Electrocardiography

P. Pujowaskito
Circulation System, Block General Ahmad Yani University

Electrocardiography

Electrical phenomena, science Simple, cheap, usefull but limited Almost all arrhythmias Infarction or ischaemia LVH Electrolyte imbalance

Bipolar standard leads I, II and III

The unipolar limb leads and their axes

Locations of unipolar precordial leads

The precordial leads and their axes

 The 12 leads allow tracing of electric vector in all three planes of interest Not all the leads are independent, but are recorded for redundant information

ECG Information

Electrocardiographic views of the heart

Regions of the Myocardium

Lateral I, AVL, V5-V6

Anterior / Septal V1-V4
PED 596

Inferior II, III, aVF

ECG recording

Electrical phenomena

Electrical phenomena

Recording

Waves
T

P U? Q S
Katrina Kardos, MD PGY-3 Albany Medical Center

Nomenclature

Cardiac Cycle

Upward/ Positive deflection

Garis Isoelektris/ baseline

Downward/ Negative deflection

Normal ECG pattern

ELEKTROKARDIOGRAM N a m a : ......... Kalibrasi : voltase...mV, speedmm/detik Heart rate : .............../minute, teratur tidak teratur rhythm : .............................. Gelombang P Kontour : normal tidak normal, Alasan:....................................................... Konfigurasi: normal tidak normal, Alasan: .................................................. Durasi : detik normal tidak normal Amplitudo: mV normal tidak normal PR interval detik normal tidak normal Konfigurasi gelombang Q: normal tidak normal, Alasan:....................................... Kompleks QRS: Durasi : normal tidak normal, Alasan:........................................................... Axis : .....derajat Normal LAD RAD Superior Konfigurasi: normal tidak normal, Alasan:..................................................... Segmen ST : normal tidak normal, Alasan:.................................................... Gelombang T : normal tidak normal, Alasan:.................................................... Gelombang U : normal tidak normal, Alasan:................................................... QTc : ................................detik normal tidak normal Index hipertrofi ventrikel: LVH: Score Romhilt-estes: ............................................................ ................................. normal tidak normal RVH: R/S ratio di V1: ............................. normal tidak normal Kesimpulan:

ECG paper

Small box

: 1 x 1 mm : 0.1 mV x 0.04 s

Moderate box: 5 x 5 mm : 0.5 mV x 0.2 s

Big box

: 25 x 25 mm : 2.5 mV x 1 s

S1

Paper speed and voltage calibration in ECG recording

MENGHITUNG LAJU JANTUNG : A. Jarak R R : -1 kotak sedang -2 kotak sedang -3 kotak sedang -4 kotak sedang -5kotak sedang -6 kotak sedang = 300 x / minute = 150 x / minute = 100 x / minute = 75 x / minute = 60 x / minute = 50 x / minute

B. Hitung jumlah R- R dalam 6 kotak besar = 6 detik Jumlah R x 10 = heart rate / minute
C. 1500 / jarak R-R ( dlm mm ) = heart rate / minute

Rapid Estimation of Heart rate

Start
300 150 100

75

Start
300 150 100

75

60

50

43

38

Heavy black line

Heavy black line Mnemonic

Pace maker

Rhythm Sinus Rhythm

ISO ELECTRICE

Amplitudo: voltase Durasi

Rhythm

Pace maker

Junctional Rhythm

ISO ELECTRICE

Amplitudo: voltase Durasi

Normal Sinus Rhythm Rate: 60-100 b/min Rhythm: regular P waves: upright in leads I, II, aVF PR interval: < .20 s QRS: < .10 s

P wave
Contour : -normal : smooth, monophasic (except V1) -abnormal: monophasic > 0.25mV or P biphasic (notched) Configuration : -normal : positive at I,II, aVF, V3-V6, negative at aVR -abnormal: negative at II,III or aVF, may be an inversal leads or junctional rhytm Duration (horisontal axis): 0.08-010 second (2-2.5 small box) Amplitudo (vertikal axis): 0.25 mV or 2.5mm or 2.5 small box PR interval: 0.12-0.20 second (3-5 small box), -short PR interval: may be preexitacion syndrome -long PR interval: may be AV blokade

Direction of the normal frontal and horizontal plane P vectors with resulting P wave in the 12-lead ECG

P wave

Q wave
Configuration : -normal : small q -abnormal : patologic Q, wide ( 0.04s) and deep ( 4mm or 25% R) Lead of abnormal Q: infarction area -lead V1-V4 : anteroseptal -lead V1-V6, I and aVL : anterior extensive -lead V4-V6, I and aVL : anterolateral -lead V3-V5 : anterior -lead II,III and aVF : inferior -lead I and aVL : high lateral -Mirror image of V1-V3 to horisontal line: true posterior
The significance of Q for old infarction if more than 1 lead

QRS complex
Capital letter for deflection > 5mm (Q,R,S), Small letter for deflection < 5mm (q,r,s). QRS complex could be variable Duration: normal: < 0.12s (narrow QRS) abnormal: > 0.12s (wide QRS/bizare)

QRS complex configuration

Genesis of left ventricular epicardial complex

Genesis of right ventricular epicardial complex

Genesis of transitional zone ventricular epicardial complex

Genesis of right ventricular cavity complex

Electric Axis of the Heart

This axis changes during cardiac cycle as shown earlier generally lies between +30 and -110 in the frontal plane and +30 and -30 in the transverse plane Clinically, it is generally taken where the QRS complex has the largest positive deflection Note: Often use aVR Deviation to R: increased activity in R vent. obstruction in lung, pulmonary emboli, some heart disease Deviation to L: increased activity in L vent. hypertension, aortic stenosis, ischemic heart disease

QRS frontal axis

QRS frontal axis

normal: -30 to +110 LAD (left axis deviation): -30 to -90 RAD (right axis deviation): +110 to -180 Superior (extreme RAD): +180 to -90

Determination of axis deviation

QRS axis: look at the net deflection in I and aVF

QRS frontal axis

Horizontal plane electrocardiographic patterns (QRS horisontal axis)

QRS horisontal axis

QRS horisontal axis

ST Segment

Depol.

Repol.

Restoration of ionic balance

Normal: Isoelektris Abnormal: - Elevation: > 1mm - Depression: horizontal, downsloping, upsloping > 1mm was significant; deeper: more specific

ST Segment depression : Ischaemic area

Lead of ST depression: ischaemic area -lead V1-V4 : anteroseptal -lead V1-V6, I and aVL : anterior extensive -lead V4-V6, I and aVL : anterolateral -lead V3-V5 : anterior -lead II,III and aVF : inferior -lead I and aVL : high lateral

T Wave

Normal adult: positive T wave in all lead except aVR and V1. Abnormal: - Tall T/ hyperacute T: Injury/ Acute Infarction - Negative T (vector of T was on opposite direction than QRS vector/ T inversi): myocardial ischaemia, more specific if arrow head T inversion. Area of injury or ischaemic

Nomogram for rate correction of Q-T interval

Bazetts formula

QTc =

QT R-R

U Wave
Normal: unpresent U (interferrence with T wave). wave

Abnormal: prominent U wave, particularly in V2 and V3 (suspect hypokalemia)

RIGHT ATRIAL HYPERTROPHY

P prominent: tall 2.5 mm and spike (interval 0.11 detik) at lead II, III dan aVF Initial deflection of P wave at V1 1.5 mm COPD or cor pulmonale, so we call P Pulmonal

LEFT ATRIAL HYPERTROPHY Wide P Interval 0.12s at lead II and notched (two peak) P wave with negative terminal deflection at V1, duration 0.04s and deeper 1 mm P wave of left atrial abnormality was called P Mitral

LVH index: Romhilt-Estes score

LEFT VENTRICULAR HYPERTROPHY (LVH) criteria
1. LV by voltage: R or S 20 mm at extremities lead, or S at RV complex (V1-V2) 25 mm, or R at LV complex (V5-V6) 25 mm, or S at V1-V2 plus R at V5-V6 35 mm 2. ST Depression and T inversion at LV complex V5-V6 (strain pattern ) 3. Left Atrial Abnormality (P mitral) 4. QRS complex frontal axis > -15 (LAD) 5. Prolong interval of QRS complex at V5-V6, 0.09s or ventricular activation time 0.04s Score 3

3 3 2 1

If score > 5 : definitive LVH If score =4 : porobable LVH

RIGHT VENTRICULAR HYPERTROPHY (RVH):

1. Reversal R/S ratio, at V1 > 1, at V6 < 1 2. QRS complex frontal axis deviate to the right (RAD) Aux criteria: ventricular activation time at V1 0.035s, ST depression and T inversion at V1, S at I, II, and III

Acute Coronary Syndrome

Ischaemia: mild and reversible, ST T changes Injury: moderate, but reversible Necrosis/ myocardial Infarction: permanent, patologic Q

ST Segment depression : Ischaemic area

ST Elevation Myocardial Infarction (STEMI)

Diagnosis 1. Basic rhythm: sinus, junctional, Ventricular, Atrial Fibrillation (AF), Ventricular Fibrillation (VF), Supra-Ventricular Tachycardia (SVT), Ventricular Tachycardia (VT) 2. Heart rate 3. QRS complex axis 4. Abnormality Example: sinus rhythm 80 x/minute, normal axis (normal sinus rhythm) sinus rhythm 80 x/minute, LAD, LVH sinus rhythm 75 x/minute, RAD, RA abnormality, RVH sinus bradycardia 50x/minute, normal axis, Inferior LV wall ischaemic sinus tachycardia 110 x/minute, normal axis, acute myocardial infarction on anterior LV wall

Refference
1. Mirvis DM, Goldberger AL. Electrocardiography. In: Braunwalds Heart Disease, A Textbook of Cardiovascular Medicine. Eighth Edition. Philadelphia: Saunders Elsevier; 2008. p. 155-183. 2. Ferry DR. ECG In 10 Days. Second Edition. Singapore: Mc Graw Hill; 2007. p. 37-93 and 151-193. 3. The Alan E. Lindsay. ECG Learning Center in Cyberspace. http://library.med.utah.edu/kw/ecg/image_index 4. Pratanu S. Buku Pedoman Kursus Elektrokardiografi. Surabaya; PT. Karya Pembina Swajaya; 2000. h. 19-36.