Basic and Clinical Practice of

Electrocardiography
Andi Wahjono Adi, SpJP(K) FIHA
• 1887, British physiologist Augustus
Waller discovered it was possible to record
heart activity from the skin’s surface. He used
an instrument called a capillary
electrometer to trace heart signals onto
photographic plates.
• 1902, Dutch physiologist Willem Einthoven was
developed an instrument to record traces of
the heart’s activity. His string galvanometer
was critical to the manufacture of early
electrocardiograph machines in 1908.
1908 1920 Present
Depolarization-Repolarization

Goldberger,2013
Cardiac Conduction Pathway

Leonard S Lily, 2011

 Three basic laws of electrocardiography

A, A positive complex is seen in any lead if the wave of depolarization spreads toward the positive pole of that
lead.B, A negative complex is seen if the depolarization wave spreads toward the negative pole (away from the
positive pole) of the lead. C, A biphasic (partly positive, partly negative) complex is seen if the mean direction
of the wave is at right angles (perpendicular) to the lead. These three basic laws apply to both the P wave (atrial
depolarization) and the QRS complex (ventricular depolarization).
Goldberger,2013
 Spatial relationships of the six chest leads,
which record electrical voltages transmitted
onto the horizontal plane.

Spatial relationships of the six limb leads,

which record electrical voltages transmitted
onto the frontal plane of the body.
Goldberger,2013
ECG Paper

Goldberger,2013
Calibration

Before taking an ECG, the operator must check to see that the machine is properly
calibrated, so that the 1-mV standardization mark is 10 mm tall. A,
Electrocardiograph set at normal standardization. B, One-half standardization. C,
Two times normal
Goldberger,2013
How to Calculate Heart Rate..?

Heart rate (beats per minute) can be measured by counting the number of large (0.2-
sec) time boxes between two successive QRS complexes and dividing 300 by this
number (300 ÷ 4 = 75 beats/min)
or the number of small (0.04-sec) time boxes between successive QRS complexes
can be counted (about 20 beats) and divided into 1500
Goldberger,2013
1 Minute ECG Record

Goldberger,2013
Limb Lead Placement

Shirley A. Jones,2005
Precordial Lead Placement

Lead Positive Electrode Placement View of Heart

V1 4th Intercostal space to right of sternum Septum

V2 4th Intercostal space to left of sternum Septum
V3 Directly between V2 and V4 Anterior
V4 5th Intercostal space at left midclavicular Anterior
V5 line Lateral
V6 Level with V4 at left anterior axillary line Lateral
Level with V5 at left midaxillary line

Shirley A. Jones,2005
Right Ventricle Lead Placement

Chest lead Position

V1R 4th Intercostal space to left of sternum

V2R 4th Intercostal space to right of sternum
V3R Directly between V2R and V4R
V4R 5th Intercostal space at right midclavicular line
V5R Level with V4R at right anterior axillary line
V6R Level with V5R at right midaxillary line

Shirley A. Jones,2005
Posterior Lead Placement

Chest lead Position Heart views

V4R 5th Intercostal space in right anterior Right ventricle
midclavicular line
V8 Posterior 5th intercostal space in left Posterior wall of
midscapular line LV
V9 Directly between V8 and spinal Shirley A. Jones,2005
column at posterior 5th intercostal space Posterior wall of
LV
Emergency Lead Placement

Shirley A. Jones,2005
Artifacts

Goldberger,2013
Sinus rhythm
Sinus Bradycardia- sinus tachycardia
Sinus Aritmia

Heart rate normally increases on inspiration and slows down with expiration as a result of
changes in vagal tone associated with or induced by the different phases of respiration (increase
with inspiration; decrease with expiration). This finding, a key aspect of heart rate variability, is
physiologic and is especially noticeable in children, young adults, and athletes.
Artifacts

Goldberger,2013
Reverse Lead

As a general rule, when lead I shows a negative P wave and a negative QRS,
reversal of the left and right arm electrodes should be suspected
Goldberger,2013
Axis Deviation
Frontal axis

Leonard S Lily, 2011

Left Axis Deviation(LAD) RAD Superior/Extreme

Goldberger,2013
Horizontal Axis

Clockwise

Counter Clockwise

R waves in the chest leads normally become relatively taller from lead V1 to the left chest leads. A, Notice the
transition in lead V3. B, Somewhat delayed R wave progression, with the transition in lead V5. C, Early transition
in lead V2.
Goldberger,2013
Chamber Enlargement
Right and left atrium atrium enlargement
Overload of the right atrium (RA) may cause tall, peaked P waves in the extremity chest
leads. An abnormality of the left atrium (LA) may cause broad, often notched P waves in
the extremity leads and a biphasic P wave in lead V1 with a prominent negative
component representing delayed depolarization of the left atrium

Goldberger,2013
Right atrial enlargement

P Pulmonal

George J Taylor,2006
Left atrial enlargement

P Terminal
Force P Mitral

George J Taylor,2006
Left Ventricular Hypertrophy

Goldberger,2013
LVH Criteria
Sokolow-Lyon voltages SV1 + R V5 > 3.5 mV (35 mm), or
RaVL > 1.1 mV (11 mm)
Romhilt-Estes point Any limb lead R wave or S wave >2.0 mV(3 points)
score system* or S V1 or S V2 ≥3.0 mV (3 points)
or R V5 to R V6 ≥3.0 mV (3 points)
ST-T wave abnormality, no digitalistherapy (3 points)
ST-T wave abnormality, digitalis therapy(1 point)
Left atrial abnormality (3 points)
Left axis deviation ≥ −30°(2 points)
QRS duration ≥ 90 msec (1 point)
Intrinsicoid deflection in V5 or V6≥50 msec (1 point)
Cornell voltage criteria SV3 + R aVL ≥2.8 mV (for men)
SV3 + R aVL >2.0 mV (for women)

Goldberger,2013
Right Ventricular Hypertrophy

Goldberger,2013
RVH Criteria
R in V1 ≥ 0.7 mV
QR in V1
R/S in V1> 1 with R >0.5 mV
R/S in V5 or V6 <1
S in V5 or V6 >0.7 mV
R in V5 or V6 ≥0.4 mV with S in V1 ≤0.2 mV
Right axis deviation (>90°)
S1Q3 pattern
S1S2S3 pattern
P pulmonale

Goldberger,2013
Ischemia,Injury,Necrosis
Ischemia,Injury,Necrosis
Wellen sign
Evolution of an Acute Myocardial Infarction
Localization of Infarction
Lead Localization Artery
V1-V2 Septal LAD-septal perforator branch
V3-V4 Anterior LAD-Diagonal branch
V5-V6 Lateral LCx-anterolateral marginal branch,LAD diagonal-
V1-V4 Anteroseptal branch
V3-V6 Anterolateral LAD septal perforator,diagonal branch
V1-V6,I,AVL Anterior Extensive LCx-anterolateral marginal branch,LAD diagonal-
I,AVL High Lateral branch
II,III,AVF Inferior LAD,LCx
V7-V9 Posterior LCx
V4R-6R Right Ventricle RCA or LCx
RCA or LCx
RCA
Infarct Related Artery
Infarct Related Artery
Premature Complexes
Atrial extrasystole /Premature atrial contraction
Ventricular extrasystole/Premature ventricular contraction
Single PVC

Bigemini

Couplet Salvo

Khawaja,2006
Trigemini
Compensatory Pause
Ventricular Atrial
Atrial

Angela Rowlands,2011
Compensatory Pause

Complete vs incomplete

Ventricular Atrial
Lown Criteria

Malignant

ventricular extrasystoles contributed significant additional risk for cardiac death even in the three
highest Lown grades, 4A, 4B, and 5. The Lown grading system assumes that, of the four
complex features used, R on T ventricular extrasystoles have the greatest risk for
subsequent cardiac death.
J Thomas Bigger et
al,1981
Escape Rhythm
Junctional rhythm
Idioventricular rhythm
Bradyarrhythmias&Heart Block
Atrioventricular Block
1st Degree AV Block
2nd Degree AV Block-Wenkebach
2nd AV Block-Mobitz Type 2
3rd Degree AV Block(Total AV Block)
Bundle Branch Block
Left Bundle Branch Block

LBBB may be the first clue to four previously undiagnosed but clinically important
abnormalities: Advanced coronary artery disease, Valvular heart disease, Hypertensive
heart disease, Cardiomyopathy
Right Bundle Block
Tachyarrhythmia
Atrial Fibrilation
Atrial Flutter
Atrial tachycardia
Supraventricular Tachycardia (SVT)
Ventricular Tachycardia (VT)
Torsades de pointes

Spindle
Ventricular Fibrilation (VF)
Asystole