ELEKTROKARDIOGRAFI DASAR

Cardiology & Vascular Medicine Departement

Faculty of Medicine
University of Brawijaya
Elektrokardiogram (EKG)

Rekaman grafik potensial listrik yang dihasilkan

oleh jaringan jantung
Goldman & Goldschlager

Cara Perekaman EKG :

- Permukaan
- Epikardial
- Endokardial / intrakardial
Peran Diagnostik EKG

 Hipertrofi /dilatasi atrium dan ventrikel

 Aritmia /gangguan konduksi : RBBB, LBBB, VES,
SVT, VT, AF, VF dll.
 Iskemia dan infark miokard akut atau infark lama
 Efek obat-obatan : digitalis, antiaritmia
 Gangguan keseimbangan elektrolit : kalium
(hipo/hiper kalemia ), kalsium
Indikasi EKG

• Gangguan irama jantung

• Sinkop/pra sinkop
• Dicurigai PJK
• Hipertensi
• Dicurigai kelainan kongenital
• Kelainan katup
• dll
Arah Defleksi

Arah impuls Arah defleksi

Menuju Elektroda (positif) Ke atas (positif)

Menjauhi Elektroda (negatif) Ke bawah (negatif)

Menuju kemudian menjauhi Bifasik

Elektroda
SANDAPAN EKG (ECG LEADS)

Untuk rekaman rutin, terdapat 12 sandapan,

yaitu :
a. Tiga buah sandapan bipolar standar (I, II dan
III)
b. Tiga buah sandapan unipolar ekstremitas (aVR,
aVL dan aVF)
c. Enam buah sandapan unipolar prekordial (VI
sampai dengan V6)
SANDAPAN BAKU BIPOLAR
(BIPOLAR STANDARD LEAD EINTHOVEN)

Sandapan I : selisih potensial antara lengan

kanan (RA) & lengan kiri (LA), di
mana LA bermuatan lebih positif
dari RA.
Sandapan II : selisih potensial antara lengan
kanan dan tungkai kiri (LL), di
mana LL bermuatan lebih positif
dari RA
Sandapan III : selisih potensial antara lengan
kiri
dan tungkai kiri, di mana LL
bermuatan lebih positif dari LA
SANDAPAN EKSTREMITAS UNIPOLAR
(UNIPOLAR LIMB LEAD WILSON)

Sandapan aVR = sandapan unipolar lengan

kanan yang diperkuat
(augmented)
Sandapan aVL = sandapan unipolar lengan
kiri yang diperkuat
(augmented)
Sandapan aVF = sandapan unipolar
tungkai
kiri yang diperkuat
SANDAPAN DADA UNIPOLAR
(UNIPOLAR CHEST LEAD = V LEAD)
Sandapan V1 :
Sela iga IV garis sternal kanan
Sandapan V2 :
Sela iga IV sternal kiri
Sandapan V3 :
pertengahan antara V2 dan V4
Sandapan V4 :
Sela iga V garis midklavikula kiri
semua sandapan selanjutnya V5-
V9 diambil dalam bidang horizontal
seperti V4
Sandapan V5 : Setinggi V4 aksilaris anterior kiri
Sandapan V6 : Setinggi V4 garis mid aksilaris kiri
Sandapan V7 : Garis aksilaris posterior
Sandapan V8 : Garis skapularis posterior
Sandapan V9 : Batas kiri kolumna vertebralis
Sandapan V3R-V9R : Dada sisi kanan dengan tempat yang
sama seperti sandapan V3-9 sisi kiri
ECG Calibration

Standard Rekaman EKG :

Kecepatan rekaman : 25 mm/detik
Kalibrasi : 1 milivolt (mV) = 10 mm
( standar ganda, separuh, seperempat )

Ukuran di Kertas EKG :

Garis horizontal
- Tiap satu mm= 1/25 detik = 0,04 detik
- Tiap lima mm = 5/25 detik = 0,20 detik
- Tiap 25 mm = 25 x 0,04 = 1,00 detik
Garis vertikal
- 1 mm = 0,10 mV
- 10 mm = 1,00 mV
Basic Waveforms and Intervals
EKG NORMAL
 GELOMBANG P

Menggambarkan aktivitas depolarisasi atrium kanan dan

kiri ( dari kanan ke kiri dan ke bawah )

Karakteristik EKG :
• Arah gelombang P normal :
Selalu positif di II dan selalu negatif di aVR.
• Tinggi : kurang dari 3 mm (2,5 mm)
• Durasi ( lebar ): kurang dari 3 mm (0,10 detik)

Kepentingan :
1. Menandakan adanya aktivitas atrium
2. Menunjukkan arah aktivitas atrium
3. Menunjukkan tanda-tanda hipertrofi atrium
 GELOMBANG Ta

Menggambarkan proses repolarisasi

atria, gelombang ini biasanya tidak
tampak karena terlalu kecil dan tertutup
oleh kompleks QRS.
GELOMBANG Q

DEFLEKSI KE BAWAH YANG PERTAMA KOMPLEKS QRS

Menggambarkan awal dari fase depolarisasi

ventrikel.
Ciri-ciri gelombang Q patologis :
1. Lebarnya sama atau lebih dari 0,04 detik (1 mm)
2. Dalamnya lebih dari 25% amplitudo gelombang R
Kepentingan :
 Menunjukkan adanya nekrosis miokard (infark
miokard)
Gelombang Q pada sandapan aVR : normal
GELOMBANG R
Adalah defleksi positif pertama kompleks QRS

Menggambarkan fase depolarisasi ventrikel

Nilai normal : akan dibahas dalam bagian
tentang hipertrofi
Bentuk normal : akan dibahas dalam bagian
tentang B.B.B
Abnormal :
1. Menandakan adanya hipertrofi ventrikel
2. Menandakan adanya tanda-tanda B.B.B
3. Dan lain-lain
GELOMBANG S

adalah defleksi negatif sesudah gelombang R

Menggambarkan fase depolarisasi ventrikel

Nilai normal : akan dibahas dalam bagian
tentang hipertrofi
Bentuk normal : akan dibahas dalam bagian
B.B.B
Kepentingan : hampir sama dengan
gelombang R
 GELOMBANG T

Menggambarkan fase repolarisasi ventrikel

Arah normal :
- Sesuai dengan arah gelombang utama kompleks QRS
- Positif di sandapan II

Amplitudo normal :
 < 10 mm di sandapan dada
 < 5 mm di sandapan ekstremitas
 Minimum 1 mm

Abnormal :
1. Menandakan adanya iskemia/ infark
2. Menandakan adanya kelainan elektrolit
GELOMBANG U
Asal usulnya tidak diketahui dan paling jelas
terlihat di sandapan dada V1 - V4
Normal :
- kurang dari 2 mm
- Selalu lebih kecil dari gelombang T di sandapan II
Abnormal :
Bila amplitudo U > 2 mm atau >T, menandakan
adanya hipokalemia
Gelombang U yang terbalik terdapat pada iskhemia
dan hipertrofi
 Introduction
ECG Interpretation

RHYTHM
RATE

? AXES
INTERVAL
QRS
ST- SEGMENT
OTHERS
 ECG
RHYTHYM

• SA Node
– Normal Impulse
– 60 – 100 x / minute

• AV Node
– 40 -60 x / minute

• Ventrikel
– <40 x / minnute
 ECG
RHYTHYM

Sinus rhythm characteristics :

• Rate 60-100 bpm
• Constant R – R interval
• Negative P wave in aVR and positive di II
• P wave is always followed by QRS complex
Langkah 1: Adakah gelombang P ?
Langkah 2: Adakah kompleks QRS ?
Langkah 3: Apakah gelombang P dan kompleks
QRS ‘berhubungan’ ?
 Atrial Fibrillation
- No visible “P” waves
- Irregular R – R interval
 ECG
Rates

Determination heart rate (normal

paper speed 25 mm/s):
• 300 / Count number of large square
(bold boxes in one R – R’ interval)
• 1500 / Count number of small
square in one R – R’ intervals
• Number of QRS complex in 6
seconds, multiply by 10
 Rate
 HR of 60-100 per minute is normal
 HR > 100 = tachycardia
 HR < 60 = bradycardia
What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm
 ECG
Rates ?
 ECG
Superior Axes AXES
- 180⁰ s/d -90 ⁰ LAD
- 90⁰ s/d - 30 ⁰

aVR aVL

Normal Axes
RAD
- 30⁰ s/d + 90 ⁰
+ 90⁰ s/d + 180 ⁰

III aVF II
 The Quadrant Approach
 QRS up in I and up in aVF = Normal
Horizontal Axis
 What is the axis?
Normal- QRS up in I and aVF
ATRIAL ABNORMALITY
• To recognize a large P wave  know
dimensions normal P wave
• Normal P wave in every lead:
– amplitude: ≤ 2.5mm (0.25mV)
– Width: < 0.12 second (three small
boxes)
• P wave exceeding either of these
dimensions in any lead is abnormal

Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th ed

 Right Atrium Enlargement
Overload of the right atrium
 abnormal tall P wave (> 2.5 mm)
 width of the P wave is normal (< 0.12 sec).
The abnormal P wave in right atrial abnormality (RAA)  P
pulmonale in leads II, III, and aVF resulting in a P axis of
more than 70 degrees
a positive deflection of the P wave in lead V1 or V2 > 0.15 mV

Surawicz: Chou's Electrocardiography in Clinical Practice, 6th ed

Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th ed
A positive deflection of the P wave in lead V1 or V2 >
0.15 mV
 Right Atrium Enlargement

• Usually associated with right ventricular

enlargement.
• Most common clinical causes:
– The pulmonary disease:
• acute (bronchial asthma, pulmonary embolism)
• chronic (emphysema, bronchitis).
– Congenital heart disease:
• PS, ASD, Ebstein's anomaly (a malformation of the
tricuspid valve), and TOF.

Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th ed

 Left Atrium Enlargement
• Characteristics:
– P wave is notched
– P wave with a duration of
≥ 0.12 sec in lead I,II or
aVF (P mitrale)
– P wave’s amplitude
(height): normal or
increased.
– P terminal force in lead V1
≥ 0.04 sec & >1mm in
deep.
– Lead V1: large biphasic P
wave with wide terminal
Surawicz: Chou's Electrocardiography in Clinical Practice, 6th ed
component Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th
A, wide, sometimes notched P
waves in one or more limb leads
(formerly referred to as P mitrale
pattern); and/or

B, wide biphasic P waves in lead

V1.
Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th ed
 The patterns of LAA
and RAA

Patients with
enlargement of both
atria (biatrial
enlargement or
abnormality)
 may show a
combination of patterns
(e.g., tall and wide P
waves

Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th ed

 Biatrial Abnormality
• The presence of a large diphasic P wave in lead V1 with the
initial positive component >1.5 mm and the terminal
negative component reaching 1 mm in amplitude, >0.04
second in duration (“abnormal P terminal force”).
• The presence of a tall, peaked P wave (>1.5 mm) in the right
precordial lead and a wide, notched P wave in the limb
leads or left precordial leads (V5 and V6)
• An increase in both the amplitude (≥2.5 mm) and duration
(≥0.12 second) of the P wave in the limb lead

Surawicz: Chou's Electrocardiography in Clinical Practice, 6th ed

 ECG
Interval

• Interval P (durasi) : < 0,12 detik

• Interval PR : 0,12 – 0,20 detik
• Interval QRS : 0,07 – 0,10 detik
• Interval QT tergantung frekwensi jantung
1st degree AV block
PR interval > 0.20
 Blocks
 AV blocks
 First degree block
 PR interval fixed and > 0.2 sec
 Second degree block, Mobitz type 1
 PR gradually lengthened, then drop QRS
 Second degree block, Mobitz type 2
 PR fixed, but drop QRS randomly
 Type 3 block
 PR and QRS dissociated
 What is this?
First degree AV block PR is
fixed and longer than 0.2 sec
 What is this?
Type 1 second degree block (Wenckebach)
 What is this?

Type 2 second degree AV block Dropped

QRS
 What is this?
3rd degree heart block (complete)
ECG
QRS
• Bentuk gel P, QRS, T normal
• ST segment normal
• Gel R di V1 kecil semakin ke V6 semakin tinggi
• Gel S di V1 dalam semakin ke V6 semakin hilang
 Q R S Abnormality
Bundle Branch Block

LBBB
RBBB
 Q R S Abnormality
Bundle Branch Block

Right Bundle Branch Block

QRS melebar, S yang lebar dan dalam di I
dan V6 (V5), dan berbentuk RR’ di V1 (V2)
 Q R S Abnormality
Bundle Branch Block

Left Bundle Branch Block

QRS melebar, bentuk R di I dan V6
(V5), dan S yang dalam di V1 (V2,V3)
Right Ventricular Hypertrophy

Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th ed

Right Ventricular Hypertrophy

Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th ed

Right Ventricular Hypertrophy

Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th ed

 Q R S Abnormality
The Hypertrophy : LVH

1. Kriteria Voltase : Voltase 2. Depresiasi ST dan inversi T di

Ventrikel Kiri meninggi
Kreteria :(dapat dipilih salah
3. AAKi / LAA
satu)
• R atau S di sandapan
ekstremitas ≥ 20 mm
• S di kompleks VKa ≥ 25 mm
• R di kompleks VKi ≥ 25 m m
• S di VKa + VKi ≥ 35 mm
kompleks VKi (sering disebut
“strain pattern”)
4. Sumbu QRS pada bidang
Frontal > -15o
5. Interval QRS atau WAV di
kompleks VKi memanjang :
• Interval QRS >= 0,09 detik
• WAV >= 0,04 detik
 Q R S Abnormality
The Hypertrophy : LVH

Kriteria Romhilt - Estes

• No. 1= nilai 3
• No. 2= nilai 3
• No. 3= nilai 3
• No. 4= nilai 2
• No. 5= nilai 1
Bila jumlah nilai > 5, dianggap definitif HVKi
Bila jumlah nilai = 4, dianggap kemungkinan HVKi.
 BIVENTRICULAR HYPERTROPHY
• The ECG has a relatively low sensitivity for diagnosis of
biventricular hypertrophy but has an acceptable specificity
and positive predictive value.
• The ECG pattern usually modification of the feature of LVH
and include :
1. Tall R- wave in both right and left precordial leads
2. Vertical heart position or RAD in the presence of criteria for
LVH.
3. Deep S wave in left precordial leads + LVH.
4. Shift the precordial transition zone to the left + LVH.

Goldberger: Clinical Electrocardiography: A Simplified Approach, 7th ed

 ECG
ST – T (Coronary Artery Disease)

Normal Acute Infarct

Iskemia Old Infarct
ECG Changes
 ECG
ST – T (Coronary Artery Disease)
 r
Inferior and Anterior Ischemia
 What is the diagnosis?
Acute inferior MI with ST elevation in
leads II, III, aVF
 What do you see in this EKG?
ST depression II, III, aVF, V3-V6 = ischemia
BB

RBBB
Others
PVC

Multifocal PVCs

Ventricular Bigeminy
Ventricular Quadrigeminy
 Others
PVC

Grade 0 : No Premature Beat

Grade 21 : Fequent
Occasional
( > (<
30/h)
30/h)
Grade 3 : Multiform
Grade 4A : Repetitive (Couplets)
Grade 4B : Repetitive (Salvos)
Grade 5 : R on T Pattern
 Others
Hyperkalemia

Tall, narrow and symmetric T waves

 Others
Digitalis effect

Dubin, 4th ed. 1989

 Supraventricular Tachycardia

Retrograde P waves

Narrow complex, regular; retrograde P waves, rate <220

Ventricular Tachycardia
 Torsades de Pointes

Notice twisting pattern

Treatment: Magnesium 2 grams IV
ARTIFACT ON THE ECG

93
FIND THE ARTEFACT

94
WANDERIN BASELINE

95
SOMATIC TREMOR

96
ELECTRICAL INTERFERANCE

97
 1. Irama sinus rate antara 60-100 x/m, setiap gel P diikuti
komplek QRS. Rate dihitung dari interval R-R atau P-P teratur.
Kriteria EKG 2. Sumbu frontal normal antara -30⁰ hingga +90⁰
Normal: 3. Bentuk gel P, QRS, T, U normal. ST segment normal.
4. Gel R di V1 kecil semakin ke V6 semakin tinggi. Gel S di V1
dalam semakin ke V6 semakin hilang.
Thank You