to detect movement, and 'irritates' the nerve with a silver wire. This produces movement of the muscle, which may be due to the induction of a small electrical charge - although Swammerdam is unaware of this.<br />
<br />
'''1729''' Stephen Gray, English scientist, distinguishes between conductors and insulators of electricity. He demonstrates the transfer of static electrical charge to a cork ball across 150 meters of wet hemp thread. Later he finds that the transfer can be achieved over greater distances through brass wire. <br />
<br />
[[Image:Leyden_Jar.png|thumb|100px|A Leyden Jar]]'''1745''' Dutch physicist Pieter van Musschenbroek discovers that a partly filled jar with a nail projecting from a cork in its neck can store an electrical charge. The jar is named the 'Leyden Jar' after the place of its discovery. Ewald Georg von Kliest of Pomerania invents the same device independently.<br />
<br />
Using a Leyden jar in 1746, Jean-Antoine Nollet, French physicist and tutor to the royal family of France, sends an electrical current through 180 Royal Guards during a demonstration for King Louis XV.<br />
<br />
'''1769''' Edward Bancroft, an American scientist, suggests that the 'shock' from the torpedo fish is electrical rather than mechanical in nature. He shows that the properties of the shock are similar to those from a Leyden jar in that it can be conducted or insulated with appropriate materials. The torpedo fish and other species are widely known to deliver shocks and are often used for therapeutic reasons. However, electrical theory at this time dictates that electricity will always flow through conductors and diffuse away from areas of high charge to areas of low charge. Since living tissues are known to be conductors, it is impossible to imagine how an imbalance of charge can exist within an animal. Therefore animals can not use electricity for nerve conduction - or to deliver shocks. Furthermore, 'water and electricity do not mix' so the idea of an 'electric fish' is generally not accepted. <cite>Bancroft</cite><br />
<br />
'''1773''' John Walsh, Fellow of the Royal Society and Member of Parliament, obtains a visible spark from the electric eel Electrophorus electricus. The eel is out of water, as it is not possible to produce the spark otherwise. Walsh uses thin strips of tin foil to demonstrate his technique to many colleagues and visitors at his house in London. Unfortunately, he never publishes his eel experiment, though he does win the Copley medal in 1774 and 1783 for his work. Walshes observations , and those of Bancroft before him, adds to the argument that some form of animal electricity. <cite>Walsh</cite><br />
<br />
'''1774''' The Rev. Mr Sowdon and Mr Hawes, apothecary, report on the surprising effects of electricity in a case report of recovery from sudden death published in the annual report of the newly founded Humane Society (now the Royal Humane Society). The Society develops from 'The Institution for Affording Immediate Relief to Persons Apparently Dead from Drowning'. It is "instituted in the year 1774, to protect the industrious from the fatal consequences of unforseen accidents; the young and inexperienced from being sacrificed to their recreations; and the unhappy victims of desponding melancholy and deliberate suicide from the miserable consequences of self-destruction."<br />
<br />
A Mr Squires, of Wardour Street, Soho, lives opposite the house from which a three year old girl, Catherine Sophia Greenhill falls from a first story window on 16th July 1774. After the attending apothecary declares that nothing could be done for the child, Mr Squires, "with the consent of the parents very humanely tried the effects of electricity. At least twenty minutes had elapsed before he could apply the shock, which he gave to various parts of the body without any apparent success; but at length, upon transmitting a few shocks through the thorax, he perceived a small pulsation: soon after the child began to sigh, and to breathe, though with great difficulty. In about ten minutes she vomited: a kind of stupor, occasioned by the depression of the cranium, remained for some days, but proper means being used, the child was restored to perfect health and spirits in about a week.<br />
<br />
"Mr. Squires gave this astonishing case of recovery to the above gentlemen, from no other motive than a desire of promoting the good of mankind; and hopes for the future that no person will be given up for dead, till various means have been used for their recovery."<br />
<br />
Since it is clear she sustained a head injury, the electricity probably stimulated the child out of deep coma rather than providing cardiac defibrillation (see also 1788, Charles Kite). Annual Report 1774: Humane Society, London. pp 31-32 <br />
<br />
'''1775''' Abildgaard shows that hens can be made lifeless with electrical impulses and he can restore a pulse with electrical shocks across the chest. "With a shock to the head, the animal was rendered lifeless, and arose with a second shock to the chest; however, after the experiment was repeated rather often, the hen was completely stunned, walked with some difficulty, and did not eat for a day and night; then later it was very well and even laid an egg." <cite>Abildgaard</cite><br />
<br />
'''1786''' [[Image:Luigi_Galvani_oil-painting.jpg|thumb|150px|left|Italian Anatomist '''Luigi Galvani''']]Italian Anatomist '''Luigi Galvani''' notes that a dissected frog's leg twitches when touched with a metal scalpel. He has been studying the effects of electricity on animal tissues this summer.<br />
<br />
[[Image:Galvani_experiment.jpg|thumb|150px|Luigi Galvani's frog leg]]On 20th September 1786 he wrote, "I had dissected and prepared a frog in the usual way and while I was attending to something else I laid it on a table on which stood an electrical machine at some distance from its conductor and separated from it by a considerable space. Now when one of the persons present touched accidentally and lightly the inner crural nerves of the frog with the point of a scalpel, all the muscles of the legs seemed to contract again and again as if they were affected by powerful cramps."<br />
<br />
He later shows that direct contact with the electrical generator or the ground through an electrical conductor leads to a muscle contraction. Galvani also uses brass hooks attached to the frog's spinal cord and suspended from an iron railing in a part of his garden. He notices that the frogs' legs twitch during lightening storms and when the weather is fine. He interprets these results in terms of "animal electricity" or the preservation in the animal of "nerveo-electrical fluid" similar to that of an electric eel. He later also shows that electrical stimulation of a frog's heart leads to cardiac muscular contraction. Galvani. De viribus Electritatis in motu musculari Commentarius. 1791<br />
<br />
Galvani's name is given to the 'galvanometer', an instrument for measuring (and recording) electricity - this is essentially what an ECG is; a sensitive galvanometer.<br />
<br />
'''1788''' Charles Kite wins the Silver Medal of the Humane Society (awarded at the first prize medal ceremony of the Society, co-judged with the Medical Society of London) with an essay on the use of electricity in the diagnosis and resuscitation of persons apparently dead. This essay is often cited as the first record of cardiac defibrillation, but the use of electricity suggested by Mr Kite is much different. For example, on describing a case of drowning from 1785, in which resuscitation was attempted with artificial respiration, warmth, tobacco, "volatiles thrown into the stomach, frictions, and various lesser stimuli" for nearly an hour, he then recalls the use of electricity. "Electricity was then applied, and shocks sent through in every possible direction; the muscles through which the fluid [electricity] passed were thrown into strong contractions." He concludes that electricity is a valuable tool that can be used to resuscitate a person who appeared dead. Annual Report 1788: Humane Society, London. pp 225-244. Kite C. An Essay on the Recovery of the Apparently Dead. 1788: C. Dilly, London. <br />
<br />
[[Image:Alessandro_Volta.jpg|150px|thumb|left|Alessandro Volta]]'''1792''' Alessandro Volta, Italian Scientist and inventor, attempts to disprove Galvani's theory of "animal electricity'" by showing that electrical current is generated by the combination of two dissimilar metals. [[Image:Voltaic_Pile.jpg|150px|thumb|Voltaic pile]]His assertion is that the electrical current comes from metals and not animal tissues. (We now know that both Galvani and Volta were right.) To prove his theory he develops the voltaic pile in 1800 (a column of alternating metal discs - zinc with copper or silver - separated by paperboard soaked in saline) which can deliver a substantial and steady current of electricity. Enthusiasm in the use of electricity leads to further attempts at reanimation of the dead with experiments on recently hanged criminals. Giovani Aldini (the nephew of Galvani) conducts an experiment at the Royal College of Surgeons in London in 1803. The executed criminal has lain in a temperature of 30 degrees F for one hour and is transported to the College. "On applying the conductors to the ear and to the rectum, such violent muscular contractions were executed, as almost to give the appearance of the reanimation". Aldini, J. Essai: Théorique et expérimental sur le Galvanisme, Paris (1804), Giovani Aldini. General Views on the Application of Galvanism to Medical Purposes Principally in cases of suspended Animation (London: J. Callow, Princes Street and Burgess and Hill, Great Windmill Street, 1819). Mary Shelly's Frankenstein is published in 1818. Louis Figuier, Les merveilles de la Science (Paris, 1867), p.653<br />
<br />
{{clr}}<br />
<br />
==1800 - 1895==<br />
'''1819''' While demonstrating to students the heating of a platinum wire with electricity from a voltaic pile at the University of Copenhagen, Danish physicist Hans Christian Oersted notices that a nearby magnetized compass needle moves each time the electrical current is applied. He discovers electromagnetism, which is given a theoretical basis (with remarkable speed) by André Marie Ampère. <br />
<br />
'''1820''' Johann (Johan) Schweigger of Nuremberg increases the movement of magnetized needles in electromagnetic fields. He finds that wrapping the electric wire into a coil of 100 turns multiplies the effect on the needle. He proposes that a magnetic field revolved around a wire carrying a current. This was later proven by Michael Faraday. Schweigger announces his discovery at the University of Halle on 16th September 1820. <br />
<br />
'''1825''' Leopold Nobili, Professor of Physics at Florence, develops an 'astatic galvanometer'. Using two identical magnetic needles of opposite polarity, either fixed together with a figure of eight arrangement of wire loops (in earlier versions), or one movable needle with a wire loop and one with a scale (in later versions), Nobili is able to compensate for the effects of the earth's magnetic field. In 1827, using this instrument, he manages to detect the flow of current in the body of a frog from muscles to spinal cord. He detects the electricity running along saline-moistened cotton thread joining the dissected frog's legs in one jar to its body in another jar. Nobili feels that this work proves the theory of animal electricity. <br />
<br />
[[Image:Matteucci.jpg|thumb|150px|left|Carlo Matteucci]]'''1838''' Carlo Matteucci, Professor of Physics at the University of Pisa, a student of Nobili, shows that an electric current accompanies each heart beat. He uses a preparation known as a 'rheoscopic frog', in which the cut nerve of a frog's leg is used as the electrical sensor and twitching of the muscle is used as the visual sign of electrical activity. He also uses Nobili's astatic galvanometer for the study of electricity in muscles, typically inserting one galvanometer wire into the open end of the dissected muscle and the other onto the surface of the muscle. He goes on to try to demonstrate conduction in nerve, but is unable to do so (since his galvanometers are not sensitive enough). <cite>Matteucci</cite><br />
<br />
'''1840''' Dr Golding Bird, a physician, accomplished chemist and member of the London Electrical Society, opens an electrical therapy room at Guy's Hospital, London, treating a large range of diseases. Although the application of electricity is popular, it is not considered a subject worthy of serious investigation. Because of Bird's reputation as a researcher, electrical therapy achieves popularity among London physicians, including his mentor, Dr Thomas Addison. <cite>Bird</cite><br />
<br />
[[Image:Emil_Dubois.jpg|thumb|150px|left|Physiologist Emil Du Bois-Reymond]]'''1843''' German physiologist Emil Du Bois-Reymond describes an "action potential" accompanying each muscular contraction. He detects the small voltage potential present in resting muscle and notes that this diminishes with contraction of the muscle. To accomplish this he had develops one of the most sensitive galvanometers of his time. His device has a wire coil with over 24,000 turns - 5 km of wire. Du Bios Reymond devises a notation which he called the 'disturbance curve' for his galvanometer. "O" was the stable equilibrium point of the astatic galvanometer needle and p, q, r and s (and also k and h) were other points in its deflection. Du Bois-Reymond, E. Untersuchungen uber thierische Elektricitat. Reimer, Berlin: 1848.<br />
<br />
'''1850''' Bizarre unregulated actions of the ventricles (later called ventricular fibrillation) is described by Hoffa during experiments with strong electrical currents across the hearts of dogs and cats. He demonstrates that a single electrical pulse can induce fibrillation. <cite>Hoffa</cite><br />
<br />
'''1856''' Rudolph von Koelliker and Heinrich Muller confirm that an electrical current accompanies each heart beat by applying a galvanometer to the base and apex of an exposed ventricle. They also apply a nerve-muscle preparation, similar to Matteucci's, to the ventricle and observe that a twitch of the muscle occurs just prior to ventricular systole, followed by a much smaller twitch after systole. These twitches will later be recognized as caused by the electrical currents of the QRS and T waves. von Koelliker A, Muller H. Nachweis der negativen Schwankung des Muskelstroms am naturlich sich kontrahierenden Herzen. Verhandlungen der Physikalisch-Medizinischen Gesellschaft in Wurzberg. 1856;6:528-33. <br />
<br />
'''1858''' William Thompson (Lord Kelvin), professor of natural philosophy at Glasgow University, invents the 'mirror galvanometer' for the reception of transatlantic telegraph transmissions. A small, freely rotating mirror, with magnets stuck to its back, is suspended in a fine copper coil and a reflected spot of light from this mirror 'amplifies' small movements when electrical current is present. The whole apparatus is suspended in an air chamber and the pressure inside can be adjusted to vary the damping seen on the signals. This galvanometer is sensitive enough for transatlantic telegraphy.<br />
<br />
'''1867''' Thompson improves telegraph transmissions with the 'Siphon Recorder'. Before d'Arsonval (1880), Thompson uses a fine coil suspended in a strong magnetic magnetic field. Attached to the coil but isolated from it by ebonite (an insulator) is a siphon of ink. The siphon is charged with high voltage so that the ink is sprayed onto the paper, which moved over a metal surface. The siphon recorder could therefore not only detect currents; it could also record them onto paper.<br />
<br />
'''1869-70''' Alexander Muirhead, an electrical engineer and pioneer of telegraphy, possibly records a human electrocardiogram at St Bartholomew's Hospital, London but this is disputed. He is thought to have used a Thompson Siphon Recorder. Elizabeth Muirhead, his wife, writes a book of his life, claiming that he refrained from publishing his own work for fear of misleading others. Elizabeth Muirhead. Alexander Muirhead 1848 - 1920. Oxford, Blackwell: privately printed 1926.<br />
<br />
'''1872''' French physicist Gabriel Lippmann invents a capillary electrometer. It is a thin glass tube with a column of mercury beneath sulphuric acid. The mercury meniscus moves with varying electrical potential and is observed through a microscope.<br />
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'''1872''' Mr Green, a surgeon, publishes a paper on the resuscitation of a series of patients who suffered cardiac and/or respiratory arrest during anaesthesia with chloroform. He uses a galvanic pile (battery) of 200 cells generating 300 Volts, which he applies to the patient as follows "One pole should be applied to the neck and the other to the lower rib on the left side." Green T. On death from chloroform: its prevention by galvanism. Br Med J 1872 1: 551-3. Although this has been reported as an example of cardiorespiratory resuscitation, it is unclear what the exact mechanism seems to be. It is unlikely to be electric cardioversion or external pacing. It seems to be another example of electrophrenic stimulation (See also Duchenne 1872).<br />
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[[image:Duchenne_de_belogne.jpg|thumb|150px|left|Guillaume Benjamin Amand Duchenne de Boulogne]]'''1872''' Guillaume Benjamin Amand Duchenne de Boulogne, pioneering neurophysiologist, describes the resuscitation of a drowned girl with electricity in the third edition of his textbook on the medical uses of electricity. This episode has sometimes been described as the first 'artificial pacemaker' but he used an electrical current to induce electrophrenic rather than myocardial stimulation. Duchenne GB. De l'electrisation localisee et de son application a la pathologie et la therapeutique par courants induits at par courants galvaniques interrompus et continus. [Localised electricity and its application to pathology and therapy by means of induced and galvanic currents, interrupted and continuous] 3ed. Paris. JB Bailliere et fils; 1872<br />
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'''1874''' A. Vulpian described ''mouvement fibrillaire'' in his article published in 1874, which would be the basis for the name ventricular fibrillation now used for this arrhythmia.<cite>Vulpian</cite><br />
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'''1875''' Richard Caton, a Liverpool physician, presents to the British Medical Association in July 1875 in Edinburgh. Using a Thompson 'mirror galvanometer' in animals he shows it is possible to detect 'feeble currents of varying direction ... when the electrodes are placed on two points of the external surface, or one electrode on the grey matter and one on the surface of the skull'. This is the first report of the EEG (or electroencephalogram). Caton was proving another Physician's hypothesis, John Hughlings Jackson, who suggested in 1873 that epilepsy was due to excessive electrical activity in the grey matter of the brain. Caton R: The electric currents of the brain. BMJ 1875; 2:278, Mumenthaler, Mattle Eds. Neurology. 4th Edition. Stuttgart, Thieme: 2004.<br />
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'''1876''' Marey uses the electrometer to record the electrical activity of an exposed frog's heart. Marey EJ. Des variations electriques des muscles et du couer en particulier etudies au moyen de l'electrometre de M Lippman. Compres Rendus Hebdomadaires des Seances de l'Acadamie des sciences 1876;82:975-977<br />
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'''1878''' British physiologists John Burden Sanderson and Frederick Page record the heart's electrical current with a capillary electrometer and shows it consists of two phases (later called QRS and T). Burdon Sanderson J. Experimental results relating to the rhythmical and excitatory motions of the ventricle of the frog. Proc R Soc Lond 1878;27:410-414<br />
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'''1880''' French physicist Arsène d'Arsonval in association with Marcel Deprez, improves the galvanometer. Instead of a magnetized needle moving when electrical current flows through a surrounding wire coil the Deprez-d'Arsonval galvanometer has a fixed magnet and moveable coil. If a pointer is attached to the coil it can move over a suitably calibrated scale. The d'Arsonval galvanometer is the basis for most modern galvanometers. Comptes rendus de l'Académie des sciences, 1882, 94: 1347-1350 <br />
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'''1884''' John Burden Sanderson and Frederick Page publish some of their recordings. Burdon Sanderson J, Page FJM. On the electrical phenomena of the excitatory process in the heart of the tortoise, as investigated photographically. J Physiol (London) 1884;4:327-338<br />
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[[image:Waller.jpg|thumb|150px|left|A.D. Waller with his famous bulldog Jimmy]]'''1887''' British physiologist Augustus D. Waller of St Mary's Medical School, London publishes the first human electrocardiogram. It is recorded with a capilliary electrometer from Thomas Goswell, a technician in the laboratory. <cite>Waller</cite> This is shortly after the "Cruelty to Animals Act" is accepted in the British parliament, which leads to questions in the House of Commons.<br />
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Q. 'At a converzaione [sic] of the Royal Society at Burlington House on May 12th last, a bulldog was cruelly treated when a leather strap with sharp nails was wound around his neck and his feet were immersed in glass jars containing salts in solution, and the jars in turn were connected with wires to galvanometers. Such a cruel procedure should surely be dealt with under the "Cruelty to Animals Act" of 1876?'<br />
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A. 'The dog in question wore a leather collar ornamented with brass studs, and he was placed to stand in water to which some sodium chloride had been added, or in other words, common salt. If my honourable friend had ever paddled in the sea, he will appreciate fully the sensation obtained thereby from this simple pleasurable experience!'<br />
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'''1887''' McWilliam provides the first detailed description of VF, and demonstrated how VF in man can be terminated by electric shocks applied through a large pair of electrodes; the first description of defibrillation in man.<cite>McWilliam1</cite><cite>McWilliam2</cite><br />
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'''1889''' Dutch physiologist Willem Einthoven sees Waller demonstrate his technique at the First International Congress of Physiologists in Bale. Waller often demonstrated by using his dog "Jimmy" who would patiently stand with paws in glass jars of saline.<br />
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'''1890''' GJ Burch of Oxford devises an arithmetical correction for the observed (sluggish) fluctuations of the electrometer. This allows the true waveform to be seen, but only after tedious calculations. <cite>Burch</cite><br />
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'''1891''' British physiologists William Bayliss and Edward Starling of University College London improve the capillary electrometer. They connect the terminals to the right hand and to the skin over the apex beat and show a "triphasic variation accompanying (or rather preceding) each beat of the heart". These deflections are later called P, QRS and T. <cite>Bayliss1</cite> and <cite>Bayliss2</cite> They also demonstrate a delay of about 0.13 seconds between atrial stimulation and ventricular depolarisation (later called PR interval). On the electromotive phenomena of the mammalian heart. Proc Phys Soc (21st March) in J Physiol (London) 1891;12:xx-xxi <br />
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'''1893''' Willem Einthoven introduces the term 'electrocardiogram' at a meeting of the Dutch Medical Association. (Later he claims that Waller was first to use the term). Einthoven W: Nieuwe methoden voor clinisch onderzoek [New methods for clinical investigation]. Ned T Geneesk 29 II: 263-286, 1893<br />
{{clr}}<br />
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==1895 - 1949==<br />
[[image:Einthoven_portrait.jpg|thumb|150px|left|Willem Einthoven]][[Image:Einthoven_ECG3.jpg|thumb|150px|ECG recordings as registered by Einthoven]][[Image:einthoven.jpg|150px|left|thumb|Willem Einthoven]][[image:Einthoven_ECG2.jpg|thumb|150px|right|Einthoven's ECG recording including putting the patients feet in baths filled with saline to improve electrical conduction]][[Image:Einthoven_ECG.jpg|thumb|150px|An electrocardiograph as used by Einthoven]]<br />
'''1895''' Einthoven, using an improved electrometer and a correction formula developed independently of Burch, distinguishes five deflections which he names P, Q, R, S and T. <cite>Einthoven2</cite><br />
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Why PQRST and not ABCDE? The four deflections prior to the correction formula are labeled ABCD and the 5 derived deflections are labeled PQRST. The choice of P is a mathematical convention (as used also by Du Bois-Reymond in his galvanometer's 'disturbance curve' 50 years previously) by using letters from the second half of the alphabet. N has other meanings in mathematics and O is used for the origin of the Cartesian coordinates. In fact Einthoven uses O ..... X to mark the time line on his diagrams. P is simply the next letter. A lot of work has been undertaken to reveal the true electrical waveform of the ECG by eliminating the damping effect of the moving parts in the amplifiers and using correction formulae. If you look at the diagram in Einthoven's 1895 paper you will see how close it is to the string galvanometer recordings and the electrocardiograms we see today. The image of the PQRST diagram may be striking enough to be adopted by the researchers as a true representation of the underlying form. It would then be logical to continue the same naming convention when the more advanced string galvanometer starts creating electrocardiograms a few years later. <br />
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'''1897''' Clement Ader, a French electrical engineer, reports his amplification system for detecting Morse code signals transmitted along undersea telegraph lines. It is never intended to be used as a galvanometer. Einthoven later quotes Ader's work but seems to have developed his own amplification device independently. <cite>Ader</cite><br />
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'''1899''' Karel Frederik Wenckebach publishes a paper "On the analysis of irregular pulses" describing impairment of AV conduction leading to progressive lengthening and blockage of AV conduction in frogs. This will later be called Wenckebach block (Mobitz type I) or Wenckebach phenomenon.<br />
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'''1899''' Jean-Louis Prevost, Professor of Biochemistry, and Frederic Batelli, Professor of Physiology, both of Geneva, discover that large electrical voltages applied across an animal's heart can stop ventricular fibrillation. <cite>Prevost</cite><br />
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'''1901''' Einthoven invents a new galvanometer for producing electrocardiograms using a fine quartz string coated in silver, based on ideas by Deprez and d'Arsonval (who used a wire coil). His "string galvanometer" weighs 600 pounds. Einthoven acknowledges the similar system by Ader but later (1909) calculates that his galvanometer is in fact many thousands of times more sensitive. <cite>Einthoven3</cite><br />
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'''1902''' Einthoven publishes the first electrocardiogram recorded on a string galvanometer. <cite>Einthoven4</cite><br />
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'''1903''' Einthoven discusses commercial production of a string galvanometer with Max Edelmann of Munich and Horace Darwin of Cambridge Scientific Instruments Company of London. <br />
1905<br />
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Einthoven starts transmitting electrocardiograms from the hospital to his laboratory 1.5 km away via telephone cables. On March 22nd the first 'telecardiogram' is recorded from a healthy and vigorous man and the tall R waves are attributed to his cycling from laboratory to hospital for the recording.<br />
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'''1905''' John Hay, of Liverpool, publishes pressure recordings from a 65 year old man. The recording shows heart block in which AV conduction does not seem to be impaired, since the a-c intervals on the jugular venous waves is unchanged in the conducted beats. This is the first demonstration of what we now call Mobitz type II AV block. <cite>Hay</cite><br />
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'''1906''' Einthoven publishes the first organised presentation of normal and abnormal electrocardiograms recorded with a string galvanometer. Left and right ventricular hypertrophy, left and right atrial hypertrophy, the U wave (for the first time), notching of the QRS, ventricular premature beats, ventricular bigeminy, atrial flutter and complete heart block are all described. Einthoven W. Le telecardiogramme. Arch Int de Physiol 1906;4:132-164 (translated into English. Am Heart J 1957;53:602-615) <br />
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'''1906''' Cremer records the first oesophageal electrocardiogram which he achieved with the help of a professional sword swallower. Oesophageal electrocardiography later developed in the 1970s to help differentiate atrial arrhythmias. He also records the first fetal electrocardiogram from the abdominal surface of a pregnant woman. Cremer. Ueber die direkte Ableitung der Aktionströme des menslichen Herzens vom Oesophagus und über das Elektrokardiogramm des Fötus. Munch. Med. Wochenschr. 1906;53:811 <br />
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'''1907''' Arthur Cushny, professor of pharmacology at University College London, publishes the first case report of atrial fibrillation. His patient was 3 days post-op following surgery on an "ovarian fibroid" when she developed a "very irregular" pulse at a rate of 120 - 160 bpm. Her pulse was recorded with a "Jacques sphygmochronograph" which shows the radial pulse pressure against time - much like the arterial line blood pressure recordings used in Intensive Care today. Cushny AR, Edmunds CW. Paroxysmal irregularity of the heart and auricular fibrillation. Am J Med Sci 1907;133:66-77. <br />
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'''1908''' Edward Schafer of the University of Edinburgh is the first to buy a string galvanometer for clinical use. <br />
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'''1909''' Thomas Lewis, of University College Hospital, London, buys a string galvanometer and so does Alfred Cohn of Mt Sinae Hospital, New York. Thomas Lewis publishes a paper in the BMJ detailing his careful clinical and electrocardiographic observations of atrial fibrillation. At one point Lewis identifies a fibrillating horse's heart using the string galvanometer's electrocardigram recording. He then followed the horse to the slaughterhouse, where he could visually confirm the fibrillating atrium. <cite>Lewis</cite><br />
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'''1909''' Nicolai and Simmons report on the changes to the electrocardiogram during angina pectoris. Nicolai DF, Simons A. (1909) Zur klinik des elektrokardiogramms. Med Kiln 5;160<br />
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'''1910''' Walter James, Columbia University and Horatio Williams, Cornell University Medical College, New York, publish the first American review of electrocardiography. It describes ventricular hypertrophy, atrial and ventricular ectopics, atrial fibrillation and ventricular fibrillation. The recordings were sent from the wards to the electrocardiogram room by a system of cables. There is a great picture of a patient having an electrocardiogram recorded with the caption "The electrodes in use".James WB, Williams HB. The electrocardiogram in clinical medicine. Am J Med Sci 1910;140:408-421, 644-669<br />
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'''1911''' Levy & Lewis demonstrate that when VF occurred during chloroform anesthesia, it was often preceded by the appearance of multiform ventricular premature beats or ventricular tachycardia.<cite>Lewis</cite><br />
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Thomas Lewis publishes a classic textbook. The mechanism of the heart beat. London: Shaw & Sons and dedicates it to Willem Einthoven.<br />
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'''1912''' Einthoven addresses the Chelsea Clinical Society in London and describes an equilateral triangle formed by his standard leads I, II and III later called 'Einthoven's triangle'. This is the first reference in an English article to the abbreviation 'EKG' that I have seen.Einthoven W. The different forms of the human electrocardiogram and their signification. Lancet 1912(1):853-861 <br />
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Hoffman published the first ECG of ventricular fibrillation in man.<cite>Hoffman</cite><br />
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'''1918''' Bousfield describes the spontaneous changes in the electrocardiogram during angina. <cite>Bousfield</cite><br />
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'''1920''' Hubert Mann of the Cardiographic Laboratory, Mount Sinai Hospital, describes the derivation of a 'monocardiogram', later to be called 'vectorcardiogram'. <cite>Mann</cite><br />
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'''1920''' Harold Pardee, New York, publishes the first electrocardiogram of an acute myocardial infarction in a human and describes the T wave as being tall and "starts from a point well up on the descent of the R wave". <cite>Pardee</cite><br />
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'''1924''' Willem Einthoven wins the Nobel prize for inventing the electrocardiograph. <br />
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'''1924''' Woldemar Mobitz publishes his classification of heart blocks (Mobitz type I and type II) based on the electrocardiogram and jugular venous pulse waveform findings in patients with second degree heart block. Mobitz W. Uber die unvollstandige Storung der Erregungsuberleitung zwischen Vorhof und Kammer des menschlichen Herzens. (Concerning partial block of conduction between the atria and ventricles of the human heart). Z Ges Exp Med 1924;41:180-237. <br />
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'''1926''' A doctor from the Crown Street Women's Hospital in Sydney, who wishes to remain anonymous, resuscitates a new-born baby with an electrical device later called a 'pacemaker'. The doctor wants to remain anoymous because of the controversy surrounding research that artificially extends human life. <br />
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'''1928''' Ernstine and Levine report the use of vacuum tubes to amplify the electrocardiogram instead of the mechanical amplification of the string galvanometer. <cite>Ernstine</cite> <br />
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'''1928''' Frank Sanborn's company (founded 1917 and acquired by Hewlett-Packard in 1961 and since 1999, Philips Medical Systems) converts their table model electrocardiogram machine into their first portable version weighing 50 pounds and powered by a 6-volt automobile battery.<br />
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'''1929''' Sydney doctor Mark Lidwill, physician, and Edgar Booth, physicist, report the electrical resuscitation of the heart to a meeting in Sydney. Their portable device uses an electrode on the skin and a transthoracic catheter. Edgar Booth's design could deliver a variable voltage and rate and is employed to deliver 16 volts to the ventricles of a stillborn infant. <br />
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[[image:White_stamp.gif|thumb|150px|left|Dr. Paul Dudley White]]'''1930''' Wolff, Parkinson and White report an electrocardiographic syndrome of short PR interval, wide QRS and paroxysmal tachycardias. Wolff L, Parkinson J, White PD. Bundle branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia. Am Heart J 1930;5:685. Later, when other published case reports are examined for evidence of pre-excitation,earlier examples of 'Wolff Parkinson White' syndrome, which were not recognized as a clinical entity at the time, are identified. The earliest example was published by Hoffmann in 1909. Von Knorre GH. The earliest published electrocardiogram showing ventricular preexcitation. Pacing Clin Electrophysiol. 2005 Mar;28(3):228-30<br />
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'''1930''' Sanders first describes infarction of the right ventricle. <cite>Sanders</cite><br />
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'''1931''' Charles Wolferth and Francis Wood describe the use of exercise to provoke attacks of angina pectoris. They investigate the ECG changes in normal subjects and those with angina, but dismissed the technique as too dangerous "to induce anginal attacks indiscriminately". <cite>Wood</cite><br />
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'''1931''' Dr Albert Hyman patents the first 'artificial cardiac pacemaker', which stimulates the heart by using a transthoracic needle. His aim is to produce a device that is small enough to fit in a doctor's bag and be able to stimulate the right atrial area of the heart with a suitably insulated needle. His experiments are on animals. His original machine was powered by a crankshaft (it is later prototyped by a German company but is never successful). "By March 1, 1932 the artificial pacemaker had been used about 43 times, with a successful outcome in 14 cases." It is not until 1942 that a report of its successful short term use in Stokes-Adams attacks is presented. <cite>Hyman</cite><br />
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'''1932''' Goldhammer and Scherf propose the use of the electrocardiogram after moderate exercise as an aid to the diagnosis of coronary insufficiency. Goldhammer S, Scherf D. Elektrokardiographische untersuchungen bei kranken mit angina pectoris. Z Klin Med 1932;122:134 <br />
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'''1932''' Charles Wolferth and Francis Wood describe the clinical use of chest leads. Wolferth CC, Wood FC. The electrocardiographic diagnosis of coronary occlusion by the use of chest leads. Am J Med Sci 1932;183:30-35 <br />
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'''1934''' By joining the wires from the right arm, left arm and left foot with 5000 Ohm resistors Frank Wilson defines an 'indifferent electrode' later called the 'Wilson Central Terminal'. The combined lead acts as an earth and is attached to the negative terminal of the ECG. An electrode attached to the positive terminal then becomes 'unipolar' and can be placed anywhere on the body. Wilson defines the unipolar limb leads VR, VL and VF where 'V' stands for voltage (the voltage seen at the site of the unipolar electrode). <cite>Wilson</cite> <br />
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'''1935''' McGinn and White describe the changes to the electrocardiogram during acute pulmonary embolism, including the S1 Q3 T3 pattern. <cite>McGinn</cite> <br />
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'''1938''' The American Heart Association and the Cardiac Society of Great Britain define the standard positions, and wiring, of the chest leads V1 - V6. The 'V' stands for voltage. Barnes AR, Pardee HEB, White PD. et al. Standardization of precordial leads. Am Heart J 1938;15:235-239 <br />
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'''1938''' Tomaszewski notes changes to the electrocardiogram in a man who died of hypothermia. Tomaszewski W. Changements electrocardiographiques observes chez un homme mort de froid. Arch Mal Coeur 1938;31:525. <br />
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'''1939''' Langendorf reports a case of atrial infarction discovered at autopsy which, in retrospect, could have been diagnosed by changes on the ECG. <cite>Langendorf</cite><br />
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'''1942''' Emanuel Goldberger increases the voltage of Wilson's unipolar leads by 50% and creates the augmented limb leads aVR, aVL and aVF. When added to Einthoven's three limb leads and the six chest leads we arrive at the 12-lead electrocardiogram that is used today. <br />
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'''1942''' Arthur Master standardizes the two step exercise test (now known as the Master two-step) for cardiac function. Master AM, Friedman R, Dack S. The electrocardiogram after standard exercise as a functional test of the heart. Am Heart J. 1942;24:777 <br />
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'''1944''' Young and Koenig report deviation of the P-R segment in a series of patients with atrial infarction. Young EW, Koenig BS. Auricular infarction. Am Heart J. 1944;28:287. <br />
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'''1947''' Gouaux and Ashman describe an observation that helps differentiate aberrant conduction from ventricular tachycardia. The 'Ashman phenomenon' occurs when a stimulus takes place during the relative or absolute refractory period of the ventricles and the aberrancy is more pronounced. In atrial fibrillation with aberrant conduction, this is demonstrated when the broader complexes are seen terminating a relatively short cycle that follows a relatively long one. The QRS terminating the shorter cycle is conducted 'more aberrantly' because it falls in the refractory period. The aberrancy is usually of a RBBB pattern. <cite>Gouaux</cite><br />
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'''1947''' Claude Beck, a pioneering cardiovascular surgeon in Cleveland, successfully defibrillates a human heart during cardiac surgery. The patient is a 14 year old boy - 6 other patients had failed to respond to the defibrillator. His prototype defibrillator followed experiments on defibrillation in animals performed by Carl J. Wiggers, Professor of Physiology at the Western Reserve University. <cite>Beck</cite><br />
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'''1948''' Rune Elmqvist, Swedish engineer who had trained as a doctor but never practiced, introduces the first ink jet printer for the transcription of analog physiological signals. He demonstrates its use in the recording of ECGs at the First International Congress of Cardiology in Paris in 1950. The machine (the mingograph) was developed by him at the company that later became Siemens. (Luderitz, 2002)<br />
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'''1949''' Montana physician Norman Jeff Holter develops a 75 pound backpack that can record the ECG of the wearer and transmit the signal. His system, the Holter Monitor, is later greatly reduced in size, combined with tape / digital recording and used to record ambulatory ECGs. <cite>Holter</cite><br />
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== 1950 - to date==<br />
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'''1949''' Sokolow and Lyon propose diagnostic criteria for left ventricular hypertrophy i.e. LVH is present if the sum of the size of the S wave in V1 plus the R wave in V6 exceeds 35 mm. <cite>Sokolow</cite><br />
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'''1950''' John Hopps, a Canadian electrical engineer and researcher for the National Research Council, together with two physicians (Wilfred Bigelow, MD of the University of Toronto and his trainee, John C. Callaghan, MD) show that a coordinated heart muscle contraction can be stimulated by an electrical impulse delivered to the sino-atrial node. The apparatus, the first cardiac pacemaker, measures 30cm, runs on vacuum tubes and is powered by household 60Hz electrical current. <cite>Bigelow</cite><br />
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'''1953''' Osborn, whilst experimenting with hypothermic dogs, describes the prominent J (junctional) wave which has often been known as the "Osborn wave". He found the dogs were more likely to survive if they had an infusion of bicarbonate and supposed the J wave was due to an injury current caused by acidosis. Osborn JJ. Experimental hypothermia: respiratory and blood pH changes in relation to cardiac function. Am J Physiol 1953;175:389. <br />
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'''1955''' Richard Langendorf publishes the "rule of bigeminy" whereby ventricular bigeminy tends to perpetuate itself. Langendorf R, Pick A, Winternitz M. Mechanisms of intermittent ventricular bigeminy. I. Appearence of ectopic beats dependent upon the length of the ventricular cycle, the "rule of bigeminy." circulation 1955;11:442. <br />
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[[image:Zoll_portrait.jpg|thumb|150px|left|Paul Zoll]]'''1956''' Paul Zoll, a cardiologist, uses a more powerful defibrillator and performs closed-chest defibrillation in a human. <cite>Zoll</cite><br />
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'''1957''' Anton Jervell and Fred Lange-Nielsen of Oslo describe an autosomal recessive syndrome of long-QT interval, deafness and sudden death later known as the Jervell-Lange-Nielsen syndrome. <cite>Jervell</cite><br />
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'''1958''' Professor Ake Senning, of Sweden, places the first implantable cardiac pacemaker designed by Rune Elmqvist into a 43-year-old patient with complete heart block and syncope (Arne Larsson).<br />
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'''1959''' Myron Prinzmetal describes a variant form of angina in which the ST segment is elevated rather than depressed. <cite>Prinzmetal</cite><br />
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'''1960''' Smirk and Palmer highlight the risk of sudden death from ventricular fibrillation particularly when ventricular premature beats occur at the same time as the T wave. The 'R on T' phenomenon. Smirk FH, Palmer DG. A myocardial syndrome, with particular reference to the occurrence of sudden death and of premature systoles interrupting antecedent T waves. Am J Cardiol 1960;6:620. <br />
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'''1963''' Italian paediatrician C. Romano and Irish paediatrician O. Conor Ward (the following year) independently report an autosomal dominant syndrome of long-QT interval later known as the Romano-Ward syndrome. <cite>Romano</cite><cite>Ward</cite><br />
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[[image:Bruce_portrait.jpg|thumb|150px|left|Robert Bruce]]'''1963''' Robert Bruce and colleages describe their multistage treadmill exercise test later known as the Bruce Protocol. "You would never buy a used car without taking it out for a drive and seeing how the engine performed while it was running," Bruce says, "and the same is true for evaluating the function of the heart." <cite>Bruce1</cite><cite>Bruce2</cite><br />
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'''1963''' Baule and McFee are the first to detect the magnetocardiogram which is the electromagnetic field produced by the electrical activity of the heart. It is a method that can detect the ECG without the use of skin electrodes. Although potentially a useful technique it has never gained clinical acceptance, partly because of its greater expense. <cite>Baule</cite><br />
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'''1966''' Mason and Likar modify the 12-lead ECG system for use during exercise testing. The right arm electrode is placed at a point in the infraclavicular fossa medial to the border of the deltoid muscle, 2 cm below the lower border of the clavicle. The left arm electrode is placed similarly on the left side. The left leg electrode is placed at the left iliac crest. Although this system reduces the variability in the ECG recording during exercise it is not exactly equivalent to the standard lead positions. The Mason-Likar lead system tends to distort the ECG with a rightward QRS axis shift, a reduction in R wave amplitude in lead I and aVL, and a significant increase in R wave amplitude in leads II, III and aVF. <cite>Papouchado</cite><br />
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'''1966''' François Dessertenne of Paris publishes the first case of '[[Torsade de pointes]]' Ventricular Tachycardia. <cite>Dessertenne</cite><br />
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'''1968''' Journal of Electrocardiography, the Official Journal of the International Society for Computerized Electrocardiology and the International Society of Electrocardiology, is founded by Zao and Lepeschkin. <br />
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'''1968''' Henry Marriott introduces the Modified Chest Lead 1 (MCL1) for monitoring patients in Coronary Care. <br />
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'''1969''' Rosenbaum reviews the classification of ventricular premature beats and adds a benign form that arises from the right ventricle and is not associated with heart disease. This becomes known as the 'Rosenbaum ventricular extrasystole'. <cite>Rosenbaum</cite><br />
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'''1974''' Jay Cohn, of University of Minnesota Medical School, describes the 'syndrome of right ventricular dysfunction in the setting of acute inferior wall myocardial infarction'. <cite>Cohn</cite><br />
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'''1974''' Gozensky and Thorne introduce the term 'Rabbit ears' to electrocardiography. Rabbit ears describe the appearence of the QRS complex in lead V1 with an rSR' pattern (good rabbit) being typical of Right Bundle Branch Block and an RSr' (bad rabbit) suggesting a ventricular origin i.e. ventricular ectopy / tachycardia. <cite>Gozensky</cite><br />
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'''1976''' Erhardt and colleagues describe the use of a right-sided precordial lead in the diagnosis of right ventricular infarction which had previously been thought to be electrocardiographically silent. <cite>Erhardt</cite><br />
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'''1988''' Professor John Pope Boineau of Washington University School of Medicine publishes a 30-year percpective on the modern history of electrocardiography. <cite>Boineau</cite><br />
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[[image:Brugada.jpg|thumb|150px|left|Pedro Brugada]]'''1992''' Pedro Brugada and Josep brugada of Barcelona publish a series of 8 cases of sudden death, Right Bundle Branch Block pattern and ST elevation in V1 - V3 in apparently healthy individuals. This 'Brugada Syndrome' may account for 4-12% of unexpected sudden deaths and is the commonest cause of sudden cardiac death in individuals aged under 50 years in South Asia. The technology of the electrocardiogam, which is over 100 years old, can still be used to discover new clinical entities in cardiology. <cite>Brugada</cite><br />
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'''1992''' Cohen and He describe a new non-invasive approach to accurately map cardiac electrical activity by using the surface Laplacian map of the body surface electrical potentials. <cite>He</cite><br />
[[Image:modern_ecg.jpg|thumb|150px|The last generation of ECG equipment. Image courtesy of [http://www.gehealthcare.com/euen/cardiology/ General Electric]]]<br />
'''1993''' Robert Zalenski, Professor of Emergency Medicine, Wayne State University Detroit, and colleagues publish an influential article on the clinical use of the 15-lead ECG which routinely uses V4R, V8 and V9 in the diagnosis of acute coronary syndromes. Like the addition of the 6 standardised unipolar chest leads in 1938 these additional leads increase the sensitivity of the electrocardiogram in detecting myocardial infarction. <cite>Zalenski</cite><br />
<br />
'''1999''' Researchers from Texas show that 12-lead ECGs transmitted via wireless technology to hand-held computers is feasible and can be interpreted reliably by cardiologists. <cite>Pettis</cite><br />
<br />
'''2000''' Physicians from the Mayo Clinic describe a new hereditary form of Short QT syndrome associated with syncope and sudden death that they discovered in 1999. Several genes have since been implicated. <cite>Gussak</cite><br />
<br />
'''2005''' Danish cardiologists report the successful reduction in the time between onset of chest pain and primary angioplasty when the ECG of patients is transmitted wirelessly from ambulance to the cardiologist's handheld PDA (Personal Digital Assistant). The clinician can make an immediate decision to redirect patients to the catheter lab saving time in transfers between hospital departments. <cite>Clemmensen</cite><br />
<br />
'''2008''' Dr. Haïssaguerre et al. have studied ECGs from patients with idiopathic ventricular fibrillation and find that patients with early repolarization on their ECG (elevation of the QRS-ST junction of at least 0.1 mV from baseline, which is usually considered a benign finding) is associated with a doubled risk of ICD shock during follow up. <cite>Haiss</cite><br />
<br />
==External Links==<br />
*[http://www.ecglibrary.com/ecghist.html ECG history on ECGlibrary.com]<br />
*[http://www.hrsonline.org/News/ep-history/timeline/ History of electrophysiology on the website of the Heart Rhythm Society]<br />
<br />
==References==<br />
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#Vulpian Vulpian A. 1874. ''Notes sur les éffets de la faradisation directe des ventricules du coeur chez le chien.'' Arch. Physiol. Norm. Path. 6: 975– 82 <br />
#Abildgaard Abildgaard, Peter Christian. ''Tentamina electrica in animalibus.'' Inst Soc Med Havn. 1775; 2:157-61. <br />
#Ader Ader C. ''Sur un nouvel appareil enregistreur pour cables sous-marins.'' C R Acad Sci (Paris) 1897;124:1440-1442 <br />
#Prevost Prevost JL, Batelli F: ''Sur quelques effets des descharges electriques sur le coeur des mammiferes.'' Acad. Sci. Paris, FR.: 1899; 129:1267-1268. <br />
#Holter Holter NJ, Generelli JA. ''Remote recording of physiologic data by radio.'' Rocky Mountain Med J. 1949;747-751.<br />
#Ernstine Ernstine AC, Levine SA. ''A comparison of records taken with the Einthoven string galvanomter and the amplifier-type electrocardiograph.'' Am Heart J 1928;4:725-731 <br />
#Dubois Du Bois-Reymond, E. ''Untersuchungen über thierische Elektricität''. Reimer, Berlin: 1848.<br />
#Waller Waller AD. ''A demonstration on man of electromotive changes accompanying the heart's beat.'' J Physiol (London) 1887;8:229-234 <br />
#Waller2 Waller AD. ''Introductory Address on The Electromotive Properties of the Human Heart''. Brit. Med J, 1888;2:751-754<br />
#Burch Burch GJ. ''On a method of determining the value of rapid variations of a difference potential by means of a capillary electrometer.'' Proc R Soc Lond (Biol) 1890;48:89-93<br />
#Chauveau Chauveau MA. ''De La Dissociation Du Rythme Auriculaire et du Rythme Ventriculaire.'' Rev. de Méd. Tome V. - Mars 1885: 161-173.<br />
#Hoffa Hoffa M, Ludwig C. 1850. ''Einige neue versuche uber herzbewegung''. Zeitschrift Rationelle Medizin, 9: 107-144<br />
#Waller Waller AD. ''A demonstration on man of electromotive changes accompanying the heart's beat.'' J Physiol (London) 1887;8:229-234<br />
#Wood Wood FC, Wolferth CC, Livezey MM. ''Angina pectoris.'' Archives Internal Medicine 1931;47:339 <br />
#Pardee Pardee HEB. ''An electrocardiographic sign of coronary artery obstruction.'' Arch Int Med 1920;26:244-257 <br />
#Sanders Sanders, A.O. ''Coronary thrombosis with complete heart block and relative ventricular tachycardia: a case report,'' American Heart Journal 1930;6:820-823. <br />
#Einthoven Einthoven W. ''Le telecardiogramme''. Arch Int de Physiol 1906;4:132-164<br />
#Einthoven2 Einthoven W. ''Über die Form des menschlichen Electrocardiogramms''. Pfügers Archiv march 1895, p 101-123<br />
#Einthoven3 Einthoven W. ''Un nouveau galvanometre.'' Arch Neerl Sc Ex Nat 1901;6:625-633 <br />
#Einthoven4 Einthoven W. ''Galvanometrische registratie van het menschilijk electrocardiogram. In: Herinneringsbundel Professor S. S. Rosenstein.'' Leiden: Eduard Ijdo, 1902:101-107 <br />
#Prinzmetal pmid=14434946<br />
#Marey Marey EJ. ''Des variations electriques des muscles et du couer en particulier etudies au moyen de l'electrometre de M <br />
Lippman.'' Compres Rendus Hebdomadaires des Seances de l'Acadamie des sciences 1876;82:975-977 <br />
#Gouaux Gouaux JL, Ashman R. ''Auricular fibrillation with aberration simulating ventricular paroxysmal tachycardia.'' Am Heart J 1947;34:366-73. <br />
#Marquez pmid=12177632<br />
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#Gilbert Gilbert W. ''De Magnete, magneticisique corporibus, et de magno magnete tellure.'' 1600<br />
#Browne Browne, Sir Thomas. Pseudodoxia Epidemica: Or, enquiries Into Very Many Received Tenents, and Commonly Presumed Truths. 1646: Bk II, Ch. 1. London<br />
#Descartes Descartes R. De Homine (Treatise of Man); 1662: Moyardum & leffen, Leiden.<br />
#Bancroft Bancroft, E. ''An essay on the natural history of Guiana'', London:T. Becket and P. A. de Hondt, 1769.<br />
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#Wilson Wilson NF, Johnston FE, Macleod AG, Barker PS. ''Electrocardiograms that represent the potential variations of a single electrode.'' Am Heart J. 1934;9:447-458.<br />
#Sokolow pmid=18107386<br />
#Hyman Hyman AS. ''Resuscitation of the stopped heart by intracardial therapy.'' Arch Intern Med. 1932;50:283<br />
#Lewis Lewis T. ''Auricular fibrillation: a common clinical condition.'' BMJ 1909;42:1528.<br />
#Hay Hay J. ''Bradycardia and cardiac arrhythmias produced by depression of certain functions of the heart.'' Lancet 1906;1:138-143. <br />
#Bousfield Bousfield G. ''Angina pectoris: changes in electrocardiogram during paroxysm.'' Lancet 1918;2:475 <br />
#Mann Mann H. ''A method of analyzing the electrocardiogram.'' Arch Int Med 1920;25:283-294 <br />
#McGinn McGinn S, White PD. ''Acute cor pulmonale resulting from pulmonary embolism: its clinical recognition.'' JAMA 1935;114:1473.<br />
#Bigelow pmid=15433219<br />
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#Beck Beck CS, Pritchard WH, Feil SA: ''Ventricular fibrillation of long duration abolished by electric shock.'' JAMA 1947; 135: 985-989.<br />
#Wiggers Wiggers CJ, Wegria R. ''Ventricular fibrillation due to single localized induction in condenser shock supplied during the vulnerable phase of ventricular systole.'' Am J Physiol 1939;128:500 <br />
#Haiss pmid=1846337<br />
#McWilliam1 pmid=16991467<br />
#McWilliam2 McWilliam JA. ''Electrical stimulation of the heart in man.'' 1889. Br. Med. J. 1: 348 <br />
#Lewis Levy AG, Lewis T. ''Heart irregularities, resulting from the inhalation of low percentages of chloroform vapour, and their relationship to ventricular fibrillation.'' 1911. Heart 3: 99– 112 <br />
#Hoffman Hoffman A. ''Fibrillation of ventricles at the end of an attack of paroxysmal tachycardia in man''. 1912. Heart 3: 213– 18 <br />
#Bayliss1 Bayliss WM, Starling EH. ''On the electrical variations of the heart in man.'' Proc Phys Soc (14th November) in J Physiol (London) 1891;13:lviii-lix <br />
#Bayliss2 Bayliss WM, Starling EH. ''On the electromotive phenomena of the mammalian heart.'' Proc R Soc Lond 1892;50:211-214<br />
#Matteucci Matteucci C. ''Sur un phenomene physiologique produit par les muscles en contraction.'' Ann Chim Phys 1842;6:339-341<br />
#Bird Bird G. ''Lectures on Electricity and Galvanism, in their physiological and therapeutical relations, delivered at the Royal College of Physicians,'' in March, 1847 (Wilson & Ogilvy, London, 1847) <br />
#Walsh Walsh, J. ''On the electric property of torpedo:'' in a letter to Ben. Franklin. Phil. Trans. Royal Soc. 1773;63:478-489<br />
#Hoffa Hoffa M, Ludwig C. 1850. ''Einige neue versuche uber herzbewegung''. Zeitschrift Rationelle Medizin, 9: 107-144 <br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=A_Concise_History_of_the_ECG&diff=9974
A Concise History of the ECG
2010-01-26T20:56:02Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= Dr Dean Jenkins & Dr. Stephen Gerred<br />
|moderator= [[user:Drj|J.S.S.G. de Jong]]<br />
|supervisor= <br />
}}<br />
<br />
{| class="wikitable"<br />
|This overview has been adapted from Dean Jenkins's and Stephen Gerred's [http://www.ecglibrary.com ECGlibary.com], for which they are gratefully acknowledged.<br />
|}<br />
<br />
The history of the ECG goes back more than one and a half centuries. <br />
==1600 - 1800==<br />
'''1600.''' William Gilbert, Physician to Queen Elizabeth I, President of the Royal College of Physicians and creator of the 'magnetic philosophy', introduces the term 'electrica' for objects (insulators) that hold static electricity. He derives the word from the Greek for amber (electra). It has been known from ancient times that amber when rubbed could lift light materials. Gilbert adds other examples such as sulphur and describes what will later be known as 'static electricity' to distinguish it from the more noble magnetic force. He sees his ideas as part of a philosophy to replace forever the prevailing Aristotlean view of matter. <cite>Gilbert</cite><br />
<br />
'''1649.''' Sir Thomas Browne, Physician, while writing to dispel popular ignorance in many subjects, is the first to use the word 'electricity'. Browne calls the attractive force "Electricity, that is, a power to attract strawes or light bodies, and convert the needle freely placed". (He is also the first to use the word 'computer' - referring to people who compute calendars.)<cite>Browne</cite><br />
<br />
'''1660'''. Otto Von Guericke builds the first static electricity generator.<br />
<br />
'''1662'''. The work of Rene Descartes, French Philosopher, is published (posthumously) and explains human movement in terms of a complex mechanical interaction of threads, pores, passages and 'animal spirits'. He has worked on his ideas in the 1630s but did not publish because of the persecution of other radical thinkers such as Galileo. William Harvey developed similar ideas but they were never published. <cite>Descartes</cite><br />
<br />
[[Image:Jan_Swammerdam.jpg|thumb|150px|left|Jan Swammerdam]]'''1664'''. Jan Swammerdam, a Dutchman, disproves Descartes' mechanistic theory of animal motion by removing the heart of a living frog and showing that the frog is still able to swim. When the brain is removed all movement stops (which could be in keeping with Descarte's theory) but then, when the frog is dissected and a severed nerve end stimulated with a scalpel, the muscles twitch. This proves that movement of a muscle can occur without any connection to the brain.Therefore the transmission of 'animal spirits' is not necessary.<br />
<br />
Swammerdam's ideas are not widely known and his work is not published until after his death. However, he writes many letters and his friend, Nicolaus Steno, attacks Cartesian ideas in a lecture in Paris in 1665. Boerhaave publishes Swammerdam's 'Book of Nature' in the 1730s.It is translated into English in 1758.<br />
<br />
'''1668''' Swammerdam refines his experiments on muscle contraction and nerve conduction. He demonstrates some of his work to notable figures such as the Grand-Duke Cosimo of Tuscany when the Grand Duke visits Swammerdam's father's house on the Oude Schans in Amsterdam. In one experiment he suspends a muscle on a brass hook inside a glass tube with a water droplet, to detect movement, and 'irritates' the nerve with a silver wire. This produces movement of the muscle, which may be due to the induction of a small electrical charge - although Swammerdam is unaware of this.<br />
<br />
'''1729''' Stephen Gray, English scientist, distinguishes between conductors and insulators of electricity. He demonstrates the transfer of static electrical charge to a cork ball across 150 meters of wet hemp thread. Later he finds that the transfer can be achieved over greater distances through brass wire. <br />
<br />
[[Image:Leyden_Jar.png|thumb|100px|A Leyden Jar]]'''1745''' Dutch physicist Pieter van Musschenbroek discovers that a partly filled jar with a nail projecting from a cork in its neck can store an electrical charge. The jar is named the 'Leyden Jar' after the place of its discovery. Ewald Georg von Kliest of Pomerania invents the same device independently.<br />
<br />
Using a Leyden jar in 1746, Jean-Antoine Nollet, French physicist and tutor to the royal family of France, sends an electrical current through 180 Royal Guards during a demonstration for King Louis XV.<br />
<br />
'''1769''' Edward Bancroft, an American scientist, suggests that the 'shock' from the torpedo fish is electrical rather than mechanical in nature. He shows that the properties of the shock are similar to those from a Leyden jar in that it can be conducted or insulated with appropriate materials. The torpedo fish and other species are widely known to deliver shocks and are often used for therapeutic reasons. However, electrical theory at this time dictates that electricity will always flow through conductors and diffuse away from areas of high charge to areas of low charge. Since living tissues are known to be conductors, it is impossible to imagine how an imbalance of charge can exist within an animal. Therefore animals can not use electricity for nerve conduction - or to deliver shocks. Furthermore, 'water and electricity do not mix' so the idea of an 'electric fish' is generally not accepted. <cite>Bancroft</cite><br />
<br />
'''1773''' John Walsh, Fellow of the Royal Society and Member of Parliament, obtains a visible spark from the electric eel Electrophorus electricus. The eel is out of water, as it is not possible to produce the spark otherwise. Walsh uses thin strips of tin foil to demonstrate his technique to many colleagues and visitors at his house in London. Unfortunately, he never publishes his eel experiment, though he does win the Copley medal in 1774 and 1783 for his work. Walshes observations , and those of Bancroft before him, adds to the argument that some form of animal electricity. <cite>Walsh</cite><br />
<br />
'''1774''' The Rev. Mr Sowdon and Mr Hawes, apothecary, report on the surprising effects of electricity in a case report of recovery from sudden death published in the annual report of the newly founded Humane Society (now the Royal Humane Society). The Society develops from 'The Institution for Affording Immediate Relief to Persons Apparently Dead from Drowning'. It is "instituted in the year 1774, to protect the industrious from the fatal consequences of unforseen accidents; the young and inexperienced from being sacrificed to their recreations; and the unhappy victims of desponding melancholy and deliberate suicide from the miserable consequences of self-destruction."<br />
<br />
A Mr Squires, of Wardour Street, Soho, lives opposite the house from which a three year old girl, Catherine Sophia Greenhill falls from a first story window on 16th July 1774. After the attending apothecary declares that nothing could be done for the child, Mr Squires, "with the consent of the parents very humanely tried the effects of electricity. At least twenty minutes had elapsed before he could apply the shock, which he gave to various parts of the body without any apparent success; but at length, upon transmitting a few shocks through the thorax, he perceived a small pulsation: soon after the child began to sigh, and to breathe, though with great difficulty. In about ten minutes she vomited: a kind of stupor, occasioned by the depression of the cranium, remained for some days, but proper means being used, the child was restored to perfect health and spirits in about a week.<br />
<br />
"Mr. Squires gave this astonishing case of recovery to the above gentlemen, from no other motive than a desire of promoting the good of mankind; and hopes for the future that no person will be given up for dead, till various means have been used for their recovery."<br />
<br />
Since it is clear she sustained a head injury, the electricity probably stimulated the child out of deep coma rather than providing cardiac defibrillation (see also 1788, Charles Kite). Annual Report 1774: Humane Society, London. pp 31-32 <br />
<br />
'''1775''' Abildgaard shows that hens can be made lifeless with electrical impulses and he can restore a pulse with electrical shocks across the chest. "With a shock to the head, the animal was rendered lifeless, and arose with a second shock to the chest; however, after the experiment was repeated rather often, the hen was completely stunned, walked with some difficulty, and did not eat for a day and night; then later it was very well and even laid an egg." <cite>Abildgaard</cite><br />
<br />
'''1786''' [[Image:Luigi_Galvani_oil-painting.jpg|thumb|150px|left|Italian Anatomist '''Luigi Galvani''']]Italian Anatomist '''Luigi Galvani''' notes that a dissected frog's leg twitches when touched with a metal scalpel. He has been studying the effects of electricity on animal tissues this summer.<br />
<br />
[[Image:Galvani_experiment.jpg|thumb|150px|Luigi Galvani's frog leg]]On 20th September 1786 he wrote, "I had dissected and prepared a frog in the usual way and while I was attending to something else I laid it on a table on which stood an electrical machine at some distance from its conductor and separated from it by a considerable space. Now when one of the persons present touched accidentally and lightly the inner crural nerves of the frog with the point of a scalpel, all the muscles of the legs seemed to contract again and again as if they were affected by powerful cramps."<br />
<br />
He later shows that direct contact with the electrical generator or the ground through an electrical conductor leads to a muscle contraction. Galvani also uses brass hooks attached to the frog's spinal cord and suspended from an iron railing in a part of his garden. He notices that the frogs' legs twitch during lightening storms and when the weather is fine. He interprets these results in terms of "animal electricity" or the preservation in the animal of "nerveo-electrical fluid" similar to that of an electric eel. He later also shows that electrical stimulation of a frog's heart leads to cardiac muscular contraction. Galvani. De viribus Electritatis in motu musculari Commentarius. 1791<br />
<br />
Galvani's name is given to the 'galvanometer', an instrument for measuring (and recording) electricity - this is essentially what an ECG is; a sensitive galvanometer.<br />
<br />
'''1788''' Charles Kite wins the Silver Medal of the Humane Society (awarded at the first prize medal ceremony of the Society, co-judged with the Medical Society of London) with an essay on the use of electricity in the diagnosis and resuscitation of persons apparently dead. This essay is often cited as the first record of cardiac defibrillation, but the use of electricity suggested by Mr Kite is much different. For example, on describing a case of drowning from 1785, in which resuscitation was attempted with artificial respiration, warmth, tobacco, "volatiles thrown into the stomach, frictions, and various lesser stimuli" for nearly an hour, he then recalls the use of electricity. "Electricity was then applied, and shocks sent through in every possible direction; the muscles through which the fluid [electricity] passed were thrown into strong contractions." He concludes that electricity is a valuable tool that can determine whether a person, apparently dead, can be successfully resuscitated. Annual Report 1788: Humane Society, London. pp 225-244. Kite C. An Essay on the Recovery of the Apparently Dead. 1788: C. Dilly, London. <br />
<br />
[[Image:Alessandro_Volta.jpg|150px|thumb|left|Alessandro Volta]]'''1792''' Alessandro Volta, Italian Scientist and inventor, attempts to disprove Galvani's theory of "animal electricity'" by showing that the electrical current is generated by the combination of two dissimilar metals. [[Image:Voltaic_Pile.jpg|150px|thumb|Voltaic pile]]His assertion was that the electrical current came from the metals and not the animal tissues. (We now know that both Galvani and Volta were right.) To prove his theory he develops the voltaic pile in 1800 (a column of alternating metal discs - zinc with copper or silver - separated by paperboard soaked in saline) which can deliver a substantial and steady current of electricity. Enthusiasm in the use of electricity leads to further attempts at reanimation of the dead with experiments on recently hanged criminals. Giovani Aldini (the nephew of Galvani) conducts an experiment at the Royal College of Surgeons in London in 1803. The executed criminal had lain in a temperature of 30 F for one hour and was transported to the College. "On applying the conductors to the ear and to the rectum, such violent muscular contractions were executed, as almost to give the appearance of the reanimation". Aldini, J. Essai: Théorique et expérimental sur le Galvanisme, Paris (1804), Giovani Aldini. General Views on the Application of Galvanism to Medical Purposes Principally in cases of suspended Animation (London: J. Callow, Princes Street and Burgess and Hill, Great Windmill Street, 1819). Mary Shelly's Frankenstein was published in 1818. Louis Figuier, Les merveilles de la Science (Paris, 1867), p.653<br />
<br />
{{clr}}<br />
<br />
==1800 - 1895==<br />
'''1819''' While demonstrating to students the heating of a platinum wire with electricity from a voltaic pile at the University of Copenhagen, Danish physicist Hans Christian Oersted notices that a nearby magnetized compass needle moves each time the electrical current is turned on. He discovers electromagnetism which is given a theoretical basis (with remarkable speed) by André Marie Ampère. <br />
<br />
'''1820''' Johann (Johan) Schweigger of Nuremberg increases the movement of magnetized needles in electromagnetic fields. He found that by wrapping the electric wire into a coil of 100 turns the effect on the needle was multiplied. He proposed that a magnetic field revolved around a wire carrying a current which was later proven by Michael Faraday. Schweigger had invented the first galvanometer and announced his discovery at the University of Halle on 16th September 1820. <br />
<br />
'''1825''' Leopold Nobili, Professor of Physics at Florence, develops an 'astatic galvanometer'. Using two identical magnetic needles of opposite polarity, either fixed together with a figure of eight arrangment of wire loops (in earlier versions), or one moveable needle with a wire loop and one with a scale (in later versions), the effects of the earth's magnetic field could be compensated for. In 1827, using this instrument, he managed to detect the flow of current in the body of a frog from muscles to spinal cord. He detected the electricity running along saline moistened cotton thread joining the dissected frog's legs in one jar to its body in another jar. Nobili was working to support the theory of animal electricity and this conduction, transmitted without wires, he felt demonstrated animal electricity. <br />
<br />
[[Image:Matteucci.jpg|thumb|150px|left|Carlo Matteucci]]'''1838''' Carlo Matteucci, Professor of Physics at the University of Pisa, and student of Nobili, shows that an electric current accompanies each heart beat. He used a preparation known as a 'rheoscopic frog' in which the cut nerve of a frog's leg was used as the electical sensor and twitching of the muscle was used as the visual sign of electrical activity. He also used Nobili's astatic galvanometer for the study of electricity in muscles typically inserting one galvanometer wire in the open end of the dissected muscle and the other on the surface of the muscle. He went on to try and demonstrate conduction in nerve but was unable to do so (since his galvanometers were not sensitive enough). <cite>Matteucci</cite><br />
<br />
'''1840''' Dr Golding Bird, a Physician, accomplished chemist and member of the London Electrical Society, opens an electrical therapy room at Guy's Hospital, London treating a large range of diseases. Although the application of electricity was popular it was not considered a subject worthy of serious investigation. Because of Bird's reputation as a researcher electrical therapy achieved popularity amongst London Physicians including his mentor Dr Thomas Addison. <cite>Bird</cite><br />
<br />
[[Image:Emil_Dubois.jpg|thumb|150px|left|Physiologist Emil Du Bois-Reymond]]'''1843''' German physiologist Emil Du Bois-Reymond describes an "action potential" accompanying each muscular contraction. He detected the small voltage potential present in resting muscle and noted that this diminished with contraction of the muscle. To accomplish this he had developed one of the most sensitive galvanometers of his time. His device had a wire coil with over 24,000 turns - 5 km of wire. Du Bios Reymond devised a notation for his galvanometer which he called the 'disturbance curve'. "o" was the stable equilibrium point of the astatic galvanometer needle and p, q, r and s (and also k and h) were other points in its deflection. Du Bois-Reymond, E. Untersuchungen uber thierische Elektricitat. Reimer, Berlin: 1848.<br />
<br />
'''1850''' Bizarre unregulated actions of the ventricles (later called ventricular fibrillation) is described by Hoffa during experiments with strong electrical currents across the hearts of dogs and cats. He demonstrated that a single electrical pulse can induce fibrillation. <cite>Hoffa</cite><br />
<br />
'''1856''' Rudolph von Koelliker and Heinrich Muller confirm that an electrical current accompanies each heart beat by applying a galvanometer to the base and apex of an exposed ventricle. They also applied a nerve-muscle preparation, similar to Matteucci's, to the ventricle and observed that a twitch of the muscle occured just prior to ventricular systole and also a much smaller twitch after systole. These twitches would later be recognised as caused by the electrical currents of the QRS and T waves. von Koelliker A, Muller H. Nachweis der negativen Schwankung des Muskelstroms am naturlich sich kontrahierenden Herzen. Verhandlungen der Physikalisch-Medizinischen Gesellschaft in Wurzberg. 1856;6:528-33. <br />
<br />
'''1858''' William thompson (Lord Kelvin), Professor of Natural Philosophy at Glasgow University, invents the 'mirror galvanometer' for the reception of transatlantic telegraph transmissions. A small, freely rotating mirror, with magents stuck to its back is suspended in a fine copper coil and a reflected spot of light from this mirror 'amplifies' the small movements when electrical current is present. The whole apparatus was suspended in an air chamber and the pressure inside could be adjusted to vary the damping seen on the signals. This galvanometer was sensitive enough for transatlantic telegraphy.<br />
<br />
'''1867''' Thompson improves telegraph transmissions with the 'Siphon Recorder'. Before d'Arsonval (1880), Thompson uses a fine coil suspended in a strong magnetic magnetic field. Attached to the coil but isolated from it by ebonite (an insulator) was a siphon of ink. The siphon was charged with high voltage so that the ink was sprayed onto the paper that moved over an earthed metal surface. The siphon recorder could therefore not only detect currents it could also record them onto paper.<br />
<br />
'''1869-70''' Alexander Muirhead, an electrical engineer and pioneer of telegraphy, may have a recorded a human electrocardiogram at St Bartholomew's Hospital, London but this is disputed. If he had he is thought to have used a Thompson Siphon Recorder. Elizabeth Muirhead, his wife, wrote a book of his life and claimed that he refrained from publishing his own work for fear of misleading others. Elizabeth Muirhead. Alexander Muirhead 1848 - 1920. Oxford, Blackwell: privately printed 1926.<br />
<br />
'''1872''' French physicist Gabriel Lippmann invents a capillary electrometer. It is a thin glass tube with a column of mercury beneath sulphuric acid. The mercury meniscus moves with varying electrical potential and is observed through a microscope.<br />
<br />
'''1872''' Mr Green, a surgeon, publishes a paper on the resuscitation of a series of patients who had suffered cardiac and / or respiratory arrest during anaesthesia with chloroform. He uses a galvanic pile (battery) of 200 cells generating 300 Volts which he applied to the patient as follows "One pole should be applied to the neck and the other to the lower rib on the left side." Green T. On death from chloroform: its prevention by galvanism. Br Med J 1872 1: 551-3. Although this has been reported as an example of cardiorespiratory resuscitation it is unclear what the exact mechanism seems to be. It is unlikely to be electric cardioversion or external pacing. It seems to be another example of electrophrenic stimulation (See also Duchenne 1872).<br />
<br />
[[image:Duchenne_de_belogne.jpg|thumb|150px|left|Guillaume Benjamin Amand Duchenne de Boulogne]]'''1872''' Guillaume Benjamin Amand Duchenne de Boulogne, pioneering neurophysiologist, describes the resuscitation of a drowned girl with electricity in the third edition of his textbook on the medical uses of electricity. This episode has sometimes been described as the first 'artificial pacemaker' but he used an electrical current to induce electrophrenic rather than myocardial stimulation. Duchenne GB. De l'electrisation localisee et de son application a la pathologie et la therapeutique par courants induits at par courants galvaniques interrompus et continus. [Localised electricity and its application to pathology and therapy by means of induced and galvanic currents, interrupted and continuous] 3ed. Paris. JB Bailliere et fils; 1872<br />
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'''1874''' A. Vulpian described ''mouvement fibrillaire'' in his article published in 1874, which would be the basis for the name ventricular fibrillation now used for this arrhythmia.<cite>Vulpian</cite><br />
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'''1875''' Richard Caton, a Liverpool Physician, presents to the British Medical Association in July 1875 in Edinburgh. Using a Thompson 'mirror galvanometer' in animals he shows it was possible to detect 'feeble currents of varying direction ... when the electrodes are placed on two points of the external surface, or one electrode on the grey matter and one on the surface of the skull'. This is the first report of the EEG (or electroencephalogram). Caton was proving another Physician's hypothesis, John Hughlings Jackson, who suggested in 1873 that epilepsy was due to excessive electrical activity in the grey matter of the brain. Caton R: The electric currents of the brain. BMJ 1875; 2:278, Mumenthaler, Mattle Eds. Neurology. 4th Edition. Stuttgart, Thieme: 2004.<br />
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'''1876''' Marey uses the electrometer to record the electrical activity of an exposed frog's heart. Marey EJ. Des variations electriques des muscles et du couer en particulier etudies au moyen de l'electrometre de M Lippman. Compres Rendus Hebdomadaires des Seances de l'Acadamie des sciences 1876;82:975-977<br />
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'''1878''' British physiologists John Burden Sanderson and Frederick Page record the heart's electrical current with a capillary electrometer and shows it consists of two phases (later called QRS and T). Burdon Sanderson J. Experimental results relating to the rhythmical and excitatory motions of the ventricle of the frog. Proc R Soc Lond 1878;27:410-414<br />
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'''1880''' French physicist Arsène d'Arsonval in association with Marcel Deprez, improves the galvanometer. Instead of a magnetized needle moving when electrical current flows through a surrounding wire coil the Deprez-d'Arsonval galvanometer has a fixed magnet and moveable coil. If a pointer is attached to the coil it can move over a suitably calibrated scale. The d'Arsonval galvanometer is the basis for most modern galvanometers. Comptes rendus de l'Académie des sciences, 1882, 94: 1347-1350 <br />
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'''1884''' John Burden Sanderson and Frederick Page publish some of their recordings. Burdon Sanderson J, Page FJM. On the electrical phenomena of the excitatory process in the heart of the tortoise, as investigated photographically. J Physiol (London) 1884;4:327-338<br />
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[[image:Waller.jpg|thumb|150px|left|A.D. Waller with his famous bulldog Jimmy]]'''1887''' British physiologist Augustus D. Waller of St Mary's Medical School, London publishes the first human electrocardiogram. It is recorded with a capilliary electrometer from Thomas Goswell, a technician in the laboratory. <cite>Waller</cite> This was shortly after the "Cruelty to Animals Act" had been accepted in the British parliament, which lead to questions in the House of Commons.<br />
<br />
Q. 'At a converzaione [sic] of the Royal Society at Burlington House on May 12th last, a bulldog was cruelly treated when a leather strap with sharp nails was wound around his neck and his feet were immersed in glass jars containing salts in solution, and the jars in turn were connected with wires to galvanometers. Such a cruel procedure should surely be dealt with under the "Cruelty to Animals Act" of 1876?'<br />
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A. 'The dog in question wore a leather collar ornamented with brass studs, and he was placed to stand in water to which some sodium chloride had been added, or in other words, common salt. If my honourable friend had ever paddled in the sea, he will appreciate fully the sensation obtained thereby from this simple pleasurable experience!'<br />
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'''1887''' McWilliam provided the first detailed description of VF, and demonstrated how VF in man could be terminated by electric shocks applied through a large pair of electrodes: the first description of defibrillation in man.<cite>McWilliam1</cite><cite>McWilliam2</cite><br />
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'''1889''' Dutch physiologist Willem Einthoven sees Waller demonstrate his technique at the First International Congress of Physiologists in Bale. Waller often demonstrated by using his dog "Jimmy" who would patiently stand with paws in glass jars of saline.<br />
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'''1890''' GJ Burch of Oxford devises an arithmetical correction for the observed (sluggish) fluctuations of the electrometer. This allows the true waveform to be seen but only after tedious calculations. <cite>Burch</cite><br />
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'''1891''' British physiologists William Bayliss and Edward Starling of University College London improve the capillary electrometer. They connect the terminals to the right hand and to the skin over the apex beat and show a "triphasic variation accompanying (or rather preceding) each beat of the heart". These deflections are later called P, QRS and T. <cite>Bayliss1</cite> and <cite>Bayliss2</cite> They also demonstrate a delay of about 0.13 seconds between atrial stimulation and ventricular depolarisation (later called PR interval). On the electromotive phenomena of the mammalian heart. Proc Phys Soc (21st March) in J Physiol (London) 1891;12:xx-xxi <br />
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'''1893''' Willem Einthoven introduces the term 'electrocardiogram' at a meeting of the Dutch Medical Association. (Later he claims that Waller was first to use the term). Einthoven W: Nieuwe methoden voor clinisch onderzoek [New methods for clinical investigation]. Ned T Geneesk 29 II: 263-286, 1893<br />
{{clr}}<br />
<br />
==1895 - 1949==<br />
[[image:Einthoven_portrait.jpg|thumb|150px|left|Willem Einthoven]][[Image:Einthoven_ECG3.jpg|thumb|150px|ECG recordings as registered by Einthoven]][[Image:einthoven.jpg|150px|left|thumb|Willem Einthoven]][[image:Einthoven_ECG2.jpg|thumb|150px|right|Einthoven's ECG recording including putting the patients feet in baths filled with saline to improve electrical conduction]][[Image:Einthoven_ECG.jpg|thumb|150px|An electrocardiograph as used by Einthoven]]<br />
'''1895''' Einthoven, using an improved electrometer and a correction formula developed independently of Burch, distinguishes five deflections which he names P, Q, R, S and T. <cite>Einthoven2</cite><br />
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Why PQRST and not ABCDE? The four deflections prior to the correction formula were labelled ABCD and the 5 derived deflections were labelled PQRST. The choice of P is a mathematical convention (as used also by Du Bois-Reymond in his galvanometer's 'disturbance curve' 50 years previously) by using letters from the second half of the alphabet. N has other meanings in mathematics and O is used for the origin of the Cartesian coordinates. In fact Einthoven used O ..... X to mark the timeline on his diagrams. P is simply the next letter. A lot of work had been undertaken to reveal the true electrical waveform of the ECG by eliminating the damping effect of the moving parts in the amplifiers and using correction formulae. If you look at the diagram in Einthoven's 1895 paper you will see how close it is to the string galvanometer recordings and the electrocardiograms we see today. The image of the PQRST diagram may have been striking enough to have been adopted by the researchers as a true representation of the underlying form. It would have then been logical to continue the same naming convention when the more advanced string galvanometer started creating electrocardiograms a few years later. <br />
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'''1897''' Clement Ader, a French electrical engineer, reports his amplification system for detecting Morse code signals transmitted along undersea telegraph lines. It was never intended to be used as a galvanometer. Einthoven later quoted Ader's work but seems to have developed his own amplification device independently. <cite>Ader</cite><br />
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'''1899''' Karel Frederik Wenckebach publishes a paper "On the analysis of irregular pulses" describing impairment of AV conduction leading to progressive lengthening and blockage of AV conduction in frogs. This will later be called Wenckebach block (Mobitz type I) or Wenckebach phenomenon.<br />
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'''1899''' Jean-Louis Prevost, Professor of Biochemistry, and Frederic Batelli, Professor of Physiology, both of Geneva discover that large electrical voltages applied across an animal's heart can stop ventricular fibrillation. <cite>Prevost</cite><br />
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'''1901''' Einthoven invents a new galvanometer for producing electrocardiograms using a fine quartz string coated in silver based on ideas by Deprez and d'Arsonval (who used a wire coil). His "string galvanometer" weighs 600 pounds. Einthoven acknowledged the similar system by Ader but later (1909) calculated that his galvanometer was in fact many thousands of times more sensitive. <cite>Einthoven3</cite><br />
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'''1902''' Einthoven publishes the first electrocardiogram recorded on a string galvanometer. <cite>Einthoven4</cite><br />
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'''1903''' Einthoven discusses commercial production of a string galvanometer with Max Edelmann of Munich and Horace Darwin of Cambridge Scientific Instruments Company of London. <br />
1905<br />
<br />
Einthoven starts transmitting electrocardiograms from the hospital to his laboratory 1.5 km away via telephone cables. On March 22nd the first 'telecardiogram' is recorded from a healthy and vigorous man and the tall R waves are attributed to his cycling from laboratory to hospital for the recording.<br />
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'''1905''' John Hay of Liverpool, publishes pressure recordings from a 65 year old man showing heart block in which AV conduction did not seem to be impaired since the a-c intervals on the jugular venous waves was unchanged in the conducted beats. This is the first demonstration of what we now call Mobitz type II AV block. <cite>Hay</cite><br />
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'''1906''' Einthoven publishes the first organised presentation of normal and abnormal electrocardiograms recorded with a string galvanometer. Left and right ventricular hypertrophy, left and right atrial hypertrophy, the U wave (for the first time), notching of the QRS, ventricular premature beats, ventricular bigeminy, atrial flutter and complete heart block are all described. Einthoven W. Le telecardiogramme. Arch Int de Physiol 1906;4:132-164 (translated into English. Am Heart J 1957;53:602-615) <br />
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'''1906''' Cremer records the first oesophageal electrocardiogram which he achieved with the help of a professional sword swallower. Oesophageal electrocardiography later developed in the 1970s to help differentiate atrial arrhythmias. He also records the first fetal electrocardiogram from the abdominal surface of a pregnant woman. Cremer. Ueber die direkte Ableitung der Aktionströme des menslichen Herzens vom Oesophagus und über das Elektrokardiogramm des Fötus. Munch. Med. Wochenschr. 1906;53:811 <br />
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'''1907''' Arthur Cushny, professor of pharmacology at University College London, publishes the first case report of atrial fibrillation. His patient was 3 days post-op following surgery on an "ovarian fibroid" when she developed a "very irregular" pulse at a rate of 120 - 160 bpm. Her pulse was recorded with a "Jacques sphygmochronograph" which shows the radial pulse pressure against time - much like the arterial line blood pressure recordings used in Intensive Care today. Cushny AR, Edmunds CW. Paroxysmal irregularity of the heart and auricular fibrillation. Am J Med Sci 1907;133:66-77. <br />
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'''1908''' Edward Schafer of the University of Edinburgh is the first to buy a string galvanometer for clinical use. <br />
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'''1909''' Thomas Lewis of University College Hospital, London buys a string galvanometer and so does Alfred Cohn of Mt Sinae Hospital, New York. Thomas Lewis publishes a paper in the BMJ detailing his careful clinical and electrocardiographic observations of atrial fibrillation. At one point Lewis identified a fibrillating horse using the string galvanometer's electrocardigram recording. He then followed the horse to the slaughterhouse where he could visually confirm the fibrillating atrium. <cite>Lewis</cite><br />
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'''1909''' Nicolai and Simmons report on the changes to the electrocardiogram during angina pectoris. Nicolai DF, Simons A. (1909) Zur klinik des elektrokardiogramms. Med Kiln 5;160<br />
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'''1910''' Walter James, Columbia University and Horatio Williams, Cornell University Medical College, New York publish the first American review of electrocardiography. It describes ventricular hypertrophy, atrial and ventricular ectopics, atrial fibrillation and ventricular fibrillation. The recordings were sent from the wards to the electrocardiogram room by a system of cables. There is a great picture of a patient having an electrocardiogram recorded with the caption "The electrodes in use".James WB, Williams HB. The electrocardiogram in clinical medicine. Am J Med Sci 1910;140:408-421, 644-669<br />
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'''1911''' Levy & Lewis demonstrated that when VF occurred during chloroform anesthesia, it was often preceded by the appearance of multiform ventricular premature beats or ventricular tachycardia.<cite>Lewis</cite><br />
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Thomas Lewis publishes a classic textbook. The mechanism of the heart beat. London: Shaw & Sons and dedicates it to Willem Einthoven.<br />
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'''1912''' Einthoven addresses the Chelsea Clinical Society in London and describes an equilateral triangle formed by his standard leads I, II and III later called 'Einthoven's triangle'. This is the first reference in an English article I have seen to the abbreviation 'EKG'.Einthoven W. The different forms of the human electrocardiogram and their signification. Lancet 1912(1):853-861 <br />
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Hoffman published the first ECG of ventricular fibrillation in man.<cite>Hoffman</cite><br />
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'''1918''' Bousfield describes the spontaneous changes in the electrocardiogram during angina. <cite>Bousfield</cite><br />
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'''1920''' Hubert Mann of the Cardiographic Laboratory, Mount Sinai Hospital, describes the derivation of a 'monocardiogram' later to be called 'vectorcardiogram'. <cite>Mann</cite><br />
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'''1920''' Harold Pardee, New York, publishes the first electrocardiogram of an acute myocardial infarction in a human and describes the T wave as being tall and "starts from a point well up on the descent of the R wave". <cite>Pardee</cite><br />
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'''1924''' Willem Einthoven wins the Nobel prize for inventing the electrocardiograph. <br />
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'''1924''' Woldemar Mobitz publishes his classification of heart blocks (Mobitz type I and type II) based on the electrocardiogram and jugular venous pulse waveform findings in patients with second degree heart block. Mobitz W. Uber die unvollstandige Storung der Erregungsuberleitung zwischen Vorhof und Kammer des menschlichen Herzens. (Concerning partial block of conduction between the atria and ventricles of the human heart). Z Ges Exp Med 1924;41:180-237. <br />
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'''1926''' A doctor from the Crown Street Women's Hospital in Sydney, who wished to remain anonymous, resuscitates a new-born baby with an electrical device later called a 'pacemaker'. The doctor wanted to remain anoymous because of the controversy surrounding research that artificially extended human life. <br />
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'''1928''' Ernstine and Levine report the use of vacuum-tubes to amplify the electrocardiogram instead of the mechanical amplification of the string galvanometer. <cite>Ernstine</cite> <br />
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'''1928''' Frank Sanborn's company (founded 1917 and acquired by Hewlett-Packard in 1961 and since 1999, Philips Medical Systems) converts their table model electrocardiogram machine into their first portable version weighing 50 pounds and powered by a 6-volt automobile battery.<br />
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'''1929''' Sydney doctor Mark Lidwill, physician, and Edgar Booth, physicist, report the electrical resuscitation of the heart to a meeting in Sydney. Their portable device uses an electrode on the skin and a transthoracic catheter. Edgar Booth's design could deliver a variable voltage and rate and was employed to deliver 16 volts to the ventricles of a stillborn infant. <br />
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[[image:White_stamp.gif|thumb|150px|left|Dr. Paul Dudley White]]'''1930''' Wolff, Parkinson and White report an electrocardiographic syndrome of short PR interval, wide QRS and paroxysmal tachycardias. Wolff L, Parkinson J, White PD. Bundle branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia. Am Heart J 1930;5:685. Later, when other published case reports were examined for evidence of pre-excitation, examples of 'Wolff Parkinson White' syndrome were identified which had not been recognised as a clinical entity at the time. The earliest example was published by Hoffmann in 1909. Von Knorre GH. The earliest published electrocardiogram showing ventricular preexcitation. Pacing Clin Electrophysiol. 2005 Mar;28(3):228-30<br />
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'''1930''' Sanders first describes infarction of the right ventricle. <cite>Sanders</cite><br />
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'''1931''' Charles Wolferth and Francis Wood describe the use of exercise to provoke attacks of angina pectoris. They investigated the ECG changes in normal subjects and those with angina but dismissed the technique as too dangerous "to induce anginal attacks indiscriminately". <cite>Wood</cite><br />
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'''1931''' Dr Albert Hyman patents the first 'artificial cardiac pacemaker' which stimulates the heart by using a transthoracic needle. His aim was to produce a device that was small enough to fit in a doctor's bag and stimulate the right atrial area of the heart with a suitably insulated needle. His experiments were on animals. His original machine was powered by a crankshaft (it was later prototyped by a German company but was never successful). "By March 1, 1932 the artificial pacemaker had been used about 43 times, with a successful outcome in 14 cases." It was not until 1942 that a report of its successful short term use in Stokes-Adams attacks was presented. <cite>Hyman</cite><br />
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'''1932''' Goldhammer and Scherf propose the use of the electrocardiogram after moderate exercise as an aid to the diagnosis of coronary insufficiency. Goldhammer S, Scherf D. Elektrokardiographische untersuchungen bei kranken mit angina pectoris. Z Klin Med 1932;122:134 <br />
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'''1932''' Charles Wolferth and Francis Wood describe the clinical use of chest leads. Wolferth CC, Wood FC. The electrocardiographic diagnosis of coronary occlusion by the use of chest leads. Am J Med Sci 1932;183:30-35 <br />
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'''1934''' By joining the wires from the right arm, left arm and left foot with 5000 Ohm resistors Frank Wilson defines an 'indifferent electrode' later called the 'Wilson Central Terminal'. The combined lead acts as an earth and is attached to the negative terminal of the ECG. An electrode attached to the positive terminal then becomes 'unipolar' and can be placed anywhere on the body. Wilson defines the unipolar limb leads VR, VL and VF where 'V' stands for voltage (the voltage seen at the site of the unipolar electrode). <cite>Wilson</cite> <br />
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'''1935''' McGinn and White describe the changes to the electrocardiogram during acute pulmonary embolism including the S1 Q3 T3 pattern. <cite>McGinn</cite> <br />
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'''1938''' American Heart Association and the Cardiac Society of Great Britain define the standard positions, and wiring, of the chest leads V1 - V6. The 'V' stands for voltage. Barnes AR, Pardee HEB, White PD. et al. Standardization of precordial leads. Am Heart J 1938;15:235-239 <br />
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'''1938''' Tomaszewski notes changes to the electrocardiogram in a man who died of hypothermia. Tomaszewski W. Changements electrocardiographiques observes chez un homme mort de froid. Arch Mal Coeur 1938;31:525. <br />
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'''1939''' Langendorf reports a case of atrial infarction discovered at autopsy which, in retrospect, could have been diagnosed by changes on the ECG. <cite>Langendorf</cite><br />
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'''1942''' Emanuel Goldberger increases the voltage of Wilson's unipolar leads by 50% and creates the augmented limb leads aVR, aVL and aVF. When added to Einthoven's three limb leads and the six chest leads we arrive at the 12-lead electrocardiogram that is used today. <br />
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'''1942''' Arthur Master, standardises the two step exercise test (now known as the Master two-step) for cardiac function. Master AM, Friedman R, Dack S. The electrocardiogram after standard exercise as a functional test of the heart. Am Heart J. 1942;24:777 <br />
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'''1944''' Young and Koenig report deviation of the P-R segment in a series of patients with atrial infarction. Young EW, Koenig BS. Auricular infarction. Am Heart J. 1944;28:287. <br />
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'''1947''' Gouaux and Ashman describe an observation that helps differentiate aberrant conduction from ventricular tachycardia. The 'Ashman phenomenon' occurs when a stimulus falls during the relative or absolute refractory period of the ventricles and the aberrancy is more pronounced. In atrial fibrillation with aberrant conduction this is demonstrated when the broader complexes are seen terminating a relatively short cycle that follows a relatively long one. The QRS terminating the shorter cycle is conducted 'more aberrantly' because it falls in the refractory period. The aberrancy is usually of a RBBB pattern. <cite>Gouaux</cite><br />
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'''1947''' Claude Beck, a pioneering cardiovascular surgeon in Cleveland, successfully defibrillates a human heart during cardiac surgery. The patient is a 14 year old boy - 6 other patients had failed to respond to the defibrillator. His prototype defibrillator followed experiments on defibrillation in animals performed by Carl J. Wiggers, Professor of Physiology at the Western Reserve University. <cite>Beck</cite><br />
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'''1948''' Rune Elmqvist, Swedish engineer who had trained as a doctor but never practiced, introduces the first ink jet printer for the transcription of analog physiological signals. He demonstrates its use in the recording of ECGs at the First International Congress of Cardiology in Paris in 1950. The machine (the mingograph) was developed by him at the company that later became Siemens. (Luderitz, 2002)<br />
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'''1949''' Montana physician Norman Jeff Holter develops a 75 pound backpack that can record the ECG of the wearer and transmit the signal. His system, the Holter Monitor, is later greatly reduced in size, combined with tape / digital recording and used to record ambulatory ECGs. <cite>Holter</cite><br />
<br />
== 1950 - to date==<br />
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'''1949''' Sokolow and Lyon propose diagnostic criteria for left ventricular hypertrophy i.e. LVH is present if the sum of the size of the S wave in V1 plus the R wave in V6 exceeds 35 mm. <cite>Sokolow</cite><br />
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'''1950''' John Hopps, a Canadian electrical engineer and researcher for the National Research Council, together with two physicians (Wilfred Bigelow, MD of the University of Toronto and his trainee, John C. Callaghan, MD) show that a coordinated heart muscle contraction can be stimulated by an electrical impulse delivered to the sino-atrial node. The apparatus, the first cardiac pacemaker, measures 30cm, runs on vacuum tubes and is powered by household 60Hz electrical current. <cite>Bigelow</cite><br />
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'''1953''' Osborn, whilst experimenting with hypothermic dogs, describes the prominent J (junctional) wave which has often been known as the "Osborn wave". He found the dogs were more likely to survive if they had an infusion of bicarbonate and supposed the J wave was due to an injury current caused by acidosis. Osborn JJ. Experimental hypothermia: respiratory and blood pH changes in relation to cardiac function. Am J Physiol 1953;175:389. <br />
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'''1955''' Richard Langendorf publishes the "rule of bigeminy" whereby ventricular bigeminy tends to perpetuate itself. Langendorf R, Pick A, Winternitz M. Mechanisms of intermittent ventricular bigeminy. I. Appearence of ectopic beats dependent upon the length of the ventricular cycle, the "rule of bigeminy." circulation 1955;11:442. <br />
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[[image:Zoll_portrait.jpg|thumb|150px|left|Paul Zoll]]'''1956''' Paul Zoll, a cardiologist, uses a more powerful defibrillator and performs closed-chest defibrillation in a human. <cite>Zoll</cite><br />
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'''1957''' Anton Jervell and Fred Lange-Nielsen of Oslo describe an autosomal recessive syndrome of long-QT interval, deafness and sudden death later known as the Jervell-Lange-Nielsen syndrome. <cite>Jervell</cite><br />
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'''1958''' Professor Ake Senning, of Sweden, places the first implantable cardiac pacemaker designed by Rune Elmqvist into a 43-year-old patient with complete heart block and syncope (Arne Larsson).<br />
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'''1959''' Myron Prinzmetal describes a variant form of angina in which the ST segment is elevated rather than depressed. <cite>Prinzmetal</cite><br />
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'''1960''' Smirk and Palmer highlight the risk of sudden death from ventricular fibrillation particularly when ventricular premature beats occur at the same time as the T wave. The 'R on T' phenomenon. Smirk FH, Palmer DG. A myocardial syndrome, with particular reference to the occurrence of sudden death and of premature systoles interrupting antecedent T waves. Am J Cardiol 1960;6:620. <br />
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'''1963''' Italian paediatrician C. Romano and Irish paediatrician O. Conor Ward (the following year) independently report an autosomal dominant syndrome of long-QT interval later known as the Romano-Ward syndrome. <cite>Romano</cite><cite>Ward</cite><br />
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[[image:Bruce_portrait.jpg|thumb|150px|left|Robert Bruce]]'''1963''' Robert Bruce and colleages describe their multistage treadmill exercise test later known as the Bruce Protocol. "You would never buy a used car without taking it out for a drive and seeing how the engine performed while it was running," Bruce says, "and the same is true for evaluating the function of the heart." <cite>Bruce1</cite><cite>Bruce2</cite><br />
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'''1963''' Baule and McFee are the first to detect the magnetocardiogram which is the electromagnetic field produced by the electrical activity of the heart. It is a method that can detect the ECG without the use of skin electrodes. Although potentially a useful technique it has never gained clinical acceptance, partly because of its greater expense. <cite>Baule</cite><br />
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'''1966''' Mason and Likar modify the 12-lead ECG system for use during exercise testing. The right arm electrode is placed at a point in the infraclavicular fossa medial to the border of the deltoid muscle, 2 cm below the lower border of the clavicle. The left arm electrode is placed similarly on the left side. The left leg electrode is placed at the left iliac crest. Although this system reduces the variability in the ECG recording during exercise it is not exactly equivalent to the standard lead positions. The Mason-Likar lead system tends to distort the ECG with a rightward QRS axis shift, a reduction in R wave amplitude in lead I and aVL, and a significant increase in R wave amplitude in leads II, III and aVF. <cite>Papouchado</cite><br />
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'''1966''' François Dessertenne of Paris publishes the first case of '[[Torsade de pointes]]' Ventricular Tachycardia. <cite>Dessertenne</cite><br />
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'''1968''' Journal of Electrocardiography, the Official Journal of the International Society for Computerized Electrocardiology and the International Society of Electrocardiology, is founded by Zao and Lepeschkin. <br />
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'''1968''' Henry Marriott introduces the Modified Chest Lead 1 (MCL1) for monitoring patients in Coronary Care. <br />
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'''1969''' Rosenbaum reviews the classification of ventricular premature beats and adds a benign form that arises from the right ventricle and is not associated with heart disease. This becomes known as the 'Rosenbaum ventricular extrasystole'. <cite>Rosenbaum</cite><br />
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'''1974''' Jay Cohn, of University of Minnesota Medical School, describes the 'syndrome of right ventricular dysfunction in the setting of acute inferior wall myocardial infarction'. <cite>Cohn</cite><br />
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'''1974''' Gozensky and Thorne introduce the term 'Rabbit ears' to electrocardiography. Rabbit ears describe the appearence of the QRS complex in lead V1 with an rSR' pattern (good rabbit) being typical of Right Bundle Branch Block and an RSr' (bad rabbit) suggesting a ventricular origin i.e. ventricular ectopy / tachycardia. <cite>Gozensky</cite><br />
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'''1976''' Erhardt and colleagues describe the use of a right-sided precordial lead in the diagnosis of right ventricular infarction which had previously been thought to be electrocardiographically silent. <cite>Erhardt</cite><br />
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'''1988''' Professor John Pope Boineau of Washington University School of Medicine publishes a 30-year percpective on the modern history of electrocardiography. <cite>Boineau</cite><br />
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[[image:Brugada.jpg|thumb|150px|left|Pedro Brugada]]'''1992''' Pedro Brugada and Josep brugada of Barcelona publish a series of 8 cases of sudden death, Right Bundle Branch Block pattern and ST elevation in V1 - V3 in apparently healthy individuals. This 'Brugada Syndrome' may account for 4-12% of unexpected sudden deaths and is the commonest cause of sudden cardiac death in individuals aged under 50 years in South Asia. The technology of the electrocardiogam, which is over 100 years old, can still be used to discover new clinical entities in cardiology. <cite>Brugada</cite><br />
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'''1992''' Cohen and He describe a new non-invasive approach to accurately map cardiac electrical activity by using the surface Laplacian map of the body surface electrical potentials. <cite>He</cite><br />
[[Image:modern_ecg.jpg|thumb|150px|The last generation of ECG equipment. Image courtesy of [http://www.gehealthcare.com/euen/cardiology/ General Electric]]]<br />
'''1993''' Robert Zalenski, Professor of Emergency Medicine, Wayne State University Detroit, and colleagues publish an influential article on the clinical use of the 15-lead ECG which routinely uses V4R, V8 and V9 in the diagnosis of acute coronary syndromes. Like the addition of the 6 standardised unipolar chest leads in 1938 these additional leads increase the sensitivity of the electrocardiogram in detecting myocardial infarction. <cite>Zalenski</cite><br />
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'''1999''' Researchers from Texas show that 12-lead ECGs transmitted via wireless technology to hand-held computers is feasible and can be interpreted reliably by cardiologists. <cite>Pettis</cite><br />
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'''2000''' Physicians from the Mayo Clinic describe a new hereditary form of Short QT syndrome associated with syncope and sudden death that they discovered in 1999. Several genes have since been implicated. <cite>Gussak</cite><br />
<br />
'''2005''' Danish cardiologists report the successful reduction in the time between onset of chest pain and primary angioplasty when the ECG of patients is transmitted wirelessly from ambulance to the cardiologist's handheld PDA (Personal Digital Assistant). The clinician can make an immediate decision to redirect patients to the catheter lab saving time in transfers between hospital departments. <cite>Clemmensen</cite><br />
<br />
'''2008''' Dr. Haïssaguerre et al. have studied ECGs from patients with idiopathic ventricular fibrillation and find that patients with early repolarization on their ECG (elevation of the QRS-ST junction of at least 0.1 mV from baseline, which is usually considered a benign finding) is associated with a doubled risk of ICD shock during follow up. <cite>Haiss</cite><br />
<br />
==External Links==<br />
*[http://www.ecglibrary.com/ecghist.html ECG history on ECGlibrary.com]<br />
*[http://www.hrsonline.org/News/ep-history/timeline/ History of electrophysiology on the website of the Heart Rhythm Society]<br />
<br />
==References==<br />
<biblio><br />
#Gozensky pmid=4495389<br />
#Erhardt pmid=1266713<br />
#Boineau pmid=3063766<br />
#Brugada pmid=1309182<br />
#He pmid=1487281<br />
#Zalenski pmid=8470834<br />
#Pettis pmid=10502225<br />
#Gussak pmid=11173780<br />
#Clemmensen pmid=16226101<br />
#Vulpian Vulpian A. 1874. ''Notes sur les éffets de la faradisation directe des ventricules du coeur chez le chien.'' Arch. Physiol. Norm. Path. 6: 975– 82 <br />
#Abildgaard Abildgaard, Peter Christian. ''Tentamina electrica in animalibus.'' Inst Soc Med Havn. 1775; 2:157-61. <br />
#Ader Ader C. ''Sur un nouvel appareil enregistreur pour cables sous-marins.'' C R Acad Sci (Paris) 1897;124:1440-1442 <br />
#Prevost Prevost JL, Batelli F: ''Sur quelques effets des descharges electriques sur le coeur des mammiferes.'' Acad. Sci. Paris, FR.: 1899; 129:1267-1268. <br />
#Holter Holter NJ, Generelli JA. ''Remote recording of physiologic data by radio.'' Rocky Mountain Med J. 1949;747-751.<br />
#Ernstine Ernstine AC, Levine SA. ''A comparison of records taken with the Einthoven string galvanomter and the amplifier-type electrocardiograph.'' Am Heart J 1928;4:725-731 <br />
#Dubois Du Bois-Reymond, E. ''Untersuchungen über thierische Elektricität''. Reimer, Berlin: 1848.<br />
#Waller Waller AD. ''A demonstration on man of electromotive changes accompanying the heart's beat.'' J Physiol (London) 1887;8:229-234 <br />
#Waller2 Waller AD. ''Introductory Address on The Electromotive Properties of the Human Heart''. Brit. Med J, 1888;2:751-754<br />
#Burch Burch GJ. ''On a method of determining the value of rapid variations of a difference potential by means of a capillary electrometer.'' Proc R Soc Lond (Biol) 1890;48:89-93<br />
#Chauveau Chauveau MA. ''De La Dissociation Du Rythme Auriculaire et du Rythme Ventriculaire.'' Rev. de Méd. Tome V. - Mars 1885: 161-173.<br />
#Hoffa Hoffa M, Ludwig C. 1850. ''Einige neue versuche uber herzbewegung''. Zeitschrift Rationelle Medizin, 9: 107-144<br />
#Waller Waller AD. ''A demonstration on man of electromotive changes accompanying the heart's beat.'' J Physiol (London) 1887;8:229-234<br />
#Wood Wood FC, Wolferth CC, Livezey MM. ''Angina pectoris.'' Archives Internal Medicine 1931;47:339 <br />
#Pardee Pardee HEB. ''An electrocardiographic sign of coronary artery obstruction.'' Arch Int Med 1920;26:244-257 <br />
#Sanders Sanders, A.O. ''Coronary thrombosis with complete heart block and relative ventricular tachycardia: a case report,'' American Heart Journal 1930;6:820-823. <br />
#Einthoven Einthoven W. ''Le telecardiogramme''. Arch Int de Physiol 1906;4:132-164<br />
#Einthoven2 Einthoven W. ''Über die Form des menschlichen Electrocardiogramms''. Pfügers Archiv march 1895, p 101-123<br />
#Einthoven3 Einthoven W. ''Un nouveau galvanometre.'' Arch Neerl Sc Ex Nat 1901;6:625-633 <br />
#Einthoven4 Einthoven W. ''Galvanometrische registratie van het menschilijk electrocardiogram. In: Herinneringsbundel Professor S. S. Rosenstein.'' Leiden: Eduard Ijdo, 1902:101-107 <br />
#Prinzmetal pmid=14434946<br />
#Marey Marey EJ. ''Des variations electriques des muscles et du couer en particulier etudies au moyen de l'electrometre de M <br />
Lippman.'' Compres Rendus Hebdomadaires des Seances de l'Acadamie des sciences 1876;82:975-977 <br />
#Gouaux Gouaux JL, Ashman R. ''Auricular fibrillation with aberration simulating ventricular paroxysmal tachycardia.'' Am Heart J 1947;34:366-73. <br />
#Marquez pmid=12177632<br />
#Hurst pmid=9799216<br />
#Gilbert Gilbert W. ''De Magnete, magneticisique corporibus, et de magno magnete tellure.'' 1600<br />
#Browne Browne, Sir Thomas. Pseudodoxia Epidemica: Or, enquiries Into Very Many Received Tenents, and Commonly Presumed Truths. 1646: Bk II, Ch. 1. London<br />
#Descartes Descartes R. De Homine (Treatise of Man); 1662: Moyardum & leffen, Leiden.<br />
#Bancroft Bancroft, E. ''An essay on the natural history of Guiana'', London:T. Becket and P. A. de Hondt, 1769.<br />
#Langendorf pmid=14352386<br />
#Zoll pmid=13309666<br />
#Dessertenne pmid=4956181<br />
#Jervell pmid=13435203<br />
#Wilson Wilson NF, Johnston FE, Macleod AG, Barker PS. ''Electrocardiograms that represent the potential variations of a single electrode.'' Am Heart J. 1934;9:447-458.<br />
#Sokolow pmid=18107386<br />
#Hyman Hyman AS. ''Resuscitation of the stopped heart by intracardial therapy.'' Arch Intern Med. 1932;50:283<br />
#Lewis Lewis T. ''Auricular fibrillation: a common clinical condition.'' BMJ 1909;42:1528.<br />
#Hay Hay J. ''Bradycardia and cardiac arrhythmias produced by depression of certain functions of the heart.'' Lancet 1906;1:138-143. <br />
#Bousfield Bousfield G. ''Angina pectoris: changes in electrocardiogram during paroxysm.'' Lancet 1918;2:475 <br />
#Mann Mann H. ''A method of analyzing the electrocardiogram.'' Arch Int Med 1920;25:283-294 <br />
#McGinn McGinn S, White PD. ''Acute cor pulmonale resulting from pulmonary embolism: its clinical recognition.'' JAMA 1935;114:1473.<br />
#Bigelow pmid=15433219<br />
#Romano pmid=14158288<br />
#Ward pmid=14136838<br />
#Bruce1 pmid=14070531<br />
#Bruce2 pmid=5261245<br />
#Baule pmid=14045992<br />
#Papouchado pmid=3653124<br />
#Rosenbaum pmid=4189497<br />
#Cohn pmid=4810018<br />
#Beck Beck CS, Pritchard WH, Feil SA: ''Ventricular fibrillation of long duration abolished by electric shock.'' JAMA 1947; 135: 985-989.<br />
#Wiggers Wiggers CJ, Wegria R. ''Ventricular fibrillation due to single localized induction in condenser shock supplied during the vulnerable phase of ventricular systole.'' Am J Physiol 1939;128:500 <br />
#Haiss pmid=1846337<br />
#McWilliam1 pmid=16991467<br />
#McWilliam2 McWilliam JA. ''Electrical stimulation of the heart in man.'' 1889. Br. Med. J. 1: 348 <br />
#Lewis Levy AG, Lewis T. ''Heart irregularities, resulting from the inhalation of low percentages of chloroform vapour, and their relationship to ventricular fibrillation.'' 1911. Heart 3: 99– 112 <br />
#Hoffman Hoffman A. ''Fibrillation of ventricles at the end of an attack of paroxysmal tachycardia in man''. 1912. Heart 3: 213– 18 <br />
#Bayliss1 Bayliss WM, Starling EH. ''On the electrical variations of the heart in man.'' Proc Phys Soc (14th November) in J Physiol (London) 1891;13:lviii-lix <br />
#Bayliss2 Bayliss WM, Starling EH. ''On the electromotive phenomena of the mammalian heart.'' Proc R Soc Lond 1892;50:211-214<br />
#Matteucci Matteucci C. ''Sur un phenomene physiologique produit par les muscles en contraction.'' Ann Chim Phys 1842;6:339-341<br />
#Bird Bird G. ''Lectures on Electricity and Galvanism, in their physiological and therapeutical relations, delivered at the Royal College of Physicians,'' in March, 1847 (Wilson & Ogilvy, London, 1847) <br />
#Walsh Walsh, J. ''On the electric property of torpedo:'' in a letter to Ben. Franklin. Phil. Trans. Royal Soc. 1773;63:478-489<br />
#Hoffa Hoffa M, Ludwig C. 1850. ''Einige neue versuche uber herzbewegung''. Zeitschrift Rationelle Medizin, 9: 107-144 <br />
</biblio></div>
KGoldin
https://en.ecgpedia.org/index.php?title=Introduction&diff=9973
Introduction
2010-01-26T04:40:31Z
<p>KGoldin: </p>
<hr />
<div>{{nav|<br />
|previouspage=/<br />
|previousname=/<br />
|nextpage=Basics<br />
|nextname=Basics<br />
}}<br />
{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|supervisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= <br />
}}<br />
[[Image:nsr.png|thumb| A short ECG registration of normal heart rhythm (sinus rhythm)]]<br />
The aim of this course is to enable the student to understand and recognize normal ECGs and interpret abnormalities. The course is divided into two different sections. First the '''[[basics]]''' will be presented. This is followed by the interpretation of the normal ECG according to the 7+2 step plan:<br />
==7+2 step plan==<br />
{{box|<br />
* Step 1: [[Rhythm]]<br />
* Step 2: [[Rate]]<br />
* Step 3: [[Conduction]] (PQ,QRS,QT)<br />
* Step 4: [[Heart axis]]<br />
* Step 5: [[P wave morphology]]<br />
* Step 6: [[QRS morphology]]<br />
* Step 7: [[ST morphology]]<br />
* Step 7+1: [[Compare_the_old_and_new_ECG|Compare the current ECG with a previous one]]<br />
* Step 7+2: [[Conclusion]]<br />
}}<br />
<br />
'''Note:''' It is important to realize that not all these steps may be applicable when you encounter ECG abnormalities. If, for example, the rhythm is not sinus in the [[Rhythm|first step]], the algorithm to analyze [[dysrhythmias]] should be followed. If a [[LBBB|Left Bundle Branch Block]] is present in [[Conduction|step 3]], [[ST morphology]] will be strongly influenced by this defect.<br />
<br />
Finally the '''real world''' is presented through [[Cases and Examples|'''practice ECGs''']].<br />
<br />
Afteryou have finished the course you are invited to come back to read more about abnormal ECGs in the '''ECG textbook'''.<br />
==ECG textbook==<br />
{{box|<br />
* [[Normal Tracing|Normal Tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus_node_rhythms_and_arrhythmias|Sinus Rhythms]]<br />
** [[Sinus Tachycardia]]<br />
** [[Sinus Bradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|Supraventricular]]<br />
** [[Junctional Tachycardias|Junctional]]<br />
** [[Ventricular Arrhythmias|Ventricular]]<br />
** [[Genetic Arrhythmias|Genetic]]<br />
** [[Ectopic Beats|Ectopic Beats]]<br />
* [[AV Conduction|AV Conduction]]<br />
* [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargement|Chamber Hypertrophy]]<br />
* [[Repolarization (ST-T,U) Abnormalities|Repolarization]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECGs in Athletes]]<br />
* [[Pediatric ECGs|ECGs in Children]]<br />
* [[Accuracy of Computer Interpretation]]<br />
}}<br />
Also read our '''[[Frequently Asked Questions]]''' section.<br />
{{clr}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Introduction&diff=9972
Introduction
2010-01-26T04:36:32Z
<p>KGoldin: </p>
<hr />
<div>{{nav|<br />
|previouspage=/<br />
|previousname=/<br />
|nextpage=Basics<br />
|nextname=Basics<br />
}}<br />
{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|supervisor=<br />
|coauthor=<br />
|moderator= [[user:Drj|J.S.S.G. de Jong, MD]]<br />
|editor= <br />
}}<br />
[[Image:nsr.png|thumb| A short ECG registration of normal heart rhythm (sinus rhythm)]]<br />
The aim of this course is to enable the student to understand and recognize normal ECGs and interpret abnormalities. The course is divided into two different sections. First the '''[[basics]]''' will be presented. This is followed by the interpretation of the normal ECG according to the 7+2 step plan:<br />
==7+2 step plan==<br />
{{box|<br />
* Step 1: [[Rhythm]]<br />
* Step 2: [[Rate]]<br />
* Step 3: [[Conduction]] (PQ,QRS,QT)<br />
* Step 4: [[Heart axis]]<br />
* Step 5: [[P wave morphology]]<br />
* Step 6: [[QRS morphology]]<br />
* Step 7: [[ST morphology]]<br />
* Step 7+1: [[Compare_the_old_and_new_ECG|Compare the current ECG with a previous one]]<br />
* Step 7+2: [[Conclusion]]<br />
}}<br />
<br />
'''Note:''' It is important to realize that not all these steps may be applicable when you encounter ECG abnormalities. If, for example, the rhythm is not sinus in the [[Rhythm|first step]], the algorithm to analyze [[dysrhythmias]] should be followed. If a [[LBBB|Left Bundle Branch Block]] is present in [[Conduction|step 3]], [[ST morphology]] will be strongly influenced by this defect.<br />
<br />
Finally the '''real world''' is presented through [[Cases and Examples|'''practice ECGs''']].<br />
<br />
Afteryou have finished the course you are invited to come back to read more about abnormal ECGs in the '''ECG textbook'''.<br />
==ECG textbook==<br />
{{box|<br />
* [[Normal Tracing|Normal Tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus_node_rhythms_and_arrhythmias|Sinus Rhythms]]<br />
** [[Sinus Tachycardia]]<br />
** [[Sinus Bradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|supraventricular]]<br />
** [[Junctional Tachycardias|junctional]]<br />
** [[Ventricular Arrhythmias|ventricular]]<br />
** [[Genetic Arrhythmias|genetic]]<br />
** [[Ectopic Beats|ectopic beats]]<br />
* [[AV Conduction|AV Conduction]]<br />
* [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargement|Chamber Hypertrophy]]<br />
* [[Repolarization (ST-T,U) Abnormalities|Repolarization]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECGs in Athletes]]<br />
* [[Pediatric ECGs|ECGs in Children]]<br />
* [[Accuracy of Computer Interpretation]]<br />
}}<br />
Also read our '''[[Frequently Asked Questions]]''' section.<br />
{{clr}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Frequently_Asked_Questions&diff=9864
Frequently Asked Questions
2010-01-22T22:46:53Z
<p>KGoldin: </p>
<hr />
<div>;What is ECGpedia?<br />
:ECGpedia is an free online electrocardiography (ECG) course and textbook. All content is freely accessible. Anyone can contribute to the website and changes are supervised by physicians. <br />
<br />
;Who are the people behind ECGpedia?<br />
:ECGpedia is an initiative of [http://cardionetworks.org Cardionetworks.org], a non-profit foundation whose goal is to advance medical knowledge, especially in the field of cardiology. The main contributors are: [[user:Drj|Jonas S.S.G. de Jong MD]], cardiology resident, author and moderator; [[user:Vdbilt|I.A.C. van der Bilt, MD]], cardiology resident, author and moderator; [[user:Tymen|Tymen T. Keller MD, PhD]], cardiology resident, author and moderator; [[user:Pgpostema|Pieter G. Postema MD]], cardiology research fellow, author and moderator; [http://www.medischeillustraties.nl Rob Kreuger], medical illustrator of most of the drawings; and [[user:Bart|Bart Duineveld]], medical student, helper with technical issues, animations and lay-out.<br />
<br />
;What is the relationship between ECGpedia and Wikipedia?<br />
:There is no relationship between ECGpedia and Wikipedia. Both websites use the same software and share the idea of open access to information. The founders of ECGpedia have chosen to build a separate website, since an encyclopedia format does not allow the course- like setup of ECGpedia. It would also be difficult to incorporate information like the De Voogt archive. Furthermore, the ECGpedia license is somewhat more restricted than the Wikipedia license: reference to the source is compulsory when information from ECGpedia is used. <br />
<br />
;How can I change / add content?<br />
:ECGpedia is based on [http://www.mediawiki.org Mediawiki], the same software that is used by the [http://www.wikipedia.org Wikipedia] encyclopedia. You are invited to improve this website. Simply click 'edit' to start. You will be redirected to an edit screen. Read this [http://meta.wikimedia.org/wiki/Help:Editing tutorial] and this [http://en.wikipedia.org/wiki/Wikipedia:Cheatsheet cheatsheet] to learn how to improve the readability of your edits. All edits are screened by physician moderators. DO NOT SUBMIT COPYRIGHTED WORK WITHOUT PERMISSION!<br />
: If you edit a page, please provide references to the source of the information. Please only post statements that are true and correct to your knowledge. Additions that are phrased in an objective and scientific manner and that are up-to-date are valued most by the editors.<br />
<br />
;Can I use a certain image / animation / video / piece of text in a non-commercial presentation?<br />
:Yes, in most cases you can. All material that is made by or for the Cardionetworks foundation is available under a [http://creativecommons.org/licenses/by-nc/3.0/nl/deed.en_GB Creative Commons Attribution Noncommercial Share-Alike] license. This means you it is free to use it for non-commercial use under the condition that you credit the author and it's origin (e.g. state somewhere readable: ''ECG courtesy of Dr. De Voogt and ECGpedia.org'' if you would use one of Dr De Voogts ECGs for a presentation). We do appreciate it when you [http://www.cardionetworks.org/contactCN.php let us know] that you have used content from ECGpedia, just to have an idea who our audience is. <br />
<br />
:There are certain exceptions to this rule. Some images on ECGpedia were provided by book or journal publishers who gave us permission to use that image on this site. The descriptions of these images will read something like: "reproduced with permission from...". If you want to use such items, you will have to ask the entity that holds the copyright. <br />
<br />
;Can I use a certain image / animation / video / piece of text in a commercial presentation?<br />
:In general yes, but not without asking. In general we will not object your using any of our material as long as you do not copy-paste the whole website on a CD and sell it for money :-)... Please [http://www.cardionetworks.org/contact/ e-mail us for permission].<br />
<br />
;How can I use a flash movie from your site in my powerpoint presentation?<br />
:Read [http://www.adobe.com/go/tn_18822 this document] by Adobe to learn how.<br />
<br />
;When do I know enough to say that I can confidently interpret ECGs?<br />
:Of course, there is no definite answer to this question. However, the American College of Cardiology has published a list of [[ACC list|abnormalities a professional should be able to recognize]]. It is advisable to go through this list at the end of the course in order to recognize areas that need your attention. Understanding every item on the list does not guarantee that you will make the right decisions in every clinical situation.<br />
<br />
;My own ECG shows an abnormality what should I do?<br />
:The information on this site should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. For questions like these we advise you to contact your physician.<br />
<br />
;Can I trust the information on your site?<br />
:Please read our [[ECGpedia:General_disclaimer|disclaimers]].<br />
<br />
;Do you protect the privacy of the patients whose ECGs / images / cases are presented?<br />
{{ECGpedia:Privacy_policy}}<br />
<br />
;What is the financial source of this project?<br />
:The [http://cardionetworks.org Cardionetworks.org] foundation is a non-profit charity foundation. The content of all websites maintained by the Cardionetworks foundation is not influenced by sponsors. Current benefactors are summed on the [http://www.cardionetworks.org/benefactors-of-the-foundation/ Foundations website]. Feel free to [http://www.cardionetworks.org/contact/ contact the foundation] if you would like to sponsor or have sponsorship suggestions. We do not allow any advertisements on our sites. We also do not allow sponsors to influence any contents.<br />
:Any form of advertisement introduced by user edits (links, banners, content, etc.) is not permitted.<br />
<br />
;How can I contact you?<br />
:Please contact the [http://www.cardionetworks.org/contact/ secretary of Cardionetworks] for any further questions.<br />
<br />
;How can I contribute content to ECGpedia?<br />
{{:Contribute to ECGpedia}}<br />
<br />
We subscribe to the [http://www.hon.ch/HONcode/Conduct.html?HONConduct571624 HONcode] principles of the Health On the Net Foundation. [[Image:HONConduct571624.gif]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Frequently_Asked_Questions&diff=9863
Frequently Asked Questions
2010-01-22T22:45:05Z
<p>KGoldin: </p>
<hr />
<div>;What is ECGpedia?<br />
:ECGpedia is an free online electrocardiography (ECG) course and textbook. All content is freely accessible. Anyone can contribute to the website and changes are supervised by physicians. <br />
<br />
;Who are the people behind ECGpedia?<br />
:ECGpedia is an initiative of [http://cardionetworks.org Cardionetworks.org], a non-profit foundation whose goal is to advance medical knowledge, especially in the field of cardiology. The main contributors are: [[user:Drj|Jonas S.S.G. de Jong MD]], cardiology resident, author and moderator; [[user:Vdbilt|I.A.C. van der Bilt, MD]], cardiology resident, author and moderator; [[user:Tymen|Tymen T. Keller MD, PhD]], cardiology resident, author and moderator; [[user:Pgpostema|Pieter G. Postema MD]], cardiology research fellow, author and moderator; [http://www.medischeillustraties.nl Rob Kreuger], medical illustrator, made most of the drawings; and [[user:Bart|Bart Duineveld]], medical student, helps with technical issues, animations and lay-out.<br />
<br />
;What is the relationship between ECGpedia and Wikipedia?<br />
:There is no relationship between ECGpedia and Wikipedia. Both websites use the same software and share the idea of open access to information. The founders of ECGpedia have chosen to build a separate website, since an encyclopedia format does not allow the course- like setup of ECGpedia. It would also be difficult to incorporate information like the De Voogt archive. Furthermore, the ECGpedia license is somewhat more restricted than the Wikipedia license: reference to the source is compulsory when information from ECGpedia is used. <br />
<br />
;How can I change / add content?<br />
:ECGpedia is based on [http://www.mediawiki.org Mediawiki], the same software that is used by the [http://www.wikipedia.org Wikipedia] encyclopedia. You are invited to improve this website. Simply click 'edit' to start. You will be redirected to an edit screen. Read this [http://meta.wikimedia.org/wiki/Help:Editing tutorial] and this [http://en.wikipedia.org/wiki/Wikipedia:Cheatsheet cheatsheet] to learn how to improve the readability of your edits. All edits are screened by physician moderators. DO NOT SUBMIT COPYRIGHTED WORK WITHOUT PERMISSION!<br />
: If you edit a page, please provide references to the source of the information. Please only post statements that are true and correct to your knowledge. Additions that are phrased in an objective and scientific manner and that are up-to-date are valued most by the editors.<br />
<br />
;Can I use a certain image / animation / video / piece of text in a non-commercial presentation?<br />
:Yes, in most cases you can. All material that is made by or for the Cardionetworks foundation is available under a [http://creativecommons.org/licenses/by-nc/3.0/nl/deed.en_GB Creative Commons Attribution Noncommercial Share-Alike] license. This means you it is free to use it for non-commercial use under the condition that you credit the author and it's origin (e.g. state somewhere readable: ''ECG courtesy of Dr. De Voogt and ECGpedia.org'' if you would use one of Dr De Voogts ECGs for a presentation). We do appreciate it when you [http://www.cardionetworks.org/contactCN.php let us know] that you have used content from ECGpedia, just to have an idea who our audience is. <br />
<br />
:There are certain exceptions to this rule. Some images on ECGpedia were provided by book or journal publishers who gave us permission to use that image on this site. The descriptions of these images will read something like: "reproduced with permission from...". If you want to use such items, you will have to ask the entity that holds the copyright. <br />
<br />
;Can I use a certain image / animation / video / piece of text in a commercial presentation?<br />
:In general yes, but not without asking. In general we will not object your using any of our material as long as you do not copy-paste the whole website on a CD and sell it for money :-)... Please [http://www.cardionetworks.org/contact/ e-mail us for permission].<br />
<br />
;How can I use a flash movie from your site in my powerpoint presentation?<br />
:Read [http://www.adobe.com/go/tn_18822 this document] by Adobe to learn how.<br />
<br />
;When do I know enough to say that I can confidently interpret ECGs?<br />
:Of course, there is no definite answer to this question. However, the American College of Cardiology has published a list of [[ACC list|abnormalities a professional should be able to recognize]]. It is advisable to go through this list at the end of the course in order to recognize areas that need your attention. Understanding every item on the list does not guarantee that you will make the right decisions in every clinical situation.<br />
<br />
;My own ECG shows an abnormality what should I do?<br />
:The information on this site should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. For questions like these we advise you to contact your physician.<br />
<br />
;Can I trust the information on your site?<br />
:Please read our [[ECGpedia:General_disclaimer|disclaimers]].<br />
<br />
;Do you protect the privacy of the patients whose ECGs / images / cases are presented?<br />
{{ECGpedia:Privacy_policy}}<br />
<br />
;What is the financial source of this project?<br />
:The [http://cardionetworks.org Cardionetworks.org] foundation is a non-profit charity foundation. The content of all websites maintained by the Cardionetworks foundation is not influenced by sponsors. Current benefactors are summed on the [http://www.cardionetworks.org/benefactors-of-the-foundation/ Foundations website]. Feel free to [http://www.cardionetworks.org/contact/ contact the foundation] if you would like to sponsor or have sponsorship suggestions. We do not allow any advertisements on our sites. We also do not allow sponsors to influence any contents.<br />
:Any form of advertisement introduced by user edits (links, banners, content, etc.) is not permitted.<br />
<br />
;How can I contact you?<br />
:Please contact the [http://www.cardionetworks.org/contact/ secretary of Cardionetworks] for any further questions.<br />
<br />
;How can I contribute content to ECGpedia?<br />
{{:Contribute to ECGpedia}}<br />
<br />
We subscribe to the [http://www.hon.ch/HONcode/Conduct.html?HONConduct571624 HONcode] principles of the Health On the Net Foundation. [[Image:HONConduct571624.gif]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9862
Main Page
2010-01-22T22:38:34Z
<p>KGoldin: </p>
<hr />
<div>__NOTOC__<br />
<!-- BANNER ACROSS TOP OF PAGE --><br />
{| id="mp-topbanner" style="width:100%; background:#fcfcfc; margin-top:-1em; border:1px solid #ccc;"<br />
| style="width:56%; color:#000;" |<br />
<!-- "WELCOME TO ECGPEDIA" AND ARTICLE COUNT --><br />
{| style="width:280px; border:none; background:none;"<br />
| style="width:280px; text-align:center; white-space:nowrap; color:#000;" |<br />
<div style="font-size:162%; border:none; margin:0; padding:.1em; color:#000;">Welcome to [[Frequently_Asked_Questions|ECGpedia]],</div><br />
<div style="top:+0.2em; font-size:95%;">a free electrocardiography (ECG) course and textbook to which anyone can contribute ,<br /> designed for medical professionals such as cardiac care nurses and physicians.</div><br />
<div id="articlecount" style="width:100%; text-align:center; font-size:85%;">ECGpedia has received more than 250.000 visitors from 188 countries.</div><br />
|}<br />
<!-- PORTAL LIST ON RIGHT-HAND SIDE --><br />
| style="width:15%; font-size:95%;" |<br />
* [[ECG course|ECG course]]<br />
* [[Textbook|ECG textbook]]<br />
* [[Practice ECGs|Practice ECGs]]<br />
| style="width:15%; font-size:95%;" |<br />
* [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECGpedia pocket reference card]<br />
| style="width:15%; font-size:95%;" |<br />
* [[Frequently_Asked_Questions|FAQ]]<br />
* [http://www.cardionetworks.org/benefactors-of-the-foundation/ Benefactors]<br />
* [http://www.cardionetworks.org/contact/ecgpedia-feedback/ Contact]<br />
|}<br />
<!-- 3 boxes --><br />
<div style="padding:10px"><br />
<!-- course boxes --><br />
{| width="100%" cellspacing="5"<br />
|-<br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Course</h2><br />
<div align="center">[[File:Course.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">ECG course</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
#[[Rhythm]]<br />
#[[Rate]]<br />
#[[Conduction|Conduction (PQ,QRS,QT)]]<br />
#[[Heart Axis]]<br />
#[[P Wave Morphology]]<br />
#[[QRS Morphology]]<br />
#[[ST Morphology]]<br />
| valign="top" align="left"|<br />
#[[Compare_the_Old_and_New_ECG|Compare with previous ECG]] <br />
#[[Conclusion]]<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG reference pocket card]</div><br />
<div style="border:1px solid #ccc;padding:3px;margin-top:8px;background:white">[[File:ECG_reference_card_thumbnail.jpg|link=printing instructions|200px]]</div><div style="font-size:8pt">Download and print our '''[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG Reference Card] as PDF''' (new improved version November 2009!, read the [[printing instructions]])</div><br />
<div style="text-align:center;font-size:8pt;border-top:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;"><br />
[http://nl.ecgpedia.org/wiki/Powerpoint_presentaties_van_ECG_cursussen Ready-made presentation files for ECG courses (in Dutch)].<br />
</div><br />
</div><br />
<!--start 2nd center box--><br />
|style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Textbook</h2><br />
<div align="center">[[File:book.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Browse the [[Textbook|ECG Textbook]]:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal Tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus Node Rhythms and Arrhythmias|Sinus Rhythms]]<br />
** [[Sinus Tachycardia]]<br />
** [[Sinus Bradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|Supraventricular]]<br />
** [[Junctional Tachycardias|Junctional]]<br />
** [[Ventricular Arrhythmias|Ventricular]]<br />
** [[Genetic Arrhythmias|Genetic]]<br />
***[[Long QT Syndrome|LQTS]]<br />
***[[Brugada Syndrome|Brugada]]<br />
***[[Arrythmogenic Right Ventricular Cardiomyopathy|ARVD]]<br />
***[[Catecholamine-Induced Ventricular Tachycardia|CPVT]]<br />
** [[Ectopic Complexes|Ectopic Complexes]]<br />
* Conduction<br />
** [[AV Conduction|AV Conduction]]<br />
** [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargment|Chamber Hypertrophy]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECG in Athletes]]<br />
* [[Pediatric ECGs|ECG in Children]]<br />
* [[Accuracy of computer interpretation]]<br />
* [[Special:Allpages| A-Z index]]<br />
|}<br />
</div><br />
<!--start 3nd right box--><br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">Cases and Examples</h2><br />
<div align="center">[[File:cases.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Cases:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
*[[Guess the Culprit]]<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*[[Rarities]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 ECGs<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[[DV_Case_4|ECG Case of the Month]]</div><br />
<div style="padding:5px;background:white;border:1px solid #ccc;"><br />
<div align="center" style="margin-top:15px;"><br />
<div align="center">[[File:DVA0004.jpg|A slow heart beat|link=|200px]]</div><br />
[[DV_Case_4| A slow heart beat]]<br />
</div><br />
</div><br />
</div><br />
|}<br />
</div><br />
<!--end of main boxes --><br />
<!--start in other language --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''ECGpedia in other languages.'''</h2><br />
*ECGpedia is also available in [http://nl.ecgpedia.org '''Dutch'''].<br />
*We are '''looking for translators''' for other languages! Please [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact us] for more information if you would like to help.<br />
</div><br />
</div><br />
<!--end in other language --><br />
<!--start popular item --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''Popular items'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.linkedin.com/groups?gid=1872552 LinkedIn Cardionetworks Group] is a meeting for interested users and editors.<br />
*The [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf whole course on 1 A4 paper.]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
*Measuring the QT Interval - [[Conduction#The_QT_Interval|Beginners]] - [[Difficult QT|advanced]]<br />
*Calculate the QTc with the [[QTc Calculator]] Using the QT Interval and the Heart Rate.<br />
*[[Brugada Syndrome]]<br />
*[[Aivr|Accelerated Idioventricular Rhythm]]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
|<br />
{| class="wikitable" align="right" style="margin:0px;border:1px solid #a3bfb1;"<br />
|<flashow>http://nl.ecgpedia.org/images/c/cc/Heartaxis.swf|height=250px|width=100%|</flashow><br />
|-<br />
| <small>The [[Heart_axis|Heart axis simulator]], made by Bart Duineveld. '''Click and drag''' the heart axis arrow to change the axis.</small><br />
|}<br />
|}<br />
</div><br />
</div><br />
<!--end popular item --><br />
<!--start news--><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px;"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''News & Background'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.cardionetworks.org/timeline/ historic timeline] of the Cardionetworks Foundation shows the development.<br />
*All Cardionetworks sites now run on green power from NaturEnergie AG.<br />
*April 2008. Due to high traffic, all websites have been moved to a new server.<br />
*The first [[media:Normal_SR.swf|animation]] made by Bart Duineveld for ECGpedia is finished.<br />
*Give us feedback on how to improve this site: [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact / feedback form].<br />
*ECGpedia.org is part of [http://www.cardionetworks.org Cardionetworks].<br />
*Read the section with [[Frequently Asked Questions]] for more information.<br />
*[[Authors|These people]] have contributed to ECGpedia. <br />
*Also read how you can [[Contributing to ECGpedia|contribute to ECGpedia]]! <br />
*Follow the [[Timeline|development of ECGpedia]].<br />
*General [[References]].<br />
| width="50%" align="right" |<br />
<flashow>http://nl.ecgpedia.org/images/0/09/Normal_SR.swf|align=right|height=300px|width=300px</flashow><br />
|}<br />
</div><br />
</div><br />
<!--end news --><br />
<br />
[[nl:Hoofdpagina]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9861
Main Page
2010-01-22T22:35:50Z
<p>KGoldin: </p>
<hr />
<div>__NOTOC__<br />
<!-- BANNER ACROSS TOP OF PAGE --><br />
{| id="mp-topbanner" style="width:100%; background:#fcfcfc; margin-top:-1em; border:1px solid #ccc;"<br />
| style="width:56%; color:#000;" |<br />
<!-- "WELCOME TO ECGPEDIA" AND ARTICLE COUNT --><br />
{| style="width:280px; border:none; background:none;"<br />
| style="width:280px; text-align:center; white-space:nowrap; color:#000;" |<br />
<div style="font-size:162%; border:none; margin:0; padding:.1em; color:#000;">Welcome to [[Frequently_Asked_Questions|ECGpedia]],</div><br />
<div style="top:+0.2em; font-size:95%;">a free electrocardiography (ECG) course and textbook to which anyone can contribute ,<br /> designed for medical professionals such as cardiac care nurses and physicians.</div><br />
<div id="articlecount" style="width:100%; text-align:center; font-size:85%;">ECGpedia has received more than 250.000 visitors from 188 countries.</div><br />
|}<br />
<!-- PORTAL LIST ON RIGHT-HAND SIDE --><br />
| style="width:15%; font-size:95%;" |<br />
* [[ECG course|ECG course]]<br />
* [[Textbook|ECG textbook]]<br />
* [[Practice ECGs|Practice ECGs]]<br />
| style="width:15%; font-size:95%;" |<br />
* [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECGpedia pocket reference card]<br />
| style="width:15%; font-size:95%;" |<br />
* [[Frequently_Asked_Questions|FAQ]]<br />
* [http://www.cardionetworks.org/benefactors-of-the-foundation/ Benefactors]<br />
* [http://www.cardionetworks.org/contact/ecgpedia-feedback/ Contact]<br />
|}<br />
<!-- 3 boxes --><br />
<div style="padding:10px"><br />
<!-- course boxes --><br />
{| width="100%" cellspacing="5"<br />
|-<br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Course</h2><br />
<div align="center">[[File:Course.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">ECG course</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
#[[Rhythm]]<br />
#[[Rate]]<br />
#[[Conduction|Conduction (PQ,QRS,QT)]]<br />
#[[Heart Axis]]<br />
#[[P Wave Morphology]]<br />
#[[QRS Morphology]]<br />
#[[ST Morphology]]<br />
| valign="top" align="left"|<br />
#[[Compare_the_Old_and_New_ECG|Compare with previous ECG]] <br />
#[[Conclusion]]<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG reference pocket card]</div><br />
<div style="border:1px solid #ccc;padding:3px;margin-top:8px;background:white">[[File:ECG_reference_card_thumbnail.jpg|link=printing instructions|200px]]</div><div style="font-size:8pt">Download and print our '''[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG Reference Card] as PDF''' (new improved version November 2009!, read the [[printing instructions]])</div><br />
<div style="text-align:center;font-size:8pt;border-top:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;"><br />
[http://nl.ecgpedia.org/wiki/Powerpoint_presentaties_van_ECG_cursussen Ready-made presentation files for ECG courses (in Dutch)].<br />
</div><br />
</div><br />
<!--start 2nd center box--><br />
|style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Textbook</h2><br />
<div align="center">[[File:book.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Browse the [[Textbook|ECG Textbook]]:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal Tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus Node Rhythms and Arrhythmias|Sinus Rhythms]]<br />
** [[Sinus Tachycardia]]<br />
** [[Sinus Bradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|Supraventricular]]<br />
** [[Junctional Tachycardias|Junctional]]<br />
** [[Ventricular Arrhythmias|Ventricular]]<br />
** [[Genetic Arrhythmias|Genetic]]<br />
***[[Long QT Syndrome|LQTS]]<br />
***[[Brugada Syndrome|Brugada]]<br />
***[[Arrythmogenic Right Ventricular Cardiomyopathy|ARVD]]<br />
***[[Catecholamine-Induced Ventricular Tachycardia|CPVT]]<br />
** [[Ectopic Complexes|Ectopic Complexes]]<br />
* Conduction<br />
** [[AV Conduction|AV Conduction]]<br />
** [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargment|Chamber Hypertrophy]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECG in Athletes]]<br />
* [[Pediatric ECGs|ECG in Children]]<br />
* [[Accuracy of computer interpretation]]<br />
* [[Special:Allpages| A-Z index]]<br />
|}<br />
</div><br />
<!--start 3nd right box--><br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">Cases and Examples</h2><br />
<div align="center">[[File:cases.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Cases:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
*[[Guess the Culprit]]<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*[[Rarities]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 ECGs<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[[DV_Case_4|ECG Case of the Month]]</div><br />
<div style="padding:5px;background:white;border:1px solid #ccc;"><br />
<div align="center" style="margin-top:15px;"><br />
<div align="center">[[File:DVA0004.jpg|A slow heart beat|link=|200px]]</div><br />
[[DV_Case_4| A slow heart beat]]<br />
</div><br />
</div><br />
</div><br />
|}<br />
</div><br />
<!--end of main boxes --><br />
<!--start in other language --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''ECGpedia in other languages.'''</h2><br />
*ECGpedia is also available in [http://nl.ecgpedia.org '''Dutch'''].<br />
*We are '''looking for translators''' for other languages! Please [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact us] for more information if you would like to help.<br />
</div><br />
</div><br />
<!--end in other language --><br />
<!--start popular item --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''Popular items'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.linkedin.com/groups?gid=1872552 LinkedIn Cardionetworks Group] is a meeting for interested users and editors.<br />
*The [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf whole course on 1 A4 paper.]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
*Measuring the QT Interval - [[Conduction#The_QT_Interval|Beginners]] - [[Difficult QT|advanced]]<br />
*Calculate the QTc with the [[QTc Calculator]] Using the QT Interval and the Heart Rate<br />
*[[Brugada Syndrome]]<br />
*[[Aivr|Accelerated Idioventricular Rhythm]]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
|<br />
{| class="wikitable" align="right" style="margin:0px;border:1px solid #a3bfb1;"<br />
|<flashow>http://nl.ecgpedia.org/images/c/cc/Heartaxis.swf|height=250px|width=100%|</flashow><br />
|-<br />
| <small>The [[Heart_axis|Heart axis simulator]], made by Bart Duineveld. '''Click and drag''' the heart axis arrow to change the axis.</small><br />
|}<br />
|}<br />
</div><br />
</div><br />
<!--end popular item --><br />
<!--start news--><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px;"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''News & Background'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.cardionetworks.org/timeline/ historic timeline] of the Cardionetworks Foundation shows the development.<br />
*All Cardionetworks sites now run on green power from NaturEnergie AG.<br />
*April 2008. Due to high traffic, all websites have been moved to a new server.<br />
*The first [[media:Normal_SR.swf|animation]] made by Bart Duineveld for ECGpedia is finished.<br />
*Give us feedback on how to improve this site: [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact / feedback form].<br />
*ECGpedia.org is part of [http://www.cardionetworks.org Cardionetworks].<br />
*Read the section with [[Frequently Asked Questions]] for more information.<br />
*[[Authors|These people]] have contributed to ECGpedia. <br />
*Also read how you can [[Contributing to ECGpedia|contribute to ECGpedia]]! <br />
*Follow the [[Timeline|development of ECGpedia]].<br />
*General [[References]].<br />
| width="50%" align="right" |<br />
<flashow>http://nl.ecgpedia.org/images/0/09/Normal_SR.swf|align=right|height=300px|width=300px</flashow><br />
|}<br />
</div><br />
</div><br />
<!--end news --><br />
<br />
[[nl:Hoofdpagina]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9860
Main Page
2010-01-22T22:33:25Z
<p>KGoldin: </p>
<hr />
<div>__NOTOC__<br />
<!-- BANNER ACROSS TOP OF PAGE --><br />
{| id="mp-topbanner" style="width:100%; background:#fcfcfc; margin-top:-1em; border:1px solid #ccc;"<br />
| style="width:56%; color:#000;" |<br />
<!-- "WELCOME TO ECGPEDIA" AND ARTICLE COUNT --><br />
{| style="width:280px; border:none; background:none;"<br />
| style="width:280px; text-align:center; white-space:nowrap; color:#000;" |<br />
<div style="font-size:162%; border:none; margin:0; padding:.1em; color:#000;">Welcome to [[Frequently_Asked_Questions|ECGpedia]],</div><br />
<div style="top:+0.2em; font-size:95%;">a free electrocardiography (ECG) course and textbook to which anyone can contribute ,<br /> designed for medical professionals such as cardiac care nurses and physicians.</div><br />
<div id="articlecount" style="width:100%; text-align:center; font-size:85%;">ECGpedia has received more than 250.000 visitors from 188 countries.</div><br />
|}<br />
<!-- PORTAL LIST ON RIGHT-HAND SIDE --><br />
| style="width:15%; font-size:95%;" |<br />
* [[ECG course|ECG course]]<br />
* [[Textbook|ECG textbook]]<br />
* [[Practice ECGs|Practice ECGs]]<br />
| style="width:15%; font-size:95%;" |<br />
* [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECGpedia pocket reference card]<br />
| style="width:15%; font-size:95%;" |<br />
* [[Frequently_Asked_Questions|FAQ]]<br />
* [http://www.cardionetworks.org/benefactors-of-the-foundation/ Benefactors]<br />
* [http://www.cardionetworks.org/contact/ecgpedia-feedback/ Contact]<br />
|}<br />
<!-- 3 boxes --><br />
<div style="padding:10px"><br />
<!-- course boxes --><br />
{| width="100%" cellspacing="5"<br />
|-<br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Course</h2><br />
<div align="center">[[File:Course.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">ECG course</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
#[[Rhythm]]<br />
#[[Rate]]<br />
#[[Conduction|Conduction (PQ,QRS,QT)]]<br />
#[[Heart Axis]]<br />
#[[P Wave Morphology]]<br />
#[[QRS Morphology]]<br />
#[[ST Morphology]]<br />
| valign="top" align="left"|<br />
#[[Compare_the_Old_and_New_ECG|Compare with previous ECG]] <br />
#[[Conclusion]]<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG reference pocket card]</div><br />
<div style="border:1px solid #ccc;padding:3px;margin-top:8px;background:white">[[File:ECG_reference_card_thumbnail.jpg|link=printing instructions|200px]]</div><div style="font-size:8pt">Download and print our '''[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG Reference Card] as PDF''' (new improved version November 2009!, read the [[printing instructions]])</div><br />
<div style="text-align:center;font-size:8pt;border-top:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;"><br />
[http://nl.ecgpedia.org/wiki/Powerpoint_presentaties_van_ECG_cursussen Ready-made presentation files for ECG courses (in Dutch)].<br />
</div><br />
</div><br />
<!--start 2nd center box--><br />
|style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Textbook</h2><br />
<div align="center">[[File:book.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Browse the [[Textbook|ECG Textbook]]:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal Tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus Node Rhythms and Arrhythmias|Sinus Rhythms]]<br />
** [[Sinus Tachycardia]]<br />
** [[Sinus Bradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|Supraventricular]]<br />
** [[Junctional Tachycardias|Junctional]]<br />
** [[Ventricular Arrhythmias|Ventricular]]<br />
** [[Genetic Arrhythmias|Genetic]]<br />
***[[Long QT Syndrome|LQTS]]<br />
***[[Brugada Syndrome|Brugada]]<br />
***[[Arrythmogenic Right Ventricular Cardiomyopathy|ARVD]]<br />
***[[Catecholamine-Induced Ventricular Tachycardia|CPVT]]<br />
** [[Ectopic Complexes|Ectopic Complexes]]<br />
* Conduction<br />
** [[AV Conduction|AV Conduction]]<br />
** [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargment|Chamber Hypertrophy]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECG in Athletes]]<br />
* [[Pediatric ECGs|ECG in Children]]<br />
* [[Accuracy of computer interpretation]]<br />
* [[Special:Allpages| A-Z index]]<br />
|}<br />
</div><br />
<!--start 3nd right box--><br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">Cases and Examples</h2><br />
<div align="center">[[File:cases.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Cases:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
*[[Guess the Culprit]]<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*[[Rarities]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 ECGs<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[[DV_Case_4|ECG Case of the Month]]</div><br />
<div style="padding:5px;background:white;border:1px solid #ccc;"><br />
<div align="center" style="margin-top:15px;"><br />
<div align="center">[[File:DVA0004.jpg|A slow heart beat|link=|200px]]</div><br />
[[DV_Case_4| A slow heart beat]]<br />
</div><br />
</div><br />
</div><br />
|}<br />
</div><br />
<!--end of main boxes --><br />
<!--start in other language --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''ECGpedia in other languages.'''</h2><br />
*ECGpedia is also available in [http://nl.ecgpedia.org '''Dutch'''].<br />
*We are '''looking for translators''' for other languages! Please [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact us] for more information if you would like to help.<br />
</div><br />
</div><br />
<!--end in other language --><br />
<!--start popular item --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''Popular items'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.linkedin.com/groups?gid=1872552 LinkedIn Cardionetworks Group] is a meeting for interested users and editors.<br />
*The [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf whole course on 1 A4 paper.]<br />
*[[LBBB|Left bundle branch block]]<br />
*Measuring the QT interval - [[Conduction#The_QT_interval|beginners]] - [[Difficult QT|advanced]]<br />
*Calculate the QTc with the [[QTc calculator]] using the QT interval and the heart rate<br />
*[[Brugada Syndrome]]<br />
*[[Aivr|Accelerated Idioventricular Rhythm]]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
|<br />
{| class="wikitable" align="right" style="margin:0px;border:1px solid #a3bfb1;"<br />
|<flashow>http://nl.ecgpedia.org/images/c/cc/Heartaxis.swf|height=250px|width=100%|</flashow><br />
|-<br />
| <small>The [[Heart_axis|Heart axis simulator]], made by Bart Duineveld. '''Click and drag''' the heart axis arrow to change the axis.</small><br />
|}<br />
|}<br />
</div><br />
</div><br />
<!--end popular item --><br />
<!--start news--><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px;"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''News & Background'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.cardionetworks.org/timeline/ historic timeline] of the Cardionetworks Foundation shows the development.<br />
*All Cardionetworks sites now run on green power from NaturEnergie AG.<br />
*April 2008. Due to high traffic, all websites have been moved to a new server.<br />
*The first [[media:Normal_SR.swf|animation]] made by Bart Duineveld for ECGpedia is finished.<br />
*Give us feedback on how to improve this site: [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact / feedback form].<br />
*ECGpedia.org is part of [http://www.cardionetworks.org Cardionetworks].<br />
*Read the section with [[Frequently Asked Questions]] for more information.<br />
*[[Authors|These people]] have contributed to ECGpedia. <br />
*Also read how you can [[Contributing to ECGpedia|contribute to ECGpedia]]! <br />
*Follow the [[Timeline|development of ECGpedia]].<br />
*General [[References]].<br />
| width="50%" align="right" |<br />
<flashow>http://nl.ecgpedia.org/images/0/09/Normal_SR.swf|align=right|height=300px|width=300px</flashow><br />
|}<br />
</div><br />
</div><br />
<!--end news --><br />
<br />
[[nl:Hoofdpagina]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9859
Main Page
2010-01-22T22:29:38Z
<p>KGoldin: </p>
<hr />
<div>__NOTOC__<br />
<!-- BANNER ACROSS TOP OF PAGE --><br />
{| id="mp-topbanner" style="width:100%; background:#fcfcfc; margin-top:-1em; border:1px solid #ccc;"<br />
| style="width:56%; color:#000;" |<br />
<!-- "WELCOME TO ECGPEDIA" AND ARTICLE COUNT --><br />
{| style="width:280px; border:none; background:none;"<br />
| style="width:280px; text-align:center; white-space:nowrap; color:#000;" |<br />
<div style="font-size:162%; border:none; margin:0; padding:.1em; color:#000;">Welcome to [[Frequently_Asked_Questions|ECGpedia]],</div><br />
<div style="top:+0.2em; font-size:95%;">a free electrocardiography (ECG) course and textbook to which anyone can contribute ,<br /> designed for medical professionals such as cardiac care nurses and physicians.</div><br />
<div id="articlecount" style="width:100%; text-align:center; font-size:85%;">ECGpedia has received more than 250.000 visitors from 188 countries.</div><br />
|}<br />
<!-- PORTAL LIST ON RIGHT-HAND SIDE --><br />
| style="width:15%; font-size:95%;" |<br />
* [[ECG course|ECG course]]<br />
* [[Textbook|ECG textbook]]<br />
* [[Practice ECGs|Practice ECGs]]<br />
| style="width:15%; font-size:95%;" |<br />
* [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECGpedia pocket reference card]<br />
| style="width:15%; font-size:95%;" |<br />
* [[Frequently_Asked_Questions|FAQ]]<br />
* [http://www.cardionetworks.org/benefactors-of-the-foundation/ Benefactors]<br />
* [http://www.cardionetworks.org/contact/ecgpedia-feedback/ Contact]<br />
|}<br />
<!-- 3 boxes --><br />
<div style="padding:10px"><br />
<!-- course boxes --><br />
{| width="100%" cellspacing="5"<br />
|-<br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Course</h2><br />
<div align="center">[[File:Course.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">ECG course</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
#[[Rhythm]]<br />
#[[Rate]]<br />
#[[Conduction|Conduction (PQ,QRS,QT)]]<br />
#[[Heart axis]]<br />
#[[P wave morphology]]<br />
#[[QRS morphology]]<br />
#[[ST morphology]]<br />
| valign="top" align="left"|<br />
#[[Compare_the_Old_and_New_ECG|Compare with previous ECG]] <br />
#[[Conclusion]]<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG reference pocket card]</div><br />
<div style="border:1px solid #ccc;padding:3px;margin-top:8px;background:white">[[File:ECG_reference_card_thumbnail.jpg|link=printing instructions|200px]]</div><div style="font-size:8pt">Download and print our '''[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG Reference Card] as PDF''' (new improved version November 2009!, read the [[printing instructions]])</div><br />
<div style="text-align:center;font-size:8pt;border-top:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;"><br />
[http://nl.ecgpedia.org/wiki/Powerpoint_presentaties_van_ECG_cursussen Ready-made presentation files for ECG courses (in Dutch)]<br />
</div><br />
</div><br />
<!--start 2nd center box--><br />
|style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Textbook</h2><br />
<div align="center">[[File:book.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Browse the [[Textbook|ECG Textbook]]:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal Tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus Node Rhythms and Arrhythmias|Sinus Rhythms]]<br />
** [[Sinus Tachycardia]]<br />
** [[Sinus Bradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|Supraventricular]]<br />
** [[Junctional Tachycardias|Junctional]]<br />
** [[Ventricular Arrhythmias|Ventricular]]<br />
** [[Genetic Arrhythmias|Genetic]]<br />
***[[Long QT Syndrome|LQTS]]<br />
***[[Brugada Syndrome|Brugada]]<br />
***[[Arrythmogenic Right Ventricular Cardiomyopathy|ARVD]]<br />
***[[Catecholamine-Induced Ventricular Tachycardia|CPVT]]<br />
** [[Ectopic Complexes|Ectopic Complexes]]<br />
* Conduction<br />
** [[AV Conduction|AV Conduction]]<br />
** [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargment|Chamber Hypertrophy]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECG in Athletes]]<br />
* [[Pediatric ECGs|ECG in Children]]<br />
* [[Accuracy of computer interpretation]]<br />
* [[Special:Allpages| A-Z index]]<br />
|}<br />
</div><br />
<!--start 3nd right box--><br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">Cases and Examples</h2><br />
<div align="center">[[File:cases.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Cases:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
*[[Guess the Culprit]]<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*[[Rarities]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 ECGs<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[[DV_Case_4|ECG Case of the Month]]</div><br />
<div style="padding:5px;background:white;border:1px solid #ccc;"><br />
<div align="center" style="margin-top:15px;"><br />
<div align="center">[[File:DVA0004.jpg|A slow heart beat|link=|200px]]</div><br />
[[DV_Case_4| A slow heart beat]]<br />
</div><br />
</div><br />
</div><br />
|}<br />
</div><br />
<!--end of main boxes --><br />
<!--start in other language --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''ECGpedia in other languages'''</h2><br />
*ECGpedia is also available in [http://nl.ecgpedia.org '''Dutch''']<br />
*We are '''looking for translators''' for other languages! Please [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact us] for more information if you would like to help.<br />
</div><br />
</div><br />
<!--end in other language --><br />
<!--start popular item --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''Popular items'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.linkedin.com/groups?gid=1872552 LinkedIn Cardionetworks Group] is a meeting for interested users and editors.<br />
*The [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf whole course on 1 A4 paper.]<br />
*[[LBBB|Left bundle branch block]]<br />
*Measuring the QT interval - [[Conduction#The_QT_interval|beginners]] - [[Difficult QT|advanced]]<br />
*Calculate the QTc with the [[QTc calculator]] using the QT interval and the heart rate<br />
*[[Brugada Syndrome]]<br />
*[[Aivr|Accelerated Idioventricular Rhythm]]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
|<br />
{| class="wikitable" align="right" style="margin:0px;border:1px solid #a3bfb1;"<br />
|<flashow>http://nl.ecgpedia.org/images/c/cc/Heartaxis.swf|height=250px|width=100%|</flashow><br />
|-<br />
| <small>The [[Heart_axis|Heart axis simulator]], made by Bart Duineveld. '''Click and drag''' the heart axis arrow to change the axis.</small><br />
|}<br />
|}<br />
</div><br />
</div><br />
<!--end popular item --><br />
<!--start news--><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px;"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''News & Background'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.cardionetworks.org/timeline/ historic timeline] of the Cardionetworks Foundation shows the development.<br />
*All Cardionetworks sites now run on green power from NaturEnergie AG.<br />
*April 2008. Due to high traffic, all websites have been moved to a new server.<br />
*The first [[media:Normal_SR.swf|animation]] made by Bart Duineveld for ECGpedia is finished.<br />
*Give us feedback on how to improve this site: [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact / feedback form].<br />
*ECGpedia.org is part of [http://www.cardionetworks.org Cardionetworks].<br />
*Read the section with [[Frequently Asked Questions]] for more information.<br />
*[[Authors|These people]] have contributed to ECGpedia. <br />
*Also read how you can [[Contributing to ECGpedia|contribute to ECGpedia]]! <br />
*Follow the [[Timeline|development of ECGpedia]].<br />
*General [[References]].<br />
| width="50%" align="right" |<br />
<flashow>http://nl.ecgpedia.org/images/0/09/Normal_SR.swf|align=right|height=300px|width=300px</flashow><br />
|}<br />
</div><br />
</div><br />
<!--end news --><br />
<br />
[[nl:Hoofdpagina]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9858
Main Page
2010-01-22T22:26:29Z
<p>KGoldin: </p>
<hr />
<div>__NOTOC__<br />
<!-- BANNER ACROSS TOP OF PAGE --><br />
{| id="mp-topbanner" style="width:100%; background:#fcfcfc; margin-top:-1em; border:1px solid #ccc;"<br />
| style="width:56%; color:#000;" |<br />
<!-- "WELCOME TO ECGPEDIA" AND ARTICLE COUNT --><br />
{| style="width:280px; border:none; background:none;"<br />
| style="width:280px; text-align:center; white-space:nowrap; color:#000;" |<br />
<div style="font-size:162%; border:none; margin:0; padding:.1em; color:#000;">Welcome to [[Frequently_Asked_Questions|ECGpedia]],</div><br />
<div style="top:+0.2em; font-size:95%;">a free electrocardiography (ECG) course and textbook to which anyone can contribute ,<br /> designed for medical professionals such as cardiac care nurses and physicians.</div><br />
<div id="articlecount" style="width:100%; text-align:center; font-size:85%;">ECGpedia has received more than 250.000 visitors from 188 countries.</div><br />
|}<br />
<!-- PORTAL LIST ON RIGHT-HAND SIDE --><br />
| style="width:15%; font-size:95%;" |<br />
* [[ECG course|ECG course]]<br />
* [[Textbook|ECG textbook]]<br />
* [[Practice ECGs|Practice ECGs]]<br />
| style="width:15%; font-size:95%;" |<br />
* [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECGpedia pocket reference card]<br />
| style="width:15%; font-size:95%;" |<br />
* [[Frequently_Asked_Questions|FAQ]]<br />
* [http://www.cardionetworks.org/benefactors-of-the-foundation/ Benefactors]<br />
* [http://www.cardionetworks.org/contact/ecgpedia-feedback/ Contact]<br />
|}<br />
<!-- 3 boxes --><br />
<div style="padding:10px"><br />
<!-- course boxes --><br />
{| width="100%" cellspacing="5"<br />
|-<br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Course</h2><br />
<div align="center">[[File:Course.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">ECG course</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
#[[Rhythm]]<br />
#[[Rate]]<br />
#[[Conduction|Conduction (PQ,QRS,QT)]]<br />
#[[Heart axis]]<br />
#[[P wave morphology]]<br />
#[[QRS morphology]]<br />
#[[ST morphology]]<br />
| valign="top" align="left"|<br />
#[[Compare_the_Old_and_New_ECG|Compare with previous ECG]] <br />
#[[Conclusion]]<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG reference pocket card]</div><br />
<div style="border:1px solid #ccc;padding:3px;margin-top:8px;background:white">[[File:ECG_reference_card_thumbnail.jpg|link=printing instructions|200px]]</div><div style="font-size:8pt">Download and print our '''[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG Reference Card] as PDF''' (new improved version November 2009!, read the [[printing instructions]])</div><br />
<div style="text-align:center;font-size:8pt;border-top:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;"><br />
[http://nl.ecgpedia.org/wiki/Powerpoint_presentaties_van_ECG_cursussen Ready-made presentation files for ECG courses (in Dutch)]<br />
</div><br />
</div><br />
<!--start 2nd center box--><br />
|style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Textbook</h2><br />
<div align="center">[[File:book.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Browse the [[Textbook|ECG Textbook]]:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal Tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus Node Rhythms and Arrhythmias|Sinus Rhythms]]<br />
** [[Sinus Tachycardia]]<br />
** [[Sinus Bradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|supraventricular]]<br />
** [[Junctional Tachycardias|junctional]]<br />
** [[Ventricular Arrhythmias|ventricular]]<br />
** [[Genetic Arrhythmias|genetic]]<br />
***[[Long QT Syndrome|LQTS]]<br />
***[[Brugada Syndrome|Brugada]]<br />
***[[Arrythmogenic Right Ventricular Cardiomyopathy|ARVD]]<br />
***[[Catecholamine-Induced Ventricular Tachycardia|CPVT]]<br />
** [[Ectopic Beats|ectopic beats]]<br />
* Conduction<br />
** [[AV Conduction|AV Conduction]]<br />
** [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargment|Chamber Hypertrophy]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECG in Athletes]]<br />
* [[Pediatric ECGs|ECG in Children]]<br />
* [[Accuracy of computer interpretation]]<br />
* [[Special:Allpages| A-Z index]]<br />
|}<br />
</div><br />
<!--start 3nd right box--><br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">Cases and Examples</h2><br />
<div align="center">[[File:cases.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Cases:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
*[[Guess the Culprit]]<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*[[Rarities]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 ECGs<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[[DV_Case_4|ECG Case of the Month]]</div><br />
<div style="padding:5px;background:white;border:1px solid #ccc;"><br />
<div align="center" style="margin-top:15px;"><br />
<div align="center">[[File:DVA0004.jpg|A slow heart beat|link=|200px]]</div><br />
[[DV_Case_4| A slow heart beat]]<br />
</div><br />
</div><br />
</div><br />
|}<br />
</div><br />
<!--end of main boxes --><br />
<!--start in other language --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''ECGpedia in other languages'''</h2><br />
*ECGpedia is also available in [http://nl.ecgpedia.org '''Dutch''']<br />
*We are '''looking for translators''' for other languages! Please [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact us] for more information if you would like to help.<br />
</div><br />
</div><br />
<!--end in other language --><br />
<!--start popular item --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''Popular items'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.linkedin.com/groups?gid=1872552 LinkedIn Cardionetworks Group] is a meeting for interested users and editors.<br />
*The [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf whole course on 1 A4 paper.]<br />
*[[LBBB|Left bundle branch block]]<br />
*Measuring the QT interval - [[Conduction#The_QT_interval|beginners]] - [[Difficult QT|advanced]]<br />
*Calculate the QTc with the [[QTc calculator]] using the QT interval and the heart rate<br />
*[[Brugada Syndrome]]<br />
*[[Aivr|Accelerated Idioventricular Rhythm]]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
|<br />
{| class="wikitable" align="right" style="margin:0px;border:1px solid #a3bfb1;"<br />
|<flashow>http://nl.ecgpedia.org/images/c/cc/Heartaxis.swf|height=250px|width=100%|</flashow><br />
|-<br />
| <small>The [[Heart_axis|Heart axis simulator]], made by Bart Duineveld. '''Click and drag''' the heart axis arrow to change the axis.</small><br />
|}<br />
|}<br />
</div><br />
</div><br />
<!--end popular item --><br />
<!--start news--><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px;"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''News & Background'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.cardionetworks.org/timeline/ historic timeline] of the Cardionetworks Foundation shows the development.<br />
*All Cardionetworks sites now run on green power from NaturEnergie AG.<br />
*April 2008. Due to high traffic, all websites have been moved to a new server.<br />
*The first [[media:Normal_SR.swf|animation]] made by Bart Duineveld for ECGpedia is finished.<br />
*Give us feedback on how to improve this site: [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact / feedback form].<br />
*ECGpedia.org is part of [http://www.cardionetworks.org Cardionetworks].<br />
*Read the section with [[Frequently Asked Questions]] for more information.<br />
*[[Authors|These people]] have contributed to ECGpedia. <br />
*Also read how you can [[Contributing to ECGpedia|contribute to ECGpedia]]! <br />
*Follow the [[Timeline|development of ECGpedia]].<br />
*General [[References]].<br />
| width="50%" align="right" |<br />
<flashow>http://nl.ecgpedia.org/images/0/09/Normal_SR.swf|align=right|height=300px|width=300px</flashow><br />
|}<br />
</div><br />
</div><br />
<!--end news --><br />
<br />
[[nl:Hoofdpagina]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9857
Main Page
2010-01-22T22:21:51Z
<p>KGoldin: </p>
<hr />
<div>__NOTOC__<br />
<!-- BANNER ACROSS TOP OF PAGE --><br />
{| id="mp-topbanner" style="width:100%; background:#fcfcfc; margin-top:-1em; border:1px solid #ccc;"<br />
| style="width:56%; color:#000;" |<br />
<!-- "WELCOME TO ECGPEDIA" AND ARTICLE COUNT --><br />
{| style="width:280px; border:none; background:none;"<br />
| style="width:280px; text-align:center; white-space:nowrap; color:#000;" |<br />
<div style="font-size:162%; border:none; margin:0; padding:.1em; color:#000;">Welcome to [[Frequently_Asked_Questions|ECGpedia]],</div><br />
<div style="top:+0.2em; font-size:95%;">a free electrocardiography (ECG) course and textbook to which anyone can contribute ,<br /> designed for medical professionals such as cardiac care nurses and physicians.</div><br />
<div id="articlecount" style="width:100%; text-align:center; font-size:85%;">ECGpedia has received more than 250.000 visitors from 188 countries.</div><br />
|}<br />
<!-- PORTAL LIST ON RIGHT-HAND SIDE --><br />
| style="width:15%; font-size:95%;" |<br />
* [[ECG course|ECG course]]<br />
* [[Textbook|ECG textbook]]<br />
* [[Practice ECGs|Practice ECGs]]<br />
| style="width:15%; font-size:95%;" |<br />
* [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECGpedia pocket reference card]<br />
| style="width:15%; font-size:95%;" |<br />
* [[Frequently_Asked_Questions|FAQ]]<br />
* [http://www.cardionetworks.org/benefactors-of-the-foundation/ Benefactors]<br />
* [http://www.cardionetworks.org/contact/ecgpedia-feedback/ Contact]<br />
|}<br />
<!-- 3 boxes --><br />
<div style="padding:10px"><br />
<!-- course boxes --><br />
{| width="100%" cellspacing="5"<br />
|-<br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Course</h2><br />
<div align="center">[[File:Course.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">ECG course</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
#[[Rhythm]]<br />
#[[Rate]]<br />
#[[Conduction|Conduction (PQ,QRS,QT)]]<br />
#[[Heart axis]]<br />
#[[P wave morphology]]<br />
#[[QRS morphology]]<br />
#[[ST morphology]]<br />
| valign="top" align="left"|<br />
#[[Compare_the_Old_and_New_ECG|Compare with previous ECG]] <br />
#[[Conclusion]]<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG reference pocket card]</div><br />
<div style="border:1px solid #ccc;padding:3px;margin-top:8px;background:white">[[File:ECG_reference_card_thumbnail.jpg|link=printing instructions|200px]]</div><div style="font-size:8pt">Download and print our '''[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG Reference Card] as PDF''' (new improved version November 2009!, read the [[printing instructions]])</div><br />
<div style="text-align:center;font-size:8pt;border-top:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;"><br />
[http://nl.ecgpedia.org/wiki/Powerpoint_presentaties_van_ECG_cursussen Ready-made presentation files for ECG courses (in Dutch)]<br />
</div><br />
</div><br />
<!--start 2nd center box--><br />
|style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Textbook</h2><br />
<div align="center">[[File:book.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Browse the [[Textbook|ECG Textbook]]:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal Tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus Node Rhythms and Arrhythmias|Sinus Rhythms]]<br />
** [[Sinus Tachycardia]]<br />
** [[Sinus Bradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|supraventricular]]<br />
** [[Junctional Tachycardias|junctional]]<br />
** [[Ventricular Arrhythmias|ventricular]]<br />
** [[Genetic Arrhythmias|genetic]]<br />
***[[Long QT Syndrome|LQTS]]<br />
***[[Brugada Syndrome|Brugada]]<br />
***[[Arrythmogenic Right Ventricular Cardiomyopathy|ARVD]]<br />
***[[Catecholamine-Induced Ventricular Tachycardia|CPVT]]<br />
** [[Ectopic Beats|ectopic beats]]<br />
* Conduction<br />
** [[AV Conduction|AV Conduction]]<br />
** [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargment|Chamber Hypertrophy]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECG in Athletes]]<br />
* [[Pediatric ECGs|ECG in Children]]<br />
* [[Accuracy of computer interpretation]]<br />
* [[Special:Allpages| A-Z index]]<br />
|}<br />
</div><br />
<!--start 3nd right box--><br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">Cases and Examples</h2><br />
<div align="center">[[File:cases.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Cases:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
*[[Guess the Culprit]]<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*[[Rarities]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 ECGs<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[[DV_Case_4|ECG Case of the Month]]</div><br />
<div style="padding:5px;background:white;border:1px solid #ccc;"><br />
<div align="center" style="margin-top:15px;"><br />
<div align="center">[[File:DVA0004.jpg|A slow heart beat|link=|200px]]</div><br />
[[DV_Case_4| A slow heart beat]]<br />
</div><br />
</div><br />
</div><br />
|}<br />
</div><br />
<!--end of main boxes --><br />
<!--start in other language --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''ECGpedia in other languages'''</h2><br />
*ECGpedia is also available in [http://nl.ecgpedia.org '''Dutch''']<br />
*We are '''looking for translators''' for other languages! Please [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact us] for more information if you would like to help.<br />
</div><br />
</div><br />
<!--end in other language --><br />
<!--start popular item --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''Popular items'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.linkedin.com/groups?gid=1872552 LinkedIn Cardionetworks Group] is a meeting for interested users and editors.<br />
*The [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf whole course on 1 A4 paper.]<br />
*[[LBBB|Left bundle branch block]]<br />
*Measuring the QT interval - [[Conduction#The_QT_interval|beginners]] - [[Difficult QT|advanced]]<br />
*Calculate the QTc with the [[QTc calculator]] using the QT interval and the heart rate<br />
*[[Brugada Syndrome]]<br />
*[[Aivr|Accelerated Idioventricular Rhythm]]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
|<br />
{| class="wikitable" align="right" style="margin:0px;border:1px solid #a3bfb1;"<br />
|<flashow>http://nl.ecgpedia.org/images/c/cc/Heartaxis.swf|height=250px|width=100%|</flashow><br />
|-<br />
| <small>The [[Heart_axis|Heart axis simulator]], made by Bart Duineveld. '''Click and drag''' the heart axis arrow to change the axis.</small><br />
|}<br />
|}<br />
</div><br />
</div><br />
<!--end popular item --><br />
<!--start news--><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px;"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''News & Background'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.cardionetworks.org/timeline/ historic timeline] of the Cardionetworks Foundation shows the development<br />
*All Cardionetworks sites now run on green power from NaturEnergie AG<br />
*April 2008. Due to high traffic, all websites have been moved to a new server.<br />
*The first [[media:Normal_SR.swf|animation]] made by Bart Duineveld for ECGpedia is finished.<br />
*Give us feedback on how to improve this site: [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact / feedback form]<br />
*ECGpedia.org is part of [http://www.cardionetworks.org Cardionetworks]<br />
*Read the section with [[Frequently Asked Questions]] for more information.<br />
*[[Authors|These people]] have contributed to ECGpedia. <br />
*Also read how you can [[Contributing to ECGpedia|contribute to ECGpedia]]! <br />
*Follow the [[Timeline|development of ECGpedia]]<br />
*General [[References]]<br />
| width="50%" align="right" |<br />
<flashow>http://nl.ecgpedia.org/images/0/09/Normal_SR.swf|align=right|height=300px|width=300px</flashow><br />
|}<br />
</div><br />
</div><br />
<!--end news --><br />
<br />
[[nl:Hoofdpagina]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Main_Page&diff=9856
Main Page
2010-01-22T22:17:32Z
<p>KGoldin: </p>
<hr />
<div>__NOTOC__<br />
<!-- BANNER ACROSS TOP OF PAGE --><br />
{| id="mp-topbanner" style="width:100%; background:#fcfcfc; margin-top:-1em; border:1px solid #ccc;"<br />
| style="width:56%; color:#000;" |<br />
<!-- "WELCOME TO ECGPEDIA" AND ARTICLE COUNT --><br />
{| style="width:280px; border:none; background:none;"<br />
| style="width:280px; text-align:center; white-space:nowrap; color:#000;" |<br />
<div style="font-size:162%; border:none; margin:0; padding:.1em; color:#000;">Welcome to [[Frequently_Asked_Questions|ECGpedia]],</div><br />
<div style="top:+0.2em; font-size:95%;">a free electrocardiography (ECG) course and textbook to which anyone can contribute ,<br /> designed for medical professionals such as cardiac care nurses and physicians.</div><br />
<div id="articlecount" style="width:100%; text-align:center; font-size:85%;">ECGpedia has received more than 250.000 visitors from 188 countries.</div><br />
|}<br />
<!-- PORTAL LIST ON RIGHT-HAND SIDE --><br />
| style="width:15%; font-size:95%;" |<br />
* [[ECG course|ECG course]]<br />
* [[Textbook|ECG textbook]]<br />
* [[Practice ECGs|Practice ECGs]]<br />
| style="width:15%; font-size:95%;" |<br />
* [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECGpedia pocket reference card]<br />
| style="width:15%; font-size:95%;" |<br />
* [[Frequently_Asked_Questions|FAQ]]<br />
* [http://www.cardionetworks.org/benefactors-of-the-foundation/ Benefactors]<br />
* [http://www.cardionetworks.org/contact/ecgpedia-feedback/ Contact]<br />
|}<br />
<!-- 3 boxes --><br />
<div style="padding:10px"><br />
<!-- course boxes --><br />
{| width="100%" cellspacing="5"<br />
|-<br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Course</h2><br />
<div align="center">[[File:Course.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">ECG course</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
First read the [[Introduction]] and the [[Basics]], then follow the 7+2 step plan:<br />
#[[Rhythm]]<br />
#[[Rate]]<br />
#[[Conduction|Conduction (PQ,QRS,QT)]]<br />
#[[Heart axis]]<br />
#[[P wave morphology]]<br />
#[[QRS morphology]]<br />
#[[ST morphology]]<br />
| valign="top" align="left"|<br />
#[[Compare_the_old_and_new_ECG|Compare with previous ECG]] <br />
#[[Conclusion]]<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG reference pocket card]</div><br />
<div style="border:1px solid #ccc;padding:3px;margin-top:8px;background:white">[[File:ECG_reference_card_thumbnail.jpg|link=printing instructions|200px]]</div><div style="font-size:8pt">Download and print our '''[http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf ECG Reference Card] as PDF''' (new improved version November 2009!, read the [[printing instructions]])</div><br />
<div style="text-align:center;font-size:8pt;border-top:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;"><br />
[http://nl.ecgpedia.org/wiki/Powerpoint_presentaties_van_ECG_cursussen Ready-made presentation files for ECG courses (in Dutch)]<br />
</div><br />
</div><br />
<!--start 2nd center box--><br />
|style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">The ECG Textbook</h2><br />
<div align="center">[[File:book.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Browse the [[Textbook|ECG Textbook]]:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
* [[Normal tracing|Normal tracing]]<br />
* [[A Concise History of the ECG]]<br />
* [[Technical Problems|Technical Problems]]<br />
* [[Sinus node rhythms and arrhythmias|Sinus rhythms]]<br />
** [[Sinustachycardia]]<br />
** [[Sinusbradycardia]]<br />
* [[Arrhythmias|Arrhythmias:]]<br />
** [[Supraventricular Rhythms|supraventricular]]<br />
** [[Junctional Tachycardias|junctional]]<br />
** [[Ventricular Arrhythmias|ventricular]]<br />
** [[Genetic Arrhythmias|genetic]]<br />
***[[Long QT Syndrome|LQTS]]<br />
***[[Brugada Syndrome|Brugada]]<br />
***[[Arrythmogenic Right Ventricular Cardiomyopathy|ARVD]]<br />
***[[Catecholamin Induced Ventricular Tachycardia|CPVT]]<br />
** [[Ectopic Beats|ectopic beats]]<br />
* Conduction<br />
** [[AV Conduction|AV Conduction]]<br />
** [[Intraventricular Conduction|Intraventricular Conduction]]<br />
* [[Myocardial Infarction|Myocardial Infarction]]<br />
* [[Chamber Hypertrophy and Enlargment|Chamber Hypertrophy]]<br />
* [[Clinical Disorders|Clinical Disorders]]<br />
* [[Electrolyte Disorders|Electrolyte Disorders]]<br />
* [[Pacemaker|Pacemaker]]<br />
* [[ECG in Athletes]]<br />
* [[Pediatric ECGs|ECG in Children]]<br />
* [[Accuracy of computer interpretation]]<br />
* [[Special:Allpages| A-Z index]]<br />
|}<br />
</div><br />
<!--start 3nd right box--><br />
| style="border:1px solid #E2ACB1;background-color:#FFF5F5;padding:5px;" width="33%" valign="top" |<br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:center;color:#000;padding:0.2em 0.4em;">Cases and Examples</h2><br />
<div align="center">[[File:cases.jpg|link=|140px]]</div><br />
<div align="center" style="margin-top:15px;"><br />
<div style="font-size:10pt;font-weight:bold;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em">Cases:</div><br />
{| style="background:transparent;font-size:9pt" align="left"<br />
|-<br />
| style="background:transparent" valign="top" align="left"|<br />
*Learn from these [[Cases and Examples|cases and examples]]<br />
*[[Guess the Culprit]]<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*[[Rarities]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 ECGs<br />
|}<br />
<div style="clear:both"></div><br />
<div style="font-size:10pt;font-weight:bold;border-top:1px solid #E2ACB1;border-bottom:1px solid #E2ACB1;color:#000;padding:0.2em 0.4em;margin-top:5px;margin-bottom:5px;">[[DV_Case_4|ECG Case of the Month]]</div><br />
<div style="padding:5px;background:white;border:1px solid #ccc;"><br />
<div align="center" style="margin-top:15px;"><br />
<div align="center">[[File:DVA0004.jpg|A slow heart beat|link=|200px]]</div><br />
[[DV_Case_4| A slow heart beat]]<br />
</div><br />
</div><br />
</div><br />
|}<br />
</div><br />
<!--end of main boxes --><br />
<!--start in other language --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''ECGpedia in other languages'''</h2><br />
*ECGpedia is also available in [http://nl.ecgpedia.org '''Dutch''']<br />
*We are '''looking for translators''' for other languages! Please [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact us] for more information if you would like to help.<br />
</div><br />
</div><br />
<!--end in other language --><br />
<!--start popular item --><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''Popular items'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.linkedin.com/groups?gid=1872552 LinkedIn Cardionetworks Group] is a meeting for interested users and editors.<br />
*The [http://www.ecgpedia.org/A4/ECGpedia_on_1_A4En.pdf whole course on 1 A4 paper.]<br />
*[[LBBB|Left bundle branch block]]<br />
*Measuring the QT interval - [[Conduction#The_QT_interval|beginners]] - [[Difficult QT|advanced]]<br />
*Calculate the QTc with the [[QTc calculator]] using the QT interval and the heart rate<br />
*[[Brugada Syndrome]]<br />
*[[Aivr|Accelerated Idioventricular Rhythm]]<br />
*[[LBBB|Left Bundle Branch Block]]<br />
|<br />
{| class="wikitable" align="right" style="margin:0px;border:1px solid #a3bfb1;"<br />
|<flashow>http://nl.ecgpedia.org/images/c/cc/Heartaxis.swf|height=250px|width=100%|</flashow><br />
|-<br />
| <small>The [[Heart_axis|Heart axis simulator]], made by Bart Duineveld. '''Click and drag''' the heart axis arrow to change the axis.</small><br />
|}<br />
|}<br />
</div><br />
</div><br />
<!--end popular item --><br />
<!--start news--><br />
<div style="border:1px solid #E2ACB1;padding:4px;text-align:left;background-color:#FFF5F5;margin-top:10px;"><br />
<div style="padding:15px"><br />
<h2 style="margin:0px;margin-bottom:15px;background-color:#D1DAEB;font-size:120%;font-weight:bold;border:1px solid #a3bfb1;text-align:left;color:#000;padding:0.2em 0.4em;">'''News & Background'''</h2><br />
{| width=100% style="background:transparent"<br />
|-<br />
| width="50%" align="left" valign="top" |<br />
*The [http://www.cardionetworks.org/timeline/ historic timeline] of the Cardionetworks Foundation shows the development<br />
*All Cardionetworks sites now run on green power from NaturEnergie AG<br />
*April 2008. Due to high traffic, all websites have been moved to a new server.<br />
*The first [[media:Normal_SR.swf|animation]] made by Bart Duineveld for ECGpedia is finished.<br />
*Give us feedback on how to improve this site: [http://www.cardionetworks.org/contact/ecgpedia-feedback/ contact / feedback form]<br />
*ECGpedia.org is part of [http://www.cardionetworks.org Cardionetworks]<br />
*Read the section with [[Frequently Asked Questions]] for more information.<br />
*[[Authors|These people]] have contributed to ECGpedia. <br />
*Also read how you can [[Contributing to ECGpedia|contribute to ECGpedia]]! <br />
*Follow the [[Timeline|development of ECGpedia]]<br />
*General [[References]]<br />
| width="50%" align="right" |<br />
<flashow>http://nl.ecgpedia.org/images/0/09/Normal_SR.swf|align=right|height=300px|width=300px</flashow><br />
|}<br />
</div><br />
</div><br />
<!--end news --><br />
<br />
[[nl:Hoofdpagina]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Rhythm_Puzzles&diff=9855
Rhythm Puzzles
2010-01-22T22:15:40Z
<p>KGoldin: </p>
<hr />
<div>These Rhythm Puzzles have been published in the '''Netherlands Heart Journal''' and are reproduced here with permission from the publisher, '''Bohn Stafleu Van Loghum'''.<br />
<br />
==2009==<br />
# [[An Unexpected Narrow QRS Complex -1-]]<br />
# [[An Irregular Heart Beat]]<br />
# [[Syncope in an Old Lady]]<br />
<br />
==2008==<br />
# [[Wide QRS Complexes in the Setting of Acute Myocardial Infarction: Good News or Bad?]]<br />
# [[Just an Ordinary Flutter?]]<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm - 3]]<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm - 4]]<br />
# [[The ECG of a Cardiomyopathy - 2]]<br />
<br />
==2007==<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm - 2]]<br />
# [[Palpitations after a MAZE Procedure]]<br />
# [[Abnormal Repolarization, Spot Diagnosis]]?<br />
# [[An Irregular Rhythm at Older Age]]<br />
# [[Palpitations all the Time]]<br />
# [[Five Years of Palpitations]]<br />
# [[An Abnormal ECG?]]<br />
==2006==<br />
# [[Right You Are]]<br />
# [[Should I be Worried?]]<br />
# [[A Pre-excited Wide QRS Complex: is That all There is?]]<br />
# [[An Old Lady with Chest Pain]]<br />
# [[Palpitations and Dizziness in a 65-Year-Old-Man]]<br />
# [[A Narrow QRS Complex Tachycardia Sensitive to Isoptin]]<br />
# [[And What About the ECG?]]<br />
# [[Palpitations Again, Have a Closer Look]]<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm]]<br />
==2005==<br />
# [[ECG puzzle: Appearances Can be Deceiving]]<br />
# [[Where Do the Extras Come From?]]<br />
# [['The Turtle and the Hare']]<br />
# [[Now You See it, Now You Don't]] <br />
# [[It's Not What You Think it Is]]<br />
# [[One is Enough, Two is Too Many]]<br />
# [[The ECG of a (Cardio)myopathy?]]<br />
# [[The Ions Have It]]<br />
<br />
==2004==<br />
# [[Puzzle 2004 2 73, A Fainting Lady with Some Extrasystoles|A fainting lady with some extrasystoles]]<br />
# [[Syncopated Rhythm]]<br />
# [[Rhythm Puzzle: An Irregular Rhythm at Older Age|An Irregular Rhythm at Older Age]]<br />
# [[I Think a Niece of Mine was Referred to a Neurologist]]<br />
# [[Just One Collapse During Soccer]]<br />
# [[Tachycardia Terminated by Adenosine]]<br />
# [[Nightly Phenomena, Day Time Work?]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Rhythm_Puzzles&diff=9854
Rhythm Puzzles
2010-01-22T22:14:26Z
<p>KGoldin: </p>
<hr />
<div>These Rhythm Puzzles have been published in the '''Netherlands Heart Journal''' and are reproduced here with permission from the publisher, '''Bohn Stafleu Van Loghum'''.<br />
<br />
==2009==<br />
# [[An Unexpected Narrow QRS Complex -1-]]<br />
# [[An Irregular Heart Beat]]<br />
# [[Syncope in an Old Lady]]<br />
<br />
==2008==<br />
# [[Wide QRS Complexes in the Setting of Acute Myocardial Infarction: Good News or Bad?]]<br />
# [[Just an Ordinary Flutter?]]<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm - 3]]<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm - 4]]<br />
# [[The ECG of a Cardiomyopathy - 2]]<br />
<br />
==2007==<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm - 2]]<br />
# [[Palpitations after a MAZE Procedure]]<br />
# [[Abnormal Repolarization, Spot Diagnosis]]?<br />
# [[An Irregular Rhythm at Older Age]]<br />
# [[Palpitations all the Time]]<br />
# [[Five Years of Palpitations]]<br />
# [[An Abnormal ECG?]]<br />
==2006==<br />
# [[Right You Are]]<br />
# [[Should I be Worried?]]<br />
# [[A Pre-excited Wide QRS Complex: is That all There is?]]<br />
# [[An Old Lady with Chest Pain]]<br />
# [[Palpitations and Dizziness in a 65-Year-Old-Man]]<br />
# [[A Narrow QRS Complex Tachycardia Sensitive to Isoptin]]<br />
# [[And What About the ECG?]]<br />
# [[Palpitations Again, Have a Closer Look]]<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm]]<br />
==2005==<br />
# [[ECG puzzle: Appearances Can be Deceiving]]<br />
# [[Where Do the Extras Come From?]]<br />
# [['The Turtle and the Hare']]<br />
# [[Now You See it, Now You Don't]] <br />
# [[It's Not What You Think it Is]]<br />
# [[One is Enough, Two is Too Many]]<br />
# [[The ECG of a (Cardio)myopathy?]]<br />
# [[The Ions Have It]]<br />
<br />
==2004==<br />
# [[Puzzle 2004 2 73, A Fainting Lady with Some Extrasystoles|A fainting lady with some extrasystoles]]<br />
# [[Syncopated rhythm]]<br />
# [[Rhythm Puzzle: An Irregular Rhythm at Older Age|An irregular rhythm at older age]]<br />
# [[I Think a Niece of Mine was Referred to a Neurologist]]<br />
# [[Just One Collapse During Soccer]]<br />
# [[Tachycardia Terminated by Adenosine]]<br />
# [[Nightly Phenomena, Day Time Work?]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Rhythm_Puzzles&diff=9853
Rhythm Puzzles
2010-01-22T22:12:42Z
<p>KGoldin: </p>
<hr />
<div>These Rhythm Puzzles have been published in the '''Netherlands Heart Journal''' and are reproduced here with permission from the publisher, '''Bohn Stafleu Van Loghum'''.<br />
<br />
==2009==<br />
# [[An Unexpected Narrow QRS Complex -1-]]<br />
# [[An Irregular Heart Beat]]<br />
# [[Syncope in an Old Lady]]<br />
<br />
==2008==<br />
# [[Wide QRS Complexes in the Setting of Acute Myocardial Infarction: Good News or Bad?]]<br />
# [[Just an Ordinary Flutter?]]<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm - 3]]<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm - 4]]<br />
# [[The ECG of a Cardiomyopathy - 2]]<br />
<br />
==2007==<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm - 2]]<br />
# [[Palpitations after a MAZE Procedure]]<br />
# [[Abnormal Repolarization, Spot Diagnosis]]?<br />
# [[An Irregular Rhythm at Older Age]]<br />
# [[Palpitations all the Time]]<br />
# [[Five Years of Palpitations]]<br />
# [[An Abnormal ECG?]]<br />
==2006==<br />
# [[Right You Are]]<br />
# [[Should I be Worried?]]<br />
# [[A pre-excited wide QRS complex: is that all there is?]]<br />
# [[An Old Lady with Chest Pain]]<br />
# [[Palpitations and Dizziness in a 65-Year-Old-Man]]<br />
# [[A Narrow QRS Complex Tachycardia Sensitive to Isoptin]]<br />
# [[And what about the ECG?]]<br />
# [[Palpitations Again, Have a Closer Look]]<br />
# [[Wide Complexes Intervening Regular Sinus Rhythm]]<br />
==2005==<br />
# [[ECG puzzle: Appearances Can be Deceiving]]<br />
# [[Where Do the Extras Come From?]]<br />
# [['The Turtle and the Hare']]<br />
# [[Now You See it, Now You Don't]] <br />
# [[It's Not What You Think it Is]]<br />
# [[One is Enough, Two is Too Many]]<br />
# [[The ECG of a (Cardio)myopathy?]]<br />
# [[The Ions Have It]]<br />
<br />
==2004==<br />
# [[Puzzle 2004 2 73, A Fainting Lady with Some Extrasystoles|A fainting lady with some extrasystoles]]<br />
# [[Syncopated rhythm]]<br />
# [[Rhythm Puzzle: An Irregular Rhythm at Older Age|An irregular rhythm at older age]]<br />
# [[I Think a Niece of Mine was Referred to a Neurologist]]<br />
# [[Just One Collapse During Soccer]]<br />
# [[Tachycardia Terminated by Adenosine]]<br />
# [[Nightly Phenomena, Day Time Work?]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Cases_and_Examples&diff=9850
Cases and Examples
2010-01-22T21:56:32Z
<p>KGoldin: </p>
<hr />
<div>Below you can find some common examples. ECGs can be magnified by clicking on the image....<br />
==Ischemia & Myocardial Infarction==<br />
[[Image:coronary_anatomy.png|thumb| An overview of the coronary arteries. LM = 'Left Main' = mainstem; LAD = 'Left Anterior Descending' artery; RCX = Ramus Circumflexus; RCA = 'Right Coronary Artery'.]]<br />
Guess the culprit coronary artery that was occluded in these examples of myocardial infarctions<br />
{| class="wikitable" <br />
! colspan="2" |examples of myocardial infarctions<br />
|-<br />
|<br />
*[[MI 1]]<br />
*[[MI 2]]<br />
*[[MI 3]]<br />
*[[MI 4]]<br />
*[[MI 5]]<br />
*[[MI 6]]<br />
*[[MI 7]]<br />
*[[MI 8]]<br />
*[[MI 10]]<br />
*[[MI 11]]<br />
*[[MI 12]]<br />
|<br />
*[[MI 13]]<br />
*[[MI 14]]<br />
*[[MI 15]]<br />
*[[MI 16]]<br />
*[[MI 17]]<br />
*[[MI 18]]<br />
*[[MI 19]]<br />
*[[MI 20]]<br />
*[[MI 21]]<br />
*[[MI 22]]<br />
*[[MI 23]]<br />
|}<br />
<br />
==Arrhythmias==<br />
[[File:Casus1_2.jpg|100px|link=Case 1|[[Case 1]]]]<br />
[[File:KJcasus3.jpg|100px|link=Case 2|[[Case 2]]]]<br />
[[File:KJcasus9.jpg|100px|link=Case 3|[[Case 3]]]]<br />
[[File:Triblock.png|100px|link=Case 4|[[Case 4]]]]<br />
[[File:JJ00004.png|100px|link=Case 5|[[Case 5]]]]<br />
[[File:ECG000006.jpg|100px|link=Example 26|[[Example 26]]]]<br />
<br />
==Electrolyte Disorders==<br />
*[[Case 100]]<br />
*[[Case 101]]<br />
==Miscellaneous==<br />
Click on the text below the ECG for the '''answers'''. Click on the ECG for '''enlargement of the ECG''' itself...<br />
<br />
<gallery><br />
Image:RVDB1.jpg|[[Example 23]]<br />
Image:DVA0011.jpg|[[Example 24]]<br />
Image:DVA0229.jpg|[[Example 25]]<br />
</gallery><br />
<br />
{{Box|<br />
==Advanced Cases==<br />
For more advanced cases see:<br />
*[[Rhythm Puzzles]] by Prof. A.A.M. Wilde, MD, PhD<br />
*[[Case reports by W.G. De Voogt%2C MD%2C PhD]]<br />
*The ''[[De Voogt ECG Archive]]'' contains > 2000 categorized ECGs<br />
}}<br />
<br />
[[Category:Cases and Examples]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Pacemaker&diff=9849
Pacemaker
2010-01-22T21:54:08Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
{{clr}}<br />
{{Box|<br />
A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The '''pacemaker rhythm''' can easily be recognized on the ECG. It shows '''pacemaker spikes''': vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing.<br />
<br />
In the first example, the atria are being paced, but not the ventricles, resulting in an '''atrial paced rhythm'''. Accordingly the ventricular complex is delayed until the atrial signal has passed through the AV node. In the second image the ventricles are paced directly, resulting in a '''ventricular paced rhythm'''. As ventricular pacing occurs exclusively in the right ventricle the ECG shows a left bundle branch block pattern. An exception to this rule is left ventricular pacing in patients with congenital anomalies and patients with surgically placed epicardial pacemakers. Another exception is septal or RVOT placement of the pacing lead, which results in a less widened to normal QRS complex.<br />
}}<br />
{{clr}}<br />
{|align="right"<br />
|<br />
[[Image:picture_pacemaker.jpg|thumb|A (used) DDDr pacemaker]]<br />
[[Image:chest_xray_pacemaker.jpg |thumb| Chest x-ray of a patient with a pacemaker]]<br />
[[Image:paced2.gif|thumb| Ventricular paced rhythm shows ventricular pacemaker spikes]]<br />
[[Image:ddd_paced_12lead.jpg |thumb| DDD paced rhythm]]<br />
[[Image:Pacemaker2.jpg |thumb| Atrial sensed, ventricular paced rhythm (tracking). Note the LBBB morphology with left axis deviation indicating the pacing lead in the right ventricular apex.]]<br />
[[Image:DVA0838.jpg|thumb|Atrial paced rhythm]]<br />
|}<br />
==Pacemaker Coding==<br />
Pacemakers can be categorized according to the NASPE coding system, that usually consists of 3-5 letters. <br />
<br />
{| class="wikitable" width="80%"<br />
|+ '''The revised NASPE/BPEG generic code for antibradycardia pacing'''<cite>Bernstein</cite><br />
! I || II || III || IV || V <br />
|-<br />
| Chamber(s) paced || Chamber(s) sensed || Response to sensing || Rate modulation || Multisite pacing<br />
|-<br />
| O = None || O = None || O = None || O = None || O = None<br />
|-<br />
| A = Atrium || A = Atrium || T = Triggered || R = Rate modulation || A = Atrium<br />
|- <br />
| V = Ventricle || V = Ventricle || I = Inhibited || || V = Ventricle<br />
|-<br />
| D = Dual (A+V) || D = Dual (A+V) || D = Dual (T+I) || || D = Dual (A+V)<br />
|-<br />
|}<br />
<br />
==Commonly Used Pacemakers==<br />
The most often used codes are:<br />
* '''AAI''': The atria are paced, when the intrinsic atrial rhythm falls below the pacemaker's threshold.<br />
* '''VVI''': The ventricles are paced, when the intrinsic ventricular rhythm falls below the pacemaker's threshold.<br />
* '''VDD''': The pacemaker senses atrial and ventricular events, but can only pace the ventricle. This type of pacemaker is used in patients with a reliable sinus node, but with an AV-block.<br />
* '''DDD''': The pacemaker records both atrial and ventricular rates and can pace either chamber when needed.<br />
* '''DDDR''': As above, but the pacemaker has a sensor that records a demand for higher cardiac output and can adjust the heart rate accordingly.<br />
* Biventricular pacemakers ('''CRT-P'''): Leads in both ventricles are present for synchronized contraction. The lead pacing the left ventricle is usually positioned in the coronary sinus. This cardiac resynchronization therapy can improve symptoms and survival in some heart failure patients. Several optimizing methods are being evaluated to find the most effective pacing delay between left and right ventricles. They include echocardiography, finding the narrowest QRS, and invasive hemodynamic measurements with pressure and flow wires.<br />
* '''[[ICD]]''' (Internal Cardioversion Device): This device can detect and treat [[Ventricular Tachycardia]] and [[Ventricular Fibrillation]]. ICDs are a separate category and usually not considered pacemakers although they do have a pacing function. Usually the first treatment is anti-tachy pacing (pacing at a rate +- 10% above the ventricular rate in ventricular tachycardia, which can convert the rhythm to sinus rhythm). If this is not effective, a defibrillator shock is delivered, usually with 16-36 Joules of energy. ICDs can save lives in patients who have a high risk of ventricular arrhythmias. All ICDs have optional pacemaker activity to treat bradycardias. New biventricular ICDs have 3 leads: an atrial lead, a left ventricular lead and a right ventricular lead.<br />
* Biventricular ICDs ('''CRT-D'''): an ICD with biventricular pacing option.<br />
{{clr}}<br />
==Pacemaker Indications==<br />
A full list of pacemaker indications can be read in the ESC guidelines on cardiac pacing <cite>Vardas</cite>. A selection of class I indications is: chronic symptomatic third- or second degree (Mobitz I or II) atrioventricular block, syncope with sinus node disease, alternating bundle branch block, and persisting AV block after surgery.<br />
<br />
===Atrial-sensed ventricular-paced rhythm===<br />
===AV dual-paced rhythm===<br />
===Pacemaker Malfunction===<br />
to be filled in ...<br />
====Failure of appropriate capture, atrial====<br />
[[Image:DVA0856.jpg|thumb|Failure of atrial capture in a patient with atrial standstill, no P waves are seen after the atrial stimuli]]<br />
{{clr}}<br />
<br />
====Failure of appropriate capture, ventricular====<br />
[[File:ECG000020.jpg|thumb|Failure of ventricular capture]]<br />
<br />
====Failure of Appropriate Inhibition, Atrial====<br />
====Failure of Appropriate Inhibition, Ventricular====<br />
====Failure of Appropriate Pacemaker Firing====<br />
====Retrograde Atrial Activation====<br />
====Pacemaker Mediated Tachycardia====<br />
{{clr}}<br />
{{Box|<br />
==External Links==<br />
[http://www.hrsonline.org/swPositionStatementFiles/ps101036428.asp Heart Rhytm Society]<br />
}}{{clr}}{{Box|<br />
==References==<br />
<biblio><br />
#Vardas pmid=17726042<br />
#Gregoratos pmid=12379588<br />
#Bernstein pmid=11916002<br />
</biblio><br />
}}<br />
{{clr}}<br />
[[Category:ECG Textbook]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Pacemaker&diff=9848
Pacemaker
2010-01-22T21:50:53Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
{{clr}}<br />
{{Box|<br />
A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The '''pacemaker rhythm''' can easily be recognized on the ECG. It shows '''pacemaker spikes''': vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing.<br />
<br />
In the first example, the atria are being paced, but not the ventricles, resulting in an '''atrial paced rhythm'''. Accordingly the ventricular complex is delayed until the atrial signal has passed through the AV node. In the second image the ventricles are paced directly, resulting in a '''ventricular paced rhythm'''. As ventricular pacing occurs exclusively in the right ventricle the ECG shows a left bundle branch block pattern. An exception to this rule is left ventricular pacing in patients with congenital anomalies and patients with surgically placed epicardial pacemakers. Another exception is septal or RVOT placement of the pacing lead, which results in a less widened to normal QRS complex.<br />
}}<br />
{{clr}}<br />
{|align="right"<br />
|<br />
[[Image:picture_pacemaker.jpg|thumb|A (used) DDDr pacemaker]]<br />
[[Image:chest_xray_pacemaker.jpg |thumb| Chest x-ray of a patient with a pacemaker]]<br />
[[Image:paced2.gif|thumb| Ventricular paced rhythm shows ventricular pacemaker spikes]]<br />
[[Image:ddd_paced_12lead.jpg |thumb| DDD paced rhythm]]<br />
[[Image:Pacemaker2.jpg |thumb| Atrial sensed, ventricular paced rhythm (tracking). Note the LBBB morphology with left axis deviation indicating the pacing lead in the right ventricular apex.]]<br />
[[Image:DVA0838.jpg|thumb|Atrial paced rhythm]]<br />
|}<br />
==Pacemaker Coding==<br />
Pacemakers can be categorized according to the NASPE coding system, that usually consists of 3-5 letters. <br />
<br />
{| class="wikitable" width="80%"<br />
|+ '''The revised NASPE/BPEG generic code for antibradycardia pacing'''<cite>Bernstein</cite><br />
! I || II || III || IV || V <br />
|-<br />
| Chamber(s) paced || Chamber(s) sensed || Response to sensing || Rate modulation || Multisite pacing<br />
|-<br />
| O = None || O = None || O = None || O = None || O = None<br />
|-<br />
| A = Atrium || A = Atrium || T = Triggered || R = Rate modulation || A = Atrium<br />
|- <br />
| V = Ventricle || V = Ventricle || I = Inhibited || || V = Ventricle<br />
|-<br />
| D = Dual (A+V) || D = Dual (A+V) || D = Dual (T+I) || || D = Dual (A+V)<br />
|-<br />
|}<br />
<br />
==Commonly Used Pacemakers==<br />
The most often used codes are:<br />
* '''AAI''': The atria are paced, when the intrinsic atrial rhythm falls below the pacemaker's threshold.<br />
* '''VVI''': The ventricles are paced, when the intrinsic ventricular rhythm falls below the pacemaker's threshold.<br />
* '''VDD''': The pacemaker senses the atrial and ventricular events, but can only pace the ventricle. This type of pacemaker is used in patients with a reliable sinus node, but with an AV-block.<br />
* '''DDD''': The pacemaker records both the atrial and ventricular rate and can pace either chamber when needed.<br />
* '''DDDR''': As above, but the pacemaker has a sensor that records a demand for higher cardiac output and can adjust the heart rate accordingly.<br />
* Biventricular pacemakers ('''CRT-P'''): Leads in both ventricles are present to synchronized contraction. The lead pacing the left ventricle is usually positioned in the coronary sinus. This cardiac resynchronization therapy can improve symptoms and survival in some heart failure patients. Several optimizing methods are being evaluated to find the most effective pacing delay between left and right ventricles. They include echocardiography, finding the narrowest QRS, and invasive hemodynamic measurements with pressure and flow wires.<br />
* '''[[ICD]]''' (Internal Cardioversion Device): This device can detect and treat [[Ventricular Tachycardia]] and [[Ventricular Fibrillation]]. ICDs are a separate category and usually not considered pacemakers although they do have a pacing function. Usually the first treatment is anti-tachy pacing (pacing at a rate +- 10% above the ventricular rate in ventricular tachycardia, which can convert the rhythm to sinus rhythm). If this is not effective, a defibrillator shock is delivered, usually with 16-36 Joules of energy. ICDs can save lives in patients who have a high risk of ventricular arrhythmias. All ICDs have optional pacemaker activity to treat bradycardias. New biventricular ICDs have 3 leads: an atrial lead, a left ventricular lead and a right ventricular lead.<br />
* Biventricular ICDs ('''CRT-D'''): an ICD with biventricular pacing option.<br />
{{clr}}<br />
==Pacemaker Indications==<br />
A full list of pacemaker indications can be read in the ESC guidelines on cardiac pacing <cite>Vardas</cite>. A selection of class I indications is: chronic symptomatic third- or second degree (Mobitz I or II) atrioventricular block, syncope with sinus node disease, alternating bundle branch block, and persisting AV block after surgery.<br />
<br />
===Atrial-sensed ventricular-paced rhythm===<br />
===AV dual-paced rhythm===<br />
===Pacemaker Malfunction===<br />
to be filled in ...<br />
====Failure of appropriate capture, atrial====<br />
[[Image:DVA0856.jpg|thumb|Failure of atrial capture in a patient with atrial standstill, no P waves are seen after the atrial stimuli]]<br />
{{clr}}<br />
<br />
====Failure of appropriate capture, ventricular====<br />
[[File:ECG000020.jpg|thumb|Failure of ventricular capture]]<br />
<br />
====Failure of Appropriate Inhibition, Atrial====<br />
====Failure of Appropriate Inhibition, Ventricular====<br />
====Failure of Appropriate Pacemaker Firing====<br />
====Retrograde Atrial Activation====<br />
====Pacemaker Mediated Tachycardia====<br />
{{clr}}<br />
{{Box|<br />
==External Links==<br />
[http://www.hrsonline.org/swPositionStatementFiles/ps101036428.asp Heart Rhytm Society]<br />
}}{{clr}}{{Box|<br />
==References==<br />
<biblio><br />
#Vardas pmid=17726042<br />
#Gregoratos pmid=12379588<br />
#Bernstein pmid=11916002<br />
</biblio><br />
}}<br />
{{clr}}<br />
[[Category:ECG Textbook]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Pacemaker&diff=9847
Pacemaker
2010-01-22T21:49:17Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
{{clr}}<br />
{{Box|<br />
A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The '''pacemaker rhythm''' can easily be recognized on the ECG. It shows '''pacemaker spikes''': vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing.<br />
<br />
In the first example, the atria are being paced, but not the ventricles, resulting in an '''atrial paced rhythm'''. Accordingly the ventricular complex is delayed until the atrial signal has passed through the AV node. In the second image the ventricles are paced directly, resulting in a '''ventricular paced rhythm'''. As ventricular pacing occurs exclusively in the right ventricle the ECG shows a left bundle branch block pattern. An exception to this rule is left ventricular pacing in patients with congenital anomalies and patients with a surgically placed epicardial pacemaker. Another exception is septal or RVOT placement of the pacing lead, which results in a less widened to normal QRS complex.<br />
}}<br />
{{clr}}<br />
{|align="right"<br />
|<br />
[[Image:picture_pacemaker.jpg|thumb|A (used) DDDr pacemaker]]<br />
[[Image:chest_xray_pacemaker.jpg |thumb| Chest x-ray of a patient with a pacemaker]]<br />
[[Image:paced2.gif|thumb| Ventricular paced rhythm shows ventricular pacemaker spikes]]<br />
[[Image:ddd_paced_12lead.jpg |thumb| DDD paced rhythm]]<br />
[[Image:Pacemaker2.jpg |thumb| Atrial sensed, ventricular paced rhythm (tracking). Note the LBBB morphology with left axis deviation indicating the pacing lead in the right ventricular apex.]]<br />
[[Image:DVA0838.jpg|thumb|Atrial paced rhythm]]<br />
|}<br />
==Pacemaker Coding==<br />
Pacemakers can be categorized according to the NASPE coding system, that usually consists of 3-5 letters. <br />
<br />
{| class="wikitable" width="80%"<br />
|+ '''The revised NASPE/BPEG generic code for antibradycardia pacing'''<cite>Bernstein</cite><br />
! I || II || III || IV || V <br />
|-<br />
| Chamber(s) paced || Chamber(s) sensed || Response to sensing || Rate modulation || Multisite pacing<br />
|-<br />
| O = None || O = None || O = None || O = None || O = None<br />
|-<br />
| A = Atrium || A = Atrium || T = Triggered || R = Rate modulation || A = Atrium<br />
|- <br />
| V = Ventricle || V = Ventricle || I = Inhibited || || V = Ventricle<br />
|-<br />
| D = Dual (A+V) || D = Dual (A+V) || D = Dual (T+I) || || D = Dual (A+V)<br />
|-<br />
|}<br />
<br />
==Commonly Used Pacemakers==<br />
The most often used codes are:<br />
* '''AAI''': The atria are paced, when the intrinsic atrial rhythm falls below the pacemaker's threshold.<br />
* '''VVI''': The ventricles are paced, when the intrinsic ventricular rhythm falls below the pacemaker's threshold.<br />
* '''VDD''': The pacemaker senses the atrial and ventricular events, but can only pace the ventricle. This type of pacemaker is used in patients with a reliable sinus node, but with an AV-block.<br />
* '''DDD''': The pacemaker records both the atrial and ventricular rate and can pace either chamber when needed.<br />
* '''DDDR''': As above, but the pacemaker has a sensor that records a demand for higher cardiac output and can adjust the heart rate accordingly.<br />
* Biventricular pacemakers ('''CRT-P'''): Leads in both ventricles are present to synchronized contraction. The lead pacing the left ventricle is usually positioned in the coronary sinus. This cardiac resynchronization therapy can improve symptoms and survival in some heart failure patients. Several optimizing methods are being evaluated to find the most effective pacing delay between left and right ventricles. They include echocardiography, finding the narrowest QRS, and invasive hemodynamic measurements with pressure and flow wires.<br />
* '''[[ICD]]''' (Internal Cardioversion Device): This device can detect and treat [[Ventricular Tachycardia]] and [[Ventricular Fibrillation]]. ICDs are a separate category and usually not considered pacemakers although they do have a pacing function. Usually the first treatment is anti-tachy pacing (pacing at a rate +- 10% above the ventricular rate in ventricular tachycardia, which can convert the rhythm to sinus rhythm). If this is not effective, a defibrillator shock is delivered, usually with 16-36 Joules of energy. ICDs can save lives in patients who have a high risk of ventricular arrhythmias. All ICDs have optional pacemaker activity to treat bradycardias. New biventricular ICDs have 3 leads: an atrial lead, a left ventricular lead and a right ventricular lead.<br />
* Biventricular ICDs ('''CRT-D'''): an ICD with biventricular pacing option.<br />
{{clr}}<br />
==Pacemaker Indications==<br />
A full list of pacemaker indications can be read in the ESC guidelines on cardiac pacing <cite>Vardas</cite>. A selection of class I indications is: chronic symptomatic third- or second degree (Mobitz I or II) atrioventricular block, syncope with sinus node disease, alternating bundle branch block, and persisting AV block after surgery.<br />
<br />
===Atrial-sensed ventricular-paced rhythm===<br />
===AV dual-paced rhythm===<br />
===Pacemaker Malfunction===<br />
to be filled in ...<br />
====Failure of appropriate capture, atrial====<br />
[[Image:DVA0856.jpg|thumb|Failure of atrial capture in a patient with atrial standstill, no P waves are seen after the atrial stimuli]]<br />
{{clr}}<br />
<br />
====Failure of appropriate capture, ventricular====<br />
[[File:ECG000020.jpg|thumb|Failure of ventricular capture]]<br />
<br />
====Failure of Appropriate Inhibition, Atrial====<br />
====Failure of Appropriate Inhibition, Ventricular====<br />
====Failure of Appropriate Pacemaker Firing====<br />
====Retrograde Atrial Activation====<br />
====Pacemaker Mediated Tachycardia====<br />
{{clr}}<br />
{{Box|<br />
==External Links==<br />
[http://www.hrsonline.org/swPositionStatementFiles/ps101036428.asp Heart Rhytm Society]<br />
}}{{clr}}{{Box|<br />
==References==<br />
<biblio><br />
#Vardas pmid=17726042<br />
#Gregoratos pmid=12379588<br />
#Bernstein pmid=11916002<br />
</biblio><br />
}}<br />
{{clr}}<br />
[[Category:ECG Textbook]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Pacemaker&diff=9846
Pacemaker
2010-01-22T21:48:23Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
{{clr}}<br />
{{Box|<br />
A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The paced '''pacemaker rhythm''' can easily be recognized on the ECG. It shows '''pacemaker spikes''': vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing.<br />
<br />
In the first example, the atria are being paced, but not the ventricles, resulting in an '''atrial paced rhythm'''. Accordingly the ventricular complex is delayed until the atrial signal has passed through the AV node. In the second image the ventricles are paced directly, resulting in a '''ventricular paced rhythm'''. As ventricular pacing occurs exclusively in the right ventricle the ECG shows a left bundle branch block pattern. An exception to this rule is left ventricular pacing in patients with congenital anomalies and patients with a surgically placed epicardial pacemaker. Another exception is septal or RVOT placement of the pacing lead, which results in a less widened to normal QRS complex.<br />
}}<br />
{{clr}}<br />
{|align="right"<br />
|<br />
[[Image:picture_pacemaker.jpg|thumb|A (used) DDDr pacemaker]]<br />
[[Image:chest_xray_pacemaker.jpg |thumb| Chest x-ray of a patient with a pacemaker]]<br />
[[Image:paced2.gif|thumb| Ventricular paced rhythm shows ventricular pacemaker spikes]]<br />
[[Image:ddd_paced_12lead.jpg |thumb| DDD paced rhythm]]<br />
[[Image:Pacemaker2.jpg |thumb| Atrial sensed, ventricular paced rhythm (tracking). Note the LBBB morphology with left axis deviation indicating the pacing lead in the right ventricular apex.]]<br />
[[Image:DVA0838.jpg|thumb|Atrial paced rhythm]]<br />
|}<br />
==Pacemaker Coding==<br />
Pacemakers can be categorized according to the NASPE coding system, that usually consists of 3-5 letters. <br />
<br />
{| class="wikitable" width="80%"<br />
|+ '''The revised NASPE/BPEG generic code for antibradycardia pacing'''<cite>Bernstein</cite><br />
! I || II || III || IV || V <br />
|-<br />
| Chamber(s) paced || Chamber(s) sensed || Response to sensing || Rate modulation || Multisite pacing<br />
|-<br />
| O = None || O = None || O = None || O = None || O = None<br />
|-<br />
| A = Atrium || A = Atrium || T = Triggered || R = Rate modulation || A = Atrium<br />
|- <br />
| V = Ventricle || V = Ventricle || I = Inhibited || || V = Ventricle<br />
|-<br />
| D = Dual (A+V) || D = Dual (A+V) || D = Dual (T+I) || || D = Dual (A+V)<br />
|-<br />
|}<br />
<br />
==Commonly Used Pacemakers==<br />
The most often used codes are:<br />
* '''AAI''': The atria are paced, when the intrinsic atrial rhythm falls below the pacemaker's threshold.<br />
* '''VVI''': The ventricles are paced, when the intrinsic ventricular rhythm falls below the pacemaker's threshold.<br />
* '''VDD''': The pacemaker senses the atrial and ventricular events, but can only pace the ventricle. This type of pacemaker is used in patients with a reliable sinus node, but with an AV-block.<br />
* '''DDD''': The pacemaker records both the atrial and ventricular rate and can pace either chamber when needed.<br />
* '''DDDR''': As above, but the pacemaker has a sensor that records a demand for higher cardiac output and can adjust the heart rate accordingly.<br />
* Biventricular pacemakers ('''CRT-P'''): Leads in both ventricles are present to synchronized contraction. The lead pacing the left ventricle is usually positioned in the coronary sinus. This cardiac resynchronization therapy can improve symptoms and survival in some heart failure patients. Several optimizing methods are being evaluated to find the most effective pacing delay between left and right ventricles. They include echocardiography, finding the narrowest QRS, and invasive hemodynamic measurements with pressure and flow wires.<br />
* '''[[ICD]]''' (Internal Cardioversion Device): This device can detect and treat [[Ventricular Tachycardia]] and [[Ventricular Fibrillation]]. ICDs are a separate category and usually not considered pacemakers although they do have a pacing function. Usually the first treatment is anti-tachy pacing (pacing at a rate +- 10% above the ventricular rate in ventricular tachycardia, which can convert the rhythm to sinus rhythm). If this is not effective, a defibrillator shock is delivered, usually with 16-36 Joules of energy. ICDs can save lives in patients who have a high risk of ventricular arrhythmias. All ICDs have optional pacemaker activity to treat bradycardias. New biventricular ICDs have 3 leads: an atrial lead, a left ventricular lead and a right ventricular lead.<br />
* Biventricular ICDs ('''CRT-D'''): an ICD with biventricular pacing option.<br />
{{clr}}<br />
==Pacemaker Indications==<br />
A full list of pacemaker indications can be read in the ESC guidelines on cardiac pacing <cite>Vardas</cite>. A selection of class I indications is: chronic symptomatic third- or second degree (Mobitz I or II) atrioventricular block, syncope with sinus node disease, alternating bundle branch block, and persisting AV block after surgery.<br />
<br />
===Atrial-sensed ventricular-paced rhythm===<br />
===AV dual-paced rhythm===<br />
===Pacemaker Malfunction===<br />
to be filled in ...<br />
====Failure of appropriate capture, atrial====<br />
[[Image:DVA0856.jpg|thumb|Failure of atrial capture in a patient with atrial standstill, no P waves are seen after the atrial stimuli]]<br />
{{clr}}<br />
<br />
====Failure of appropriate capture, ventricular====<br />
[[File:ECG000020.jpg|thumb|Failure of ventricular capture]]<br />
<br />
====Failure of Appropriate Inhibition, Atrial====<br />
====Failure of Appropriate Inhibition, Ventricular====<br />
====Failure of Appropriate Pacemaker Firing====<br />
====Retrograde Atrial Activation====<br />
====Pacemaker Mediated Tachycardia====<br />
{{clr}}<br />
{{Box|<br />
==External Links==<br />
[http://www.hrsonline.org/swPositionStatementFiles/ps101036428.asp Heart Rhytm Society]<br />
}}{{clr}}{{Box|<br />
==References==<br />
<biblio><br />
#Vardas pmid=17726042<br />
#Gregoratos pmid=12379588<br />
#Bernstein pmid=11916002<br />
</biblio><br />
}}<br />
{{clr}}<br />
[[Category:ECG Textbook]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Pacemaker&diff=9845
Pacemaker
2010-01-22T21:42:04Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
{{clr}}<br />
{{Box|<br />
A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The paced '''pacemaker rhythm''' can easily be recognized on the ECG. It shows '''pacemaker spikes''': vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing.<br />
<br />
In the first example, the atria are being paced, but not the ventricles, resulting in an '''atrial paced rhythm'''. Accordingly the ventricular complex is delayed until the atrial signal has passed through the AV node. In the second image the ventricles are paced directly, resulting in a '''ventricular paced rhythm'''. As ventricular pacing occurs exclusively in the right ventricle the ECG shows a left bundle branch block pattern. An exception to this rule is left ventricular pacing in patients with congenital anomalies and patients with a surgically placed epicardial pacemaker. Another exception is septal or RVOT placement of the pacing lead, which results in a less widened to normal QRS complex.<br />
}}<br />
{{clr}}<br />
{|align="right"<br />
|<br />
[[Image:picture_pacemaker.jpg|thumb|A (used) DDDr pacemaker]]<br />
[[Image:chest_xray_pacemaker.jpg |thumb| Chest x-ray of a patient with a pacemaker]]<br />
[[Image:paced2.gif|thumb| Ventricular paced rhythm shows ventricular pacemaker spikes]]<br />
[[Image:ddd_paced_12lead.jpg |thumb| DDD paced rhythm]]<br />
[[Image:Pacemaker2.jpg |thumb| Atrial sensed, ventricular paced rhythm (tracking). Note the LBBB morphology with left axis deviation indicating the pacing lead in the right ventricular apex.]]<br />
[[Image:DVA0838.jpg|thumb|Atrial paced rhythm]]<br />
|}<br />
==Pacemaker Coding==<br />
Pacemakers can be categorized according to the NASPE coding system, that usually consists of 3-5 letters. <br />
<br />
{| class="wikitable" width="80%"<br />
|+ '''The revised NASPE/BPEG generic code for antibradycardia pacing'''<cite>Bernstein</cite><br />
! I || II || III || IV || V <br />
|-<br />
| Chamber(s) paced || Chamber(s) sensed || Response to sensing || Rate modulation || Multisite pacing<br />
|-<br />
| O = None || O = None || O = None || O = None || O = None<br />
|-<br />
| A = Atrium || A = Atrium || T = Triggered || R = Rate modulation || A = Atrium<br />
|- <br />
| V = Ventricle || V = Ventricle || I = Inhibited || || V = Ventricle<br />
|-<br />
| D = Dual (A+V) || D = Dual (A+V) || D = Dual (T+I) || || D = Dual (A+V)<br />
|-<br />
|}<br />
<br />
==Commonly Used Pacemakers==<br />
The most often used codes are:<br />
* '''AAI''': The atria are paced, when the intrinsic atrial rhythm falls below the pacemakers threshold.<br />
* '''VVI''': The ventricles are paced, when the intrinsic ventricular rhythm falls below the pacemakers threshold.<br />
* '''VDD''': The pacemaker senses the atrial in ventricular events, but can only pace the ventricle. This type of pacemaker is used in patients with a reliable sinus node, but with an AV-block.<br />
* '''DDD''': The pacemaker records both the atrial and ventricular rate and can pace one of each chambers when needed.<br />
* '''DDDR''': As above, but the pacemaker has a sensor that records a demand for higher cardiac output and can adjust the heart rate accordingly.<br />
* Biventricular pacemakers ('''CRT-P'''): Leads in both ventricles are present to synchronized contraction. The lead pacing the left ventricle is usually positioned in the coronary sinus. This cardiac resynchronization therapy can improve symptoms and survival in some heart failure patients. Several optimizing methods are being evaluated to find the most effective pacing delay between left and right ventricles. They include echocardiography, finding the narrowest QRS, and invasive hemodynamic measurements with pressure and flow wires.<br />
* '''[[ICD]]''' (Internal Cardioversion Device): This device can detect and treat [[Ventricular Tachycardia]] and [[Ventricular Fibrillation]]. ICDs are a separate category and usually not considered pacemakers although they do have a pacing function. Usually the first treatment is anti-tachy pacing (pacing at a rate +- 10% above the ventricular rate in ventricular tachycardia, which can convert the rhythm to sinus rhythm). If this is not effective, a defibrillator shock is delivered, usually with 16-36 Joules of energy. ICDs can save lives in patients who have a high risk of ventricular arrhythmias. All ICDs have optional pacemaker activity to treat bradycardias. New biventricular ICDs have 3 leads: an atrial lead, a left ventricular lead and a right ventricular lead.<br />
* Biventricular ICDs ('''CRT-D'''): an ICD with biventricular pacing option.<br />
{{clr}}<br />
==Pacemaker Indications==<br />
A full list of pacemaker indications can be read in the ESC guidelines on cardiac pacing <cite>Vardas</cite>. A selection of class I indications is: chronic symptomatic third- or second degree (Mobitz I or II) atrioventricular block, syncope with sinus node disease, alternating bundle branch block, and persisting AV block after surgery.<br />
<br />
===Atrial-sensed ventricular-paced rhythm===<br />
===AV dual-paced rhythm===<br />
===Pacemaker Malfunction===<br />
to be filled in ...<br />
====Failure of appropriate capture, atrial====<br />
[[Image:DVA0856.jpg|thumb|Failure of atrial capture in a patient with atrial standstill, no P waves are seen after the atrial stimuli]]<br />
{{clr}}<br />
<br />
====Failure of appropriate capture, ventricular====<br />
[[File:ECG000020.jpg|thumb|Failure of ventricular capture]]<br />
<br />
====Failure of Appropriate Inhibition, Atrial====<br />
====Failure of Appropriate Inhibition, Ventricular====<br />
====Failure of Appropriate Pacemaker Firing====<br />
====Retrograde Atrial Activation====<br />
====Pacemaker Mediated Tachycardia====<br />
{{clr}}<br />
{{Box|<br />
==External Links==<br />
[http://www.hrsonline.org/swPositionStatementFiles/ps101036428.asp Heart Rhytm Society]<br />
}}{{clr}}{{Box|<br />
==References==<br />
<biblio><br />
#Vardas pmid=17726042<br />
#Gregoratos pmid=12379588<br />
#Bernstein pmid=11916002<br />
</biblio><br />
}}<br />
{{clr}}<br />
[[Category:ECG Textbook]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Pacemaker&diff=9844
Pacemaker
2010-01-22T20:50:47Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[user:Drj|J.S.S.G. de jong]]<br />
|supervisor= <br />
}}<br />
{{clr}}<br />
{{Box|<br />
A pacemaker is indicated when electrical impulse conduction or formation is dangerously disturbed. The paced '''pacemaker rhythm''' can easily be recognized on the ECG. It shows '''pacemaker spikes''': vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar than in bipolar pacing.<br />
<br />
In the first example, the atria are being paced, but not the ventricles, resulting in an '''atrial paced rhythm'''. Accordingly the ventricular complex is delayed until the atrial signal has passed through the AV node. In the second image the ventricles are paced directly, resulting in a '''ventricular paced rhythm'''. As ventricular pacing occurs exclusively in the right ventricle the ECG shows a left bundle branch block pattern. An exception to this rule is left ventricular pacing in patients with congenital anomalies and patients with a surgically placed epicardial pacemaker. Another exception is septal or RVOT placement of the pacing lead, which results in a less widened to normal QRS complex.<br />
}}<br />
{{clr}}<br />
{|align="right"<br />
|<br />
[[Image:picture_pacemaker.jpg|thumb|A (used) DDDr pacemaker]]<br />
[[Image:chest_xray_pacemaker.jpg |thumb| Chest x-ray of a patient with a pacemaker]]<br />
[[Image:paced2.gif|thumb| Ventricular paced rhythm shows ventricular pacemaker spikes]]<br />
[[Image:ddd_paced_12lead.jpg |thumb| DDD paced rhythm]]<br />
[[Image:Pacemaker2.jpg |thumb| Atrial sensed, ventricular paced rhythm (tracking). Note the LBBB morphology with left axis deviation indicating the pacing lead in the right ventricular apex.]]<br />
[[Image:DVA0838.jpg|thumb|Atrial paced rhythm]]<br />
|}<br />
==Pacemaker Coding==<br />
Pacemakers can be categorized according to the NASPE coding system, that usually consists of 3-5 letters. <br />
<br />
{| class="wikitable" width="80%"<br />
|+ '''The revised NASPE/BPEG generic code for antibradycardia pacing'''<cite>Bernstein</cite><br />
! I || II || III || IV || V <br />
|-<br />
| Chamber(s) paced || Chamber(s) sensed || Response to sensing || Rate modulation || Multisite pacing<br />
|-<br />
| O = None || O = None || O = None || O = None || O = None<br />
|-<br />
| A = Atrium || A = Atrium || T = Triggered || R = Rate modulation || A = Atrium<br />
|- <br />
| V = Ventricle || V = Ventricle || I = Inhibited || || V = Ventricle<br />
|-<br />
| D = Dual (A+V) || D = Dual (A+V) || D = Dual (T+I) || || D = Dual (A+V)<br />
|-<br />
|}<br />
<br />
==Commonly Used Pacemakers==<br />
The most often used codes are:<br />
* '''AAI''': the atria are paced, when the intrinsic atrial rhythm falls below the pacemakers threshold<br />
* '''VVI''': the ventricles are paced, when the intrinsic ventricular rhythm falls below the pacemakers threshold<br />
* '''VDD''': the pacemaker senses the atrial in ventriculair events, but can only pace the ventricle. This type of pacemaker is used in patients with a reliable sinus node, but with an AV-block.<br />
* '''DDD''': the pacemaker records both the atrial and ventricular rate and can pace one of each chambers when needed.<br />
* '''DDDR''': as above, but the pacemaker has a sensor that records a demand for higher cardiac output and can adjust the heart rate accordingly.<br />
* Biventricular pacemakers ('''CRT-P'''): leads in both ventricles are present to synchronize contraction. The lead pacing the left ventricle is usually positioned in the coronary sinus. This cardiac resynchronization therapy can improve symptoms and survival in some heart failure patients. Several optimizing methods are being evaluated to find the most effective pacing delay between left and right ventricle They include echocardiography, finding the narrowest QRS, and invasive hemodynamic measurements with pressure and flow wires.<br />
* '''[[ICD]]''' (Internal Cardioversion Device): this device can detect and treat [[Ventricular Tachycardia]] and [[Ventricular Fibrillation]]. ICDs are a separate category and usually not put into the pacemaker category, although they do have a pacing function. Usually the first treatment is anti-tachy pacing (pacing at a rate +- 10% above the ventricular rate in ventricular tachycardia, which can convert the rhythm to sinus rhythm). If this is not effective, a defibrillator shock is delivered, usually with 16-36 Joules of energy. ICDs can save lives in patients who have a high risk of ventricular arrhythmias. All ICDs have optional pacemaker activity to treat bradycardias. New biventricular ICDs have 3 leads: an atrial lead, a left ventricular lead and a right ventricular lead.<br />
* Biventricular ICDs ('''CRT-D'''): an ICD with biventricular pacing option.<br />
{{clr}}<br />
==Pacemaker Indications==<br />
A full list of pacemaker indications can be read in the ESC guidelines on cardiac pacing <cite>Vardas</cite>. A selection of class I indications are: chronic symptomatic third- or second degree (Mobitz I or II) atrioventricular block, syncope with sinus node disease, alternating bundle branch block, and persisting AV block after surgery.<br />
<br />
===Atrial-sensed ventricular-paced rhythm===<br />
===AV dual-paced rhythm===<br />
===Pacemaker Malfunction===<br />
to be filled in ...<br />
====Failure of appropriate capture, atrial====<br />
[[Image:DVA0856.jpg|thumb|Failure of atrial capture in a patient with atrial standstill, no P waves are seen after the atrial stimuli]]<br />
{{clr}}<br />
<br />
====Failure of appropriate capture, ventricular====<br />
[[File:ECG000020.jpg|thumb|Failure of ventricular capture]]<br />
<br />
====Failure of appropriate inhibition, atrial====<br />
====Failure of appropriate inhibition, ventricular====<br />
====Failure of appropriate pacemaker firing====<br />
====Retrograde atrial activation====<br />
====Pacemaker mediated tachycardia====<br />
{{clr}}<br />
{{Box|<br />
==External Links==<br />
[http://www.hrsonline.org/swPositionStatementFiles/ps101036428.asp Heart Rhytm Society]<br />
}}{{clr}}{{Box|<br />
==References==<br />
<biblio><br />
#Vardas pmid=17726042<br />
#Gregoratos pmid=12379588<br />
#Bernstein pmid=11916002<br />
</biblio><br />
}}<br />
{{clr}}<br />
[[Category:ECG Textbook]]</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Electrolyte_Disorders&diff=9843
Electrolyte Disorders
2010-01-22T20:29:39Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[T.T. Keller]]<br />
|supervisor= <br />
}}<br />
==Hypercalcemia==<br />
Hypercalcemia, high blood calcium, speeds repolarization. Characteristics of hypercalcemia:<br />
*Mild: broad based tall peaking T waves<br />
*Severe: extremely wide QRS, low R wave, disappearance of p waves, tall peaking T waves.<br />
<br />
==Hypocalcemia==<br />
ECG-characteristics of hypocalcemia, low blood calcium:<br />
*Narrowing of the QRS complex<br />
*Reduced PR interval<br />
*T wave flattening and inversion<br />
*Prolongation of the QT-interval <br />
*Prominent U-wave<br />
*Prolonged ST and ST-depression<br />
<br />
==Hyperkalemia==<br />
ECG characteristics of hyperkalemia, high blood potassium:<br />
*Tall peaked T waves<br />
*Flattening p-waves. In extreme hyperkalemia p-waves may disappear altogether.<br />
*Prolonged depolarization leading to QRS widening (nonspecific intraventricular conduction defect) sometimes > 0.20 seconds<br />
<br />
At concentrations > 7.5 mmol/L atrial and [[Ventricular Fibrillation|ventricular fibrillation]] can occur.<br />
<gallery consecutive ECGs of a patient with severe hypokalemia><br />
Image:KJcasu18-3.jpg|Consecutive ECGs of a patient with hyperkalemia. ECG1<br />
Image:KJcasu18-2.jpg|Consecutive ECGs of a patient with hyperkalemia. ECG2<br />
Image:KJcasu18-1.jpg|Consecutive ECGs of a patient with hyperkalemia. After correction of potassium levels. ECG3<br />
</gallery><br />
{{clr}}<br />
<br />
==Hypokalemia==<br />
Hypokalemia, low blood potassium, results in:<br />
*ST depression and flattening of the T wave<br />
*Negative T waves<br />
*A U-wave may be visible<br />
<gallery><br />
Image:KJcasu17-1.jpg| patient A<br />
Image:KJcasu17-2.jpg| patient A<br />
Image:KJcasu17-3.jpg| patient B<br />
Image:JJ0003.jpg| Patient C, Potassiumlevel of 1.5<br />
</gallery><br />
{{clr}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Electrolyte_Disorders&diff=9842
Electrolyte Disorders
2010-01-22T20:27:22Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Drj|J.S.S.G. de Jong]]<br />
|moderator= [[T.T. Keller]]<br />
|supervisor= <br />
}}<br />
==Hypercalcemia==<br />
Hypercalcemia results in a faster repolarization. Characteristics of hypercalcemia:<br />
*Mild: broad based tall peaking T waves<br />
*Severe: extremely wide QRS, low R wave, disappearance of p waves, tall peaking T waves.<br />
<br />
==Hypocalcemia==<br />
ECG-characteristics of hypocalcemia:<br />
*Narrowing of the QRS complex<br />
*Reduced PR interval<br />
*T wave flattening and inversion<br />
*Prolongation of the QT-interval <br />
*Prominent U-wave<br />
*Prolonged ST and ST-depression<br />
<br />
==Hyperkalemia==<br />
ECG characteristics of hyperkalemia:<br />
*Tall peaked T waves<br />
*Flattening p-waves. In extreme hyperkalemia p-waves may disappear altogether.<br />
*Prolonged depolarization leading to QRS widening (nonspecific intraventricular conduction defect) sometimes > 0.20 seconds<br />
<br />
At concentrations > 7.5 mmol/L atrial and [[Ventricular Fibrillation|ventricular fibrillation]] can occur.<br />
<gallery consecutive ECGs of a patient with severe hypokalemia><br />
Image:KJcasu18-3.jpg|Consecutive ECGs of a patient with hyperkalemia. ECG1<br />
Image:KJcasu18-2.jpg|Consecutive ECGs of a patient with hyperkalemia. ECG2<br />
Image:KJcasu18-1.jpg|Consecutive ECGs of a patient with hyperkalemia. After correction of potassium levels. ECG3<br />
</gallery><br />
{{clr}}<br />
<br />
==Hypokalemia==<br />
Hypokalemia, low blood potassium, results in:<br />
*ST depression and flattening of the T wave<br />
*Negative T waves<br />
*A U-wave may be visible<br />
<gallery><br />
Image:KJcasu17-1.jpg| patient A<br />
Image:KJcasu17-2.jpg| patient A<br />
Image:KJcasu17-3.jpg| patient B<br />
Image:JJ0003.jpg| Patient C, Potassiumlevel of 1.5<br />
</gallery><br />
{{clr}}</div>
KGoldin
https://en.ecgpedia.org/index.php?title=Clinical_Disorders&diff=9841
Clinical Disorders
2010-01-22T20:23:11Z
<p>KGoldin: </p>
<hr />
<div>{{authors|<br />
|mainauthor= [[user:Vdbilt|I.A.C. van der Bilt, MD]]<br />
|moderator= [[T.T. Keller]]<br />
|supervisor=<br />
}}<br />
<br />
==Medication==<br />
===Digoxin===<br />
[[Image:med_digitalis.png|thumb|300px|Typical for digoxin intoxication is the oddly shaped ST-depression]]<br />
ECG changes typical for digoxin intoxication (digoxin = Lanoxin) are:<br />
*Oddly shaped ST-depression. <br />
*T wave flat, negative or biphasic<br />
*Short QT interval<br />
*Increased u-wave amplitude<br />
*Prolonged PR-interval<br />
*Bradyarrhythmias:<br />
**Sinus bradycardia<br />
**AV block. Including complete AV block and Wenkebach.<br />
*Tachyarrhythmias:<br />
**Junctional tachycardia<br />
**Atrial tachycardia<br />
**Ventricular ectopia, bigemini, monomorphic ventricular tachycardia, bidirectional ventricular tachycardia<br />
<br />
Intoxication can lead to an SA-block or AV-block, sometimes in combination with tachycardia. '''NB''' these effects are increased by hypokalemia. In extreme high concentrations rhythm disturbances (''ventricular tachycardia, ventricular fibrillation, atrial fibrillation'') may develop.<br />
{{clr}}<br />
===Antiarrhythmics===<br />
* '''Anti-arrhythmics:''' These may lead to several ECG-changes;<br />
**Broad and irregular P-wave<br />
**Broad QRS complex<br />
**Prolonged QT interval (brady-, tachycardia, AV-block, ventricular tachycardia)<br />
**Prominent U-wave<br />
**In case of intoxication, the above mentioned characteristics are more prominent<br />
<br />
Additionally, several arrhthytmias can be seen.<br />
<br />
=== Nortriptyline Intoxication ===<br />
<div align="center"><br />
{|<br />
|<br />
[[Image:ECG_nortr_intox.png|thumb|left|300px|An example of severe nortriptyline intoxication. The inhibitory effect on the sodium channel manifests as a broadened QRS complex and a prolonged QT interval.]]<br />
|<br />
[[Image:ECG_TCA_intox.jpg|thumb|left|300px| Another example of severe nortriptyline intoxication.]]<br />
{{clr}}<br />
|}<br />
</div><br />
=== Amitriptyline Intoxication ===<br />
<div align="center"><br />
{|<br />
|<br />
[[Image:ECG_amitr_OD_during.jpg|thumb|300px| An example of a severe amitriptyline intoxication. The inhibitory effect on the sodium channel manifests as a broadened QRS complex.]]<br />
|<br />
[[Image:ECG_amitr_OD_before.jpg|thumb|300px| An ECG of the same patient before the intoxication.]]<br />
|}<br />
</div><br />
{{clr}}<br />
<br />
==Pericarditis==<br />
[[Pericarditis]]<br />
<br />
==Myocarditis==<br />
<br />
[[w:Myocarditis|Myocarditis]] is an inflammation of the myocardium and the interstitium. The symptoms are faint chest pain, abnormal heart rate and progressive heart failure. It can be caused by several factors: viruses, bacteria, fungi, parasites, spirochetes, auto-immune reactions, borreliosis (Lyme's disease) and HIV/AIDS. <br />
<br />
Acute peri/myocarditis causes nonspecific ST segment changes. These can be accompanied by supraventricular and ventricular rhythm disturbances and T-wave abnormalities.<br />
<br />
==Pulmonary Embolism==<br />
See the chapter [[Pulmonary Embolism]]<br />
<br />
==Chronic Pulmonary Disease Pattern==<br />
The ECG shows low voltage QRS complexes in leads I, II, and III and a right axis deviation. This is caused by the increased pressure on the right chamber. This leads to right ventricular hypertrophy.<br />
<br />
==Pacemaker==<br />
See the chapter [[Pacemaker]]<br />
<br />
==Tamponade==<br />
[[Image:ECG000028.jpg|thumb|Electrical alternans on the ECG]]<br />
In case of tamponade, fluid collects in the pericardium. Because the pericardium is stiff, the heart is compressed, resulting in filling difficulties. This is a potentially life-threatening situation and should be treated with pericardiocentesis, drainage of the fluid. Tamponade can be the result of pericarditis or myocarditis. After a myocardial infarction a tamponade can also develop; this is called Dresslers' Syndrome. In case of cancer,increased pericardial fluid may develop. This is usually caused by pericarditis carcinomatosis, meaning that the cancer has spread to the pericardium<br />
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The ECG shows:<br />
*Sinus tachycardia<br />
*Low-voltage QRS complexes [[microvoltages]]<br />
*Alternation of the QRS complexes, usually in a 2:1 ratio. Electrical alternans can also be seen in myocardial ischemia, acute pulmonary embolism, and tachyarrhythmias<br />
*PR segment depression (this can also be observed in an [[Ischemia#Atriaal_.2F_boezem_infarct|atrial infarction]])<br />
{{clr}}<br />
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==Ventricular Aneurysm==<br />
The ECG pattern suggests an acute MI. All classical signs of MI may occur:; Q waves, ST segment elevations (>1mm, >4 weeks present)and T wave inversions are present. To exclude an acute MI, comparison with old ECG's is compulsory (MI has occurred years before).<br />
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==Dilated Cardiomyopathy==<br />
Often, a LBBB or broadened QRS-complex can be seen. Additionally, nonspecific ST segment changes are present with signs of left atrial enlargement.<br />
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==Hypertrophic Obstructive Cardiomyopathy==<br />
A HOCM is a hereditary illness.<br />
On the ECG there are signs of [[hypertrophy|left ventricular hypertrophy]] and [[P wave morphology|left atrial enlargement]].<br />
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==Electrolyte Disturbances==<br />
See chapter: [[electrolyte disturbances]]<br />
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==Hypothermia==<br />
[[Image:osborne.png|thumb|left|250px| An Osborne J wave]]<br />
<div style="float:right"><br />
<gallery><br />
Image:osborne_ecg.jpg|A 12 lead ECG of a patient with a body temperature of 32 degrees Celsius. Note the sinus bradycardia, the prolonged QT interval (QTc is not prolonged) and the Osborne J wave, most prominently in leads V2-V5<br />
Image:JJ0001.jpg|An ECG of a patient with a body temperature of 28 degrees Celsius.<br />
</gallery><br />
</div><br />
In hypothermia a number of specific changes can be seen;<cite>hypoth</cite><br />
* Sinus bradycardia<br />
* Prolonged QTc-interval<br />
* ST segment elevation (inferior and left precordial leads)<br />
* Osborne-waves (slow deflections at the end of the QRS-complex)<br />
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==ECG Changes after Neurologic Events==<br />
[[Image:ECG_SAB.png|thumb| ECG of a 74 year old patient with a subarachnoid hemorrhage. Note the negative T-waves and the prolonged QT interval.]]<br />
In 1938, Aschenbrenner <cite>Aschenbrenner</cite> noted that repolarization abnormalities may occur after increased intracranial pressure. Since then, many publications have described ECG changes after acute neurological events.<br />
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ECG changes that may occur are: <br />
*Q waves<br />
*ST segment elevations, <br />
*ST segment depressions, <br />
*T wave changes. Large negative T waves over the precordial leads are observed frequently.<br />
*Prolonged QT-interval.<br />
*Prominent u-waves.<br />
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These abnormalities are frequently seen after [[w:Subarachnoid_hemorrhage|subarachnoid_hemorrhage (SAH)]] (if measured serially, almost every SAH patients has at least one abnormal ECG.), but also in [[w:Subdural_hematoma|subdural hematoma]], ischemic [[w:Cerebrovascular_accident|CVA]]'s, [[w:Brain_tumor|brain Tumors]], [[w:Guillain-Barre|Guillain Barré]], [[w:Epilepsy|epilepsy]] and [[w:Migraine|migraine]]. The ECG changes are generally reversible and have limited prognostic value. However, the ECG changes can be accompanied with myocardial damage and echocardiographic changes. The cause of the ECG changes is not yet clear. The most common hypothesis is that of a neurotramitter "catecholamine storm" caused by sympathetic stimulation.<br />
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==Cardiac Contusion==<br />
Cardiac contusion (in latin: contusio cordis or commotio cordis) is caused by a blunt trauma to the chest, often caused by a car or motorbike accident or in martial arts<cite>Maron</cite>. Rhythm disturbances and even heart failure can occur. Diagnosis is made using echocardiography and laboratory testing for cardiac enzymes. <br />
Possible ECG changes are:<cite>Sybrandy</cite><br />
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'''Nonspecific changes'''<br />
*Pericarditis-like ST elevation or PTa depression<br />
*Prolonged QT interval<br />
'''Myocardial damage'''<br />
*New Q waves<br />
*ST-T segment elevation or depression<br />
'''Conduction delay'''<br />
*Right bundle branch block<br />
*Fascicular blok<br />
*AV delay(1st, 2nd, and 3rd degree AV blok)<br />
'''Arrhythmias'''<br />
*Sinus tachycardia<br />
*Atrial and ventricular extrasystoles<br />
*Atrial fibrillation<br />
*Ventricular tachycardia<br />
*[[Arrhythmias#Ventricular fibrillation|Ventricular fibrillation]]<br />
*Sinus bradycardia<br />
*Atrial tachycardia<br />
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==Lown Ganong Levine Syndrome==<br />
The Lown Ganong Levine Syndrome is a pre-excitation syndrome in which the atria are connected to the lower part of the AV node or bundle of His. On the ECG:<br />
* Short PR interval, < 120 ms<br />
* Normal QRS complex<br />
* No delta wave<br />
==Left and right bundle branch block==<br />
See: [[Conduction_delay|Conduction delay]]<br />
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==Cocaine Intoxication==<br />
|<!--col1-->[[Image:JJ00001.jpg|200px]]<br />
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{{Box|<br />
==References==<br />
<biblio><br />
#Sybrandy pmid=12695446<br />
#Rodger pmid=11018210<br />
#Ferrari pmid=9118684<br />
#Aschenbrenner Aschenbrenner R, Bodechtel G, ''Ãber Ekg.-Veränderungen bei Hirntumorkranken''. Journal of Molecular Medicine, 17, 9, 2/1/1938, Pages 298-302, http://dx.doi.org/10.1007/BF01778563<br />
#Maron pmid=14681516<br />
#hypoth pmid=2738372<br />
</biblio><br />
}}<br />
[[Category:ECG Textbook]]</div>
KGoldin