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WORKSHOP ELEKTROKARDIOGRAFI

Bentuk dan nilai EKG normal, menentukan denyut jantung, aksis jantung dan gambaran hipertrofi

DEPARTEMEN KARDIOLOGI DAN KEDOKTERAN VASKULER FAKULTAS KEDOKTERAN

UNIVERSITAS SUMATERA UTARA

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KERTAS REKAMAN EKG

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Cardinal features of sinus rhythm The P wave is upright in leads I and

II Each P wave is usually followed by a QRS complex The heart rate is 60-99 beats/min

Characteristics of the P wave Positive in leads I and II Best seen in leads II and V1 Commonly biphasic in lead V1 < 3 small squares in duration < 2.5 small squares in amplitude

Nomenclature in QRS complexesQ wave: Any initial negative deflectionR wave: Any positive deflectionS wave: Any negative deflection after an R wave

The T wave should generally be at least 1/8 but less than 2/3 of the amplitude of the corresponding R wave; T wave amplitude rarely exceeds 10 mm

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DEFINISI KONFIGURASI GELOMBANG EKG

Kertas EKGHorizontal menyatakan kecepatan kertas dalam waktu1 mm = 0,04 detik 5 mm = 0,2 detikVertikal menyatakan voltage elektris jantung dalam millivolt10 mm = 1 mVPada pemeriksaan rutin kecepatan rekaman kertas EKG 25 mm/detik

1 mm = 0,1 mV

10 mm = 1 mV

1 mm = 0,04 detik

5 mm = 0,2 detik

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NILAI NORMAL :

Gelombang P : durasi : 0.08 – 0.10 / 0,12 detik

tinggi (voltase) : < 2,5 mm

Interval PR : 0,12 – 0,20 detik

Kompleks QRS : durasi : 0,06 – 0,10 detik

tinggi : > 5 mm standard limb lead ; > 10 mm chest lead

Interval QT : ♀ < 0,42 ; ♂ < 0,44 detik

Interval QTc : QT √ RR

Gelombang T : 1/8 – 2/3 dari tinggi gelombang R

Segmen ST : isoelektris

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Menentukan Heart Rate dari Electrocardiogram

Ada berbagai metode yang dapat digunakan untuk menghitung denyut jantung dari EKG, dengan kecepatan kertas EKG25 mm/sec. Salah satu metode adalah membagi 1500 dengan jumlah kotak kecil diantara dua gelombang R (garis panah merah). Sebagai contoh, rate diantara beat 1 dan 2 pada EKG diatas adalah 1500/22, yang sama dengan 68 denyut /min. Alternatif lain,adalah dengan membagi 300 dengan jumlah kotak besar (garis panah biru pada diagram), yaitu 300/4.4 (68 denyut /min). Metode lain, adalah "count off" method. Dengan menghitung jumlah kotak besar diantara gelombang R mengikuti rate: 300 - 150 - 100 - 75 - 60. Sebagai contoh jika ada 3 kotak besar diantara gelombang R denyut jantung adalah 100 denyut/min.

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MENGHITUNG DENYUT JANTUNG DARI EKG :a. Irama Sinus : 1.1500 / jarak RR (kotak kecil)

2. 300 / jarak RR (kotak besar)

b. Sinus aritmia : 1. Hitung jumlah RR dalam 5 detik atau,

2. Hitung jumlah RR dalam 6 detik atau,

3. Hitung jumlah RR dalam 10 detik,

kemudian

1. HR = (jumlah RR dalam 5 detik x 12), atau

2. HR = (jumlah RR dalam 6 detik x 10 atau), atau

3. HR = (jumlah RR dalam 10 detik x 6)

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5 6

HR = jumlah gel R x 60/5 atau jumlah gel R x 60/6

0 10

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1 kotak besar = 300

2 kotak besar = 150

3 kotak besar = 100

4 kotak besar = 75

5 kotak besar = 60

6 kotak besar = 50

7 kotak besar = 43

8 kotak besar = 37

1 2 3 4 5 6 70 8

“Count off" method

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AKSIS JANTUNG

Stimulus depolarisasi dan repolarisasi didalam jantung menyebar ke berbagai arah didalam jantung sesuai dengan posisi anatomi jantung

Aksis jantung : 1. Aksis QRS

2. Aksis gelombang P

3. Aksis gelombang T

1. Aksis QRS : arah depolarisasi gelombang QRS pada frontal plane yang ditentukan oleh posisi anatomi jantung

2. Aksis P : arah depolarisasi gelombang P pada frontal plane

3. Aksis T : arah repolarisasi gelombang T pada frontal plane

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Determining the Mean Electrical Axis (QRS axis)

Lead I : 4 – 0 = 4

Lead aVF : 12 – 2 = 10

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Lead I : 4 – 0 = 4

Lead aVF : 12 – 2 = 10

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aVF

+ = 90°

+ = 0°/360°- = 180°

- = 270°

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Axis nomenclature Lead I Lead aVF1. Normal axis (0 to +90 degrees) Positive Positive2. Left axis deviation (-30 to -90) Also check lead II. To be true left axis deviation, it should also be down in lead II. If the QRS is upright in II, the axis is still normal (0 to -30).

Positive Negative

3. Right axis deviation (+90 to +180) Negative Positive4. Indeterminate axis (-90 to -180) Negative Negative

Determining the Mean Electrical Axis (QRS axis)

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Differential Diagnosis

Left axis deviation

LVH, left anterior fascicular block, inferior wall MI, PVC from the right ventricle, WPW syndrome activating the right ventricle, Pregnancy, Ascites, Abdominal tumor, exhalation.

Right axis deviation

RVH, left posterior fascicular block, lateral wall MI, PVC from the left ventricle, WPW syndrome activating the left ventricle, Emphysema, Inhalation

ARTI KLINIS AKSIS QRS

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Causes of a Northwest axis (= axis kanan atas) (no man's land)Emphysema, hyperkalaemia lead transposition artificial cardiac pacing, ventricular tachycardia

Causes of right axis deviationnormal finding in children and tall thin adults right ventricular hypertrophy chronic lung disease even without pulmonary hypertension anterolateral myocardial infarction, left posterior hemiblock, pulmonary embolus Wolff-Parkinson-White syndrome - left sided accessory pathway atrial septal defect ventricular septal defect

Causes of left axis deviationleft anterior hemiblock, Q waves of inferior myocardial infarction artificial cardiac pacing, emphysema, hyperkalaemia Wolff-Parkinson-White syndrome - right sided accessory pathway tricuspid atresia, ostium primum ASD injection of contrast into left coronary artery

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Hipertrofi JantungHipertrofi Jantung : 1. Atrium : a. Atrium kiri

b. Atrium kanan

c. Biatrial

2. Ventrikel : a. Ventrikel kiri

b. Ventrikel kanan

c. Biventrikel

1. Pembesaran atrium : (leads II and V1).

a. Hipertrofi atrium kiri - lead II : Notched wide (> 3mm) gelombang P. - V1 : defleksi terminal negatif bertambah

b. Hipertrofi atrium kanan - lead II : Amplitudo gelombang P > 2.5mm. - V1 : defleksi terminal negatif bertambah.

c. Biatrial : gabungan

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P PulmonalHipertrofi atrium : (leads II and V1).

P Mitral

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Hipertrofi atrium kiri

Hipertrofi atrium kanan Biatrial

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2. Ventrikel : a. Ventrikel kiri

b. Ventrikel kanan

c. Biventrikel

•1. LVH: (Left ventricular hypertrophy). a. Gelombang S (terbesar) di V1 atau V2 (dlm mm) ditambah gelombang R (terbesar) di V5 atau V6 (dlm mm) > 35mm. ("voltage criteria“) b. Gelombang R > 12 mm di aVL (LVH is more likely with a "strain pattern" which is asymmetric T wave inversion in those leads showing LVH).

a. Ventrikel kiri

Summary :• S wave V1 or V2 or R wave V5 or V6

of 30mm or greater. • LAD• QRS duration upper limit of normal• Shift in the ST segment or T wave

(strain pattern) V5 and V6

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b. Ventrikel kanan

Summary of Criteria for RVHRemember, again, that the electrocardiographic criteria for chamber enlarge-ment have both low sensitivity and specificity. In summary, these are thethings to look for when trying to diagnose RVH:1. R to S ratio of >1.0 in V1 or V22. RAD3. Normal QRS duration4. Strain pattern V1 or V2 and in limb leads with the tallest R wave

•RVH: (Right ventricular hypertrophy). Gelombang R > gelombang S di V1 dan Gelombang R menurun dari V1 sampai V6.

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c. Biventrikel

Merupakan gabungan kriteria RVH dan LVH

ARTI KLINIS HIPERTROFI JANTUNG :1. Pembesaran atrium kanan : ASD, PAPVR, Ebstein anomali

2. Pembesaran atrium kiri : Mitral stenosis, Mitral regurgitasi

3. Hipertrofi ventrikel kiri : Hipertensi, Aortic stenosis, Aortic regurgitasi, Mitral regurgitasi, VSD, PDA

4. Hipertrofi ventrikel kanan : PPOK, ASD, Pulmonal stenosis

27RAE LAE

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RVH LVH

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SISTEM HANTARAN JANTUNG

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BUNDLE BRANCH BLOCK :1. KOMPLIT : - kanan : RIGHT BUNDLE BRANCH BLOCK (>0,12”) - kiri : LEFT BUNDLE BRANCH BLOCK2. INKOMPLIT : - kanan : INCOMPLETE RIGHT BUNDLE BRANCH BLOCK (<0,12”) - kiri : INCOMPLETE LEFT BUNDLE BRANCH BLOCK

1. RIGHT BUNDLE BRANCH BLOCK (RBBB)2. LEFT BUNDLE BRANCH BLOCK (LBBB)3. LEFT ANTERIOR HEMI BLOCK (LAH)4. LEFT POSTERIOR HEMI BLOCK (LPH)

INTRAVENTRICULAR CONDUCTION DELAY

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Diagnostic criteria for right bundle branch block1. QRS duration >0.12 s2. A secondary R wave (R’) in V1 or V23. Wide slurred S wave in leads I, V5, and V6Associated feature1. ST segment depression and T wave inversion

in the right precordial leads

RIGHT BUNDLE BRANCH BLOCK (RBBB)

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Diagnostic criteria for left bundle branch block1. QRS duration of >0.12 s 2. Broad monophasic R wave in leads 1, V5, and V63. Absence of Q waves in leads V5 and V6Associated features1. Displacement of ST segment and T wave in an opposite direction to the

dominant deflection of the QRS complex (appropriatediscordance)2. Poor R wave progression in the chest leads3. RS complex, rather than monophasic complex, in leads V5 and V64. Left axis deviation—common but not invariable finding

LEFT BUNDLE BRANCH BLOCK (LBBB)

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KRITERIA LAH :1. LAD, sering mendekati −60 derjats2. Gelombang R kecil di lead III3. Gelombang Q kecil di lead I4. Normal QRS durasi

LEFT ANTERIOR HEMIBLOCKS

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KRITERIA LPH :1. RAD, sering mendekati +120 derjats2. Gelombang Q kecil di lead III3. Gelombang R kecil di lead I4. Normal QRS durasi

LEFT POSTERIOR HEMIBLOCKS

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TERIMA KASIH