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Elektrokardiofisiologi

Cardiac Muscle Contraction


Heart muscle:
Is stimulated by nerves and is self-excitable
(automaticity)
Contracts as a unit
Has a long (250 ms) absolute refractory
period

Cardiac muscle contraction is similar to


skeletal muscle contraction

Extrinsic Innervation of the Heart


Heart is stimulated
by the sympathetic
cardioacceleratory
center
Heart is inhibited
by the
parasympathetic
cardioinhibitory
center

Figure 18.15

Heart Physiology: Intrinsic


Conduction System
Autorhythmic cells:
Initiate action potentials
Have unstable resting potentials called
pacemaker potentials
Use calcium influx (rather than sodium) for
rising phase of the action potential

Cell Depolarization
Flow of sodium ions into cell during activation

Depol

Repol.

Restoration of
ionic balance

Pacemaker and Action


Potentials of the Heart

Figure 18.13

Heart Physiology: Sequence of


Excitation
Sinoatrial (SA) node generates impulses
about 75 times/minute
Atrioventricular (AV) node delays the
impulse approximately 0.1 second
Impulse passes from atria to ventricles via
the atrioventricular bundle (bundle of His)

Heart Physiology: Sequence


of Excitation
AV bundle splits into two pathways in the
interventricular septum (bundle branches)
Bundle branches carry the impulse toward the
apex of the heart
Purkinje fibers carry the impulse to the heart
apex and ventricular walls

Heart Physiology: Sequence of


Excitation

Figure 18.14a

Normal Impulse Conduction


Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers

Impulse Conduction & the ECG


Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers

Cardiac Cycle
Cardiac cycle refers to all events
associated with blood flow through the
heart
Systole contraction of heart muscle
Diastole relaxation of heart muscle

Phases of the Cardiac Cycle


Ventricular filling mid-to-late diastole
Heart blood pressure is low as blood enters atria
and flows into ventricles
AV valves are open, then atrial systole occurs

Phases of the Cardiac Cycle


Ventricular systole
Atria relax
Rising ventricular pressure results in closing of
AV valves
Isovolumetric contraction phase
Ventricular ejection phase opens semilunar
valves

Phases of the Cardiac Cycle


Isovolumetric relaxation early diastole
Ventricles relax
Backflow of blood in aorta and pulmonary trunk
closes semilunar valves

Dicrotic notch brief rise in aortic pressure


caused by backflow of blood rebounding off
semilunar valves

Phases of the Cardiac Cycle

Figure 18.20

What is an ECG?
The electrocardiogram (ECG) is a
representation of the electrical events of the
cardiac cycle.
Each event has a distinctive waveform, the
study of which can lead to greater insight
into a patients cardiac pathophysiology.

BASIC TERMINOLOGY
Arrhythmia:

Abnormal rhythm

Baseline:Flat, straight, isoelectric line


Waveform:
up or down

Movement away from the

Segment:

A line between waveforms

Interval: A waveform plus a segment


Complex:
waveforms

Combination of several

baseline,

12 ECG LEADS

ECG Limb Leads

ECG Augmented Limb Leads

ECG Precordial Leads

The ECG Paper


Horizontally
One small box - 0.04 s
One large box - 0.20 s

Vertically
One large box - 0.5 mV

The ECG Paper (cont)


3 sec

3 sec

Every 3 seconds (15 large boxes) is


marked by a vertical line.
This helps when calculating the heart rate.
NOTE: the following strips are not marked
but all are 6 seconds long.

Electrocardiography
Electrical activity is recorded by
electrocardiogram (ECG)
P wave corresponds to depolarization of SA node
QRS complex corresponds to ventricular
depolarization
T wave corresponds to ventricular repolarization
Atrial repolarization record is masked by the
larger QRS complex

Electrophysiology

Cardiac Current Flow

Cardiac Current Flow

ECG Signal
Heart behaves as a syncytium:
a propagating wave that once
initiated continues to propagate
uniformly into the region that is
still at rest.
The depolarization wavefront
defines a dividing line between
activated and resting cells.
Elsewhere, the signal is zero
Will propagate along conduction
paths sinus node AV node
bundle branches Purkinjie
fibers

Normal ECG Signal


P atrial
depolarization
QRS complex
ventricular
depolarization
T ventricular
repolarization

Electrocardiography

Figure 18.16

Electrocardiogram
Normal P wave has
amplitude of 0.25 mV
Q wave is first
downward deflection
after P wave; signals
start of ventricular
depolarization
R wave is positive
deflection after Q wave
S wave is negative
deflection preceded by
Q or R waves
T wave follows QRS

ECG Signal
The excitation begins at the
sinus (SA) node and spreads
along the atrial walls
The resultant electric vector
is shown in yellow
Cannot propagate across the
boundary between atria and
ventricle
The projections on Leads I, II
and III are all positive

ECG Signal
Atrioventricular (AV) node
located on atria/ventricle
boundary and provides
conducting path
Pathway provides a delay to
allow ventricles to fill
Excitation begins with the
septum

ECG Signal
Depolarization continues to
propagate toward the apex of
the heart as the signal moves
down the bundle branches
Overall electric vector points
toward apex as both left and
right ventricles depolarize
and begin to contract

ECG Signal
Depolarization of the right
ventricle reaches the
epicardial surface
Left ventricle wall is thicker
and continues to depolarize
As there is no compensating
electric forces on the right,
the electric vector reaches
maximum size and points left
Note the atria have
repolarized, but signal is not
seen

ECG Signal
Depolarization front
continues to propagate to the
back of the left ventricular
wall
Electric vector decreases in
size as there is less tissue
depolarizing

ECG Signal
Depolarization of the
ventricles is complete and
the electric vector has
returned to zero

ECG Signal
Ventricular repolarization
begins from the outer side of
the ventricles with the left
being slightly dominant
Note that this produces an
electric vector that is in the
same direction as the
depolarization traveling in the
opposite direction
Repolarization is diffuse and
generates a smaller and longer
signal than depolarization

ECG Signal
Upon complete
repolarization, the heart is
ready to go again and we
have recorded an ECG trace

Heart Excitation Related to ECG

Figure 18.17

Electrophysiology
When myocardial muscle is completely
polarized or depolarized, the ECG will not
record any electrical potential but rather a
flat line, isoelectric line.
After depolarization, myocardial cells
undergo repolarization to return to
electrical state at rest.

Electrophysiology
P wave represents depolarization of atria which
causes atrial contraction
Repolarization of atria not normally detectable on
an ECG
Excitation of bundle of His and bundle branches
occur in middle of PR interval
QRS complex reflects depolarization of ventricles
T wave reflects repolarization of muscle fibers in
ventricles

ECG Time & Voltage


ECG machines can run at 50 or 25 mm/sec.
Major grid lines are 5 mm apart, at standard
25 mm/s, 5 mm corresponds to 0.20
seconds.
Minor lines are 1 mm apart, at standard 25
mm/s, 1 mm corresponds to 0.04 seconds.
Voltage is measured on vertical axis.
Standard calibration is 0.1 mV per mm of
deflection.

Aksis QRS

A Review Of The Waves


& Intervals Of The EKG

The P Wave
The P Wave Is The Signal That Electrical
Potential Has Left The SA Node, Swept
Across The Atria, & Has Initiated Atrial
Contraction.

What Is A Normal P Wave ?


Duration : The Normal Duration Of A P
Wave is 2.0 - 2.5 mm (.04 - .1 sec)
If It Is Greater Than 2.75 mm (.11 sec) It
Is Considered To Be An Abnormal P
Wave.

Amplitude
A Normal Amplitude For A
P Wave Is 2-3 mm.

The P Wave Should Always Be Gently


Rounded - Never Pointed Or Peaked.
Abnormal Amplitude Of The P Wave Is
Often Seen In Cor Pulmonale, A-V Valve
Disease, Hypertension & In Patients With
Congenital Heart Disease
P Waves Within The Same Lead That Are
Multiformic Indicate The Presence Of
More Than One Pacemaker In The Right
Atrium.

In The Six Limb Leads, Generally P Waves


in the upright position except In aVR & V1
They are negatively deflected.

Biphasic P Waves frequently seen in


lead III, lead V2 & occasionally in lead
aVL.

BiPhasic P Wave In V1

The PR Interval
After The P Wave There Is A Silent
Period Where Nothing Is Happening In
The EKG Tracing. This Quiescent Period
Is Called The PR Interval.

The PR Interval Is A Time Lag And


Represents The Period During Which
There Is AV Nodal Capture Of The SA
Node Signal.
The PR Interval Allows The Atria To
Contract (atrial systole) Which Tops Off
The Ventricles With Blood - An Event
Called Atrial Kick.

The PR interval is measured from the


beginning of the P wave to the
beginning of the Q wave or the
beginning of the R wave if the Q wave
is absent.
The PR interval represents the time
period encompassing atrial
depolarization up to but not including
the start of ventricular depolarization.

Duration : The adult PR interval is


normally between 3-5 mm or 0.12 -0.20
seconds in duration. some cardiologists
will say it is normal out to 0.22 seconds (5
1/2 mm)
If the PR interval is longer than 5 mm, it is
called a prolonged PR interval & may
indicate the presence of an AV Block.

The PR interval shortens during exercise


because of the sympathetic tone that
predominates over the heart.
If the PR Interval could not shorten,
along with other segments in the ECG,
then acceleration of heart rate during
exercise would be difficult if not
impossible.

In young children, The PR Interval is shorter


than in adults. the childs heart rate is also
faster.
in a 1 year old child at rest, the normal PR
interval is typically 0.11 sec. or slightly under
3 mm.
For children who are 6 years of age, the PR
interval at rest is 0.13 seconds or slightly
over 3 mm.

in children 12 years of age, the PR


interval at rest will be 0.14 seconds or
about 3.5 mm.
In Adults 18 Years Of Age And Older, The
P-R Interval At Rest Will Be 3-5 mm In
Length.
Prolonged P-R Intervals Are Symptomatic
Of : AV Blocks Due To Coronary Disease
& Rheumatic Fever.

The Q Wave
Definition : The Q wave is the first downward
deflection after the P wave & before the R
wave.
Sometimes Q waves are present &
sometimes they are absent depending on
the lead.

It is common to normally see Q waves in


leads I, II, aVL and in V4-6.
A normal Q wave is not wider in duration
than 0.5 mm or about 0.02 seconds. its
normal amplitude is < 1 mm.
Q waves are an indication of ventricular
septal wall depolarization.

They appear before the QRS complex


because the fascicle that conducts the
signal is higher than the right and left
bundle branch that give you the QRS
complex.
Q waves of normal size have no
diagnostic meaning in normal hearts
except that the septum has depolarized.

The R Wave
Definition : The R wave is the first upward
deflection after the P wave.
In the precordial chest leads, there should
be an R wave progression - i.e. - an ever
increasing amplitude of the R wave from
V1 through V6

R wave progression occurs because the


precordial chest leads sweep across the
thoracic cage looking from the thinner
right ventricle across to the thicker left
ventricle.
Loss of the R wave progression is
abnormal and signals the possible
presence of bundle branch blocks or the
occurrence of a myocardial infarction.

The S Wave
Definition : The s wave is defined as the
first downward deflection after the R wave.
There is a normal progressive decrease in
the size of the S wave in the precordial
leads
V1 through V2 should have large S waves
with a decreasing appearance of S through
V5 and V6.

QRS Complex Generalities


Mostly Upward Deflected QRS Complexes
Are Found In Leads I, II, III, aVF, aVL, V4,
V5, and V6.
Mostly Downward Deflected QRS
Complexes Will Be Seen In Leads aVR
And V1,V2, And Sometimes V3.
The QRS Complex Signals The
Depolarization Of The Ventricles.

A normal QRS complex has a duration of


~ 0.06 - 0.12 Sec. or about 1.5 - 3.0 mm.
If the QRS Is >3mm, there is an abnormal
intraventricular conduction pathway.

The ST Segment
The ST segment is the pause after the
QRS Complex - the interval between the
end of the QRS complex & the beginning
of the T wave.

it symbolizes the end of ventricular


depolarization to the start of
ventricular repolarization.

It is during this phase of the ECG when


the heart is being passively perfused
The ST segment slopes gently up toward
the isoelectric line from the J point and
ends at the beginning of the T wave.

The ST Segment

Normal EKG w/ J Point In aVL

Normal up sloping of the ST segment may


be 1-2 mm in Asian-Europeans and as much
as 4 mm in African-Americans
The normal duration of the ST segment is
about 2-3 mm.

ST Segment Elevation
When the ST segment is elevated in A
patient with known disease, it is usually
A sign of an evolving transmural
infarction - an MI in progress.
ST segment elevations will be seen in
the lateral chest leads - Leads I, aVL
and V5 and V6.

ST Segment Elevation

ST Segment Elevation

The Classic Signs Of An Acute MI In


Progress Are :
Elevated ST Segment
Inverted T Wave
Presence Of A Q Wave

ST Segment Depression
When The ST Segment Is Depressed,
Then It Is Usually A Sign Of Cardiac
Ischemia.

Types Of
ST Segment Depression

ST Segment Depression May Be A


Permanent Part Of The EKG Tracing.
At Rest The Patient May Have A Normal
ST Segment. However, It May Become
Depressed As The Persons Exercise
Level Is Increased Above The Hearts
Ability To Receive Adequate Perfusion.

The ST segment depression will begin


to appear as the heart becomes
ischemic
It will continue to be more depressed
the more ischemic the heart becomes.

The ST segment will normalize once the


exercise intensity is reduced to a level in
which the heart receives enough perfusion
to support the work that is being
demanded.

The T Wave
The T Wave Represents Repolarization
Of The Ventricles.
Repolarization Proceeds From The Apex
Of The Heart To The Base Of The Heart.
In Normal Hearts, The T Wave Is Usually
Upright In Leads I, II, III, aVF, aVL, & V2V6.

In normal hearts, the T wave will usually


be upside down in aVR and V1.
The normal duration of the T wave is
about 1-2 mm.
Normal amplitude for the T wave is highly
variable.
T waves get taller during exercise.

T Waves During Infarction


With infarction, the T wave usually
becomes tall and narrow - referred to
as peaking.
With time and the onset of ischemia,
the T wave will invert.

The QT Interval
The QT Interval Encompasses The Time
From The Beginning Of The Q Or R Wave
Through The End Of The T Wave.
The QT Interval Represents 40% Of The
Normal Cardiac Cycle Whether At Rest Or
During Exercise.
The QT Interval Becomes Shorter As The
Heart Rate Increases.

Summary Of Durations &


Amplitudes Of The P-QRS-T
P Waves
Normal Duration : 2.5 mm
Normal Amplitude : 2-3 mm

PR Intervals
Normal

Duration : 3-5 mm

Q Waves
Normal

Duration : < .5 mm
Normal Amplitude : <25% of R
amplitude or ~ 1.0 mm

QRS Complex
Normal

Duration : < 3.0 mm


Normal Amplitude : Variable

ST Segment
Normal

Amplitude : 1-2 mm
Normal Duration : 2-3 mm

T Wave
Normal

Duration : 2 mm
Normal Amplitude : < 5 mm in Limb
Leads & < 10 mm in Precordial
Leads

Pola Membaca EKG

Irama
Rate QRS
Aksis QRS
Morfologi Gelombang P
Interval PR
Durasi QRS
Morfologi QRS
Deviasi Segmen ST
Morfologi Gelombang T
Morfologi Gelombang U
Lain-lain (LVH,LV Strain,BBB,
QT interval)
Kesimpulan EKG

Nilai Normal :
Interval PR

0,12 s/d 0,20

Durasi QRS

0,04 s/d 0,12

Aksis Normal

- 300

s/d + 1100

EKG Abnormal

Penyakit Jantung Koroner


Sindroma Koroner Akut
Takiaritmia
Bradiaritmia
Gangguan Elektrolit
Kelainan Struktur Jantung : Kelainan Katup,
Pembesaran Ruang Jantung, Efusi Perikard,
penyakit jantung bawaan.

Rhythm Analysis

Step 1:
Step 2:
Step 3:
Step 4:
Step 5:

Calculate rate.
Determine regularity.
Assess the P waves.
Determine PR interval.
Determine QRS duration.

Step 1: Calculate Rate


3 sec

3 sec

Option 1
Count the # of R waves in a 6 second rhythm
strip, then multiply by 10.
Reminder: all rhythm strips in the Modules are
6 seconds in length.

Interpretation?

9 x 10 = 90 bpm

Step 1: Calculate Rate


R wave

Option 2
Find a R wave that lands on a bold line.
Count the # of large boxes to the next R
wave. If the second R wave is 1 large box
away the rate is 300, 2 boxes - 150, 3 boxes 100, 4 boxes - 75, etc. (cont)

Step 1: Calculate Rate


3 1 1
0 5 0 7 6 5
0 0 0 5 0 0

Option 2 (cont)
Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50

Interpretation?

Approx. 1 box less than


100 = 95 bpm

Step 2: Determine regularity


R

Look at the R-R distances (using a caliper or


markings on a pen or paper).
Regular (are they equidistant apart)?
Occasionally irregular? Regularly irregular?
Irregularly irregular?
Interpretation?

Regular

Step 3: Assess the P waves

Are there P waves?


Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation?
Normal P waves with 1 P
wave for every QRS

Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds.


(3 - 5 boxes)

Interpretation?

0.12 seconds

Step 5: QRS duration

Normal: 0.04 - 0.12 seconds.


(1 - 3 boxes)

Interpretation?

0.08 seconds

Rhythm Summary

Rate
Regularity
P waves
PR interval
QRS duration
Interpretation?

90-95 bpm
regular
normal
0.12 s
0.08 s

Normal Sinus Rhythm

Normal Sinus Rhythm (NSR)


Etiology: the electrical impulse is formed in
the SA node and conducted normally.
This is the normal rhythm of the heart;
other rhythms that do not conduct via the
typical pathway are called arrhythmias.

NSR Parameters

Rate
60 - 100 bpm
Regularity regular
P waves
normal
PR interval 0.12 - 0.20 s
QRS duration
0.04 - 0.12 s
Any deviation from above is sinus tachycardia,
sinus bradycardia or an arrhythmia

Arrhythmia Formation
Arrhythmias can arise from problems in
the:
Sinus node
Atrial cells
AV junction
Ventricular cells

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