ELECTROCARDIOGRAM

Agus Harsoyo, MD
Clinical Cardiac Electrophysiologist and Device Implantable
Cardiology Intervensionist

Unit Clinical Cardiac Electrophysiology and Device Implantable and Cardiology

Intervensional
Faculty of Medicine University Pembangunan Nasional Jakarta
Department of Cardiology
Gatot Soebroto Army Center Hospital Jakarta Indonesia
2013
12/21/15

Anatomy of the heart

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Conducting system : atrial and

ventricle

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Conducting system : atrial and

ventricle

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Depolarization and
Repolarization

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Depolarization and
Repolarization

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Depolarization
Repolarization

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and

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Electromechanical coupling

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10

Ventricle : Contraction and

relaxation

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11

Plane view

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12

Einthovens Triangel
Unipolar Lead I, II, III

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13

Einthovens Triangel
Unipolar Lead I, II, III

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14

Electrode site : limb Bipolar

lead
( Einthoven )

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15

Electrode site : limb Unipolar

lead
( Goldberger )

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16

Hexaxial system from limb

lead Bipolar ( Einthoven ) and Unipolar
( Goldberger )

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17

Hexaxial system from limb

lead Bipolar ( Einthoven ) and Unipolar
( Goldberger )

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18

Limb Bipolar and Unipolar

lead
(Extremity
Einthoven
Goldberger )
LEAD and
:
RED
YELLOW
GREEN
BLACK

: RIGHT HAND
: LEFT HAND
: LEFT FOOT
: RIGHT FOOT

I, II, III, aVR, aVL, aVF

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19

Precardiac Unipolar Lead

( Wilson )
v1 : ICS IV RIHGT para sternal
v2 : ICS IV LEFT para sternal
v4 : ICS V LEFT mid klavikuler
v3: v2 & v4
v6: ~ v4 LEFT mid axillaris
v5: v4 & v6

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20

Precardiac Unipolar Lead

( Wilson )

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21

Placement chest electrode

Superior view

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22

Placement chest electrode

Anterior view

Lead perspective

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24

Lead perspective

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25

Normal standarization

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26

Calibration signal
LB = 5 MB

MB
= 5 SB

SB

1 mm/ 25 mm/ s = 0,04 s

J point and ST Segment

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28

Interval and Duration

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29

Interval and Segment

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30

Interval and Segment

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31

Interval
and
Amplitude

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32

Transitional zone

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33

Transitional zone

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34

Configuration QRS

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35

Configuration QRS
qRS

rS
RS
qRs

Rs

QS
QRr

rs

rSR
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36

Configuration QRS

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37

Intrinsicoid deflection

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38

HR Determination

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39

HR Determination

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40

Determination QT Interval

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41

Direction of Depolarization

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42

Direction of Vector

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43

Sequence of Ventricle Depolarization

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44

Two Quadrant

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45

Vector Determination

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46

Vector Direction

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47

Mean QRS axis determination

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48

QRS axis Deviation

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49

QRS axis Deviation

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50

Mean QRS Determination

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51

Mean qrs determination

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52

Normal Axis

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53

Left Axis Deviation

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54

Right Axis Deviation

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55

Superior/ extrem Axis

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56

INTERPRETASI EKG

1. Monitor :
Sinus :
( >< Aritmia )
1 gel P + 1 QRS kompl
PR Interval N (<5 kotak kecil, <20 det)
angka / rate : > 100 ST
60 100 SR
60 SB
interaksi keseluruhan n
2. Rekaman 12 lead EKG, contigous lead II-III-avF ; IAvI-V5-V6; V1V2V3V4; V7V8V9;V1RV2RV3RV4R;
3. Irama dasar, HR, Aksis, Pwave, PRint, QRS dur, QT
int, ST segmen, T wave, irama tambahan -->
Kesimpulan
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57

read EKG
Kalibrasi, Irama, Hr, gel p, pr int, aksis, qrs kompl,

st seg, gel t, block, irama tambahan

kesimpulan

Contoh :

af, hr 110 140, p mitral, aksis lad, qrs n,

st t changes ( - ), lafb
af v r r, lae, hhd

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58

Normal 12 lead ekg

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59

The end

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60

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61

Arrhythmia
Agus Harsoyo, MD
Clinical Cardiac Electrophysiologist and Device Implantable
Cardiology Intervensionist

Unit Clinical Cardiac Electrophysiology and Device Implantable and Cardiology

Intervensional
Faculty of Medicine University Pembangunan Nasional Jakarta
Department of Cardiology
Gatot Soebroto Army Center Hospital Jakarta Indonesia
12/21/15

2013

62

Rhythm determination : RRCR

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63

Pacemaker sites

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64

Supraventricular and ventricular beats

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65

Wide QRS supraventricle rhythm

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66

SB, SR, ST

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67

Sinus arrhytmia

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68

Atrial Premature Contraction

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69

Junctional premature beat

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70

Wandering atrial pacemaker

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71

Multifocal atrial tachycardia

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72

Accelerated junctional rhythm

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73

Paroxismal Atrial Tachycardia

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74

Atrial Flutter

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75

Atrial Fibrilation

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76

AF and Ashman beat

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77

Ventricle Premature Contraction

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78

Ves multifocal

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79

VES Bi / Tri geminy

N

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80

Ves couplet / salvo

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81

Ventricular Parasystole

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82

Ves R on T

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83

Accelerated idioventricular rhythm

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84

Ventricle Tachycardi

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85

Ventricle fibrilation

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86

VT Torsade de pointes

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87

The end
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89

Heart block
Agus Harsoyo, MD
Clinical Cardiac Electrophysiologist and Device Implantable
Cardiology Intervensionist

Unit Clinical Cardiac Electrophysiology and Device Implantable and Cardiology

Intervensional
Faculty of Medicine University Pembangunan Nasional Jakarta
Department of Cardiology
Gatot Soebroto Army Center Hospital Jakarta Indonesia
12/21/15

2013

90

Anatomy of Heart block

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91

1st AV Block

Pr int 0,20 sec

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92

2nd AV Block tipe 1

Pr int gradually lengthen

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93

2nd AV Block tipe 2

Pr int constans

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94

3rd AV Block

Atrial beat independently of ventricle

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95

Intraventricular Block

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96

Complete Right Bundle Block

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97

Incomplete Right Bundle Block

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98

Complete Left Bundle Block

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99

inComplete left bundle block

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100

Left Post / Ant Fascicular Block

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101

The end
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102

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103

Acute Coronary Syndrome

Agus Harsoyo, MD
Clinical Cardiac Electrophysiologist and Device Implantable
Cardiology Intervensionist

Unit Clinical Cardiac Electrophysiology and Device Implantable and Cardiology

Intervensional
Faculty of Medicine University Pembangunan Nasional Jakarta
Department of Cardiology
Gatot Soebroto Army Center Hospital Jakarta Indonesia
12/21/15

2013

104

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105

Normal t wave and ischemia

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106

J point and ST segment

normal injury

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107

Q infarction

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108

Location of AMI

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109

Evolution AMI

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110

Non Q Q AMI

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111

Atrial ami

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112

The end
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113

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114

Atrial and Ventricle

hypertrophy

Agus Harsoyo, MD
Clinical Cardiac Electrophysiology and Device Implantable
Cardiology Intervensionist

Unit Clinical Cardiac Electrophysiology and Device Implantable and Cardiology

Intervension
Department of Cardiology Army Center Hospital Gatot Soebroto
Jakarta
12/21/15

2013

115

Normal and hypertrophy

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116

LAE

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117

RAE

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118

LVH

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119

Estes criteria LVH

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120

RVH

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121

The end
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122

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123

Drug electrolyte others

Agus Harsoyo, MD
Clinical Cardiac Electrophysiology and Device Implantable
Cardiology Intervensionist

Unit Clinical Cardiac Electrophysiology and Device Implantable and Cardiology

Intervension
Department of Cardiology Army Center Hospital Gatot Soebroto
Jakarta
12/21/15

2013

124

Digoxin effect

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125

anti arhythmia effect

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126

Electrolyte imbalance
hyperkalemia

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127

Electrolyte imbalance
hypokalemia

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128

Hyper/ hypo calcemia

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129

hypotermia

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130

Cerebro vascular accident

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131

Non spesific st-t changes and

ventricle strain

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132

pericarditis

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133

Early repolarization

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134

Lv aneurisms

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135

Pulmonary embolism

ST, RAE, C/ IRBBB, ST-T, RAD

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136

copd

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137

Reentry mechanism

antegrade, retrograde
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138

Preexcitation
WPW syndrome

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139

Preexcitation
LGL syndrome

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140

Aberrant ventricle conduction

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141

DD Wide QRS Tachycardia

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142

Lowns grading for VES

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143

Sick sinus syndrome

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144

Pacemaker pattern

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145

Exercise stress test

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146

The end
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147

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148