TSP Merch!

After creating so many illustrations for the various study pages I have added (and a few future ones), I thought it might be nice to put them to more use.

To this end, I have set up an online store HERE.

Many of the original images you see on this website can now be worn, written in, or used to hold beverages when you’re on placement! A selection of the items available are on display here, but do go and check out the store to have a look at everything on offer. They’re all of a high-quality and available in a variety of styles, too, so I hope you find something you like.

I’ll keep adding new designs, so be sure to check back often, and every penny made through sales will go towards furthering this website.

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Thank you!

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Review: BMJ Best Practice

Download the IOS app: Free

Download the Android app: Free

(In-app Purchases: £5-£60 approx.)

Developer: BMJ, London


BMJ Best Practice is an app that aims to aid diagnosis and guide the practitioner through the treatment process of a number of pathologies. Guidelines on examinations, tests and medications are provided across 977 topics. These are not all available initially; some conditions are presented as a free sample, whilst the rest must be purchased either in one go (£59.99), or by categories such as Critical Care and Emergency Medicine (£15.99), and Cardiovascular Disorders, Vascular and Cardiothoracic Surgery (£7.99). Institutional access is available, so if your trust/ university subscribes to the service, you can access all of the content for free.

BMJ Phone


These are the good things BMJBP does. Unfortunately, it does a great deal worse when it comes to every other aspect of its content and execution.

Whilst the level of content is very good, straightforward and to the point, it’s unlikely that you’ll actually get to see any of it, as the sample pages don’t always load, and when they do, they don’t save. Frequently, I left the app to take a call, and returned to it to find it had rebooted. In addition, whilst the developer’s ability to extract the subscription fee for paid content suffers no problems, their ability to supply said content is non-existent. I purchased the “Cardiovascular Disorders…” category for £7.99, and was told by the “My Topics” section of the app, that I didn’t own any of the documents, yet was told by the “Subscribe” page, that I did..! Either way, I couldn’t (and still can’t) view any of the content I have paid for.

I sent an email over to the BMJ customer service department, and was politely informed that subscriptions were handled by Google, and there was nothing that BMJ could themselves do. As it turns out, subscribed content is entirely the responsibility of the BMJ, so when I pointed this out, and asked for a refund, I was met with a wall of silence that is currently ongoing.

Although it may be tempting to download this app, I strongly recommend that you do not; the content isn’t there, the app itself is buggy and the developer’s desire to help with problems is as present as the paid topics, in that both have yet to materialise. Judging by the user reviews left on Google Play, I am not the only user to have faced any of these problems, so it’s not as though the devs are unaware.

This app doesn’t do enough, regarding functionality, to warrant being this unfinished. It genuinely frightens me to think that someone was paid a wage to develop this, and even more frightening, is that the BMJ are charging for content, despite the numerous complaints of bugs and such. The app lists its last update as 2015, but lord knows what it addressed, or how much worse it was before, if this is considered sufficient.

This, dear reader, is how NOT to make a mobile app.

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Coronary Artery Bypass Graft and Mitral Valve Repair

I had the rather marvellous opportunity today; spending a day in cardiac theatres and, under the guidance and tutelage of two cardiac surgeons and an anaesthetist, learning the processes and methodologies behind CABG and MV repair.

I arrived at the Bristol Royal Infirmary surgical centre at 7:45am and was quickly changed into some scrubs and inducted into the OR’s team: three surgeons, two anaesthetists, one perfusionist and a selection of nurses both scrub, and regular. It was clear to me that each of these individuals knew one another well, just by the way they talked to each other; everyone seemed at ease with the rest of their colleagues. It turns out, I was right. Many of them knew each other from other hospitals, university or simply having been mentored by each other during training. This camaraderie bled into the surgery, as each team member knew not only their role, but that of the others, also, so equipment was passed over or set up without being requested, making for a seamless procedure.

The patient was, until the last year or so, a very fit and active 79y/o, who had suffered from AF for at least 10 years, and had developed a stenosed left anterior descending coronary artery as a result. In addition, echo had shown a severe mitral regurgitation due to valvular prolapse. The procedure would attempt to bypass the LAD using the left internal mammary artery (LIMA), as shown below.

LIMA bypass graft
Figure 1: The left internal mammary artery (shown in situ on the right) is relocated from the chest wall to bypass the stenosed section of the LAD.

The plan was to perform the bypass graft, and then set about repairing the damaged mitral valve.


After the patient’s ID and contraindicators had been checked, the anaethetists set about carefully monitoring their respiratory and cardiovascular function as the GA took effect. The ECG, arterial and venous pressure traces were available on lots of screens around the rooms, as whilst they must be monitored all of the time, it becomes particularly important to keep an eye on the given values as the heart is both stopped and re-started.

Interestingly, I noticed a pattern in conversation with each patient throughout the day, as the anaesthetic was administered. The patient was asked to think of their favourite place and the team then asked where that place was. Each time, this was met with silence, but just to make sure, the patient was always asked if they were warm enough. When no answer was forthcoming, they were wheeled into the theatre room proper.

Not everyone on the team was scrubbed up and sterilised, as obviously some would not be required to touch the patient, and others would be required to fetch replacement equipment should it be needed. This created a “sterile field” around the operating table, so only sterile members of staff were permitted within it.

After 1 hour and a whole heap of sterile gowns and drapes were applied over the patient, with only a small window showing the surgical site, the operation began.

Step 1 required access to the thoracic cavity. In case of blood splatter, masks fitted with facial protection were supplied to myself and the other team members who would be in the direct vicinity of the patient when the chest was opened.

Full Face Mask

An incision was made as illustrated below. This is known as a median sternotomy, and extends from the sternal notch to the xyphoid process. In order to progress past the sternum, an oscillating saw is used to cut throught it. There is a surprising amount of finesse involved in this stage, despite how much pressure is required and as a result, how brutal it appears.

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The incision is deepened and cauterised until it travels through the pericardium, so as to allow access to the heart and, after the bleeding vessels around the wound are cauterised, a finochietto retractor is used to hold the sternum open. During this time, the LIMA is found and carefully removed from the chest wall. It is then held in an accessible place with forceps, to be used later.

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Lung and cardiac function is transfered to a cardiopulmonary bypass machine, which allows both the heart and lungs to be stopped/emptied, allowing even greater access to the heart due to the lack of lung obstruction, and intricate work to be perfomed whilst the heart is not beating.

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The cardiopulmonary bypass apparatus purifies the blood that passes through it from the patient via cannulas placed in the heart and pumps it back, thereby doing the work of the heart and lungs. The heart is fed nutrients at the same time, so as to keep it healthy for the extended period of inactivity. This method of on-pump surgery is known to be incredibly safe- between 1 and 2% of high risk patients will suffer adverse effects as a result of the treatment, and surgical teams are well versed in assessing this via risk factors.

Once the LAD has been correctly identified, an incision is made, creating an opening that roughly matches the size of the end of the LIMA, and the two are stitched together using sutures made of polypropylene,which are no thicker than a human hair, yet can withstand the pressure that would be required to rupture a healthy vessel. To test the suture site, blood is passed through the vessel, and in the event of any gaps in the connection, this blood will be seen outside of the join, which can then be further secured as necessary.

The process, whilst quick to document, was a long one, as each step of the technique was scrutinised carefully before considered complete. In addition, each stitch required at least two people directly, to exact it; one to add the suture, and the rest to support the structures surrounding it.

The second stage of this case was the mitral valve repair, which was in itself a multi-stepped procedure. It is possible to repair a damaged mitral valve using less invasive, keyhole methods, but due to the need for a bypass graft, this wasn’t an option this time.

After gaining access to the valve itself, via an incision in the left atrium, the condition of the valve leaflets is assessed. This particular patient’s posterior leaflet had a prolapsing middle scallop, which meant that the below procedure was necessary to repair it.

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The process off attaching the ring was a long one, involving a lot of organisation and intricate knotting. The sutures are applied to both the ring and the valve, the latter is then gently pushed down the threads and into place. These suture strings are then tied off and cut.

temporary_1464194828160.pngOnce this has been completed, the valve integrity and functionality was tested by flushing water through the heart. In this case, the valve was still slightly prolapsing, as the water flushed through the valve in an unwanted quantity. The entire process, then, was considered from the beginning, and the valve only said to be repaired, when the regurgitation seen through the valve was minimal.

When performing the annuloplasty removed the surplus anterior leaflet, it took with it a tendineae chordeae, so in order to stabilise it further, an artificial heart string (made of Gore-Tex) was attached to the leaflet and papillary muscle.

A final transesophageal echo was performed, to assess the level of air still present in the heart, and to then assess the function of the repaired mitral valve, and after all of this was successfully accomplished, the long task to gently remove all of the cannulas that were used to bypass the cardiopulmonary system were begun to be removed. Each chamber was sutured in sequence, and the corresponding section of the perfusion apparatus turned off. All of this time, the anaesthetist monitored the patient’s drug infusions and every member of the team monitored pressure and ECG traces. This was still going on whilst the SpR set about cauterising vessels and wiring the sternum before pulling it back together. None of this section of the procedure involved any real finesse; pulling the wires taut so as to close the chest cavity is a test of strength. Each pull caused the patient to move for the first time since coming into the theatre, so I guess that was why it was the only section of the surgery that almost made me wince (something the theatre lead noticed and laughed about). Once it was done, the multiple layers of sutures were applied to seal the surface wound and the patient was taken to recovery.

In all honesty, the most difficult part for me, was in standing for so long. This was echoed by the surgeons, who said that they always felt backed up by their colleagues, so they felt confident that the procedure itself would go well, but standing, often in an unnatural position for so six hours at a time played havoc with their backs and legs. The anaesthetists, being required fully at the beginning and the end of the surgery, spent a great deal of time sat waiting, save for occasionally changing an infusion as and when required. The people working solidly were the surgeons and the scrub nurse, but even the surgeons swapped roles, observed one another without participating, and even took breaks periodically. None of this diminishes any one role, however; each member of the team was required, be it constantly or otherwise, and when one was needed, it took a single word for everyone in the room to know what was required, and by whom. Despite the procedure itself being amazing, it was the mechanical and seamless nature of the professionals in the room that was the most astounding part of the day.

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Introduction to Pacing

Exams are over, coursework is in, and I’ve FINALLY got some time to devote to TSP, so I’ll endeavour to post updates with the same level of regularity as I did a few moths ago. It’s been a while since I added anything other than study pages, so it’s proving difficult to get back into the swing of reflective writing. I shall try to be clear, however.

The first week of my 15 week placement has been an interesting and challenging one. I’ve been in pacing clinics (the third of which allowed me to have some hands-on experience), tape clinics and have analysed my first full 24 hour ECG recording, so the amount of information I’ve absorbed has been of a high volume in a short space of time.

I’m not going to comment on tape analysis or clinics just yet, as I’m yet to have my completed work assessed, so I’ll wait until I’ve gained some feedback on my current performance. Pacing, however, is extracurricular, so I’ll glady share my experience.

Pacing checks were very fun; during eight or so hours of lingering/observation, I was gradually allowed to do a bit more with regards to clinical practice; analysing lead outputs and EGM readings, setting up programming equipment and learning my way around each box-specific bit of software, etc.

The majority of patients that came into the clinic were annual follow-ups, and six week post-insertion assessments, wherein the overestimated pacing parameters are altered so as to preserve battery life, and due to their nature, each was simply a case of checking each value and adjusting accordingly, meaning each 15 or 20 minute consult went off without a hitch, and I got a feel for the regular procedure and could have some of the physics explained to me. It also allowed my tutors to ask me questions and test me a bit.

The third and final clinic, however, allowed me to assume the role of primary (under strict supervision, of course) and perform threshold tests on my patient. It’s amazing how quickly it’s possible to forget everything you’ve spent the last few days learning, when it comes to actually doing it; the sudden pressure of being thrown into practical learning caused my mind to go completely blank, but with a bit of time, I settled into the role and things started to make sense as I was doing them. There’s a really overwhelming feeling of resposibility when you’re charged with manually increasing or decreasing your patient’s heart rate during threshold tests, and in addition, spotting the loss of atrial capture is, in most cases, far more difficult that that of ventricular capture. It was an exillerating experience, though, and I really felt like I had accomlished something at the end of the clinic. In three days I felt like I could quantify my progression, so the first week has left me feeling excited for the rest of the placement block.

Until this week, I’d never considered pacing as a future specialism – I was focussed on echo –  but getting some real exposure has shown me how much I could enjoy a future in the discipline. I can’t wait to do more.

I’ll write more about my own research into pacing as I do it, so keep an eye out for that.



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Review: Acadoodle


Price: $99/ £66 per annum (approx)

Authors: Dr John Ryan, Dr John Seery

Acadoodle is a subscription-based online resource for ECG training that boasts a large selection of video tutorials which can be viewed individually, or as part of a tested course. The ECG Teacher sections are the primary focus of this review, but other courses such as blood gas analysis are available, however.

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Produced by Drs John Seery and John Ryan, I found these courses to compliment my study, and even when I wasn’t watching them directly, I found myself letting them play in the background as I read a textbook, or went over my lecture notes.

The videos themselves are well produced and make understanding the ECG and its subsequent analysis much easier. The animations are slick and the narration is clear, concise and full of all the pertinent diagnostic information you will require.

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Each area of study is tailored to a specific area of electrocardiogram diagnostics, so each playlist/module flows from one video to the next. In addition, the flow of the modules themselves makes sense, and the learning curve increases in a logical order and as such, each section follows on from the one that precedes it in a manner that doesn’t overload you with information before you’re ready.

A small selection of the videos are available on YouTube, so if you wished to try before you buy, then searching for “Acadoodle” would throw up some of the more basic tutorials for you to have a look at. I noticed that these YouTube videos are also embedded in the Acadoodle site proper, giving rise to a sometimes noticeable drop in picture quality, on occasion.

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It’s nearly impossible to fault the content and structure, as these videos have helped me immeasurably throughout the last six or seven months, but it is an expensive purchase for anyone, let alone students, especially when you consider that almost all of the content is in some way available via lectures or found in other, similar video courses on YouTube. In that respect, despite the quality of the content, I find it hard to recommend Acadoodle to physiology students who are considering purchasing a personal subscription, but for lecturers or professional bodies and universities, it should prove to be a valuable asset when clarifying concepts to a class full of students.

That isn’t to say that a student purchasing a subscription wouldn’t get a lot out of Acadoodle; it’s certainly worth it, it’s just expensive at a time when disposeable income is generally spent on textbooks or… food and shelter. If splitting £66 is something that you and a few peers feel is possible, then I highly recommend it, as the website can be used from multiple PCs with little to no issue.

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Being A Patient: Part I

(or “what I learned when the tests I have done to others, were done to me”)

The tests presented in this post are intentionally not explained thoroughly here. I have focussed, currently, on patient experience. If you wish to learn more about the things presented here, and the interpretation of the possible results, wait for them to be explained in your lectures, or, perform a quick Google search.

Before the new semester began proper, I was asked to assist with some physiology practicals on my campus. I agreed because I felt (much in the same way a chef will sample his/her food before selling it to the masses) that it would be good for my overall learning to experience the same anxieties and physical exertions -if applicable- that a patient may endure when they undergo physiological testing. When one repeatedly performs tests day in, day out, it’s easy to forget that the patient likely does not have anywhere near the same levels of familiarity with the procedure and proficiency with them as that of you, the practitioner, so to gain an insight into the emotional and physical aspects from the other side would, I felt, be good practice.

Day one was one of a cardio nature, in that I performed lots of exercise tests at a physiologist’s disposal. (Some of these tests are reserved for respiratory physiologists, but if you’re studying and are not yet at the point of choosing which PTP pathway to follow, you’ll experience these, too).

I discovered upon entry, that I would be performing the following:

  • YMCA step test
  • Bleep test
  • Treadmill test: ramp protocol (similar to the Bruce Protocol)

The wait to enter the lab was, (obviously not the same in terms of anxiety levels, but regardless) akin to a patient’s wait to enter a clinic testing room; knowing that I was going to have to perform tests, but not knowing exactly what they were was rather nerve-jangling (especially considering my then-unknown weight gain after the obligatory food-filled, sedentary lifestyle commonly experienced over the festive break).

The real difficulties stemmed from trying to comprehend the techniques required for each test. Explaining, or writing about them is one thing, but actually doing them is another thing entirely.

The YMCA step test itself wasn’t particularly challenging, given that it only involved 3 minutes of steady box steps. The difficulty came in not influencing heart rate on recovery. Knowing that my HR was being documented every minute meant I kept looking at the oximeter, and as has been documented (a quick google search will give you confirmation of this), it is relatively easy to change your HR on command.

For a patient, this last point may not be of particular issue, given that they might not be particularly aware of the potential influence they can have on their HR, but I can easily see how repeatedly stepping onto and off of a box could be difficult task for a patient of advanced age.

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Bonus Clinical Perspective: In this test the Heart Rate Recovery and VO2 max doesn’t appear to be particularly accurate, when using normal values, especially when compared with the VO2 max displayed through the other tests, either. The values are based on age, as oppose to individual physiological characteristics, so assume a physical ideal that doesn’t necessarily transcend to real life.  

The bleep test wasn’t like ones I have previously attempted in the gym, or what have you; rather, it was more about timing, ensuring there were no stops. This involved slowing down so as to reach the end of the designated track in time with the beep, then speeding up to repeat, meaning that pacing yourself was a must. The resulting strain on my legs caused them to become incredibly painful, incredibly quickly..! (I’m aware that bleep test procedure differs between fitness centres, so forgive my whinging if you use this format regularly).

Encouraging a patient to exhaust themselves doing this test would take a great deal of commitment from both parties; I’m not particularly unfit, but I had nothing tangible to aim for, with regards to an end point, so with no time to “beat”, I didn’t have anything to work towards and as a result, I gave up after 10 or so minutes, despite the fact I could have carried on for a while longer.  For the average patient that would frequent clinics to perform this test, achieving maximal exertion may not be something that can be coaxed out of them, especially if they had already endured other tests in the same day.

Already I was beginning to understand the plight of the patient, when it comes to tests that require their full participation, and I still had the hardest one to come… I was not looking forward to the post-lunchbreak activities.

It turns out, the Ramp Protocol test was actually the most enjoyable of the day. Perhaps this was simply because I was growing used to being fatigued/dehydrated, or perhaps it was the setup of the test itself, but I could have happily continued running on the treadmill for a great deal longer than I did, time allowing.

The ramp protocol treadmill test involves the face mask setup presented in the pictures, and a steady speed and incline increase on the treadmill for as long as it takes for the patient to reach their VO2 max, but it is up to the patient when they stop. Unlike the bleep test, which involved travelling at an uncomfortably slow rate at times, the ramp protocol was a fairly rapid journey to a pace similar to that of a distance runner. It was far from comfortable, so would still require a great deal of coaxing and encouragement in order to get the patient to work hard to complete the test, but it was certainly more comfortable than the test that had preceded it.

The whole day not only reminded me of tests and theory that I had almost forgotten, but it really helped me to understand what a patient has to go through when they visit a hospital. The feelings and tests that I personally experienced were, on the whole, not pleasant, but I wanted to be there. For a patient, this will most likely not be the case. When your clinic list is seemingly never-ending and you don’t have time for restarts, it’s easy for the fact that patients don’t know the requirements and procedures as well as you might, to slip your mind, but thanks to this experience, it’s something that I’ll never forget, and I feel it solidifies a vital skill that students require to be able to operate efficiently and fairly: empathy.

Tomorrow brings a different kind of discomfort, in that I will be having my first echocardiogram. I’ll add that experience to part II

The ramp protocol will also get the full write up treatment, as it was by far the most complex and in addition, I have a detailed set of results.

Thanks for reading.


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Holiday-Only Arrhythmias

During the festive season, its easy to indulge in excess; too many sprouts, an increase in afternoon napping, festive drinks… You know the score. It isn’t all smiles and sunshine, though, as we shall see.

One particular result of all the festive excess relevant to cardiac professionals, has been reported across the globe, but particularly in Entirely Fictitious Primary Care Centres (EFPCCs); Bacardi Branch Blocks, or BacBBs

BacBBs are thought to affect the heart as a whole, but it can be seen that they have a particularly odd effect on the ventricles, and cause an odd, never-seen-in-real-life depolarisation wave on the ECG, that actually defies physics and medical science by going back in time!

Symptom sheets compared with the compiled ambulatory data have shown unanimously that BacBBs are present sporadically within sinus rhythms, but coincide with that one-drink-too-many during a family game of Monopoly (Mr Moneybags isn’t thought to be an underlying cause, so the activity isn’t seen as a risk factor).

Atrial activity stops altogether, presumably because the SA node just forgets what it’s doing, as it’s seen enough crepe paper hats and screwdriver sets fly from crackers to last it a lifetime.

After an episode of BacBB, sinus rhythm resumes, and the patient will return to whatever their festive-norm may be until the next instance.

This phenomenon seems to disappear entirely during the first couple of weeks of January, when normal working hours begin again, hence, I feel that it is triggered by the holidays themselves.

None of this is being researched, or is even disputed, because it is both totally false, and invented entirely by me.

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Bacardi Branch Block

  • Common holiday rhythm abnormality only found during the festive season, and even then, only in fictitious settings
  • HR between 80-120bpm
    • Depends entirely on board game leader-board position
  • No P waves
  • Abnormal ventricular action
    • Resembles upturned cocktail glass
  • Is thought to only contribute to familial tolerance levels during prolonged exposure to each other



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Pathological causes of LVH

My last article looked at the assessment of Left Ventricular Hypertrophy; its contextual clinical significance and subsequent electrocardiographic findings, and concluded with possible pathological reasons for the development of LVH of which I wanted to discuss in my next article.

Sadly, due to an onslaught of assignments more intimidating than Xerxes Persian army in the film 300, I haven’t had the time to write any subsequent material.

However, now the assignments are over I have the time to explore these pathological causes of LVH.

Just as a recap, LVH is an increase in the size and proportion of the left ventricular myocardium. Just like any muscle, the more it is permitted to carry out work (contract) the greater it will increase in size (hypertrophy).

This increase in muscular size results from increased recruitment of sarcomeres (basic subunit of muscle cells) as well as extra cellular matrix remodeling (the scaffolding material of tissue). As a result of these anatomical adaptations the ventricle changes in size and proportion. Its normal conoid shape may be altered.

Concentric/Eccentric Hypertrophy

This remodeling will present as either Concentric or Eccentric hypertrophy depending on the underlying cause.

Concentric hypertrophy results from chronic pressure overload commonly associated with chronic hypertension and aortic stenosis. New sarcomeres are added in parallel to existing sarcomeres. Wall thickness greatly increases and persistence over time will significantly reduce chamber radius. The remodeled ventricle has reduced contractility  and compliance leading to diastolic and eventually systolic dysfunction (impaired filling/ejection).

Eccentric hypertrophy often occurs with volume and pressure overload; pathological associations include heart failure; aortic/mitral regurgitation (volume overload) and chronic hypertension (pressure overload). Ventricular remodeling results in increased chamber radius and moderate increases in wall thickness. Chamber dilation occurs as new sarcomeres are added in series to existing sarcomeres.



Physiological consequences of LVH

LVH usually develops as a compensatory response to the underlying pathologies mentioned above. Increased arterial pressure (afterload) as a result of chronic hypertension and/or aortic stenosis increases the pressure required of the LV to eject this blood.  Increased LV wall tension compensates via concentric hypertrophy.

Volume overload within the heart (heart failure) is often a resultant of valvular regurgitation and/or systolic dysfunction. Aortic/mitral regurgitation will increase the volume of blood left in the ventricle after systole (End Systolic Volume). During the next systolic cycle the LV has to contract with greater force to eject this increased volume of blood (End Diastolic Volume). Frank Starlings law of the heart states that increased stretch on the myocardial wall (Preload) increases strength of contraction. This pressure/volume overload induces chamber dilation and eccentric hypertrophy.

The hypertrophied LV becomes less compliant reducing its filling and contractile capacities. This culminates in systolic dysfunction. Systolic dysfunction is a significant reduction in cardiac output and will present with symptoms of dizziness, fatigue and shortness of breath. Systolic dysfunction of the LV will also lead to pulmonary congestion due to the back up of pressure generated by increased atrial and pulmonary venous pressures resulting from the increased EDV.

LVH is one of the strongest predictors of cardiac morbidity in hypertensive patients. The degree of hypertrophy correlates with the development of congestive heart failure, angina, arrhythmia, myocardial infarction and cardiac death (Lilly).

Another pathological subcategory I have not eluded to that is also a major contributor to LVH is cardiomyopathies. This is something I will look at in detail in my next article. Thanks for reading 🙂



I’d just like to take the opportunity to thank my good friend and partner in crime Christopher Wild for firstly creating this fantastic physiology based resource and secondly giving me the opportunity to participate in its progression.

3 months since creation and the TSP has already received nearly 1500 hits, recognition and support from numerous universities and academics across the country as well as our professional governing body.

My buddy deserves massive acclamation for this achievement and I know there is much more to come!

Whilst writing this article it has again reminded me how interconnected many pathologies, symptoms and clinical findings can be. About half way through writing I felt as though I’d opened a big can of worms as there are so many different tangents on which you could proceed to discuss. Added to this is the limited knowledge I have as I’m only a second year student! Therefore please don’t take this information as cardiology gospel! I have and always will, use reliable sources of information, but this is my interpretation of such material and I can’t guarantee inclusion of every detail.  Nevertheless, I have personally found writing such articles to be of great benefit; and thus if there are any other physiology students out there that may be interested in writing for TSP we would greatly welcome your support.

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Lilly, L. S. (ed.) (2010) Pathophysiology of heart disease: A collaborative project of medical students and faculty. Editor, Leonard S. Lilly. 5th edn. Philadelphia, PA: Lippincott Williams and Wilkins.
(Lilly, 2010, pp. 315 – 315)


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Review: AliveCor Mobile ECG Monitor (3rd gen)

Download the android app: Free

Purchase the monitor: £75 approx.

Developer: AliveCor, David Albert

Thus far, my reviews have been mostly confined to apps, with the only exception being Windows/Linux software, simECG. This review is quite exciting for me, as it involves a physical monitor as well as a companion app. I picked up the now world-famous AliveCor Mobile ECG Monitor a couple of days ago to road test it, and I’m pleased to say that for patients, it’s fantastic, and for students, it’s just as good.

As far as functionality goes, this app serves as a personal event monitor with a particular focus on atrial fibrillation, and it has a ton of nice features that make it a worthwhile investment for patients regular to cardiac departments.


Out of the box, the dual-electrode plate can be attached to the back of your mobile device via an adhesive strip, or kept separate; AliveCor works either way, and if you do attach the monitor and change your phone, you can pick up additional attachment plates for around £6.

Obtaining a trace is a very quick process; it only took me a few seconds to open the app and begin recording, and the trace is saved automatically after 15 seconds, with the limit set at 30. The user is then presented with a series of tick-able boxes such as hand or chest ECG, and a notes section to document any symptoms. These are then stored with the trace.

In this video, you can see that AliveCor jumps straight into recording once fired up.

Heart rate and beat fluctuation are tracked and graphed automatically to allow patients to relate multiple recordings in conjunction with the particular activity being performed during monitor operation.


In addition to this, the app comes with an algorithm that determines the presence of atrial fibrillation and keeps track of how many instances this occurs.

AliveCor offers a great deal of options when it comes to sharing data and to physical useage: once the trace has been recorded, the user can email it, save it as a fully notated PDF and print either from the app or a different program.


Holding the device in your hands, as shown in the app instructions gives you a trace in lead I, and it’s possible to obtain leads II and III by placing the two electrodes in different areas of the body (I have provided these instructions at the bottom of the page). Handily, AliveCor doesn’t just measure biopotentials in the peripherals, but also in the chest. A Lewis lead configuration is possible to view atrial activity with more clarity.

I experienced a minor issue with artefact at the start of recording, but this was almost definitely user error, as AliveCor ‘steadies’ itself pretty quickly if you remain relaxed and support you arms. This learning curve is honestly the only problem I had with the product, and after 10 or so minutes, it wasn’t a problem at all. I don’t want to speak for everyone, but I feel it’s fairly easy to get to grips with, so I doubt that your average patient would have too much trouble with it after a short while.

Traces themselves look very clean and, thanks to the standard calibration and the inclusion of a regular ECG paper grid, various amplitudes, intervals and waveforms can be measured manually. The trace screen also gives the option to invert the recording, and filter enhancement is selectable for each one.

As an event monitor, this device is invaluable. It comes with its own built-in symptom sheet and it’s incredibly quick and easy to record a good quality trace. AliveCor has been given the thumbs up from the FDA and NICE, so it’ll be interesting to see how the SCST view the monitor; I’ve reached out to them, but haven’t heard anything yet. If I do, I shall update accordingly.

I assume that in the U.S. this app allows patients to forgo some of the high cost of continued medical care by way of allowing the trace to be sent directly to a clinician for review. The UK version gives the option to send the trace to a Cardiac Physiologist for £5 and provides the analysis results within 24 hours, allowing the patient to present an official ECG report to their GP, should they need to.

As an added bonus, the AliveCor app has an educational area that features breakdowns of common arrhythmias and cardiac anatomy. The illustrations are aesthetically very pleasing and straightforward. The information contained within it is not as comprehensive as the information you’ll find in your lectures or textbooks, but it isn’t designed for the use of practitioners, so what is there is entirely sufficient.

All in all, AliveCor truly is a technical feat and not only does exactly what it sets out to do, but gives a glimpse of the future of ECG technology. This is an extremely good way for patients to become actively involved in their own heart health, with a relatively small price tag. The app provides a simple, intuitive UI and doesn’t require any Bluetooth connectivity between monitor and phone: it works right out of the box so that any patient can use it with ease. There’s a reason this product has garnered praise around the globe.

I will add that the device’s creator, Dr David Albert, is one of the nicest individuals with whom I have ever had the pleasure of conversing. His instructions for getting the most out of AliveCor for the purposes of this review have been invaluable, and even though he really didn’t have to, he answered every question I asked him, swiftly too. I’d like to thank David for being kind enough to help me get to grips with the product all the way from his residence in Oklahoma. Students need input such as this; it cements that we are valued and encourages learning outside of regular studies.

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Positioning data:

Lead I: LH – RH

Lead II: LL (knee) – RH

Lead III: LL – LH

Lewis: Electrode 1 on V1, device angled vertically