Conduction: Difference between revisions

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|previousname=Step 2: Rate
|previousname=Step 2: Rate
|nextpage=Heart axis
|nextpage=Heart axis
|nextname=Step 4: Learn how to determine the heart axis
|nextname=Step 4: Learn how to determine the heart's conduction axis
}}
}}
{{authors|
|mainauthor= [[user:Drj|J.S.S.G. de Jong, MD]]
|moderator= [[J.S.S.G. de Jong]]
|supervisor=
}}
<div style="float:left">__TOC__</div>
{{clr}}
[[Image:QRSwaves.jpg|thumb|300px|right]]
==The PQ interval==
[[Image:Conduction_ap.svg|thumb|300px|right|The PQ duration depends on the conduction velocity in the atria, AV node, His bundle, bundle branches and Purkinje fibers]]
'''The PQ interval starts at the beginning of the atrial contraction and ends at the beginning of the ventricular contraction.'''


==The PQ interval==
The PQ interval (sometimes referred to as the PR interval as a Q wave is not always present) indicates how fast the action potential is transmitted through the AV node (atrioventricular) from the atria to the ventricles. Measurement should start at the beginning of the P wave and end at the beginning of the QRS segment.
The PQ interval starts at the beginning of the atrial contraction and ends at the beginning of the ventricular contraction.
[[Image:QRSwaves.jpg|thumb]]


The PQ interval indicates how fast the action potential is transmitted through the AV node (atrioventricular) from the atria to the ventricles. Measurement should start at the beginning of the P wave to the beginning of the QRS segment.
'''The normal PQ interval is between 0.12 and 0.22 seconds'''.


'''The normal PQ interval is between 0.12 and 0.20 seconds'''.
A prolonged PQ interval is a sign of a degradation of the conduction system or increased vagal tone (Bezold-Jarisch reflex), or it can be pharmacologically induced.  


A prolonged PQ interval is a sign of a degradation of the conduction system. This is called [[Arrhythmias#Atrioventricular_block|1st, 2nd or 3rd degree AV block]].
This is called [[Arrhythmias#Atrioventricular_block|1st, 2nd or 3rd degree AV block]].


A short PQ interval can be seen in the [[Arrhythmias#WPW_syndrome|WPW syndrome]] in which a faster connection exists between the atria and the ventricles.
A short PQ interval can be seen in the [[Arrhythmias#WPW_syndrome|WPW syndrome]] in which faster-than-normal conduction exists between the atria and the ventricles.
{{clr}}


==The QRS duration==
==The QRS duration==
The QRS duration indicates how fast the ventricles depolarize.  
'''The QRS duration indicates how fast the ventricles depolarize. The normal QRS is < 0.10 seconds'''
 
The ventricles depolarize  normally within 0.10 seconds. When this is longer than 110 miliseconds<cite>aha</cite>, this is a [[conduction delay| conduction delay]]. Possible causes of a QRS duration > 110 miliseconds include:
* [[LBBB|Left bundle branch block]]
* [[RBBB|Right bundle branch block]]
* [[Electrolyte Disorders]]
* [[Idioventricular Rhythm|Idioventricular rhythm]] and [[Pacemaker|paced rhythm]]


The ventricles depolarize  normally within 0.10 seconds. When this is longer than 0.12 seconds, this is a [[conduction delay| conduction delay]] ([[LBBB|Left bundle branch block]] or [[RBBB|Right bundle branch block]]).
For the diagnosis of LBBB or RBBB QRS duration must be >120 ms.


==The QT interval==
==The QT interval==
The QT interval indicates how fast the ventricles are repolarized and how fast they are ready for a new heart cycle
[[File:E000571.jpg|thumb|400px| The QT interval starts at the onset of the Q wave and ends where the tangent line for the steepest part of the T wave intersects with the baseline of the ECG. ]]
The normal value for QTc(orrected) is: 440ms for men and 450 ms for women.
[[File:QTeyeballing.png|thumb|400px|The eyeballing method to estimate QT prolongation. If the QT interval ends before the imaginary boundary halfway two QRS complexes, the QTc is probably normal. If the QTc reaches beyond the halfway line, the QTc is probably prolonged. This method is only 'valid' in registrations with normal (60-100/min) heart rates.]]
 
'''The normal QTc (corrected) interval'''
[[Image:QRSinterval.jpg|thumb| The QT interval start at the onset of the Q wave and ends where the tangent line for the steepest part of the T wave intersects with the baseline of the ECG. Click on the image for a bigger image]]
The QT interval indicates how fast the ventricles are repolarized, becoming ready for a new cycle.
 
The QT interval comprises the QRS-complex, the ST-segment, and the T-wave.
The normal value for QTc is: '''below 450ms for men and below 460ms for women''' as agreed upon by the ACC / HRS. <cite>aha2</cite>
 
In  a (serious) prolonged QT time, is takes longer for the myocardial cells to be ready for a new cardiac cycle. There is a possibility that some cells are not yet repolarized, but that a new cardiac cycle is already initiated. These cells are at risk for uncontrolled depolarization and induce a [[Arrhythmias#Torsade_de_pointes|torsade de pointes]], a ventricular tachycardia.


The QT interval is defined as follows: <cite>Lepeschkin</cite> The time between the beginning of the Q until the point where the steepest tangent line from the end of the T-wave intersects with the base line of the ECG.
In a recent ACC consensus document an expert writing group suggest that in a hospital setting the upper limit be raised to the 99th percentile of normal: 470ms in males and 480 ms in females, as approximately 10% to 20% of the general population have a QTc > 440m s. For both men and women QTc > 500ms is considered highly abnormal.<cite>TdP</cite>


The difficult part is that the QT interval gets shorter if the heart rate increases. This cab be solved by correcting the QT time for heart rate using the Bazett formula::
If QTc is < 340ms [[Short_QT_Syndrome|short QT syndrome]] can be considered.


[[Image:Formule_QTc.png]]
The QT interval comprises the QRS-complex, the ST-segment, and the T-wave. One difficultly of QT interpretation is that the QT interval gets shorter as the heart rate increases. This problem can be solved by correcting the QT time for heart rate using the Bazett formula: [[Image:Formule_QTc.png]]


''at an RR interval 1 second, the (heart frequency 60/min) QTc=QT''
Thus at a heart rate of 60 bpm, the RR interval is 1 second and the QTc equals QT/1. The '''[[QTc calculator]]''' can be used to easily calculate QTc from the QT and the heart rate or RR interval.


Using the QTc calculator on the right, the QTc is easy extractable.
On modern ECG machines, the QTc is given. However, the machines are not always capable of making the correct determination of the end of the T wave. Therefore, it is important to check the QT time manually.


<flash>file=QTc.swf|width=300|height=200|quality=best|align=right|salign=R||bgcolor=#FFF5F5</flash>
Alternatives to the Bazzett correction formula are the Fridericia, Framingham and Hodges formulas. The latter two perform better at high heart rates (>100 /min). <cite>Indik</cite><cite>T</cite>
*Fridericia: QTc = QT{HR/60}1/3
*Framingham: QTc = QT + 0.154{1 – (60/HR)}
*Hodges: QTc = QT + 1.75 (heart rate - 60).


On the modern ECG machines, the QTc is given. However, the machines are not always capable of recognizing the correct QT time. Therefore, it is important to check this manually..
Although QT prolongation is potentially lethal, measurement of the QT interval by physicians is not standardized, since different definitions of the end of the T wave exist.<cite>Viskin</cite> Most QT experts define the end of the T wave as the intersection of the steepest tangent line from the end of the T-wave with the base line of the ECG.<cite>Lepeschkin</cite> This leads to the following stepwise approach:


The following formula is indicative for normal values of QT time (uncorrected):
{| class="wikitable" width="800px"
!Stepwise approach to correct measurement of the QT interval
|-
|
#Use lead II. Use lead V5 alternatively if lead II cannot be read.
#Draw a line through the baseline (preferably the PR segment)
#Draw a tangent against the steepest part of the end of the T wave. If the T wave has two positive deflections, the taller deflection should be chosen. If the T wave is biphasic, the end of the taller deflection should be chosen.
#The QT interval starts at the beginning of the QRS interval and ends where the tangent and baseline cross.
#If the QRS duration exceeds 120ms the amount surpassing 120ms should be deducted from the QT interval (i.e. QT=QT-(QRS width-120ms) ).
#Calculate QTc according to Bazett: [[Image:Formule_QTc.png]]. You can use the '''[[QTc calculator]]''' for this.
|}


[[Image:Formule_QTn_nl.png]]
During ventricular pacing this method overestimates the QTc. The Framingham formula performs better during pacing, but still overestimates the QTc in sinus rhythm (in the same patient) by about 37-43 msec.<cite>Chiladakis</cite>
{{clr}}


===Difficult QT intervals===
In a pathological prolonged QT time, it takes longer than the normal amount of time for the myocardial cells to be ready for a new cycle. There is a possibility that some cells are not yet repolarized, but that a new cycle is already initiated. These cells are at risk for uncontrolled depolarization, induction of  [[Torsade de Pointes]] and subsequent [[Ventricular Fibrillation]].
In some examples of the QT interval it can be difficult to measure a correct QT time. We have made a separate chapter: [[Difficult_QT| Measurement of difficult QT intervals]].


===Causes of a prolonged QT interval===
{| class="wikitable" width="800px"
*Medication (i.e. anti-arrhythmics, tricyclic antidepressants, phenothiazedes, for a complete list look on [http://www.torsades.org Torsades.org]
! Causes of QT prolongation
*Inherited [[Long QT syndrome|long QT syndrome]] (LQTS)
|-
*Cerebral (subarachnoid haemorrhage, stroke,  trauma)
|
*Post infarct
The QT interval is prolonged in congenital [[long QT syndrome]], but QT prolongation can also occur be acquire as a results of:
* Medication (anti-arrhythmics, tricyclic antidepressants, phenothiazedes, for a complete list see [http://www.torsades.org Torsades.org]  
* Electrolyte imbalances
* Ischemia.
QT prolongation is often treated with beta blockers.
|}


===Short QT syndrome===
If the QT segment is abnormal, it can be difficult to define the end of the T wave. Below are a number of examples that suggest how QT should be measured in these patients.
There is controversy whether short QT intervals are associated with sudden death. One trial found QTc intervals < 300ms to be associated with sudden death.<cite>Gaita</cite> However, a recent Finnish study in a random selection of healthy males (n=5658) did not find an increased incidence of sudden death. They defined <320ms as 'very short' and < 340ms as 'short'.<cite>Anttonen</cite>
{| class="wikitable" width="800px" style="margin:5px"
!colspan='3'|How to measure QT if the QT segement is abnormal
|-
|valign="top"|[[File:lastigeQT1.png|250px|center]]
|valign="top"|[[File:lastigeQT2.png|250px|center]]
|valign="top"|[[File:lastigeQT3.png|250px|center]]
|-
|valign="top"|<div style="margin:5px">The T wave is broad, but the tangent crosses the baseline before the T wave joins the baseline. The QT interval would be overestimated when this last definition of the end of the T wave would be used.</div>
|valign="top"|<div style="margin:5px">The ECG does not meet the baseline after the end of the T wave. Still, the crossing of the tangent and baseline should be used for measurements.</div>
|valign="top"|<div style="margin:5px">A bifasic T wave. The tangent to the 'hump' with the largest amplitude is chosen. This can change from beat to beat, making it more important to average several measurements.</div>
|}


{{box|
== References ==
== References ==
<biblio>
<biblio>
#aha pmid=19228822
#bazett Bazett HC. ''An analysis of the time-relations of electrocardiograms''. Heart 1920;7:353-370.
#bazett Bazett HC. ''An analysis of the time-relations of electrocardiograms''. Heart 1920;7:353-370.
#Lepeschkin pmid=14954534
#Lepeschkin pmid=14954534
#Gaita pmid=12925462
#Gaita pmid=12925462
#Anttonen pmid=17679619
#Moss pmid=8256751
#aha2 pmid=19228821
#Viskin pmid=15922261
#Indik pmid=16945790
#T pmid=15842424
#TdP pmid=20185054
#Chiladakis pmid=23118006
</biblio>
</biblio>
 
}}
<analytics uacct="UA-807577-6"></analytics>
[[Category:ECG Course]]

Latest revision as of 05:29, 13 September 2021

«Step 2: Rate Step 4: Learn how to determine the heart's conduction axis»


Author(s) J.S.S.G. de Jong, MD
Moderator J.S.S.G. de Jong
Supervisor
some notes about authorship


QRSwaves.jpg

The PQ interval

The PQ duration depends on the conduction velocity in the atria, AV node, His bundle, bundle branches and Purkinje fibers

The PQ interval starts at the beginning of the atrial contraction and ends at the beginning of the ventricular contraction.

The PQ interval (sometimes referred to as the PR interval as a Q wave is not always present) indicates how fast the action potential is transmitted through the AV node (atrioventricular) from the atria to the ventricles. Measurement should start at the beginning of the P wave and end at the beginning of the QRS segment.

The normal PQ interval is between 0.12 and 0.22 seconds.

A prolonged PQ interval is a sign of a degradation of the conduction system or increased vagal tone (Bezold-Jarisch reflex), or it can be pharmacologically induced.

This is called 1st, 2nd or 3rd degree AV block.

A short PQ interval can be seen in the WPW syndrome in which faster-than-normal conduction exists between the atria and the ventricles.

The QRS duration

The QRS duration indicates how fast the ventricles depolarize. The normal QRS is < 0.10 seconds

The ventricles depolarize normally within 0.10 seconds. When this is longer than 110 miliseconds[1], this is a conduction delay. Possible causes of a QRS duration > 110 miliseconds include:

For the diagnosis of LBBB or RBBB QRS duration must be >120 ms.

The QT interval

The QT interval starts at the onset of the Q wave and ends where the tangent line for the steepest part of the T wave intersects with the baseline of the ECG.
The eyeballing method to estimate QT prolongation. If the QT interval ends before the imaginary boundary halfway two QRS complexes, the QTc is probably normal. If the QTc reaches beyond the halfway line, the QTc is probably prolonged. This method is only 'valid' in registrations with normal (60-100/min) heart rates.

The normal QTc (corrected) interval The QT interval indicates how fast the ventricles are repolarized, becoming ready for a new cycle.

The normal value for QTc is: below 450ms for men and below 460ms for women as agreed upon by the ACC / HRS. [2]

In a recent ACC consensus document an expert writing group suggest that in a hospital setting the upper limit be raised to the 99th percentile of normal: 470ms in males and 480 ms in females, as approximately 10% to 20% of the general population have a QTc > 440m s. For both men and women QTc > 500ms is considered highly abnormal.[3]

If QTc is < 340ms short QT syndrome can be considered.

The QT interval comprises the QRS-complex, the ST-segment, and the T-wave. One difficultly of QT interpretation is that the QT interval gets shorter as the heart rate increases. This problem can be solved by correcting the QT time for heart rate using the Bazett formula: Formule QTc.png

Thus at a heart rate of 60 bpm, the RR interval is 1 second and the QTc equals QT/1. The QTc calculator can be used to easily calculate QTc from the QT and the heart rate or RR interval.

On modern ECG machines, the QTc is given. However, the machines are not always capable of making the correct determination of the end of the T wave. Therefore, it is important to check the QT time manually.

Alternatives to the Bazzett correction formula are the Fridericia, Framingham and Hodges formulas. The latter two perform better at high heart rates (>100 /min). [4][5]

  • Fridericia: QTc = QT{HR/60}1/3
  • Framingham: QTc = QT + 0.154{1 – (60/HR)}
  • Hodges: QTc = QT + 1.75 (heart rate - 60).

Although QT prolongation is potentially lethal, measurement of the QT interval by physicians is not standardized, since different definitions of the end of the T wave exist.[6] Most QT experts define the end of the T wave as the intersection of the steepest tangent line from the end of the T-wave with the base line of the ECG.[7] This leads to the following stepwise approach:

Stepwise approach to correct measurement of the QT interval
  1. Use lead II. Use lead V5 alternatively if lead II cannot be read.
  2. Draw a line through the baseline (preferably the PR segment)
  3. Draw a tangent against the steepest part of the end of the T wave. If the T wave has two positive deflections, the taller deflection should be chosen. If the T wave is biphasic, the end of the taller deflection should be chosen.
  4. The QT interval starts at the beginning of the QRS interval and ends where the tangent and baseline cross.
  5. If the QRS duration exceeds 120ms the amount surpassing 120ms should be deducted from the QT interval (i.e. QT=QT-(QRS width-120ms) ).
  6. Calculate QTc according to Bazett: Formule QTc.png. You can use the QTc calculator for this.

During ventricular pacing this method overestimates the QTc. The Framingham formula performs better during pacing, but still overestimates the QTc in sinus rhythm (in the same patient) by about 37-43 msec.[8]

In a pathological prolonged QT time, it takes longer than the normal amount of time for the myocardial cells to be ready for a new cycle. There is a possibility that some cells are not yet repolarized, but that a new cycle is already initiated. These cells are at risk for uncontrolled depolarization, induction of Torsade de Pointes and subsequent Ventricular Fibrillation.

Causes of QT prolongation

The QT interval is prolonged in congenital long QT syndrome, but QT prolongation can also occur be acquire as a results of:

  • Medication (anti-arrhythmics, tricyclic antidepressants, phenothiazedes, for a complete list see Torsades.org
  • Electrolyte imbalances
  • Ischemia.

QT prolongation is often treated with beta blockers.

If the QT segment is abnormal, it can be difficult to define the end of the T wave. Below are a number of examples that suggest how QT should be measured in these patients.

How to measure QT if the QT segement is abnormal
LastigeQT1.png
LastigeQT2.png
LastigeQT3.png
The T wave is broad, but the tangent crosses the baseline before the T wave joins the baseline. The QT interval would be overestimated when this last definition of the end of the T wave would be used.
The ECG does not meet the baseline after the end of the T wave. Still, the crossing of the tangent and baseline should be used for measurements.
A bifasic T wave. The tangent to the 'hump' with the largest amplitude is chosen. This can change from beat to beat, making it more important to average several measurements.


References

  1. Surawicz B, Childers R, Deal BJ, Gettes LS, Bailey JJ, Gorgels A, Hancock EW, Josephson M, Kligfield P, Kors JA, Macfarlane P, Mason JW, Mirvis DM, Okin P, Pahlm O, Rautaharju PM, van Herpen G, Wagner GS, Wellens H, American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology, American College of Cardiology Foundation, and Heart Rhythm Society. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation. 2009 Mar 17;119(10):e235-40. DOI:10.1161/CIRCULATIONAHA.108.191095 | PubMed ID:19228822 | HubMed [aha]
  2. Rautaharju PM, Surawicz B, Gettes LS, Bailey JJ, Childers R, Deal BJ, Gorgels A, Hancock EW, Josephson M, Kligfield P, Kors JA, Macfarlane P, Mason JW, Mirvis DM, Okin P, Pahlm O, van Herpen G, Wagner GS, Wellens H, American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology, American College of Cardiology Foundation, and Heart Rhythm Society. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part IV: the ST segment, T and U waves, and the QT interval: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation. 2009 Mar 17;119(10):e241-50. DOI:10.1161/CIRCULATIONAHA.108.191096 | PubMed ID:19228821 | HubMed [aha2]
  3. Drew BJ, Ackerman MJ, Funk M, Gibler WB, Kligfield P, Menon V, Philippides GJ, Roden DM, Zareba W, American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Council on Cardiovascular Nursing, and American College of Cardiology Foundation. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol. 2010 Mar 2;55(9):934-47. DOI:10.1016/j.jacc.2010.01.001 | PubMed ID:20185054 | HubMed [TdP]
  4. Indik JH, Pearson EC, Fried K, and Woosley RL. Bazett and Fridericia QT correction formulas interfere with measurement of drug-induced changes in QT interval. Heart Rhythm. 2006 Sep;3(9):1003-7. DOI:10.1016/j.hrthm.2006.05.023 | PubMed ID:16945790 | HubMed [Indik]
  5. Dogan A, Tunc E, Varol E, Ozaydin M, and Ozturk M. Comparison of the four formulas of adjusting QT interval for the heart rate in the middle-aged healthy Turkish men. Ann Noninvasive Electrocardiol. 2005 Apr;10(2):134-41. DOI:10.1111/j.1542-474X.2005.05604.x | PubMed ID:15842424 | HubMed [T]
  6. Viskin S, Rosovski U, Sands AJ, Chen E, Kistler PM, Kalman JM, Rodriguez Chavez L, Iturralde Torres P, Cruz F FE, Centurión OA, Fujiki A, Maury P, Chen X, Krahn AD, Roithinger F, Zhang L, Vincent GM, and Zeltser D. Inaccurate electrocardiographic interpretation of long QT: the majority of physicians cannot recognize a long QT when they see one. Heart Rhythm. 2005 Jun;2(6):569-74. DOI:10.1016/j.hrthm.2005.02.011 | PubMed ID:15922261 | HubMed [Viskin]
  7. LEPESCHKIN E and SURAWICZ B. The measurement of the Q-T interval of the electrocardiogram. Circulation. 1952 Sep;6(3):378-88. DOI:10.1161/01.cir.6.3.378 | PubMed ID:14954534 | HubMed [Lepeschkin]
  8. Chiladakis JA, Kalogeropoulos A, Zagkli F, Koutsogiannis N, Chouchoulis K, and Alexopoulos D. Facilitating assessment of QT interval duration during ventricular pacing. Europace. 2013 Jun;15(6):907-14. DOI:10.1093/europace/eus357 | PubMed ID:23118006 | HubMed [Chiladakis]

  9. Bazett HC. An analysis of the time-relations of electrocardiograms. Heart 1920;7:353-370.

    [bazett]
  10. Gaita F, Giustetto C, Bianchi F, Wolpert C, Schimpf R, Riccardi R, Grossi S, Richiardi E, and Borggrefe M. Short QT Syndrome: a familial cause of sudden death. Circulation. 2003 Aug 26;108(8):965-70. DOI:10.1161/01.CIR.0000085071.28695.C4 | PubMed ID:12925462 | HubMed [Gaita]
  11. Moss AJ. Measurement of the QT interval and the risk associated with QTc interval prolongation: a review. Am J Cardiol. 1993 Aug 26;72(6):23B-25B. DOI:10.1016/0002-9149(93)90036-c | PubMed ID:8256751 | HubMed [Moss]
All Medline abstracts: PubMed | HubMed
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