Electrocardiography

Basic
Dr Budi Enoch
- An electrocardiogram (ECG or EKG) is a graphic
recording of electric potentials generated by the
heart. The signals are detected by means of metal
electrodes attached to the extremities and chest wall
and then are amplified and recorded by the
electrocardiograph. ECG leads actually display the
instantaneous differences in potential between the
electrodes.
- The clinical utility of the ECG derives from its
immediate availability as a noninvasive,
inexpensive, and highly versatile test.
- In addition to its use in detecting arrhythmias,
conduction disturbances, and myocardial ischemia,
electrocardiography may reveal other findings related
to life-threatening metabolic disturbances (e.g.,
hyperkalemia) or increased susceptibility to sudden
cardiac death (e.g., QT prolongation syndromes).
Electrophysiology
 Depolarization of the heart is the initiating event
for cardiac contraction. The electric currents that
spread through the heart are produced by three
components: cardiac pacemaker cells, specialized
conduction tissue, and the heart muscle itself.
The ECG, however, records only the
depolarization (stimulation) and
repolarization (recovery) potentials
generated by the atrial and ventricular
myocardium.
The depolarization stimulus for the normal
heartbeat originates in the sinoatrial (SA)
node, or sinus node, a collection of pacemaker
cells. These cells fire spontaneously; that is, they
Kita melihat defleksi positif atau negatif, tergantung
dari resultante arah arus listriknya, contohnya pada
elektroda yang terpasang didada
 The first phase of cardiac electrical activation is the
spread of the depolarization wave through the right
and left atria, followed by atrial contraction.
Next, the impulse stimulates pacemaker and
specialized conduction tissues in the atrioventricular
(AV) nodal and His-bundle areas; together, these
two regions constitute the AV junction.
The bundle of His bifurcates into two main branches,
the right and left bundles, which rapidly transmit
depolarization wavefronts to the right and left
ventricular myocardium by way of Purkinje fibers.
The main left bundle bifurcates into two primary
subdivisions: a left anterior fascicle and a left posterior
fascicle. The depolarization wavefronts then spread
through the ventricular wall, from endocardium to
epicardium, triggering ventricular contraction.
 Since the cardiac depolarization and
repolarization waves have direction and
magnitude, they can be represented by vectors.
Vector analysis illustrates a central concept of
electrocardiography: The ECG records the
complex spatial and temporal summation of
electrical potentials from multiple myocardial
fibers conducted to the surface of the body.
This principle accounts for inherent limitations in
both ECG sensitivity (activity from certain cardiac
regions may be canceled out or may be too weak
to be recorded) and specificity (the same
vectorial sum can result from either a selective
gain or a loss of forces in opposite directions).
 ECG Waveforms and
Intervals
The ECG waveforms are labeled
alphabetically, beginning with the P wave,
which represents atrial depolarization
The QRS complex represents ventricular
depolarization, and the ST-T-U complex (ST
segment, T wave, and U wave) represents
ventricular repolarization.
The J point is the junction between the end of
the QRS complex and the beginning of the ST
segment.
Atrial repolarization is usually too low in
amplitude to be detected, but it may become
apparent in conditions such as acute
pericarditis and atrial infarction
5 garis besar vertikal menandakan 1 detik,
sedangkan 1 garis besar horizontal
menyatakan kekuatan arus 1 millivolt.
Gambaran ini adalah gambaran normal EKG
yang diambil pada satu bagian elektroda
 The QRS-T waveforms of the surface ECG correspond
in a general way with the different phases of
simultaneously obtained ventricular action potentials,
the intracellular recordings from single myocardial
fibers .
The rapid upstroke (phase 0) of the action potential
corresponds to the onset of QRS. The plateau (phase
2) corresponds to the isoelectric ST segment, and
active repolarization (phase 3) corresponds to the
inscription of the T wave.
Factors that decrease the slope of phase 0 by
impairing the influx of Na+ (e.g., hyperkalemia and
drugs such as flecainide) tend to increase QRS
duration. Conditions that prolong phase 2
(amiodarone, hypocalcemia) increase the QT interval.
In contrast, shortening of ventricular repolarization
(phase 2), such as by digitalis administration or
hypercalcemia, abbreviates the ST segment.
 The electrocardiogram ordinarily is recorded on special
graph paper that is divided into 1-mm 2 gridlike boxes.
Since the ECG paper speed is generally 25 mm/s, the
smallest (1 mm) horizontal divisions correspond to 0.04
(40 ms), with heavier lines at intervals of 0.20 s (200
ms).
Vertically, the ECG graph measures the amplitude of a
specific wave or deflection (1 mV = 10 mm with standard
calibration; the voltage criteria for hypertrophy
mentioned below are given in millimeters).
There are four major ECG intervals: R-R, PR, QRS, and
QT . The heart rate (beats per minute) can be computed
readily from the interbeat (R-R) interval by dividing the
number of large (0.20 s) time units between consecutive
R waves into 300 or the number of small (0.04 s) units
into 1500.
The PR interval measures the time (normally 120200
ms) between atrial and ventricular depolarization, which
includes the physiologic delay imposed by stimulation of
 ECG Leads
The 12 conventional ECG leads record the difference in
potential between electrodes placed on the surface of the
body. These leads are divided into two groups: six limb
(extremity) leads and six chest (precordial) leads. The limb
leads record potentials transmitted onto the frontal plane, and
the chest leads record potentials transmitted onto the
horizontal plane
The spatial orientation and polarity of the six frontal plane
leads is represented on the hexaxial diagram.
The six chest leads are unipolar recordings obtained by
electrodes in the following positions: lead V1, fourth intercostal
space, just to the right of the sternum; lead V2, fourth
intercostal space, just to the left of the sternum; lead V3,
midway between V2 and V4; lead V4, midclavicular line, fifth
intercostal space; lead V5, anterior axillary line, same level as
V4; and lead V6, midaxillary line, same level as V4 and V5.
Limb lead mencatat perbedaan potensial
listrik secara berdepanan (frontal plane)
 chest lead mencatat perbedaan potensial
listrik secara horizontal (horizontal plane )
potongan melintang
Axis dan Deviasi
Frontal plane direpresentasikan dalam diagram
hexoaxial, tiap lead mempunyai orientasi pandangan
dan polaritas (kutub positif) tersendiri. Kutub (+)
ditera dalam garis solid, kutub (-) dalam garis putus2.
Karena itu itu kita dapat menentukan axis dari jantung
 kompleks QRS di lead I dan dibandingan
dengan jumlah arus pada kompleks QRS di
lead II kita bisa menentukan axis jantung
(cardiac vector)
secara pastinya axis ini bisa dihitung dengan
memakai daftar
Genesis of the Normal ECG
 P Wave
The normal atrial depolarization vector is oriented
downward and toward the subject's left, reflecting the
spread of depolarization from the sinus node to the
right and then the left atrial myocardium.
Since this vector points toward the positive pole of
lead II and toward the negative pole of lead aVR, the
normal P wave will be positive in lead II and negative
in lead aVR.
By contrast, activation of the atria from an ectopic
pacemaker in the lower part of either atrium or in the
AV junction region may produce retrograde P waves
(negative in lead II, positive in lead aVR). The normal P
wave in lead V1 may be biphasic with a positive
component reflecting right atrial depolarization,
followed by a small (<1 mm2) negative component
reflecting left atrial depolarization.
 QRS Complex
Normal ventricular depolarization proceeds as a rapid,
continuous spread of activation wave fronts. This complex process
can be divided into two major sequential phases, and each phase
can be represented by a mean vector.
The first phase is depolarization of the interventricular septum from
the left to the right and anteriorly (vector 1). The second results
from the simultaneous depolarization of the right and left
ventricles; it normally is dominated by the more massive left
ventricle, so that vector 2 points leftward and posteriorly.
Therefore, a right precordial lead (V 1) will record this biphasic
depolarization process with a small positive deflection (septal r
wave) followed by a larger negative deflection (S wave). A left
precordial lead, e.g., V6, will record the same sequence with a small
negative deflection (septal q wave) followed by a relatively tall
positive deflection (R wave). Intermediate leads show a relative
increase in R-wave amplitude (normal R-wave progression) and a
decrease in S-wave amplitude progressing across the chest from
right to left. The precordial lead where the R and S waves are of
approximately equal amplitude is referred to as the transition zone
(usually V3 or V4)
 T Wave and U Wave
Normally, the mean T-wave vector is oriented roughly
concordant with the mean QRS vector (within about 45 in
the frontal plane). Since depolarization and repolarization
are electrically opposite processes, this normal QRST-wave
vector concordance indicates that repolarization normally
must proceed in the reverse direction from depolarization
(i.e., from ventricular epicardium to endocardium).
The normal U wave is a small, rounded deflection (1 mm)
that follows the T wave and usually has the same polarity
as the T wave. An abnormal increase in U-wave amplitude is
most commonly due to drugs (e.g., dofetilide, amiodarone,
sotalol, quinidine, procainamide, disopyramide) or to
hypokalemia.
Very prominent U waves are a marker of increased
susceptibility to the torsades de pointes type of ventricular
tachycardia . Inversion of the U wave in the precordial leads
is abnormal and may be a subtle sign of ischemia
konfigurasi
EKG biasanya direkam pada
kecepatan 25 mm/detik sehingga
jarak antara 2 garis besar berdiri
adalah 0,2 detik yang berisi 5 garis
berdiri yang lebih halus. Akibatnya
jarak antara tiap garis halus berdiri
adalah 0,04 detik
 Cara termudah untuk menghitung
frekwensi jantung adalah bagikan 300
dengan jumlah jarak diantara 2
garis besar berdiri pada 2 irama
jantung yang berurutan
Frekwensi jantung : Jumlah dari
segiempat besar diantara 2 komplex
yang berurutan
300 x/mnt 1 (300/1)
150 x/mnt 2 (300/2)
100 x/mnt 3 (300/3)
75 x/mnt 4 (300/4)
 Grup sadapan 2, Lead penguatan
(augmented unipolar lead)
Sadapannya dikenal dengan AVR
(augmented right), AVL (augmented left)
dan AVF (augmented left lead)
AVR adalah lead dimana hanya elektroda
postif pada lengan kanan sedangkan
elektroda lain indeferen (unipolar lead)
AVL elektrodanya pada lengan kanan
AVF elektrodanya pada kaki kiri
Maksud dari lead ini adalah untuk melihat
resultante arus listrik jantung langsung
dari arah kanan atas (AVR), dari arah kiri
atas (AVL) dan dari bawah atau dinding
inferior jantung (AVF)