Conduction

«Step 2: Rate

Step 4: Learn how to determine the heart axis»

The PQ interval

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

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 0.20 seconds.

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

A short PQ interval can be seen in the WPW syndrome in which a faster connection exists between the atria and the ventricles.

The QRS duration

The QRS duration indicates how fast the ventricles depolarize. 

The ventricles depolarize normally within 0.10 seconds. When this is longer than 0.12 seconds, this is a conduction delay (Left bundle branch block or Right bundle branch block).

The QT interval

The QT interval indicates how fast the ventricles are repolarized and how fast they are ready for a new heart cycle
The normal value for QTc(orrected) is: 440ms for men and 450 ms for women.

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 comprises the QRS-complex, the ST-segment, and the T-wave.

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 torsade de pointes, a ventricular tachycardia.

The QT interval is defined as follows: [1] 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.

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::

at an RR interval 1 second, the (heart frequency 60/min) QTc=QT

Using the QTc calculator on the right, the QTc is easy extractable.

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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..

The following formula is indicative for normal values of QT time (uncorrected):

Difficult QT intervals

In some examples of the QT interval it can be difficult to measure a correct QT time. We have made a separate chapter: Measurement of difficult QT intervals.

Causes of a prolonged QT interval

• Medication (i.e. anti-arrhythmics, tricyclic antidepressants, phenothiazedes, for a complete list look on Torsades.org
• Inherited long QT syndrome (LQTS)
• Cerebral (subarachnoid haemorrhage, stroke, trauma)
• Post infarct

Short QT syndrome

There is controversy whether short QT intervals are associated with sudden death. One trial found QTc intervals < 300ms to be associated with sudden death.[2] However, a recent Finnish study in a random selection of healthy subjects (n=10 822) did not find an increased incidence of sudden death. They defined <320ms as 'very short' and < 340ms as 'short'. In total, 15 deaths occured in the group with QTc <340ms, with only one possible sudden death (cause of death unknown). They used Friderica's method for QTc correction: QTfc=QT^3 / SQRT(RR)[3][4]

References

1. 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 |
2. 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 |
3. Anttonen O, Junttila MJ, Rissanen H, Reunanen A, Viitasalo M, and Huikuri HV. Prevalence and prognostic significance of short QT interval in a middle-aged Finnish population. Circulation. 2007 Aug 14;116(7):714-20. DOI:10.1161/CIRCULATIONAHA.106.676551 |

4. Fridericia LS. Die Systolendauer im Elektrokardiogramm bei normalen

   Menschen und bei Herzkranken. Acta Med Scand. 1920;53:469–486.

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

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