Peer Reviewed

CE Article #1

Obtaining and Interpreting

Electrocardiograms
Michelle St John, LVT, VTS (Cardiology)
Upstate Veterinary Specialties
Latham, New York

s their role expands, veterinary technicians are

required to perform more diagnostic tests. In addition to assisting veterinarians, technicians often
have primary responsibility for performing tests and reporting the results to a veterinarian. Technicians need to ensure
that these tests are performed proficiently and provide data
of a quality that veterinarians can rely on to make proper
diagnoses.
This article can help improve technicians skills in
obtaining and interpreting electrocardiograms (ECGs).
Technicians should be able to identify artifacts and correct
them, obtain ECGs of diagnostic quality, and locate and
identify common arrhythmias on ECGs.

The Basics
An ECG is a recording of the electric activity of the heart.
The P-QRS-T complex represents the depolarization and
repolarization of both atria and ventricles. The P wave represents atrial depolarization, the QRS complex represents
ventricular depolarization, and the T wave signifies ventricular repolarization. An ECG allows clinicians to identify arrhythmias, calculate heart rate, and to some extent,
estimate heart chamber size. Continuous ECGs are used
for postsurgical or long-term monitoring of the heart rate
and rhythm or for monitoring patients at risk of developing
arrhythmias. In addition, the effectiveness of antiarrhythmic drug therapy can be monitored with 24-hour (Holter)
or continuous ECGs.
ECGs are requested for many reasons (BOX 1). When a
patient has an audible arrhythmia or what seems to be an
inappropriate heart rate on auscultation, a baseline ECG
is useful. However, ECGs are also obtained for preanesthesia work-ups, monitoring during anesthesia and after
surgery, trauma and shock management, and evaluation of
certain metabolic diseases, drug toxicosis, syncope (fainting
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spells), and seizures. ECGs are also helpful in determining

the effectiveness of antiarrhythmic therapy.
A standard six-lead ECG tracing records leads I, II, and
III; aVR; aVL; and aVF. Leads I, II, and III are bipolar standard limb leads. aVR, aVL, and aVF are unipolar limb leads
that are part of the four limb leads (TABLE 1). The cables
(leads) are usually color coded and labeled using human
medical terminology indicating where to attach them to the
patient (TABLE 1).1
Before using an ECG machine, familiarize yourself with
it. In the owners manual, read about all the functions that
the machine offers. Know where the power switch is, how
to replace the paper supply, how to make adjustments if
artifacts are present, and how to change the sizes of the
complexes to facilitate interpretation. Technicians should
be able to change the paper speed and the gain, adjust the
filter, and record all the leads or only specific ones. Most
BOX 1

Clinical Uses of Electrocardiograms

Characterizing arrhythmias
Evaluating patients with syncopal or seizure episodes
Performing a preanesthesia work-up
Monitoring during anesthesia
Postsurgical monitoring
Monitoring during trauma or shock
Evaluating dyspneic patients
E valuating patients with certain metabolic or endocrine disorders (Addisons disease, renal disease)
M
 onitoring drug therapy for arrhythmias or heart
failure
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CE Article #1
TABLE 1

Lead Placement

FIGURE 1

Limb Placement

Color

Human Code

Right front leg

White

RA (right arm)

Left front leg

Black

LA (left arm)

Right rear leg

Green

RL (right leg)

Left rear leg

Red

LL (left leg)

new machines simultaneously record all six leads, but

many older machines require the operator to switch from
lead to lead.
Paper speed is usually set at 25 or 50 mm/sec. The faster
the paper speed, the easier it is to measure and evaluate
each complex. The lead II rhythm strip may be recorded
at 50 or 25 mm/sec. A slower speed increases the number of complexes on the paper, allowing better comparison
between heartbeats. Adjusting the filter helps minimize
high-frequency artifacts created by patient trembling or
purring, but such adjustments decrease the amount of
high-frequency information available in the QRS complex
and may affect overall QRS voltage in some circumstances.
Feline ECGs are often harder to evaluate because the complexes are smaller and P waves may be almost nonexistent.
Increasing the ECG gain setting, which determines how
large the complexes appear for each mV of voltage input,
can make these small complexes larger, allowing easier
ECG interpretation. The standard gain setting is 1 cm = 1
mV; adjustment can be made in both directions (e.g., the
gain can be increased to 2 cm = 1 mV for patients with
low-amplitude complexes or decreased to cm = 1 mV for
patients with high-amplitude complexes that are too large
for the ECG paper at the standard calibration).

Preparation
To obtain an ECG, position the patient in right lateral
recumbency (FIGURE 1). To help minimize artifacts and
increase comfort, the table on which the patient lies should
be covered with a thick towel or rubber mat. Laying the
patient directly on a stainless-steel tabletop increases the
possibility of electric artifacts. With the patient in lateral
recumbency, extend the front and rear legs away from the
patients body and parallel to each other. If the electrodes
are attached too close to the chest or the legs remain flexed
(folded against the body), increased respiratory motion artifact may result. The cables (leads) are attached as indicated
in TABLE 1. The LA and RA leads are ideally placed below
the left and right elbows, respectively, where the skin is
thin and loose (the legs are essentially volume conductors
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MAY 2010 | Veterinary Technician

Proper patient positioning for obtaining an ECG.

for the torso, so the exact location of the leads on the limbs
is unimportant; the leads should simply be placed to minimize all motion artifacts). The rear leads (RL and LL) are
ideally placed below the stifles. A small amount of electrode
gel (ideally) or alcohol must be applied to each electrode
unless disposable gel electrodes are used. To minimize
respiratory motion artifacts, ensure that the leads are not
lying against the patients chest wall. The person restraining
the patient should avoid touching the electrodes because
motion artifacts can be easily caused.
If a patient is stressed, dyspneic, or too large to place on
the table, an ECG can be recorded with the patient in sternal recumbency or a standing position. Irregularities such
as abnormal heart rhythm or rate can be identified on an
ECG with the patient in any position, but measurement
of waveforms (complexes) is more accurate with patients
in right lateral recumbency. If the patient becomes less
stressed and can be placed in lateral recumbency, another
ECG can be obtained for a better tracing.

Identifying Artifacts
Technicians should be able to identify three common artifacts (i.e., respiratory, other movement, and electric artifacts), which are usually easy to resolve.
Respiratory artifacts, which appear as a wandering or
uneven baseline correlating with the patients breathing,
are caused by patient panting, respirations (deep), dyspnea,
or purring (FIGURE 2). Calming the patient and applying
gentle chest pressure may help resolve these artifacts. If
panting is the problem, hold the patients mouth closed for
a few seconds or blow on the patients nose. With dyspneic
patients, technicians may have to accept a wandering baseline or wait until the patient is more stable.
Patient movement (e.g., shaking, trembling, twitching) artifacts are best resolved by having an extra person
help calm or distract the patient so that it stops moving.
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FIGURE 2

FIGURE 3
R
P
QS

A purring artifact. Note the undulating baseline (arrow).

R
P
QS

Movement artifacts change the baseline only when the

patient moves. For example, the baseline may be clean
and flat as it should be until the patient trembles, which
can make the baseline uneven. Movement may be difficult
to control while a patient is standing; it is hard to keep
a standing patient from moving its feet. If trembling is
causing the movement, roll up a small towel and place it
between the patients legs; this often allows the cable leads
to avoid direct contact with moving (trembling) legs and
muscles and helps create a better tracing.
Electric (60 Hz) artifacts appear as a saw-toothed jagged baseline (FIGURE 3). This can be minimized by placing a rubber mat under the patient, rewetting the leads to
ensure proper contact, and ensuring that no one is touching
the leads. Electric equipment (e.g., clippers, fans) plugged
into the same circuit as the ECG machine should be turned
off. If this does not help, try moving the ECG machine to
another room or having another person help restrain the
patient. Sometimes, a person unknowingly discharges static
electricity, interfering with the machine.1

Recording
Once the patient is positioned and the leads are placed,
look at your tracing and answer the following questions: Is
the tracing free of artifacts? Is the baseline clean? Can you
clearly see and identify the complexes? If the answer to all
the questions is yes, proceed with recording the ECG. If
the answer to any of the questions is no, make adjustments
to remedy the situation. Depending on the ECG machine,
either the operator manually scrolls through the leads to
record all six (i.e., leads I, II, and III; aVR; aVL; aVF) at a
paper speed of 25 or 50 mm/sec or the machine automatically does this. After the six-lead recording is complete, the
paper speed should usually be slowed to 25 mm/sec and a
lead-II rhythm strip recorded. If the ECG is being performed
because an arrhythmia was auscultated during the physiVetlearn.com

Electric interference (arrow).

cal examination, wait until the arrhythmia appears before

recording. Intermittent arrhythmias, such as an occasional
dropped or premature beat, can be very difficult to detect.
A lead-II tracing is usually recorded for approximately 2
minutes or two pages. Other methods (e.g., Holter monitors) can help detect more infrequent irregularities.

Understanding Electric Impulses and Complexes

Before evaluating an ECG, it is important to know how the
heart is activated electrically and what the ECG complexes
signify. Normally, the first electric activity in the heart is
generated in the sinoatrial (SA) node, which is located in
the right atrium near the entrance of the cranial vena cava.
The impulse originating from the SA node depolarizes the
right and left atria in sequence, causing the P wave. The
impulse continues to the atrioventricular (AV) node, where
the conduction velocity slows. The electric impulse then
travels out of the AV node, down the rapidly conducting
bundle of His, and into the Purkinje fibers, which divide
into the right and left bundle branches, rapidly distributing
the electric activation impulse to the ventricles, which then
depolarize from the endocardial surface to the epicardial
surface. The sequence of atrial and ventricular activation is
similar in dogs and cats, resulting in the typical P-QRS-T
waveforms.
Knowing what each segment of the waveform represents
is helpful in evaluating the ECG. Each waveform (complex)
should have a P wave, QRS complex, and T wave (FIGURE
3). The P wave represents atrial depolarization. The P-R
interval is the amount of time it takes from the beginning
of the P wave until the first deflection of the QRS complex;
it represents the time of atrial activation and conduction
through the AV node. On the ECG, the P-R interval appears
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CE Article #1
FIGURE 4

FIGURE 5

VPCs

Inspiration

Normal sinus arrhythmia: the heart rate increases with inspiration and
slows during exhalation.

as a straight line between the beginning of the P wave and

the beginning of the QRS complex. The QRS complex follows the P-R interval and signifies depolarization of the
right and left ventricles. The S-T segment is the period of
time from the completion of ventricular depolarization to
the beginning of ventricular repolarization. The Q-T interval, measured from the first deflection of the QRS complex
until the end of the T wave, represents the total amount of
time it takes for depolarization and repolarization of the
ventricles.
ECG paper has a standard format. For standard gain calibration, 1 cm in height equals 1 mV as recorded by the ECG.
Time is measured in seconds or milliseconds on the horizontal axis. When the width of a wave, such as a P wave, is
measured, the time the wave takes from beginning to end is
measured in seconds. Most ECG paper has heavy and fine
gridlines. At a paper speed of 50 mm/sec, each box created
by heavy gridlines represents 0.1 second along the horizontal axis, and each box created by fine gridlines represents
0.02 second along the horizontal axis (FIGURE 3). This is
important to remember when calculating heart rate. The fine
gridlines create 25 boxes within the heavy gridlines. At standard gain calibration (1 cm = 1 mV), each fine-gridline box
represents 0.1 mV on the vertical axis. Each heavy-gridline
box represents 0.5 mV (1 mV = 1 cm) on the vertical axis.2

Evaluation
To evaluate an ECG, answer the following questions: Is the
heart rate normal for the environmental circumstance and
species? Is the heart rhythm regular? Are P waves present? If
so, are they uniform? Is there a P wave in front of every QRS
complex at a reasonable P-R interval? Is there a QRS complex for every P wave? Are the P-R intervals uniform? Are
the QRS complexes uniform and of a normal duration? If
all of these criteria are met, the rhythm is probably sinus. A
normal sinus rhythm usually shows little variation between
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Exhalation

QRS complexes

Two VPCs followed by QRS complexes.

waveforms, but there are a few exceptions. A sinus arrhythmia shows cyclic variation with respiration (FIGURE 4). As
the patient inhales, its heart rate increases; as the patient
exhales, its heart rate decreases. A patient with a wandering
pacemaker may show variation in the P-R interval and the
P-wave morphology. The P waves may become notched or
flat or have a negative or biphasic deflection. Wandering
pacemakers and sinus arrhythmia are found in many healthy
patients and generally require no medical treatment.

Heart Rate
Heart rate can be manually calculated by various methods.
The easiest method to understand and perform, once the
paper speed is known, is to determine how many PQRST
wave complexes occur in either 6 seconds (then multiply
that number by 10 to get the heart rate per minute) or in 3
seconds (then multiply that number by 20). The following
two methods are also reliable and frequently used:
The 1500 or 3000 method is very useful and accurate
for calculating regular rhythms. At a paper speed of
50 mm/sec, there are 3000 fine-gridline boxes/min.
For two complexes, count the fine-gridline boxes
between two R waves, and divide 3000 by the result.
At a paper speed of 25 mm/sec, there are 1500 finegridline boxes/min. For two complexes, count the
fine-gridline boxes between two R waves, and divide
1500 by the result.
The 10 or 20 method uses hash marks visible at the
edge of the paper. At a paper speed of 50 mm/sec, one
hash mark to the next represents 1.5 seconds. To calculate the heart rate at this speed, count all the complexes for 3 seconds (within three hash marks) and
multiply the result by 20. At a paper speed of 25 mm/
sec, one hash mark to the next represents 3 seconds.
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FIGURE 7

FIGURE 6

Ventricular tachycardia.

VPCs

Three consecutive VPCs: a triplet.

Normal

V-tach

First-degree heart block: a longer-than-normal P-R interval (arrow).

FIGURE 8

V-tach that breaks into normal sinus rhythm.

To calculate the heart rate at this speed, count all the

complexes for 6 seconds (within three hash marks)
and multiply the result by 10. The 10 or 20 method
helps to determine heart rates when P waves are not
consistently present with QRS waves.1
Cats and dogs that are stressed by being in a clinic
can have high heart rates that decrease in a familiar
environment.1

Arrhythmia
If the heart rhythm looks abnormal (e.g., too fast, slow, or
irregular), determine what is wrong. Normal sinus rhythm
rates are 60 to 160 per minute in most dogs and 140 to 220
per minute in cats. Heart rates above these limits are classified as tachycardia; heart rates below these limits are classified as bradycardia. Are there P waves without subsequent
QRS complexes? Are there QRS complexes that appear out
of line or too early? Is there a long pause without a QRS
complex? Does the whole tracing look strange? Are you
sure this is not due to an artifact?

Ventricular Premature Complexes

Ventricular premature complexes (VPCs) are common
arrhythmias (FIGURE 5). VPCs indicate that an electric
impulse originated in the ventricle, before the next normal complex was expected. On the ECG, a VPC appears as
a QRS complex that is wider and appears different than norVetlearn.com

Second-degree heart block, Mobitz type II: the P-R intervals (arrows) have
the same duration.

mal QRS complexes. In most instances, VPCs do not have

associated P waves. VPCs can be present for multiple reasons. VPCs can be caused by stress, splenic disease, cardiac
disease, infections that irritate the heart muscle, trauma,
and unknown causes. VPCs can originate in the right or left
ventricle and can appear as a single deflection or in pairs
called couplets. VPCs occurring in a pattern of three or more
in a row are called ventricular tachycardia (v-tach; FIGURE
6). V-tach can be a medical emergency if it is sustained (>30
seconds without a normal sinus complex). In this situation,
cardiac efficiency and output usually decrease dramatically
and an antiarrhythmic medication such as lidocaine must
be injected to try to convert this abnormal rhythm back to
sinus rhythm.2

Heart Block
Heart block is described as an impediment to conduction
between the atria and ventricles. There are three basic forms
of heart block. Evaluation of the P wave and QRS complex
helps determine whether heart block is present.
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Glossary

FIGURE 9

Atrial fibrillation.

Amplitudeheight of a waveform
Arrhythmiaan abnormal heart rhythm
Atrial fibrillationa rapid, irregular heart rhythm
in which the atria are chaotically depolarized by
impulses that do not originate in the sinus node
AV nodeatrioventricular node; the electric
connection between the atria and the ventricles
where impulse conduction slows
Depolarizationelectric activation
Durationwidth of a waveform; the amount of
time a waveform takes
First-degree AV blockon an ECG, the P-R
intervals are longer than normal

No P waves.

Repolarizationelectric resetting so that

depolarization can occur
SA nodesinoatrial node
Second-degree AV block, Mobitz type Ion
an ECG, some P waves are not followed by QRS
complexes in which the P-R intervals often
gradually lengthen before the blocked (missing)
QRS complex
Second-degree AV block, Mobitz type IIon
an ECG, some P waves are not followed by QRS
complexes in which the P-R intervals are constant,
leading up to the blocked QRS complexes
Third-degree AV blockon an ECG, the P waves
are independent of the QRS complexes: the P waves
occur at their own rate (generally normal or rapid),
and the QRS complexes occur at their own rate
(slow, escape) and usually appear as ventricular
escape complexes
Ventricular escape complexa ventricularoriginating complex that occurs after a long pause
in the rhythm
VPCventricular premature complex; occurs when
an electric impulse originates prematurely in one of
the ventricles
V-tachventricular tachycardia; three or more
consecutive VPCs with a faster-than-normal heart rate

First-degree heart block (first-degree AV block) is

indicated by a longer-than-normal P-R interval (FIGURE
7). When the P-R interval is >0.13 seconds (in dogs), firstdegree heart block is present. This finding generally needs
no medical treatment but may be a sign of a drug effect
(e.g., due to digoxin or -adrenergic blockade).
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No P waves, a fast heart rate of ~190 bpm, and an irregularly

irregular rhythm.

Second-degree heart block (second-degree AV block)

is often subdivided into Mobitz type I and Mobitz type II
(FIGURE 8). In Mobitz type I, the P-R interval is variable,
often is progressively prolonging before the blocked QRS
complex. In Mobitz type II, the P-R interval is fixed, leading
to the blocked QRS complex. In both cases, the key finding is P waves without an ensuing QRS complex. There is a
concern that Mobitz type II can develop into third-degree
heart block. Low-grade (i.e., infrequent) Mobitz type I is
rarely a serious clinical problem and is a normal finding in
some animals with marked sinus arrhythmia.
Third-degree heart block (third-degree AV block) is
usually a medical emergency, often requiring implantation of a pacemaker. On an ECG, third-degree heart block
appears as many P waves with no regularly associated QRS
complexes. The P waves occur at their own rate, meaning
that they are independent of the ventricular rate, which is
much slower than the atrial rate. The atrial and ventricular rates need to be measured. It is not uncommon for an
affected patient to have bradycardia with a heart rate of 40
bpm. Third-degree heart block is usually due to disease
of the AV node, which prevents proper conduction to the
electric impulse from the atria to the ventricles.2

Atrial Fibrillation
Atrial fibrillation is a rapid, irregular heart rhythm in which
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the atria are constantly and chaotically being depolarized

by abnormal electric impulses that do not originate in the
sinus node (FIGURE 9). Certain giant-breed dogs, such as
Great Danes and Irish wolfhounds, are prone to atrial fibrillation, which can cause tachycardia (ventricular response
rates usually 160 bpm) and affect cardiac performance.
ECG characteristics of atrial fibrillation are a lack of P waves
(fine, undulating waves called F waves may be visible in
the ECG baseline) and a rapid heart rate with QRS complexes that are irregularly irregular (i.e., irregular variation
between R waves). Atrial fibrillation can be treated with
medications that reduce conduction velocity in the AV node
to slow the ventricular response to the fibrillating atria and
improve cardiac output. If untreated, atrial fibrillation can
lead to heart failure.2
***
Many more types of arrhythmias can be detected on an
ECG. The ones discussed here are easily recognizable and

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common in clinical practice. A technicians ability to recognize these abnormalities can help the veterinarian make
a diagnosis and help stabilize patients in medical emergencies. For example, if an anesthetized patient is being monitored by ECG and the technician notices that its heart rate
has doubled, recognizing the difference between v-tach and
sinus tachycardia on the ECG tracing can expedite the decision for treatment.

Conclusion
The ECG is an essential part of veterinary medicine that
can be used in various areas of a hospital. Technicians can
strengthen the veterinary team by knowing how to obtain
and interpret ECGs and alerting the veterinarian to medical
emergencies.

References

1. Edwards NJ. ECG Manual for the Veterinary Technician.

Philadelphia: WB Saunders; 1993.
2. Fox PR, Sisson D, Moise NS, eds. Textbook of Canine and Feline
Cardiology. 2nd ed. Philadelphia: WB Saunders; 1999.

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CE Article #1

Article #1 FREE CE Test

The article you have read qualifies for 1.0 credit hour. To receive credit from Alfred State College, choose the best answer to each of the following questions. Take the test online at Vetlearn.com.
1. Which type of heart block results in independent
atrial and ventricular heart rates?

a. third-degree heart block

b. first-degree heart block

c. second-degree heart block, Mobitz type II

d. atrial fibrillation

6. An ECG that does not show a QRS complex for every

P wave indicates that

a. atrial fibrillation is present.

b. the electrodes were poorly grounded.

c. an AV block is present.

d. bradycardia is present.

2.

7. An ECG with a paper speed of 25 mm/sec was

obtained for a puppy, revealing a heart rate of 150
bpm. Using the 10 or 20 method, how many complexes were counted in 6 seconds?

a. 10
c. 20

b. 15
d. 30

Which artifact can be caused by panting?

a. electric interference
b. a wandering baseline
c. tachycardia
d. a wandering pacemaker

3. At a paper speed of 50 mm/sec, a technician

counts 20 small boxes between the R-R intervals.
If the 1500 or 3000 method is used, the patients
heart rate is ____ bpm.

a. 300
c. 150

b. 200
d. 120
4. Proper patient positioning for a standard six-lead
ECG tracing is

a. right lateral recumbency with the limbs
outstretched.

b. left lateral recumbency with the limbs outstretched.

c. right lateral recumbency with only the front limbs
outstretched.

d. right lateral recumbency with the limbs in a relaxed
position.
5. Which of the following is least in need of continuous
ECG monitoring?

a. splenectomy

b. arrhythmia

c. monitoring the efficacy of lidocaine treatment in a
patient with v-tach

d. murmur evaluation

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MAY 2010 | Veterinary Technician

8. Which part of the waveform represents a delay in

electric activity at the AV node to allow proper atrial
contraction and ventricular filling?

a. the P wave
c. the Q-T interval

b. the S-T segment d. the P-R interval
9. The length of a straight line between the beginning
of the P wave and the beginning of the QRS complex
is

a. the P-R interval.

b. atrial depolarization.

c. the atrial relaxation period.

d. the transelectric period.
10. Located at the junction of the right atrium and the
interventricular septum, the ________ allow(s) (1)
electric conduction to slow and (2) proper filling of
both ventricles before ventricular depolarization.

a. AV node

b. SA node

c. Purkinje fibers

d. right and left bundle branches

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Copyright 2010 MediMedia Animal Health. This document is for internal purposes only. Reprinting or posting on an external website without written permission from MMAH is a violation of copyright laws.