ELEKTROKARDIOGRAFI

DR.dr. Zaenal Muttaqien Sofro, , AIFM,

Sport & Circ.Med
School of Medicine Gadjah Mada
University
ERGOMETRY TEST
The Heart-Brain Connection
hat does “environment” mean?
 AUTOMATICITY
Na+ K+
Gradually
increasing PNa

Na+ K +

-70 mV -0

THRESHOLD
RESTING
 Channels & Local Potentials
 The ionic basis of the action potential
 membrane permeability
 ion channels
 Voltage gated Na+ and K+ Channels
Cardiac Physiology Electrocardiography Diagnosis
Willem Einthoven
(1860-1927)
Cardiac Physiology Electrocardiography Diagnosis
Absolute Refractory Period (ARP)
Relative Refractory Period (RRP)

Electrical activity

Source Undetermined
12
 Location of Heart

• posterior to sternum
• medial to lungs
• anterior to vertebral column
• base lies beneath 2nd rib
• apex at 5th intercostal space
• lies upon diaphragm
Steps to Interpreting an EKG
 Rate
 Rhythm
 Axis
 Intervals (PR, QRS, QTc)
 Hypertrophy
 ST segments
 T waves
 Q waves
SA Node Action Potential = Primary Pacemaker
-Phase 4 :
-progressive decrease K+ perm
-Increase in Na+ perm
-Modified by Sym & Para Sym

Note Phase 4

Source Undetermined 18
 Parasympathetic

Source Undetermined

Similar to M&H Fig 2.6

19
 NE -- Na+ Perm (more “+” leak in)

Ach -- K+ Perm (more “+” leak out)

+/- Chronotropic

McGraw-Hill

20
 “apparent”
McGraw-Hill Phase 4 diastolic depolarization 21
 Na+ perm 1 2 Ca++ perm (sustained)

Na+ perm 0
3 K+ perm

McGraw-Hill

22
 Phase 2 = gain Ca++ and
retain K+
Log Scale

McGraw-Hill
23
 So why can’t heart muscle develop tetanic contractions?

Source Undetermined

Ventricular action potential lasts almost as long as the

mechanical tension development so there is little or no
tension left (after Refractory period) to build upon.
24
So why is the ECG so small (1 mv) and
action potential so big (110 mv)?
?Bag of batteries?
AC and DC Coupling

Entire heart
At Body
Surface =
1 MV

One LV cell AP =
110 MV

Source Undetermined 25
 P QRS T
Source Undetermined
26
 Electrocardiogram (ECG/EKG)

 Note: Tissue fluids

conduct electricity.

 EKG:
 Measure of the
electrical activity
of the heart.
 - I +

4.2 MH
Source Undetermined 29
12 Lead ECG allows a more detailed
electrical assessment of heart

Frontal Plane (6 Leads)

3 Regular Limb - I +
3 Augmented

Cross Sectional Plane (6 leads)

Precordial (chest) Leads

4.2 MH
Source Undetermined 31
 6 Precordial Leads
&
V6 Conventions
V1
V2
V5
V3 V4
Mohrman and Heller. Cardiovascular
Physiology. McGraw-Hill, 2006. 6th ed.

Chest Cross Section

Call it: V6
Q if 1st e.g. V4, V5, V6
V5
R if 1st e.g. V1, V2, V3
S if 1st after R e.g. all 4.7 MH
V4
V1 V3
Source Undetermined V2 33
Cardiac Physiology Electrocardiography Diagnosis
Cardiac Physiology Electrocardiography Diagnosis

P T

Q
S
Cardiac Physiology Electrocardiography Diagnosis

P T

Q
S
Cardiac Physiology Electrocardiography Diagnosis

R 1 sec

P T

Q
S
0.5 Sec
 Ventricular arrhythmias

depolarization

“twisting of points”

MH Fig 5.3
Mohrman and Heller. Cardiovascular Physiology. McGraw-Hill, 2006. 6th ed.
40
Electrocardiogram
 ECG Deflection Waves
60 seconds ÷ 0.8 seconds = resting heart rate of 75 beats/minute

1st Degree Heart

Block = P-Q interval
longer than 0.2
seconds.
 ECG Deflection Wave
Irregularities

Enlarged QRS =

Hypertrophy of
ventricles
 ECG Deflection Wave
Irregularities

Prolonged QT
Interval =

Repolarization
abnormalities
increase chances
of ventricular
arrhythmias.
 ECG Deflection Wave
Irregularities

Elevated T wave :

Hyperkalemia
 ECG Deflection Wave
Irregularities

Flat T wave :

Hypokalemia
or ischemia
 Heart Blocks
P T
Normal ECG
QRS

Not a QRS for

2nd Degree Block
each P wave

No P waves. Rate
determined by
3rd Degree Block autorhythmic cells
in ventricles
 ECG Deflection Waves
60 seconds ÷ 0.8 seconds = resting heart rate of 75 beats/minute
 Lead I

Lead II Lead III

Frontal Plane
aV = augmented
voltage
Mohrman and Heller. Cardiovascular Physiology. McGraw-Hill, 2006. 6th ed. 50
 4.7 MH
6 Frontal Plane Leads
Mohrman and Heller. Cardiovascular Physiology. McGraw-Hill, 2006. 6th ed. 51
 Hexaxial Array for Axis Determination

determination of the
angle of the
main cardiac vector
in the frontal plain
Vector
 Vector represents magnitude &
direction of force; polarity if electrical
+
force. +

+
Hexaxial array and ECG
vectors from various
leads.
1. Find net + or – QRS in
lead 1
2. Find net + or _ QRS in
Lead aVF
3. Resultant Vector. This is
Mean Electrical Axis of
Heart or Cardiac
Vector.

Electrical axis is about

+60o
 Axis Determination – Quick Locate Step 1

Lead I

If lead I is mostly
positive, the
axis must lie in the
right half of
of the coordinate
system; the main
vector is moving
mostly toward the
lead’s positive
electrode.
 Axis Determination – Quick Locate Step 2

Lead aVF

If lead aVF is
mostly positive, the
axis must lie in the
bottom half of
of the coordinate
system; the main
vector is moving
mostly toward the
lead’s positive
electrode
 Axis Determination – Quick Locate Step 3

I aVF

Combining the two

plots, we see
that the axis must
lie in the bottom
right hand quadrant
 Axis Determination – Quick Locate Step 4
I aVF aVL

Once the quadrant has

been determined, find
the most equiphasic
(smallest net deflection)
or smallest limb lead.
The axis will lie about
90o away from this lead.
Example above; aVL is
the most equiphasic
lead. Axis must be
about 90o from this lead;
here shown to be
approximately 60o.
 Axis Determination – Quick Locate Step 5
I aVF aVL

Since QRS complex in

aVL is a slightly more
positive, the true axis
will lie a little closer to
aVL (the depolarization
vector is moving a little
more towards aVL than
away from it). A better
estimate would be
about 50o (normal axis).
Accuracy + or – 15o.
 Axis Determination – Example 2

Lead I

If lead I is mostly
negative, the
axis must lie in
the left half of
of the coordinate
system.
 Axis Determination – Example 2

I aVF II

Once the quadrant

has been
determined, find the
most equiphasic or
smallest limb lead.
The axis will lie
about 90o away from
this lead. Given that
II is the most
equiphasic lead, the
axis here is at
approximately 150o.
 Axis Determination – Example 2

I aVF II

Since the QRS in II

is a slightly more
negative, the true
axis will lie a little
farther away from
lead II than just 90o
(the depolarization
vector is moving a
little more away from
lead II than toward
it). A better estimate
would be 160o.
Precise Axis
Calculation
Precise calculation
of the axis can be
done using the
coordinate system
to plot net voltages
of perpendicular
leads, drawing a Net voltage = 12
resultant rectangle, Since Lead III is
then connecting the most

Net voltage = 7
the origin of the equiphasic lead
coordinate system and it is slightly
with the opposite more positive
corner of the than negative,
rectangle. A this axis could be
protractor can then estimated at
be used to about 40o.
measure the
deflection from 0.
 Normal Axis
• LAD
• Anterior Hemiblock
LAD = -30 to -90
• Inferior MI
No Man’s Land Axis
• WPW – right pathway
= -90 to +- 180
• Emphysema

• RAD
• Children, thin adults
• RVH
• Chronic Lung Disease
• WPW – left pathway
• Pulmonary emboli
• Posterior Hemiblock

• No Man’s Land
• Emphysema
• Hyperkalemia
• Lead Transposition
• V-Tach Normal Axis = -30 to +120
RAD =+120 to +180
ST Elevation Infarction
Here’s a diagram depicting an evolving infarction:
A. Normal ECG prior to MI

B. Ischemia from coronary artery occlusion

results in ST depression (not shown) and
peaked T-waves

C. Infarction from ongoing ischemia results in

marked ST elevation

D/E. Ongoing infarction with appearance of

pathologic Q-waves and T-wave inversion

F. Fibrosis (months later) with persistent Q-

waves, but normal ST segment and T-
waves
 ST changes: axis + anatomy
 Lateral:
 I, aVL
 LCA, CFX

 Anterior:
 V1, V2, V3, V4
 LAD
Inferior:
-II, III and aVF Memorize this slide
-RCA (or LCA)
Location of infarct
combinations

I aVR V1 V4

ANT
LATERAL
POST ANT
II aVL V2
SEPTAL
V5

ANT
V3 V6 LAT
III aVF
INFERIOR