dr.

I Nyoman Wiryawan, SpJP, FIHA

 Definition
• Electrocardiography : the procedure
to record electrical activity of the
heart muscle (not just only a single
cell) by means of placing electrodes
on the surface of the heart.

• 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
An Early Electrocardiogram
 Sel-sel otot jantung:
susunan ion yang
berbeda  intra dan
ekstra sel: Na+/K+
 K+ Na+
+++++++++++++++
---------------------

K+ Na
- - 90 mV
---------------------
+
+++++++++++++++
 K+ Na+
+++++++++++++++
---------------------
0
K+ Na
0 mV
---------------------
0
+++++++++++++++
 Istirahat Aktivasi (Repolarisasi)
(polarisasi) (depolarisasi)
+++++ ----- +++++

------- +++ -------

------- +++ -------

+++++ ----- +++++
 POTENSIAL AKSI
• Perbedaan potensial listrik antara intra dgn ekstra sel
saat mendapat stimulus, maka perubahan potensial yg
terjadi sbg fungsi waktu > potensial aksi
• Kurva potensial aksi mempunyai karakteristk yg khas tdri
4 fase
- Fase 0 lonjakan potensial mencapai
+ 20mv karena masuknya ion Na
- Fase 1 masa repolarisasi awal potensial
kembali dari + 20 mv ke 0 mv.
- Fase 2 fase ini masuk ion Ca menghimbangi gerak
keluar ion K.
- Fase 3 fase repolarisasi cepat dmn potensial kembali
secara tajam ke tingkat awal yaitu fase 4
The Summation of Myocytes Potentials
Sistem Sandapan Pada EKG
 Electrocardiographic Leads
• Bipolar limb leads ( I,II,III)
• Unipolar limb leads( aVR,aVL,aVF )
• Unipolar precordial leads ( V1,V2,V3,V4,V5,V6 )
Bipolar Limb Leads
Unipolar Limb Leads
Unipolar Precordial Leads
 Konsep Vektor
Pada
Elektrokardiografi
Relationship of Vectors to Deflections
Relationship of Vectors to Deflections
Relationship of Vectors to Deflections
Impulse Origination and Atrial Depolarization
Septal Depolarization
Apical and Early Ventricular
Depolarization
Late Ventricular Depolarization
Sumbu Bidang Frontal
Sumbu Bidang Horizontal
 Interpretasi EKG Normal

• Terminologi.
- Kalibrasi sblm lakukan rekaman EKG
kecepatan standar kertas 25 mm/dt defleksi yg
sesuai 10 mm sesuai dgn 1 mV.
- Garis mendatar tanpa potensial listrik = garis
isoelektrik.
- defleksi mengarah ke atas = defleksi positif,
defleksi mengarah ke bawah = defleksi negatif.
Basic Principles of ECG Interpretation

 Be Systematic
 Rhythm: Sinus, Blocks, Atrial, Ventricular
 Rate: Fast-Normal-Slow
 Axis: Normal, Right, Left
 Intervals and Durations
 Waveforms and Segments (Morphology)
Basic Principles of ECG Interpretation

 Be Systematic
Rhythm: Sinus, Blocks, Atrial, Ventricular
Rhythm – Sinus? Fast or Slow?
Regular or Irregular ?
• Sinus Rhythm
– P wave regular, uniform, positive in I, II, AVF,
negative in AVR
– Every QRS is preceded by P, and every P is
followed by QRS
– P-R intervals normal (0,12-0,20 mS) and
constant
– Heart Rate between 60-100/ minutes

Rowlands, Derek J; Understanding the ECG

Basic Principles of ECG Interpretation

 Be Systematic
 Rhythm: Sinus, Blocks, Atrial, Ventricular
 Rate: Fast-Normal-Slow
Rate – Fast-Normal-Slow
Basic Principles of ECG Interpretation

 Be Systematic
 Rate: Fast-Normal-Slow
 Rhythm: Sinus, Blocks, Atrial, Ventricular
 Axis:
Axis – Normal ? Right
Normal, Right, Left ? Left ?
 Determining The Axis
• Step 1: Locate a quadrant using I and
AVF
• Step 2: Among the remaining four limb
leads, find a lead with an equiphasic QRS
complex (in which the height R wave=
depth of S)
– The QRS axis is perpendicular to the lead
with an equiphasic QRS complex

Rowlands, Derek J, Understanding the ECG,

 RA&LA Left Axis
Extreme
Axis
+I/-AVF
-AVF

-I +I
•RA LA

Right Axis Normal

+AVF
-I/+AVF +I/+AVF Axis
 Example

• AVL (-30°) shows

biphasic QRS
complex
• Axis must be either
in -120° or +60°
• See AVR and Lead
II, which is dominant
upward= Lead II +60 °

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified
Approach. 7th ed. St. Louis: Mosby Year
Book, 2006

Khan,G., Rapid ECG Interpretation 3rd ed.,New Jersey:

Humana Press,2003
 L A D R A D
• LVH • RVH
• Inferior wall MCI • Lateral wall MCI
• Chronic Lung Disease • Chronic lung disease
• Hyperkalemia • Dextrocardia
• LAFB • Emboli paru
• LBBB • LPFB
• ASD ostium primum • ASD ostium secundum
 GELOMBANG P
Gambaran yang ditimbulkan oleh depolarisasi atrium

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

Kepentingan
Mengetahui kelainan di Atrium
“Gelombang P Mitral”

“ Gelombang P Pulmonal “
Basic Principles of ECG Interpretation

 Be Systematic
 Rate: Fast-Normal-Slow
 Rhythm: Sinus, Blocks, Atrial, Ventricular
 Axis: Normal, Right, Left
 Intervals and Durations
Intervals and Durations:
Short ? Long ?
 QRS Complex

• 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?

• >1/4 of QRS complex

QR Q/QS
 Intervals
• PR Interval
• QRS Duration
• QT Interval

PR interval QRS duration QT Interval

Normal: .12-.20 sec
Normal: .07-.10 sec Normal (corrected for rate
(3-5 small boxes)
or QTc): .440-.470 sec
Basic Principles of ECG Interpretation

 Be Systematic
 Rate: Fast-Normal-Slow
 Rhythm: Sinus, Blocks, Atrial, Ventricular
 Axis: Normal, Right, Left
 Intervals and Durations
 Waveforms
Waveforms and Segments
and Segments (Morphology)
(Morphology)
 ST Segment
• Begins at J-point
• Between ventricular depolarization and
ventricular repolarization
• Generally isoelectric
 T wave

• Ventricular repolarization, followed by

ventricular relaxation
• Positive in lead : I, II, V3-V6
• Negative in lead avR
 U wave
• Positive deflection after T wave
• Abnormal if inverted (eg: LVH or
Myocardial ischemia ) or exceeds the
height of the preceding T wave (eg:
hypokalemia)

Rowlans, Derek J; Understanding the ECG

 Summary: 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
Artifacts
Interpretasi EKG secara lengkap;

 Irama : sinus / tidak sinus

 Frekwensi : kali / menit
 Aksis : normal / LAD ( bergeser ke kiri ) /
RAD ( bergeser ke kanan ) / Superior
 Gelombang P : normal / LAE ( P mitral ) / RAE ( P Pulmonal )
 Interval PR : normal / memendek / memanjang
 Lebar QRS : normal / melebar
 Morfologi QRS : normal / LVH / RVH / RBBB / LBBB / WPW
 Segmen ST : normal / depresi / elevasi ( ukuran dan letak )
 Gelombang T : normal / negatif ( letak )

Kesan ……
Thank You