Pre-Procedural Activities
10%of exam
Performing Resting ECG
14%of exam
Analyzing 12-Lead ECG
22%of exam
Performing Stress Tests
10%of exam
Ambulatory Monitoring
4%of exam
Performing Rhythm Analysis
40%of exam
Quick Facts
- Exam
- CCT
- Credential
- Cardiographic Technician
- Body
- CCI
- Items
- 130 (110 scored)
- Time
- 2 hours
- Pass
- 650/900 scaled
- Fee
- $175
- Level
- Entry-level
Pre-Procedural Steps
- Verify order
- Correct test ordered
- Two identifiers
- Name and DOB
- Consent
- Explain the procedure
- Skin prep
- Clean, dry, abrade
- Landmarks
- Palpate intercostal spaces
Limb Lead Colors
Snow over grass; smoke over fire
White RA, green RLBlack LA, red LLRight: snow over grassLeft: smoke over fire
Artifact vs Arrhythmia
Artifact
- Normal underlying rhythm
- Patient looks stable
- Moves with motion
Arrhythmia
- True rhythm change
- Symptoms may occur
- Consistent abnormal complexes
Check pulse and patient
Normal Values & Grid
- PR interval
- Normal duration0.12-0.20s
- QRS duration
- Normal width<0.12s
- QT interval
- Rate-dependent limit<0.44s
- P wave
- Width and height limit<0.12s, <2.5mm
- Heart rate
- Normal sinus range60-100 bpm
- Small box
- 0.04s wide, 1mm0.04s / 0.1mV
- Large box
- 5 small boxes0.20s
- Paper speed
- Standard recording speed25 mm/s
- Calibration
- Standard gain10 mm/mV
- ST elevation
- Significant threshold≥1mm limb
Limb Lead Placement
- RA
- Right armWhite
- LA
- Left armBlack
- LL
- Left legRed
- RL
- Right leg groundGreen
- Lead I
- RA to LA
- Lead II
- RA to LL
- Lead III
- LA to LL
- aVR, aVF, aVL
- Augmented limb leads
- Einthoven's triangle
- I + III = II
Precordial Leads V1-V6
- V1
- 4th ICS, right sternalSeptal
- V2
- 4th ICS, left sternalSeptal
- V3
- Midway V2 and V4Anterior
- V4
- 5th ICS midclavicular lineAnterior
- V5
- Anterior axillary, V4 levelLateral
- V6
- Midaxillary line, V4 levelLateral
- V4R
- Right-sided; RV infarct
- V7-V9
- Posterior wall leads
ECG Artifacts
- Wandering baseline
- Respiration, loose electrodes
- 60-Hz interference
- AC electrical, fine spikes
- Somatic tremor
- Muscle movement, jagged
- Motion artifact
- Patient movement spikes
- Loose lead
- Sudden erratic tracing
Bundle Branch Blocks
WiLLiaM MaRRoW
W-V1 M-V6 = LBBBM-V1 W-V6 = RBBBQRS ≥0.12s
RBBB vs LBBB
RBBB
- RSR' in V1
- Rabbit ears
- Wide S in V6
LBBB
- Broad R in V6
- QS or rS in V1
- Notched R wave
V1 up vs down
MI Localization by Leads
- ST↑ in II, III, aVF→Inferior MI(RCA)
- ST↑ in V1-V2→Septal MI(LAD)
- ST↑ in V3-V4→Anterior MI(LAD)
- ST↑ in I, aVL, V5-V6→Lateral MI(LCx)
- Tall R, ST↓ V1-V2→Posterior MI(Get V7-V9)
- Inferior MI + V4R↑→RV infarct(Preload dependent)
Waves, Segments & Intervals
- P wave
- Atrial depolarization
- QRS complex
- Ventricular depolarization
- T wave
- Ventricular repolarization
- U wave
- Late repolarization; hypokalemia
- PR interval
- Start P to QRS0.12-0.20s
- PR segment
- End P to QRS
- QRS duration
- Ventricular activation width<0.12s
- QT interval
- Depolarize plus repolarize
- ST segment
- J-point to T
- J point
- QRS meets ST
- Isoelectric line
- Flat baseline reference
- R-wave progression
- Grows V1 to V6
MI Territories
RCA inferior, LAD front, LCx side
Inferior: II, III, aVFSeptal: V1-V2Anterior: V3-V4Lateral: I, aVL, V5-V6
STEMI vs Ischemia
STEMI
- ST elevation
- Acute injury pattern
- Reciprocal changes
Ischemia
- ST depression
- T-wave inversion
- No ST elevation
Elevation vs depression
Conduction System
- SA node
- Cardiac pacemaker60-100
- AV node
- Delays impulse40-60
- Bundle of His
- AV to bundle branches
- Bundle branches
- Right and left
- Purkinje fibers
- Ventricular spread20-40
- Pathway
- SA→AV→His→Purkinje
Axis Quadrants
Leads I and aVF both up = normal
I+ aVF+ = normalI+ aVF− = leftI− aVF+ = rightBoth − = extreme
Axis Determination
- Normal axis
- -30° to +90°
- LAD
- -30° to -90°
- RAD
- +90° to +180°
- Extreme axis
- -90° to -180°
- Lead I + aVF
- Both up = normal
- LAD pattern
- I up, aVF down
- RAD pattern
- I down, aVF up
MI Localization
- Inferior
- II, III, aVFRCA
- Septal
- V1-V2LAD
- Anterior
- V3-V4LAD
- Anteroseptal
- V1-V4LAD
- Lateral
- I, aVL, V5, V6LCx
- Posterior
- Tall R, V1-V2RCA/LCx
- RV infarct
- V4R ST elevationRCA
Ischemia, Infarction & Hypertrophy
- ST elevation
- Acute injury / STEMI
- ST depression
- Ischemia or reciprocal
- T inversion
- Ischemia marker
- Pathologic Q
- Prior infarct scar
- Hyperacute T
- Earliest STEMI sign
- LVH
- Sokolow-Lyon ≥35mmS-V1 + R-V5/6
- RBBB
- RSR' in V1≥0.12s
- LBBB
- Broad R in V6≥0.12s
Stress Test Protocols
- Bruce
- 3-min stages, speed+grade
- Modified Bruce
- Two warm-up stages
- Naughton
- 2-min, ~1 MET steps
- Target HR
- 85% × (220−age)
- Max HR
- 220 − age
- MET
- Metabolic workload unit
- Stop test
- ≥2mm ST depression
- BP drop
- Ischemia warning sign
Ambulatory Monitoring Types
- Holter
- Continuous 24-48 hours
- Event monitor
- Patient-activated symptoms
- Loop recorder
- Continuous loop memory
- Telemetry
- Inpatient real-time
- Patient diary
- Log symptoms + activity
Rate Sequence
300, 150, 100, 75, 60, 50
Count large boxesMemorize the sequenceStart on heavy line
Mobitz I vs Mobitz II
Mobitz I
- PR lengthens each beat
- Then drops one QRS
- AV node level
- Usually benign
Mobitz II
- Constant PR interval
- Sudden dropped QRS
- Below AV node
- May need pacemaker
Lengthens vs sudden drop
Rhythm ID Logic
- Check R-R regularity first→Assess regularity(Step 1)
- Irregular, no P waves→AFib(Fibrillatory baseline)
- Sawtooth flutter waves→Atrial flutter(Atrial 250-350)
- Narrow, regular, 150-250→SVT(P wave hidden)
- Wide, regular, >100→VT(Emergency)
- Chaotic, no QRS→VFib(Defibrillate)
- Flatline tracing→Asystole(No shock)
- Upright P, 60-100→Sinus rhythm(Normal)
Rate Calculation Methods
- 300 method
- 300 / large boxes
- 1500 method
- 1500 / small boxes
- 6-second method
- QRS in 6s × 10
- Sequence
- 300-150-100-75-60-50
- Regular rhythm
- Use box methods
- Irregular rhythm
- Use 6-second method
- Normal rate
- 60-100 bpm
AFib vs Atrial Flutter
AFib
- Irregularly irregular rhythm
- No P waves
- Fibrillatory baseline
Atrial Flutter
- Sawtooth F waves
- Atrial 250-350 bpm
- Often regular ventricles
Chaotic vs sawtooth
AV Block Differentiation
- PR >0.20s, all conduct→1° AV block(Constant PR)
- PR lengthens then drops→Mobitz I(Wenckebach)
- Constant PR, sudden drop→Mobitz II(May need pacer)
- P and QRS unrelated→3° block(Complete block)
- Regular P, some blocked→2:1 block(Watch closely)
Sinus & Atrial Rhythms
- Sinus rhythm
- Upright P, 60-100 bpm
- Sinus brady
- Sinus, rate <60
- Sinus tachy
- Sinus, rate >100
- Sinus arrhythmia
- Rate varies with breathing
- PAC
- Early abnormal P wave
- AFib
- Irregularly irregular, no P
- Atrial flutter
- Sawtooth, atrial 250-350
- SVT/PSVT
- Narrow, regular, 150-250
- WAP
- Wandering, varying P shapes
- MAT
- ≥3 P shapes, >100
VT vs SVT
VT
- Wide QRS complex
- Rate 100-250
- AV dissociation
- Life-threatening
SVT
- Narrow QRS complex
- Rate 150-250
- P waves hidden
Wide vs narrow QRS
Ventricular & Junctional Rhythms
- PVC
- Wide, early, no P
- Junctional
- Inverted/absent P, 40-60
- VT
- ≥3 PVCs, rate >100
- VFib
- Chaotic, no organized QRS
- Asystole
- Flatline, no activity
- PEA
- Organized rhythm, no pulse
- Idioventricular
- Wide escape, 20-40
- Bigeminy
- Every other beat PVC
- Couplet
- Two consecutive PVCs
- Torsades
- Polymorphic VT, long QT
PAC vs PVC
PAC
- Early P wave
- Narrow QRS
- Non-compensatory pause
PVC
- No preceding P
- Wide bizarre QRS
- Compensatory pause
Narrow vs wide QRS
AV Blocks
- 1° AV block
- PR >0.20s, constant
- Mobitz I
- PR lengthens, drops QRS
- Mobitz II
- Constant PR, drops QRS
- 3° block
- P and QRS independent
- 2:1 block
- Every other P conducts
Common Traps
V1/V2 lead placement
4th ICS correct ≠ Not 2nd ICS
Mobitz I vs II
Type I PR lengthens ≠ Type II PR constant
AFib vs flutter
AFib has no pattern ≠ Flutter is sawtooth
Two meanings of LAD
LAD = coronary artery ≠ LAD = left-axis deviation
Rate calculation methods
300 / large boxes ≠ 1500 / small boxes
Sinus arrhythmia is normal
Normal breathing variant ≠ Not pathologic
Wide tachycardia
Assume VT until proven ≠ Not always SVT
Last Minute
- 1.Weights: Rhythm 40%, 12-lead 22%
- 2.PR normal 0.12-0.20s
- 3.QRS normal <0.12s
- 4.Rate: 300 / large boxes
- 5.V1: 4th ICS right sternal
- 6.Inferior MI = II, III, aVF
- 7.Anterior MI = V3-V4 (LAD)
- 8.Mobitz II drops without warning
- 9.AFib = irregularly irregular
- 10.Flutter = sawtooth, 250-350
- 11.VT = wide, regular, >100
- 12.Target HR = 85%×(220−age)
- 13.SA→AV→His→Purkinje pathway
- 14.Normal axis: I and aVF up
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