Electrocardiography

Definition
 Electrocariogram is a graphic
recording of the electrical potential
produced in association with
heartbeat
 Measure:
 Rate and regularity of heartbeats
 Size and position of the chambers
 Presence of any damage to the heart
 Effects of drugs or devices used to
regulate the heart
 Systemic condition that gives effect to the
heart
The Normal Conduction System
How does it work?
 The heart is a muscle with well-
coordinated electrical activity, so
the electrical activity within the
heart can be easily detected from
outside of the body.

 After the appropriate leads are

attached to the body, a heated
stylus moves upward with positive
voltage and downward for negative
voltage.

• On the moving heat-sensitive

paper, voltage is traced out.
ECG lead
 Electrodes used to measure electrical
activity of the hearts
 2 basic types
 Bipolar leads (standard limb leads) utilize
a single positive and a single negative
electrode between which electrical
potentials are measured.
 Unipolar leads (augmented leads and
chest leads) have a single positive
recording electrode and utilize a
combination of the other electrodes to
serve as a composite negative electrode.
Limb lead (bipolar)

- +/-

+
Extremity lead (unipolar)

Menggunakan terminal sentral sebagai titik nol

Precordial lead (unipolar)
Location of Electrode and
lead
Limb lead
Red(R) → Right Arm
Yellow(L) → Left Arm
Green(F) → Left Foot
Black(RF) → Right Foot

Chest lead
V1 ( red ) right sternal margin,ICS4
V2 ( yellow) left sternal margin,ICS 4
V3 ( green ) midway V2 and V4
V4 ( purple ) left midclav line,ICS 5
V5 ( brown ) left anterior axillary line
V6 ( black ) left mid axillary line
V7 posterior axillary line
V8 posterior scapullar line
V9 left border of spine
 Kertas EKG
 Kertas grafik garis horizontal
dan vertical dengan jarak 1
mm.
 Garis lebih tebal terdapat pada
setiap 5 mm.
 Garis horizontal
menggambarkan waktu
1 mm = 0,04“
5mm = 0,20“.
 Garis vertikal
menggambarkan voltase
1 mm = 0,1 milivolt
10 mm = 1 milivolt.
 Kecepatan perekaman 25
mm/detik.
 Kalibrasi 1 milivolt yang
menghasilkan defleksi setinggi
10 mm.
ECG Terminology
 P wave : activation of the atria
 PR interval: duration of AV
conduction
 QRS complex:activation of right and
left ventricular
 QRS duration: duration of ventricular
muscle depolarization
 PP interval: duration of atrial cycle
(an indicator or atrial rate)
 RR interval: duration of ventricular
cardiac cycle (an indicator of
ventricular rate
 QT interval: duration of ventricular
depolarization and repolarization
 Normal ECG
 P wave
 Width < 0.12 s
 Height < 0.3 milliVolt
 Always positive in lead II, negative in aVR
 PR interval
 From the start of P wave to the start of QRS
 Normal duration 0.12 – 0.20 s
 QRS complex
 Width 0.06 – 0.12 s (~ 0.10 s)
 Length varies among leads
 Q  first negative deflection
 R  first positive deflection
 S  negative deflection after R
 ST segment
 From the end of S to the start of T
 Normal : iso-electrical
 T wave
 Positive in lead I, II, V3 – V6 and negative in
aVR
Normal ECG
Basic interpretation

Rate
Rhythm
Axis
P wave morphology
PR interval
QRS complex morphology
ST segment morphology
T wave morphology
U wave morphology
QTc interval
Determining the Heart Rate
 Rule of 300
 300/[number of large boxes between two R waves].
 only works for regular rhythms !!

300/7.5 large boxes = rate 40

 Six second methods

 Count the number of R-R intervals in six seconds and multiply by 10
 Useful for irregular rhythm  average rate

There are 8 R-R intervals

within 30 boxes. Multiply 8 x
10 = Rate 80
Determining the Rhythm
 Source of depolarization

 Sino-atrial (SA) node: sinus rhythm

 Depending on rate can be sinus bradicardia or sinus tachycardia

 Non-sinus: atrial/ventricular rhythm (see arrhythmia section)

Normal ECG
Axis

Defleksi positif Defleksi negatif

P morphology
 Indicate wave of atrial depolarization
 Normal characteristic:
1. Smooth and rounded
2. Upright in leads I, II, aVF, aVL
3. Upright or downward in lead III
4. Biphasic in right precordial lead (V1,V2)
5. P wave duration: 120 milliseconds
(measured in the widest P wave)
6. Amplitude in limb lead: < 0.25 mV and
terminal negative deflection in V1 or V2 <
0.1 mV in depth
P morphology
PR interval
Including P wave until the beginning of QRS complex
Normal duration is 0.12-0.2 seconds
QRS duration

 Wave of ventricular depolarization

 5-20 mm tall
 Duration 0.06-0.10/0.12 seconds
QRS Duration
Wave of ventricular depolarization 5-20 mm tall
Duration 0.06-0.10/0.12 seconds
QRS morphology
qRs Rs R rS

QR Q/QS rSr’
RsR’
Q wave
 Any pathological Q wave or not
• >1/3 of QRS complex

QR Q/QS
R wave progression
ST segment
 Begins at J point
 Between ventricular depolarization and
ventricular repolarization
 Generally isoelectric
QT interval
 Correctedfor heart rate
 QT/square root of R-R (in sec)
T wave

 Ventricular repolarization, followed by

ventricular relaxation
 Positive in lead : I, II, V3-V6
 Negative in lead avR
ECG abnormalities

Hypertrophy
Ischemia/infarct
Arrhythmia
Atrial Abnormality
 Abnormal atrial activation and conduction
 Shift in the site of initial activation
 Result: negative p wave in leads that normally upright
(I,II,aVF,and V4-V6)
 Conduction delay within the atria alter duration and pattern of P
waves
 Delay from right to left atrium within Bachmann bundle: P
duration>120ms, two humps in lead II ( P mitrale)
 Biatrial abnormality: large biphasic P wave in leads V1, tall and
broad P waves in II,III, aVF
Atrial Hypertrophy
 Right atrial enlargement
 Tall, peaked p wave
 Left atrial enlargement
 Widening p wave, M-
shape, notched
 Deep, negative component
p wave in V1
Diagnostic Criteria for LVH
 Sokolow-Lyon index
 SV1+(RV5 or RV6)=3.5 mV
 RaVL>1.1mV

 Cornellvoltage criteria
 Romhilt-Estes point score system
Diagnostic Criteria for RVH
R in V1≥0.7 mV
 QR in V1
 R/S in V1>1 with R>0.5 mV
 R/S in V5 or V6<1
 S in V5 or V6>0.7 mV
 Right axis deviation ≥+90 degrees
 S1Q3 pattern
 S1S2S3 pattern
 P pulmonale
R/S in V1 > 1 or R/S in V6 < 1
Biventricular Enlargement
 Tall R wave in both right and left precordial
leads
 Vertical heart position or right axis
deviation in the presence of criteria for
LVH
 Deep S in left precordial leads + LVH
criteria
 Shift in precordial transition zone to the left
in the presence of LVH
Intraventricular Conduction
Delays
 Left Anterior Fascicular Block
 Marked left axis deviation (-30 and -45°)
 rS pattern in inferior leads and qR in I,aVL
 QRS duration <120ms

 Left Posterior Fascicular Block

 QRS axis>120 degree
 RS in I, aVL and qR in inferior leads
 QRS duration <120 ms
 Exclusion of other factors causing right axis
deviation
 Left Bundle Branch Block
 QRS duration>120ms
 Broad,notched R in V5,V6 and I, aVL
 Small or absent initial r in V1,V2 followed by
deep S wave
 Right Bundle Branch Block
 QRS duration >120ms
 Broad,notched R (rsr’,rsR’,rSR pattern in
V1,V2
 Wide and deep S in V5,V6
Infarct / Ischemia
 Evolution of MI
 Hyperacute T wave changes - increased T
wave amplitude and width; may also see
ST elevation
 Marked ST elevation with hyperacute T
wave changes (transmural injury)
 Pathologic Q waves, less ST elevation,
terminal T wave inversion (necrosis)
 Pathologic Q waves, T wave inversion
(necrosis and fibrosis)
 Pathologic Q waves, upright T waves
(fibrosis)
•I, aVL, V5
•V2-V4
Arrhythmia
 Classification
 Supraventrivular arrythmia
 Sinus pause or arrest, SA block, PAC, atrial flutter,
atrial fibrillation, etc
 Ventricular arrythmia
 PVC, VT, torsade de pointes, VF, etc
 AV conduction abnormalities
 AV block, WPW syndrome, etc
Rhythm
 Rhythm Guidelines:
 Check the bottom rhythm strip for regularity, i.e. - regular,
regularly irregular, and irregularly irregular.
 Check for a P wave before each QRS, QRS after each P.
 Check PR interval (for AV blocks) and QRS (for bundle branch
blocks). Check for prolonged QT.
 Recognize "patterns" such as atrial fibrillation, PVC's, PAC's,
escape beats, ventricular tachycardia, paroxysmal atrial
tachycardia, AV blocks and bundle branch blocks
Blocks
 SA node block
 Failure of the SA node to transmit an impulse
 Complete pause of 1 beat ("skipped beat")

 AV node block
 Block which delays the electrical impulse as it travels between
the atria and the ventricles in the AV node
 Presented by PR interval
Blocks…
 1st degree AV block
 PR interval greater than 0.2 seconds (200ms or 1 large box)

 2nd degree AV block

 Type I (Wenckebach)  PR interval gets longer (by shorter
increments) until a nonconducted P wave occurs
 Type II (Mobitz)  PR intervals are constant until a
nonconducted P wave occurs
Blocks…
 3rd degree AV block
 Complete block of signals from the atria to the ventricles 
complete dissociation between the timing of the P-waves
and the QRS complexes
Supraventricular Arrythmia
 Premature atrial contraction
 Single or repetitive, unifocal or multifocal

 Atrial fibrillation
 Atrial activity is poorly defined; may see course or fine undulations
or no atrial activity at all
 Ventricular response is irregularly irregular
Supraventricular…
 Atrial flutter
 Regular atrial activity with a "clean" saw-tooth appearance
 The ventricular response may be 2:1, 3:1 (rare), 4:1, or irregular

 Paroxysmal supraventricular tachycardia

 Arise from structure above his bundle
 Reciprocating tachycardias because they
utilize the mechanism of reentry
Ventricular Arrythmia
 Premature ventricular contraction
 May be unifocal, multifocal or multiformed
 Occur as isolated single events or as couplets, triplets, and salvos (4-6 PVCs
in a row ~ brief VT)
 R-on-T PVCs  vulnerable to ventricular tachycardia or fibrillation

 Ventricular tachycardia
 Sustained (lasting >30 sec) vs. nonsustained
 Monomorphic (uniform morphology) vs. polymorphic vs. Torsade-de-pointes
Ventricular…
 Ventricular fibrillation
 Chaotic, wide, ventricular tachyarrythmia with grossly
irregular morphology
 No consistent identifiable QRS complexes