Basics of

Electrocardiography
Dr. Darmadi SpPD
RSU. Cut Meutia
Lhokseumawe

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 ECG Complex
P wave
PR Interval
QRS complex
ST segment
T Wave
QT Interval
RR Interval

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Y- Axis Amplitude in mill volts
ECG Graph Paper

X- Axis time in seconds

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SISTEMATIKA PEMBACAAN EKG
1. IRAMA/RHYTME : SINUS/BUKAN, REGULER/IRREGULER

2. FREKWENSI DENYUT JANTUNG ( HR )

3. AKSIS JANTUNG ( SUMBU JANTUNG )

4. PEMBESARAN JANTUNG ( ATRIUM/VENTRIKEL)

5. ISKEMIA/OKLUSI ARTERI KORONER

6. ARITMIA JANTUNG
* GANGGUAN HANTARAN (BLOK)
* IRAMA EKTOPIK : SUPRAVENTRIKULAR/VENTRIKULAR
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1. TENTUKAN IRAMA JANTUNG

Normal ECG

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2. TENTUKAN FREKWENSI DENYUT JANTUNG

Rate Determination
No. of Big R R Interval Rate Cal. Rate
T
Boxes A
One 0.2 sec 60 0.2 300 C
H
Two 0.4 sec 60 0.4 150 Y

Three 0.6 sec 60 0.6 100 N

O
Four 0.8 sec 60 0.8 75 R
M
A
Five 1.0 sec 60 1.0 60
L
Six 1.2 sec 60 1.2 50 B
R
Seven 1.4 sec 60 1.4 43 A
D
Eight 1.6 sec 60 1.6 37 Y
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What is the Heart Rate ?

Answer on next slide

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 What is the Heart Rate ?
To find out the heart rate we need to know
The R-R interval in terms of # of big squares
If the R-R intervals are constant
In this ECG the R-R intervals are constant
R-R are approximately 3 big squares apart
So the heart rate is 300 3 = 100

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What is the Heart Rate ?

Answer on next slide

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 What is the Heart Rate ?

To find out the heart rate we need to know

The R-R interval in terms of # of Big
Squares
If the R-R intervals are constant
In this ECG the R-R intervals are not constant
R-R are varying from 2 boxes to 3 boxes
It is an irregular rhythm Sinus arrhythmia
Heart rate is 300 2 to 3 = 150 to 100 approx
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3. TENTUKAN AKSIS JANTUNG

NW QRS Axis NE

SW SE
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Axis Determination

ALL UPRIGHT MEET LEAVE

NORMAL RIGHT LEFT

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What is the Axis ?

LEAD 1
aVR

LEAD 2 aVL

LEAD 3 aVF

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What is the Axis ?

LEAD 1

LEAD 2

LEAD 3
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What is the Axis ?

LEAD 1 aVR

LEAD 2 aVL

LEAD 3 aVF
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4. TENTUKAN PEMBESARAN JANTUNG

Atrial Waves ( Gel P)

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 Left Atrial Enlargement
Always examine V 1 and Lead 1 for LAE

Biphasic P Waves, Prolonged P waves

P wave 0.16 sec, Downward component

Systemic Hypertension, MS and or MR

Aortic Stenosis and Regurgitation

Left ventricular hypertrophy with dysfunction

Atrial Septal Defect with R to L shunt 19

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Left Atrial Enlargement
(Gelombang P mitral)

P wave duration is 4 boxes-0.04 x 4 = 0.16

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Left Atrial Enlargement

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 Right Atrial Enlargement
Always examine Lead 2 for RAE
Tall Peaked P Waves, Arrow head P waves
Amplitude is 4 mm ( 0.4 mV) - abnormal
Pulmonary Hypertension, Mitral Stenosis
Tricuspid Stenosis, Regurgitation
Pulmonary Valvular Stenosis
Pulmonary Embolism
Atrial Septal Defect with L to R shunt

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Right Atrial Enlargement
(Gelombang P pulmonal)

P wave voltage is 4 boxes or 4 mm

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Right Atrial Enlargement

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Ventricular Hypertrophy
Ventricular Muscle Hypertrophy
QRS voltages in V1 and V6, L 1
and aVL
We may have to record to
standardization
T wave changes opposite to QRS
direction
Associated Axis shifts
Associated Atrial hypertrophy

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Right Ventricular Hypertrophy

Tall R in V1 with R >> S, or R/S ratio > 1

Deep S waves in V4, V5 and V6
The DD is RVH, Posterior MI, Anti-clock
wise rotation of Heart
Associated Right Axis Deviation, RAE
Deep T inversions in V1, V2 and V3
Absence of Inferior MI

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Right Ventricular Hypertrophy

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Is there any hypertrophy ?

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What is in this ECG ?

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 ECG OF MS with RVH, RAE
Classical changes seen are
Right ventricular hypertrophy
Right axis deviation
Right Bundle Branch Block
P Pulmonale - Right Atrial enlargement
P Mitrale Left Atrial enlargement
If Atrial Fibrillation develops P
disappears

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 Left Ventricular Hypertrophy

High QRS voltages in limb leads

R in Lead I + S in Lead III > 25 mm
S in V1 + R in V5 > 35 mm
R in aVL > 11 mm or S V3 + R aVL > 24 , > 20
Deep symmetric T inversion in V4, V5 & V6
QRS duration > 0.09 sec
Associated Left Axis Deviation, LAE

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Left Ventricular Hypertrophy

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What is in this ECG ?

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5. TENTUKAN ADA/TIDAK ISKEMIA JANTUNG

Blood Supply of Heart

RCA

LCX

LAD

RCA

LCA

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Ischemia, Injury & Infarction

1. Ischemia produces ST segment
Myocardial depression with or without T
Ischemia inversion

Myocardial Injury 1. Injury causes ST segment elevation

with or without loss of R wave
voltage

Myocardial 1. Infarction causes deep Q waves

Infarction with loss of R wave voltage.

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Myocardial Injury

TRANSMURAL Injury ST
Elevation

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 Ischemic Heart Disease (IHD)

Blood supply Sub-endocardia Transmural

Ischemia Stable Variant

Transient loss Angina Angina
Infarction NSTEMI STEMI
Persistent loss ACS ACS
ST Segment Depressed Elevated

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Evolution of Acute MI

A Normal ST segment and T waves

B ST mild and prominent T waves
C Marked ST + merging upright T
D ST elevation reduced, T,Q starts
E Deep Q waves, ST segment returning to
baseline, T wave is inverted
F ST became normal, T Upright, Only Q+

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Interpret this ECG

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 NSTEMI
Non ST MI or NSTEMI, Non Q MI
Or also called sub-endocardial Infarction
Non transmural, restricted to the sub-endocardial
region - there will be no ST or Q waves
ST depressions in anterio-lateral & inferior leads
Prolonged chest pain, autonomic symptoms like
nausea, vomiting, diaphoresis
Persistent ST-segment even after resolution of
pain

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What are these ECGs

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 STEMI and QWMI
STEMI and QWMI
ST signifies severe transmural myocardial injury
This is early stage before death of the muscle tissue
the infarction
Q waves signify muscle death They appear late in
the sequence of MI and remain for a long time
Presence of either is an indication for thrombolysis

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Very Striking

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 Hyper Acute MI
Note the hyper acute elevation of ST
The R wave is continuing with ST and the
complexes are looking rectangular
Some times tall and peaked T waves in the
precardial leads may be the only evidence of
impending infarct
Sudden appearance LBBB indicates MI
MI in Dextro-cardia right sided leads are
to be recorded

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Interpret this ECG

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 Acute Anterio-lateral MI
Note the marked ST elevations in chest leads
V2 to V5 and also ST in L1 & aVL
T inversions have not appeared as yet
R wave voltages have dropped markedly in
V3, V4, V5 and V6
Small R in L1 and aVL.

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Which wall MI ?

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 Acute Inferior wall MI
Note the ST elevations in Inferior
leads- namely L2, L3 and aVF
T inversions yet to appear
aVL lead shows complimentary
STand T inversion

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Acute True Posterior MI

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 Acute True Posterior MI
Due to occlusion of the distal Left
circumflex artery or posterior descending
or distal right coronary artery
Mirror image changes or reciprocal
changes in the anterior precardial leads
Lead V1 shows unusually tall R wave (it is
the mirror image of deep Q)
V1 R/S > 1, Differential Diagnosis - RVH

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6. ARRYTHMIA CORDIS

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 A. IRAMA EKTOPIK

Atrial Ectopics
Note the premature (ectopic) beats marked as
APC (Atrial Premature Contractions)
These occurred before the next expected QRS
complex (premature)
Each APC has a P wave preceding the QRS of
that beat So impulse has originated in the atria
The QRS duration is normal < 0.08, not wide

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Atrial Ectopics (APB/APC)

APC APC

APC APC

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Supra Ventricular Tachycardia
(SVT)

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Atrial Fibrilasi

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Atrial Flutter

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Ventricular tachycardia

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Ventricular Flutter/Fibrilation

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B. Gangguan Hantaran

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 Complete RBBB
Complete RBBB has a QRS duration > 0.12 sec
R' wave in lead V1 (usually see rSR' complex)
S waves in leads I, aVL, V6, R wave in lead aVR
QRS axis in RBBB is -30 to +90 (Normal)
Incomplete RBBB has a QRS duration of 0.10 to
0.12 sec with the same QRS features as above
The "normal" ST-T waves in RBBB should be
oriented opposite to the direction of the QRS

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Complete RBBB

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 Complete LBBB
Complete LBBB has a QRS duration > 0.12 sec
Prominent S waves in lead V1, R in L I, aVL, V6
Usually broad, Bizarre R waves are seen, M pattern
Poor R progression from V1 to V3 is common.
The "normal" ST-T waves in LBBB should be oriented
opposite to the direction of the QRS
Incomplete LBBB looks like LBBB but QRS duration
is 0.10 to 0.12 sec, with less ST-T change.
This is often a progression of LVH changes.

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Complete LBBB

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LATIHAN INTERPRETASI EKG

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TERIMOENG GEUNASEH !!!

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