Part one
Information provided by ECG
Part two
Abnormal ECG
ECG is…?
SA Node
Internodal branch
AV Node
Hiss Bundle
Purkinje Fiber
Contraction
One ‘complex’ of ECG waveform
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 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
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
QR Q/QS rSr’
RsR’
ST segment
Begins at J point
Between ventricular depolarization and
ventricular repolarization
Generally isoelectric
T wave
Myocardial ischemia/infarct
Hypertrophy
Hyperkalemia
Arrhythmia
Myocardial ischemia/infarct
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 )
IMA STEMI:
– Aspirin 320 mg and clopidogrel 300 mg,
Antiangina
< 6 hour: thrombolytic → anticoagulan
> 6 hour: anticoagulan
• Peaking T
• Shortening QT interval
• Widening P wave,
QRS complex
• Prolongation PR interval
Treatment:
QRS complex
Normal-looking QRS complex?
Wide / narrow ?
P wave ?
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:
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
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
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 2
Missing QRS
Second-degree AV block, Mobitz II
P P P P P P P
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: