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Electrocardiography is an essential tool in the arsenal of many medical professionals, used to diagnose potentially life-threatening dysrhythmias or identify ischaemic changes. Traditionally, patients were required to attend healthcare practitioners to have an electrocardiogram (ECG) to be performed. This meant that many intermittent arrhythmias were likely missed. Holter monitors allow for longer periods of home monitoring, but were still limited and results traditionally are delayed. The advent of wearable ECG devices built-in to smartwatches has allowed unparalleled access to ECG monitoring for patients, but this has its own challenges. Accuracy, managing patient expectations and incorporating into clinical guidelines and pathways have all arisen as challenges for the modern clinician. This article provides a primer on the basic science underpinning the ECG, how this has been applied in the wearable ECG and some future directions.