ELECTROCARDIOGRAPH

Y
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

One complex of ECG waveform

right and left ventricular
depolarization (normally the
ventricles are activated
simultaneously)

the sequential activation

(depolarization) of the
right and left atria

ventricular
repolarization

Limb leads

Einthoven Triangle

Chest lead

Chest lead

Chest lead

V1: 4th intercostal space of right sternal

border
V2: 4th intercostal space of left sternal
border
V3: halfway between V2 and V4
V4: 5th 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

ECG interpretation?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Calibration
Rate and rhythm
QRS axis
P morphology
PR interval
QRS duration
QRS morphology
ST segment morphology
T morphology
U morphology
Others: LVH, LV strain, BBB, QT interval
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

1.
2.
3.

Wave of atrial depolarization

Normal characteristic:
Smooth and rounded
3 mm tall
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

QR

Q/QS

RsR

rS

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

NSTEMI

Unstable Angina

ST Elevation

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, V5, and V6

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

HIPERKALEMIA
Peaking T
Shortening QT interval
Widening P wave,
QRS complex
Prolongation PR interval

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

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

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

1st degree AV block

Prolonged PR interval

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

2nd degree AV block, type 1

Missing QRS

Missing QRS

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

2nd degree AV block, type

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

Total AV Block /
3rd degree AV block
QRS

QRS

QRS

Third-degree AV block

hythm : Regular
ate : 40 60 if block in His bundle;
30 40 if block involves bundle branches
wave : Sinus P wave present; bear no relationship to QRS;
can be found hidden in QRS complexes and T waves
R : 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