Electrocardiography

dr. Muhammad Ridwan, MAppSc, SpJP (K)- FIHA

Department of Physiology
Department of Cardiology and Vascular Medicine
Faculty of Medicine, Syiah Kuala University, 2017
 Objectives
• Preparation and how to take an
ECG recording
– Standar precordial electrodes
– RV electrodes
– Posterior electrodes
• Callibration and speed of ECG
• Normal ECG waves
• Lead reversal
• Abnormal ECG waves
• Frontal axis of an ECG
• Heart Rate calculation
– Regular HR
– Irregular HR
• Sinus bradycardia
• Sinus tachycardia
• Atrial arrhythmias
– Atrial fibrillation
– Atrial flutter
– MAT
• Ventricular arrhythmia
– VT
– Ventricular Fibrillation
• AV block
– First degree
– Second degree
– Third degree, TAVB
 Electrocardiogram (ECG)
• 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
(commonly known as an ECG).
• ECG: Composite of all action potentials of nodal and
myocardial cells detected, amplified and recorded by
electrodes on arms, legs and chest
 ECG Electrodes
• Chest Electrodes
– V1 : ICS II, right parasternal line
– V2 : ICS II, left parasternal line
– V3 : between V2 and V4
– V4 : ICR IV, left midclavicular line
– V5 : Horizontal to V4, front axillary line
– V6 : Horizontal to V4, middle axillary line
• Extremity electrodes
– Right arm:RA
– Left arm: LA
– Left leg: LL
– Right leg: N
 ECG LEADS
• Bipolar
– Lead I : connecting electrodes of left and right arms
– Lead II : connecting electrodes of right arm and left leg
– Lead III : connecting electrodes of left arm and left leg
• Unipolar
– Lead V1-V6
– Lead aVL, aVR and aVF
Standard precordial electrodes
RV Electrodes
Posterior Electrodes
Normal ECG
ECG Waves and Intervals
 The Cardiac Axis
• Average direction of spread of the depolarization wave
through the ventricles as seen from the front.
• Depolarization wave normally spreads through ventricle
from 11 o’clock to 5 o’clock. So, deflection in lead aVR
will be mainly negative (downward) and in lead II will be
mainly positive (upward)
• Can be determined from deflection in lead I, II and III (1)
or in lead I, II and aVF (2).
• Results:
– Normal Axis
– Right axis deviation
– Left axis deviation
Heart Electrical Axis (1)
Heart Electrical Axis (2)
Normal ECG
Calculating HR from an ECG (if Regular)
 Cardiac Rhythm
• Systole = contraction; diastole = relaxation
• Sinus rhythm
– set by SA node, adult at rest is 70 to 80 bpm
• Ectopic foci - region of spontaneous firing (not
SA)
– nodal rhythm - set by AV node, 40 to 50 bpm
– intrinsic ventricular rhythm - 20 to 40 bpm
• Arrhythmia - abnormal cardiac rhythm
– heart block: failure of conduction system
• AV blocks
P wave
 PR interval
• The PR interval is the time between the
onset of atrial depolarisation and the onset of
ventricular depolarisation, and it is measured
from the beginning of the P wave to the first
deflection of the QRS complex whether this
be a Q wave or an R wave.
• The normal duration of the PR interval is
three to five small squares (0.12-0.20 s).
• Abnormalities of the conducting system may
lead to transmission delays, prolonging the
PR interval  AV Block
 QRS Complex
• Represents the electrical forces generated by
ventricular depolarisation.
• The duration is measured in the lead with
the widest complex < 0.10 s
Various types of QRS complexes
 ST Segmen
• The QRS complex terminates at the J point
or ST junction. The ST segment lies
between the J point and the beginning of
the T wave, and represents the period
between the end of ventricular
depolarisation and the beginning of
repolarisation.
• The ST segment should be level with the
subsequent “TP segment” and is normally
fairly flat, though it may slope upwards
slightly before merging with the T wave.
• In leads V1 to V3 the rapidly ascending S
wave merges directly with the T wave,
making the J point indistinct and the ST
segment difficult to identify. This produces
elevation of the ST segment, and this is
known as “high take-off.”
• Non-pathological elevation of the ST
segment is also associated with benign
early repolarisation which is particularly
common in young men, athletes, and black
people.
 T wave • No widely accepted criteria exist regarding
T wave amplitude.
• As a general rule, T wave amplitude
• Ventricular repolarisation produces the T corresponds with the amplitude of the
wave. The normal T wave is asymmetrical, preceding R wave, though the tallest T
the first half having a more gradual slope waves are seen in leads V3 and V4.
• than the second half. • Tall T waves may be seen in acute
• T wave orientation usually corresponds with myocardial ischaemia and are a feature of
that of the QRS complex, and thus is hyperkalaemia.
inverted in lead aVR, and may be inverted in
lead III. T wave inversion in lead V1 is also
common.
• It is occasionally accompanied by T wave
inversion in lead V2, though isolated T wave
inversion in lead V2 is abnormal.
• T wave inversion in two or more of the right
precordial leads is known as a persistent
juvenile pattern; it is more common in black
people.
• The presence of symmetrical, inverted T
waves is highly suggestive of myocardial
ischaemia, though asymmetrical inverted T
waves are frequently a non-specific finding.
 QT interval
• The QT interval lengthens as the heart rate
slows, and thus when measuring the QT
interval the rate must be taken into account.
• As a general guide the QT interval should be
0.35- 0.45 s, and should not be more than
half of the interval between adjacent R
waves (R-R interval).
• The QT interval increases slightly with age
and tends to be longer in women than in
men.
• Bazett’s correction is used to calculate the
QT interval corrected for heart rate (QTc):
QTc = QT/√R-R (seconds).
.
 U wave
• The U wave is a small deflection that
follows the T wave. It is generally upright
except in the aVR lead and is often most
prominent in leads V2 to V4.
• U waves result from repolarisation of the
mid-myocardial cells—that is, those
between the endocardium and the
epicardium—and the His-Purkinje system.
• Many electrocardiograms have no
discernible U waves.
• Prominent U waves may be found in athletes
and are associated with hypokalaemia and
hypercalcaemia..
Bradycardia

• Bradycardia is a HR < 60
beats/min.
• Sinus bradycardia may be a
normal or result from a cardiac or
non-cardiac disorder.
• Other cause of bradycardia are
AV blocks
AV Block grade 1 and 2
AV Bloc grade III (Total AV Block-TAVB)
RBBB
RBBB
LBBB
LBBB
Atrial arrhythmias
Sinus tachycardia
Atrial Fibrillation
Atrial Flutter
Atrial Flutter
Atrial tachycardia
VT
VT features: AV dissosiation
VT features: Capture beat, fusion beat
VT features:
Concordace
Torsades de pointes tachycardia
 Sistematika Membaca EKG
1. ID px, tgl pemeriksaan, operator EKG
2. Kalibrasi dan kecepatan mesin
3. Irama :
sinus : P jelas, bentuk sama, reguler pada sadapan
yang sama
asinus
4. HR: N, Bradikardia, takikardia, x/m
5. Axis :
frontal : N, LAD, RAD, Superior
Horizontal: N, CWR, CCWR
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6. Gel P: N, lebar (P Mitral), tinggi (P Pulmonal)
7. PR interval : N, memedek, memanjang
8. Kompleks QRS:
Durasi : N, lebar
Amplitudo: N, high voltage, low voltage
Morfologi: Q patologis, M shape, rS
Progresi: N, rasio R/S di V1 dan V5, Slow
progression of R

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9. Segmen ST: isoelektrik, elevasi, depresi
10. Gelombang T: normal, tall, flat, inverted
11. Gelombang U
12. Interval QT: N, memanjang (prologed)

QTc= Inteval QT dan jarak RR dalam satuan detik.

N : < 0,44
13. Kesimpulan

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 What have we learned?
• Preparation and how to take an
ECG recording
– Standar precordial electrodes
– RV electrodes
– Posterior electrodes
• Callibration and speed of ECG
• Normal ECG waves
• Lead reversal
• Abnormal ECG waves
• Frontal axis of an ECG
• Heart Rate calculation
– Regular HR
– Irregular HR
• Sinus bradycardia
• Sinus tachycardia
• Atrial arrhythmias
– Atrial fibrillation
– Atrial flutter
– MAT
• Ventricular arrhythmia
– VT
– Ventricular Fibrillation
• AV block
– First degree
– Second degree
– Third degree, TAVB