ELECTROCARDIOGRAPHY

CHRISTIAN YOSAPUTRA, MD
Department of Emergency RSPI Puri Indah
Pondok Indah Hospital Group ( PIHG ) Jakarta 2014
ANATOMY OF THE HEART
 The hea
sue (FIG
tive sac
has an
fibrous
pericard
lubricati
traction.
epicardiu
thick m
cardium
lines the
My
sue foun
appeara
has som
These pr
sion of e

HEART
To preve
Figure 1.1 ■ Location of the heart. traction,
 Chapter 1 An

cle. The tricusp

um and ventric
of three feathe
which has onl
The AV valves
the intra-atria
pressure durin
ular contractio
The other
functions by si
flow of blood b
The two semi
located in the
the pulmonary
the left ventric

Endocardium HEART CHAM

Myocardium Parietal The heart is a h
(heart muscle) pericardium of connective t
Epicardium Fibrous pericardium (FIG. 1-4). The
(visceral pericardium) (pericardial sac) right and left
Pericardial cavity blood as it en
chambers.
Figure 1.2 ■ Layers of the heart. The more
heart are called
 to collective
Pulmonary semilunar
valve
CORONAR
Coronary artery
The corona
Aortic semilunar ply to the h
valve Tricuspid
valve

Superior ven
Ri
pulmonary art

Rig
pulmonary vein
Pulmona
Fibrous semilunar val
skeleton Right atrium
Tricu
Mitral valve v
Inferior vena

Posterior
Figure 1.3 ■ Valves of the heart. The atria have been removed in
this superior view. Figure 1.4 ■
 Brachiocephalic Left common carotid artery
artery Left subclavian artery
Superior vena cava
Aortic arch
Right
Left pulmonary artery
pulmonary artery 01Jones ECG (F)-01 5/21/07 1:08 PM Page 4
Left atrium
Right Left pulmonary veins
pulmonary veins
Mitral valve
Pulmonary
semilunar valve Left ventricle
Aortic semilunar
Right atrium
valve
Tricuspid
valve Interventricular4 ECG Success
septum
Inferior vena cava
Apex Aorta Coronary sinus
Chordae Right
tendineae ventricle Papillary Left coronary artery
muscles
Anterior
Figure 1.4 ■ Heart chambers and great vessels. descending branch
Circumflex branch
Great cardiac
vein
Posterior
artery and
vein

Small
Right coronary artery cardiac vein
A Right coronary vein B
Figure 1.5 ■ Coronary vessels. (A) Coronary vessels in anterior
view. (B) Coronary vessels in posterior view.
 SA node
Left bundle
Internodal branch
pathways
AV Node
Purkinje
fibers
Bundle of His

Right bundle
branch

Figure 1.10 ■ Conduction system of the heart.

CARDIAC CYCLE
BASIC ECG
SUPRAVENTRICULAR
RHYTHMS
VENTRICULAR RHYTMS
ISCHEMIC HEART
DISEASE
HEART BLOCKS
 CHAMBER
ENLARGEMENT
EPONYMOUS
SYNDROMES
MISCELLANEOUS
DISORDERS
SUMMARY SEQUENCE OF
ECG INTERPRETATION
Table 4.5. Summary of Sequence of ECG Interpretation

1. Calibration
• Check 1.0 mV vertical box inscription (normal standard ! 10 mm)
2. Rhythm
• Sinus rhythm is present if
• Each P wave is followed by a QRS complex
• Each QRS is preceded by a P wave
• P wave is upright in leads I, II, and III
• PR interval is "0.12 sec (3 small boxes)
• If these criteria are not met, determine type of arrhythmia (see Chapter 12)
3. Heart rate
• Use one of three methods:
• 1,500/(number of mm between beats)
• Count-off method: 300—150—100—75—60—50
• Number of beats in 6 sec # 10
• Normal rate ! 60–100 bpm (bradycardia $60, tachycardia "100)
4. Intervals
• Normal PR ! 0.12–0.20 sec (3–5 small boxes)
• Normal QRS % 0.10 sec (%2.5 small boxes)
• Normal QT % half the R–R interval, if heart rate normal
5. Mean QRS axis
• Normal if QRS is primarily upright in leads I and II (&90° to '30°)
• Otherwise, determine axis by isoelectric/perpendicular method
6. P wave abnormalities
• Inspect P in leads II and V1 for left and right atrial enlargement
7. QRS wave abnormalities
• Inspect for left and right ventricular hypertrophy
• Inspect for bundle branch blocks
• Inspect for pathologic Q waves: What anatomic distribution?
8. ST segment or T wave abnormalities
• Inspect for ST elevations:
• ST segment elevation MI
• Pericarditis (see Chapter 14)
• Inspect for ST depressions or T wave inversions:
• Myocardial ischemia or non-ST elevation MI
• Usually accompany ventricular hypertrophy or bundle branch blocks
• Metabolic or chemical abnormalities (see Fig. 4.27)
9. Compare with patient’s previous ECGs