ECG

Dr. Benny TM Togatorop SpJP, FIHA

DEFINITION

Electrocardiography : the
procedure to record electrical activity
of the heart by means of placing
electrodes on the surface of the
heart.

Electrocardiograph → the
recording’s result
Goldberger AL, Goldberger E. Clinical Electrocardiography: A
Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
ANATOMY OF HEART’S CONDUCTION SYSTEM

www.cssolutions.biz/ ecg1s.html
 Basic Principles of ECG

Three principles laws of ECG :

1. Positive (upward) deflection→ if

the wave of depolarization
spreads toward the positive pole
of the lead.
2. Negative (downward) deflection
→ the wave of depolarization
spreads toward negative pole of
the lead.
3. Biphasic (positive and negative)
deflection at equal size → mean
of depolarization perpendicular
of the lead.
Goldberger AL, Goldberger E. Clinical Electrocardiography: A
Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 ECG Paper

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 CALIBRATION MARKER

.
ECG LEADS
12 standard leads :
• 6 Limb lead, comprises of :
3 unipolar lead (AVL, AVF,
AVR)
3 bipolar lead (I,II,III)
• Precordial Leads
Precordial Lead Placement :
V1 4th ICS, 2 cm to the right
sternum
V2 4th ICS, 2 cm to the left
sternum
V3 midway between V2 and V4
V4 5th ICS, left midclavicular line
V5 5th ICS, left anterior axillary
line
V6 5th ICS, left midaxillary line
LIMB
LEADS

Khan,G., Rapid ECG Interpretation 3rd

ed.,New Jersey: Humana Press,2003

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
LIMB
LEADS
Precordial Lead
COMPONENTS OF NORMAL ECG

Thaler, M.S., The Only ECG Book You’ll Ever Need 5th ed. Lippincott,2007
 Normal ECG
• P wave
– Width < 0.12 s
– Height < 0.3 milliVolt
– Always positive in lead II, negative in
aVR
• PR interval
– From the start of P wave to the start of
QRS
– Normal duration 0.12 – 0.20 s
• QRS complex
– Width 0.06 – 0.12 s (~ 0.10 s)
– Length varies among leads
– Q → first negative deflection
– R → first positive deflection
– S → negative deflection after R
• ST segment
– From the end of S to the start of T
– Normal : iso-electrical
• T wave
– Positive in lead I, II, V3 – V6 and
negative in aVR
 P Wave

• Represent atrial depolarization → initiated by sinus node in RA.

• Normal sinus rhythm : AVR (-), Lead II (+)
• First half is component of the RA, and the other half represent LA.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Thaler, M.S., The Only ECG Book You’ll Ever Need 5th
Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
ed. Lippincott,2007
PR interval

• Represent the time from the

start of atrial depolarization
to the start of ventricular
depolarization
• Normal : 0.12-0.2 s

PR segment
Time from the end of
atrial depolarization
until the beginning of
ventricular
depolarization
Thaler, M.S., The Only ECG Book You’ll
Ever Need 5th ed. Lippincott,2007
QRS Complex

▪ Represent the ventricular depolarization.

▪ Component of QRS Complex :
a. First downward deflection → Q wave
b. First upward deflection → R wave
c. Downward deflection following Rwave →
S wave
d. The second upward deflection → R’
• QRS interval : 0,06 s– 0,12s (~ 0,1 s)

Goldberger AL,
Goldberger E.
Clinical
Electrocardiograph
y: A Simplified
Approach. 7th ed.
St. Louis: Mosby
Year Book, 2006
 Axis

Defleksi positif Defleksi negatif

Another method :
1. Lead I & II, if primarily upward for both, then axis is
normal
2. determine the most isoelectric axis, the electrical axis is
perpendicular to that lead. Inspect the lead that is
perpendicular to the lead containing the isoelectric
complex. If the QRS in that perpendicular lead is
primarily upward, then the mean axis point to + pole of
that lead, if primarily negative, then the mean QRS
points to the – pole of the lead.
ST segment
• Time from the end of ventricular depolarization until the
beginning of ventricular repolarization
• Normally isoelectric

Goldberger AL, Goldberger E.

Clinical Electrocardiography: A
Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
T wave
▪ Describe ventricular repolarization
▪ Deflection follows the QRS complex
▪Height 1/3 to 2/3 of R wave
▪ asymetric, more toward the half end
 QT intervals

• Time from the beginning of ventricular

depolarization until the end of ventricular
repolarization
• From the beginning of QRS complex until
the end of the T wave
• Affected by Heart Rate
• QTc = QT/ √RR
• Normal QTc =< 0,44 s

Thaler, M.S., The Only ECG Book You’ll Ever

Need 5th ed. Lippincott,2007
 Determining the Heart Rate
• Rule of 300
– 300/[number of large boxes between two R waves].
– only works for regular rhythms !!

300/7.5 large boxes = rate 40

 Six second methods

◼ Count the number of R-R intervals in six seconds and multiply by
10
◼ Useful for irregular rhythm → average rate

There are 8 R-R intervals

within 30 boxes. Multiply 8 x
10 = Rate 80
NORMAL ECG
ECG Interpretation
sequence :
• Rhytm
• Rate
• Axis
• P wave
• PR interval
• QRS interval and
morphology
• ST segmen
•T wave
• QT duration

Khan,G., Rapid ECG Interpretation 3rd

ed.,New Jersey: Humana Press,2003
 ECG
ABNORMALITIES
 Axis

Defleksi positif Defleksi negatif

Indeterminate Axis

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified Approach. 7th ed.
St. Louis: Mosby Year Book, 2006
 ATRIAL ENLARGEMENT

• Abnormality in P
wave morphology
(Normal height=
<0,25 mV, width
<0.12 s.
• P pulmonale, tall P
→ RAH
• P mitrale, broad and
notch P → LAH
• Lead II, V1

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified Approach. 7th
ed. St. Louis: Mosby Year Book, 2006
 Ventricular Hypertrophy
• LVH (sokolow, Lyon)
– S di V1 + R di V5 atau V6 > 35 mm
– R di V5 atau V6 > 26 mm
– R + S di lead precordial > 45 mm
• RVH
– R/S di V1 > 1 atau R/S di V6 < 1
AV CONDUCTION BLOCK

Goldberger AL, Goldberger E. Clinical

Electrocardiography: A Simplified Approach. 7th
ed. St. Louis: Mosby Year Book, 2006
First Degree AV Block

Constant PR interval prolongation.

Prolonged PR interval can also occur in hyperkalemia, digitalis, acute
rheumatic fever

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Second Degree AV Block

Mobitz Type I (Weckenbach), characteristics :

1. Sequence of a progressive lengthening of the PR interval followed by a
nonconducted P wave.
2. shortening of the PR interval in the beat immediately after nonconducted
one.
Location : AV node

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Second Degree AV Block

Mobitz Type II haracteristics :

Sudden appearance of a single, non conducted sinus P wave without (1)
progressive prolongation of PR interval (2) shortening of PR interval in the
beat after the non conducted P wave.
Location : His bundle or bundle branches

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
Third Degree AV Block (Total AV Block)

Third degree AV block characteristics :

• P waves are present, with a regular atrial rate faster than the ventricular
rate.
• QRS complexes are present, with a slow (usually fixed) ventricular rate.
• P waves bear no relation to the QRS complexed, PR intervals are
completely variable.

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
 Intraventricular Conduction
Delays
• Left Anterior Fascicular Block
– Marked left axis deviation (-30 and -45°)
– rS pattern in inferior leads and qR in I,aVL
– QRS duration <120ms
• Left Posterior Fascicular Block
– QRS axis>120 degree
– RS in I, aVL and qR in inferior leads
– QRS duration <120 ms
– Exclusion of other factors causing right axis
deviation
• Left Bundle Branch Block
– QRS duration>120ms
– Broad,notched R in V5,V6 and I, aVL
– Small or absent initial r in V1,V2 followed by
deep S wave
• Right Bundle Branch Block
– QRS duration >120ms
– Broad,notched R (rsr’,rsR’,rSR pattern in
V1,V2
– Wide and deep S in V5,V6
Complete and
Incomplete Block :
• Complete : QRS
duration > 0,12
• Incomplete :
QRS duration 0,1
-0,12

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified Approach. 7th ed. St.
Louis: Mosby Year Book, 2006
 BRADYARRHYTHMIAS/BRADYCARDIA

Simplified Classification :
• Sinus Bradycardia, excluding sinoatrial
block
• AV junctional escape rhythm
• Atrial fibrillation or flutter with slow
ventricular response.
• Idioventricular escape rhythm
Sinus Bradycardia :
• Sinus rhythm with rate < 60 beat/mnt.
• Each P wave is followed by QRS complex

AV Junctional Escape Rhythm :

• P wave (if seen) is negative in II and positive in AVR
(retrograde P waves)
• retrograde P wave immediately precede or follow QRS
complex
• P wave dissapeared (burried) within QRS complex.
Atrial Fibrillation with a slow ventricular response
A very slow ,regularized ventricular response in AF
suggest the present of underlying complete AV block.

Idioventricular Rhythm :
• SA node and AV junctional pacemaker fail to function
• very slow pacemaker in ventricular conduction
• rate < 45 beats/mnt
• QRS wide without any preceding P wave

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
TACHYARRHYTHMIAS/TACHYCARDIA

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Narrow Complex Tachycardia
Sinus Tachycardia : Sinus Rhythm with QRS rate 100 -130
bpm

Atrioventricular Nodal Reentrant Tachycardia

• The most commont cause of a paroxysmal, narrow,
regular QRS tachycardia
• Rapid, regular rhythm 150-225 bpm.
• 45% cases P waves appear hidden, but on careful
observation they are visible in the end of QRS complex,
pseudo S wave in II,III,AVF. Pseudo r’ wave in V1.
Atrial Flutter: Atrial Fibrillation:
• “saw tooth “flutter wave • rapid irregular undulation of the
• Constant or variable ventricular baseline (fibrillatory waves) instead
rate of P waves.
• The most commont cause of a • ventricular rate is usually irregular’
paroxysmal, narrow, regular QRS
tachycardia

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Multifocal Atrial Tachycardia
• Multiple ectopic foci stimulating the atria.
• P waves with different shapes at rate > 100 bpm.
“flutter wave
• Constant or variable ventricular rate
• The most common cause of a paroxysmal, narrow, regular QRS
tachycardia

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 Wide Complex Tachycardia

Differential diagnosis :
• VT (B)
• SVT with aberrancy due to bundle branch
block and WPW preexitation (A)

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
STEMI
Goldberger AL, Goldberger E. Clinical Electrocardiography: A
Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
PREEXCITATION

Wolf –Parkinson- White Preexcitation

• Short PR
• Wide QRS
• Delta Wave

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 WPW Syndrome

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006

Lown- Ganong- Levine

Syndrome
• Short PR interval < 0,12 s
• QRS complex is not widened
• No delta wave
Thaler, M.S., The Only ECG Book You’ll Ever
Need 5th ed. Lippincott,2007
QT INTERVALS ABNORMALITY
• Prolonged QT interval : electrolyte
disturbance (hypokalemia or
hypocalcemia), drug effects (quinidine,
procainamide, amiodarone, sotalol) or
myocardial ischemia with T invertion
• Shortened QT : hypercalcemia and
digitalis effect.
PERICARDITIS AND MYOCARDITIS

Pericarditis :
• Diffuse ST segment elevations, usually in one or more of the chest leads
and also in I,AVL,II,AVF.
• PR segment elevation AVR and PR segment depression in other leads.
Myocarditis :
• Non Specific ST segment changes similar with pericarditis and myocardial
ischemia

Pericarditis

Goldberger AL, Goldberger E.

Clinical Electrocardiography: A
Simplified Approach. 7th ed. St. Louis:
Mosby Year Book, 2006
ELECTROLYTES ABNORMALITIES

Hyperkalemia
• Affecting of both depolarization (QRS complex) and repolarization (ST-T
segment)
• First changes : Tall T with “tented” or “pinched “ shape.
• Prolonged of PR interval and P wave is dissappear
• Further increase : intraventricular conduction blocks and widening QRS
complex
• Lethal concentration : undulating (sine-wave pattern ) and asystole

Goldberger AL, Goldberger E. Clinical Electrocardiography: A Simplified

Approach. 7th ed. St. Louis: Mosby Year Book, 2006
Hypokalemia
• ST depression with prominent U waves
• Prolonged repolarization

Goldberger AL, Goldberger

E. Clinical
Electrocardiography: A
Simplified Approach. 7th ed.
St. Louis: Mosby Year
Book, 2006
Hypocalcemia and Hypercalcemia

Hypocalcemia : shortening QT interval by shorten ST segmen

Hypercalcemia : lengthening QT interval by stretching ST segment

Goldberger AL, Goldberger E. Clinical Electrocardiography: A

Simplified Approach. 7th ed. St. Louis: Mosby Year Book, 2006
 Sistematika membaca EKG
• Irama
• QRS rate
• Axis
• Gel P
• PR int
• QRS dur
• ST-T changes
THANK
Untuk latihan
1. Normal sinus rhytym
2. SINUS BRADIKARDIA
3. SINUS TACHYCARDIA
4. Low voltage
5. LAD
6. RAD
7. POSTERIOR AXIS
8. Right atrial enlargement
9. Left atrial enlargement
10. First degree av block
11. Second degree av block
12. Second degree AV block
13. Third degree
14. Hyperacute T
15. Acute ant stemi
16. Inferior stemi
17. Stemi lateral
18. posterior
19. posterior
20. Right Ventrikel
21. Right Ventrikel
22. LV aneurysm
23. pac
24. PVC
25. PVC
26. af
27. aflut
28. LBBB
29. RBBB
30. LVH
31. RVH
33. BVH
34. COPD
35. SAH
36. Junctional Rhytym
37. PERICARDITIS
38. TAMPONADE