ECG Interpretation

Dr. Anna Fuji Rahimah, SpJP

Cardiology and Vascular
Medicine Laboratory
Faculty of Medicine
University of Brawijaya

The Normal Conduction

System

Standard Rekaman EKG

- Kecepatan rekaman
: 25 mm/detik
- Kalibrasi
: 1 milivolt (mV) = 10 mm
( standar ganda, separuh, seperempat )
Ukuran di Kertas EKG
Garis horizontal
- Tiap satu mm = 1/25 detik
- Tiap lima mm = 5/25 detik
- Tiap 25 mm = 25 x 0,04 =
Garis vertikal
- 1 mm = 0,10 mV
- 10 mm
= 1,00 mV

:
= 0,04 detik
= 0,20 detik
1,00 detik

Lead Placement

aVF

All Limb Leads

Precordial Leads

EKG Distributions

Anteroseptal: V1, V2, V3,

V4
Anterior: V1V6
Anterolateral: V4V6, I,
aVL
Lateral: I and aVL
Inferior: II, III, and aVF
Inferolateral: II, III, aVF,
and V5 and V6

Waveforms

Introduction
ECG Interpretation

RHYTHM
RATE
AXES
INTERVAL
QRS

ST- SEGMENT

OTHERS

ECG
RHYTHYM
SA Node
Normal Impulse
60 100 x / minute

AV Node
40 -60 x / minute

Ventrikel
<40 x / minnute

ECG
RHYTHYM

Sinus rhythm characteristics :

Rate 60-100 bpm
Constant R R interval
Negative P wave in aVR and positive di
II
P wave is always followed by QRS
complex

Langkah 1: Adakah gelombang P ?

Langkah 2: Adakah kompleks QRS ?
Langkah 3: Apakah gelombang P dan kompleks
QRS berhubungan ?

Atrial Fibrillation
- No visible P waves
- Irregular R R interval

ECG
Rates

Determination heart
rate (normal paper
speed 25 mm/s):
300 / Count number of
large square (bold boxes in
one R R interval)
1500 / Count number of
small square in one R R
intervals
Number of QRS complex
in 6 seconds, multiply by
10

Rate

HR of 60-100 per minute is normal

HR > 100 = tachycardia
HR < 60 = bradycardia

Differential Diagnosis of
Tachycardia
Tachycardi Narrow
a
Complex
ST
Regular
SVT
Atrial flutter

Wide Complex
ST w/
aberrancy
SVT w/
aberrancy

VT

Irregular

A-fib
A-flutter w/
variable
conduction

A-fib w/
aberrancy

A-fib w/ WPW
VT

What is the heart rate?

www.uptodate.com

(300 / 6) = 50 bpm

ECG
Rates ?

ECG
AXES

Superior
Axes
- 180 s/d
-90

LAD
- 90 s/d 30

aV
R

aV
L
I

RAD
+ 90 s/d +
180

II
I

aV
F

II

Normal Axes
- 30 s/d +
90

The Quadrant Approach

QRS up in I and up in aVF =

Normal

What is the axis?

Normal- QRS up in I and aVF

ECG
Interval

Interval
Interval
Interval
Interval
jantung

P (durasi) : < 0,12 detik

: 0,12 0,20 detik
PR
QRS : 0,07 0,10 detik
QT tergantung frekwensi

1st degree AV
block
PR interval >
0.20

Blocks

AV blocks

First degree block

Second degree block, Mobitz type 1

PR gradually lengthened, then drop QRS

Second degree block, Mobitz type 2

PR interval fixed and > 0.2 sec

PR fixed, but drop QRS randomly

Type 3 block

PR and QRS dissociated

What is this?
First degree AV block
PR is fixed and longer than 0.2 sec

What is this?
Type 1 second degree block
(Wenckebach)

What is this?
Type 2 second degree AV block
Dropped QRS

What is this?
3rd degree heart block (complete)

ECG
QRS

Bentuk gel P, QRS, T normal

ST segment normal
Gel R di V1 kecil semakin ke V6 semakin tinggi
Gel S di V1 dalam semakin ke V6 semakin hilang

Q R S Abnormality
Bundle Branch Block

RBBB

LBBB

Q R S Abnormality
Bundle Branch Block

Right Bundle Branch Block

QRS melebar, S yang lebar dan dalam di I
dan V6 (V5), dan berbentuk RR di V1 (V2)

Q R S Abnormality
Bundle Branch Block

Left Bundle Branch Block

QRS melebar, bentuk R di I dan V6
(V5), dan S yang dalam di V1
(V2,V3)

Q R S Abnormality
The Hypertrophy : LVH
1. Kriteria Voltase : Voltase
Ventrikel Kiri meninggi
Kreteria :(dapat dipilih
salah satu)

R atau S di sandapan
ekstremitas 20 mm
S di kompleks VKa 25
mm
R di kompleks VKi 25
mm
S di VKa + VKi 35 mm

2. Depresiasi ST dan inversi

T di kompleks VKi (sering
disebut strain pattern)
3. AAKi / LAA
4. Sumbu QRS pada bidang
Frontal > -15o
5. Interval QRS atau WAV di
kompleks VKi memanjang
:

Interval QRS >= 0,09 detik

WAV >= 0,04 detik

Q R S Abnormality
The Hypertrophy : LVH
Kriteria Romhilt - Estes
No. 1 = nilai 3
No. 2 = nilai 3
No. 3 = nilai 3
No. 4 = nilai 2
No. 5 = nilai 1
Bila jumlah nilai > 5, dianggap definitif HVKi
Bila jumlah nilai = 4, dianggap kemungkinan
HVKi.

ECG
ST T (Coronary Artery Disease)

Acute Infarct
Normal
IskemiaOld Infarct
Q patologis (lebar
0,04 dtk, dalam 4 mm

ECG
ST T (Coronary Artery Disease)

Inferior and Anterior

Ischemia
r

What is the diagnosis?

Acute inferior MI with ST elevation
in leads II, III, aVF

What is the diagnosis?

Extensive Anterior STEMI
(acute)

What do you see in this

EKG?
ST depression II, III, aVF, V3-V6 =
ischemia

Iskemia

Irama sinus
Iskemia anterior ekstensif

What is the diagnosis?

Acute anterolateral MI

What is the diagnosis?

Acute inferior MI

BB

RBBB

Others

PVC

Multifocal PVCs

Ventricular Bigeminy
Ventricular Quadrigeminy

Others

PVC

rade 0 : No Premature Beat

Grade
Grade 1
2 :: Occasional
Fequent ( >(<
30/h)
30/h)
Grade 3 : Multiform
Grade 4A : Repetitive
Grade 4B : Repetitive
(Couplets)
Grade
5 : R on T
(Salvos)
Pattern

Others

Hyperkalemia

Tall, narrow and symmetric T waves

Hyperkalemia

Others

Digitalis effect

Dubin, 4th ed. 1989

Sinus tachycardia

Supraventricular
Tachycardia (SVT)

Narrow complex tachycardia at ~ 150 bpm.

No visible P waves

Supraventricular
Tachycardia

Retrograde P waves

Narrow complex, regular; retrograde P waves, rate <220

Ventricular Tachycardia

Torsades de Pointes

Notice twisting pattern

Treatment: Magnesium 2 grams IV

ARTIFACT ON THE ECG

64

FIND THE ARTEFACT

65

WANDERIN BASELINE

66

SOMATIC TREMOR

67

ELECTRICAL
INTERFERANCE

68

Kriteria
EKG
Normal:

1. Irama sinus rate antara 60-100 x/m, setiap gel P diikuti

komplek QRS. Rate dihitung dari interval R-R atau P-P
teratur.
2. Sumbu frontal normal antara -30 hingga +90
3. Bentuk gel P, QRS, T, U normal. ST segment normal.
4. Gel R di V1 kecil semakin ke V6 semakin tinggi. Gel S di
V1 dalam semakin ke V6 semakin hilang.

Thank You

Sequence of Changes in evolving

AMI

Usual ECG evolution of a Q-wave MI

Not all of the following patterns may be seen; the
time from onset of MI to the final pattern is quite
variable and related to the size of MI, the rapidity
of reperfusion (if any), and the location of the MI.
1. Normal ECG prior to MI
2. Hyperacute T wave changes - increased T wave
amplitude and width; may also see ST elevation
3. Marked ST elevation with hyperacute T wave
changes (transmural injury)
4. Pathologic Q waves, less ST elevation, terminal T
wave inversion (necrosis)
(Pathologic Q waves are usually defined as
duration 0.04 s or 25% of R-wave amplitude)
5. Pathologic Q waves, T wave inversion (necrosis
and fibrosis)
6. Pathologic Q waves, upright T waves (fibrosis)

Acute inferior wall ST segment

elevation MI (STEMI)
note ST segment elevation in leads II, III, aVF; ST segment
depression in V1-3 represents true posterior injury

OMI Inferior
Old inferior Q-wave MI; note largest Q in lead III, next largest in aVF, and
smallest in lead II (indicative of right coronary artery occlusion)

Acute posterior MI
Note ST depression in leads V1-6, ST segment elevation in V8-9 (true posterior
leads), and slight ST segment elevation in leads I and aVL. ST segment depression
in Lead V4R (right chest lead) also indicates left circumflex occlusion.

Ostial LAD occlusion (septal

STEMI)
There is a septal STEMI with ST elevation maximal in V1-2 (extending out to V3).
There is a new RBBB with marked ST elevation (> 2.5 mm) in V1 plus STE in aVR
these features suggest occlusion proximal to S1.

Hyperkalemia