Electrocardiogram (ECG)


An electrocardiogram (ECG) is a simple test that can be used to check your heart's rhythm and electrical activity.


Sensors attached to the skin are used to detect the electrical signals produced by your heart each time it beats.


These signals are recorded by a machine and are looked at by a doctor to see if they're unusual.


An ECG may be requested by a heart specialist (cardiologist) or any doctor who thinks you might have a problem with your heart, including your GP.


The test can be carried out by a specially trained healthcare professional at a hospital, a clinic or at your GP surgery.


Despite having a similar name, an ECG isn't the same as an echocardiogram, which is a scan of the heart.


When an ECG is used


An ECG is often used alongside other tests to help diagnose and monitor conditions affecting the heart.


It can be used to investigate symptoms of a possible heart problem, such as chest pain, palpitations (suddenly noticeable heartbeats), dizziness and shortness of breath.


An ECG can help detect:


arrhythmias – where the heart beats too slowly, too quickly, or irregularly


coronary heart disease – where the heart's blood supply is blocked or interrupted by a build-up of fatty substances


heart attacks – where the supply of blood to the heart is suddenly blocked


cardiomyopathy – where the heart walls become thickened or enlarged


A series of ECGs can also be taken over time to monitor a person already diagnosed with a heart condition or taking medication known to potentially affect the heart.


How an ECG is carried out


There are several different ways an ECG can be carried out. Generally, the test involves attaching a number of small, sticky sensors called electrodes to your arms, legs and chest. These are connected by wires to an ECG recording machine.


You don't need to do anything special to prepare for the test. You can eat and drink as normal beforehand.


Before the electrodes are attached, you'll usually need to remove your upper clothing, and your chest may need to be shaved or cleaned. Once the electrodes are in place, you may be offered a hospital gown to cover yourself.


The test itself usually only lasts a few minutes, and you should be able to go home soon afterwards or return to the ward if you're already staying in hospital.


Ambulatory Blood Pressure Monitoring


The diagnosis, management, and estimated mortality risk in patients with hypertension have been historically based on clinic or office blood pressure readings. Current evidence indicates that 24-hour ambulatory blood pressure monitoring should be an integral part of hypertension care. The 24-hour ambulatory monitors currently available on the market are small devices connected to the arm cuff with tubing that measure blood pressure every 15 to 30 minutes. After 24 hours, the patient returns, and the data are downloaded, including any information requested by the physician in a diary. The most useful information includes the 24-hour average blood pressure, the average daytime blood pressure, the average nighttime blood pressure, and the calculated percentage drop in blood pressure at night. The most widely used criteria for 24-hour measurements are from the American Heart Association 2017 guidelines and the European Society of Hypertension 2018 guidelines. Two important scenarios described in this document are white coat hypertension, in which patients have normal blood pressures at home but high blood pressures during office visits, and masked hypertension, in which patients are normotensive in the clinic but have high blood pressures outside of the office. The Centers for Medicare and Medicaid Services has made changes in its policy to allow reimbursement for a broader use of 24-hour ambulatory blood pressure monitoring within some specific guidelines. Primary care physicians should make more use of ambulatory blood pressure monitoring, especially in patients with difficult to manage hypertension.


What are the features to look for before buying an ECG machine?


Electrocardiography is the process of producing a recording of the electrical activity of the heart, in the form of a graph, using electrodes placed on certain specific spots on the body. This graph is called electrocardiogram.


For the purpose of producing an electrocardiogram, the standard practice now is to place 10 electrodes in the following 10 different positions on the body: 4 Limbs ( Left Arm, Right Arm, Left Leg and Right Leg) + 6 on the chest on specific locations near the heart. Potential (Voltage difference) is measured between two of the electrodes or a common virtual electrode, called as the Wilson’s central terminal. Wilson’s central terminal is the average potential measurements between three of the limb electrodes – Right arm, Left arm and Left Leg. These voltage difference measurements are called “Leads”.


In all 12 ‘leads’ are required to complete the ECG graph. These 12 leads include, 3 limb leads, 3 augmented limb leads and 6 chest leads (also called precordial leads). While the three limb leads are measurements of potential / voltage difference between the limb electrodes, the augmented limb leads and chest leads (also called precordial leads) are potential difference between the limb and chest electrodes vs the virtual electrode (Wilson’s central terminal).


Often people use the term ‘lead’ for electrodes also and hence cause confusion as to whether there are 10 leads or 12 leads in an ECG machine.


When a patient cardiac activity needs to be monitored for a longer period of time; ECG variants with fewer number of electrodes are used to help aid mobility – such as with 3-electrodes or 5-electrodes (These may be confusingly called 3-lead / 5-lead ECGs – but the numbers 3 & 5 here refer not to the number of leads obtainable but the number of electrodes used). As against the 12-leads ECGs, the 3 & 5-electrode ECGs capture less information. The 3-elecrode ECGs -capture only the limb-leads but no anterior view, hence useful for rhythm monitoring. In a 5-electrode ECG all the 6 limb leads and one chest view is also captured. If someone says e.g. 5-channel ECG or 5-leads ECG, they essentially mean 5-electrodes ECG. So, what is a channel?


Channel – The other term commonly used in reference to ECG machine is number of ‘channels’. ECG machines may come as single channel, 3-channel, 6-channel or 12-channel configurations. Each lead measurement done aPre-owned GE Mac ECG machines detailed above is then passed through an ‘amplifier’ channel and recorded. In a single-channel system, each lead is recorded and displayed one at a time.


In a multi-channel system, the ECG has a microprocessor which manages this processing of signals based on the number of channels. The signals are amplified, filtered and sent to a multiplexer. The multiplexer receives all the inputs, reconstructs signals, de-multiplexes and sends the output to display screen or chart recorder. If it is a 3-channel ECG, the microprocessor groups the signals received from the 12-leads, in 4 groups of 3 and processes them. Similarly, in 6-channel it is in two groups and 12-channel device the same 12-leads are processes simultaneously. Hence, higher the number of channels, faster the ECG recording would be. Clearly, ‘channels’ is different from ‘electrodes’ or ‘leads’.


Point-of-Care Ultrasound: A Practical Guide for Primary Care


Ultrasound has head-to-toe applications for primary care, and the newest machines are portable and affordable enough to fit into almost any practice.


Family physicians can order a wide range of imaging services for patients. But barriers such as time, money, and physical distance sometimes prevent patients from accessing those services, causing gaps in care. Incorporating point-of-care ultrasound (POCUS) into clinical practice is one way to bridge those gaps.


Technological advancements have allowed more physicians to bring ultrasound services to the office visit or bedside, and to make POCUS an integral part of practice. I [Dr. Deutchman] was an early adopter, adding ultrasound to my rural practice in 1980 after delivering a surprise set of twins in the wee hours of the morning. I have never since been surprised by twins, nor missed an ectopic pregnancy. In addition, I [Dr. Shen-Wagner] first used POCUS during residency in 2011, after a patient complained that it felt like her intrauterine device (IUD) had moved. Everything looked normal on the pelvic exam, but a hand-me-down ultrasound machine from the clinic's obstetrics department revealed the unmistakable flutter of a tiny heartbeat. The patient was pregnant, despite having an IUD for three years.


These are just two examples of the many ways POCUS can benefit doctors and patients. There is robust evidence that POCUS improves care in critically ill patients and improves the efficiency and safety of many invasive ambulatory surgeries that are otherwise performed blindly or by anatomic landmarks. There is also preliminary but growing evidence that POCUS can improve diagnostic capabilities, expedite patient care, and inform bedside treatment and management. Most recently, POCUS has proven to be a valuable tool for confirming COVID-19 diagnoses, as well as monitoring some symptoms of the disease.


The hands-on, “showing while telling” nature of POCUS advances physical diagnosis skills, fosters doctor-patient communication, and increases patient satisfaction. This article outlines some common uses for POCUS and explains how to add it to a practice.


Electrocardiogram (ECG) Solutions


Electrocardiogram (ECG) systems record the electrical activity of the heart over time by measuring electric potentials on the surface of living tissue. A biopotential electrode is used to pick up heart signals from specific locations on the body. The differential voltage between two electrodes, or the differential voltage between one electrode and the average voltage of multiple electrodes, can be measured and displayed as one channel on the ECG printout.
The primary function of the AFE is to digitize the heart signals. This process is complicated by the need to reject interference from strong RF sources, pace signals, lead-off signals, common-mode frequency, signals from other muscles, and electrical noise. Typically, the AFE includes instrumentation amplifiers (INAs), filtering, and ADCs. There are two kinds of ECG architecture design approaches—ac coupling and dc coupling.