Elektrokardiografi Dasar

Heart Excitation Related to ECG

Figure 18.17
 What is an ECG?
The electrocardiogram (ECG) is a
representation of the electrical events of the
cardiac cycle.

Each event has a distinctive waveform, the

study of which can lead to greater insight
into a patients cardiac pathophysiology.
 BASIC TERMINOLOGY
Arrhythmia: Abnormal rhythm
Baseline:Flat, straight, isoelectric line
Waveform: Movement away from the baseline,
up or down
Segment: A line between waveforms
Interval: A waveform plus a segment
Complex: Combination of several
waveforms
12 ECG LEADS
ECG Limb Leads
ECG Augmented Limb Leads
ECG Precordial Leads
 The ECG Paper
Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV
Gelombang P : depolarisasi kedua atrium
Gelombang QRS : Depolarisasi kedua Ventrikel
Gelombang T : Repolarisasi Kedua Ventrikel
 Pola Membaca EKG
Irama
Rate QRS
Aksis QRS
Morfologi Gelombang P
Interval PR
Durasi QRS
Morfologi QRS
Deviasi Segmen ST
Morfologi Gelombang T
Morfologi Gelombang U
Lain-lain (LVH,LV Strain,BBB,
QT interval) Nilai Normal :
Kesimpulan EKG Interval PR 0,12 s/d 0,20
Durasi QRS 0,04 s/d 0,12
Aksis Normal - 300 s/d + 1100
 Pola Membaca EKG
Irama
Rate QRS
Aksis QRS
Morfologi Gelombang P
Interval PR
Durasi QRS
Morfologi QRS
Deviasi Segmen ST
Morfologi Gelombang T
Morfologi Gelombang U
Nilai Normal :
Lain-lain (LVH,LV
Strain,BBB, QT interval) Interval PR 0,12 s/d 0,20
Durasi QRS 0,04 s/d 0,10
Aksis Normal - 300 s/d + 1100
 Rhythm Analysis

Step 1: Calculate rate.

Step 2: Determine regularity.
Step 3: Assess the P waves.
Step 4: Determine PR interval.
Step 5: Determine QRS duration.
Step 1: Calculate Rate
3 sec 3 sec

Option 1
Count the # of R waves in a 6 second rhythm
strip, then multiply by 10.
Reminder: all rhythm strips in the Modules are
6 seconds in length.
Interpretation?
9 x 10 = 90 bpm
Step 1: Calculate Rate

R wave

Option 2
Find a R wave that lands on a bold line.
Count the # of large boxes to the next R
wave. If the second R wave is 1 large box
away the rate is 300, 2 boxes - 150, 3 boxes -
100, 4 boxes - 75, etc. (cont)
Step 1: Calculate Rate

Option 2 (cont) : 1500/ R-R

Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50

Interpretation? Approx. 1 box less than

100 = 95 bpm
Step 2: Determine regularity
R R

Look at the R-R distances (using a caliper or

markings on a pen or paper).
Regular (are they equidistant apart)?
Occasionally irregular? Regularly irregular?
Irregularly irregular?
Interpretation?
Regular
Step 3: Assess the P waves

Are there P waves?

Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation?
Normal P waves with 1 P
wave for every QRS
Step 4: Determine PR interval

Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)

Interpretation?
0.12 seconds
Step 5: QRS duration

Normal: 0.04 - 0.12 seconds.

(1 - 3 boxes)

Interpretation?
0.08 seconds
 Rhythm Summary

Rate 90-95 bpm

Regularity regular
P waves normal
PR interval 0.12 s
QRS duration 0.08 s
Interpretation?
Normal Sinus Rhythm
Normal Sinus Rhythm (NSR)

Etiology: the electrical impulse is formed in

the SA node and conducted normally.

This is the normal rhythm of the heart;

other rhythms that do not conduct via the
typical pathway are called arrhythmias.
 NSR Parameters

Rate 60 - 100 bpm

Regularity regular
P waves normal
PR interval 0.12 - 0.20 s
QRS duration 0.04 - 0.12 s
Any deviation from above is sinus tachycardia,
sinus bradycardia or an arrhythmia
 Arrhythmia Formation
Arrhythmias can arise from problems in
the:
Sinus node

Atrial cells

AV junction

Ventricular cells
Aksis QRS
 Contoh Pembacaan EKG
Irama SR, QRS rate 70x/mnt, QRS Axis
+450, Gel P normal, Interval PR 0,18,
Durasi QRS 0,08, rSR di V1-V2, ST
Depresi 1-2mm di II,III,aVF, T inverted
simetris di II,III,aVF.

Kesan : RBBB inkomplet dengan ST depresi

dan T inverted pada sadapan inferior.
 EKG Abnormal
Penyakit Jantung Koroner
Sindroma Koroner Akut
Takiaritmia
Bradiaritmia
Gangguan Elektrolit
Kelainan Struktur Jantung : Kelainan Katup,
Pembesaran Ruang Jantung, Efusi Perikard,
penyakit jantung bawaan.
 ACUTE CORONARY SYNDROME

No ST Elevation ST Elevation

NSTEMI

Unstable Angina Qw Myocardial

N Qw Myocardial Infarction
Infarction
AHA Guidelines, 2000
 Atherosclerosis Timeline
Foam Fatty Intermediate Atheroma Fibrous Complicated
cells streaks lesion plaque lesion rupture

Endothelial Dysfunction
From First Decade From 3rd decade From 4th decade
From 3rd decade From 4th decade

Growth mainly by lipid accumulation Smooth Thrombosis

muscle and hematoma
collagen
 Infark Infark
Transmural Subendokard
Inferior myocardial infarction
Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF

Mid LAD occlusion
after the first septal
ECG : large anterior MI
perforator (arrow)
Occlusion of diagonal
branch ( arrow )

ST elevation in I and aVL

 Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6

with precordial ST depression
Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF

Early repolarization
Unstable angina
Subendocardial ischemia.
Anterolateral ST-segment depression
Acute anteroseptal myocardial infarction.
Hyperacute T-wave changes are noted
Acute anterolateral myocardial infarction
High lateral infarction
Lateral myocardial infarction
Inferior myocardial infarction
Inferior myocardial infarction.
Inferior Q waves with T-wave inversions
Acute inferoposterior myocardial infarction
Left ventricular aneurysm
Right bundle branch block
Left bundle branch block
 Takiaritmia
Sinus Tachycardia
Accelerated Atrial Tachycardia/Paroxysmal Atrial
Tachycardia
Atrial Flutter
Atrial Fibrillation
Reentrant Junctional Tachycardia (Nodal & Bypass)
Multifocal Atrial Tachycardia
Ventricular Tachycardia
 Physiologic Basis of Pacemaker
Cells

Pacemaking &
Conduction System
Perbedaan lokal pola potensial aksi
 PACE MAKER ACTIVITY
mVolt
Ca2+
influx K+
0 If efflux
influx
-20

-40 TP

-60 MDP
Phase 4 depolarization

Time

Leonardo S Lilly,Pathophysiology of heart disease, 1998

 PACE MAKER ACTIVITY
mVolt

-20

-40 TP

-60 MDP

-90 Phase 4 depolarization More negatuveMDP

Time

Leonardo S Lilly,Pathophysiology of heart disease, 1998

Konduksi di Atrial:
electrical impulse
originates in the SA
node located high in
the RA near SVC.
Impulse leaves the
SA node and spreads
radially across both
atria and through
anterior, middle and
posterior internodal
tracts which conduct
more rapidly.
Conduct to the LA via
bundle of Bachman.
AVNRT:
Slow-fast form 81.4% (antegrade conduction
over the slow pathway and retrograde
conduction over the fast pathway) / typical
Atypical:
Slow-slow 13.7%
Fast-slow 4.9%
ATRIOVENTRICULAR REENTRANT
TACHYCARDIA
Involved a reentrant circuit utilising the AV
node and accessory AV connection or
pathway, and the intervening areas of
atrial and ventricular myocardium.
Orthodromic form, antegrade conduction
occurs via the AV node and retrograde
conduction via the accessory pathway
narrow complex tachy
Antidromic form (10%) reverse direction
wide complex tachy
 Extra Nodal Accessory
Pathways
Extra nodal pathways that connect the
myocardium of the atrium and the
ventricle across the AV groove.
Delta waves detectable on an ECG 0.15 to
0.25% in general population
AP that are capable of only retrograde
conduction are reffered to as concealed,
whereas those capable of anterograde
conduction are manifest
 Classification of AP
on the basis of their location:
Along mitral annulus
Along tricuspid annulus

Type of conduction
Anterograde conduction
Retrograde
both

Type of conduction
Decremental (progressive delay in AP conduction in
response to increased paced rates)
Non decremental
 WPW syndrome
Short PR interval + delta waves
Have both preexitation and tachyarrhythmias.
AVRT is the most common arrhytmia
Antidromic AVRT occurs only 5 10% of patients
with WPW syndrome.
AF is a potentially life-threatening in WPW. If an
AP has a short anterograde refractory period,
then rapid repetitive conduction to the ventricles
during AF can result in VF. 1/3 WPW also have
AF.
 EP Study
Inducing arrhythmias and recording intracardiac
ECG from various locations within the heart.
If reentrant rhythm is easier to induce with LA
pacing (from the coronary sinus) than with RA
left sided bypass tract.
Induce with ventricular pacing macroreentrant
tachycardias not an AVNRT
 EP Study
Site of the conduction delay. Beat that
initiates reentry commonly is accompanied
by conduction delay
Tachycardia (echo) zone: range of
coupling intervals of premature beats that
will initiate reentrant tachycardia.
Macroreentry Microreentry

Atrial Flutter Atrial Fibrillation

Macroreentrant and Microreentrant
Tachycardias
A Fib/Flutter spectrum
Types of RJT
Junctional Tachycardia (RJT)
Reentry within the atrioventriocular (AV) junction can
result in a single junctional premature beat (JPB) or in
sustained junctional tachycardia
Produces narrow-complex regular tachycardia without
preceding atrial depolarization waves
RJTs often produce retrograde atrial depolarization but
these waves are usually buried within the QRS complex
RJT Schematic diagram
Delta Waves
WPW Syndrome types
Normal Sinus Rhythm

Rhythm : Regular
Rate : 60 100
P wave : Normal in configuration; precede each QRS
PR : Normal ( 0. 12 0.20 seconds )
QRS : Normal ( less than 0.12 seconds )
First-degree AV block

Rhythm : Regular
Rate : Usually normal
P wave : Sinus P wave present; one P wave to each QR
PR : Prolonged ( greater than 0.20 seconds )
QRS : Normal
Second -degree AV block, Mobitz I

Rhythm : Irregular
Rate : Usually slow but can be normal
P wave : Sinus P wave present;
some not followed by QRS complexes
PR : Progressively lengthens
QRS : Normal
Second-degree AV block, Mobitz II

Rhythm : Regular usually;

can be irreguler if conduction ratios vary
Rate : Usually slow
P wave : Two, three, or four P waves before each QRS
PR : PR interval of beat with QRS is constant;
PR interval may be normal or prolonged
QRS : Normal if block in His bundle;
wide if block involves bundle branches
Third-degree AV block

Rhythm : Regular
Rate : 40 60 if block in His bundle;
30 40 if block involves bundle branches
P wave : Sinus P wave present; bear no relationship to QRS
can be found hidden in QRS complexes and T wav
PR : Varies greatly
QRS : Normal if block in His bundle;
wide if block involves bundle branches
Mobitz I
Mobitz II atrioventricular block
Atrioventricular dissociation secondary to complete heart block
High-grade atrioventricular block
Incomplete right bundle branch block
Right bundle branch block
Left bundle branch block
Wolff-Parkinson-White syndrome
Wolff-Parkinson-White syndrome
 NBG Code Review
I II III IV V
Chamber Chamber Response Programmable Antitachy
Paced Sensed to Sensing Functions/Rate Function(s)
Modulation

V: Ventricle V: Ventricle T: Triggered P: Simple P: Pace

programmable
M: Multi-
A: Atrium A: Atrium I: Inhibited S: Shock
programmable

D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating D: Dual (P+S)

O: None O: None O: None R: Rate modulating O: None

S: Single S: Single O: None

(A or V) (A or V)
Subhanallah 32 year-old with TAVB
AVRT