Can a Patient Wear a Bra During an EKG?
No, a patient should not wear a bra during an EKG—the bra should be removed to ensure accurate electrode placement directly on the skin at the correct anatomical landmarks.
Primary Rationale for Bra Removal
The American Heart Association and American College of Cardiology guidelines emphasize that electrodes must be placed at precise anatomical locations to avoid diagnostic errors, and clothing interference prevents this accuracy 1.
Key Technical Requirements
Direct skin contact is essential: Proper electrode-to-skin interface requires removal of superficial oils through gentle abrasion and alcohol preparation, which cannot be achieved through fabric 1.
Precise anatomical landmarks must be palpated: V1 and V2 must be placed in the fourth intercostal space at the sternal borders, V4 at the fifth intercostal space in the midclavicular line, and V5-V6 in the horizontal plane of V4—all requiring direct access to the chest wall 1.
Bra straps and underwires create physical barriers: These prevent accurate identification of intercostal spaces and can cause electrode displacement, leading to the profound waveform alterations documented in mapping studies 1.
Addressing the Breast Tissue Concern
A common misconception is that bras should remain in place to "lift" breast tissue. However:
Breast tissue attenuation is negligible: Research demonstrates that breast tissue causes amplitude changes of only 15 microvolts or less per centimeter of breast protuberance, explaining less than 1% of ECG amplitude variations 2.
Electrodes should be placed on the breast surface, not underneath: The American Heart Association guidelines state that placing electrodes on top of the breast (rather than beneath) slightly increases reproducibility of ECG measurements and ensures V5 and V6 are correctly positioned at the horizontal level of V4 1.
Placing electrodes under the breast causes more errors: When V4 is positioned under the breast, V5 and V6 are often placed too inferiorly (in the sixth intercostal space or lower), which alters voltage amplitudes used for ventricular hypertrophy diagnosis 1.
Practical Implementation
Step-by-Step Approach
Explain the necessity: Inform the patient that bra removal is required for accurate electrode placement at specific rib spaces 1.
Provide privacy and draping: Use appropriate draping to maintain dignity while allowing access to the anterior chest wall 1.
Prepare the skin properly: After bra removal, shave if necessary, clean with alcohol-saturated gauze, and gently abrade the skin to reduce impedance to 5000 Ω or less 1.
Palpate bony landmarks: Identify the fourth intercostal space for V1-V2 and the fifth intercostal space for V4 by direct palpation of the chest wall 1.
Place electrodes in the horizontal plane: Ensure V5 and V6 are at the same horizontal level as V4, not following the intercostal space inferiorly 1.
Critical Pitfalls to Avoid
Never attempt electrode placement through clothing: This creates both impedance issues and prevents accurate anatomical localization 1.
Do not place electrodes too low to "avoid the breast": Inferior misplacement of V5 and V6 alters diagnostic criteria for ventricular hypertrophy and accounts for substantial variability in serial ECG measurements 1.
Avoid vertical electrode patterns: Without direct access to bony landmarks, electrode placement often becomes erroneously vertical rather than the correct horizontal orientation 1.
Special Considerations for Large-Breasted Patients
Signal stability may require tradeoffs: The American Heart Association acknowledges that electrode placement in large-breasted women can be difficult, sometimes requiring compromise between variable location and motion artifact 1.
Elastic bandage or torso net may help: Wrapping the torso with a 6-inch elastic bandage after electrode placement can reduce noise from electrode movement, especially in patients with large breasts 1.
The horizontal plane principle still applies: Even with large breasts, V5 and V6 must be placed at the horizontal level of V4 to avoid the diagnostic errors caused by inferior misplacement 1.
Quality Assurance
The American College of Cardiology recommends that all ECG personnel receive periodic retraining in proper electrode positioning, as precordial lead misplacement explains a considerable amount of variability in serial tracings and can cause erroneous diagnoses of anterior infarction or ventricular hypertrophy 1.