ECG Basics

Dr. Yudi Fadilah, SpPD

Definisi

• Elektrokardiografi: Ilmu yang mempelajari

aktifitas listrik atau elektrofisiologis otot
jantung yang diperoleh dari suatu grafis
rekaman.
• Elektrokardiogram: Suatu grafis rekaman
perbedaan potensial listrik yang disebabkan
oleh perjalanan gelombang depolarisasi dan
repolarisasi atrium dan ventrikel otot jantung.
• Elektrokardiograf: Suatu alat yang digunakan
untuk melakukan rekaman elektrokardiogram.
Cara Menilai EKG
Secara praktis ada lima hal penting yang perlu
diperhatikan:
1. Frekuensi jantung.
2. Irama jantung.
3. Axis (sumbu jantung)
4. Tanda-tanda hipertrofi.
5. Tanda-tanda iskemik atau infark.
6. Kelainan hantaran, pembesaran bentuk, dll.
Normal, Reguler
 KERTAS EKG
Kertas EKG merupakan kertas grafik
0,04 dt
yang merupakan garis horizontal dan
vertikal dengan jarak 1mm ( kotak
kecil ). Garis yang lebih tebal 0, 20 dt
terdapat pada setiap 5mm disebut
(kotak besar).
•Garis horizontal Menunjukan
waktu, dimana 1mm = 0,04 dtk,
sedangkan 5mm = 0,20 dtk.
0,1 mv 0,5
•Garis vertical Menggambarkan
voltage, dimana 1mm = 0,1 mv , mv
sedangkan setiap 5 mm =0,5 mv.
 The Standard 12-lead ECG
This space should contain the following
You
Whathave
is missing
each received
in this blank
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information:
of this ECG…
space?
•Patient identifiers (e.g. name, hospital number,
treating physician, etc.)
•Date and time that the ECG was obtained
•Vital signs, including BP and HR
•Comment on any relevant symptoms (e.g. chest
pain), cardiovascular drugs and special lead
placements…
 The Standard 12-lead ECG
• The 12 leads are:
– Six limb leads (I, II, III, aVR, aVL and aVF)
– Six precordial (chest) leads: V1 to V6

• The 12 leads are displayed at a standardised

tracing speed of 25 mm per second, and with 1 cm
representing 1.0 mV on the vertical axis.

 Check the calibration mark.

GAMBAR EKG
 CHEST LEADS
• 6 UNIPOLAR LEADS
• V1
• V2
• V3
• V4
• V5
• V6

8
RULING OUT LIMB LEAD REVERSAL

• Avr is always negative

• Lead I is always positive

• Lead II and III positive for the P wave and

usually the QRS complex

9
 Quality of the ECG
• Patient name
• Date of the ECG
• Is there any interference?
• Is there electrical activity from all 12 leads?

• Calibration:
- speed = 25mm/second
- height = 1cm/mV
Calibration
 ECG interpretation
• Quality of ECG?

• Rate
• Rhythm
• Axis

• P wave
• PR interval
• QRS duration
• QRS morphology
• Abnormal Q waves
• ST segment
• T wave
• QT interval
 Rate
• 300/number of big squares between R waves

• Rate is either:
- normal
- bradycardic
- tachycardic
 CARA MENGHITUNG HRI
Menentukan frekuensi jantung
A. 300 = ( jml kotak besar dlm 60 detik )
Jml kotak besar antara R – R

B. 1500 = (jml kotak kecil dlm 60 detik )

Jml kotak kecil antara R – R

C. Ambil EKG strip sepanjang 6 detik, hitung jumlah QRS

dan kalikan 10.

CAT : RUMUS A/B UNTUK EKG YANG TERATUR.

RUMUS C UNTUK YANG TIDAK TERATUR.
Rate
 Rhythm

• Are there P waves?

• Are they regular?
• Does one precede every QRS complex?

• Regular vs. irregular

Axis

Positive in I and II =
NORMAL

Positive in I and negative in

II = LAD

Negative in I and positive in

II = RAD
 ECG interpretation
• Quality of ECG?

• Rate
• Rhythm
• Axis

• P wave
• PR interval
• QRS duration
• QRS morphology
• Abnormal Q waves
• ST segment
• T wave
• QT interval
 P wave
• Are there P waves present?

• Bifid = P mitrale (LA hypertrophy)

• Pointy = P pulmonale (RA hypertrophy)
P mitrale
P pulmonale
 PR interval
• Start of P wave to start of QRS complex

• Normal = 0.12 - 0.2 seconds (3-5 small squares)

• Decreased = can indicate an accessory pathway

• Increased = indicates AV block (1st/2nd/3rd)

 PR interval

 Start of P wave to start of QRS

 Normal = 0.12-0.2s

 Too short – can mean WPW syndrome (ie.

an accessory pathway), or normal!

 Too long –means AV block (heart block) -

1st/2nd/3rd degree
 ECG interpretation
• Quality of ECG?

• Rate
• Rhythm
• Axis

• P wave
• PR interval
• QRS duration
• QRS morphology
• Abnormal Q waves
• ST segment
• T wave
• QT interval
 QRS complex
• Normal = <0.12 seconds

• >0.12 seconds = Bundle Branch Block

 QRS complex
• Should be <0.12s duration
• >0.12s = BBB (either LBBB or RBBB)

• ‘Pathological’ Q waves can mean a previous MI

(? territory)

• >25% size of subsequent complex

• Q waves are allowed in V1, aVR and III
QRS complex

W I LL ia m = LBBB

M a RR o w = RBBB
 QRS complex
• Is there LVH?
• Sum of the Q or S wave in V1 and the
tallest R wave in V5 or V6
>35mm is suggestive of LVH
 Q waves
• Q waves are allowed in V1, aVR & III

• Pathological Q waves can indicate previous MI

 ECG interpretation
• Quality of ECG?

• Rate
• Rhythm
• Axis

• P wave
• PR interval
• QRS duration
• QRS morphology
• Abnormal Q waves
• ST segment
• T wave
• QT interval
 ST segment
• ST depression
- downsloping or horizontal = ABNORMAL

• ST elevation
- infarction
- pericarditis (widespread)
ST segment
ST segment
ST segment
 T wave
• Small = hypokalaemia

• Tall = hyperkalaemia

• Inverted/biphasic = ischaemia/previous
infarct
T wave
T wave
Acute Coronary Syndrome

Sindroma Koroner Akut

 Structure
• •Composed
Composed of of 33
histologically distinct
histologically distinct
tissues
tissues
––Epicardium
Epicardium
––Myocardium
Myocardium
––Endocardium
Endocardium
• •Surrounded
Surrounded by by fibrous
fibrous
sac
sac
––Pericardium
Pericardium
 Diagnosis

Anamnesis
Pemeriksaan Fisik
Pemeriksaan Penunjang :
1. Elektrokardiogram
2. Laboratorium
3. Thoraks Foto
Anamnesis
• Nyeri dada, nyeri epigastrium hebat seperti :
 dihimpit benda berat
 Terasa tercekik
 Rasa ditekan, ditinju, ditikam
 Rasa terbakar
Biasanya dirasakan dibelakang stenum  seluruh
dada
terutama kiri, dapat ke tengkuk, rahang, bahu,
punggung, lengan kiri atau kedua lengan
• laki-laki > 35 tahun dan Wanita > 40 tahun
• disertai mual atau muntah, dapat pula rasa tidak
enak disertai sesak nafas, lemah, penurunan
kesadaran, dan keringat banyak
44
Anamnesis untuk UAP

• 3 kategori presentasi klinik UAP:

 Angina saat istirahat (resting angina)
 Angina awitan baru (new onset angina)
 Angina yang bertambah berat (increasing
angina)

• Riwayat penyakit dahulu :

 Riwayat angina on effort, infark atau
operasi pintas
 Riwayat penggunaan nitrogliserin
 Identifikasi faktor-faktor risiko
45
Clinical Spectrum of Acute Coronary
Syndrome
Acute Coronary Syndrome

Non-ST Segment ST Segment

Elevation Elevation

STEMI

NSTEMI
Unstable Non-Q-wave Q-wave
Angina Pectoris Acute Myocardial Infarction
 DEFINISI
Suatu sindroma klinik yang menandakan
adanya iskemia miokard akut, terdiri dari :
 Infark miokard akut Q wave (STEMI)
 Infark miokard akut non-Q (NSTEMI)
 Angina pektoris tidak stabil (UAP)

Ketiga kondisi ini sangat berkaitan erat,

berbeda hanya dalam derajat beratnya
iskemi dan luasnya miokard yang
mengalami nekrosis.
47
 Diagnosis Banding
1. Gangguan : muskuloskeletal, neurogenik
2. Penyakit esofageal, GI atas atau traktus
biliaris
3. Penyakit paru : pneumotoraks, emboli,
pleuritis, asma
4. Sindroma hiperventilasi
5. Perikarditis, miokarditis
6. Nyeri angina atipikal pada kardiomiopati
hipertrofi
7. Diseksi aorta
48
8. Psikogen
 Unstable
NSTEMI STEMI
Angina

Occluding thrombus Complete thrombus

Non occlusive occlusion
sufficient to cause
thrombus
tissue damage & mild
myocardial necrosis ST elevations on
Non specific ECG or new LBBB
ECG
ST depression +/-
T wave inversion on Elevated cardiac
Normal enzymes
ECG
cardiac
enzymes More severe
Elevated cardiac
enzymes symptoms
Pain Patterns with
Myocardial Ischemia

50
Pemeriksaan Fisik
• tampak cemas, gelisah, pucat, dan keringat dingin
• vital sign:
 Denyut nadi cepat, reguler, dapat bradi atau
tachycardia, irama ireguler
 TD biasanya normal bila belum terjadi
komplikasi, dapat hipo atau hipertensi
 Bunyi jantung dapat terdengar redup
 S3 dapat terdengar bila kerusakan miokard luas
 Paru-paru dapat terdengar ronkhi basah dan
atau wheezing yang menandakan terjadinya
bendungan paru  tergantung ada tidaknya
gangguan fungsi ventrikel kiri
51
Pemeriksaan Penunjang

• Pemeriksaan EKG

Gambaran EKG infark miokard akut Q-wave (STEMI)

:

 Elevasi segmen ST  1 mm pada  2 sadapan

extremitas

 Atau  2 mm pada  2 sadapan prekordial yang

berurutan

 Atau gambaran LBBB baru atau diduga baru

52
ST-segment elevation
Gambaran EKG infark miokard akut non-Q-
wave (NSTEMI) atau angina pektoris
tidak stabil (UAP) :

– Depresi segment ST atau gelombang T

terbalik pada  2 sadapan berurutan

– Inversi gelombang T minimal 1 mm pada

2 sadapan atau lebih yang berurutan.

– Perubahan segment ST saat keluhan dan

kembali normal saat keluhan hilang 
sangat menyokong UAP 56
ST-segment depression
T-wave inversion
 ELEKTROKARDIOGRAM

Current-of-injury patterns with acute

ischemia

59
• Pemeriksaan Penanda Jantung/Enzim
jantung
(Cardiac Markers):

Yang lazim adalah CKMB, dapat pula troponin T (TnT)

atau troponin I (TnI)

Peningkatan marka jantung akan terlihat pada infark

miokard akut Q-wave (STEMI) dan non-Q-wave
(NSTEMI)

60
Plot of the appearance of cardiac markers in blood
versus time after onset of symptoms

A myoglobin C CK-MB
61
B troponin D troponin in UA
Manajemen
 DELAY TO THERAPY

1. From onset of symptoms to patient

recognition

2. Out-hospital transport

3. In-hospital evaluation
ISCHEMIC CHEST PAIN ALGORYTHM
Chest pain suggestive of ischemia
 ISCHEMIC CHEST PAIN

TYPICAL ANGINA EQUIVALENT ANGINA

1. NO CHEST DISCOMFORT
1. CHEST DISCOMFORT 2. LOCATION
2. LOCATION 3. INDIGESTION
3. RADIATION 4. UNEXPLAINED WEAKNESS
4. UNLIKELINESS 5. DIAPORESIS
6. SHORTNESS OF BREATH
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Chest discomfort suggestive of ischemia

Immediate ED assessment ( 10 min) Immediate ED general treatment

• Vital sign • O2 at 4 L/min (maintain O2 sat 90%)
• Oxygen saturation • Aspirin 160-325 mg
• Obtain IV access • Nitroglycerin SL, spray, or IV
• Obtain ECG 12 lead • Morphine IV 2-4 mg repeated every
• Brief history and physical exam 5-10 minutes (if pain not relieved
• Check contraindication for fibrinolytic with nitroglycerine)
• Initial serum cardiac markers
• Initial electrolyte and coagulation Memory: “MONA” greets all patients
study
• Portable chest x-ray ( 30 minutes)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or
presumably new LBBB
strongly suspicious for
injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or

presumably new LBBB dynamic T-wave
strongly suspicious for inversion strongly
injury suspicious for injury

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or Normal or non-

presumably new LBBB dynamic T-wave diagnostic changes
strongly suspicious for inversion strongly in ST-segment or T-
injury (STEMI) suspicious for injury waves (intermediate/
(UA/NSTEMI) low-risk UA)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or Normal or non-

presumably new LBBB
strongly suspicious for
injury (STEMI)
Start adjunctive treatment
dynamic T-wave diagnostic changes
inversion strongly in ST-segment or T-
suspicious for injury waves (intermediate/
(UA/NSTEMI) low-risk UA)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 ADJUNCTIVE TREATMENT
(Do not delay reperfusion)

1. Beta-adrenergic receptor blocker

2. Clopidogrel

3. Heparin (UFH or LMWH)

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves

Start adjunctive treatment

Time from onset of

symptoms
 12 hours
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB
- Statin

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Acute coronary syndrome algorithm
Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves

Start adjunctive treatment Start adjunctive treatment

Time from onset of

symptoms
 12 hours
- Reperfusion strategy: PCI (90 min)
or fibrinolysis (30 min)
- ACE-I/ARB within 24 hours of onset
- Statin

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Adjunctive treatment

• Heparin (UFH/LMWH)

• Glycoprotein IIb/IIIa receptor inhibitors

• -Adrenoreceptor blockers

• Clopidogrel

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves

Start adjunctive treatment Start adjunctive treatment

Time from onset of  12 hrs Admit to monitored bed

symptoms Assess risk status
 12 hours
- Reperfusion strategy: PCI (90 - High risk: early invasive
min) or fibrinolysis (30 min) strategy
- ACE-I/ARB within 24 h of - Continue ASA, heparin,
symptom onset) ACE-I, statin
- Statin

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 VERY HIGH-RISK PATIENT

1. Refractory chest pain

2. Recurrent/persistent ST deviation

3. Ventricular tachycardia

4. Hemodynamic instability

5. Sign of pump failure

6. Shock within 48 hours

2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
 Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or ST-depression or dynamic Normal or non-

presumably new LBBB T-wave inversion strongly diagnostic changes in
strongly suspicious for suspicious for injury ST-segment or T-
injury waves

Start adjunctive treatment Start adjunctive treatment Develops high or

Time from onset of
symptoms
 12 hours
- Reperfusion strategy: PCI (90
min) or fibrinolysis (30 min)
- ACE-I/ARB within 24 h of
symptom onset)
- Statin
2005 AHA-ILCOR Guidelines for CPR and ECC. Circulation 2005;112 (Suppl):IV-90
intermediate risk criteria
or troponin-positive
 12 hrs Admit to monitored bed
Assess risk status
Monitored bed in ED
- High risk: early invasive
strategy Develops high or
- Continue ASA, heparin, intermediate risk criteria
ACE-I, statin or troponin-positive
No evidence of ischemia and MI: discharge with follow-up