Dasar-Dasar

Electrocardiography
 Electrocardiography
• Electrical phenomena, science
• Simple, cheap, usefull but limited
• Almost all arrhythmias
• Infarction or ischaemia
• LVH
• Electrolyte imbalance
Bipolar standard leads I, II and III
 The unipolar
limb leads and
their axes
Locations of unipolar
precordial leads
The precordial leads and their axes
 ECG Information
• The 12 leads allow
tracing of electric
vector in all three
planes of interest
• Not all the leads are
independent, but are
recorded for
redundant
information
Electrocardiographic views of the heart
Regions of the Myocardium

Lateral
I, AVL,
V5-V6

Anterior /
Inferior Septal
II, III, aVF V1-V4

PED 596
ECG recording
Electrical phenomena
Electrical phenomena
 Recording

R
Waves
T
P
U?

Q
S Katrina Kardos, MD
PGY-3
Albany Medical Center
Nomenclature
Cardiac Cycle
 Upward/
Positive deflection
Garis Isoelektris/ baseline

Downward/
Negative deflection

Normal ECG pattern

 ELEKTROKARDIOGRAM
N a m a : ……………………………….........
Kalibrasi : voltase……...mV, speed…………mm/detik
Heart rate : .............../minute,  teratur tidak teratur
rhythm : ..............................
Gelombang P
Kontour :  normal tidak normal, Alasan:.......................................................
Konfigurasi:  normal tidak normal, Alasan: ..................................................
Durasi : ……………detik  normal tidak normal
Amplitudo: ……………mV  normal tidak normal
PR interval ……………detik normal tidak normal
Konfigurasi gelombang Q:  normal tidak normal, Alasan:.......................................
Kompleks QRS:
Durasi :  normal tidak normal, Alasan:...........................................................
Axis : ………….....……derajat  Normal LAD  RAD Superior
Konfigurasi:  normal tidak normal, Alasan:.....................................................
Segmen ST :  normal tidak normal, Alasan:....................................................
Gelombang T :  normal tidak normal, Alasan:....................................................
Gelombang U :  normal tidak normal, Alasan:...................................................
QTc : …................…………................detik  normal tidak normal
Index hipertrofi ventrikel:
LVH: Score Romhilt-estes: ……………............................................................
.................................  normal tidak normal
RVH: R/S ratio di V1: …………….............................  normal tidak normal
Kesimpulan:
 Diagnosis

1. Basic rhythm: sinus, junctional, Ventricular, Atrial Fibrillation

(AF), Ventricular Fibrillation (VF), Supra-Ventricular
Tachycardia (SVT), Ventricular Tachycardia (VT)
2. Heart rate
3. QRS complex axis
4. Abnormality

Example:
• sinus rhythm 80 x/minute, normal axis (normal sinus
rhythm)
• sinus rhythm 80 x/minute, LAD, LVH
• sinus rhythm 75 x/minute, RAD, RA abnormality, RVH
• sinus bradycardia 50x/minute, normal axis, Inferior LV wall
ischaemic
• sinus tachycardia 110 x/minute, normal axis, acute
myocardial infarction on anterior LV wall
 ECG paper

Small box : 1 x 1 mm : 0.1 mV x 0.04 s

Moderate box: 5 x 5 mm : 0.5 mV x 0.2 s

Big box : 25 x 25 mm : 2.5 mV x 1 s

 S1

S½

Paper speed and voltage calibration in ECG recording

MENGHITUNG LAJU JANTUNG :
A. Jarak R – R :

-1 kotak sedang = 300 x / minute

-2 kotak sedang = 150 x / minute
-3 kotak sedang = 100 x / minute
-4 kotak sedang = 75 x / minute
-5kotak sedang = 60 x / minute
-6 kotak sedang = 50 x / minute

B. Hitung jumlah R- R dalam 6 kotak besar = 6 detik

Jumlah R x 10 = heart rate / minute

C. 1500 / jarak R-R ( dlm mm ) = heart rate / minute

 Rapid Estimation of Heart rate

Start Start
75 38
300 150 100 300 150 100 75 60 50 43

R R R R

Heavy black line Heavy black line

Mnemonic
 Rhythm
Pace maker
Sinus Rhythm

Amplitudo: voltase

ISO ELECTRICE

Durasi
 Rhythm

Pace maker Junctional

Rhythm

Amplitudo: voltase

ISO ELECTRICE

Durasi
Normal Sinus Rhythm
• Rate: 60-100 b/min
• Rhythm: regular
• P waves: upright in
leads I, II, aVF
• PR interval: < .20 s
• QRS: < .10 s
 P wave

Contour :
-normal : smooth, monophasic (except V1)
-abnormal: monophasic > 0.25mV or P biphasic (notched)
Configuration :
-normal : positive at I,II, aVF, V3-V6, negative at aVR
-abnormal: negative at II,III or aVF,
may be an inversal leads or junctional rhytm
Duration (horisontal axis): 0.08-010 second (2-2.5 small box)
Amplitudo (vertikal axis): ≤ 0.25 mV or 2.5mm or 2.5 small box
PR interval: 0.12-0.20 second (3-5 small box),
-short PR interval: may be preexitacion syndrome
-long PR interval: may be AV blokade
 Direction of the
normal frontal and
horizontal plane P
vectors with
resulting P wave in
the 12-lead ECG
P wave
 Q wave
Configuration :
-normal : small q
-abnormal : patologic Q, wide (≥ 0.04s)
and deep ( 4mm or ≥ 25% R)
Lead of abnormal Q: old infarction area
-lead V1-V4 : anteroseptal
-lead V1-V6, I and aVL : anterior extensive
-lead V4-V6, I and aVL : anterolateral
-lead V3-V5 atau V1-V6: anterior
-lead II,III and aVF : inferior
-lead I and aVL : high lateral
-Mirror image of V1-V3 to horisontal line: true posterior

The significance of Q for old infarction if more than 1 lead

 QRS complex
• Capital letter for deflection > 5mm
(Q,R,S),
• Small letter for deflection < 5mm (q,r,s).
• QRS complex could be variable
• Duration:
 normal: < 0.12s (narrow QRS)
 abnormal: > 0.12s (wide QRS/bizare)
QRS complex configuration
 Genesis of left
ventricular epicardial
complex
 Genesis of right
ventricular epicardial
complex
 Genesis of
transitional zone
ventricular epicardial
complex
Genesis of right
ventricular
cavity complex
 Electric Axis of the Heart
• This axis changes during cardiac cycle as shown earlier –
generally lies between +30º and -110º in the frontal plane
and +30º and -30º in the transverse plane
• Clinically, it is generally taken where the QRS complex
has the largest positive deflection
• Note: Often use –aVR
• Deviation to R: increased activity in R vent. – obstruction
in lung, pulmonary emboli, some heart disease
• Deviation to L: increased activity in L vent. –
hypertension, aortic stenosis, ischemic heart disease
QRS frontal axis
 QRS frontal axis

• normal: -30 to +110

• LAD (left axis deviation): -30 to -90
• RAD (right axis deviation): +110 to -180
• Superior (extreme RAD): +180 to -90
Determination of
axis deviation
QRS axis: look at the net deflection in I and aVF
QRS frontal axis
Horizontal plane electrocardiographic patterns
(QRS horisontal axis)
QRS horisontal axis
QRS horisontal axis
 ST Segment

•Normal: Isoelektris
•Abnormal:
Depol. Repol. Restoration of - Elevation: > 1mm
ionic balance - Depression: horizontal,
downsloping,
upsloping
> 1mm was significant;
deeper: more specific
ST Segment depression : Ischaemic area

Lead of ST depression: ischaemic area

-lead V1-V4 : anteroseptal
-lead V1-V6, I and aVL : anterior extensive
-lead V4-V6, I and aVL : anterolateral
-lead V3-V5 : anterior
-lead II,III and aVF : inferior
-lead I and aVL : high lateral
 T Wave

• Normal adult: positive T wave in all lead except aVR and V1.
• Abnormal: - Tall T/ hyperacute T: Injury/ Acute Infarction
- Negative T (vector of T was on opposite direction
than QRS vector/ T inversi): myocardial ischaemia,
more specific if arrow head T inversion.
• Area of injury or ischaemic
 Nomogram for
rate correction of
Q-T interval

Bazett’s formula
QT
QTc =
 R-R
 U Wave

Normal: unpresent U wave

(interferrence with T wave).

Abnormal: prominent U wave,

particularly in V2 and V3 (suspect
hypokalemia)
Refference

1. Mirvis DM, Goldberger AL. Electrocardiography. In:

Braunwald’s Heart Disease, A Textbook of Cardiovascular
Medicine. Eighth Edition. Philadelphia: Saunders Elsevier;
2008. p. 155-183.
2. Ferry DR. ECG In 10 Days. Second Edition. Singapore: Mc
Graw Hill; 2007. p. 37-93 and 151-193.
3. The Alan E. Lindsay. ECG Learning Center in Cyberspace.
http://library.med.utah.edu/kw/ecg/image_index
4. Pratanu S. Buku Pedoman Kursus Elektrokardiografi.
Surabaya; PT. Karya Pembina Swajaya; 2000. h. 19-36.