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CCI CCT Cheat Sheet

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Pre-Procedural Activities

  • 10% of exam
  • Pre-Procedural Steps Patient ID + Consent Skin Prep Safety Checks

Performing Resting ECG

  • 14% of exam
  • Limb Lead Placement Precordial Leads V1-V6 Normal Values & Grid ECG Artifacts

Analyzing 12-Lead ECG

  • 22% of exam
  • Waves, Segments & Intervals Axis Determination MI Localization Conduction System Ischemia, Infarction & Hypertrophy

Performing Stress Tests

  • 10% of exam
  • Stress Test Protocols Target HR Bruce Protocol Termination Criteria

Ambulatory Monitoring

  • 4% of exam
  • Ambulatory Monitoring Types Holter Event Monitor Telemetry

Performing Rhythm Analysis

  • 40% of exam
  • Rate Calculation Methods Sinus & Atrial Rhythms Ventricular & Junctional Rhythms AV Blocks

Quick Facts

  • Exam CCT
  • Credential Cardiographic Technician
  • Body CCI
  • Items 130 (110 scored)
  • Time 2 hours
  • Pass 650/900 scaled
  • Fee $175
  • Level Entry-level

Pre-Procedural Steps PR

  • Verify order Correct test ordered
  • Two identifiers Name and DOB
  • Consent Explain the procedure
  • Skin prep Clean, dry, abrade
  • Landmarks Palpate intercostal spaces

Limb Lead Colors RE

  • Snow over grass; smoke over fire
  • White RA, green RL Black LA, red LL Right: snow over grass Left: smoke over fire

Artifact vs Arrhythmia RE

Artifact

  • Normal underlying rhythm
  • Patient looks stable
  • Moves with motion

Arrhythmia

  • True rhythm change
  • Symptoms may occur
  • Consistent abnormal complexes
  • Check pulse and patient

Normal Values & Grid RE

  • PR interval Normal duration 0.12-0.20s
  • QRS duration Normal width <0.12s
  • QT interval Rate-dependent limit <0.44s
  • P wave Width and height limit <0.12s, <2.5mm
  • Heart rate Normal sinus range 60-100 bpm
  • Small box 0.04s wide, 1mm 0.04s / 0.1mV
  • Large box 5 small boxes 0.20s
  • Paper speed Standard recording speed 25 mm/s
  • Calibration Standard gain 10 mm/mV
  • ST elevation Significant threshold ≥1mm limb

Limb Lead Placement RE

  • RA Right arm White
  • LA Left arm Black
  • LL Left leg Red
  • RL Right leg ground Green
  • Lead I RA to LA
  • Lead II RA to LL
  • Lead III LA to LL
  • aVR, aVF, aVL Augmented limb leads
  • Einthoven's triangle I + III = II

Precordial Leads V1-V6 RE

  • V1 4th ICS, right sternal Septal
  • V2 4th ICS, left sternal Septal
  • V3 Midway V2 and V4 Anterior
  • V4 5th ICS midclavicular line Anterior
  • V5 Anterior axillary, V4 level Lateral
  • V6 Midaxillary line, V4 level Lateral
  • V4R Right-sided; RV infarct
  • V7-V9 Posterior wall leads

ECG Artifacts RE

  • Wandering baseline Respiration, loose electrodes
  • 60-Hz interference AC electrical, fine spikes
  • Somatic tremor Muscle movement, jagged
  • Motion artifact Patient movement spikes
  • Loose lead Sudden erratic tracing

Bundle Branch Blocks AN

  • WiLLiaM MaRRoW
  • W-V1 M-V6 = LBBB M-V1 W-V6 = RBBB QRS ≥0.12s

RBBB vs LBBB AN

RBBB

  • RSR' in V1
  • Rabbit ears
  • Wide S in V6

LBBB

  • Broad R in V6
  • QS or rS in V1
  • Notched R wave
  • V1 up vs down

MI Localization by Leads AN

  • ST↑ in II, III, aVF → Inferior MI ( RCA )
  • ST↑ in V1-V2 → Septal MI ( LAD )
  • ST↑ in V3-V4 → Anterior MI ( LAD )
  • ST↑ in I, aVL, V5-V6 → Lateral MI ( LCx )
  • Tall R, ST↓ V1-V2 → Posterior MI ( Get V7-V9 )
  • Inferior MI + V4R↑ → RV infarct ( Preload dependent )

Waves, Segments & Intervals AN

  • P wave Atrial depolarization
  • QRS complex Ventricular depolarization
  • T wave Ventricular repolarization
  • U wave Late repolarization; hypokalemia
  • PR interval Start P to QRS 0.12-0.20s
  • PR segment End P to QRS
  • QRS duration Ventricular activation width <0.12s
  • QT interval Depolarize plus repolarize
  • ST segment J-point to T
  • J point QRS meets ST
  • Isoelectric line Flat baseline reference
  • R-wave progression Grows V1 to V6

MI Territories AN

  • RCA inferior, LAD front, LCx side
  • Inferior: II, III, aVF Septal: V1-V2 Anterior: V3-V4 Lateral: I, aVL, V5-V6

STEMI vs Ischemia AN

STEMI

  • ST elevation
  • Acute injury pattern
  • Reciprocal changes

Ischemia

  • ST depression
  • T-wave inversion
  • No ST elevation
  • Elevation vs depression

Conduction System AN

  • SA node Cardiac pacemaker 60-100
  • AV node Delays impulse 40-60
  • Bundle of His AV to bundle branches
  • Bundle branches Right and left
  • Purkinje fibers Ventricular spread 20-40
  • Pathway SA→AV→His→Purkinje

Axis Quadrants AN

  • Leads I and aVF both up = normal
  • I+ aVF+ = normal I+ aVF− = left I− aVF+ = right Both − = extreme

Axis Determination AN

  • Normal axis -30° to +90°
  • LAD -30° to -90°
  • RAD +90° to +180°
  • Extreme axis -90° to -180°
  • Lead I + aVF Both up = normal
  • LAD pattern I up, aVF down
  • RAD pattern I down, aVF up

MI Localization AN

  • Inferior II, III, aVF RCA
  • Septal V1-V2 LAD
  • Anterior V3-V4 LAD
  • Anteroseptal V1-V4 LAD
  • Lateral I, aVL, V5, V6 LCx
  • Posterior Tall R, V1-V2 RCA/LCx
  • RV infarct V4R ST elevation RCA

Ischemia, Infarction & Hypertrophy AN

  • ST elevation Acute injury / STEMI
  • ST depression Ischemia or reciprocal
  • T inversion Ischemia marker
  • Pathologic Q Prior infarct scar
  • Hyperacute T Earliest STEMI sign
  • LVH Sokolow-Lyon ≥35mm S-V1 + R-V5/6
  • RBBB RSR' in V1 ≥0.12s
  • LBBB Broad R in V6 ≥0.12s

Stress Test Protocols ST

  • Bruce 3-min stages, speed+grade
  • Modified Bruce Two warm-up stages
  • Naughton 2-min, ~1 MET steps
  • Target HR 85% × (220−age)
  • Max HR 220 − age
  • MET Metabolic workload unit
  • Stop test ≥2mm ST depression
  • BP drop Ischemia warning sign

Ambulatory Monitoring Types AM

  • Holter Continuous 24-48 hours
  • Event monitor Patient-activated symptoms
  • Loop recorder Continuous loop memory
  • Telemetry Inpatient real-time
  • Patient diary Log symptoms + activity

Rate Sequence RH

  • 300, 150, 100, 75, 60, 50
  • Count large boxes Memorize the sequence Start on heavy line

Mobitz I vs Mobitz II RH

Mobitz I

  • PR lengthens each beat
  • Then drops one QRS
  • AV node level
  • Usually benign

Mobitz II

  • Constant PR interval
  • Sudden dropped QRS
  • Below AV node
  • May need pacemaker
  • Lengthens vs sudden drop

Rhythm ID Logic RH

  • Check R-R regularity first → Assess regularity ( Step 1 )
  • Irregular, no P waves → AFib ( Fibrillatory baseline )
  • Sawtooth flutter waves → Atrial flutter ( Atrial 250-350 )
  • Narrow, regular, 150-250 → SVT ( P wave hidden )
  • Wide, regular, >100 → VT ( Emergency )
  • Chaotic, no QRS → VFib ( Defibrillate )
  • Flatline tracing → Asystole ( No shock )
  • Upright P, 60-100 → Sinus rhythm ( Normal )

Rate Calculation Methods RH

  • 300 method 300 / large boxes
  • 1500 method 1500 / small boxes
  • 6-second method QRS in 6s × 10
  • Sequence 300-150-100-75-60-50
  • Regular rhythm Use box methods
  • Irregular rhythm Use 6-second method
  • Normal rate 60-100 bpm

AFib vs Atrial Flutter RH

AFib

  • Irregularly irregular rhythm
  • No P waves
  • Fibrillatory baseline

Atrial Flutter

  • Sawtooth F waves
  • Atrial 250-350 bpm
  • Often regular ventricles
  • Chaotic vs sawtooth

AV Block Differentiation RH

  • PR >0.20s, all conduct → 1° AV block ( Constant PR )
  • PR lengthens then drops → Mobitz I ( Wenckebach )
  • Constant PR, sudden drop → Mobitz II ( May need pacer )
  • P and QRS unrelated → 3° block ( Complete block )
  • Regular P, some blocked → 2:1 block ( Watch closely )

Sinus & Atrial Rhythms RH

  • Sinus rhythm Upright P, 60-100 bpm
  • Sinus brady Sinus, rate <60
  • Sinus tachy Sinus, rate >100
  • Sinus arrhythmia Rate varies with breathing
  • PAC Early abnormal P wave
  • AFib Irregularly irregular, no P
  • Atrial flutter Sawtooth, atrial 250-350
  • SVT/PSVT Narrow, regular, 150-250
  • WAP Wandering, varying P shapes
  • MAT ≥3 P shapes, >100

VT vs SVT RH

VT

  • Wide QRS complex
  • Rate 100-250
  • AV dissociation
  • Life-threatening

SVT

  • Narrow QRS complex
  • Rate 150-250
  • P waves hidden
  • Wide vs narrow QRS

Ventricular & Junctional Rhythms RH

  • PVC Wide, early, no P
  • Junctional Inverted/absent P, 40-60
  • VT ≥3 PVCs, rate >100
  • VFib Chaotic, no organized QRS
  • Asystole Flatline, no activity
  • PEA Organized rhythm, no pulse
  • Idioventricular Wide escape, 20-40
  • Bigeminy Every other beat PVC
  • Couplet Two consecutive PVCs
  • Torsades Polymorphic VT, long QT

PAC vs PVC RH

PAC

  • Early P wave
  • Narrow QRS
  • Non-compensatory pause

PVC

  • No preceding P
  • Wide bizarre QRS
  • Compensatory pause
  • Narrow vs wide QRS

AV Blocks RH

  • 1° AV block PR >0.20s, constant
  • Mobitz I PR lengthens, drops QRS
  • Mobitz II Constant PR, drops QRS
  • 3° block P and QRS independent
  • 2:1 block Every other P conducts

Common Traps

V1/V2 lead placement

  • 4th ICS correct ≠ Not 2nd ICS

Mobitz I vs II

  • Type I PR lengthens ≠ Type II PR constant

AFib vs flutter

  • AFib has no pattern ≠ Flutter is sawtooth

Two meanings of LAD

  • LAD = coronary artery ≠ LAD = left-axis deviation

Rate calculation methods

  • 300 / large boxes ≠ 1500 / small boxes

Sinus arrhythmia is normal

  • Normal breathing variant ≠ Not pathologic

Wide tachycardia

  • Assume VT until proven ≠ Not always SVT

Last Minute

  • 1. Weights: Rhythm 40%, 12-lead 22%
  • 2. PR normal 0.12-0.20s
  • 3. QRS normal <0.12s
  • 4. Rate: 300 / large boxes
  • 5. V1: 4th ICS right sternal
  • 6. Inferior MI = II, III, aVF
  • 7. Anterior MI = V3-V4 (LAD)
  • 8. Mobitz II drops without warning
  • 9. AFib = irregularly irregular
  • 10. Flutter = sawtooth, 250-350
  • 11. VT = wide, regular, >100
  • 12. Target HR = 85%×(220−age)
  • 13. SA→AV→His→Purkinje pathway
  • 14. Normal axis: I and aVF up

CCI CCT Certified Cardiographic Technician

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