Habibie Arifianto

PPDS Kardiologi & KV FK UNS

Heart Anatomy

Heart Anatomy - Valves

Heart Anatomy Vascularization

Conduction System of
the Heart

Depolarization &
Repolarization

The heart cell

specialties
Property

Ability

Automaticity

Generates electrical impulses without

involving the nervous system

Excitability

Responds to electrical stimulaton

Conductivity

Passes or propagates electrical impulses

from cell to cell

Contractility

Shortnens in response to electrical

stimulation

Conduction System

Sinoatrial Node (SA Node)

Internodal Pathway

Rhythmic rate : 60 100 bpm

Anterior, middle, posterior pathways

Atrioventricular Node (AV Node)

Regions : atrionodal (AN), nodal (N),

nodal-His (NH)
Delays the impulse

Conduction System

Bundle of His

Bundle Branches

Rate : 40 60 bpm
LBB & RBB
LBB : anterior, posterior, septal
fascicles

Purkinje Fibers

Rate : 20 40 bpm

How its all begun?

Wilhelm Einthoven

Semarang , Oost
Indische
1860

Development of the
machine!

Standard EKG Leads

Standard Bipolar Limb Leads

I
II
III

Standard Unipolar Limb Leads (Augmented)

aVR (augmented voltage right)

aVL (augmented voltage left)
aVF (augmented voltage foot)

Standard Precordial Leads

V1, V2
V3, V4
V5, V6

Extremity Leads
Placement

Bipolar Limb Leads

(Einthoven Leads)

Augmented Unipolar Limb Leads

(Wilson Leads)

Standard Precordial
Leads

Precordial Leads
Placement

Standard Precordial Leads Placement

Lead V1 : 4th ICS right sternal border

Lead V2 : 4th ICS left sternal border
Lead V3 : between V2-V4
Lead V4 : 5th ICS left mid clavicular
Lead V5 : 5th ICS left anterior
axillaries line
Lead V6 : 5th ICS left mid axillaries
line

Additional Precordial
Leads
Lead V7 : 5th ICS left posterior axillaries line
Lead V8 : 5th ICS left posterior scapular line
Lead V9 : 5th ICS left posterior vertebral line
Lead V3R-V5R : Right side chest, equal
position with standard V3, V4, V5

Performed when theres an acute

myocardial infarction on inferior leads

Reverse Precordial
Leads

Posterior Precordial
Leads

EKG paper

EKG wave form

nomenclature

Normal EKG wave

P wave
No more than 2.5 mm in
height
No more than 0.11 sec in
duration
Positive : I,II,aVF,V
2-6

May be positive, negative, or

biphasic : III,aVL,V1

Normal EKG wave

PR interval
0.12 0.20 sec in adult,
may be shorter in children
and longer in elders

Normal EKG wave

QRS Complex
0.06 0.10 sec
Q : 1st negative deflection after P
R : 1st positive deflection after P
S : negative deflection
after R

Normal EKG wave

ST Segment
Isoelectric (flat)

Normal EKG wave

T wave
Limb leads : no more than 5 mm
(height)
Precordial leads : no more than 10
mm (height)

R wave progression
Progression of R waves on
precordial leads
Poor R-wave progression :
Infarction (anteroseptal)
LBBB
LVH
Dilated Cardiomyopathy
Severe COPD (emphysema)

Territorial EKG
Leads

View of Heart

I, aVL

High Lateral

II, III, aVF

Inferior

V1, V2

Septal

V3, V4

Localized Anterior

V5, V6

Lateral

V7, V8, V9

Posterior

V3R, V4R, V5R

Right Ventricel

V1-V4

Anteroseptal

V3-V6

Anterolateral

V1-V6

Anterior

I, aVL, V1-V6

Extensive anterior

How to read an EKG?

1.
2.
3.
4.
5.

Heart Rate
Rhythm
Axis
Enlargement/ hypertrophy
Injury (ischemic/ infarct)

Heart Rate
Large Boxes 300/R-R interval
Small Boxes 1500/R-R interval
Six-Second Strip Method
count how many complete QRS
complexes in 6 sec strip x 10

Try to count this one..

Try to count this EKG rate

How about this?

How about the arrhythmia

Heart Rate

Triplets methods

Help count the rate!

Now, try for this one

 P QRS relationships
P waves?
Regularity of R R
intervals
Wide/ narrow QRS
complex

4
3
2
1

Rhythm

Rhythm

Axis

Axis

Lead
I

Lead
aVF

Normo Axis

Left Axis
Deviation

Right Axis
Deviation

Extreme Right
Axis Deviation

Axis

Extreme Right Axis Deviation (no

mans land)
emphysematous
hyperkalemia
Leads transposition
artificial cardiac pacing
Ventricular Tachycardia

Axis

Right Axis Deviation

Normal on children and skinny adults

Right Ventricular Hypertrophy
Chronic lung disease
Anterolateral MCI
Left posterior hemiblock
Pulmonary Embolism
Wolff-Parkinson-White syndrome
Left sided accessory pathway
Atria septal defect

Axis

Left Axis Deviation

Left anterior hemiblock

Inferior MCI
Artificial cardiac pacing
Emphysema
Hiperkalemia
Wolff-Parkinson-White syndrome - right sided
accessory pathway
Tricuspid atresia
Ostium primum ASD
Left Ventricular Hypertrophy

Axis

Try to guess the axis..

Axis

How about this?

Axis

One more

Enlargement

Right Atrial Enlargement

Left Atrial Enlargement
Right Ventricular Hypertrophy
Left Ventricular Hypertrophy

Enlargement (Atrial)
Right Atrial Enlargement
Etiology:
Tricuspid valve regurgitation
Tricuspid valve stenosis
Pulmonal regurgitation
Pulmonal stenosis
Pulmonary hypertension
Chronic lung disease
Left ventricular hypertrophy
Atrial septal defect

Enlargement (Atrial)

Tall and peaked P wave (p pulmonal)

Best

seen at lead II, III, aVF

Early dominant biphasic p wave on V1

Enlargement (Atrial)

Enlargement (Atrial)
Left Atrial Enlargement
Etiology:
Mitral valve stenosis
Mitral valve regurgitation
Aortic valve stenosis
Aortic valve regurgitation
Left Ventricular Hypertrophy

Enlargement (Atrial)

Wide and notched p wave (p mitral)

Negative dominant biphasic p wave on
V1(p terminal force)

Enlargement (Atrial)

Enlargement (Atrial)

How the p wave was formed

Enlargement (Atrial)

Just look at V1

Enlargement
(Ventricular)
Right Ventricular Hypertrophy
Etiology:
Chronic lung disease
Ventricular Septal Defect
Tetralogy of Fallot

Enlargement
(Ventricular)

Criteria:

Enlargement
(Ventricular)

Enlargement
(Ventricular)
Left Ventricular Hypertrophy
Etiology
Hipertensive Heart Disease
Dilated Cardiomyopathy
Aortic Stenosis
Aortic Regurgitation

Enlargement
(Ventricular)

Criteria

Enlargement
(Ventricular)

Enlargement

A 67 years old men with long standing

hypertension

Enlargement

A 71 years old man with COPD.

Help the ER doctor!

A 45 years old man with history of alcoholic

abuse, and now suffered with severe dilated
cardiomyopathy

Enlargement

A 26 years old girl with ventricular

septal defect

Injury

Ischaemic
Acute Myocardial Infarction
Old Myocardial Infarction

Injury
Signs of myocardial ischemia
EKG
ST segment elevation ?

No

Yes

Acute Myocardial
Infarction

Lab

Biochemical cardiac markers ?

Yes

NSTEMI

No
Unstable Angina

Injury

Injury

Injury

Injury

Q wave duration of
more than 0.04
seconds
Q wave depth of more
than 25% of ensuing r
wave
ST elevation in leads
facing infarct (or
depression in opposite
leads)
Deep T wave
inversion overlying
and adjacent to infarct

Injury
Characteristic changes in AMI

ST segment elevation over area of damage

ST depression in leads opposite infarction
Pathological Q waves
Reduced R waves
Inverted T waves

Injury
R
ST

ST segment
elevation
Occurs in the early
stages
Occurs in the leads
facing the
infarction
Slight ST elevation
may be normal in
V1 or V2
Two small box for
precordial leads,
one small boxes
for limb leads
Convex shaped

Injury

R
ST
P

T
Q

Q wave
Only diagnostic
change of
myocardial
infarction
At least 0.04
seconds in
duration
Depth of more
than 25% of
ensuing R wave

Injury

R
ST

T
Q

Inverted T wave
Late change
Occurs as ST elevation i
returning to normal
Apparent in many leads

Injury
Evolution on EKG

1 minute after onset

A day or so after onset

A few minutes or
so after onset

Latter changes

A few hours or
So after onset

Old myocardial infarction

Injury
57 years old man, heavy smoker, came with sub sternal pressure pain

Injury

Injury
58th years old man with left arm squeezing sensation, for 8 hours

Injury
66th years old Lady with abdominal discomfort

Injury

Injury
83 years old lady with sudden shortness
of breath and cold extremities

Injury
58 years old male with severe acute
chest pain..

Injury
56 years old uncontrolled diabetic male
feel sudden chest discomfort 5 hours
ago

Arrhythmias

Disturbances of automaticity

Narrow complex QRS

SA

node
Atrial
Junctional

Wide complex QRS

Disturbance of conductivity

Block
SA

Block
AV block
Interventricular block

Preexitation syndrome

Arrhythmias

Disturbance of conductivity

AV block
1

AV block
2 AV Block

Mobitz I (Wenkebach)
Mobitz II

AV Block / Total AV block

1st AV Block

1st AV block

Rhythm : Regular
Rate : Usually normal
P wave : Sinus P wave present; one P wave
to each QRS
PR : Prolonged ( greater than 0.20 seconds )
QRS : Normal

1st AV Block

2nd AV Block

2nd 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

2nd AV Block

Key points:

Progressive lengthening of PR interval

A P wave then fails to be conducted (drop
beats)
PR interval resets and cycle repeats

2nd AV Block

2nd AV block, Mobitz II

Rhythm : Regular usually; can be irregular 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

2nd AV Block

Key points:

PR intervals normal and constant

An occasion p waves fails to be conducted

3rd AV block

3 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 waves
PR : Varies greatly
QRS : Normal if block in His bundle; wide if block
involves
bundle branches

3rd AV block

Key point:

No relationship between P and QRS

Interventricular Block

Interventricular Block

Arrhythmias

Arrhythmias

Arrhythmias

Disturbances of automaticity

Narrow complex QRS

SA

node
Atrial
Junctional

Wide complex QRS

Arrhythmias

SA node

Arrhythmias

SA node

Arrhythmias

SA node

Arrhythmias

SA node

Arrhythmias

Atrial

Arrhythmias

Atrial

Arrhythmias

Atrial

Arrhythmias

Atrial

Arrhythmias

Atrial

Atrial Fibrillation

Atrial Fibrillation

Types (onset)
Paroxismal

- less 48 hrs
Persistent - less 2 weeks
Permanent AF as basic rhythm

Types (Ventricular Response)

Rapid

VR (HR>100 bpm)
Controlled / normo VR (HR 60-100 bpm)
Slow VR (HR<60 bpm)

Atrial Fibrillation

Cause:

Cardiac
Accute

myocardial infarction

LAE

Extra cardiac
Hyperthyroid
Electrolytes
Toxic

imbalance

Atrial Fibrillation

Physical Examination

Pulsus deficit
Irregularly irregular heart beat

Therapy

Rhythm control
Rate control

Arrhythmias

Junctional

Arrhythmias

Ventricular

Arrhythmias

Ventricular

Arrhythmias

Ventricular

Arrhythmias

Ventricular

Arrhythmias

Ventricular

Arrhythmias

How to identify arrhythmias ?

Treat the patient, not the monitor

Its not important

Where was the bird came
from
But the most important is
How far will the bird can
fly

TERIMA KASIH