Electrocardiograph

y
Reviewing

Yassin Oki Purbayanto
DEFINITION

Electrocardiography : the
procedure to record electrical
activity of the heart by means
of placing electrodes on the
surface of the heart.

Electrocardiograph the
recordings result
Goldberger AL, Goldberger E. Clinical Electrocardiography: A
Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 PHYSIOLOGY OF CONDUCTION SYSTEM

Sino-atrial node
(generate action
potential)
Impulse spread
across two atria
atrial systole Left
Anterior
AV node delay Bundle
0,1 s Branch
Bundle of His Left Purkinje
Bundle Left Fibre
Branch Posterio
r Bundle
Branch
Ventricula
Right r
Bundle myocytes
Branch
Levick, JR. An Introduction to Cardiovascular Physiology, 3 rd ed. London:
 ECGs Paper

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 CALIBRATION MARKER

Standard calibration : 1 mV = 10 mm
deflection, speed 25 mm/s , so it is 0,04
s /mm.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
ECG LEADS
12 standard leads :
Precordial Lead Placement :
6 Limb lead, comprises
of :
V1 4th ICS, 2 cm to the right
3 unipolar lead (AVL,
sternum
AVF, AVR)
V2 4th ICS, 2 cm to the left
3 bipolar lead (I,II,III)
sternum
6 Precordial Leads
V3 midway between V2 and V4
(unipolar)
V4 5th ICS, left midclavicular line
V5 5th ICS, left anterior axillary
line
V6 5th ICS, left midaxillary line
LIMB
LEADS
PRECORDIAL LEADS

Depolarization Gambar
begins at the left Lilly hal
to right side of 90
the septum, and
then forces
progress
posteriorly
toward the left
ventricle. Thus Thaler, M.S., The Only ECG Book Youll Ever Need 5 th ed. Lippincott,2007

V1, records and Lilly,LS.,Pathophysiology of Heart Disease , 4th ed.

initial upward Baltimore: Lippincott, 2007.

deflection
followed by a
downward wave,
whereas V6
 14 feature to analyze
an
ECG
Standardization ( calibration ) and technical quality
Heart rate
Rhythm
P wave
PR interval
QRS width
QRS axis
QRS voltage
QT interval
R wave progression in chest lead
Abnormal Q wave
ST segment
T wave
U wave
 Heart Rate
Tentukan frekuensi ( heart rate ), caranya ;
300 dibagi kotak sedang antara R-R
1500 dibagi kotak kecil antara R-R,
lead panjang 6 detik - jml gel QRS dikali 10.
 Heart Rate (contd)

1 kotak sedang : 300 x/mnt
2 kotak sedang : 150 x/mnt
3 Kotak sedang : 100x/mnt
4 kotak sedang : 75x/mnt
5 kotak sedang : 60 x/mnt
Normal Sinus Rhythm
Rhythm : Regular
Rate : 60 100
P wave : Normal in configuration; precede each QRS
PR : Normal ( 0. 12 0.20 seconds )
QRS : Normal ( less than 0.12 seconds )

SINUS BRADYCARDIA
SINUS ARRYTMIA

SINUS TACHYCARDIA
 Inget syarat syarat normosinus
rhythm

1. Ada gelombang P
2. Ada kompleks QRS yang mengikuti
gelombang P
3. Jarak R-R atau P-P selalu sama.
4. HR 60 100 BPM

Kalo ngga terpenuhi syarat diatas??

 Sinus Aritmia

Sinus Takikardia
Sinus Bradikardia

Kedua macam sinus diatas nggak memenuhi

syarat frekuensi normal (60 100 BPM)
 Aritmia

Kalo aritmia tanpa ada kata kata sinus
didepannya, pasti :
1. Jarak R-R atau P-P tidak sama
2. Gelombang P bisa ada bisa tidak
3. Gelombang P tanpa diikuti kompleks
QRS
4. QRS kompleks tanpa didahului
gelombang P
5. HR bisa sangat cepat, bisa sangat lambat,
bisa normal.
 Nomenclature ECG

R
Gelombang P
Depolarisasi Atrium
Diikuti kontraksi atrium
Sinus Ritme : + di II
Sinus Ritme : - di avR
N ; lebar < 0,12 dtk
N : tinggi < 0,3 mV
P T
U

Q
S
Depolarisasi
atrium
 Nomenclature ECG

QRS duration
R

PR interval : 0,12 - 0,20 dtk
QTc < 0,42 ( tergantung HR)

ST segmen
P T
U

Q
S

PR
interval QT interval
 Nomenclature ECG

Gelombang QRS
Depolarisasi ventrikel
Depolarisasi ventrikel
R Diikuti kontraksi ventrikel
Lebar 0,06 - 0,12 dtk
Tinggi tergantung lead
Q patologis: tanda infark
miokard
Transisisonal zone untuk gel.
R

Q
S
QRS COMPLEX

 Nomenclature ECG
Depolarisasi ventrikel

P T
U

Q
S
Depolarisasi
atrium Repolarisasi ventrikel
Ini yg dimaksud tinggi QRS
tergantung lead

ST segment

Time from the end of ventricular depolarization until the beginning

of ventricular
repolarization
Normally isoelectric

Goldberger AL, Goldberger E.

Clinical Electrocardiography: A
Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
T depresi dan perubahan gelombang T

ST depresi dianggap bermakna bila > 1 mm di bawah garis dasar PT di tit

itik J didefinisikan sebagai akhir kompleks QRS dan permulaan segmen S

entuk segmen ST :

up-sloping ( tidak spesifik )

horizontal ( lebih spesifik untuk iskemia )
down-sloping ( paling terpercaya untuk iskemia )

Perubahan gelombang T pada

iskemia kurang begitu spesifik

Gelombang T hiperakut
kadang2 merupakan satu-satunya
perubahan EKG yang terlihat
ST DEPRESSION

HORIZONTAL

DOWN
SLOOPING

UP SLOOPING
Acute anterolateral myocardial
Nomenclature ECG

Gelombang T
Repolarisasi ventrikel
Diikuti relaksasi ventrikel
+ di lead : I,II,V3-V6
- di lead avR

Repolarisasi ventrikel
Ini apaa hayoo?

Determining Axis

 How to determine it?
-90o
1. Buat dulu gambar kuadran

180
o
0o I

+90
o

AVF

2. Lead I (sumbu X) 2. Lead AVF (sumbu Y)
Amplitudo Amplitudo
gelombang R gelombang R
Amplitudo Amplitudo
gelombang S gelombang S

3. Kalau udah ketemu (x,y) tarik garis dari titik
(0,0) kearah titik (x,y) itu.
Atrial Hypertrophy


LAH RAH
1. Durasi P di lead II 1. P tinggi & lancip
0,12 detik (tinggi 2,5mm,
2. Ada gambaran P lebar 0,11s) di
mitrale. II,III,AVF
3. Defleksi akhir yang 2. P pulmonale
lebar ( 0,04 s) dan 3. Defleksi awal di V1
dalam(1mm) pada 1,5 mm
gelombang P bifasik
di V1

Ventricular
Hypertrophy

LVH
LVH
RVH
RVH
Myocardial Infarction

Pathophysiology of Heart Disease , 5th

ed. Baltimore: Lippincott, 2011.
Pathologic Q waves in
MI

Pathophysiology of Heart Disease , 5th

ed. Baltimore: Lippincott, 2011.
Clinical aspect of
cardiac
arrhythmias

 Sinus Tachycardia

Rhythm : Reguler
Rate : >100bpm
P wave : Normal
QRS : Normal, narrow
Cause :Sympathetic nerve stimulation,
exercise,infection,hyperthyroid,hypovolemia.

Pathophysiology of Heart Disease , 5 th ed.

Baltimore: Lippincott, 2011.
 Sinus Bradycardia

Rhythm : Reguler
Rate : <60 bpm
P wave : Normal
QRS : Normal, narrow
Cause :Parasympathetic nerve stimulation,
vasodilator,beta blocker ,hypothyroid.
Pathophysiology of Heart Disease , 5 th ed.
Baltimore: Lippincott, 2011.
 Atrial Fibrillation

Rhythm : Irregular
Rate : 140 160 bpm
Rapid irregular undulation of the baseline
(fibrillatory waves) instead of P waves.
Ventricular rate (QRS) is usually irregular
Pathophysiology of Heart Disease , 5th ed.
Baltimore: Lippincott, 2011.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 Atrial Flutter

Rate : 180 350 bpm
Saw tooth flutter wave
Constant or variable ventricular rate
The most commont cause of a paroxysmal,
narrow, regular QRS tachycardia
Pathophysiology of Heart Disease , 5
Baltimore: Lippincott, 2011.
th
ed.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 Ventricular
Tachycardia

Malignant Arrythmias
Wide QRS complex Pathophysiology of Heart Disease , 5th
ed. Baltimore: Lippincott, 2011.
Rate : 200 bpm or faster

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Ventricular Fibrillation

Another malignant arrhythmias
Need intervention of electrical defibrillator
immediately
Life threatening
Irregular,chaos,polymorphic rhythm
Pathophysiology of Heart Disease , 5th ed.
Baltimore: Lippincott, 2011.
Reading the holter monitor
QRS
complex -
asistol RJP
DC
+ VF
shock
Tachycardia
Fast/slow
(>100)
Bradycardia
(<60)
Wide/narrow Wide (Ventricular)
Narrow
(Supravent)
Reg/irreg

Normal/abnorma
P wave l
P wave + QRS 1P followed 1
complex QRS?
PR segment
prolonged/tidak?


Terimakasih