Dr. David D Ariwibowo, Sp.

JP
ECG
 The ECG a recording of the heart's electrical activity.
 Through perturbations in the normal electrical patterns  we
are able to diagnose many different cardiac disorders.
Heart Excitation Related to ECG

Figure 18.17
Standard 12 leads ECG

Limb Lead Precordial Lead

Standard 12 leads ECG

Standard Configuration
Right Arm (white)
Left Arm (black)
Exercise Configuration
The right & left arm
electrodes are transferred to
the upper torso while the leg Standard Configuration
electrodes are transferred to Right Leg (green - ground)
the lower torso
Left Leg (red)

Precordial
Leads

V1 red V3 green V5 orange

V2 yellow V4 blue V6 violet
Anatomical placement of exercise electrodes
Electrode Anatomical Location
Right Arm (RA) The base of the right shoulder against the deltoid border about 2 cm
below the clavicle but above border of pectoralis (in deltoid fossa).

Left Arm (LA) The base of the left shoulder against the deltoid border about 2 cm
below the clavicle but above border of pectoralis (in deltoid fossa).

Right Leg (RL) Right anterior axillary line a few centimeters above the umbilicus
Left Leg (LL) Left anterior axillary line a few centimeters above the umbilicus
V1 Fourth intercostal space at right sternal border.

V2 Fourth intercostal space at left sternal border.

V3 Midway between positions for V2 and V4.

V4 Fifth intercostal space at left midclavicular line.

V5 Horizontal level of V4 at left anterior axillary line.

V6 Horizontal level of V4 at left midaxillary line.

The Concept of a "Lead"
Limb Leads

LEAD I

LEAD III LEAD II

Remember, the RL
is always the ground
Limb Leads
Precordial Leads
V9
The ECG waves
 P wave : atrial R
depolarisation

 QRS complex :
ventricular
depolarisation P T

 T wave : ventricular
repolarisation
Q
 Atrial repolarisation S
hidden by QRS
The ECG Complex
QRS • The depolarization
duration traveling acros the
< 0.10
sec
heart continue
traveling through the
body
R ST
T • By examining the
segment different leads, shape,
time intervals,
P contour, frequency,
U and type of the ECG
complexes, we can
diagnose cardiac
Q
illnesses.
0.12 - 0.20 0.35 - 0.45
sec S sec
PR QT
interval interval
 Standard recording:
ECG Paper - Speed: 25 mm/s
- Voltage: 1 mV
 ---- -- ++++ ++++
---- ----
++++
----
++++ ++ ++
--
--
++++ ++ ++ ---- ---- ----
---- --
Generation of the ++++ ++++ ++++

ECG complexes -- ++ ++++ ++++

---- ---- ++
++++ ---- ----
++++
++++
--
--
 A wave of depolarization ++++ ---- ++ ++ ---- ----
---- -- ++++ ++++
moving toward an electrode
will cause an upward
deflection on the ECG. ---- --
---- ++
++++
----
++++ ---- ++
++++ ++++
++++
++++ --
--
++++ ---- ---- ++ ++ ----
---- -- ++++

---- ---- ---- ----

++++ ---- ++++
++++
++++ ++++
++++ ++++ ++++
++++
++++ ---- ---- ---- ----
----
 Depolarization of the atria in Lead II
 Atrial depolarization proceeds
from the top down in all
directions.
 Summing these vectors of
depolarization  the main
atrial depolarization vector
(large green arrow).
o
 It is moving towards the lead II 60

 resulting in an upward
deflection of the ECG.
.
Depolarization of the LV in Lead II.
 Septum depolarizes from inside out
 resulting depolarization wave
moves away from Lead II.
 The rest ventricle depolarizes o
60
counter-clockwise from inside out
 main cardiac vector (large arrow)
which is sum of all of the small
depolarization vectors.
 This vector in normal heart, almost
always moving directly toward Lead
II  a mostly positive QRS complex.
 The RV is much smaller and
contributes little to the overall main
vector of depolarization
Repolarization of the LV in Lead II
 Repolarization is the beginning of
depolarization left off .
 Proceeding clockwise from the
lateral wall back to the septum.
 The vector is moving away from the
Lead II  T-wave is always positive.
 The process much slower than
depolarization  T-wave is wide &
rounded.
All waves are negative in lead aVR

Q S
Pacemaking & conduction System
Rules of pacemaker & Conduction
1. Setiap sel jantung dapat berperan sebagai
pacemaker.
2. Pacemaker dengan frekuensi pulsus
tertinggi yang menentukan frekuensi
denyut jantung.
3. Pulsus secara normal di konduksikan dari
atrium ke ventrikel hanya melalui AV
node.
4. Pulsus dari atrium mengalami
perlambatan di AV node sebelum
dikonduksikan ke ventrikel.
5. AV node memiliki masa refrakter
tertentu(masa tidak dapat dirangsang).
6. Pulsus yang berasal dari supra ventrikel
akan mengeksitasi ventrikel dengan cepat
 gambaran QRS sempit.
7. Pulsus yang berasal dari ventrikel akan
mengeksitasi ventrikel dengan lambat 
gambaran QRS lebar.
Thank You