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BASICS OFELECTROCARDIOGRAPH

Y

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REFERENCE

Dr. Annapoorna Kalia, Associate Consultant Dept.

of Cardiology

2

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Outline

1. Review of the

conduction system

2. EKG waveforms and

intervals

3. EKG leads

4. Determining heart rate

5. Determining QRS axis

1.Review dari sistem konduksi

Bentuk gelombang

2.EKG dan interval

3.lead EKG

4.Menentukan denyut jantung

5.Menentukan sumbu QRS

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The Normal Conduction System

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Cardiac Impulse

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Cardiac Impulse

1. Cardiac impulse originates in the SA node

2. Traverses the atria simultaneously no specialconduction wires in atria so the delay

3. Reaches AV node the check post so delay

4. Enters bundle of His and branches throughspecialized conducting wires called Purkinjenetwork - activates both ventricles quick QRS

5. First the septum from L to R, then right ventricle and

then the left ventricle and finally the apex6. Then the ventricles recover for next impulse

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1. Impuls jantung berasal dari SA node

2. Melintasi atrium secara bersamaan - tidak ada kabel konduksi

khusus di atrium - sehingga keterlambatan

3. Capai AV node - pos pemeriksaan - sehingga menunda

4. Memasuki berkas His dan cabang - melalui kabel khusus

melakukan disebut jaringan Purkinje - mengaktifkan kedua

ventrikel - QRS cepat

5. Pertama septum dari L ke R, maka ventrikel kanan dan kemudian

ventrikel kiri dan akhirnya puncak

6. Kemudian ventrikel pulih untuk impuls berikutnya

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CARDIAC CONDUCTIO

8

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What is an EKG?

The electrocardiogram (EKG) is arepresentation of the electricalevents of the cardiac cycle.

Each event has a distinctive

waveform, the study of whichcan lead to greater insight into apatients cardiacpathophysiology.

Elektrokardiogram (EKG)

adalah representasi dari

peristiwa listrik dari siklus

jantung.

Setiap acara memiliki

gelombang yang khas, studi

yang dapat menyebabkan

wawasan yang lebih besar

patofisiologi jantung pasien.

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WHAT IS AN

ELECTROCARDIOGRAM? (ECG/

EKG)The ECGis a graphical recordingof the hearts electrical activity

during each of its cycles. It is the

most common investigation of the

heart performed by physicians and

is extremely useful.

EKG adalah rekaman grafis dari

aktivitas listrik jantung selama setiap

siklus nya. Ini adalah penyelidikan

yang paling umum dari jantung yangdilakukan oleh dokter dan sangat

berguna.

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What types of pathology can we identify and study

from EKGs?

Arrhythmias Myocardial ischemia and

infarction

Pericarditis

Chamber hypertrophy Electrolyte disturbances

(i.e. hyperkalemia,hypokalemia)

Drug toxicity (i.e. digoxinand drugs which prolongthe QT interval)

-aritmia

-Iskemia miokard dan infark

-pericarditis

-Chamber hipertrofi

-Gangguan elektrolit

(misalnya hiperkalemia,

hipokalemia)

-Toksisitas obat (yaitu

digoxin dan obat-obatan yang

memperpanjang interval QT)

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WHEN IS AN ECG USED?

The ECG is used to investigate suspected problemswith the electrical conduction system of the heartas

well as some other abnormalities such as metabolic

disturbances (e.g. excess potassium).

The ECG is an essential tool for health

professionals in making a diagnosis of abnormalheart rhythms when one is suspected. It is a routine

investigation in people who complain of symptoms

such as chest painas well as breathlessness.

The findings of the ECG can also have an effect on

treatment of certain conditions, for example it ishelpful in deciding some aspects of treatment in

people who have suffered from a heart attack.

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EKG ini digunakan untuk menyelidiki dugaan masalah dengan

sistem konduksi listrik jantung serta beberapa kelainan lain seperti

gangguan metabolik (misalnya kalium yang berlebih).

EKG adalah alat penting bagi para profesional kesehatan dalam

membuat diagnosis dari irama jantung abnormal ketika seseorang

dicurigai. Ini adalah investigasi rutin pada orang yang mengeluhkan

gejala seperti nyeri dada serta sesak napas.

Temuan EKG juga dapat memiliki efek pada pengobatan kondisi

tertentu, misalnya akan sangat membantu dalam menentukan

beberapa aspek dari pengobatan pada orang yang telah menderita

serangan jantung.

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HOW TO PREPARE FOR AN ECG

First reassure yourself that there is no

danger or paininvolved in performing theprocedure and try to relax breathing

steadily.

Rest your arms by your side with your legs

flat, making sure that your legs aren'ttouching one another.

Make sure that your chest is exposed as

well as your arms and legs.

The nurse should then clean your skin witha sterile wipe prior to placing the electrodes

in place

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Pertama meyakinkan diri sendiri bahwa tidak ada bahaya atau sakit

yang terlibat dalam melakukan prosedur dan mencoba untuk bersantai

bernapas mantap.

Istirahatkan tangan Anda di sisi Anda dengan kaki datar, memastikan

bahwa kaki Anda tidak menyentuh satu sama lain.

Pastikan dada Anda terkena serta lengan dan kaki.

Perawat kemudian harus membersihkan kulit Anda dengan

menghapus steril sebelum menempatkan elektroda di tempat

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WHAT CAN YOU EXPECT DURING AN

ECG? After the preparations that take place before an

ECG is performed, various electrodes with aplastic head and an adhesive gel are placed at

strategically located points on your body.

These points are shown in the diagram to the

right, and include: 6 points on your chest starting just to the right of your breast

bone extending sideways towards the left hand border of your

rib cage called V1 - V6.

4 points, one on each limb, the ones on the arms are placed

below the levels of the shoulders and on the legs they are

placed below the level of your groin (note that the closer the

electrodes are placed to your heart the more intense the

reading is, and the easier it is to interpret).

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Setelah persiapan yang berlangsung sebelum EKG dilakukan,

berbagai elektroda dengan kepala plastik dan gel perekat

ditempatkan pada titik-titik strategis yang terletak di tubuh Anda.

Titik-titik ini ditunjukkan dalam diagram di sebelah kanan, dan

meliputi:

-6 poin di dada Anda mulai hanya di sebelah kanan tulang dada Anda

memperpanjang samping menuju perbatasan kiri tulang rusuk Anda

disebut V1 - V6.

- 4 poin, satu pada setiap anggota tubuh, yang di lengan ditempatkan di

bawah tingkat bahu dan kaki mereka ditempatkan di bawah tingkatpangkal paha (perhatikan bahwa semakin dekat elektroda ditempatkan

ke jantung Anda semakin intens membaca adalah, dan semakin mudah

untuk menafsirkan).

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WHAT DOES THE ECG RECORD?

During the process of the recording the

signal is calculated and amplified from

the 10 electrodes placed on your bodyand subsequently recorded on a piece of

graph paper with specific dimensions.

Depending what 'lead' (the vector formed

between the different electrodes) you are

looking at the ECG appears different.

There are 12 such leads in a regular 12

lead ECG, each of which analyse a

different plane of the heart and are

therefore useful in diagnosing different

conditions and localising disease. The

'leads' or vectors on the chest wall arenamed V1, V2, V3, V4, V5 & V6 going

from right to left on the patient, and

therefore analyse the heart in order from

the right to the left i.e. from V1 to V6.

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Selama proses rekaman sinyal dihitung dan diperkuat dari 10 elektroda

ditempatkan pada tubuh Anda dan kemudian direkam pada selembar

kertas grafik dengan dimensi tertentu. Tergantung apa yang 'memimpin'

(vektor terbentuk antara elektroda yang berbeda) yang Anda cari di

EKG muncul berbeda.

Ada 12 lead tersebut dalam biasa 12 lead EKG, yang masing-masingmenganalisis pesawat yang berbeda dari hati dan karena itu berguna

dalam mendiagnosa kondisi yang berbeda dan melokalkan penyakit.

The 'lead' atau vektor pada dinding dada bernama V1, V2, V3, V4, V5

& V6 pergi dari kanan ke kiri pada pasien, dan karena itu menganalisis

hati dalam urutan dari kanan ke kiri yaitu dari V1 ke V6 .

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The leads on the chest are called unipolar leads

because their vector is only pointing in one direction

i.e. in a direction perpendicular to the chest wall. There are 4 electrodes on the patients limbs, but only 3

of which are used to form leads and one which is used

as an earth, just like the one found on a plug for an

electrical device.

The 3 limb electrodes used are the right arm, the leftarm and the left leg. From these 3 electrodes 6 limb

leads are formed, these are named I, II, III, aVR, aVL,

and AVF. The leads are formed by using various

combinations of the 3 leads, with leads I-III using 2

electrodes to form a vector (bipolar leads) and leads

aVR, aVL and aVF using 3 electrodes (augmented

bipolar leads).

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Mengarah pada dada disebut lead unipolar karena vektor mereka hanya

menunjuk satu arah yaitu ke arah tegak lurus terhadap dinding dada.

Ada 4 elektroda pada pasien anggota badan, tetapi hanya 3 dari yang

digunakan untuk membentuk memimpin dan salah satu yang digunakan

sebagai bumi, seperti yang ditemukan pada sebuah plug untuk perangkat

listrik.

3 elektroda ekstremitas yang digunakan adalah lengan kanan, lengan kiri dan

kaki kiri. Dari ini 3 elektroda 6 ekstremitas lead terbentuk, ini bernama I, II,

III, aVR, aVL, dan aVF. The lead dibentuk dengan menggunakan berbagai

kombinasi dari 3 lead, dengan lead I-III menggunakan 2 elektroda untuk

membentuk vektor (lead bipolar) dan mengarah aVR, aVL, dan aVF

menggunakan 3 elektroda (augmented lead bipolar).

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Bipolar leads

I = Right arm to left arm

II= Right arm to left leg

III = Left arm to left leg

Augmented bipolar leads

aVR = Right arm to left arm and left leg

aVL = Left arm to left leg and right arm

aVF = Left leg to left arm and right arm

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Usually the ECG is recorded on special graph paper that

is divided into 1-mm2boxes. Each box represents a

specific time interval since the ECG always records at a

particular velocity. By counting these boxes horizontally, the doctor is able

to discern the heart rate as well as the timings of the

different parts of the ECG.

The heart rate, the timings of the intervals (as seen in

the diagram below), the height of the recording as wellas the leads in which the abnormalities are present all

help to make a diagnosis. An ECG readout will look like

a series of 'waveforms', a single one of which is shown

below. The image also highlights the electrical activity in

the heart at the time, that causes the distinctive wave.

Depolarisation indicates that a wave of electricity has

just passed through an area of the heart such as the

ventricles of atria, causing them to contract.

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Biasanya EKG dicatat pada kertas grafik khusus yang dibagi menjadi kotak-1

mm2. Setiap kotak mewakili interval waktu tertentu sejak EKG selalu mencatat

pada kecepatan tertentu.

Dengan menghitung kotak-kotak ini horizontal, dokter mampu membedakan

denyut jantung serta timing dari bagian yang berbeda dari EKG.

Denyut jantung, timing interval (seperti terlihat dalam diagram di bawah),

ketinggian rekaman serta memimpin di mana kelainan hadir semua bantuan untuk

membuat diagnosis. Sebuah pembacaan EKG akan terlihat seperti serangkaian

'gelombang', satu pun dari yang ditunjukkan di bawah ini. Gambar juga

menyoroti aktivitas listrik di jantung pada waktu itu, yang menyebabkan

gelombang khas. Depolarisasi menunjukkan bahwa gelombang listrik baru saja

melewati daerah jantung seperti ventrikel dari atrium, menyebabkan mereka

untuk kontrak.

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WHAT CAN YOU EXPECT AFTER AN

ECG?

After the ECG recording is made, the leads will beremoved from your body and the doctor present will

attempt to make a diagnosis on the basis of what

was found.

If the ECG shows a serious abnormality, or there is

more information that is needed, other investigations

which are more interventional may be indicated, for

example an echocardiogram(an ultrasound

examination of the heart).

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Setelah rekaman EKG dibuat, lead akan dikeluarkan dari

tubuh Anda dan dokter ini akan mencoba untuk membuat

diagnosis berdasarkan apa yang ditemukan.

Jika EKG menunjukkan kelainan yang serius, atau ada

informasi lebih lanjut yang diperlukan, investigasi lain yang

lebih intervensi dapat diindikasikan, misalnya

ekokardiogram (pemeriksaan USG jantung).

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What are Some Possible Results From an

ECG and What Do These Mean?

There are a very large number of possible disorders that

can be found on an ECG, but there are some main

categories into which a majority of the abnormalities can

be grouped. Abnormalities of the Left heartAbnormalities of the Right heart

Abnormalities of the atria

Abnormally fast rates (tachycardias)

Abnormally slow rates (bradycardias and conduction

blocks)Heart attacks

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Beberapa Kemungkinan Hasil Dari EKG dan Apa Artinya ini?

Ada jumlah yang sangat besar gangguan yang mungkin yang dapatditemukan pada EKG, tetapi ada beberapa kategori utama di mana

mayoritas kelainan dapat dikelompokkan.

Kelainan jantung Kiri

Kelainan jantung kanan

Kelainan atrium

Tarif normal cepat (takikardia)

Tingkat abnormal lambat (bradycardias dan blok konduksi)

serangan jantung

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What these abnormalities Apa ini berarti kelainan tergantung pada

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What these abnormalities

mean depends on their

severity and the patient in

question. The diagnosis of an

abnormality on ECG does not

necessarily mean that an

abnormality is present, and if

there is an abnormality found

that doesn't correlate withpatients symptoms, the ECG

should be checked and

performed again. It is

important to make sure that

errors weren't made in theplacement of electrodes or in

the interpretation of results,

because there is always a

Apa ini berarti kelainan tergantung pada

tingkat keparahan dan pasien yang

bersangkutan. Diagnosis kelainan pada

EKG tidak berarti bahwa kelainan hadir,

dan jika ada kelainan yang ditemukan

yang tidak berhubungan dengan gejala

pasien, EKG harus diperiksa dandilakukan lagi. Hal ini penting untuk

memastikan bahwa kesalahan tidak

dibuat dalam penempatan elektroda atau

dalam interpretasi hasil, karena selalu

ada margin of error dengan

penyelidikan.

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IMPORTANT PRECAUTIONS Correct Lead placement and good

contact

Proper earth connection, avoid

other gadgets

Deep inspiration record of L3, aVF

Compare serial ECGs if available

Relate the changes to Age, Sex,Clinical history

Consider the co-morbidities that

may effect ECG

Make a xerox copy of the record for

future use

Interpret systematically to avoid

errors

-Memimpin penempatan yang benar dan

kontak yang baik

-Hubungan bumi yang tepat,menghindari gadget lainnya

-Catatan inspirasi yang mendalam dari

L3, aVF

-Bandingkan EKG seri jika tersedia

-Menghubungkan perubahan Age, Sex,sejarah klinis

-Pertimbangkan komorbiditas yang

dapat mempengaruhi EKG

-Membuat salinan fotokopi dari catatan

untuk penggunaan masa depan-Menafsirkan secara sistematis untuk

menghindari kesalahan

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ECG Complex

P wave

PR Interval

QRS complex

ST segment

T Wave

QT Interval

RR Interval

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ECG Complex P Wave is Atrial contraction

Normal 0.12 sec

PR interval is from the beginning

of P wave to the beginning of

QRSNormal up to 0.2 sec

QRS is Ventricular contraction

Normal 0.08 sec

ST segmentNormal Isoelectic

(electric silence)

QT IntervalFrom the beginning

of QRS to the end of T wave

Normal0.40 sec

RR IntervalOne Cardiac cycle

0.80 sec

- P Wave adalah kontraksi atrium - normal 0.12sec

- Interval PR adalah dari awal gelombang P ke

awal QRS - normal hingga 0,2 sec

- QRS adalah ventrikel kontraksi-Normal 0.08

sec

- Segmen ST - normal Isoelectic (keheningan

listrik)

- QT Interval - Dari awal QRS ke akhir

gelombang T - normal - 0.40 sec

- RR Interval - Satu siklus jantung 0.80 sec

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+

+ +

- - -

ECG BIPOLAR LIMB LEADS

R L

F

R

F

L

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Standard ECG is recorded in12 leads

Six Limb leads L1, L2, L3,

aVR, aVL, aVF

Six Chest Leads V1 V2 V3

V4 V5 and V6

L1, L2 and L3 are called

bipolar leads

L1 between LA and RA

L2 between LF and RA

L3 between LF and LA

ECG BIPOLAR LIMB LEADS

-Standard EKG tercatat dalam 12 lead

-Enam Limb memimpin - L1, L2, L3,

aVR, aVL, aVF

- Enam Dada Memimpin - V1 V2 V3

V4 V5 dan V6

-L1, L2 dan L3 disebut lead bipolar

-L1 antara LA dan RA

-L2 antara LF dan RA

-L3 antara LF dan LA

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ECG Unipolar Limb Leads

++

+

Lead aVR Lead aVL Lead aVF

R L

F

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Standard ECG is recorded in 12

leads

Six Limb leadsL1, L2, L3, aVR,

aVL, aVF

Six Chest LeadsV1 V2 V3 V4 V5

and V6 aVR, aVL, aVF are called unipolar

leads

aVRfrom Right Arm Positive

aVLfrom Left Arm Positive aVFfrom Left Foot Positive

ECG Unipolar Limb Leads

-Standard EKG tercatat Dalam, 12

lead

-Enam Limb memimpin - L1, L2, L3,

aVR, aVL, aVF

-Enam Dada Memimpin - V1 V2 V3

V4 V5 Dan V6

-L1, L2 Dan L3 disebut memimpin

bipolar

-L1 ANTARA LA Dan RA

-L2 ANTARA LF Dan RA

-L3 ANTARA LF Dan LA

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ECG Chest Leads

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Precardial (chest) Lead Position

V1 Fourth ICS, right sternalborder

V2 Fourth ICS, left sternal

border V3 Equidistant between V2 and

V4

V4 Fifth ICS, left Mid clavicularLine

V5 Fifth ICS Left anterioraxillary line

V6 Fifth ICS Left mid axillaryline

ECG Chest Leads

Precardial (dada) Posisi Memimpin

-V1 Keempat ICS, batas sternum

kanan

-V2 Keempat ICS, batas sternum

kiri-V3 Repetitively antara V2 dan V4

-V4 Kelima ICS, kiri Mid

clavicular Baris

-V5 Kelima ICS Left anterior garis

aksila-V6 Kelima ICS Kiri garis mid

aksila

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The Six Chest Leads

TRANSVERSE

PLANE

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ECG Graph Paper

X- Axis time in seconds

Y-AxisAmp

litudeinmillvolts

43

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X-Axis represents time - Scale X-Axis1 mm = 0.04 sec Y-Axis represents voltage - Scale Y-Axis1 mm = 0.1 mV

One big square on X-Axis = 0.2 sec (big box)

Two big squares on Y-Axis = 1 milli volt (mV)

Each small square is 0.04 sec (1 mm in size) Each big square on the ECG represents 5 small squares

= 0.04 x 5 = 0.2 seconds

5 such big squares = 0.2 x 5 = 1sec = 25 mm

One second is 25 mm or 5 big squares One minute is 5 x 60 = 300 big squares

ECG GRAPH PAPER

X Axis merupakan waktu Skala X Axis 1 mm = 0 04 detik

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- X-Axis merupakan waktu - Skala X-Axis - 1 mm = 0,04 detik

- Y-Axis merupakan tegangan - Skala Y-Axis - 1 mm = 0,1 mV

- Salah satu persegi besar di X-Axis = 0,2 detik (kotak besar)- Dua kotak besar pada Y-Axis = 1 mili volt (mV)

- Setiap kotak kecil adalah 0,04 detik (1 mm)

- Setiap persegi besar pada EKG mewakili 5 kotak kecil

= 0,04 x 5 = 0,2 detik

- 5 kotak besar seperti = 0,2 x 5 = 1sec = 25 mm

- Satu detik adalah 25 mm atau 5 kotak besar

- Satu menit adalah 5 x 60 = 300 kotak besar

45

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Rate Determination

Next

QRS

QRS

Rate Determination

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Rate Determination

No. of Big

Boxes

RR Interval Rate Cal. Rate

One 0.2 sec 60 0.2 300

Two 0.4 sec 60 0.4 150

Three 0.6 sec 60 0.6 100

Four 0.8 sec 60 0.8 75

Five 1.0 sec 60 1.0 60

Six 1.2 sec 60 1.2 50

Seven 1.4 sec 60 1.4 43

Eight 1.6 sec 60 1.6 37

BR

A

D

Y

T

A

C

H

Y

NO

R

M

A

L

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What is the Heart Rate ?

Answer on next slide

What is the Heart Rate ?

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To find out the heart

rate we need to know The R-R interval in

terms of # of big squares

If the R-R intervals areconstant

In this ECG the R-R

intervals are constant R-R are approximately

3 big squares apart

So the heart rate is 3003 = 100

What is the Heart Rate ?

Untuk mengetahui detak jantung

kita perlu tahu

-The R-R Interval dalam hal #

kotak besar

-Jika interval R-R adalah konstan

Dalam EKG ini interval R-R adalahkonstan

R-R adalah sekitar 3 kotak besar

terpisah

Jadi denyut jantung adalah 300 3

= 100

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What is the Heart Rate ?

Answer on next slide

What is the Heart Rate ?

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To find out the heart rate we

need to know

The R-R interval in terms

of # of big squares

If the R-R intervals are

constant

In this ECG the R-R intervals

are constant

R-R are approximately 4.5

big squares apart So the heart rate is 300 4.5

= 67

Untuk mengetahui detak

jantung kita perlu tahu

-The R-R Interval dalam

hal # kotak besar

-Jika interval R-R adalah

konstan

Dalam EKG ini interval R-

R adalah konstan

R-R adalah sekitar 4,5

kotak besar terpisah

Jadi denyut jantung adalah300 4,5 = 67

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What is the Heart Rate ?

Answer on next slide

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What is the Heart Rate ? To find out the heart ratewe need to know

The R-R interval interms of # of Big

Squares

If the R-R intervals are

constant

In this ECG the R-R

intervals are not constant

R-R are varying from 2

boxes to 3 boxes

It is an irregular rhythm Sinus arrhythmia

Heart rate is 300 2 to 3 =

150 to 100 approx

Untuk mengetahui detak jantung

kita perlu tahu The R-R Interval dalam hal #

Kuadrat Big

Jika interval R-R adalah konstan

Dalam EKG ini interval R-R tidakkonstan

R-R yang bervariasi dari 2 kotak

untuk 3 kotak

Ini adalah ritme yang luar biasa -

aritmia Sinus

Denyut jantung adalah 300 2

sampai 3 = 150-100 approx

QRS A i

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QRS Axis

SE

NENW

SW

QRS Axis

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The QRS electrical (vector) axis

can have 4 directions

Normal Axis - when it is

downward and to the left southeast quadrant from -30

to +90 degrees

Right Axis when it is

downward and to the right

southwest quadrantfrom +90to 180 degrees

Left Axis when it is upward

and to the left Northeast

quadrant from -30 to -90

degrees

Indeterminate Axiswhen it is

upward & to the right

Northwest quadrantfrom -90

to +180

QRS listrik (vektor) axis dapat

memiliki 4 arah

Axis biasa - ketika itu adalah ke

bawah dan ke kiri - kuadran

tenggara - dari -30 sampai +90

derajat

Kanan Axis - ketika itu adalah kebawah dan ke kanan - kuadran barat

daya - 90-180 derajat

Left Axis - ketika itu adalah ke atas

dan ke kiri - Timur Laut kuadran-

dari -30 sampai -90 derajat Tak tentu Axis - ketika itu atas & ke

kanan - Northwest kuadran - dari -

90 sampai +180

A i D t i ti

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Axis Determination

NORMAL RIGHT LEFT

MEET LEAVEALL UPRIGHT

A i D t i ti

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Axis Determination

Axis LI LIII oraVF

TIP

Normal Positive Positive Both Up

Right Negative Positive Meet

Left Positive Negative Leave

Indeterminate Negative Positive Meet

57

Wh t i th A i ?

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LEAD 1

LEAD 2

LEAD 3

aVR

aVL

aVF

What is the Axis ?

ECG With Normal Axis

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ECG With Normal Axis

Note the QRS voltages arepositive and upright in theleads - L1, L2, L3 and aVF

L2, L3 and aVF tell that it is

downward L1, aVL tell that it is to the

left

Downward and leftward isNormal Axis

Normal QRS axis

Catatan tegangan QRS positif dan

tegak di lead - L1, L2, L3 dan aVF

L2, L3 dan aVF mengatakan bahwa

itu adalah ke bawah

L1, aVL mengatakan bahwa itu

adalah ke kiri

Downward dan ke kiri adalahnormal Axis

Axis QRS yang normal

59

Wh t i th A i ?

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LEAD 1

LEAD 2

LEAD 3

What is the Axis ?

ECG With Right Axis

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Note the QRS voltages are

positive and upright in leads L2,

L3

Negative in Lead 1

L2, L3 tell that it is downward

L1 tells that it is not to the left

but to right Downward and rightward is Right

Axis

See the RightMeet criterion

QRS in L1 and L3 meet Right Axis Deviation - RAD

- Catatan tegangan QRS positif dan tegak

dalam memimpin L2, L3

- Negatif di Lead 1

- L2, L3 mengatakan bahwa itu adalah ke

bawah

- L1 mengatakan bahwa tidak ke kiri tapi

ke kanan

- Downward dan kanan yang Tepat Axis

Lihat kriteria kanan Bertemu QRS di

L1 dan L3 bertemu

- Penyimpangan Axis Kanan - RAD

61

Wh t i th A i ?

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LEAD 1

LEAD 2

LEAD 3

aVR

aVL

aVF

What is the Axis ?

ECG With Left Axis Note the QRS voltages are

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Note the QRS voltages arepositive and upright in leadsL1and aVL

Negative in L2, L3 and aVF

L1, aVL tell that it is leftward

L2, L3, and aVF tell that it is notdown ward - instead it is

upward Upward and Leftward is Left

Axis

See the Left - Leave criterion

QRS in L1 and L3 leaveeach other

Left Axis Deviation - LAD

Catatan tegangan QRS positif

dan tegak di lead aVL L1and

Negatif di L2, L3 dan aVF L1, aVL mengatakan bahwa

itu adalah ke kiri

L2, L3, dan aVF mengatakan

bahwa itu tidak bangsal turun- tetapi itu adalah ke atas

Upward dan ke kiri adalah

Left Axis

Lihat Kiri - Tinggalkan kriteria

QRS di L1 dan L3

meninggalkan satu sama lain

Left Axis Deviation - LAD

Normal ECG

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Normal ECG

Normal ECG

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Normal ECG

Standardization10 mm (2 boxes) = 1 mV

Double and half standardization if required

Sinus RhythmEach P followed by QRS, R-R constant

P wavesalways examine for in L2, V1, L1

QRS positive in L1, L2, L3, aVF and aVL.Neg in aVR

QRS is < 0.08 narrow, Q in V5, V6 < 0.04, < 3 mm

R wave progression from V1 to V6, QT interval < 0.4

Axis normalL1, L3, and aVF all will be positive

ST Isoelectric, T waves , Normal T in aVR,V1, V2

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- Standardisasi - 10 mm (2 kotak) = 1 mV

- Double dan setengah standardisasi jika diperlukan

- Sinus Rhythm - Setiap P diikuti oleh QRS, RR konstan

- Gelombang P - selalu memeriksa untuk di L2, V1, L1

- QRS positif di L1, L2, L3, aVF dan aVL. - Neg di aVR

- QRS adalah

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Pediatric ECG

Pediatric ECG

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This is the ECG of a 6

year old child Heart rate is 100

Normal for the age

See V1 + V5 R >> 35

Not LVHNormal T in V1, V2, V3

Normal in child

Base line disturbances in

V5, V6 due tomovement by child

Ini adalah EKG seorang anak

berusia 6 tahun

Denyut jantung adalah 100 -

normal untuk usia

Lihat V1 + V5 R >> 35 - TidakLVH - normal

T di V1, V2, V3 - normal pada

anak

Gangguan garis dasar di V5, V6 -

karena gerakan oleh anak

Juvenile ECG

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Be aware of normal ECG Normal Resting ECG cannot

exclude disease

69

ECG Resting normal - tidak bisa

mengecualikan penyakit

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exclude disease

Ischemia may be covertsupply /demand equation

Changes of MI take some time todevelop in ECG

Mild Ventricular hypertrophy - notdetectable in ECG

Some of the ECG abnormalities are

non specific

Single ECG cannot give progress Need serial ECGs

ECG changes not always correlatewith Angio results

Paroxysmal events will be missedin single ECG

mengecualikan penyakit

Iskemia mungkin rahasia - supply

persamaan permintaan /

Perubahan MI mengambil beberapa

waktu untuk mengembangkan di

EKG

Mild ventrikel hipertrofi - tidak

terdeteksi di EKG Beberapa kelainan EKG yang non

spesifik

EKG tunggal tidak dapat memberikan

kemajuan - Butuh EKG seri

Perubahan EKG tidak selaluberkorelasi dengan hasil Angio

Peristiwa paroksismal akan tertinggal

dalam satu EKG

Normal Variations in ECG May have slight left axis due to

rotation of heartMungkin memiliki sumbu kiri sedikit

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rotation of heart

May have high voltage QRS simulating LVH

Mild slurring of QRS butduration < 0.09

J point depression, earlyrepolarization

T inversions in V2, V3 and V4 Juvenile T

Similarly in women also T

Low voltages in obese womenand men

Non cardiac causes of ECGchanges may occur

karena rotasi hati

Mungkin memiliki QRS tegangan tinggi -simulasi LVH

Slurring ringan QRS tapi durasi

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y p

This ECG has all normal features

The ST-T (J) Junction point is

elevated. T waves are tall, May be inverted in LIII, The ST

segment initial portion is concave. This does not signify Ischemia

Pseudo Normalization

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Pseudo Normalization

Before

Chest pain

DuringChest pain

Chest pain

Relieved

T

T

T

Atrial Waves

73

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Left Atrial

E l

74

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Enlargement

Left Atrial Enlargement

75

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g

P wave duration is 4 boxes-0.04 x 4 = 0.16

Always examine V 1 and Lead 1 for

Left Atrial Enlargement

Selalu memeriksa V 1 dan Lead 1 untuk

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LAE

Biphasic P Waves, Prolonged P

waves

P wave 0.16 sec, Downward

component

Systemic Hypertension, MS and or

MR

Aortic Stenosis and Regurgitation

Left ventricular hypertrophy with

dysfunction

Atrial Septal Defect with R to Lshunt

Selalu memeriksa V 1 dan Lead 1 untuk

LAE

Biphasic P Waves, gelombang P

berkepanjangan

P gelombang 0,16 detik, komponen

Downward Hipertensi sistemik, MS dan atau MR

Aortic Stenosis dan Regurgitasi

Hipertrofi ventrikel kiri dengan

disfungsi

Atrial Septal Defect dengan R ke L shun

Right Atrial Enlargement

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Right Atrial Enlargement

78

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P wave voltage is 4 boxes or 4 mm

Always examine Lead 2 for RAE

Right Atrial Enlargement

Selalu memeriksa Lead 2 untuk RAE

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Tall Peaked P Waves, Arrow

head P waves Amplitude is 4 mm ( 0.4 mV) -

abnormal

Pulmonary Hypertension,

Mitral Stenosis Tricuspid Stenosis,

Regurgitation

Pulmonary Valvular Stenosis

Pulmonary Embolism Atrial Septal Defect with L to R

shunt

Selalu memeriksa Lead 2 untuk RAE

Tinggi Gelombang P Peaked, kepala

panah gelombang P

Amplitudo 4 mm (0,4 mV) - normal

Hipertensi Paru, Mitral Stenosis

Stenosis trikuspid, RegurgitasiPulmonary Stenosis katup

Embolisme paru

Atrial Septal Defect dengan L untuk R

shunt

Ventricular Hypertrophy

80

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Ventricular Muscle Hypertrophy

QRS voltages in V1 and V6, L 1

and aVL

We may have to record to

standardization

T wave changes opposite to QRSdirection

Associated Axis shifts

Associated Atrial hypertrophy

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Ventricular Hypertrophy Otot

Tegangan QRS di V1 dan V6, L 1 dan aVL

Kita mungkin harus merekam standardisasi

Perubahan gelombang T berlawanan dengan arah QRS

Pergeseran Associated Axis

Associated Atrial hipertrofi

Right Ventricular Hypertrophy

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Tall R in V1 with R >> S, or

Right Ventricular Hypertrophy

-Tinggi R di V1 dengan R >> S

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R/S ratio > 1

Deep S waves in V4, V5 andV6

The DD is RVH, Posterior MI,

Anti-clock wise rotation of

Heart

Associated Right Axis

Deviation, RAE

Deep T inversions in V1, V2

and V3

Absence of Inferior MI

Tinggi R di V1 dengan R >> S,

atau rasio R / S> 1

-Jauh S gelombang di V4, V5 dan

V6

-DD adalah RVH, Posterior MI,

Anti-jam rotasi bijaksana Hati

-Associated Kanan Axis Deviation,

RAE

-Inversi T Jauh di V1, V2 dan V3

-Tidak adanya Inferior MI

84

Is there any hypertrophy ?

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Criteria of RVH

Criteria and Causes of RVH

Kriteria RVH

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Tall R in V1 with R >> S, or R/S ratio > 1

Deep S waves in V4, V5 and V6 The DD is RVH, Posterior MI, Rotation

Associated Right Axis Deviation, RAE

Deep T inversion in V1, V2 and V3

Cause of RVH

Long standing Mitral Stenosis Pulmonary Hypertension of any cause

VSD or ASD with initial L to R shunt

Congenital heart with RV over load

Tricuspid regurgitation, Pulmonary

stenosis

Tinggi R di V1 dengan R >> S, atau rasio R / S> 1

Jauh S gelombang di V4, V5 dan V6

DD adalah RVH, Posterior MI, Rotasi

Associated Kanan Axis Deviation, RAE

Jauh T inversi di V1, V2 dan V3

Penyebab RVH

Mitral Stenosis lama berdiri

Hipertensi paru sebab apapun

VSD atau ASD dengan L awal untuk R shunt

Jantung bawaan dengan RV atas beban

Regurgitasi trikuspid, stenosis pulmonal

86

What is in this ECG ?

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ECG OF MS with RVH, RAE Classical changes seen are

Right ventricular hypertrophyPerubahan Klasik lihat adalah

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g yp p y

Right axis deviation

Right Bundle Branch Block

PPulmonale - Right Atrial

enlargement

PMitraleLeft Atrial

enlargement If Atrial Fibrillation developsP

disappears

Hipertrofi ventrikel kanan

Deviasi aksis ke kanan

Bundle Branch Block Kanan

P - pulmonal - Kanan Atrial

pembesaran

P - Mitrale - Left Atrial pembesaran

Jika Atrial Fibrillation berkembang -

menghilang 'P'

Left Ventricular Hypertrophy

88

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Left Ventricular Hypertrophy

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High QRS voltages in limb leads

R in Lead I + S in Lead III > 25 mm

S in V1 + R in V5 > 35 mm

R in aVL > 11 mm or S V3 + R aVL > 24, > 20

Deep symmetric T inversion in V4, V5 & V6

QRS duration > 0.09 sec

Associated Left Axis Deviation, LAE

Cornell Voltage criteria, Estes point scoring

90

What is in this ECG ?

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Causes of LVH

Pressure overload - SystemicHypertension, Aortic Stenosis

Causes and Criteria of LVH

Penyebab LVH

Tekanan yang berlebihan - Hipertensi sistemik

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yp ,

Volume overload - AR or MR -

dilated cardiomyopathy VSD - cause both right & left

ventricular volume overload

Hypertrophic cardiomyopathy No pressure or volume overload

Criteria of LVH

High QRS voltages in limb leads R in Lead I + S in Lead III > 25 mm

or S in V1 + R in V5 > 35 mm

R in aVL > 11 mm or S V3 + R aVL >24 , > 20

Deep symmetric T inversion in V4,V5 & V6

QRS duration > 0.09 sec,Associated Left Axis Deviation, LAE

aorta Stenosis

Volume yang berlebihan - AR atau MR kardiomiopati dilatasi

VSD - menyebabkan volume ventrikel baik

kanan & kiri yang berlebihan

Kardiomiopati hipertrofik - Tidak ada tekanan

atau volume yang berlebihan

Kriteria LVHTegangan QRS tinggi di ekstremitas lead

R di Lead I + S di Lead III> 25 mm atau S d

V1 + R di V5> 35 mm

R di aVL> 11 mm atau S V3 + R aVL> 24 ,>

20 Mendalam simetris T inversi di V4, V5 & V6Durasi QRS> 0,09 detik, Associated Left Axi

Deviation, LAE

Atrial Ectopics

92

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APC

APCAPC

APC

Note the premature

(ectopic) beats marked as

Atrial Ectopics

Perhatikan dini (ektopik) ketukan

di d i b i

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( p )

APC (Atrial PrematureContractions)

These occurred before the

next expected QRS complex

(premature) Each APC has a P wave

preceding the QRS of that

beatSo impulse has

originated in the atria The QRS duration is normal

< 0.08, not wide

ditandai sebagai

APC (Atrial Prematur Kontraksi)

Ini terjadi sebelum kompleks QRS

yang diharapkan berikutnya

(prematur)

Setiap APC memiliki gelombang P

sebelum QRS dari beat itu - Jadi

impuls telah berasal dari atrium Durasi QRS normal

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Complete RBBB Complete RBBB has a QRS duration

> 0.12 sec

R' wave in lead V1 (usually see rSR'

Lengkap RBBB memiliki durasi QRS> 0,12 sec

R 'gelombang dalam memimpin V1 (biasanya

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R' wave in lead V1 (usually see rSR'

complex) S waves in leads I, aVL, V6, R wave

in lead aVR

QRS axis in RBBB is -30 to +90

(Normal)

Incomplete RBBB has a QRS

duration of 0.10 to 0.12 sec with the

same QRS features as above

The "normal" ST-T waves in RBBB

should be oriented opposite to thedirection of the QRS

melihat RSR' kompleks)

Gelombang S di lead I, aVL, V6, R gelombang

dalam memimpin aVR

QRS axis di RBBB adalah -30 sampai +90

(Normal)

Incomplete RBBB memiliki durasi QRS dari

0,10-0,12 detik dengan fitur QRS yang sama

seperti di atas

The "normal" gelombang ST-T di RBBB harus

berorientasi berlawanan dengan arah QRS

Complete LBBB

98

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Complete LBBB Complete LBBB has a QRS duration

> 0.12 sec

Prominent S waves in lead V1, R in L

Lengkap LBBB memiliki durasi QRS> 0,12sec

Tokoh gelombang S dalam memimpin V1, RL I VL V6

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I, aVL, V6

Usually broad, Bizarre R waves are

seen, M pattern Poor R progression from V1 to V3 is

common.

The "normal" ST-T waves in LBBBshould be oriented opposite to thedirection of the QRS

Incomplete LBBB looks like LBBB

but QRS duration is 0.10 to 0.12sec, with less ST-T change.

This is often a progression of LVHchanges.

L I, aVL, V6

Biasanya luas, Bizarre gelombang R terlihat,pola M Perkembangan R miskin dari V1 ke V3

adalah umum.

The "normal" gelombang ST-T di LBBBharus berorientasi berlawanan dengan arahQRS

Lengkap LBBB terlihat seperti LBBB tapidurasi QRS adalah 0,10-0,12 detik, dengan

kurang ST-T perubahan. Ini sering merupakan perkembanganperubahan LVH.

Blood Supply of Heart

100

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LCA

RCA

LAD

LCX

RCA

Blood Supply of Heart

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Heart has four surfaces

Anterior surfaceLAD, Left Circumflex (LCx)

Left lateral surfaceLCx, partly LAD

Inferior surfaceRCA, LAD terminal portion

Posterior surfaceRCA, LCx branches

Rt. and Lt. coronary arteries arise from aorta

They are 2.5 mm at origin, 0.5 mm at the end

Coronary arteries fill during diastole

Flow - epicardium to endocardiumpoverty/plenty

Ischemia, Injury & Infarction

102

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1. Ischemia produces ST segment

depression with or without T

inversion

2. Injury causes ST segment elevation

with or without loss of R wave

voltage

3. Infarction causes deep Q waves withloss of R wave voltage.

MyocardialIschemia

Myocardial Injury

Myocardial

Infarction

Ischemia and Infarction

103

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TRANSMURAL Injury ST

Elevation

Ischemic Heart Disease (IHD)

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Blood supply Sub-endocardial Transmural

Ischemia

Transient loss

Stable

Angina

Variant

Angina

Infarction

Persistent loss

NSTEMI

ACS

STEMI

ACS

ST Segment Depressed Elevated

105

Interpret this ECG

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NSTEM

N ST MI NSTEMI N Q MI

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Non ST MI or NSTEMI, Non Q MI

Or also called sub-endocardial Infarction

Non transmural, restricted to the sub-endocardial

region - there will be no ST or Q waves

ST depressions in anterio-lateral & inferior leads

Prolonged chest pain, autonomic symptoms like

nausea, vomiting, diaphoresis

Persistent ST-segment even after resolution of

pain

107

What are these ECGs

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STEMI and QWMI

STEMI d QWMI

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STEMI and QWMI

ST signifies severe transmural myocardial injury

This is early stage before death of the muscle tissue

the infarction

Q waves signify muscle deathThey appear late in thesequence of MI and remain for a long time

Presence of either is an indication for thrombolysis

Evolution of Acute MI

109

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ANormal ST segment and T waves

BST mild and prominent T waves

CMarked ST + merging upright T

DST elevation reduced, T,Q starts

EDeep Q waves, ST segment returning to

baseline, T wave is inverted

FST became normal, T Upright, Only Q+

Critical Narrowing of LAD

110

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Normal Q waves

111

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Notice the smallNormal Q in Lead I

Pathological Q wave

112

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112

Notice the deep & wide

Infarction Q in Lead I

113

Very Striking

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113

Hyper Acute MI

Note the hyper acute elevation of ST

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Note the hyper acute elevation of ST

The R wave is continuing with ST andthe complexes are looking rectangular

Some times tall and peaked T waves in

the precardial leads may be the only

evidence of impending infarct

Sudden appearance LBBB indicates MI

MI in Dextro-cardiaright sided leads

are to be recorded

115

Severe Chest Pain Why ?

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115

Acute Anterio-lateral MI

Note the marked ST elevations in chest leads

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116

Note the marked ST elevations in chest leads

V2 to V5 and also ST in L1 & aVL

T inversions have not appeared as yet

R wave voltages have dropped markedly in V3,

V4, V5 and V6

Small R in L1 and aVL.

117

Which wall MI ?

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Note the ST elevations in Inferior

Acute Inferior wall MI

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118

Note the ST elevations in Inferior

leads- namely L2, L3 and aVF

T inversions yet to appear

aVL lead shows complimentary

STand T inversion

Acute True Posterior MI

119

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119

Due to occlusion of the distal Left circumflex

Acute True Posterior MI

5/28/2018 Ekg Basic Ttm 2013

118/118

120

artery or posterior descending or distal rightcoronary artery

Mirror image changes or reciprocal changes in

the anterior precardial leads

Lead V1 shows unusually tall R wave (it is the

mirror image of deep Q)

V1 R/S > 1, Differential Diagnosis - RVH