ELECTROCARDIOGRAM

Sistem Konduksi Jantung

 Electrocardiogram
• Electrocardiogram (ECG):
Rekaman (gram) aktivitas listrik (electro) sel-
sel otot jantung (cardio) yang sampai ke
permukaan tubuh

• Non invasif
• Mudah, murah, cepat
• Sederhana, cukup bermakna
 Electrocardiogram
Berbagai kelainan yang dapat dinilai dari ECG :
• Pembesaran ruang jantung (dilatasi)
• Hipertrofi otot jantung
• Aritmia – gangguan irama
• Gangguan aliran pembuluh darah koroner
• Kematian otot jantung - lokasi
• Gangguan elektrolit
• Lain-lain (miscellaneous)
Recording Electrodes & Leads

aVF I aVR

RA LA
ICS4

II III ICS5

RSM LSM

MCL
AAL MAL
RL LL

aVF
ECG – 12 Sandapan
ECG – 15 Sandapan :
Sandapan Kanan
Sandapan Posterior
 Electrocardiogram

• Identity : Name, age, sex, (race), date,

time
• Paper speed
• Calibration
• Electrode placement
• Artifact
 Electrocardiogram

The ECG machine is very accurate at measuring interval and duration

 Electrocardiogram

ECG machine DIAGNOSIS is not always accurate

 “ Layak Baca “
Identitas : Nama, umur, sex, (ras), tanggal, waktu
Sistematika membaca ECG
• Irama
• Frekuensi denyut jantung
• Aksis
• Morfologi gelombang P
• Interval PR
• Morfologi kompleks QRS
• Morfologi segmen ST
• Morfologi gelombang T
• Tanda-tanda LVH
• Tanda-tanda RVH
• Diagnosis EKG
The Normal Cardiac Rhythm :
The Sinus Rhythm
SA node
Atrium
AV node
Ventricle
Regularity

Regular
 Heart rate

• Regular rhythm
Memorize the number sequence Mathematical method

_________300__________
Σ large boxes between R-R

_________1500_________
Σ small boxes between R-R

Speed 25 mm/second
 Frekuensi – HR (Tidak Teratur)
Frekuensi
• Strip 6 detik (30 kotak besar) :
Σ komp. QRS X 10
• Strip 12 detik (60 kotak besar) :
Σ komp. QRS X 5
 QRS complex
The Axis of QRS complex
• Normal :
-300 - +900
• Left Axis Deviation (LAD) :
-300 - -1200
• Right Axis Deviation (RAD) :
+900 - +1800
• Extreme RAD :
- 900 - +1800
 Aksis
Aksis : jumlah total seluruh arus listrik yang
terbentuk di ventrikel saat depolarisasi
 QRS complex
The Axis of QRS complex
 QRS complex
The Axis of QRS complex
 The P wave
• Contour : smooth and monophasic
(entirely negative/positive) in all leads
except V1, or occasionaly V2
• Configuration :
– Positive (upright) : I, II, aVL, aVF, V4–V6
– Negative (downward) : aVR
– Positive / negative : III
• Duration : ≤ 0.12 sec
• Amplitude : ≤ 0.2 mV
P wave
 PR interval
• The time required for an electrical impulse to
travel from the atrial myocardium adjacent to
the SA node to the ventricular myocardium
adjacent to the fibers of the Purkinje network
• Duration : 0.11 – 0.20 seconds (3-5 small
boxes)
• PR interval varies with the heart rate. The
faster the heart rate, the shorter the PR
interval
 PR interval
Abnormal PR interval : first degree AV block
 QRS complex
Q R S
QRS complex
 QRS complex
The Q wave
• A normal Q wave would be very small (less
than 0.04 second and its voltage is less than
25% of the R wave)
QRS complex
Abnormal Q waves
 QRS complex
R wave progression
 QRS complex
The S wave
• S wave should be large in V1 and then
progressively smaller to V6

Ratio R/S
• Ratio of R/S amplitude in V1 and V2 is
normally less than 1
• R in V5/V6 + S in V1/V2 is not more than 35
mm
 QRS complex
S wave regression
 QRS complex

RV1/SV1 > 1
QRS complex
 QRS complex
• Duration of the QRS complex (QRS interval)
– 0.07-0.11 second (less than 0.12 second)
– The QRS interval has no lower limit that indicates
abnormality
• Amplitude of QRS complex
– There is no arbitrary upper limit for normal voltage of
the QRS complex
– An abnormality low QRS complex when the amplitude
is no more than 0.5 mV in any limb leads and no
more than 1.0 mV in any of the precordial leads
 QRS complex

Abnormal QRS interval

 QRS complex
J point
• Junction between end of QRS complex and
beginning of ST segment
• Where QRS stops and makes a sudden sharp
change of direction
ST segment
ST segment
 T wave
• The T waves are positively directed in all leads
except aVR (negative) and V1 (biphasic)
• T waves do not normally exceed 0.5 mV in any
limb lead or 1.5 mV in any precordial lead
 Aritmia
• Tidak memenuhi kriteria NSR 🡪 Aritmia
(Disritmia)
• Gangguan pembentukan impuls
• Gangguan penghantaran impuls
• Sumber impuls:
• SA node
• Sel atrium
• AV node (AV junction)
• Sel ventrikel
Sinus Bradycardia (SB)
Sinus Tachycardia (ST)
Sinus Arrhythmia
Atrial Fibrillation (AF)
Atrial Flutter (Af)
 Atrial Fibrillation – Atrial Flutter

Frekuensi
• < 60 x/m : slow response (SVR)
• 60-100 x/m : normo response (NVR)
• >100 x/m : rapid response (RVR)
Supraventricular Tachycardia (SVT)

• Irama teratur, HR > 150 x/m

• Gelombang P kecil, kadang (-)
• Interval PR memendek atau (-),
• Kompleks QRS ≤ 0,12 detik (sempit)
Supraventricular Tachycardia (SVT)
Junctional Rhythm (JR)
Idioventricular Rhythm (IVR)
 Resume
SA NODE JUNCTION VENTRIKEL
(SINUS)
Denyut jantung 60-100 40-60 20-40

Irama Reguler Reguler Reguler

Gelombang P (+) (-) / (+) inv / ( - ) / tidak

Setelah QRS berhubungan
Interval PR Normal Normal (-)

Durasi QRS Sempit Sempit Lebar

 Ventricular Extrasystole (VES)
Premature Ventricular Contraction (PVC)

• Irama tidak teratur, karena ada extrasystole

• HR tergantung irama dasar
• Gelombang P (-), Interval PR (-)
• Kompleks QRS > 0,12 detik (lebar)
▪ VES unifocal, multifocal
▪ VES couplet, triplet, consecutive (Salvo)
▪ VES bigemini, trigemini, quadrigemini
▪ VES R on T
Ventricular Extrasystole (VES)
Unifocal
Ventricular Extrasystole (VES)
Multifocal
Ventricular Extrasystole (VES)
Coupled
Ventricular Extrasystole (VES)
Triplet
Ventricular Extrasystole (VES)
Bigeminal
Ventricular Extrasystole (VES)
Quadrigeminal
Ventricular Extrasystole (VES)
R on T
Ventricular Fibrillation (VF)
Ventricular Fibrillation (VF)
 Ventricular Tachycardia (VT)

• Irama teratur, HR >100 x/m

• Gelombang P (-), Interval PR (-)
• Kompleks QRS > 0,12 detik (lebar)
• Monomorphic, Torsade de Pointes
Torsade de Pointes
Ventricular Asystole
 Malignant Premature Beat
• Frequent
• Multifocal or multiform
• Salvo
• R on T phenomenon
 First Degree AV Block

• Irama teratur, HR umumnya 60-100 x/m

• Gelombang P normal, P : QRS = 1 : 1
• Interval PR memanjang, > 0,20 detik, konstan
• Kompleks QRS ≤ 0,12 detik (sempit)
 Second Degree AV Block
Mobitz Type 1 (Wenckebach)
 Second Degree AV Block
Type 2

• Irama atrial teratur, irama ventrikel tidak teratur

• Frekuensi A > F
• Gelombang P normal, ada satu atau lebih gelombang P
tidak diikuti kompleks QRS
• Interval PR normal atau memanjang, namun konstan
• Kompleks QRS sempit/lebar
Third Degree AV Block (TAVB)
Penyakit Jantung Koroner
Penyakit Jantung Koroner

1. Ischemia
2. Injury ~ Acute infarction
3. Infarction ~ Old infarction
Iskemia
Iskemia
Infark (acute) - Injury
Infark (old)
 1-30 menit Sekitar 1 jam Beberapa jam

Beberapa hari Hari-hari berikutnya Beberapa minggu

 Resume
• Iskemia
– Inversi gelombang T
– Depresi segmen ST

• Infark
– Elevasi segmen ST (acute 🡪 Injury)
– Elevasi segmen ST + inversi gelombang T (recent)
– Gelombang Q patologis (old)
Lokasi
TERIMA KASIH