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ECG Interpretation in Equine Practice

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www.pdfgrip.com
ECG Interpretation in Equine Practice

Katharyn Jean Mitchell

BVSc, DVCS, DVM, PhD, Diplomate ACVIM (LAIM)
Clinic for Equine Internal Medicine
Swiss Equine Cardiology Consulting
Equine Department
University of Zurich
Zurich
Switzerland

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 CABI is a trading name of CAB International
CABI CABI
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Wallingford 8th Floor
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Fax: +44 (0)1491 833508 E-mail: [email protected]
E-mail: [email protected]
Website: www.cabi.org
© Katharyn Mitchell 2020. All rights reserved. No part of this publication may be reproduced in any form or by any means, electronically, mechanically, by
photocopying, recording or otherwise, without the prior permission of the copyright owners.

A catalogue record for this book is available from the British Library, London, UK.

References to Internet websites (URLs) were accurate at the time of writing.

ISBN-13: 9781789240825 (paperback)

9781789240832 (ePDF)
9781789240849 (ePub)

Commissioning Editor: Alexandra Lainsbury

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Front cover photograph courtesy Meredith Flash-O’neil

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Foreword

From early on in my life, I was interested in cardiology. One of the first books I purchased as a veterinary student was on ECG reading in
small animals because no such book was available for practitioners with an equine focus. The aim of this book, ECG Interpretation in Equine
Practice, is to fill that gap and provide a hands-on guide for veterinarians to use when recording, diagnosing and treating arrhythmias in
equine patients.
Advances in veterinary medical technology provide easier and more affordable access to ECG recording and transmitting equipment,
making ECG recordings feasible in the field and in hospital settings. The recording of resting or exercising ECGs is now a common part of
the diagnostic evaluation in horses with arrhythmias, poor performance or cardiac disease. In addition, newer pharmacological therapies
and interventional techniques are available to treat equine patients with arrhythmias, and this field of equine cardiology research has rapidly
expanded in the last 10 years. Further work is still required to understand fully the effects of arrhythmias on performance and to describe
accurately the risk of adverse events in equine patients with arrhythmias. We will continue working in this area to help advance the field of
equine cardiology.
I hope that this book will be helpful and frequently utilized by equine practitioners when examining equine patients with arrhythmias.

 v

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www.pdfgrip.com
Acknowledgements

To my family: thank you for all your love and support, particularly to my mum Cherrie Mitchell for instilling a love of cardiology in me
from an early age.
To Professor Colin Schwarzwald: thank you for the opportunity to learn equine cardiology.
To my patients and their owners: thank you for the opportunity to explore equine cardiology and learn about electrophysiology in the most
practical way possible. Without you, none of this would be possible.

 vii

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Contents

Chapter 1: Basics of Electrocardiography 1

What is an ECG? 1
Indications for Obtaining an ECG Recording in Horses 1
Electrical Properties of the Equine Myocardium 1
Normal Cardiac Conduction and Components of P-QRS-T Complexes 4
ECG Lead terminology 9
Chapter 2: Recording an ECG 12
Equipment12
Recording devices 12
Electrodes14
Additional material 14
Lead Placement 14
Resting ECG recording 16
Short-duration recordings 16
Longer-duration recordings 20
Exercising ECG Recording 24
Tips for Obtaining Good-quality Recordings 26

 ix

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x Contents

Chapter 3: Analysing ECGs 29

Overview and Basic Rhythm Analysis 29
Detailed Rhythm Analysis 29
Heart-rate Variability Analysis 37
Chapter 4: Interpretation of arrhythmias 40
Physiological Arrhythmias 40
Sinus arrhythmia 40
Sinus pause and sinus block 45
AV blocks 45
Pathological Arrhythmias 47
Abnormal sinus rhythm generation or conduction 47
Supraventricular arrhythmias 51
Ventricular arrhythmias 60
Chapter 5: Therapy 64
Chapter 6: Assessment of risk and safety 81
Chapter 7: ECG Interpretation in Pre-purchase Examinations 83
Chapter 8: Case Examples 87
Case 1 87
Case 2 88
Case 3 89
Case 4 90
Case 5 91

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 Contents xi

Case 6 92
Case 7 93
Case 8 94
Case 9 95
Case 10 97
Case 1 Answer 99
Case 2 Answer 100
Case 3 Answer 102
Case 4 Answer 103
Case 5 Answer 104
Case 6 Answer 105
Case 7 Answer 107
Case 8 Answer 109
Case 9 Answer 110
Case 10 Answer 115
References117
Index121

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Basics of Electrocardiography 1

What is an ECG?
A surface electrocardiogram (ECG) is a graphical representation of the sum of electrical signals produced by the cardiomyocytes during
the cardiac cycle. Electrodes attached to the skin are used to detect these signals, which are then transferred by cables to an electrocar-
diograph, where the signals are filtered, amplified and printed directly on paper or displayed on a screen. Recording an ECG is essential
for diagnosing both arrhythmias and conduction disturbances.

Indications for Obtaining an ECG Recording in Horses

In horses, ECGs are required to obtain a definitive diagnosis when an abnormal heart rate or rhythm has been detected on physical
examination (Box 1.1).

Electrical Properties of the Equine Myocardium

The generation of an action potential in both nodal and ventricular myocardial tissue is explained in Fig. 1.1. The cell-to-cell propagation
of these action potentials results in depolarization (and subsequent repolarization) of larger areas of myocardial tissue, which in turn are
detected during a surface ECG recording (Opie, 1998; Bers, 2002).
© Katharyn Mitchell 2020. ECG Interpretation in Equine Practice (K. Mitchell)  1

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 Box 1.1. Indications for recording an ECG.

• When an arrhythmia is heard on physical examination.

• When horses have unexplained tachyarrhythmias or bradyarrhythmias.
• In the evaluation of horses with exercise intolerance or poor performance.
• In the evaluation of horses with evidence of moderate to severe structural heart disease potentially predisposing to the development of
arrhythmias.
• In the evaluation of horses with a history of weakness or collapse.
• To confirm normal sinus rhythm is present during a pre-purchase examination.
• When monitoring heart rhythm as part of therapy (e.g. anti-arrhythmic therapy).
• When monitoring heart rate to detect stress or pain (e.g. during a hospital stay or transport).
• When monitoring a horse during sedation or general anaesthesia.
• When monitoring a horse that is critically ill (e.g. electrolyte imbalance, intoxication).

Fig. 1.1. (A) Phases of the action potential (AP) occurring in a typical ventricular cardiomyocyte. There are four phases of the AP, with rapid
entry of sodium (Na+) ions into the cell resulting in fast depolarization (phase 0) and calcium (Ca2+) ions entering more slowly during phase 2,
resulting in full depolarization of the cell. Potassium (K+) channels open, and outward movement of K+ ions accounts for repolarization of the cell
(phases 1 and 3). Phase 4, the maintenance of the resting membrane potential in a state of polarization, results from K+ diffusing out of the cell
following the concentration gradient that is maintained by the Na+/K+-ATPase (see panel C). (B) Timing of the movement of ions across the
cellular membrane, resulting in the phases of the AP seen in panel (A). (C) Phases of the AP occurring in a typical pacemaker cell (e.g. sino-
atrial or atrioventricular node). Here, these cells have a lower resting membrane potential than other cardiomyocytes, with the cell becoming
steadily more positive during phase 4 due to slow Ca2+ influx through Ca2+ channels, eventually resulting in spontaneous Ca2+-driven depolar-
ization. Note that the slope of phase 0 is flatter (i.e. slower) than that of the ventricular AP. This spontaneous depolarization of nodal tissue is
known as automaticity. (D) A stylized cardiomyocyte, depicting examples of ion pumps, channels and exchangers that allow the movement of
ions across the cell membrane, resulting in depolarization and repolarization of the cell membrane. The Na+/K+-ATPase is primarily responsible for
maintaining the resting intracellular concentrations of ions (high intracellular K+, low intracellular Na+). Opening of the Na+ channels results in
rapid influx of Na+ during early depolarization. Calcium ions enter the cell during the AP through Ca2+ channels, leading to a Ca2+-induced Ca2+
release from the sarcoendoplasmic reticulum (SER) and subsequent contraction of actin and myosin filaments. The excess cytoplasmic Ca2+
is then either eliminated by re-uptake into the SER or removed from the cell via the Na+/Ca2+ exchanger and a Ca2+-ATPase pump. There are
several different K+ channels that allow K+ to exit the cell during repolarization and the resting state. (Adapted from Mitchell, 2019, with permission.)

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 Basics of Electrocardiography 3

(A) (C)
Phase 1 – rapid repolarization

Ph
0

ase
Phase 2 – plateau

se
Pha

3
Threshold

zation
depolari –
potential Phase 4
Phase 0
Phase 3 –
repolarization Phase 4

Ca2+
Threshold

3Na+
potential (D)

Phase 4 – resting potential Phase 4 Na+/K +-ATPase pump 2+

ATP
Ca channels

2K+
(B)

K+ channels
Ca
2+
in Na+
K+

K+ out

Ca2+

Na+ channels
Ca2+
K+ out ATP

Na+ in

3Na+
Na+/Ca2+ exchanger and
+ out
K + out K Ca2+-ATPase pump

Fig. 1.1.

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4 Chapter 1

Normal Cardiac Conduction and Components of P-QRS-T Complexes

In horses, the conduction of electrical activity across the heart follows a fairly fixed pathway from the sinoatrial (SA) node, across the atrial
myocardium, through the atrioventricular (AV) node and then down the bundle of His, bundle branches and Purkinje system to the ven-
tricular myocardium. The spontaneously depolarizing regular rhythm generated from the SA node is known as ‘normal sinus rhythm’.
This normal conduction pattern and resulting surface ECG is illustrated in Fig. 1.2.
For the depolarization or repolarization to be accurately detected on a surface ECG, a relatively large amount of myocardial tissue is
required for activation. Therefore, the sinus depolarizations are not visualized per se; rather, it is the spread of depolarization across the atria
creating the P wave that is seen on the ECG. The morphology of the P waves is highly variable between and within horses, with bifid (two
positive peaks), single-positive or biphasic (typically negative/positive) waves commonly observed, even within the same ECG trace
(Fig. 1.3A). As heart rate fluctuates, the P-wave morphology may change, while some horses display evidence of a wandering pacemaker
within the large SA node, particularly at low heart rates (i.e. with high parasympathetic tone), resulting in highly variable P-wave morphology
between individual beats. After atrial depolarization, there is a period of atrial repolarization, which can occasionally be seen on a surface
ECG as a so-called Ta wave (i.e. the atrial T wave), as seen in Fig. 1.3B.

Fig. 1.2. (A) The impulse generation and conduction system within the myocardium and (B) a base–apex surface ECG recording resulting
from impulse conduction through the different segments of the conduction system. The impulse initiates in the sinoatrial node (SAN)
and is transmitted across the atrial myocardium, generating the P wave (B; blue line). Specialized internodal and interatrial (Bachmann’s
bundle) pathways facilitate and direct impulse conduction within the atria. At the atrioventricular node (AVN), impulse conduction is delayed,
resulting in the PR interval (B; yellow line) observed on the surface ECG. Rapid conduction then occurs through the bundle of His,
bundle branches and Purkinje fibre network, activating the ventricular myocardium and generating the QRS complex (B; red line) on the
ECG. CrVCa, cranial vena cava; RA, right atrium; LA, left atrium; H, bundle of His; RV, right ventricle; LV, left ventricle. (From Mitchell,
2019, with permission. Adapted from van Loon, G. and Patteson, M. (2010) Electrophysiology and arrhythmogenesis. In: Marr, C.M. (ed.)
Cardiology of the Horse. 2nd edn. Elsevier, pp. 59–73; and from Schwarzwald, C.C., Bonagura, J.D. and Muir, W.W. (2009) The cardio-
vascular system. In: Muir, W.W. (ed.) Equine Anaesthesia, 2nd edn. Elsevier, pp. 37–100, with permission.)

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 Basics of Electrocardiography 5

CrVCa
(A) (B)

N
SA

N
RA AV LA

H
RV LV

Fig. 1.2.

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6 Chapter 1

P T

(A)

QRS

(B) P

T
QRS

Fig. 1.3. (A) Typical P-QRS-T complex morphology from a healthy horse, as recorded with a standard base–apex lead configuration,
selecting lead I to be displayed. Variable (from bifid to monophasic) P-wave morphology is observed with increasing heart rate. The
ventricular depolarization has an S morphology, while the T waves are biphasic (negative–positive). Paper speed: 25 mm/s. (B) A base–
apex ECG lead II recording from a horse with second-degree atrioventricular blocks. The atrial repolarization (Ta wave, purple arrow) is
observed as a negative depression following the P wave. The P waves have similar morphology; the ventricular depolarization has an S
morphology, while the T waves are negative. Paper speed: 25 mm/s.

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 Basics of Electrocardiography 7

(C)
(Q)RS duration

PR(Q) interval R(Q)T interval

P R T

S RR (SS) interval

Fig. 1.3. Continued.

(C) The important ECG timing intervals are indicated. The equine base–apex lead ECG does not typically have identifiable Q waves.
Therefore, the conventional nomenclature of the timing intervals may require modification – the PQ interval becomes the PR interval,
the QRS duration is the RS duration and the QT interval is actually the RT interval. Because the largest deflection of the equine QRS is
negative – this is called the S wave – so the interval measured between adjacent QRS intervals is actually the SS interval, rather than the
RR interval. However, in most instances, for simplicity and consistency across species, the intervals are still called PQ, QRS, QT and RR
intervals. Note that it can be difficult to accurately define the start and end of the individual deflections. When measuring timing intervals,
it can be helpful to increase the paper speed (e.g. from 25 to 50 or 100 mm/s), maintain a standardized approach (e.g. always measure
from the onset or end of the deflection where it deviates clearly from the baseline) and limit the number of observers (i.e. ideally, the same
person should perform the analysis if repeated measurements over time are required). (Adapted from Mitchell, 2019, with permission.)

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8 Chapter 1

In a normal equine heart, the atria and ventricles are electrically separated from each other by non-conducting fibrous tissue, except
at the level of the AV node. Conduction of the electrical impulse through the AV node is slower than through the other myocardial tissues,
resulting in a delay between the atrial and ventricular depolarization. This is physiologically important because it allows the atrial con-
tribution to ventricular filling to occur before the onset of ventricular systole, optimizing pre-load and therefore cardiac output. Healthy
horses commonly have high parasympathetic (vagal) tone, which can further slow (or even block) AV nodal conduction. Conduction
through the AV node does not result in a deflection on the surface ECG, but the conduction delay can be measured through the
PR interval (as seen in Figs 1.2B and 1.3C).
Once the impulse has travelled through the AV node, it moves rapidly through the bundle of His, bundle branches and Purkinje fibre
system to depolarize the ventricular myocardium. This near-simultaneous depolarization of a large amount of myocardial tissue results in
the largest deflections recorded on the surface ECG – the QRS complex. According to international convention, the first downward deflec-
tion is the Q wave, the first upward deflection is the R wave and the next following downward deflection is the S wave. The larger waves are
denoted in capitals, while the smaller waves are denoted in lower-case letters. Typically, horses have an rS or S morphology when an ECG
is recorded using a base–apex lead configuration (Fig. 1.3). Q waves are rarely identified on equine surface base–apex ECG recordings.
Despite the largest wave of the typical equine QRS complex being the S wave, rather than the R wave as in standard human or small-animal
ECGs, for convention, we still refer to the interval between two adjacent QRS complexes as the RR interval.
Every depolarization must be followed by repolarization; therefore every QRS complex is always followed by a T wave (representing
repolarization). Horses have extremely labile T-wave morphology, with variations in polarity and duration highly dependent on parasym-
pathetic tone and heart rate. Changes in T-wave morphology should not be overinterpreted in the diagnosis of cardiac disease; however,
they can be helpful when determining the presence of abnormal complexes (atrial or ventricular premature complexes) and distinguishing
artefacts (which do not have T waves) (Broux et al., 2016).
Recognition of the normal equine P-QRS-T morphology is critical in assessing an equine ECG recording, and particular attention
should be paid to the polarity of waveforms (particularly QRS-T) and the timing intervals. As equine ECGs are commonly missing the
Q wave, the conventional timing intervals applied from human medicine require modification. The PQ interval becomes the PR interval,
the QRS duration becomes the RS duration and the QT interval becomes the RT interval, although the conventional nomenclature is
often referred to for simplicity. These timing intervals are illustrated in Fig. 1.3C and described in Table 1.1. When measuring the time
intervals (PR(Q) interval, (Q)RS duration and R(Q)T interval), the size of the horse should be considered, as body weight is directly
correlated with the time intervals (i.e. small horses generally have shorter time intervals) (Schwarzwald et al., 2012).

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 Basics of Electrocardiography 9

Table 1.1. ECG timing intervals (mean and 95% confidence intervals) for a 500 kg horse at rest. (Data derived from Schwarzwald et al., 2012.)

Mean 95% Confidence Interval

Heart rate (bpm) 40 25–55

RR interval (ms) 1500 1050–2100
PR interval (ms) 300 200–380
QRS duration (ms) 115 85–145
QTuncorrected interval (ms) 480 400–580

It is important to note that, due to the extensive Purkinje fibre system within the equine ventricular myocardium (compared with
humans and small animals), the equine QRS complex recorded from a typical base–apex lead configuration provides no reliable information
about cardiac chamber size. Therefore, equine ECGs should not be used for the diagnosis of cardiac hypertrophy or dilation; however,
echocardiography can provide useful information about myocardial changes (Hamlin and Smith, 1965).

ECG Lead Terminology

Electrodes placed on the body surface are used to measure changes in the electrical potential created during myocardial depolarization
and repolarization. A combination of two electrodes (one negative and one positive) creates a ‘lead’. When electrodes are placed across
the surface of the body around the heart, the sum of all electrical potentials can be recorded. Movement of the electrical signal towards a
positive electrode will create an upward deflection on the ECG, while movement away from a positive electrode will result in a downward
deflection on the ECG tracing.
In the horse, many of the standard human or small-animal ECG lead placements are not commonly utilized due to the impracticality
of placing multiple limb and chest leads on a large moving object. However, many of the electrodes and ECG recorders are still labelled
for conventional human or small-animal use (i.e. right arm (RA), left arm (LA), left leg or foot (LL)).

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10 Chapter 1

Typically, most equine ECGs are recorded utilizing the principles of Einthoven’s triangle, the most simple being a ‘base–apex’ or three-
lead configuration as described in Table 1.2. The RA electrode is placed on the right caudal neck while the LA and LL electrodes are
placed on the left thorax at the heart apex (Fig. 1.4). Lead I (recorded between the RA and LA electrodes) and lead II (recorded between
the RA and LL electrodes) will produce similar ECG morphology when used in this configuration (Fig. 1.3A).
Twelve-lead ECGs (as opposed to a single-lead base–apex ECG or a traditional limb-lead ECG) provide a larger variety of projections
of the heart’s electrical activity and have the potential to help determine the origin of premature complexes in horses. However, respective
criteria for assessment have not been established so far and work is currently ongoing in this area (van Steenkiste et al., 2018).

Table 1.2. Standard base–apex electrode positioning in the horse.

ECG electrode Position

Neutral/earth If present, can be placed anywhere

Right arm (RA) Right caudal neck
Left arm (LA) Left heart apex
Left leg/foot (LL) Left heart apex

Fig. 1.4. Positioning of the ECG electrodes to obtain a standard base–apex lead from a resting horse, useful for obtaining short-term
ECG recordings. The electrode positions described by Einthoven’s triangle are modified and positioned on the body of the horse. The
right arm (RA) electrode is placed on the right neck of the horse, while the left arm (LA) and left leg (LL) electrodes are placed on the
left side of the horse over the apex of the heart. With this electrode configuration, both ‘lead I’ (RA→LA) and ‘lead II’ (RA→LL) can be
chosen on the ECG recorder to display the base–apex ECG trace. Note that the terminology (LA, RA and LL; lead I, II and III) origin-
ates from the Einthoven lead system.

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 Basics of Electrocardiography 11

R L

–
Le
ad
– I
Le
ad
II

+
– RA

III
+

ad
+

Le
LA LL

– I +
RA LA
–

II III

LL

Fig. 1.4.

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Recording an ECG 2

Equipment
The basic equipment required to obtain an ECG recording includes electrodes, a recording device and a display of the tracing (Box 2.1).
A wide variety of point-of-care medical devices have been brought to the market in recent times, making ECG recording devices easier to
use and more affordable for the equine practitioner.

Recording devices

ECG recordings of short duration can easily be obtained using hand-held devices (e.g. Alivecor Kardia Mobile ECG; Alivecor, Mountain
View, California, USA) or a variety of common multi-purpose monitoring devices (e.g. Medtronic LIFEPAK 15 monitor/defibrillator;
Physio-Control, Redmond, Washington, DC, USA). Equine-oriented, purpose-built ECG recorders (e.g. Televet 100 telemetric ECG
system; Engel Engineering Services GmbH, Heusenstamm, Germany) are also readily available. Many of these devices display the
ECG tracing on a monitor, smart phone or tablet computer. Each device must contain some type of storage capability, as an ECG recording
is considered part of the medical record. This can be as simple as a thermoprinter providing hard copies of ECG strips of any length.
Preferably, the device should save the data digitally, allowing the ECG to be post-processed, digitally analysed, interpreted, stored or sent
to an expert for further analysis.
Extended, continuous recordings (e.g. longer than 5 min) require the use of a mobile device, which preferably records both locally
(e.g. on an SD card) and remotely by sending the signal wirelessly (e.g. via Bluetooth or a mobile GSM network) to a storage device with
© Katharyn Mitchell 2020. ECG Interpretation in Equine Practice (K. Mitchell)  12

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 Recording an ECG 13

Box 2.1. Basic equipment required to record an ECG

• Electrodes (crocodile-style clip-on or self-adhesive gel-patch electrodes).

• Electrical cables and recording device.
• Display and recording system (direct print versus digital storage).

a display monitor (e.g. laptop, computer or smartphone, or a cloud-based server). For use in horses, the most commonly used veterinary
device for this purpose is the Televet recorder, although many human or small-animal devices can be adapted for equine use (e.g. Lifecard
CF; SpaceLab Healthcare, Snoqualmie, Washington, DC, USA). It is essential that the data from long-term ambulatory recordings are
digitalized, stored and available for further offline processing and analysis. This also allows the easy sharing of ECG recordings between
individuals, which can be useful when a second opinion is required.
Several products are currently in development to improve the quality and ease of ECG recording in horses, particularly during
exercise. However, at this time, the Televet recorder is most commonly utilized and, in the author’s opinion, remains the most reliable and
easy-to-use product. It should be noted that the (veterinary) medical technology market has a number of heart-rate monitors currently
available, but these should not be confused with an ECG recording device. Heart-rate monitors are supposed to detect RR intervals, but
an unknown amount of post-processing occurs with the use of proprietary signal processing algorithms and filters to remove motion arte-
facts and arrhythmias. The accuracy and reliability of these devices cannot easily be verified by the user, and some of those tested have
not provided accurate results in horses with arrhythmias or with exceptionally high heart rates during exercise (Lenoir et al., 2017).
Heart-rate monitors provide no information on P-QRS-T morphology and are not considered a substitute for an ECG recorder in
the diagnosis and management of equine arrhythmias. They can, however, be useful (acknowledging their limitations), particularly for
monitoring heart rates during exercise at home with the owner.
Recently, the use of subcutaneous, implantable loop recorders (e.g. Reveal; Medtronic, Minneapolis, Minnesota, USA) in horses has
shown encouraging preliminary results when used as event recorders over extended periods of time (weeks or months). These devices may
be useful in patients with paroxysmal arrhythmias that occur infrequently, particularly when investigating horses with collapse. However,
these devices are currently cost-prohibitive for most patients and require specific positioning to obtain an optimal ECG signal (Buhl, 2017;
J. Keen, University of Edinburgh, 2017, personal communication).

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14 Chapter 2

Electrodes

Crocodile-style clip-on electrodes attached to ECG cables can be used to obtain short-term recordings. However, these are not suitable
for longer-duration recordings, and some horses will not tolerate these, even for a short period of time. The application of water, normal
saline or alcohol to the skin/crocodile clips is often required to ensure adequate contact and a good-quality ECG recording.
Self-adhesive gel-patch electrodes provide a more comfortable alternative to crocodile clips and can remain in place for several hours of
recording without issue. For extended-duration (overnight) or exercising recordings, these sticky ECG electrodes can be further secured using
self-adhesive foam patches (Fig. 2.1A) or an elastic bandage applied on top (Fig. 2.1D). In most cases, clipping the coat is unnecessary, as long
as the gel patch remains moist and the self-adhesive part of the electrode stays dry and provides sufficient adhesive strength. Occasionally, with
a thick winter (or Icelandic or donkey) coat, clipping small patches is necessary to provide better contact of the gel electrode with the skin sur-
face. It is essential for the coat to be dry (e.g. before exercise) when the self-adhesive electrodes are applied, as they will not stick to a damp or
wet surface.

Additional material

To obtain ambulatory recordings, it is necessary to affix the mobile recording/transmitting device to the horse. This is achieved using a
reusable surcingle, purpose built for holding the device and the associated cables safely out of the way of damage, particularly if the horse
lies down (e.g. Kruuse Televet Electrode Support; Jørgen Kruuse A/S, Langeskov, Denmark) (Fig. 2.1B, C). Alternatively, the device can
be affixed using single-use sticky elastic bandages (Fig. 2.1D). Placement of appropriate padding over the withers region is important,
particularly if the device is to be worn overnight or for several days.

Lead Placement

As discussed in Chapter 1, Fig. 1.4 shows the typical lead placement for a short-duration, resting ECG recording. This is considered a
‘base–apex’ configuration, where either lead I (RA→LA) or lead II (RA→LL) can be chosen on the monitor to display the ECG trace.
Fig. 1.3A represents the typical P-QRS-T orientation when using this lead placement. Figure 2.2 displays the ‘modified base–apex’

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 Recording an ECG 15

(A) (B)

Fig. 2.1. (A) Self-adhesive gel-patch ECG electrodes

and ECG cables covered with self-adhesive foam
(C) (D) patches to further secure the electrodes and reduce
artefacts. (B, C) A commercially available, reusable
surcingle (Kruuse Televet Electrode Support; Jørgen
Kruuse A/S, Langeskov, Denmark) can be used to
secure the ECG electrodes, cables and transmitting
device; this is useful for longer-duration or exercising
ECG recordings. Pockets with Velcro are used to
protect the cables and transmitting device while
allowing easy access (e.g. for battery changes).
(D) As an alternative, the ECG electrodes, cables
and transmitting device can be secured with single-­
use, sticky elastic bandages. It is important that ad-
equate padding is applied over the withers to avoid
rubbing and pressure sores.

www.pdfgrip.com
16 Chapter 2

c­ onfiguration that the author typically uses for longer-duration ambulatory ECG recordings. With this configuration, lead I will highlight
the atrial electrical activity, producing slightly magnified P waves to aid in the differentiation of atrial ectopic complexes. Lead II will pro-
duce the typical ECG seen in Fig. 2.3. Lead III (LA→LL) will produce an alternative QRS configuration, which can aid in the detection
of ventricular ectopic complexes.
During exercise, the ECG electrodes can remain in the same position as described above (Fig. 2.4A, B), resulting in the ECG seen in
Fig. 2.5A, or can be moved to accommodate any equipment necessary (e.g. saddle, surcingle or harness). Figure 2.4C is a variation that
the author uses particularly for lunging, treadmill or ridden exercise. The downside of this lead configuration is that lead I and lead II are
very similar (Fig. 2.5B), which can make subtle changes in QRS configuration harder to identify but provides a ‘back-up’ lead in case one
electrode becomes dislodged during exercise.

Resting ECG Recording

The criteria for determining the duration of a resting ECG recording are provided in Table 2.1.

Short-duration recordings

Shorter recordings can be easily obtained from well-restrained horses standing quietly. Many of the hand-held devices require the application
of water, normal saline or alcohol to the skin to facilitate conduction of the signal. Movement artefacts frequently interfere with the recording
quality and subsequent interpretation of the ECG findings, so care should be taken to ensure a good-quality recording is obtained.

Fig. 2.2. Positioning of the ECG electrodes to obtain a modified base–apex recording from a resting horse. This electrode configuration
allows the three leads (right arm (RA) electrode, left arm (LA) electrode and left leg or foot (LL) electrode) to each highlight different aspects
of cardiac depolarization/repolarization. This configuration is particularly useful for telemetric ECG monitoring or long-term (ambulatory, Holter)
ECG ­recordings. In this example, the electrodes are coloured for use with the Televet 100 recording system. Note that the colour system
corresponds to the International Electrotechnical Commison (IEC) standard; other devices may use a different colour system (i.e. the one
defined by the American Heart Association, where RA is white, LA is black, N is green and LL is red). N, neutral/ground electrode.

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 Recording an ECG 17

R L

–
Le
– ad
Le I
ad
II

+ –
RA

I
d II
N

Lea
+
+

LA

LL

– I +
RA LA
–

II III

LL
Fig. 2.2.

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