Intrinsic Conducting

System
Departemen Fisiologi
Fakultas Kedokteran
Universitas Muhammadiyah
Sumatera Utara
 SIFAT DASAR OTOT
JANTUNG
• Inherent rhitmicity
• Conductivity
• Contractility
• Exitability
 Conducting System of the Heart

Inter- nodal Tracts

SA Node

AV Node Left Bundle

Branch

Anterior Superior Fascicle

Bundle of HIS Posterior Inferior Fascicle

Septal Depolarization Fibers

Purkinjie Fibers

Right Bundle
Branch
 Intrinsic Conducting System
• Sinoatrial node.
– Electrical pace maker.
• Atrioventricular node.
– Receives impulses
originating from SA node.
• Bundle of His
– Electrical link between atria
and ventricles.
• Purkinje fibres.
– Distribute impulses to
ventricles.
 Penilaian
Electrocardiogram
(ECG=EKG)

Abdul Majid
Bagian Fisiologi FK USU Medan
 ELECTROCARDIOGRAM

• The record of potential fluctuation during

cardiac cycle.
• ECG may be recorded by using :
– unipolar recording; an active or exploring
electrode connected to an indifferent
electrode at zero potential
– bipolar recording; using two active
electrodes
• Einthoven's triangle; A
triangle with heart at its
center.
• These are three standard
limb leads used in
electrocardiography.

• Depolarization moving toward an active

electrode produces positive deflection,
whereas depolarization moving in opposite
direction produces negative deflection
 Bipolar leads

lead I, upward
LA
deflection; left RA
- -
arm and right arm
(left arm
positive) RA - + LA
lead II, left leg LEAD I
and right arm
(leg positive)
lead III, left arm
LEAD III + LL
and left leg, (leg LL
+
LEAD II
positive)

Remember, the RL is always the ground

and never takes on a positive or negative
charge.
 Unipolar (V) leads
Positioning the limb
leads • 6 unipolar chest leads
(precordial leads)
designated V1-V6
RA LA

• 3 unipolar limb leads: VR

Red
Yellow
(right arm), VL (left arm),
and VF (left foot).
Augmented limb leads,
RL LL
designated by the letter a
Black Green (aVR, aVL, aVF), are
generally used
 The Concept of a “Lead”

Summary of the LEAD AVR

“Limb Leads” LEAD AVL
-150o -30o
Each of the limb leads (I,
II, III, AVR, AVL, AVF)
0o
can be assigned an LEAD I
angle of clockwise or
counterclockwise
rotation to describe its 60o
position in the frontal 120o LEAD II
90o
plane. Downward LEAD III
LEAD AVF
rotation from 0 is positive
and upward rotation from
0 is negative.
 ECG Paper and related Heart Rate & Voltage Computations

Memorize
These 2
 • An
electrocardiogram
is a test that
measures the
electrical activity
of the heart. This
includes the rate
and regularity of
beats as well as
the size and
position of the
chambers, any
damage to the
heart, and effects
of drugs or
devices to
regulate the heart.
 Cardiac Anatomy
Superior
vena cava

Pulmonary
veins Atrioventricular (AV) node
Sinoatrial (SA)A node Left atrium

Atrial muscle Mitral valve

Internodal
conducting
tissue
Tricuspid valve Purkinje
Ventricluar fibers
muscle
Inferior Descending aorta
vena cava
 Action Potentials in the Heart
0.12-0.2 s approx. 0.44 s

PR QT
Superior
ECG vena cava Aortic artery

SA Pulmonary artery
Pulmonary
veins AV node
SA node Left atrium

Atrial muscle Mitral valve

Atria
AV Specialized
conducting Interventricular
tissue septum

Tricuspid valve Purkinje

Purkinje fibers
Ventricluar
muscle
Ventricle Inferior Descending aorta
vena cava
Cardiac Physiology Electrocardiography Diagnosis

P T

Q
S
Cardiac Physiology Electrocardiography Diagnosis

P T

Q
S
This diagram illustrates ECG waves and intervals as well
as standard time and voltage measures on the ECG paper.

• 1. ECG Waves and Intervals:

• What do they mean?
• P wave: the sequential activation
(depolarization) of the right and left atria
QRS complex: right and left ventricular
depolarization (normally the ventricles
are activated simultaneously)
ST-T wave: ventricular repolarization
U wave: origin for this wave is not clear
- but probably represents
"afterrepolarizations" in the ventricles
PR interval: time interval from onset of
atrial depolarization (P wave) to onset of
ventricular depolarization (QRS complex)
QRS duration: duration of ventricular
muscle depolarization
QT interval: duration of ventricular
depolarization and repolarization
RR interval: duration of ventricular
cardiac cycle (an indicator of ventricular
rate)
PP interval: duration of atrial cycle (an
indicator of atrial rate)

•
1. Measurements (usually made in frontal plane leads):

Heart rate (state atrial and

ventricular, if different)

PR interval (from beginning of

P to beginning of QRS)

QRS duration (width of most

representative QRS)

QT interval (from beginning of

QRS to end of T)

QRS axis in frontal plane

Kwantitatif

•Gel.P: panjang ± 0.06 s

tinggi : 0.20 mV
•QRS: lebar : 0.06 –
0.10 s
•P-R interval: 0.12 –
0.20 s.
•Q – T interval: 0.32 –
0.40 s.
Cardiac Physiology Electrocardiography Diagnosis

R 1 sec

P T

Q
S
0.5 Sec
How to calculate Heart Rate
Behold: Einthoven's Triangle!
Each of the 6 frontal plane
leads has a negative and
positive orientation (as
indicated by the '+' and '-'
signs). It is important to
recognize that Lead I (and to a
lesser extent Leads aVR and
aVL) are right Ûleft in
orientation. Also, Lead aVF
(and to a lesser extent Leads II
and III) are superior Ûinferior
in orientation. The diagram
below further illustrates the
frontal plane hookup.
 Examples of QRS Axis
Axis in the normal range
Lead aVF is the isoelectric lead.
The two perpendiculars to aVF are
0 o and 180 o.
Lead I is positive (i.e., oriented to
the left).
Therefore, the axis has to be 0 o.
Axis in the left axis deviation (LAD)
range:
Lead aVR is the smallest and
isoelectric lead.
The two perpendiculars are -60 o and
+120 o.
Leads II and III are mostly negative
(i.e., moving away from the + left leg)
The axis, therefore, is -60 o.
Axis in the right axis deviation
(RAD) range:
Lead aVR is closest to being
isoelectric (slightly more positive
than negative)
The two perpendiculars are -60 o
and +120 o.
Lead I is mostly negative; lead III
is mostly positive.
Therefore the axis is close to +120
o. Because aVR is slightly more
positive, the axis is slightly beyond
+120 o (i.e., closer to the positive
right arm for aVR
LOCATION OF CHEST ELECTRODES IN 4TH AND 5TH INTERCOSTAL
SPACES:
• V1: right 4th intercostal
space
• V2: left 4th intercostal
space
• V3: halfway between V2
and V4
• V4: left 5th intercostal
space, mid-clavicular
line
• V5: horizontal to V4,
anterior axillary line
• V6: horizontal to V5,
mid-axillary line
 Normal ECG

• aVR "looks at" the cavities of ventricles.

Atrial depolarization, ventricular
depolarization, and ventricular repolarization
move away from the exploring electrode,
P wave, QRS complex, and T wave are all
negative (downward) deflections
• aVL and aVF look at ventricles, and
deflections are therefore predominantly
positive or biphasic.
• V1 and V2;
no Q wave,
QRS complex is small upward
deflection because ventricular
depolarization first moves
across the midportion of the
septum from left to right, then
moves down the septum and
into left ventricle away from
electrode, producing a large S
wave.
• V4-V6 (left ventricular
leads
small Q wave (left to
right septal
depolarization),

large R wave (septal and left

ventricular depolarization)
followed in V4 and V5 by a
moderate S wave (late
depolarization of the ventricular
walls moving back toward the AV
junction).
PATHOLOGICAL CHANGES:
I. - PWAVE

- QRS COMPLEX:
* DURATION
* FORM. : LBBB, RBBB
* Q wave
* R wave
* S wave

- ST SEGMENT: - ELEVATION
- DEPRESSION
- DURATION
- T WAVE
II. RHYTME
III. BLOCK : SA BLOCK
AV BLOCK
IV. ECTOPIC BEATS
 Sokolow-Lyon Indices
electrocardiographic diagnosis of
LVH

There are two criteria with these widely used

indices:

• Sum of S wave in V1 and R wave in V5

or V6 > or =3.5 mV (35 mm) and/or

• R wave in aVL > or =1.1 mV (11 mm)

AMMSR
Example 1: (Limb-lead Voltage Criteria; e.g., R in aVL >11 mm; note wide
QRS/T angle)
Example 2: (ESTES Criteria: 3 points for voltage in V5, 3 points for ST-T changes

Note also the left axis deviation of -40 degrees, and left atrial enlargement)
Differential Diagnosis of ST Segment Depression
Normal variants or artifacts: Pseudo-ST-depression
(wandering baseline due to poor skin-electrode contact)

Physiologic J-junctional depression with sinus

tachycardia (most likely due to atrial repolarization)

Hyperventilation-induced ST segment depression

Ischemic heart disease Subendocardial ischemia

(exercise induced or during angina attack - as illustrated
below)

ST segment depression is often characterized

as "horizontal", "upsloping", or
"downsloping"

Note: "Upsloping" ST depression is not an

ischemic abnormality
EKG pada APTS
Nyeri dada (-)

Nyeri dada (+)

 ECG changes in Acute Coronary Syndrome
ST depression with/ without T inverted, Q wave (-)

UAP

ST depression, deep T inverted

Non Q MCI
(NSTEMI)

hyper acute T (0-1 hrs), ST elevation (hours),

Q wave
MCI(STEMI)
Q wave (8-48 hrs), T inverted (1-2 days)
 Elevasi ST
IMA gel Q( Non QMI= STEMI) inversi T
gel Q (+)
I II III aVR aVL aVF
 -Kalibrasi: apakah 1 mV equivalent 10 mm
-Kecepatan rekaman: 25 mm/sec atau
Teknik pembuatan:
50 mm/sec.
- Getaran artefak:
+ filter tidak dipasang
+ grounding tidak dihubungkan dengan
perlu diperhatikan: earth
+ gangguan dari logam pada tubuh
Identitas pasien
pasien
Tanggal dan waktu + jelly kurang banyak.
perekaman
- Posisi elektroda
gelombang T pada sadapan aVR
menjadi positif
yang semestinya negatif.
Let it beat!