Diskusi

“EKG dalam Praktik Klinik”

IPD FKUI-RSCM
Outline
▪ Dasar EKG
▪ Aritmia
▪ Acute coronary syndrome
▪ Kondisi metabolik
▪ Catatan kondisi lain
Fisiologi Singkat
Dasar EKG
Pendekatan Dasar
▪ Periksa laju (rate)
▪ Periksa ritme (rhytm)
▪ Periksa aksis, interval, dan segmen
▪ Periksa berbagai hal lainnya

▪ Standar pelaporan: Irama ..., HR ... bpm  bila perlu ditambahkan:

PP rate dan RR rate, Axis ..., p wave durasi ... Morfologi ..., PR interval
..., QRS complex durasi ... Morfologi ..., ST segment ..., T waves ....,
kesan terdapat ...
Kelayakan EKG
Irama
▪ Definisi irama sinus:
– Irama yang berasal dari pacu SA node, ditandai dengan:
▪ Gelombang P dengan defleksi positif di lead I, II, aVF; defleksi negatif di aVR
▪ Opsional: diikuti gelombang QRS setelah setiap gelombang p

▪ Penilaian:
– Tipe irama
– Frekuensi
– Reguler atau ireguler
– Supraventrikuler atau ventrikuler
Aksis Jantung
Penyebab Deviasi Aksis:
Sindrom WPW: Deviasi kiri atau kanan

RAD  RALPH
• Right ventricular hypertrophy
• Anterolateral MI
• Left Posterior Hemiblock

LAD  VILLA
• Ventricular tachycardia
• Inferior MI
• Left ventricular hypertrophy
• Left Anterior hemiblock
Aritmia
▪ Gangguan sinus
▪ Gangguan konduksi
▪ Bradiaritmia
▪ Takiaritmia
▪ Irama alat pacu jantung
Gangguan Sinus
Gangguan Konduksi (AV Block)
Gangguan Konduksi
Right Branch Bundle Block
Left Branch Bundle Block
Irama pacu
jantung
Ventricular pacing
Irama pacu
jantung
Atrial pacing
Irama pacu
jantung
Dual chamber pacing
Takiaritmia
SVT dengan Aberans vs VT
SVT dengan Aberans vs VT
Sindroma Koroner Akut
 Myocardial Ischemia

 Due to lack of adequate blood flow to the myocardium

 Ischemia is reversible.

 Changes in ECG:
• T wave peaking
• Symmetric T wave inversion
• ST segment elevation

ECG Signal with peak T

waves

ECG with T wave inversion ST segment elevated signal

ECG in normal and ischemic condition
EVOLUSI EKG PADA STEMI
CONTIGUOUS LEADS
Location of myocardial infarction
 Sgarbossa Criteria
• First described by Elena B Sgarbossa in 1996
• Original Sgarbossa Criteria :
• The original three criteria used to diagnose infarction in patients with LBBB are:
1.Concordant ST elevation > 1mm in leads with a positive QRS complex (score 5)
2.Concordant ST depression > 1 mm in V1-V3 (score 3)
3.Excessively discordant ST elevation > 5 mm in leads with a -ve QRS complex (score 2).
These criteria are specific, but not sensitive for myocardial infarction. A total score of  ≥ 3 is
reported to have a specificity of 90% for diagnosing myocardial infarction.  
• Modified Sgarbossa Criteria
1. ≥ 1 lead with ≥1 mm of concordant ST elevation
2. ≥ 1 lead of V1-V3 with ≥ 1 mm of concordant ST depression
3. ≥ 1 lead anywhere with ≥ 1 mm STE and proportionally excessive discordant STE, as
defined by ≥ 25% of the depth of the preceding S-wave.
 ECG Changes of Left Ventricular Hypertrophy vs AMI
▪ The initial upsloping of the elevated ST segment is frequently concave in LVH as
opposed to the more likely flat/convex ST segment elevation in ACS
▪ The T wave is usually asymmetrical in LVH as opposed to the symmetrical T wave
seen in coronary ischemia
Sensitivity Specificity

Sokolow-Lyon Index 22 100

SV1 + (RV5 or RV6)>35mm

Cornell Voltage Criteria 42 96

SV3+RaVL>28 mm (men),
20mm(women)

R1 + SIII>25 mm 11 100

R in aVL> 11mm 11 100

 Chan TC, Brady WJ, Harrigan RA et al. ECG in Emergency Medicine and Acute Care. 1st
ed. Pennsylvania: Elsevier Mosby; 2005.
 Diagnostic Criteria :
Wellen’s Sign ▪ Deeply inverted T waves in leads V2
and V3 (may also be seen in leads V1,
V4, V5, and V6), OR
▪ Biphasic T waves (with initial
positivity and terminal negativity) in
V2 and V3
▪ Two patterns of T waves :
– Type-A T waves are biphasic, with initial
positivity and terminal negativity; 25% of
cases.
– Type-B T waves are deeply and symmetrically
inverted; 75% of cases. 

Sign of large proximal LAD

lesion
Kondisi Metabolik
Hiperkalemia
 LV Aneurysm
• Persistant ST elevation
following an acute MCI
• Ussually seen > 2 weeks after
MCI
• Most common in precordial
leads
• Associated with well-formed Q-
or QS waves
• Small amplitude of T waves

Pro
p ose
The Ratio of T wave to QRS complex amplitude : d
• T-wave/QRS ratio < 0.36 in ALL precordial leads  favours LV aneurysm
• T-wave/QRS ratio > 0.36 in ANY precordial leads  favours acute STEMI
Brugada Syndrome

RBBB or incomplete RBBB in V1-V3 with convex ST elevation

Wolff-Parkinson-White Syndrome

Short PR interval <0.12 sec

Prolonged QRS >0.10 sec
Delta wave
Can simulate ventricular hypertrophy, BBB and previous MI
Catatan pada Morfologi Lain
 Acute Pulmonary Embolism

- SIQIIITIII in 10-15%
- T-wave inversions, especially occurring in inferior and anteroseptal simultaneously
- RAD
Perikarditis
Acute
Pericarditis
PR Depression

Stage I
first few days  2 weeks
STE, PR depression
Stage II
last days  weeks
Normalization of STE
Stage III
after 2-3 weeks, lasts several weeks
T wave inversion
Stage IV
lasts up to several months
gradual resolution of T wave changes
Normal Variant
(benign early
repolarization)

J Point
 ECG Changes of
Pericarditis vs Benign Early Repolarization (BER)

▪ Both demonstrate initial concavity of upsloping ST segment/T wave

▪ PR depression in pericarditis; not in BER

Concave STE Large amplitude T wave

▪ Ginzton LE, Laks MM. The differential diagnosis of acute pericarditis from the normal variant: new electrocardiographic criteria. Circulation 1982; 65 (5):1004-9.

Notching or slurring of J point

ST Elevation morphologies in Brugada Syndrome

RBBB with RSR pattern

rather than rSR pattern and
there is associated STE

• RBBB
• ST Elevations limited to right
precordial leads V1 and V2
• Saddle shaped or coved shaped
ST elevation
• First described in 1992 by
Brugada and Brugada
• The syndrome has been linked
to mutations in the cardiac
sodium-channel gene
Contoh Kasus