ECG

By Dr. Devi Triyadi

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Normal Impulse Conduction

Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers dokdev

Impulse Conduction & the ECG

Sinoatrial node AV node Bundle of His Bundle Branches Purkinje fibers dokdev

Normal: P-R Int: 0,12 0,20 QRS Int : Max 0,10 QT Int : tergantung HR

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Gel T : Potensial repolarisasi dari ventrikel kanan & kiri Gel U : -Gel berukuran kecil yang sering tidak ada - Bila ada harus positip (Negative: Ischemia)

Gel P : - ukuran kecil - Hasil depolarisasi dari Atria kanan dan kiri Segmen PR : Garis isoelektrik yang menghub Gel P & Gel QRS Kompleks QRS : Hasil depolarisasi dari Ventrikel kanan dan kiri Gel Q : Gel I ke bawah R : Gel ke atas pertama S : Gel ke bawah I setelah Gel R Segmen ST : Garis isoelektrik yang menghub kompleks QRS dan Gel T

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Kecepatan rekaman standard = 25 mm/detik -Jadi 1 mm = 1/25 = 0,04 -Dalam 1 detik direkam 25 mm -1 menit = 60 x 25 mm = 1500 mm

Rekaman potensial: Kalibrasi 1 mv = 10 mm

-Heart Rate (HR) = 1500/ Interval (mm)

-PP Interval or RR Interval

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Rhythm #1

Rate? Regularity? P waves? PR interval? QRS duration?

30 bpm regular normal 0.12 s 0.10 s

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Interpretation? Sinus Bradycardia

Rhythm #2

Rate? Regularity? P waves? PR interval? QRS duration?

130 bpm regular normal 0.16 s 0.08 s

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Interpretation? Sinus Tachycardia

Gel P
Gel P yang normal berasal dari sinus Lebar < 0,11 Tinggi < 2,5 mm Positip, kecuali di AVR, V1 (Biphasik/negative) Paling jelas dilihat di II, V1 Sumbu pada bidang Frontal 0 75 Gel P merupakan depolarisasi Atrium Berubah bila ada pembesaran Atrium kiri/kanan dan gangguan irama di Atrium dokdev

P R Interval

Menunjukkan waktu penghantaran Atrio Ventrikular Diukur mulai dari permulaan Gel P sampai Gel Q Harga Normal : 0,12 0,20 Memendek < 0,12 misal : WPW Memanjang > 0,21 : AV Block

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QRS Kompleks

Merupakan depolarisasi Ventrikel Harga normal : 0,06 -0,10 (dihitung dari permulaan Q S) q : Gel negative Lead I Normal dalamnya < R Q Patologis > R (>5 mm) - menunjukkan nekrosis pada infark myokard

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Gel R

Gel puncak yang tertinggi di EKG tu. Lead I,II,III R di V1,V2 kecil, makin meninggi ke arah V5 Patologis : R tinggi -> Hypertrofi Ventrikel R rendah Voltage rendah R tidak ada seluruh tebal Myocard necrosis QRS kompleks yang lebar patologis ( > 0,10) misalnya : PVC, RBBB, LBBB, WPW syndrom

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QT Interval
Tergantung Heart Rate QT penting karena kalau memanjang bisa berbahaya

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ST Segmen

Dari akhir S ke permukaan T Merupakan garis lurus = isoelektris Ventrikel depolarisasi yang selesai dan selanjutnya merupakan permulaan fase repolarisasi Normal : 0,1 mv boleh 1 mm di atas atau 1 mm di bawah garis isoelektris

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Spesifik

Non Spesifik

Spesifik

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Gel T

Positif di I,II,aVL, aVF, V3 V6 Negatif di V1 (V2 : pada orang tua) Di Lead III : bisa pos/neg/Biphasik Tinggi Gel T : sedikitnya > 1/7 tinggi R Max < 2/3 tinggi R Abnormal : T tinggi > 2/3 tinggi R di V3 V6 Hyperkalemia

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Kriteria ECG Normal

Gel P: Bentuknya/besarnya normal ( lebar < 0,11 dan Tinggi < 2,5 mm PR Interval tetap dan normal : 0,12 0,20 QRS kompleks : besarnya 0,06 0,10 konfigurasi dari V1 V6 : R makin tinggi, S makin dangkal, Q kecil di V5, V6 Setiap Gel P diikuti oleh QRS kompleks yang normal PP Interval / RR Interval tetap (Boleh bervariasi < 0,16) Rate 60 100 x/ menit ST normal, Gel T positif dan Normal, QT Normal Sumbu gel P dan QRS Normal

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Sinus Tachycardi: KD : Irama Sinus Rate > 100 x/menit Max HR: 220 - umur

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Sinus Bradycardi KD : Irama Sinus Rate < 60 x/menit

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ECG abnormalities

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Arrhythmias
Sinus Rhythms Premature Beats Supraventricular Arrhythmias Ventricular Arrhythmias AV Junctional Blocks

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Premature Beats
Premature Atrial Contractions (PACs) Premature Ventricular Contractions (PVCs)

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Prematur Atrial Contraction

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Premature Ventricle Contraction

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Conduction System

His Bundle

L Bundle
R Bundle

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Waves
R T P
U

Q
S
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SISTIM SUMBU PADA BIDANG FRONTAL

II III dokdev PED 596

SUPERIOR

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Rate Rhythm

Axis Intervals Hypertrophy Infarct

The QRS axis is determined by overlying a circle, in the frontal plane. By convention, the degrees of the circle are as shown.
The normal QRS axis lies between -30o and +90o. A QRS axis that falls between -30o and -90o is abnormal and called left axis deviation. A QRS axis that falls between +90o and +150o is abnormal and called right axis deviation.
-90o

-120o
-150o 180o
o

-60o -30o 0o 30o

A QRS axis that falls between +150 and -90o is abnormal and called superior right axis deviation.

150o 120o 90o 60o

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QRS Complexes

I + + -

II + +

Axis normal left axis deviation right axis deviation

right superior axis deviation

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Right Axis deviation

Maybe a normal variant in children and young adults IHD Right Ventricular Hypertrophy Chronic lung disease +/pulmonary hypertension Acute right heart strain PE WPW type B ASD and VSD

Left Axis deviation

Pathological

IHD (Inferior MI) NB LVH does NOT cause LAD

WPW type A

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SISTIM SUMBU PADA BIDANG HORISONTAL

V6

V5 V1

V3 V2

V4

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Regions of the Myocardium

Lateral I, AVL, V5-V6

Inferior II, III, aVF

Anterior / Septal V1-V4

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ST segment abnormalities

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ST Elevation Infarction
The ECG changes seen with a ST elevation infarction are:

Before injury Normal ECG Ischemia Infarction Fibrosis

ST depression, peaked T-waves, then T-wave inversion

ST elevation & appearance of Q-waves ST segments and T-waves return to normal, but Q-waves persist dokdev

ST Elevation Infarction
Heres a diagram depicting an evolving infarction:
A. Normal ECG prior to MI B. Ischemia from coronary artery occlusion results in ST depression (not shown) and peaked T-waves C. Infarction from ongoing ischemia results in marked ST elevation D/E. Ongoing infarction with appearance of pathologic Q-waves and T-wave inversion F. Fibrosis (months later) with persistent Qwaves, but normal ST segment and Twaves

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ST segment depression

http://www.emedu.org/

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ST segment depression

Poor myocardial protection Incomplete revascularization Technical problem with graft (Kink, Twist) Air embolism
http://www.emedu.org/

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ST segment depression

Poor myocardial protection Incomplete revascularization Technical problem with graft (Kink, Twist) Air embolism
http://www.emedu.org/

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ST segment depression

Poor myocardial protection Incomplete revascularization Technical problem with graft (Kink, Twist) Air embolism
http://www.emedu.org/

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ST segment depression

Poor myocardial protection Incomplete revascularization Technical problem with graft (Kink, Twist) Air embolism
http://www.emedu.org/

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ST segment depression

Poor myocardial protection Incomplete revascularization Technical problem with graft (Kink, Twist) Air embolism
http://www.emedu.org/

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ST segment depression
LVH LBBB RBBB ISCHEMIA

David Arnall, Ph.D., P.T. (2000)

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ST segment Elevation

Acute MI Poor myocardial protection Incomplete revascularization Technical problem with graft (Kink, Twist, Dissection) Air embolism Preoperative Sequella dokdev http://www.emedu.org/

ST segment Elevation

http://www.emedu.org/

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ST segment Elevation

http://www.emedu.org/

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ST segment Elevation

http://www.emedu.org/

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ST segment Elevation

http://www.emedu.org/

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ST segment Elevation

http://www.emedu.org/

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ST segment Elevation

http://www.emedu.org/

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ECG: MI Evolution

OR CSU > 3 Wks

Katrina Kardos, MD PGY-3 Albany Medical Center

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Diffuse ST segment Elevation

Coronary Air embolism (+++ valve surgery) Reperfusion (coronary surgery) Reversible

http://www.emedu.org/

Diffuse ST segment Elevation

Coronary Air embolism (+++ valve surgery) Reperfusion (coronary surgery) Reversible
http://www.emedu.org/

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Diffuse ST segment Elevation

http://www.emedu.org/

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Diffuse T wave Elevation

Hyperkalemia Renal failure

http://www.emedu.org/

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Diffuse T wave Elevation

Hyperkalemia Renal failure

http://www.emedu.org/

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Diffuse T wave Depression

Digoxin

http://www.emedu.org/

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Rhythm abnormalities
Atrial level

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Atrial Fibrillation

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Atrial Flutter

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Atrial fibrillation / Flutter

Valvular heart disease (+++ mitral valve) Manipulation of right atrium (canulation) Electrolyte disturbances Hypovolemia Hyperthyroidism

Atrial fibrillation / Flutter

Valvular heart disease (+++ mitral valve) Manipulation of right atrium (canulation) Electrolyte disturbances Hypovolemia Hyperthyroidism

Atrial fibrillation / Flutter

Valvular heart disease (+++ mitral valve) Manipulation of right atrium (canulation) Electrolyte disturbances Hypovolemia Hyperthyroidism

Sinus tachycardia

Awake patient ( + Hypertension) Hypovolemia Hypoxia Hyperthyroidism

Supraventricular tachycardia

Abnormal rhythm after weaning from CPB May be poorly tolerated Amiodarone

Supraventricular tachycardia

Abnormal rhythm after weaning from CPB May be poorly tolerated Amiodarone

Supraventricular tachycardia

Abnormal rhythm after weaning from CPB May be poorly tolerated Amiodarone, adenosine

Supraventricular tachycardia

Supraventricular tachycardia

Junctional tachycardia

Valve surgery (+++)

Ectopic atrial tachycardia

Valve surgery (+++)

Multifocal Atrial tachycardia

Valve surgery (+++): Mitral, tricuspid COPD and advanced Pulmonary hypertension

Rhythm abnormalities
Ventricular level

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Ventricular fibrillation

Mechanical arrest Great O2 consumption +++ Before CPB: critical ischemia (Left main, severe CAD) During CPB: poor myocardial protection On weaning from CPB: Reperfusion After CPB: Myocardial ischemia, electrolyte disturbances

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PVC (ESV)

Bigeminism

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PVC (ESV)

paired

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PVC (ESV)

Polymorphic

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PVC (ESV)

Triplet

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PVC (ESV)

Ischemic Ventricle irritation

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PVC (ESV)

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Ventricular tachycardia

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Ventricular tachycardia

Mechanical arrest or severe hypotension Great O2 consumption +++ Before CPB: critical ischemia (Left main, severe CAD) After CPB: Myocardial ischemia, electrolyte disturbances electroshock

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Conduction abnormalities

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Sinus bradycardia

Beta-blockers Calcium Channel blockers

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LBBB

Preoperative: HTA, LVH, CHF, Ischemia New LBBB

MI poor myocardial protection incomplete revascularization Technical problem with graft (Kink, Twist) Air embolism Lesion to conduction tissues (AVR, MVR)

Risk of complete heart bloc with Swan Ganz KT

Conduction System

His Bundle

L Bundle
R Bundle

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RBBB

Preoperative: Normal (10%), RVH New RBBB

poor RV myocardial protection (imperfect retrograde cardioplegia) incomplete revascularization to RCA Technical problem with graft (Kink, Twist) to RCA Air embolism in the RCA ostium (+++ valve surgery) Lesion to conduction tissues (tricuspid)

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1st Degree AV block

Beta blockers Frequent in elderly AV node (valve surgery, MI)

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1st Degree AV block

Beta blockers Frequent in elderly AV node (valve surgery, MI)

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2nd Degree AV block type 1

Lesion to conduction tissues (AVR, MVR, TVR)

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2nd Degree AV block type 2

Lesion to conduction tissues (AVR, MVR, TVR)

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3rd Degree AV block

Lesion to conduction tissues (AVR, MVR, TVR)

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Junctional Escape Rhythm

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WPW Syndrom

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Torsades de Pointes

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Right atrial enlargement

Take a look at this ECG. What do you notice about the P waves?

The P waves are tall, especially in leads II, III and avF. Ouch! They would hurt to sit on!!

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Right atrial enlargement

To diagnose RAE you can use the following criteria:
II V1 or V2 P > 2.5 mm, or P > 1.5 mm
> 1 boxes (in height)

> 2 boxes (in height)

Remember 1 small box in height = 1 mm

A cause of RAE is RVH from pulmonary hypertension.

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Left atrial enlargement

Take a look at this ECG. What do you notice about the P waves?

Notched

Negative deflection

The P waves in lead II are notched and in lead V1 they have a deep and wide negative component.

Left atrial enlargement

To diagnose LAE you can use the following criteria:
II V1 > 0.04 s (1 box) between notched peaks, or Neg. deflection > 1 box wide x 1 box deep

Normal

LAE
A common cause of LAE is LVH from hypertension.

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Right ventricular hypertrophy

Take a look at this ECG. What do you notice about the axis and QRS complexes over the right ventricle (V1, V2)?

There is right axis deviation (negative in I, positive in II) and there are tall R waves in V1, V2.

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Right ventricular hypertrophy

Compare the R waves in V1, V2 from a normal ECG and one from a person with RVH. Notice the R wave is normally small in V1, V2 because the right ventricle does not have a lot of muscle mass. But in the hypertrophied right ventricle the R wave is tall in V1, V2.

Normal

RVH

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Right ventricular hypertrophy

To diagnose RVH you can use the following criteria:
V1 Right axis deviation, and R wave > 7mm tall

A common cause of RVH is left heart failure.

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Left ventricular hypertrophy

Take a look at this ECG. What do you notice about the axis and QRS complexes over the left ventricle (V5, V6) and right ventricle (V1, V2)?

The deep S waves seen in the leads over the right ventricle are created because the heart is depolarizing left, superior and posterior (away from leads V1, V2).

There is left axis deviation (positive in I, negative in II) and there are tall R waves in V5, V6 and deep S waves in V1, V2.

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Left ventricular hypertrophy

To diagnose LVH you can use the following criteria*:
avL R in V5 (or V6) + S in V1 (or V2) > 35 mm, or R > 13 mm

S = 13 mm R = 25 mm

* There are several other criteria for the diagnosis of LVH.

A common cause of LVH is hypertension.

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A 63 yo man has longstanding, uncontrolled hypertension. Is there evidence of heart disease from his hypertension? (Hint: There a 3 abnormalities.)

Yes, there is left axis deviation (positive in I, negative in II), left atrial enlargement (> 1 x 1 boxes in V1) and LVH (R in V5 = 27 + S in V2 = 10 > 35 mm).

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