.

ELEKTROKARDIOGRAM
GRAFIK PERUBAHAN MUATAN
LISTRIK (POTENSIAL) YANG
DIBANGKITKAN OLEH
KONTRAKSI OTOT JANTUNG
WAKTU BERDENYUT
 IMPULS
1. IMPULS YG MENGGERAKKAN OTOT-OTOT
JANTUNG TIMBUL DALAM SISTEM HANTARAN
JANTUNG.
2. IMPULS MERANGSANG SERABUT OTOT
JANTUNG UNTUK KONTRAKSI.
3. IMPULS & KONDUKSI MENIMBULKAN
MUATAN LISTRIK YG LEMAH DAN BERPENCAR
KE SELURUH TUBUH SHG DISETIAP
PERMUKAAN BADAN TERJADI MUATAN
LISTRIK YG DAPAT DI UKUR KEKUATANNYA.
 NILAI EKG
1. ELECTRO CARDIO GRAPHY REKAMAM
PERUBAHAN TENAGA LISTRIK
JANTUNG.
2. EKG: PEMERIKSAAN TAMBAHAN
UNTUK MEMPERJELAS KEADAAN
JANTUNG.
3. TAFSIRAN INI TIDAK MUTLAK, HASIL
NORMAL BISA ADA KELAINAN DALAM
KEADAAN BAIK.
 LAPORAN HASIL EKG
MENGANDUNG
1. Keadaan dan fungsi jantung yg dise
babkan atau menyertai perubahan pro
ses listrik di jantung.
2. Pengertian tentang elektrikel proses
jantung.
3. Perubahan atau kelainan pattern ECG
(EKG). Yang dibandingkan oleh
gangguan proses listrik jantung.
 CONTOH LAPORAN HASIL EKG
1. Rekaman dalam batas normal.
2. Rekaman memperlihatkan kelainan yg khas
untuk ….keadaan /penyakit.
3. Pada rekaman terlihat kelainan yg biasa tampak
pada penyakit…
4. Rekaman terlihat kelainan yg tidak khas.
5. Rekaman masih dalam batas normal
( perubahan sedikit) dan perlu rekaman berkala
untuk perubahan lebih lanjut.
 vektor
1. Suatu tenaga yg mempunyai arah dan
ukuran besar.
2. Vektor dinyatakan dengan gambaran
panah.
3. Ujung menentukan arah.
4. Panjang panah menunjukkan besarnya
tenaga.
 Vektor tenaga listrik jantung
1. Akibat depolarisasi otot jantung ada tenaga
listrik menimbulkan vektor jantung.
2. Rangsangan timbul di SA Node menjalar
keseluruh atrium, sampai di AV node masuk
ke berkas His dan Serabut parkiye.
3. Akibat rangsang ini timbul depolarisasi
atrium, ventrikel, repolarisasi ventrikel.
4. Depolarisasi menimbulkan vektor: 1,2,3,4
repolarisasi menimbulkan vektor 5.
 GAMBARAN EKG
AKIBAT VEKTOR LISTRIK DI JANTUNG

1. Depolarisasi atrium timbul P

2. Depolarisasi septum timbul
gelombang QRS komplek (Q).
3. Depolarisasi ventrikel ke 2 sampai
apek timbul QRS pattern (R)
4. Akhir depolarisasi ventrikel (S).
5. Repolarisasi ventrikel timbul (T).
E
K
G
Simple Method of EKG Interpretation

 Rate
 Rhythm
 Axis
 Hypertrophy
 Infarction and Ischemia
Rate
 Menghitung HR pada EKG.

05/22/23 12
Rhythm
 Identify basic rhythm…
 …then scan entire tracing for pauses,
premature beats, irregularity, and
abnormal waves.
 Always:
 Check for:
 P before each QRS.
 QRS after each P.
Electrocardiogram (ECG):
Electrical Activity of the Heart
 Einthoven's
triangle
 P-Wave –
atria
 QRS- wave –
ventricles
 T-wave –
repolarizatio
n
Einthoven’s triangle
Electrocardiogram (ECG):
Electrical Activity of the Heart

The electrocardiogram
Conduction System of the
Heart
Axis
Hypertrophy
Infarction and Ischemia
Normal EKG
Atrial Fibrillation with Rapid
Ventricular Response
Inferior Acute MI and RBBB
Anterior Acute MI
Left Ventricular Hypertrophy
Ventricular Fibrillation
Norm
al

Rapid
Upsloping

Minor ST
Depression

Slow
Upsloping
Horizonta
l

Downslopi
ng

Elevation
(non Q
lead)

Elevation (Q
wave lead)
 Upsloping

J point depression of 2 to 3
mm in leads V4 to V6 with
rapid upsloping ST
segments depressed
approximately 1 mm 80
msec after the J point. The
ST segment slope in leads
V4 and V5 is 3.0 mV/sec.
This response should not be
considered abnormal.
• In lead V4 , the
exercise ECG result
is abnormal early in
the test, reaching
0.3 mV (3 mm) of
horizontal ST
segment depression
at the end of
exercise.
• Consistent with a
severe ischemic
response.
•The J point at peak
exertion is depressed 2.5
mm, the ST segment slope
is 1.5 mV/sec, and the ST
segment level at 80 msec
after the J point is
depressed 1.6 mm.
•This “slow upsloping” ST
segment at peak exercise
indicates an ischemic
pattern in patients with a
high coronary disease
prevalence pretest.
•A typical ischemic pattern
is seen at 3 minutes of the
recovery phase when the ST
segment is horizontal and 5
minutes after exertion when
the ST segment is
downsloping.
•Becomes abnormal at
9:30 minutes (horizontal
arrow right) of a 12-
minute exercise test and
resolves in the immediate
recovery phase.
•This ECG pattern in
which the ST segment
becomes abnormal only
at high exercise
workloads and returns to
baseline in the immediate
recovery phase may
indicate a false-positive
result in an asymptomatic
individual without
atherosclerotic risk
factors.
•A 48-year-old man with several
atherosclerotic risk factors and a
normal rest ECG result developed
marked ST segment elevation (4 mm
[arrows]) in leads V2 and V3 with
lesser degrees of ST segment
elevation in leads V1 and V4 and J
point depression with upsloping ST
segments in lead II, associated with
angina.
•This type of ECG pattern is usually
associated with a full-thickness,
reversible myocardial perfusion defect
in the corresponding left ventricular
myocardial segments and high-grade
intraluminal narrowing at coronary
angiography. Rarely, coronary
vasospasm produces this result in the
absence of significant intraluminal
atherosclerotic narrowing.(
TERIMA KASIH.
ATAS
PERHATIANNYA.

SEMOGA BERMANFAAT
13-03-2011
Overview
 Basic EKG Review
 Introduction to Treadmill Test
 Indications and Safety
 Equipment and Protocols
 Exercise End Points
 Basics of Interpretation of the Exercise Test
 Exercise Testing to Diagnose Obstructive
Coronary Artery Disease
 Rationale and Guidelines
 Pretest Probability
 ST-Segment Interpretation
 Confounders of Stress ECG Interpretation
 Result Reporting
 Indications and Safety
 Generally a safe procedure, but both myocardial
infarction and death have been reported and can be
expected to occur at a rate of up to 1 per 2500 tests.
 Good clinical judgment should therefore be used in
deciding which patients should undergo exercise testing.
 Exercise testing should be supervised by an
appropriately trained physician.
 The electrocardiogram (ECG), heart rate, and blood
pressure should be monitored carefully and recorded
during each stage of exercise and during ST-segment
abnormalities and chest pain.
 Equipment and Protocols
 Both treadmill and cycle ergometer devices are
available for exercise testing.
 Much of the published data are based on the
Bruce protocol, there are clear advantages to
customizing the protocol to the individual patient
to allow 6 to 12 minutes of exercise.
 Exercise capacity should be reported
in estimated metabolic equivalents
(METs) of exercise.
Exercise Endpoints
 Commonly terminated when subjects
reach an arbitrary percentage of predicted
maximum heart rate.
 Other end points (summarized next slide)
are strongly preferred.
 The use of rating of perceived exertion
scales, such as the Borg scale is often
helpful in assessment of patient fatigue.
The Modified Borg Scale
SCALE SEVERITY
0 No Breathlessness* At All
0.5 Very Very Slight (Just Noticeable)
1 Very Slight
2 Slight Breathlessness
3 Moderate
4 Somewhat Severe
5 Severe Breathlessness
6  
7 Very Severe Breathlessness
8  
9 Very Very Severe (Almost Maximum)
10 Maximum
 Basics of Interpretation of
the Exercise Treadmill Test
 Interpretation of the exercise test should include
exercise capacity and clinical, hemodynamic, and
electrocardiographic response.
 The occurrence of ischemic chest pain consistent with
angina is important, particularly if it forces termination
of the test.
 The most important electrocardiographic findings are ST
depression and elevation.
 Positive exercise test result is greater than or equal to 1
mm of horizontal or downsloping ST-segment depression
or elevation for at least 60 to 80 milliseconds (ms) after
the end of the QRS complex
Overview
 Basic EKG Review
 Introduction to Treadmill Test
 Indications and Safety
 Equipment and Protocols
 Exercise End Points
 Basics of Interpretation of the Exercise Test
 Exercise Testing to Diagnose Obstructive
Coronary Artery Disease
 Rationale and Guidelines
 Pretest Probability
 ST-Segment Interpretation
 Confounders of Stress ECG Interpretation
 Result Reporting
Rationale for Using ETT to
Diagnose Obstructive CAD
 Most predictive clinical finding is a history of chest pain or
discomfort.
 Myocardial ischemia is the most important cause of chest
pain and is most commonly a consequence of underlying
coronary disease.
 CAD that has not resulted in sufficient luminal occlusion
to cause ischemia during stress can still lead to ischemic
events through spasm, plaque rupture, and thrombosis,
but most catastrophic events are associated with
extensive atherosclerosis.
 These nonobstructive lesions explain some of the events
that occur after a normal exercise test.
 Although the coronary angiogram has obvious limitations,
angiographic lesions remain the clinical gold standard.
The ACC/AHA Guidelines for the Diagnostic
Use of the Standard Exercise Test

 Class I (Definitely appropriate) - Adult males

or females (including RBBB or < 1mm resting ST
depression) with an intermediate pre-test
probability of coronary artery disease based on
gender, age and symptoms (specific exceptions
are noted under Class II and III below).
 Class IIa (Probably appropriate) - Patients
with vasospastic angina.
The ACC/AHA Guidelines for the
Diagnostic Use of the Standard Exercise
Test

 Class IIb (maybe appropriate)

 Patients with a high pretest probability of CAD
by age, symptoms, and gender.
 Patients with a low pretest probability of CAD
by age, symptoms, and gender.
 Patients with less than 1 mm of baseline ST
depression and taking digoxin.
 Patients with electrocardiographic criteria for
left ventricular hypertrophy (LVH) and less
than 1 mm of baseline ST depression.
The ACC/AHA Guidelines for the Diagnostic
Use of the Standard Exercise Test, cont’d

Class III (Not appropriate) -

1. To use the ST segment response in the diagnosis of coronary
artery disease in patients who demonstrate the following baseline
ECG abnormalities:
pre-excitation (WPW) syndrome;
electronically paced ventricular rhythm;
more than one millimeter of resting ST depression;
LBBB
2. To use the ST segment response in the
diagnosis of coronary artery disease in
MI patients
 Pretest Probability
 Based on the patient's history (including age, gender, and
chest pain characteristics), physical examination and initial
testing, and the clinician's experience with this type of
problem.
 Typical or definite angina makes the pretest probability of
disease so high that the test result does not dramatically
change the probability.
 Atypical or probable angina in a 50-year-old man or a 60-
year-old woman is associated with approximately a 50%
probability of CAD.
 Diagnostic testing is most valuable in this intermediate
pretest probability category, because the test result has the
largest potential effect on diagnostic outcome.
 Typical or definite angina can be defined as 1) substernal
chest pain or discomfort that is 2) provoked by exertion or
emotional stress and 3) relieved by rest and/or nitroglycerin.
Pre Test Probability of Coronary Disease by
Symptoms, Gender and Age

Age Gender Typical/Definite Atypical/Probable Non- Asymptomatic

Angina Pectoris Angina Pectoris Anginal
Chest Pain
30-39 Males Intermediate Intermediate low (<10%) Very low (<5%)
30-39 Females Intermediate Very Low (<5%) Very low Very low
40-49 Males High (>90%) Intermediate Intermediate low
40-49 Females Intermediate Low Very low Very low
50-59 Males High (>90%) Intermediate Intermediate Low
50-59 Females Intermediate Intermediate Low Very low
60-69 Males High Intermediate Intermediate Low

60-69 Females High Intermediate Intermediate Low

High = >90% Intermediate = 10-90% Low = <10%

Very Low = <5%
ST Segment Interpretation
 Computer summaries can help find possible
areas of ischemia – then review raw data
carefully!
 Determine PQ junction, J point, ST80, and
estimate slope
 Elevation
 Depression
 Upsloping
 Horizontal
 Downsloping
 Magnified ischemic exercise-induced ECG pattern. Three consecutive complexes with
a relatively stable baseline are selected. The PQ junction (1) and J point (2) are
determined; the ST 80 (3) is determined at 80 msec after the J point. In this example,
average J point displacement is 0.2 mV (2 mm) and ST 80 is 0.24 mV (2.4 mm). The
average slope measurement from the J point to ST 80 is –1.1 mV/sec.
Confounders of Exercise Treadmill Test Interpretation
 Digoxin
 Produces an abnormal ST-segment response to exercise. This abnormal ST
depression occurs in 25% to 40% of healthy subjects studied and is directly
related to age.
 Left Ventricular Hypertrophy
 Decreased specificity of exercise testing, but sensitivity is unaffected. Therefore, a
standard exercise test may still be the first test, with referrals for additional tests
only indicated in patients with an abnormal test result.
 Resting ST Depression
 Resting ST-segment depression has been identified as a marker for adverse
cardiac events in patients with and without known CAD.
 Left Bundle-Branch Block
 Exercise-induced ST depression usually occurs with left bundle-branch block and
has no association with ischemia. Even up to 1 cm of ST depression can occur in
healthy normal subjects. There is no level of ST-segment depression that confers
diagnostic significance in left bundle-branch block.
 Right Bundle-Branch Block
 The presence of right bundle-branch block does not appear to reduce the
sensitivity, specificity, or predictive value of the stress ECG for the diagnosis of
ischemia.
 Beta Blocker Therapy
 For routine exercise testing, it appears unnecessary for physicians to accept the
risk of stopping beta-blockers before testing when a patient exhibits possible
symptoms of ischemia or has hypertension. However, exercise testing in patients
taking beta-blockers may have reduced diagnostic or prognostic value because of
inadequate heart rate response.
Overview
 Basic EKG Review
 Introduction to Treadmill Test
 Indications and Safety
 Equipment and Protocols
 Exercise End Points
 Basics of Interpretation of the Exercise Test
 Exercise Testing to Diagnose Obstructive
Coronary Artery Disease
 Rationale and Guidelines
 Pretest Probability
 ST-Segment Interpretation
 Confounders of Stress ECG Interpretation
 Result Reporting