Penilaian

Electrocardiog
ram

(ECG=EKG)
5 Juni
2007
Abdul Majid

Bagian Fisiologi FK USU Medan

 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

Sinoatrial (SA)A node

Atrial muscle

Atrioventricular (AV) node

Left atrium
Mitral valve

Internodal
conducting
tissue
Tricuspid valve

Ventricluar
muscle
Inferior
vena cava

Purkinje
fibers
Descending aorta

Action Potentials in the Heart

0.12-0.2 s

approx. 0.44 s

PR

QT

Superior
vena cava

ECG

Pulmonary artery

SA

Atria
AV

Purkinje
Ventricle

Aortic artery

Pulmonary
veins

AV node

SA node

Left atrium

Atrial muscle

Mitral valve

Specialized
conducting
tissue
Tricuspid valve

Ventricluar
muscle
Inferior
vena cava

Interventricular
septum

Purkinje
fibers
Descending aorta

Cardiac Physiology

R
T

P
Q
S

Electrocardiography Diagnosis

Cardiac Physiology

R
T

P
Q

Electrocardiography Diagnosis

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 "afterdepolarizations" 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

1 sec

P
Q

0.5 Sec

Electrocardiography Diagnosis

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 left in
orientation. Also, Lead aVF
(and to a lesser extent Leads II
and III) are superior inferior
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:

Axis in the right axis deviation

(RAD) 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.

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

PATHOLOGICAL CHANGES:
I.

- PWAVE
- QRS COMPLEX:
* DURATION
* FORM. : LBBB, RBBB
* Q wave
* R wave
* S wave
- ST SEGMENT: - ELEVATION
- DEPRESSION
- DURATION
- T WAVE

II.
III.

RHYTME
BLOCK :

IV. ECTOPIC BEATS

SA BLOCK
AV BLOCK

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)

IMA gel Q( Non QMI= STEMI)

I

II

III

aVR

aVL

Elevasi ST
inversi T
gel Q (+)

aVF

-Kalibrasi: apakah 1 mV equivalent 10 mm

Teknik pembuatan:

perlu diperhatikan:
Identitas pasien
Tanggal dan waktu
perekaman

-Kecepatan rekaman: 25 mm/sec atau

50 mm/sec.
- Getaran artefak:
+ filter tidak dipasang
+ grounding tidak dihubungkan dengan
earth
+ gangguan dari logam pada tubuh
pasien
+ jelly kurang banyak.
- Posisi elektroda
gelombang T pada sadapan aVR
menjadi positif
yang semestinya negatif.

Cardiac Physiology

Electrocardiography Diagnosis

Normal ECG

ECG with Preventricular Contractions

1. Premature
Ventricular
Complexes
(PVCs)
unifocal

multifocal
Multiformed PVCs are
common in digitalis
intoxication.

 PVCs may
occur as isolated
single events or
as couplets,
triplets, and

salvos (4-6
PVCs in a
row), also
called brief
ventricular
tachycardias
.

 PVCs
(R-on-T
phenomenon),

dangerous in
an acute
ischemic
situation,
ventricular
tachycardia
or fibrillation.
"late" (end-diastolic)
PVCs are illustrated with
varying degrees of
fusion. For fusion to
occur the sinus P wave
must have made it to the
ventricles to start the
activation sequence, but
before ventricular
activation is completed
the "late" PVC occurs.
The resultant QRS looks
a bit like the normal
QRS, and a bit like the
PVC; i.e., a fusion QRS.

Cardiac Physiology

Electrocardiography Diagnosis

Normal ECG

ECG with Atrioventricular Block

Cardiac Physiology

Electrocardiography Diagnosis

Normal ECG

ECG during Ventricular Fibrillation