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MIT OpenCourseWarehttp://ocw.mit.edu
HST.582J / 6.555J / 16.456J Biomedical Signal and Image ProcessingSpring 2007
For information about citing these materials or our Terms of Use, visit: http://ocw.mit.edu/terms.
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Harvard-MIT Division of Health Sciences and TechnologyHST.582J: Biomedical Signal and Image Processing, Spring 2007Course Director: Dr. Julie Greenberg
Introduction to Clinical
Electrocardiography
Andrew Reisner, MD
MGH Dept. of Emergency MedicineVisiting Scientist, HST
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
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Electrocardiography
{ The heart is an electrical organ, and
its activity can be measured non-invasively
{ Wealth of information related to:z The electrical patterns proper
z The geometry of the heart tissue
z The metabolic state of the heart
{ Standard tool used in a wide-range
of medical evaluations
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A heart
Blood circulates, passing nearevery cell in the body, driven by this
pump
actually, two pumps
Atria = turbochargers
Myocardium = muscle
Mechanical systole
Electrical systoleCourtesy of Dr. Roger Mark. HST.542J Quantitative Physiology: Organ
Transport Systems, Spring 2004. (Massachusetts Institute of Technology:
MIT OpenCourseWare). http://ocw.mit.edu (accessed June 17, 2008).
Figure adapted from Phillips RE, Feeney MK, 1980 The Cardiac Rhythms.
Saunders, Philadelphia and from Hoffman BF, Cranefield PF 1960 Electrophysiologyof the Heart. McGraw Hill, New York.
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To understand the ECG:
{ Electrophysiology of a single cell
{ How a wave of electrical currentpropagates through myocardium
{ Specific structures of the heartthrough which the electrical wavetravels
{ How that leads to a measurablesignal on the surface of the body
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Part I : A li ttle electrophysiology
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
Once upon a time, there was a cell:
ATPaseATPase
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timetime
Intracellular
Intracellular
millivoltage
millivoltage
--9090
Resting comfortably
a myocyte
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timetime
Intracellular
Intracellularmillivo
ltage
millivo
ltage
Depolarizing trigger
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timetime
Intracellular
Intracellular
millivoltage
millivoltage
Na
channels
open,briefly
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
timetime
Intracellular
Intracellular
millivoltage
millivoltage
In: Na+
Mysterycurrent
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
timetime
Intracellular
Intracellular
millivoltage
millivoltage
In: Na+
Ca++ is in balance
with K+ out
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timetime
Intracellular
Intracellular
millivoltage
millivoltage
In: Na+
Excitation/Contraction Coupling:Ca++ causes the Troponin Complex
(C, I & T) to release inhibition
of Actin & Myosin
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timetime
Intracellular
Intracellular
millivoltage
millivoltage
In: Na+
Ca++ in; K+ out
More K+ out;Ca++ flow halts
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
timetime
Intracellular
Intracellular
millivoltage
millivoltage
In: Na+
In: Ca++; Out: K+
Out: K+
Sodium channels reset
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
timetime
Intracellular
Intracellular
millivoltage
millivoltage
In: Na+
Higher resting potential
Few sodium channels reset
Slower upstroke
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
timetime
Intracellular
Intracellular
millivoltage
millivoltage
a pacemaker cell
Slow current of Na+ in;
note the resting potential
is less negativein apacemaker cell
--5555
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timetime
Intracellular
Intracellularmillivoltage
millivoltage
a pacemaker cell
Threshold voltage
--4040
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
timetime
Intracellular
Intracellularmillivoltage
millivoltage
Ca++ flows in
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
timetime
Intracellular
Intracellularmillivoltage
millivoltage
. . . and K+ flows out
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
timetime
Intracellular
Intracellularmillivoltage
millivoltage
. . . and when it is negative
again, a few Na+
channels open
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How a wave of electrical current
propagates through myocardium
{ Typically, an impulse originating
anywhere in the myocardium willpropagate throughout the heart
{
Cells communicate electrically viagap junctions
{ Behaves as a syncytium
{ Think of the wave at a footballgame!
Th di l fi ld d t t fl i di l ll t th
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The dipole field due to current flow in a myocardial cell at the
advancing front of depolarization.
Vm is the transmembrane potential.
Courtesy of Dr. Roger Mark.HST.542J Quantitative Physiology: Organ Transport Systems, Spring 2004. (Massachusetts
Institute of Technology: MIT OpenCourseWare).http://ocw.mit.edu (accessed June 17, 2008).
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Cardiac Electrical Activity
Figure by MIT OpenCourseWare.
Q S
T
R
P
SA node
(Pacemaker)
AV node
(delay)
AV bundle
& branches
(Insulated)
Purkinje fibers (Activation)
Fibro-fatty atrioventricular
groove (Separates atrial and
ventricular tissue)
Contractile
Conductive
Nonconductive
Important specific structures
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Important specific structures
{ Sino-atrial node = pacemaker
(usually){ Atria{ After electrical excitation:
contraction{ Atrioventricular node (a tactical
pause){ Ventricular conducting fibers
(freeways)
{ Ventricular myocardium (surfaceroads)
After electrical excitation: contraction{
The Idealized Spherical Torso with the
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The Idealized Spherical Torso with the
Centrally Located Cardiac Source (Simple
dipole model)
Courtesy of Dr. Roger Mark. HST.542J Quantitative Physiology : Organ Transport Systems, Spring 2004. (Massachusetts
Institute of Technology: MIT OpenCourseWare).http://ocw.mit.edu (accessed June 17, 2008).
Excitation of the Heart
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Figure by MIT OpenCourseWare. After F. Netter.
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
Excitation of the Heart
E it ti f th H t
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Excitation of the Heart
Figure by MIT OpenCourseWare. After F. Netter.
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Figure by MIT OpenCourseWare.
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-1200
-1500
aVR
aVF
aVL
I
IIIII
-900
-800
-300
+300
+600
+900+120
0
+1500
1800
00
Figure by MIT OpenCourseWare.
The temporal pattern of the heart vector
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combined with the geometry of the standard
frontal plane limb leads.
Figure by MIT OpenCourseWare.
I
IIIII
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Cardiac Electrical Activity
Figure by MIT OpenCourseWare.
Courtesy of Dr. Roger Mark. HST.542J QuantitativePhysiology: OrganTransport Systems, Spring 2004.(Massachusetts Institute of Technology:MIT OpenCourseWare).http://ocw.mit.edu (accessed June 17, 2008).Figure adaptedfrom Phillips RE, Feeney MK, 1980 The Cardiac Rhythms.
Saunders, Philadelphia and from Hoffman BF, Cranefiel
PF 1960 Electrophysiologyof the Heart. McGraw Hill, New York.
Q S
T
R
P
SA node
(Pacemaker)
AV node
(delay)
AV bundle
& branches
(Insulated)
Purkinje fibers (Activation)
Fibro-fatty atrioventricular
groove (Separates atrial and
ventricular tissue)
Contractile
Conductive
Nonconductive
Normal features of the electrocardiogram.
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Figure by MIT OpenCourseWare. After p. 50 in Netter, Frank H. A Compilation of Paintings on the Normal and Pathologic
Anatomy and Physiology, Embryology, and Diseases of the Heart, edited by Fredrick F. Yonkman. Vol. 5 of The Ciba
Collection of Medical Illustrations. Summit, N.J.: Ciba Pharmaceutical Company, 1969.
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Normal sinus rhythm
Figure 15 - Normal Sinus RhythmRate 85
Figure by MIT OpenCourseWare.
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What has changed?
Figure 16 - Sinus TachycardiaRate 122
Figure by MIT OpenCourseWare.
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Sinus bradycardia
Figure 17 - Sinus BradycardiaRate 48
V1
Figure by MIT OpenCourseWare.
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timetime
Intracellula
r
Intracellula
rmillivoltag
e
millivoltag
e
Neurohumeral factors
Vagal stimulation makes
the resting potential
MORE NEGATIVE. . .
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Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
timetime
Intracellula
r
Intracellula
rmillivoltag
e
millivoltag
e
Neurohumeral factors
. . . and the pacemaker
current SLOWER. . .
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timetime
Intracellula
r
Intracellula
rmillivoltag
e
millivoltag
e
. . . and raise the
THRESHOLD
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timetime
Intracellula
r
Intracellula
rmillivoltag
e
millivoltag
e
Catecholamines make
the resting potential
MORE EXCITED. . .
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timetime
Intracellula
r
Intracellula
rmillivoltag
e
millivoltag
e
. . . and speed the
PACEMAKER
CURRENT. . .
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timetime
Intracellula
r
Intracellula
rmillivoltag
e
millivoltag
e
. . . and lower the
THRESHOLD FOR
DISCHARGE. . .
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timetime
Intracellular
Intra
cellularmillivoltage
millivoltage
Ricardo Montelban EffectVagal Stimulation:
Image removed due tocopyright restrictions.
Photo of actor RicardoMontelban.
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timetime
Intrac
ellular
Intrac
ellularmillivoltage
millivoltage
Adrenergic Stim. =
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timetime
Intrac
ellular
Intrac
ellularmillivoltage
millivoltage
Adrenergic Stim. =
Potsy Effect
Image removed due tocopyright restrictions.
Photo of characters from TV
show Happy Days, includingPotsy.
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Sinus arrhythmia
Figure 18 - Sinus Arrhythmia
Figure by MIT OpenCourseWare.
Atrial premature contractions
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Atrial premature contractions
(see arrowheads)
Figure by MIT OpenCourseWare.
Figure 25 - Atrial Premature Contractions
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{ Usually just a spark; rarely sufficientfor an explosion
{Leakiness leads to pacemaker-likecurrent
{ Early after-depolarization
{ Late after-depolarization
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Whats going on here?
Figure by MIT OpenCourseWare.
Figure 36 - Ventricular Premature Contractions
Wave-front Trajectory in a Ventricular
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j y
Premature Contraction.
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Is this the same thing?
Figure by MIT OpenCourseWare.
Figure 24 - Ventricular Escape Beat
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Whats going on here?
Figure 50 - Complete A-V Block with Junctional Escape Rhythm
Figure by MIT OpenCourseWare.
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Whats going on here?Figure 35 - Atrial Fibrillation (2 examples)
Figure by MIT OpenCourseWare.
Non-sustained ventricular tachycardia
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(3 episodes)
Figure by MIT OpenCourseWare.
Figure 43 - Short Bursts of Ventricular Tachycardia
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Slow Refractory
Quick Refractory
KeyWords:Heterogeneous, Circus, Self-Perpetuating
Side A Side B
7/30/2019 l3 Ecg Reisner
58/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
No Longer
Refractory
KeyWords:Heterogeneous, Circus, Self-Perpetuating
Side A Side B
7/30/2019 l3 Ecg Reisner
59/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
KeyWords:Heterogeneous, Circus, Self-Perpetuating
Side A Side B
7/30/2019 l3 Ecg Reisner
60/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
KeyWords:Heterogeneous, Circus, Self-Perpetuating
Side A Side B
7/30/2019 l3 Ecg Reisner
61/80
7/30/2019 l3 Ecg Reisner
62/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
KeyWords:Heterogeneous, Circus, Self-Perpetuating
Side A Side B
7/30/2019 l3 Ecg Reisner
63/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
INCREASED
Refractory
Side A Side B
7/30/2019 l3 Ecg Reisner
64/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
INCREASED
Refractory
Side A Side B
7/30/2019 l3 Ecg Reisner
65/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
INCREASED
Refractory
Side A Side B
7/30/2019 l3 Ecg Reisner
66/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
INCREASED
Refractory
Side A Side B
7/30/2019 l3 Ecg Reisner
67/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
INCREASED
Refractory
Side A Side B
7/30/2019 l3 Ecg Reisner
68/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
INCREASED
Refractory
Side A Side B
Ventricular Fibrillation
7/30/2019 l3 Ecg Reisner
69/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
Ventricular Fibrillation
Figure 45 - Three Examples of Ventricular Fibrillation
Figure by MIT OpenCourseWare.
7/30/2019 l3 Ecg Reisner
70/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
7/30/2019 l3 Ecg Reisner
71/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
7/30/2019 l3 Ecg Reisner
72/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
7/30/2019 l3 Ecg Reisner
73/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
Heart attack
7/30/2019 l3 Ecg Reisner
74/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
Heart attack
7/30/2019 l3 Ecg Reisner
75/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
Figure by MIT OpenCourseWare.
-1200
-1500
aVR
aVF
aVL
I
II
III
-900
-800
-300
+300
+600
+900+120
0
+1500
1800
00
7/30/2019 l3 Ecg Reisner
76/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
Figure by MIT OpenCourseWare.
7/30/2019 l3 Ecg Reisner
77/80
Hyperkalemia
7/30/2019 l3 Ecg Reisner
78/80
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].
See ECG Wave-Maven (http://ecg.bidmc.harvard.edu/maven/mavenmain.asp) formany other examples of how metabolic conditions can affect the ECG.
Courtesy of Ary Goldberger, M.D. Used with permission.
Source: Nathanson L A, McClennen S, Safran C, Goldberger AL. ECG Wave-Maven: Self-Assessment Program for Students andClinicians.http://ecg.bidmc.harvard.edu. Case #164.
http://ecg.bidmc.harvard.edu/maven/mavenmain.asphttp://ecg.bidmc.harvard.edu/http://ecg.bidmc.harvard.edu/http://ecg.bidmc.harvard.edu/http://ecg.bidmc.harvard.edu/http://ecg.bidmc.harvard.edu/maven/mavenmain.asp7/30/2019 l3 Ecg Reisner
79/80
7/30/2019 l3 Ecg Reisner
80/80
Questions?
Cite as: Andrew Reisner. Course materials for HST.582J / 6.555J / 16.456J, Biomedical Signal and Image Processing, Spring 2007. MIT OpenCourseWare(http://ocw.mit.edu), Massachusetts Institute of Technology. Downloaded on [DD Month YYYY].