Basic ECG Interpretation

dr. Firman B. Leksmono, SpJP

Cardiology and Vascular Department

Medical Faculty of Indonesian Muslim
University
ER

Decision
Cardiovascular disease are the number 1
cause of death globally
WHO September 2016
Anatomy
 Conduction System
• Sinoatrial Node (SA Node)
– Rhythmic rate : 60 – 100 bpm
• Internodal Pathway
– Anterior, middle, posterior pathways
• Atrioventricular Node (AV Node)
– Regions : atrionodal (AN), nodal (N),
nodal-His (NH)
– Delays the impulse

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 Conduction System
• Bundle of His
– Rate : 40 – 60 bpm
• Bundle Branches
– LBB & RBB
– LBB : anterior, posterior, septal fascicles
• Purkinje Fibers
– Rate : 20 – 40 bpm

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 Cardiac Cells Properties
• Automaticity
• Excitability
• Conductivity
• Contractility

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Action Potential
Conduction System

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 ECG
• Electrocardiography is a fundamental part of
cardiovascular assessment.
• The contraction and relaxation of cardiac muscle
results from the depolarisation and repolarisation of
myocardial cells. These electrical changes are
recorded via electrodes placed on the limbs and
chest wall and are transcribed on to graph paper to
produce an electrocardiogram
ECG
For What?
 LEADS
• Standard Limb Leads
– Lead I, II, III
• Augmented Limb Leads
– aVL, aVR, aVF
• Precordial Leads
– V1, V2, V3, V4, V5, V6
– V1R, V2R, V3R, V4R, V5R, V6R
– V7, V8, V9

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 LEADS
The extremity leads are:
 I from the right to the left arm
 II from the right arm to the left leg
 III from the left arm to the left leg

Augmented Limb leads are:

 AVL points to the left arm
 AVR points to the right arm
 AVF points to the feet

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 LEADS
PRECORDIAL LEADS
 LEADS
ADDITIONAL LEADS

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Why we need 12 leads ECG??
Leads

LEADS VIEW OF HEART

I, aVL Lateral
II, III, aVF Inferior
V1, V2 Antero-Septal
V3, V4 Antero-Apical
V5, V6 Antero-Lateral
I, aVL, V5, V6 High Lateral
V1-V6 Whole Anterior
 How to Interprate ECG?

• Rhytme? • Ischemia/Infarction?
• Rate? • Chamber
• Axis? Hipertrophy?
• P wave? • Arrhytmia?
• PR interval?
• QRS complex?
• ST segment?
• T wave?
Boxes

Standarization :
Speed Paper : 25 m/s
Amplitudo : 10 mm/1 mv
Heart Rate

Large Boxes  300/R-R interval

Small Boxes  1500/R-R
interval
Axis
Waves, Segment, Complex and Interval
Sinus Rhytme
 P wave

No more than 2.5 mm in height

No more than 0.11 sec in
duration
 P-R Interval

Duration  0.12 – 0.20 sec in adult, may

be shorter in children and longer in
elders.
 QRS Complex

Duration  0.06 – 0.12 sec

Q : 1st negative deflection after P
R : 1st positive deflection after P
S : negative deflection after R
R wave Progression
 ST segment

Normal  Isoelektrik
 T wave

Limb lead : no more than 5 mm

Precordial lead : no more than 10
mm
 Normal ECG

Sinus Rhytme, HR : 80 bpm, Normoaxis, P wave : 0,06 s, PR interval : 0,12 s, QRS

complex : 0,08 s, ST segment : isoelectric, T wave : normal.
Conclussion : Normal ECG
Myocardial Infarction
 Myocardial Infarction
• Ischemia
• Injury
• Necrosis
STEMI evolution
Infarct Location
Coronary Oclussion
Acute Anterior Infarction
Acute Inferior Infarction
Chamber Hypertrophy
Atrial Enlargement

P - Pulmonal

P - Mitral
 Ventricular Hypertrophy

• Left Ventricular Hypertrophy

– S wave in V1/V2 + R wave in
V5/V6 ≥ 35 mm (mV)
– Strain pattern in V5 and V6
– May be accompanied by
LAD
 Ventricular Hypertrophy

• Right Ventricular Hypertrophy

– RAD
– Reversed R-wave progression
(taller R waves and smaller S
waves in V1 & V2; deeper S
waves & small R waves in V5 &
V6
Common Arrhytmia
Atrial Fibrilation

No P wave, Irreguler R-R Interval

 Atrial Flutter

Saw teeth App. Reguler/Irreguler R-R

Interval
Supraventricular Tachycardia

Narrow QRS, Reguller, Ussually P waves is not

seen,
Ventricular Tachycardia

Wide QRS, Reguller

Ventricular Fibrilation
1st Degree
AV blocks

2nd Degree, Type 1 (wenckebach)

2nd Degree, Type 2

3rd Degree (Total AV block)