ELECTROCARDIOGRAPHY
Dr. Fatimah Eliana, SpPD, KEMD,FINASIM
Lecture outline
Part one
Information provided by ECG
Cardiac conduction system: anatomy
and physiology
(Normal) ECG interpretation
Part two
Abnormal ECG
ECG is…?
Printout as a result of a particular electrical
function of the heart
The standard 12-lead electrocardiogram is a
representation of the heart's electrical
activity recorded from electrodes on the
body surface
Information provided by ECG:
what do you think?
Cardiac conduction system
Impulse Transmission
SA Node
Internodal branch
AV Node
Hiss Bundle
Purkinje Fiber
Contraction
One ‘complex’ of ECG waveform
right and left ventricular depolarization
(normally the ventricles are activated
simultaneously)
the sequential activation
(depolarization) of the right
and left atria
ventricular repolarization
Limb leads
Einthoven Triangle
Chest lead
Chest lead
Chest lead
V1: 4th intercostal space of right sternal border
V2: 4th intercostal space of left sternal border
V3: halfway between V2 and V4
V4: 5th intercostal space left midclavicular line.
Subsequent lead at the same plane of V4
V5: anterior axillary line
V6: mid axillary line
V7: posterior axillary line
V8: posterior scapular line
V9: left border of the spine
V3R-V9R: Taken on the right of the chest on
the same location of the left-sided leads.
ECG interpretation…?
1. Calibration
2. Rate and rhythm
3. QRS axis
4. P morphology
5. PR interval
6. QRS duration
7. QRS morphology
8. ST segment morphology
9. T morphology
10. U morphology
11. Others: LVH, LV strain, BBB, QT interval
12. Conclusion: normal/abnormal
Calibration
1 mV = 1 cm
Important in
assessing tall waves
in hypertrophic
state
Paper speed and normal
value
One small box: 0.04 s
One large box: 0.2 s
PR Interval: 0,12’’ - 0,20’’
QRS duration: 0,04’’ - 0,12’’
Rate calculation
Method:
– 300 divided by number of large boxes
between R-R
– 1500 divided by number of small boxes
between R-R,
– Number of QRS complexes in 6 seconds
(30 large box) times 10.
Rate calculation
paper 25 mm/s
Sinus Rhythm
Sinus Rhythm
–Rhythm: Regular
–Rate: 60 – 100
–P wave: Normal in configuration; precede each
QRS
–PR: Normal (0. 12 – 0.20 s)
–QRS: Normal (<0.12 s)
QRS Axis (N:- 30 s/d + 110)
P wave
Wave of atrial depolarization
Normal characteristic:
1. Smooth and rounded
2. ≤ 3 mm tall
3. Upright in leads I, II avF
PR interval
Including P wave until the beginning
of QRS complex
Normal duration is 0.12-0.2 seconds
QRS complex
Wave of ventricular depolarization
5-20 mm tall
Duration 0.06-0.10 seconds
QRS morphology
R
qRs Rs rS
QR Q/QS rSr’
RsR’
ST segment
Begins at J point
Between ventricular depolarization and
ventricular repolarization
Generally isoelectric
T wave
Ventricular repolarization, followed by
ventricular relaxation
Positive in lead : I, II, V3-V6
Negative in lead avR
Interpret this ECG..
And this..
Abnormal ECG
Abnormal ECG
Myocardial ischemia/infarct
Hypertrophy
Hyperkalemia
Arrhythmia
Myocardial ischemia/infarct
ACUTE CORONARY SYNDROME
No ST Elevation ST Elevation
NSTEMI
Unstable Angina
Acute myocardial
infarction
STEMI Non STEMI
Mid LAD occlusion
after the first septal
ECG : large anterior MI
perforator (arrow)
Occlusion of diagonal
branch ( arrow )
ST elevation in I and aVL
ECG demonstrates large anterior infarction
Proximal large RCA occlusion
ST elevation in leads II, III, aVF, V5, and V6
with precordial ST depression
Small inferior distal RCA occlusion
ECG changes in leads II, III, and aVF
Acute inferoposterior MI
Treatment
IMA STEMI:
– Aspirin 320 mg and clopidogrel 300 mg,
Antiangina
< 6 hour: thrombolytic → anticoagulan
> 6 hour: anticoagulan
IMA Non STEMI:
– Aspirin 320 mg and clopidogrel 300 mg
– Anticoagulan
– Antiangina
Hypertrophy
Treatment:
Obat anti hipertensi golongan ACE-
inhibitor atau Angiotensin Receptor
Blocker dapat digunakan untuk
mencegah remodelling ventrikel
ACE-inhibitor:
– Captopril, Ramipril
Angiotensin Receptor Blocker:
– Valsartan, Losartan
Hyperkalemia
HIPERKALEMIA
• Peaking T
• Shortening QT interval
• Widening P wave,
QRS complex
• Prolongation PR interval
Treatment:
Kalium normal 3,5-5,5
Kalium 5,5-7:
– Kalitake 3x1
Kalium > 7
– merupakan kegawatan:
– Insulin 2 unit/jam dicampur dalam
dekstrosa 5%
Arrhythmia
How to identify arrhythmias ?
QRS complex
Regular / irregular ?
QRS complex
Normal-looking QRS complex?
Wide / narrow ?
P wave ?
Relationship between P and QRS ?
NORMAL SINUS RHYTHM
Paroxysmal Supra
Ventricular Tachycardia
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
Paroxysmal Supra Ventricular Tachycardia
Atrial Fibrillation
-from multiple area of re-entry
within atria
-or from multiple ectopic foci
-irregular, narrow QRS complex
-very rapid atrial electrical
activity
(400-700 x/min).
-no uniform atrial depolarization
Treatment:
Bila HR > 100x/menit
– Digitalis kerja cepat:
– Digoksin 1 cc dimasukan dalam Dex 5% 5
cc, diberikan secara bolus intravena
Bila HR sudah < 100 x/menit
– Digoksin tablet 0,5-1 tablet/hari
Atrial Flutter
-The result of a re-entry circuit
within
the atria
-Irregular / regular QRS rate
-Narrow QRS complex
-Rapid P waves (300x/min),
“sawtooth”
Junctional rhythm
-AV junction can function as a
pace maker (40-60 x/min).
-due to the failure of sinus node
to initiate time impulse or
conduction problem.
-normal-looking QRS.
-retrograde P wave.
-P wave may preceede, coincide
with, or follow the QRS
SR
VES
Sinus rhythm
with Multifocal VES
VES VES
SR SR
SR SR SR SR
Sinus rhythm with VES couplet
Sinus Rhythm with VES, R on T
Treatment:
Cari penyebab VES
– Gangguan elektrolit, misalnya
hipokalemia
– Kelainan katup jantung
– Penyakit jantung koroner
Ventricular Tachycardia
Torsade de Pointes
Ventricular Fibrillation
Treatment:
Ventricular Tachycardia
– Amiodarone
– Bila disertai gagal jantung/hipertensi:
dapat ditambahkan ACE-inhibiotor, ARB,
Beta bloker, Aldosteron antagonis
Ventricular Fibrilation
– Electric shock (Synchronized Direct
Current) 300 Jooule
– Amiodarone
BRADIARITMIA
Blok Nodus AV, meliputi :
Blok derajat I
Blok derajat II
Mobitz type I ( Wenkebach)
Mobitz type II
Blok derajat III (total AV Block)
Gangguan fungsi nodus SA
1st degree AV block
Prolonged PR interval
First-degree AV block
Rhythm : Regular
Rate : Usually normal
P wave : Sinus P wave present; one P wave to each QRS
PR : Prolonged ( greater than 0.20 seconds )
QRS : Normal
2nd degree AV block, type 1
Missing QRS Missing QRS
Second -degree AV block, Mobitz I
Rhythm : Irregular
Rate : Usually slow but can be normal
P wave : Sinus P wave present;
some not followed by QRS complexes
PR : Progressively lengthens
QRS : Normal
2nd degree AV block, type 2
Missing QRS
Second-degree AV block, Mobitz II
Rhythm : Regular usually;
can be irreguler if conduction ratios vary
Rate : Usually slow
P wave : Two, three, or four P waves before each QRS
PR : PR interval of beat with QRS is constant;
PR interval may be normal or prolonged
QRS : Normal if block in His bundle;
wide if block involves bundle branches
Total AV Block /
3rd degree AV block
QRS QRS QRS
P P P P P P P
Third-degree AV block
Rhythm : Regular
Rate : 40 – 60 if block in His bundle;
30 – 40 if block involves bundle branches
P wave : Sinus P wave present; bear no relationship to QRS;
can be found hidden in QRS complexes and T waves
PR : Varies greatly
QRS : Normal if block in His bundle;
wide if block involves bundle branches
Right bundle branch block
Left bundle branch block
Treatment:
AV Blok biasanya disebabkan kelainan
konduksi jantung
Terapi:
– Isopreterenol
– Pace maker bila HR < 30 X/menit
Pericarditis
Tugas
Bacalah EKG ini
