Electrocardiography

Departemen Ilmu Penyakit Dalam

FKUSU / RS. HAM / RSPM Medan
 OVERVIEW

Cardiac Physiology

Electrocardiography

Diagnosing Heart Conditions

Cardiac Physiology Electrocardiography Diagnosis

ARTERIES VEINS
distributes brings blood
blood from back to heart
heart
Cardiac Physiology Electrocardiography Diagnosis

Atria

Ventricles
Cardiac Physiology Electrocardiography Diagnosis

Sinoatrial
Node

Atrioventricular
Node
Electrocardiography (EKG)

• Prinsip Dasar EKG

• EKG Leads
• Interpretasi Basic EKG
 Prinsip Dasar EKG
• Electrical coupling among cardiac muscle
cells
• AV delay between atrial and ventricular
depolarization
• RA and LA are synchronized as one unit
• RV and LV are synchronized as one unit
• Directional spread of cardiac action
potentials within atria and ventricles
Alat EKG
 EKG Machine
• An EKG machine is a highly sensitive voltmeter
that measures voltage difference between two
points on the body surface
• The voltage difference comes from depolarization
and repolarization of cardiac muscle cells
• An EKG machine has a positive and a negative
terminal
• An EKG machine records a positive voltage when
the positive terminal is more positive than the
negative terminal, and vice versa
Electro
 Depolarization Wave
- +
EKG Resting
+++++++++++++++
--------------------
Resting 0 mV

- +
EKG + 1 mV
----- +++++++++++ Depolarization
++++--------------- Begins
Depolarization   0 mV

- +
EKG
+ 1 mV
--------------------
+++++++++++++++
Complete Depolarization Complete
0 mV
Depolarization
 Repolarization Wave
- +
EKG Complete Depolarization
--------------------
+++++++++++++++
Resting 0 mV

- +
EKG + 1 mV
---------------+++++ Repo larization
+++++++++++------ Begins
    Repolarization 0 mV

- +
EKG
+ 1 mV
+++++++++++++++
--------------------
Complete Repolarization Complete
0 mV
Repolarization
 Directions of Ventricular Depolarization
and Repolarization Waves
Depolarization Wave
Repolarization Wave

Base
-
Repolarization
EKG Depolarization
+
Apex
Major Electrical Axis of the Heart

(-) Base

Major Electrical Axis

Apex
(+)
 EKG Leads

• The 12 EKG leads measure the electrical

activity of the heart from 12 different
directions
• Bipolar Leads: Lead I, Lead II, Lead III
• Unipolar Leads: aVR, aVL, aVF
• Precordial Leads: V1, V2, V3, V4, V5, V6
Leads
Precordial leads
Bipolar Leads
- Lead I +
VII = VI + VIII

Right Arm Left Arm

-
Major Electrical Axis -
+
Lead III
+
Right Leg Left Leg
- (Ground)

Lead II +
 Unipolar Lead (aVR)
-
aVR
+
Right Arm Left Arm

Left Leg
 Unipolar Lead (aVL)
+
aVL
-
Right Arm Left Arm

Left Leg
 Unipolar Lead (aVF)

Right Arm Left Arm

-
aVF + Left Leg
 Precordial Leads (V1 to V6)

Right Arm Left Arm

+ V1
+ V2
V3
+
V4
- +
V5
+
V6
+
Left Leg
 Directionality of Bipolar and
Unipolar Leads

aVR aVL

Lead I

Lead II
Lead III
aVF
Directionality of Precordial Leads

Body Cross-section
at Heart Level
Heart
V6

V5
V4
V3
V2
V1
 Basic EKG Interpretation

• EKG Waves (P, QRS, and T waves)

• EKG Intervals (P-R, Q-T intervals)
Cardiac Physiology Electrocardiography Diagnosis
Timing of ECG
 EKG Waves
QRS Complex
(Ventricular Depolarization)

P wave T wave
(Atrial (Ventricular
Depolarization) Repolarization) P wave

One Cardiac Cycle

EKG Intervals P-R Interval = A-V Conduction Time
Q-T Interval = Ventricular Contraction
Time
R-R Interval = Cardiac Cycle Time
Heart Rate = 1/R-R Interval

QRS Complex

P wave T wave P wave

P-R Q-T
Interval Interval
Cardiac Physiology Electrocardiography Diagnosis

P T

Q
S
Cardiac Physiology Electrocardiography Diagnosis

P T

Q
S
Cardiac Physiology Electrocardiography Diagnosis

R 1 sec

P T

Q
S
0.5 Sec
Graphic ECG
ECG Graphic
 Menghitung Heart Rate

• Kecepatan standard =25 mm/sec

• 1 menit → 25x60 =1500/menit
• Kotak besar = 5mm
• 1500/5 =300
• Kotak kecil = 1mm
• 1500/1 =1500
Menghitung Heart Rate

300/6 =50 bpm

Menghitung Heart Rate

300/? =……..bpm
Mean Electricle Axis
Mean Electricle Axis
 Mean Electricle Axis
• Cari lead yang paling ‘nol’
• Axisnya adalah yg tegak lurus terhadap
‘nol’
• Garis tegak ini ada + dan -
• Lihat kembali lead ‘nol’
– Bila benar-benar nol = axis
– Bila lebih positif axis 15 derjat dekat ‘nol’
– Bila lebih negatif axis 15 derjat jauh dari ‘nol’
Cardiac Physiology Electrocardiography Diagnosis

P T

Q
S
Cardiac Physiology Electrocardiography Diagnosis

P T

Q
S
Cardiac Physiology Electrocardiography Diagnosis

R 1 sec

P T

Q
S
0.5 Sec
ECG Normal
Rhythm (Irama)

• Sinus
• Arrythmia
Frequency

• Normal
• Tachycardia
• Bradycardia
 Morphology

• Axis
• Besaran depolarisasi
 Arrythmia

SK
 Arrhytmia

Tachyarrhythmia Bradyarrhytmia
(rate >100 x/min) (rate < 60 X/min)

• QRS sempit (<0.12 ms) • AV blok derajat 1, 2 & 3

• QRS lebar (>0.12 ms) • RBBB & LBBB
 Tachyarrhythmia

• Tachyarrhythmia could be secondary to

cardiac, pulmonary or dysmetabolic diseases
• Treatment must be directed not only to the
arrhythmia but – when present – to its cause
• Our primary objective is to treat the patient
and not only the arrhythmia
 CAUSE OF CARDIAC ARRHYTHMIAS :

• Disturbances in automaticity : bertambah cepat

atau bertambah lambatnya suatu daerah otomatisitas.
Misal di sinus node, AV node, abnormal beats/
depolarisasi atrium, AV junction, ventrikel, VT, dll.

• Disturbances in conduction : konduksi terlalu cepat

(WPW) atau terlalu lambat (blok AV).

• Combinations of altered automaticity and conduction.

 Approach to
electrocardiographic diagnosis

• Duration of QRS

• Regularity of QRS

P wave ??
 QRS complex
Regular / irregular ?

QRS complex
Normal-looking QRS complex?
Wide / narrow ?

P wave ?

Relationship between P and QRS ?

 narrow-QRS tachycardia :
Supraventricular origin

narrow-QRS

Regular rhythm Irregular rhythm

Supraventricular
Sinus Tachycardia Atrial Fibrillation
Tachycardia

Atrial Flutter
Atrial Flutter :
-The result of a re-entry circuit within
the atria
-Irregular / regular QRS rate
-Narrow QRS complex
-Rapid P waves (300x/min), “sawtooth”
Atrial Flutter
Supraventricular Tachycardia ( SVT )
reentry via accessory pathway
PSVT :
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
PSVT (Paroxysmal SupraVentricular Tachyradia)
SVT
SVT
Atrial Fibrillation :

-from multiple area of re-entry within atria

-or from multiple ectopic foci
-irregular, narrow QRS complex
-very rapid atrial electrical activity
(400-700 x/min).
-no uniform atrial depolarization
 narrow-QRS tachycardia :
Supraventricular origin

narrow-QRS

Regular rhythm Irregular rhythm

Supraventricular
Sinus Tachycardia Atrial Fibrillation
Tachycardia

Atrial Flutter
Atrial Fibrillation :

-from multiple area of re-entry within atria

-or from multiple ectopic foci
-irregular, narrow QRS complex
-very rapid atrial electrical activity
(400-700 x/min).
-no uniform atrial depolarization
Rapid AF
Junctional rhythm:
-AV junction can function as a pace maker
(40-60 x/min).
-due to the failure of sinus node to initiate
time impulse or conduction problem.
-normal-looking QRS.
-retrograde P wave.
-P wave may precede, coincide with, or
follow the QRS
 VENTRIKEL EXTRA SYSTOLE

SR

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
 wide-QRS tachycardia :
Supraventricular and Ventricular origin

wide-QRS

Regular rhythm Irregular rhythm

Ventricular
SVT + BBB
Fibrillation

SVT + acc. pathway

Ventricular
Tachycardia
Ventricular Tachycardia
VT
 wide-QRS tachycardia :
Supraventricular and Ventricular origin

wide-QRS

Regular rhythm Irregular rhythm

Ventricular
SVT + BBB
Fibrillation

SVT + acc. pathway

Ventricular
Tachycardia
Ventricular Fibrillation
Torsade de pointes
 Bradyarrhytmia
(rate < 60 x/min)

Failure of impulse AV conduction

formation abnormalities
• Sinus Bradycardia • 1st and 2nd AV Block
• Sick Sinus Syndrome • Total AV Block
• BBB (Bundle Branch
Block)
Sick Sinus Syndrome
 1st degree AV block

Prolonged PR interval
2ND AV Block Type 1 :
Wenkebach

Missing QRS
 2nd degree AV block, type 1

Missing QRS Missing QRS

2ND AV Block Type 2 :
Mobitz
2nd degree AV block, type 2

Missing QRS
 Total AV Block /
3rd degree AV block

QRS QRS QRS

P P P P P P P
LBBB
 The
Deadly
Rhythms

PEA
VT VF (Pulse less
Electrical
Activity)
A systole
 Summary
Cardiac Arrthythmias
• Tachycardia: abnormally fast heart rate
• Bradycardia: Abnormally slow heart rate
• Incomplete Atrioventricular Block:
Prolonged P-R interval
• Complete Atrioventricular Block: P waves
and QRS complexes become dissociated
• Fibrillation: Complete lack of coordination
 Cardiac Physiology Electrocardiography Diagnosis

Atrioventricular Block
• Ischemia
• Nodal Compression
• Nodal Inflamation
• Extreme Stimulation
Cardiac Physiology Electrocardiography Diagnosis

Normal ECG

ECG with Atrioventricular Block

 Cardiac Physiology Electrocardiography Diagnosis

Preventricular Contractions

• Coffee
• Cigarettes
• Sleep deprivation
• Pathology
Cardiac Physiology Electrocardiography Diagnosis

Normal ECG

ECG with Preventricular Contractions

 Cardiac Physiology Electrocardiography Diagnosis

Ventricular Fibrilation
• Ischemia
• Electric Shock
Cardiac Physiology Electrocardiography Diagnosis

Normal ECG

ECG during Ventricular Fibrillation

 SUMMARY
• Atria
• Ventricles
Cardiac Physiology
• Nodes
Electrocardiography • Electrical
Propagation

Diagnosing Heart Conditions

 SUMMARY
• ECG
Measurement
Cardiac Physiology • P-Wave
• QRS-Complex
Electrocardiography • T-Wave

Diagnosing Heart Conditions

 SUMMARY

• AV Block
Cardiac Physiology • PVCs
• V-Fib
Electrocardiography

Diagnosing Heart Conditions