HOW TO READ

ELECTROCARDIOGRAPHY

Dr. HERAWATI ISNANIJAH, SpJP, FIHA

 Anatomy & Physiology
CARDIOVASCULAR SYSTEM
 Anatomy of the Heart
 Heart chambers :
 Left & right atria
 Left & right ventricles
 Heart valves :
 Atrioventricular valves :
 Right : Tricuspid

 Left : Bicuspid/Mitral

 Semilunar valves
 Right : Pulmonary valve

 Left : Aortic valve

 Anatomy of the Heart
Coronary circulation

 Aorta
 Coronary arteries
 Arterioles
 Capillaries
 Venules
 Coronary sinus
 Right atrium
 Intrinsic Conducting System

 Sinoatrial node
 Electrical pace maker

 Atrioventricular node
 Receives impulses originating

from SA node
 Bundle of His
 Electrical link between atria

and ventricles
 Purkinje fibres
 Distribute impulses to

ventricles
The Electrocardiogram ( ECG )

 P wave : atrial
depolarisation R

 QRS complex :
ventricular T
depolarisation P

 T wave : ventricular
repolarisation Q
S

 Atrial repolarisation
hidden by QRS
NORMAL
ECG INTERPRETATION
1. RATE
2. RHYTHM
3. GELOMBANG P
4. PR INTERVAL
5. QRS COMPLEX
6. AXIS
7. ST SEGMENT
8. HIPERTROPHIC SIGNS
9. ARRHYTHMIA
1. RATE
Normal heart rate : 60 – 100 x/minutes
• > 100 x/minutes : Sinus Tachycardia
• < 60 x/minutes : Sinus Bradicardia

Determination heart rate (normal paper speed 25 mm/s):

• 300
Count number of large square (bold boxes in one R – R’ interval)
• 1500
Count number of small square in one R – R’ intervals
• Number of QRS complex in 6 seconds, multiply by 10
2. RHYTHM

Normal cardiac rhythm : SINUS rhythm

Sinus rhythm characteristics :

• Rate 60-100 bpm
• Constant R – R interval
• Negative P wave in aVR and positive di II
• P wave is always followed by QRS complex
3. P Wave
 GELOMBANG P
Gambaran yang ditimbulkan oleh depolarisasi atrium

Normal
Tinggi : < 0,3 mvolt
Lebar : < 0,12 detik
Selalu positif di L II
Selalu negatif di aVR

Kepentingan
Mengetahui kelainan di Atrium
“Gelombang P Mitral”

“ Gelombang P Pulmonal “
4. PR Interval
 4. Interval PR
Diukur dari permulaan P s/d permulaan QRS

Normal : 0,12 - 0,20 detik

5. QRS Complex
5. GELOMBANG QRS
Gambaran yang ditimbulkan oleh depolarisasi ventrikel

Normal :
Lebar : 0,06 - 0,12 detik
Tinggi : Tergantung lead

Normal gelombang Q
Lebar : < 0,04 detik
Dalam : < 1/3 tinggi R
6. AXIS
RAD /Right Axis Deviation

LAD /Left Axis Deviation

LAD

RAD
7. ST Segment
ST depresi dan perubahan gelombang T

• ST depresi dianggap bermakna bila > 1 mm di bawah garis dasar PT di titik J

• Titik J didefinisikan sebagai akhir kompleks QRS dan permulaan segmen ST

Bentuk segmen ST :

• up-sloping ( tidak spesifik )

• horizontal ( lebih spesifik untuk iskemia )
• down-sloping ( paling terpercaya untuk iskemia )

Perubahan gelombang T pada

iskemia kurang begitu spesifik

Gelombang T hiperakut
kadang2 merupakan satu-satunya
perubahan EKG yang terlihat
T Wave
EVOLUSI EKG
PADA
STEMI
 Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6

with precordial ST depression
ECG, large Anterior Infarction
Occlusion of diagonal
branch ( arrow )

ST elevation in I and aVL

Mid LAD occlusion
after the first septal
perforator ( arrow )

ECG :
Anterior MI
Occlusion of diagonal
branch ( arrow )

ST elevation in I and aVL

ECG, large Anterior Infarction
 Proximal large RCA occlusion

ST elevation in leads II, III, aVF, V5, and V6

with precordial ST depression
 Small inferior distal RCA occlusion

ECG changes in leads II, III, and aVF

Unstable Angina Pectoris
Unstable Angina Pectoris
Acute Anterior Myocardial Infarction
Acute Anterolateral Myocardial Infarction
Acute Lateral Myocardial Infarction
Acute Inferoposterior Myocardial Infarction
Right Bundle Branch Block
RBBB + Anterior Infarction
LBBB
 Klasifikasi Takikardia
 Dengan QRS sempit
 Reguler
 Ireguler
 Dengan QRS lebar
 Reguler
 Ireguler
 Supraventricular Tachycardia

 Rate: 150–250 bpm

 Rhythm : Regular
 P Waves : Frequently buried in preceding QRS/T
waves and difficult to see
 PR Interval: Usually not possible to measure
 QRS : Normal (0.06–0.10 sec) but may be wide
if abn. conducted through ventricles
 Atrial flutter

 Rate : Atrial: 250–350 bpm; ventricular: slow or fast

 Rhythm : Usually regular but may be variable
 P Waves : Flutter waves have a saw-toothed appearance
 PR Interval : Variable
 QRS : Usually normal (0.06–0.10 sec), but may appear
widened if flutter waves are buried in QRS
 Atrial Fibrilation

 Rate: Atrial: 350 bpm or greater; ventricular:

slow or fast
 Rhythm : Irregular
 P Waves : No true P waves; chaotic atrial activity
 PR Interval: None
 QRS : Normal (0.06–0.10 sec)
 Ventricular Tachycardia

 Rate: 100–250 bpm

 Rhythm: Regular
 P Waves: None or not associated with the QRS
 PR Interval: None
 QRS: Wide ( 0.10 sec), bizarre appearance