ELECTROCARDIOGRAPHY

dr. Henry Pakpahan, Sp.JP, FIHA

What is Electrocardiography (ECG)?

 A graphic recording of the electrical potentials

produced by cardiac tissue.
 The graph obtained when the electrical
potentials of an electrical field originating in the
heart are recorded at the body surface.
 Provide an approximation of the voltage
produced by the source.

“ The heart is unique among the muscles of the body in that it

possesses the properties of automatic and rhythmic contraction “
 Clinical value
ECG is of diagnostic value in:
1. Atrial and ventricular hypertrophy
2. Myocardial ischemia and infarction
3. Pericarditis
4. Systemic diseases that affect the heart
5. Determination the effect of cardiac drugs
6. Disturbances in electrolyte balance
7. Evaluation of the function of pacemaker
 Electrophysiology of the heart

Normal pacemaker of
the heart

Lokasi: muara vena

cava superior
Electrophysiology of the heart
Electrophysiology of the heart
Terminology

Defleksi negatif pertama

setelah gelombang p
Terminology

Defleksi negatif setelah R

Terminology
1 Siklus Jantung
Normal ECG
 0.05-0.11 sec

0.12-0.20 sec
 . . . . Normal ECG

Quality check
Kecepatan rekaman (25mm/s, 50 mm/s)
Standardisasi ( 1 cm/mV)
Gelombang P (+) di lead I,II
Gelombang P (-) di lead aVR
R wave progression (upright di V4)
Lead I + III = II
aVR + aVL + aVF = 0
 How to read an ECG recording
1. Determine the rhythm: SR,ST,SB,AF,…
2. QRS rate : 60 – 100 bpm
3. QRS axis : 0 - +90˚
4. P wave morphology : P mitral, P Pulmonal
5. P axis
6. PR interval : 0.12 – 0.20 sec
7. QRS duration: 0.04 – 0.11 sec
8. ST – T segment changes
Apa yang harus dinilai ?

Rate
Rhythm
Axis
P wave
PR Interval
QRS duration
QRS pattern
 Apa yang harus dinilai ?
 ST Segment: isoelectric throughout.
 QT Interval
 QTc Interval
 T wave
 Extra: - aVR complexes are negative so no
evidence of limb lead misplacement

 SUMMARY: - Normal sinus rhythm,

sinus bradycardia, sinus tachycardia,
etc….
I. Determine the Rate
Normal heart rate : 60 – 100 x/minutes
> 100 x/minutes : Sinus Tachycardia
< 60 x/minutes : Sinus Bradicardia

Determine 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

II. Determine the Rhythm

Normal rhythm : Sinus Rhythm

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
III. Determine the Axis

Extreme
RAD LAD

RAD Normal
IV. Any hypertrophic signs ??
Atrial hypertrophy/enlargement?

II V1
 . . . Any hypertrophic signs?

Ventricular hypertrophy?
 Left Ventricular Hypertrophy
Sokolow and Lyon

1. R wave in lead I + S wave in III > 25 mm

2. R wave in aVL > 11 mm
3. R wave in aVF > 20 mm
4. S wave in aVR > 14 mm
5. R wave in V5 or V6 > 26 mm
6. R wave in V5 or V6 + S wave in V1 > 35 mm
7. Largest R wave + largest S wave in precordial leads >
45 mm
8. Onset of intrinsicoid deflection in V5 or V6 ≥ 0.05
second
9. ST-segment depression and T wave inversion in the
left precordial leads  LV strain

Chou. Electrocardiography in clinical practice, 3rd ed.

 Right Ventricular Hypertrophy
Myers et al, Sokolow and Lyon

1. Right axis deviation ≥ 110°

2. R/S ratio in V1 or V3R > 1
3. R wave in V1 ≥ 7 mm
4. S wave in V1 < 2 mm
5. qR pattern in V1 or V3R
6. R wave in V1 + S in V5 or V6 > 10.5 mm
7. R/S ratio in V5 or V6 ≤ 1
8. Onset of intrinsicoid deflection in V1: 0.035-
0.55 second
9. rsR` in V1 with R` ≥ 10 mm

Chou. Electrocardiography in clinical practice, 3rd ed.

V. Myocardial ischemia and
infarction
Localization anatomic area at risk
Septal wall : V1,V2
Anterior wall : V3, V4
Extensive anterior : V1-V6
Lateral wall : V5, V6
High lateral wall : I, aVL
Inferior wall : II, III, aVF
VI. Arrhythmia
. . . Arrhythmia
Left bundle branch block

Durasi QRS ≥ 0.12 detik

 Broad monophasic R di lead I, V5, dan V6
yang biasanya notched atau slurred.
Tidak ada gelombang q di lead I, V5, dan
V6.
 Delayed onset on intrinsicoid deflection
(the R peak time) di lead V5, V6.
Perubahan segmen ST dan T berlawanan
arah dengan defleksi kompleks QRS.
Right bundle branch block

Durasi QRS ≥ 0.12 detik

 A secondary R wave (R’) di prekordial
kanan. R’ lebih besar dari R (cth. rSR’)
 Delayed onset on intrinsicoid deflection
(the R peak time) di lead prekordial kanan.
Gelombang S lebar di I, V5, V6.
CONTOH
KASUS