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






the sequential activation
(depolarization) of the right
and left atria
right and left ventricular depolarization
(normally the ventricles are activated
simultaneously)
ventricular repolarization
One complex of ECG waveform
Limb leads
Einthoven Triangle
Chest lead
Chest lead
Chest lead
V1: 4
th
intercostal space of right sternal border
V2: 4
th
intercostal space of left sternal border
V3: halfway between V2 and V4
V4: 5
th
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
qRs Rs
R
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
Unstable Angina
NSTEMI
Acute myocardial
infarction
STEMI Non STEMI
Mid LAD occlusion
after the first septal
perforator (arrow)
ECG : large anterior MI
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, V
5
, and V
6

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
Peaking T
Shortening QT interval

Widening P wave,
QRS complex
Prolongation PR interval
HIPERKALEMIA
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
VES
SR
SR SR SR SR
SR SR
VES
VES
Sinus rhythm
with Multifocal VES
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
Prolonged PR interval
1
st
degree AV block
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
Missing QRS
Missing QRS
2
nd
degree AV block, type 1
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
2
nd
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
P P
P P P P P
QRS QRS
QRS
Total AV Block /
3
rd
degree AV block
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