ELECTROCARDIOGRAPHY

IN CLINICAL PRACTICE

WINDHI DWIJANARKO, MD, FIHA

COMPONENTS OF NORMAL ECG

Thaler, M.S., The Only ECG Book You’ll Ever Need 5th ed. Lippincott,2007
 Heart Rate Calculation

Box counting method

300 divided by number
of 0,2 s boxes between
2 consecutive QRS
complex (only for
regular rate)

QRS counting method

Counting the number of
QRS complex in 6 s
interval and multiply by 10

Normal ; 60-100 beats/min Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
ECG ABNORMALITIES
AXIS DEVIATION

RAD : R wave in III is

taller than R wave in II.
Lead I RS type complex
with deeper S
LAD: Tall R wave in I,
deep S wave in III.
Lead II either biphasic
RS or QS complex. Lead
I, AVL show R wave.

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified Approach. 7th ed.
St. Louis: Mosby Year Book, 2006
RAD or LAD is not necessarily a sign of significant
underlying heart disease. Nevertheless, recognition of RAD
or LAD often provides supportive evidence for LVH or
RVH, ventricular conduction disturbance (left anterior or
posterior hemiblock), or another disorder.

Indeterminate Axis

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 ATRIAL ENLARGEMENT
 Abnormality in P
wave morphology
(Normal height =
<0,25 mV, width
<0.12 s.
 P pulmonale, tall
P  RAH
 P mitrale, broad
and notch P 
LAH
 Lead II, V1

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified Approach. 7th
ed. St. Louis: Mosby Year Book, 2006
VENTRICULAR ENLARGEMENT
RVH :
1. Tall R wave in V1, equal or larger than the S wave in
that lead.
2. Often with RAD
3. T inverted in the right to middle chest lead.

Goldberger AL, Goldberger E.

Clinical Electrocardiography:
A Simplified Approach. 7th ed.
St. Louis: Mosby Year Book,
2006
VENTRICULAR ENLARGEMENT
LVH :
1. S wave in V1 + R wave in V5 or V6 > 35 mm
2. High voltage R wave in V1, when QRS axis is horisontal.
3. Repolarization abnormalities include T inverted in leads with tall R
wave (similar finding occur with ischemia)
4. Other finding : LAH, LAD, LV conduction delay (wide QRS), which
may eventually progress to incomplete or complete LBBB

Goldberger AL, Goldberger E.

Clinical Electrocardiography: A
Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
AV CONDUCTION BLOCK

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
First Degree AV Block

 Constant PR interval prolongation.

 Prolonged PR interval can also occur in hyperkalemia,
digitalis, acute rheumatic fever

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Second Degree AV Block

Mobitz Type I (Weckenbach), characteristics :

1. Sequence of a progressive lengthening of the PR
interval followed by a nonconducted P wave.
2. Shortening of the PR interval in the beat immediately
after non-conducted one.
Location : AV node

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Second Degree AV Block

Mobitz Type II characteristics :

 Sudden appearance of a single, non conducted sinus P
wave without (1) progressive prolongation of PR
interval (2) shortening of PR interval in the beat after
the non conducted P wave.
Location : His bundle or bundle branches

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Third Degree AV Block (Total AV Block)
Third degree AV block characteristics :
 P waves with a regular atrial rate faster than the ventricular rate.
 QRS complexes are present, with a slow (usually fixed) ventricular rate.
 P waves bear no relation to the QRS complexed, PR intervals are
completely variable.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
BUNDLE BRANCH BLOCKS
Left Bundle Branch Block :
V1 wide, entirely negative QS
complex (rarely, a wide rS
complex), W shape
characteristics
Lead V6, tall wide R wave
without q wave
T wave in the left precordial
leads

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
BUNDLE BRANCH BLOCKS

Right Bundle Branch Block :

V1 rSR’ complex with wide R’
wave, M shape
V6 qRS pattern with wide S wave
T wave in the right precordial
leads

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Complete and
Incomplete Block :
 Complete : QRS
duration > 0,12
 Incomplete :
QRS duration
0,1 -0,12

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
 BUNDLE BRANCH BLOCKS
Left Anterior Fascicular Block :
• Axis -45° or more negative (S wave in AVF equal or exceeds R wave in V1.
• QRS width <0,12 s
• AVL qR complexes, rS in II,III,AVF (or QS wave if there is myocardial infarct)

Left Posterior Fascicular Block :

• Axis +120 ° or more
• QRS <0,12s
• rS complexes in I, qR in II,III,AVR
• LPFB can be considered if other common cause of RAD have been
excluded
Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
BRADYARRHYTHMIAS/ BRADYCARDIA

Bradycardia Simplified Classification

1. Sinus Bradycardia, excluding sinoatrial
block
2. AV junctional escape rhythm
3. Atrial fibrillation or flutter with slow
ventricular response.
4. Idioventricular escape rhythm

Sinus Bradycardia :
Sinus rhythm with rate < 60 beat/mnt.
Each P wave is followed by QRS complex

AV Junctional Escape Rhythm :

 P wave (if seen) is negative in II and
positive in AVR (retrograde P waves)
 Retrograde P wave immediately precede
or follow QRS complex
 P wave dissapeared (burried) within
QRS complex.
Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified
Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Junctional Escape Rhythm/ Bradycardia
Atrial Fibrillation with slow ventricular response
A very slow, regularized ventricular response in AF
suggest the present of underlying complete AV block.

Idioventricular Rhythm :
• SA node and AV junctional pacemaker fail to function
• very slow pacemaker in ventricular conduction
• rate < 45 beats/mnt
• QRS wide without any preceding P wave

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 TACHYARRHYTHMIAS/ TACHYCARDIA

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Narrow Complex Tachycardia
Sinus Tachycardia : Sinus Rhythm with QRS rate 100 -150 bpm
Atrioventricular Nodal
Reentrant Tachycardia
 The most common cause of a
paroxysmal, narrow, regular
QRS tachycardia
 ECG diagnostic points : (1)
rapid, regular rhythm 150-225
bpm. A rate >230 bpm be
aware of WPW syndrome
 More than 50% care the P
waves are hidden
 45% cases P waves appear
hidden, but on careful
observation they are visible in
the end of QRS complex,
pseudo S wave in II, III, AVF.
Pseudo r’ wave in V1.

Khan,G., Rapid ECG Interpretation 3rd ed.,New

Jersey: Humana Press,2003
Atrial Flutter: Atrial Fibrillation:
 “saw tooth “flutter wave  Rapid irregular undulation of the
 Constant or variable ventricular baseline (fibrillatory waves)
rate (regular or irregular) instead of P waves.
 The most common cause of a  Ventricular rate is usually
paroxysmal, narrow, regular QRS irregular (unless with total AV
tachycardia block)

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Multifocal Atrial Tachycardia
 Multiple ectopic foci stimulating the atria.
 P waves with different shapes at rate > 100 bpm.
 “flutter wave
 Constant or variable ventricular rate
 The most common cause of a paroxysmal, narrow, regular QRS
tachycardia

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Wide Complex Tachycardia
Differential diagnosis :
 VT (B)
 SVT with aberrancy due to bundle branch
block and WPW preexitation (A)

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 Diagnostic Clues VT vs SVT with aberrancy
1. VT has AV dissociation
2. The shape of QRS in V1/V2 and V6. When QRS shape resembles
an RBBB pattern in V1 suggest SVT. single broad R wave or qR,
QR, or RS in V1 suggest VT. QRS resembles LBBB in V1 or V2 or
QR complex in V6 suggest VT
3. QRS duration
> 0,14 with RBBB configuration or >0,16 with LBBB configuration
suggest VT

Sick Sinus Syndrome and Brady-Tachy Syndrome

• Have alternating episodes of tachycardia and bradicardia

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Torsades de Pointes
Ventricular Premature Depolarization/
Ventricle Extra Systole
 Atrial Premature Depolarization/
Supra-Ventricle Extra Systole (SVES)
MYOCARDIAL ISCHEMIA AND INFARCTION
ECG changes associates with acute ischemia and
infarction :
1. Peaking T waves  hyperacute T –waves changes
2. ST segment elevation and/or depression
3. Changes in QRS complex
4. Inverted T waves
ST segment changes : “injury currents”, generated by the voltage
gradients across the boundary between ischemic and non-ischemic
myocardium during the resting and plateau phases of the ventricular
action potential, which correspond to the TQ and ST segments of the
ECG.

STEMI : ST elevation
NSTEMI : ST depression, lesser amounts of ST elevation,
abnormal ST segment elevation in less than 2 contiguous lead, T
wave inversion, or no ECG abnormality at all
SKA dengan elevasi SKA tanpa elevasi
segmen-ST segmen-ST

Trombus platelet-fibrin Trombus kaya platelet

Komponen sebaran fibrin-sel darah merah
rentan terhadap fibrinolisis, yang sebagian
“Trombus putih”
besar oklusif Biasanya tidak oklusif

CK-MB atau Troponin Troponin dapat atau normal

7
STEMI

• KRITERIA EKG:
 NEW ST ELEVATION AT THE J POINT IN AT LEAST 2
CONTIGUOUS LEADS OF ≥ 2 MM (0.2 MV) IN MEN OR ≥ 1.5
MM (0.15 MV) IN WOMEN IN LEADS V2 –V3 AND/OR OF ≥ 1
MM (0.1 MV) IN OTHER CONTIGUOUS CHEST LEADS OR THE
LIMB LEADS.
 NEW LBBB  STEMI EQUIVALENT
 ST DEPRESSION IN ≥ 2 PRECORDIAL LEADS (V 1 –V 4 )
MAY INDICATE POSTERIOR INFARCT.
(AHA GUIDELINE OF STEMI, 2013)

DI MANAKAH J POINT ??
 Khan,G., Rapid
ECG Interpretation
3rd ed.,New
Jersey: Humana
Press,2003

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
ECG EVOLUTION in STEMI
Goldberger AL, Goldberger E. Clinical Electrocardiography: A
Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
LOCATION OF ISCHEMIA/ INFARCTION
Anterior wall infarct : invariably due to occlusion of LAD 
leads V1-V6.
If occlusion in proximal part above the first septal and first
diagonal branches  ST elevation in V1-V4, I, aVL, and
often AVR. Reciprocal in II, III, aVF, often V5. More ST
elevation in aVL than aVR and more ST depression in III
than II
If occlusion between first septal and first diagonal branch
 ST segment will not elevated in V1, ST elevation
prominent in aVL and ST depression prominent in lead III.
If occlusion is located more distally, below both branches :
ST elevation will be prominent in V3-V6 and less prominent
in V2. ST elevation may occur in II, III, aVF also.
Khan,G., Rapid ECG Interpretation 3rd ed.,New Jersey: Humana Press,2003
Inferior wall infarction  ST segment elevation II, III, aVF.
Occlusion of RCA or LCx.
If RCA is occluded : ST elevation in III more prominent
than lead II. Often associated with ST depression in I, aVL.
If RCA is occluded in proximal part  RV infarction may
occur. ST elevation in V3R, V4R, often also V1.
Posterior ischemia/infarction : ST segment depression in
V1, V2, V3 that occurs in association with an inferior
wall infarction. Occlusion occurs in either RCA or LCx.
DIAGNOSIS OF ISCHEMIA /INFARCTION IN THE SETTING
OF INTRAVENTRICULAR CONDUCTION DISTURBANCE

Criteria for infarction

in the presence of
LBBB :
1. ST elevation ≥ 0,1
mV in leads with
positive QRS
complex
2. ST depression ≥
0,1 mV in V1-V3
that is, leads with
dominant S wave.
3. ST elevation ≥ 0,15
mV in leads with
negative QRS
complex.
Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified
Approach. 7th ed. St. Louis: Mosby Year Book, 2006
PRE-EXCITATION
Wolff–Parkinson–White Syndrome
• Short PR
• Wide QRS
• Delta Wave

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 WPW Syndrome

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006

Lown-Ganong-Levine
Syndrome
• Short PR interval < 0,12 s
• QRS complex is not widened
• No delta wave
Thaler, M.S., The Only ECG Book You’ll
Ever Need 5th ed. Lippincott,2007
QT INTERVALS ABNORMALITY

 Prolonged QT interval : electrolyte disturbance

(hypokalemia or hypocalcemia), drug effects
(quinidine, procainamide, amiodarone, sotalol)
or myocardial ischemia with T wave inversion
 Shortened QT : hypercalcemia and digitalis
effect.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach.

7th ed. St. Louis: Mosby Year Book, 2006
PERICARDITIS AND MYOCARDITIS
Pericarditis :
 Diffuse ST segment elevations, usually in one or more of the chest
leads and also in I, aVL, II, aVF.
 PR segment elevation aVR and PR segment depression in other leads.

Myocarditis :
Non Specific ST segment changes similar with pericarditis and myocardial
ischemia

Pericarditis

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified
Approach. 7th ed. St. Louis: Mosby
Year Book, 2006
ELECTROLYTES ABNORMALITIES
Hyperkalemia
 Affecting of both depolarization (QRS complex) and repolarization
(ST-T segment)
 First changes : Tall T with “tented” or “pinched “ shape.
 Prolonged of PR interval and P wave is disappear
 Further increase : intraventricular conduction blocks and widening
QRS complex
 Lethal concentration : undulating (sine-wave pattern ) and asystole

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach.

7th ed. St. Louis: Mosby Year Book, 2006
Hypokalemia
 ST depression with prominent U waves
 Prolonged repolarization

Goldberger AL, Goldberger

E. Clinical
Electrocardiography: A
Simplified Approach. 7th ed.
St. Louis: Mosby Year
Book, 2006
Hypocalcemia and Hypercalcemia
Hypocalcemia : shortening QT interval by shorten ST segment
Hypercalcemia : lengthening QT interval by stretching ST
segment

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
PACEMAKER DYSFUNCTION

1. Failure to sense : observing pacemaker spikes

despite patient’s own adequate rate.
Common cause : (1) dislodgement of the pacemaker
wire (2) excessive fibrosis around the tip of pacing wire

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed.

St. Louis: Mosby Year Book, 2006
2. Failure to pace : observing pacemaker spikes without
subsequent QRS complex (“failure to capture”) or by finding no
pacemaker spikes even though the patient has an excessively
slow heart rate.
Common cause : dislodgement of the pacemaker wire or fibrosis in
the tip of the pacemaker wire.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed.

St. Louis: Mosby Year Book, 2006