ELECTROCARDIO

GRAPHY

Dr CHUSNI MUBARAKH MSc SpPD

Staf Medis Fungsional Ilmu Penyakit Dalam

RSUD Purworejo
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

 SA node
 AV node
 Bundle His
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 sequentialactivation
(depolarization) of the right and
left atria

ventricular repolarization
Leads position
Limb leads
Chest lead
Chest lead
ECG interpretation…?
1. Calibration
2. Rhythm
3. Rate
4. QRS axis
5. P morphology
6. PR interval
7. QRS duration
8. QRS morphology
9. Abnormal Q wave
10. R wave progression
11. ST segment morphology
12. QT interval
13. T morphology
14. U morphology
15. Others: LVH, LV strain, BBB,
16. 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
times 10.
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
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

 Myocardial ischemia/infarct
 Hyperthrophy
 Hyperkalemia
 Arrhythmia
 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
HIPERKALEMIA

• Peaking T
• Shortening QT interval

• Widening P wave,
QRS complex
• Prolongation PR interval
PPM
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
PSVT :
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
PSVT
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
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
Ventricular Tachycardia
Torsade de Pointes
Ventricular Fibrillation
 1st degree AV block

Prolonged PR interval
 2nd degree AV block, type 1

Missing QRS Missing QRS

 2nd degree AV block, type 2

Missing QRS
 Total AV Block /
3rd degree AV block

QRS QRS QRS

P P P P P P P
Terima Kasih
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