13th Block

Circulation
system

Electrocardiography

P. Pujowaskito

2009 General Ahmad Yani University

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

Inferior
II, III, aVF

Anterior /
Septal
V1-V4
PED 596

ECG recording

Electrical phenomena

Electrical phenomena

Recording

Waves
T
P

U?
Q
S

Katrina Kardos, MD
PGY-3
Albany Medical Center

Nomenclature

Cardiac Cycle

Upward/
Positive deflection
Garis Isoelektris/
baseline

Normal ECG pattern

Downward/
Negative deflection

ELEKTROKARDIOGRAM
N a m a : .........
Kalibrasi : voltase...mV, speedmm/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:

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

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
300 150 100

Start

75

Heavy black line

300 150 100 75

Heavy black line

Mnemonic

60

50

43

38

Amplitudo: voltase

Pace maker

Rhythm
Sinus Rhythm

ISO ELECTRICE

Durasi

Rhythm

Amplitudo: voltase

Pace maker

ISO ELECTRICE

Durasi

Junctional
Rhythm

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: infarction 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
-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 +30 and -110 in the frontal plane
and +30 and -30 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

Depol.

Repol.

Restoration of
ionic balance

Normal: Isoelektris
Abnormal:
- Elevation: < 1mm
- 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

Bazetts formula

QTc = QT
R-R

U Wave
Normal: unpresent U wave
(interferrence with T wave).
Abnormal: prominent U wave,
particularly in V2 and V3
(suspect hypokalemia)

RIGHT ATRIAL HYPERTROPHY

P prominent: tall 2.5 mm
and spike (interval 0.11
detik) at lead II, III dan aVF
Initial deflection of P wave at
V1 1.5 mm
COPD or cor pulmonale, so we
call P Pulmonal

LEFT
ATRIAL
HYPERTROPHY
Wide P Interval 0.12s at
lead II and notched (two
peak)
P wave with negative
terminal deflection at V1,
duration 0.04s and
deeper 1 mm
P wave of left atrial
abnormality was called P
Mitral

LVH index: Romhilt-Estes score

LEFT VENTRICULAR HYPERTROPHY (LVH) criteria
1. LV by voltage:
R or S 20 mm at extremities lead, or
S at RV complex (V1-V2) 25 mm, or
R at LV complex (V5-V6) 25 mm, or
S at V1-V2 plus R at V5-V6 35 mm
2. ST Depression and T inversion at
LV complex V5-V6 (strain pattern )
3. Left Atrial Abnormality (P mitral)
4. QRS complex frontal axis < -15 (LAD)
5. Prolong interval of QRS complex at V5-V6, 0.09s
or ventricular activation time 0.04s

If score < 5 : definitive LVH

If score =4 : porobable LVH

Score
3

3
3
2
1

RIGHT VENTRICULAR HYPERTROPHY (RVH):

1. Reversal R/S ratio, at V1 < 1, at V6 < 1
2. QRS complex frontal axis deviate to the right
(RAD)
Aux criteria: ventricular activation time at V1
0.035s, ST depression and T inversion at V1, S at I,
II, and III

Acute Coronary Syndrome

Ischaemia: mild and reversible, ST T changes
Injury: moderate, but reversible
Necrosis/ myocardial
Infarction: permanent,
patologic Q

ST Elevation Myocardial Infarction (STEMI)

Diagnosis
1Basic rhythm: sinus, junctional, Ventricular, Atrial
Fibrillation (AF),
Ventricular Fibrillation (VF), SupraVentricular 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

13th Block
Circulation
system
TQ, 4 your
attention
2009 General Ahmad Yani University

Refference
1Ferry DR. ECG In 10 Days. Second Edition. Singapore:
Mc Graw Hill; 2007. p. 37-93 and 151-193.
2Mirvis DM, Goldberger AL. Electrocardiography. In:
Braunwalds
Heart
Disease,
A
Textbook
of
Cardiovascular Medicine. Eighth Edition. Philadelphia:
Saunders Elsevier; 2008. p. 155-183.
3Pratanu S. Buku Pedoman Kursus Elektrokardiografi.
Surabaya; PT. Karya Pembina Swajaya; 2000. h. 19-36.
4The Alan E. Lindsay. ECG Learning Center in
Cyberspace.
http://library.med.utah.edu/kw/ecg/image_index