Ex- Tx & Rx Test 1

Front 1

BP procedure
always record ? numbers and round up to ?
feet?
cuff should circle at least?
inflate cuff to ?
release at rate of ?

Back 1

even numbers and round up to nearest 2mmHg
flat
2/3 of arm (arm at heart level, supported)
20mmhg above estimates SBP
2-5mmHg/secs

Front 2

SBP is indirect measure of
DBP is indirect measure of

Back 2

Cardiac output
TPR-total peripheral resistance

Front 3

Pulse pressure equation

Back 3

SBP-DBP (big minus small)

During exercise, SBP increases while DBP will either
decrease or remain the same

Front 4

DIRECT measure of Mean arterial pressure equation

Back 4

MAP=CO x TPR

(CO=HRxSV)
(TPR=total peripheral resistance)

Front 5

INDIRECT MAP measurement equation if HR is above or below 100 BPM

Back 5

HR<100bpm
• MAP = (1/3(SBP-DBP))+DBP
HR > 100 bpm
• MAP= (1/2(SBP-DBP))+DBP

Front 6

Cardiac output = (2 equations)

Back 6

CO = HR x SV = VO2/ A-VO2 Diff

Front 7

rate pressure product
(aka rate pulse pressure equaton)

Back 7

HR x SBP/100 (heat beats=systolicbp)

The indirect measurement of myocardial oxygen consumption

Front 8

be sure to start at ? when counting HR

Back 8

ZERO at first beat then one t next

Front 9

fick equation

Back 9

VO2 (maximal oxygen consumption) = CO x (a-v) O2 difference

(VO2 increases with exercise; (a-v) O2 also increases with exercise)

Front 10

Changes in CO with body position to maintain CONSTANT CO.... standing?? and supine??? effect on HR and SV??



Back 10

(CO = HR x SV)

Supine/resting = highest SV, and lowest HR (Blood located thoracicly!)

Standing = blood flow to the whole body so HR increases and SV decreases

Front 11

Ankle brachial index used to test ?
taken at?
ratio of? what # is normal?
if abi drops with exercise then?

Back 11

severity of PVD (peripheral vascular disease)
posterior tibial artery or dorsalis pedis artery
ankle SBP/Brachial SBP
1-1.1=normal
they have PVD

Front 12

Hemoglobin (men and women #)
Hematocrit (men and women #)
fasting glucose #
kidney tests (name)
livertest (name)

Back 12

M 13.7-17 F 11.5-15.5
M 40-52 F 36-48
60-99
BUN- blood urea nitrogen,creatine
bilirubin,SGOT- serum glutamic oxaloacetic transaminase, SGPT - serum glutamic - pyruvic transamimase

Front 13

Sources of Injury for arteries

Back 13

o Dyslipidemia (abnormal cholesterol levels)
o Hypertension (HIGH BP)
o Immune responses
o Smoking
o Vasoconstrictor substances
o Viral/ bacterial infection
o Homocysteine (byproduct of red meat)
o High levels of glucose
o Loss of estrogen

Front 14

CAD Risk Factors (non-modifiable)

Back 14

o Advanced age (INC # free radicals)
o Male gender
o Family history of CVD/MI/Revascularization
 -Male 1st degree relative < 55 years
 -Female 1st degree relative < 65 years

Front 15

CAD Risk Factors (modifiable – can change with behavior/lifestyle choices)

Back 15

o Hypertension (HIGH BP)
o Dyslipidemia (abnormal lipid levels)
o HDL < 40 mg/dL
o Obesity
o Impaired fasting glucose (100-125 mg/dL)
o Smoking
o Physical inactivity/Sedentary lifestyle

Front 16

Emerging Risk Factors (no-conclusive evidence/correlation)***

Back 16

o Triglycerides
o Lipoprotein (a)
o Lipoprotein remnants
o HDL subspecies
o Apolipoproteins
o Total cholesterol to HDL ratio
o Homocysteine
o Inflammatory markers (C reactive proteins)
o Thrombogenic and hemostatic factors

Front 17

Classification of Total Serum Cholesterol Levels
3

Back 17

Total Cholesterol
< 200 mg/dL Desirable
200-239 mg/dL Borderline High
> 240 mg/dL High

Front 18

• Classification of Serum Low (LDL) and High (HDL) Cholesterol***
5
1

Back 18

LDL Cholesterol
< 100 mg/dL Optimal
100 - 129 mg/dL Near optimal
130 - 159 mg/dL Borderline high
160 - 189 mg/dL High
> 190 mg/dL Very high

HDL Cholesterol
< 40 mg/dL Low

Front 19

Classification of Fasting Serum Triglyceride Levels***
4

Back 19

Triglyceride
< 150 mg/dL Normal
150 - 199 mg/dL Borderline high
200 - 499 mg/dL High
> 500 mg/dL Very high

Front 20

Blood Pressure***
4

Back 20

Systolic Diastolic
Optimal <120 and <80
Prehypertension 120-139 or 80-89
HYPERTENSION
Stage 1 140-159 or 90-99
Stage 2 > 160 or > 100

Front 21

Treatment for Hypertension***

Back 21

o Reduce dietary fat
o Increase physical activity
 Decrease BP as well as risk for CVD
o Lose weight if overweight
o Limit alcohol intake to no more than 1 oz. a day
o Reduce sodium intake (<2.3 grams Na or <6 grams NaCl)
o maintain electrolyte balance
o Stop smoking
o Reduce saturated fat and cholesterol

Front 22

• Smoking***

Back 22

o Causes vasoconstriction
o Increases platelet aggregation
o Promotes oxidation of LDL
o Decreases lung function

Front 23

• Additional Actions of Smoking***

Back 23

o Promotes oxidation of LDL-c
o Increases sympathetic nerve activity and catecholamine release resulting in:
 Increase BP by 5-10 mmHg
 Increase HR by 10-15 bpm
 Increase myocardial contractility
 Constriction of coronary arteries

Front 24

Type I Diabetes

called?
Caused by?
They need?

Back 24

o Insulin dependent diabetes mellitus (IDDM)
 Used to be called juvenile onset
o An autoimmune disease affecting the beta cells of the islet of Langerhans of the pancreas, in which the body doesn’t produce insulin
o These patients require insulin injections to stay alive
o Comprises 5-10% of diabetic patients

Front 25

Type II Diabetes

type of disease?
prevalence?

Back 25

o Non-insulin dependent diabetes mellitus (NIDDM)
 Used to be called adult onset
o A metabolic disorder in which the body can’t make enough insulin (insufficiency) or can’t properly use it (insensitivity)
o 90-95% of diabetic patients

Front 26

Gestational Diabetes

Back 26

o Happens during pregnancy (men can’t get it)
o Associated with a 40-60% chance of developing type II diabetes within the next 5-10 years

Front 27

Diabetes Diagnostic Criteria (KNOW #s or else!)

o Glycosylated hemoglobin (A1c) value of ??% or higher
o Confirmed fasting blood glucose of > ??? mg/dL
o Confirmed blood glucose of > ??? mg/dL in response to an oral glucose tolerance test (OGTT) using ??g of glucose
o Confirmed non-fasting blood glucose of > ???mg/dL in the presence of symptoms of ?

Back 27

o Glycosylated hemoglobin (A1c) value of 6.5% or higher
o Confirmed fasting blood glucose of > 126 mg/dL
o Confirmed blood glucose of > 200 mg/dL in response to an oral glucose tolerance test (OGTT) using 75 g of glucose
o Confirmed non-fasting blood glucose of > 200 mg/dL in the presence of symptoms of diabetes (polyuria, polydipsia, unexplained weight loss)

Front 28

---Pre-Diabetes: Impaired Glucose Tolerance and Impaired Fasting Glucose
o HbA1c of ??-??%
o IGT is defined as blood glucose of ???-??? mg/dL in response to an OGTT
o IFG is defined as fasting blood glucose of ???-??? mg/dL***
 A major risk factor for ?
 Present in ? million Americans
 Especially prevalent in ?

Back 28

o HbA1c of 5.7-6.4%
o IGT is defined as blood glucose of 140-199 mg/dL in response to an OGTT
o IFG is defined as fasting blood glucose of 100-125 mg/dL***
 A major risk factor for NIDDM
 Present in 15-20 million Americans
 Especially prevalent in elderly

Front 29

Risk Factor Management

focus should be?
what is almost as important as glycemic control?
what is an importation component in management?

Back 29

o Management of identifiable risk factors should be the focus in treatment of diabetes
o Recent case studies suggest control of hypertension is as important as glycemic control
o Regular physical activity is an important component in management of diabetes

Front 30

Obesity
 ACSM/NIH BMI criteria:
• Normal
• Overweight
-----Obesity
o Class I
o Class II
o Extreme

Back 30

• Normal 18.5 - 24.9 kg/m2
• Overweight 25.0 - 29.9 kg/m2
------ Obesity
o Class I 30.0 - 34.9 kg/m2
o Class II 35.0 - 39.9 kg/m2
o Extreme > 40 kg/m2

Front 31

BMI equation?

inches to cm?
pounds to kg?

Back 31

BMI=Kg/M^2

times inches by 2.54
divided lbs by 2.2

Front 32

Obesity Definitions - Waist circumferences:

men > ?? inches
women > ?? inches

Back 32

men > 40 inches
women > 35 inches

Front 33

• Health Risks Associated with Abdominal Obesity

Back 33

o Glucose intolerance and insulin resistance
o NIDDM
o Impaired fibrinolysis and increased coagulation (blood clotting)
o Dyslipidemia
o Hypertension
o Macro vascular disease

Front 34

• New Strategies in Treatment of Obesity

Back 34

o Normalization of body weight and body fat may not be realistic goals
o Small body weight and fat losses may produce significant improvements in risk factors
o Emphasis should be on metabolic health through reduction of CAD risk factors
o Improved cardiorespiratory fitness is also beneficial; it may independently reduce risk of CAD
o Increase physical activity, reduce dietary fat (<30% of total calories)
o Begin with small, gradual weight loss (1-2 lbs per week) initial goal of 5-10% weight loss
o Focus on that goal for 6 months before attempting further loss

Front 35

-Metabolic Syndrome
6 factors and numbers?
need how many?

Back 35

o Abdominal obesity (M > 40 in/102 cm; W > 35 in/88cm)
o Triglycerides (> 150 mg/dL = Borderline High)
o HDL cholesterol (men < 40 mg/dL, women < 50 mg/dL)
o BP (>130/85 mmHg = Pre-hypertensive)
o Fasting glucose (> 100 mg/dL = Pre-diabetes)
o Prothrombotic (fibrinogen > 350 mg/dL) and pro-inflammatory (C-reactive protein > 3.0 mg/L)

**This is not diabetes (metabolic disease)
Need 3/6

Front 36

=Selected Blood Variables***
o Hemoglobin (g/dL): men ???-??; women ???-???
o Hematocrit (% RBC) men ??-??; women ??-??
o Normal Fasting glucose: ??-??mg/dL
o Kidney tests: ?
o Liver tests: ?

Back 36

o Hemoglobin (g/dL): men 13.5-17; women 11.5-15.5
o Hematocrit (% RBC) men 40-52; women 36-48
o Normal Fasting glucose: 60-99 mg/dL
o Kidney tests: Blood Urea Nitrogen (BUN) Test; Creatinine
o Liver tests: bilirubin; SGOT - Serum Glutamic-Oxaloacetic Transaminase; SGPT - Serum Glutamic-Pyruvic Transaminase

Front 37

• Pre-participation Health Screening

Back 37

o Identification and exclusion of individuals with contraindications/exclusions
o Identification of high risk individuals
o Identification of persons with disease
o Identification of special needs

Front 38

PAR-Q (Physical Activity Readiness Questionnaire)***

what is it?
has only what questions?
what to see physician?

Back 38

o Minimal standard for entry into low-moderate intensity exercise program
o Yes/no questions
o If yes is answered to any of the questions the participant needs to see a physician

Front 39

• Informed Consent

Back 39

o Purpose and explanation of procedures or test
o Risks and discomfort
o Responsibilities of participants
o Benefits to be expected –be fasted, dressed properly
o Inquiries
o Use of medical records (HIPPA)
o Freedom of consent
o Place to sign

Front 40

• Medical History

Back 40

o Medical diagnosis
o Previous findings on physical examination
o History of symptoms, allergies
o Recent illnesses and surgical procedures
o Orthopedic problems
o Medications
o Other habits
o Exercise history
o Work history
o Family history

Front 41

CVD risk factors how many?

Back 41

o There are 8 positive risk factors (bad), and 1 negative risk factor (good)
• Risk factors, very important:
o There are 8 total but the least amount you can have is -1
o Don’t just say “dyslipidemia” must explain why: low HDL, high HDL, on BP meds

Front 42

What are the risk factors?
Not criteria just names.

Back 42

Age
Family history
Smoking
Sedentary
Obesity
Hypertension
Dyslipidemia
Pre diabetes

HDl (only negative risk factor)

Front 43

Risk Factors for CVD
o Age men > ??years; women > ??years

Back 43

o Age men > 45 years; women > 55 years

Front 44

o Family history (MI, revascularization, death)
 Before ??for father or 1st degree male relative
 Before ??for mother or 1st degree female relative

Back 44

Family history (MI, revascularization, death)
 Before 55 for father or 1st degree male relative
 Before 65 for mother or 1st degree female relative

Front 45

?or those who quit within ?months or exposure to ?tobacco

Back 45

o Smoking or those who quit within six months or exposure to environmental tobacco (2nd hand smoke)

Front 46

Sedentary lifestyle

?min of exercise for ? days per week for ? months

Back 46

not participating in at least 30 minutes of moderate intensity exercise (40-60% VO2) on at least 3 days per week for at least 3 months

Front 47

Obesity

Waist girth or BMI trumps?

Back 47

(BMI > 30 kg/m2 or waist girth men > 40 inches/102 cm; women > 35 inches/88 cm)

**WAIST GIRTH TRUMPS BMI!

Front 48

o Hypertension (not ?):
> ???/?? mmHg or on ?
 Confirmed on ?+ occasions

Back 48

o Hypertension (not prehypertension):
> 140/90 mmHg or on BP medication
 Confirmed on 2+ occasions

Front 49

o Dyslipidemia:
> ??? mg/dL LDL, on ? medication, or HDL < ?? mg/dL
 If total cholesterol is only given, use > ??? mg/dL

Back 49

Dyslipidemia
> 130 mg/dL LDL, on lipid lowering medication, or HDL < 40 mg/dL
 If total cholesterol is only given, use > 200 mg/dL

Front 50

o Pre-diabetes (NOT ?):
impaired fasting glucose > ??? mg/dL but less than ???mg/dL;
or impaired oral glucose tolerance > ???mg/dL but less than ??? mg/dL confirmed on ? occasions

Back 50

Pre-diabetes (NOT diabetes):
impaired fasting glucose > 100 mg/dL but less than 126 mg/dL;
or impaired oral glucose tolerance > 140 mg/dL but less than 200 mg/dL confirmed on 2 occasions

Front 51

high serum HDL levels >?

Back 51

Negative risk factor if high serum HDL levels (> 60)

Front 52

• Other Important Risk Factors
2

Back 52

o Stress
o Type A personality- hostility

Front 53

Major Signs or Symptoms for CV or Pulmonary Disease
- If someone has any then?
- 9 total !! KNOW !!

Back 53

(angina)
(dyspnea)
Dizziness or syncope
Orthopnea
Ankle edema
Palpitation or tachycardia (over 100bpm at rest)
Intermitted claudication (PVD)
Known heart murmur
Unusual fatigue or shortness of breath

Front 54

ACSM RISK
low
moderate
high

Back 54

o Low Risk
 Asymptomatic one (or less) CVD risk factor
o Moderate Risk
 Asymptomatic 2 (or greater) CVD risk factors
o High risk
 Individual with signs/symptoms listed or have known cardiovascular, pulmonary, or metabolic disease (diabetes). (must be eval by Dr. prior)

Front 55

ACSM Recommendations for Current Medical Examination and Exercise Testing Prior to Participation
-3 ways (METS,MPH,%VO2max)

Back 55

Moderate exercise is 3-6 METS
-1MET=3.5mL/Kg/min
3-4 MPH
Less than 60% VO2 max (40-60%)

Front 56

ACSM Recommendations for Current Medical Examination and Exercise Testing Prior to Participation
- recommended at moderate exercise and ? risk
-Recommended at vigorous exercise and ? risk

Back 56

Moderate exercise and HIGH risk

Vigorous exercise and MODERATE and HIGH risk

Front 57

ACSM Recommendations for Physician’s Supervision of Exercise Tests
-recommended at sub max if ? risk
-recommended at max if ? risk

Back 57

Sub max if HIGH risk
MAX if MOD OR HIGH risk

Front 58

• Order of Tests

Back 58

o Fill out paperwork informed consents, health history, PAR-Q, etc.
o Blood pressure
o Blood work
o Body composition- height, weight, % fat
o Pulmonary function
o Aerobic measurements
o Strength measurements
o Flexibility

Front 59

• When HR is below 100 ????? increases HR***

• When HR is 100+ ???? causes HR to increase!***

Back 59

• When HR is below 100, parasympathetic activity (vagal tone) decreases, which increases HR***

• When HR is 100+, an increase in sympathetic nervous system causes HR to increase!***

Front 60

How SV increases during exercise?

Back 60

-Myocardial contractility
-INC Pre-Load/Frank Starling mechanism= optimal alignment of actin/myosin
-Decrease in afterload (pressure in aorta that the heart has to overcome) ‡ increase SV***

Front 61

CO ? with exercise
VO2 ? with exercise
SBP ? with exercise
DBP ? or stays the same with exercise
MAP ? with exercise
PNS ? with exercise
SNS ? with exercise
~? bpm during exercise
Plateaus ~?% VO2

Back 61

CO increases with exercise ( = HR x SV)
VO2 increase with exercise ( = CO x (a-vO2) difference)
Rate pulse pressure (RPP) increases with exercise ( = HR x SBP/100)
SBP increases with exercise
DBP decreases or stays the same with exercise ( = TPR)
MAP increases with exercise ( = TPR x CO)
PNS decreases with exercise ( HR < 100)
SNS increases with exercise (HR > 100)
~110 bpm during exercise
Plateaus ~40-50% VO2

Front 62

Absolute Submaximal Exercise

Back 62

Absolute Submaximal Exercise = same workload in trained vs. untrained states***

• Test an individual, train them for 6 weeks, give them the SAME exact test after training (should be easier for them to complete)

Front 63

o Same Relative Submaximal Exercise

Back 63

o Same Relative Submaximal Exercise = trained individuals have larger workloads to reach the same VO2 max percentage as untrained individuals***
• Work out feels the same for both individuals but the trained individual will be tested with more weight or a longer distance because they are more physically fit (want them to be expending just as much as an untrained person)

Front 64

-REST

HR
PNS
SNS
CO
VO2
SV
SBP
DBP
RPP

Back 64

HR ↓
PNS ↑
SNS ↓
CO -
VO2 -
SV ↑
SBP -
DBP -
RPP ↓

Front 65

-Absolute

HR
PNS
SNS
CO
VO2
SV
SBP
DBP
RPP

Back 65

HR ↓
PNS ↑
SNS ↓
CO -
VO2 -
SV ↑
SBP -
DBP -
RPP ↓

Front 66

-REST

HR
PNS
SNS
CO
VO2
SV
SBP
DBP
RPP

Back 66

HR (220 – age)
PNS-
SNS-
CO↑
VO2↑
SV↑
SBP-
DBP-
RPP-

Front 67

-REST

HR
PNS
SNS
CO
VO2
SV
SBP
DBP
RPP

Back 67

HR -
PNS-
SNS-
CO↑
VO2↑
SV↑
SBP-
DBP-
RPP-

Front 68

heart blood flow

Back 68

1. Blood that has circulated through the body, deoxygenated, enters through the inferior and superior vena cava into the right atrium of the heart.
2. The right atrium contracts and pumps the blood through the tricuspid valve and into the right ventricle.
3. The right ventricle then pumps blood through pulmonary valve into the pulmonary artery*** into the lungs.
**Pulmonary artery does not carry oxygenated blood
4. In the lungs, capillaries absorb carbon dioxide from the blood and replace it with oxygen.
5. Oxygenated blood then flows through the pulmonary vein and into the left atrium.
6. Oxygenated blood then pumps through the mitral valve and into the left ventricle.
7. The left side of the heart contracts the strongest to send blood out the left ventricle and through the aortic arch on its way to all parts of the body. At this point, there are a few options for the blood flow…blood can be pumped →
• Through the carotid artery and into the brain.
• Through the auxiliary arteries and into the arms.
• Through the aorta and into the torso and legs.
8. Blood will then move through the arteries, then through capillaries, and then return through the veins.
9. Deoxygenated blood (blood without oxygen) will then return to the heart.
10. The cycle repeats.

Front 69

heart depolarization path

Back 69

SA Node→ via intra-atrial septum into Right and Left Atria (Bachman Bundle)→ AV Node→ Bundle of His→ L/R Bundle Branches (Left bundle branch fascicles – septal, anterior, posterior) → Purkinje Fibers→ Myocardial cells

Front 70

P wave

Back 70

P wave = depolarization of R and L atria

Front 71

PR segment

Back 71

• Little time lag (PR segment) after P wave between atrial and ventricle depolarization (tenth of a second)
**Time lag important for the atria to be able to empty fully and allow ventricles to fill with blood!

Front 72

QRS complex

Back 72

QRS complex = depolarization of ventricles (repolarization of atria)

Front 73

T wave

Back 73

T wave = repolarization of ventricles

Front 74

o EKG paper speed is

Back 74

o EKG paper speed is 25 mm/sec (horizontal = time (sec); vertical = milli-volts (mV))

Front 75

• Each little box horizontally

Back 75

• Each little box horizontally = 0.04 seconds

Front 76

• Each big box horizontally

Back 76

• Each big box horizontally = 5 little boxes= 0.2 seconds

Front 77

• Each little box vertically

Back 77

• Each little box vertically = 0.1 mV

Front 78

• PR interval

Back 78

• PR interval = beginning of P wave to beginning of QRS complex (start of atrial depolarization → start of ventricular depolarization)

Front 79

• PR segment

Back 79

• PR segment = end of P wave, beginning of QRS complex (end of atrial depolarization → start of ventricular depolarization)

Front 80

• ST segment

Back 80

• ST segment = end of QRS complex, beginning of T wave (end of ventricular depolarization → start of ventricular repolarization)

Front 81

• QT interval

Back 81

• QT interval = beginning of QRS complex to end of T wave (start of ventricular depolarization → end of ventricular repolarization)

Front 82

• RR interval

Back 82

• RR interval = QRS complex to QRS complex (HR!)

**U Wave → Some people have it right after the T wave, not close to the P wave

Front 83

• Calculating HR from EKG***→ COUNT BOXES BETWEEN RR INTERVALS!!
o Small box method = ? / number of small boxes
o Large box method = ? / number of large boxes

Back 83

• Calculating HR from EKG***
→ COUNT BOXES BETWEEN RR INTERVALS!!
o Small box method = 1500 / number of small boxes
o Large box method = 300 / number of large boxes
o

Front 84

six sec method

Back 84

Six second method = 10 × number of beats between the hash marks

• In 6 seconds (2 sets of hash marks) you measure number of beats (starting with 0!), then multiply that number by 10 to get beats per minute
• MAKE SURE YOU ALWAYS GET THE MOST BEATS IN THE 6 SECOND INTERVAL YOU PICK

Front 85

• Every 1 second there are big boxes
• Every 3 seconds there’s a (15 big boxes)
• 30 big boxes in ? seconds

Back 85

• Every 1 second there are 5 big boxes
• Every 3 seconds there’s a hash mark (15 big boxes)
• 30 big boxes in 6 seconds

Front 86

R wave
Q wave
S wave

Back 86

o The first positive deflection in the complex is always the R wave
• Label the Q and S wave based on the R wave
o 1st negative deflection BEFORE positive deflection (before an R wave) = Q wave
o 1st negative deflection AFTER positive deflection (after R wave)
= S wave

Front 87

QS wave

Back 87

o ONLY one deflection going down is called a QS wave (\/) memorize***

Front 88

RSR'

Back 88

o Positive deflection, negative, then positive again = RSR’ (/\/\)

Front 89

? electrodes

Back 89

10

Front 90

? exetrmity leads
what do they measure?
what are they?

Back 90

o 6 extremity (limb) leads: measure the frontal plane***
• I, II, III, augmented voltage foot, augmented voltage R arm, augmented voltage L arm (aVR, aVL, aVF)
• Bipolar extremity leads: I, II, III***
• Unipolar extremity leads: aVR, aVL, aVF***
o “Ground” electrode is opposite aVF on the lower right side of body

Front 91

? chest/ precordial leads: measure ?
names?

Back 91

6 chest/ precordial leads: measure in the horizontal plane (cross section picture of the heart)
• V1, V2, V3, V4, V5, and V6
• These are also unipolar leads (so there are a total of 9 unipolar leads)

Front 92

• Lead I =

Back 92

• Lead I = LA - RA (aVL - aVR)

one l

Front 93

lead II

Back 93

• Lead II = LL - RA (aVF - aVR)***

two ls

Front 94

Lead III

Back 94

• Lead III = LL - LA (aVF - aVL)

three ls

Front 95

• Lead aVr

Back 95

→ Right Delta Fossa

Front 96

Lead aVl

Back 96

→ Left Delta Fossa

Front 97

Lead aVf

Back 97

Left iliac crest/off lower rib

Front 98

GROUND

Back 98

Right iliac crest/off lower rib

Front 99

V1

Back 99

• Lead V1 fourth intercostal space to right of sternum

Front 100

V2

Back 100

• Lead V2 fourth intercostal space left of the sternum

Front 101

V3

Back 101

• Lead V3 midway between leads V2 and V4

Front 102

V4

Back 102

• Lead V4 mid-clavicular line, 5th intercostal space

Front 103

V5

Back 103

• Lead V5 anterior axillary line same level as V4

Front 104

V6

Back 104

• Lead V6 mid-axillary line, same level as V4

Front 105

Transition zones

Back 105

(R WAVE PROGRESSION → R wave = S wave) in precordial leads (V1 → V6)

Front 106

Axis deviation

Back 106

(found in extremity leads)
Left (upper L)
Right (lower R)
Extreme (upper R)
Normal (lower L)

Front 107

Movement in heart

Back 107

o Movement in heart
• SA node→ AV node = right to left movement through right atria (away from V1)
• Then left to right movement through intraventricular septum (toward V1)
• Then RIGHT to LEFT movement from AV node to R and L ventricles
• Right to left atrial depolarization is moving away from V1 (toward left ventricle) → will have a large S wave (NEG deflection)
• V1 = small R, big S***
• V6 = small Q, big R***

Front 108

o Normal R wave progression

Back 108

o Normal R wave progression is when the R wave slowly gets bigger and S wave gets smaller and smaller until it becomes a Q wave

Front 109

• Axis
o Normal:
o Right axis deviated:
o Left axis deviated:
o Extreme axis deviated:
• 0 – 90 =
• -90 – 0 =
• 180 – 90 =

Back 109

• Axis
o Normal: 0 to 90 degrees
o Right axis deviated: 91 to 180 degrees***
o Left axis deviated: -1 to -90 degrees
o Extreme axis deviated: -179 to -91 degrees
• 0 – 90 = normal
• -90 – 0 = left axis
• 180 – 90 = right axis

Front 110

look at leads ? for axid dev

Back 110

leads I and aVF

Front 111

o Lead I + Lead III =

Back 111

o Lead I + Lead III = Lead II (bipolar)***

Front 112

o (-) aVR + aVL + aVF =

Back 112

o (-) aVR + aVL + aVF = 0 (unipolar)***

Front 113

o P wave:
• + in ?
• - in ?

Back 113

o P wave:
• + in lead II
• - in aVR

Front 114

o T wave:

Back 114

• Usually follows QRS complex

Front 115

o Enlargement:

Back 115

o Enlargement: dilation of chamber, caused by volume overload

Front 116

o Hypertrophy:

Back 116

o Hypertrophy: increase in muscle mass, caused by pressure overload

( sometimes a good thing because it’s in response to exercise, increased CO)

Front 117

o With enlargement or hypertrophy will cause changes in EKG:

Back 117

• Increase in duration of waves
• Increase in amplitude of waves
• Axis deviation

Front 118

• Right atrial enlargement:

Back 118

• Right atrial enlargement: P pulmonale- severe lung disease or tricuspid valve
• Increase in amplitude (> 2.5 mm) of the first portion of the P wave
• No change in duration

Front 119

• Left atrial enlargement:

Back 119

• Left atrial enlargement: P mitral- mitral valve disease
• Occasionally increased amplitude of second half of P wave
• Will definitely see an increase in duration for back half of P wave (> .12 seconds)

Front 120

• Right ventricular hypertrophy:

Back 120

• Right ventricular hypertrophy: pulmonary disease*** and congenital heart disease
• Right axis deviation- QRS complex is more negative in lead I
• Normal progression in precordial leads is disrupted → “S wave progression”
o V1, R wave is larger than S wave
o V6, S wave is larger than R wave
o If you don’t have normal R wave progression you won’t have transition zone!
• More electrically dominant than L ventricle

Front 121

• Left ventricular hypertrophy:

Back 121

systemic hypertension and valvular disease
• Will not ask for criteria exactly, but precordial leads:
o 1. R wave amplitude in lead V5 or 6 plus the S wave amplitude in lead V1 or 2 greater than 35 mm
• Most important (according to book)
o 2. R wave amplitude in lead V5 greater than 26 mm***
• Panton likes this one
o 3. R wave amplitude in V6 greater than 18 mm
o 4. R wave amplitude in lead V6 exceeds the R wave amplitude in V5
• In limb leads:
o 1. R wave amplitude in lead aVL exceeds 13 mm
• Most important (according to book)
o 2. R wave amplitude in lead aVF exceeds 21 mm
o 3. R wave amplitude in lead I exceeds 14 mm
o 4. R wave amplitude in lead I plus the S wave amplitude in lead III exceeds 25 mm
• Basically, you’ll see really high amplitudes in R and S waves of leads overlying left and right ventricles

Front 122

Strain
caused by?
will get?
What leads tell right or left?

Back 122

o With severe ventricular hypertrophy you may see strain
• This is caused by subendocardial ischemia which affects both ventricular depolarization and repolarization
• Will get:***
• ST segment depression
• T wave inversion
• Most evident in leads with tall R waves
• Right ventricular strain
o V1 and V2
• Left ventricular strain
o Leads I, aVL, V5, V6