position in the cardiac cycle, and additional features such as their radiation to other sites, changes with a person's position, the frequency of the sound as determined by the side of the stethoscope by which they are heard, and site at which they are heard loudest. Murmurs may be caused by damaged heart valves or congenital heart disease such as ventricular septal defects, or may be heard in normal hearts. A different type of sound, a pericardial friction rub can be heard in cases of pericarditis where the inflamed membranes can rub together. Blood tests Blood tests play an important role in the diagnosis and treatment of many cardiovascular conditions. Troponin is a sensitive biomarker for a heart with insufficient blood supply. It is released 4–6 hours after injury, and usually peaks at about 12–24 hours. Two tests of troponin are often taken—one at the time of initial presentation, and another within 3–6 hours, with either a high level or a significant rise being diagnostic. A test for brain natriuretic peptide (BNP) can be used to evaluate for the presence of heart failure, and rises when there is increased demand on the left ventricle. These tests are considered biomarkers because they are highly specific for cardiac disease. Testing for the MB form of creatine kinase provides information about the heart's blood supply, but is used less frequently because it is less specific and sensitive. Other blood tests are often taken to help understand a person's general health and risk factors that may contribute to heart disease. These often include a full blood count investigating for anaemia, and basic metabolic panel that may reveal any disturbances in electrolytes. A coagulation screen is often required to ensure that the right level of anticoagulation is given. Fasting lipids and fasting blood glucose (or an HbA1c level) are often ordered to evaluate a person's cholesterol and diabetes status, respectively. Electrocardiogram Using surface electrodes on the body, it is possible to record the electrical activity of the heart. This tracing of the electrical signal is the electrocardiogram (ECG) or (EKG). An ECG is a bedside test and involves the placement of ten leads on the body. This produces a "12 lead" ECG (three extra leads are calculated mathematically, and one lead is electrically ground, or earthed). There are five prominent features on the ECG: the P wave (atrial depolarisation), the QRS complex (ventricular depolarisation) and