INTERPRETASI

EKG
Deske Muhadi
FK USU
 SEJARAH (evolusi)
Willem Einthoven

Mac 400

Gambaran EKG 12 Leads secara formal dimunculkan tahun 1942

:
• Penambahan “ three augmented limb leads” (aVR, aVL and aVF) oleh

Emanuel Goldberger;

• Kemudian “ three standard leads” (I, II, III) oleh : Einthoven, Lewis,

Mackenzie, and Wilson;

• “six chest leads” (V untuk voltage 1–6,aspek teknis disempurnakan tahun

2
1938 melalui the American Heart Association and the British Cardiac Society).
 PENDAHULUAN

 Kegunaan EKG :
1. Hipertropi atria dan ventrikel
2. Infark miokard
3. Aritmia .
4. Perikarditis
5. Efek obat – obatan (digitalis, kina)
6. Gangguan elektrolit (K)
7. Beberapa penyakit sistemik (hipertiroid)
8. dsb
3
4
ANATOMI JANTUNG

5
 SIRKULASI ARTERI KORONARIA

A : Anterior View B : Posterior View 7

ARTERI KORONARIA
10
 Sandapan EKG (ECG Leads)
 Bipolar Leads : Lead I, Lead II, Lead III
 Unipolar Leads : aVR, aVL, aVF
 Precordial Leads: V1, V2, V3, V4, V5, V6

11
12
Lead Positive Negative View of
electrode electrode Heart

I LA RA Lateral
II LL RA Inferior
III LL LA Inferior

13
Lead Positive View of
electrode Heart

aVR RA None
aVL LA Lateral
aVF LL Inferior

14
Lead Positive electrode View of
Placement Heart

V1 4th Intercostal space Septum

to right of sternum

V2 4th Intercostal space Septum

to left of sternum

V3 Directly between V2 Anterior

and V4

V4 5th Intercostal space Anterior

at left midclavicular
line

V5 Level with V4 at left Lateral

anterior
axillary line

V6 Level with V5 at left Lateral

midaxillary line

15
Lead Positive electrode
Placement

V1R 4th Intercostal space to left

of sternum

V2R 4th Intercostal space to

right of sternum

V3R Directly between V2R and

V4R
V4R 5th Intercostal space at
right midclavicular line

V5R Level with V4R at right

anterior axillary line

V6R Level with V5R at right

midaxillary line

16
Unipolar Precodial (Chest) Leads
Midclavicular line
Anterior axillary line
Midaxillary line

V6R V6
V5
V5R
V4
V4R V3
V3R V2
V1

Mervin J. Goldman, MD. 11th edition Principles of clinical Electrocardiography. Clinical Professor of Medicine University of
California School of Medicine San Francisco @1995-1982
18
Unipolar Precodial (Chest) Leads

Horizontal plane of V4-6

V7 V8 V9 V9RV8RV7R

Mervin J. Goldman, MD. 11th edition Principles of clinical Electrocardiography. Clinical Professor of Medicine University of
California School of Medicine San Francisco @1995-1982
 I II III

aVL
aVF V1 V2

V3 V4 V5 V6

V3R V4R
V7 V8 V9
The Heartbeat
Cardiac Physiology Electrocardiography Diagnosis

SA
P T node

AV
node
Q
S
Cardiac Physiology Electrocardiography Diagnosis

SA
P T node

AV
node
Q
S
Relationship of electrical and mechanical events in the cardiac cycle.

26
 ECG Waves
QRS Complex
(Ventricular Depolarization)

P wave T wave
(Atrial (Ventricular
Depolarization) Repolarization) P wave

One Cardiac Cycle

Beberapa hal yang harus diketahui
1. Ritme : Sinus / Aritmia
2. Ventrikular Rate / Atrial Rate
3. Aksis (Electrical Position)
4. Gelombang P : Interval dan Amplitudo
5. PR interval
6. QRS compleks
7. Gelombang Q
8. Gelombang R
9. Gelombang S
10. Gelombang T
11. S-T segmen
12. Kesimpulan
29
 Pembacaan EKG
Nama : ….
Usia : ….
Diagnosa : ….
Tanggal (Dilakukan EKG) : ………. Jam : ……….

Ritme : sinus / aritmia

VR : …. x/i AR : …. x/i
Axis : …..
Gel P : .... mV ; ….. mm/sec
Gel Q : Lead …..
P – R interval : …. mm/sec
QRS complex : …. mm/sec
S – T segment : ……….
R : …..
S : …..
T : …..

Kesimpulan : Dr ……….
…………………………… 30
31
TERMINOLOGI
qRs Rs R rS RS

QR Q/QS rSR
RsR’ rSr’
PENGHITUNGAN EKG

33
34
 DEFINISI KONFIGURASI GELOMBANG EKG

Kertas EKG
Horizontal menyatakan kecepatan kertas
dalam waktu
1 mm = 0,04 detik
5 mm = 0,2 detik
Vertikal menyatakan voltage elektris jantung
dalam millivolt
10 mm = 1 mV
Pada pemeriksaan rutin kecepatan rekaman
kertas EKG 25 mm/detik

1 mm = 0,1 mV 1 mm = 0,04 detik

10 mm = 1 mV 5 mm = 0,2 detik

35
P
E
N
G
H
I
T
U = 1/25 = 0,04
N
G
A
N

E
K
G
36
37
38
Frekuensi jantung normal : 60 – 100 x/I
> 100 x/i  (sinus) takikardi
< 60 x/i  (sinus) bradikardi
140 – 250 x/i  takikardi (abnormal)
250 – 350 x/i  flutter
> 350 x/i  fibrillasi

39
Menentukan Heart Rate dari Electrocardiogram

Ada berbagai metode yang dapat digunakan untuk menghitung denyut jantung dari
EKG, dengan kecepatan kertas EKG25 mm/sec.
Salah satu metode adalah membagi 1500 dengan jumlah kotak kecil diantara
dua gelombang R (garis panah merah). Sebagai contah, rate diantara beat 1 dan
2 pada EKG diatas adalah 1500/22, yang sama dengan 68 denyut /min.
Alternatif lain,adalah dengan membagi 300 dengan jumlah kotak besar (garis
panah biru pada diagram), yaitu 300/4.4 (68 denyut /min).
Metode lain, adalah "count off" method. Dengan menghitung jumlah kotak besar
diantara gelombang R mengikuti rate: 300 - 150 - 100 - 75 - 60. Sebagai contoh jika
ada 3 kotak besar diantara gelombang R denyut jantung adalah 100 denyut/min.
40
 “Count off" method

1 kotak besar = 300

2 kotak besar = 150
3 kotak besar = 100
4 kotak besar = 75
5 kotak besar = 60
6 kotak besar = 50
7 kotak besar = 43
8 kotak besar = 37

0 1 2 3 4 5 6 7 8

41
Menghitung Heart Rate

42
43
44
45
49
50
 CONTOH

51
 CONTOH

52
53
54
55
56
 Arrhytmia

Tachyarrhythmia Bradyarrhytmia
(rate >100 x/min) (rate < 60 X/min)

• QRS sempit (<0.12 ms) • AV blok derajat 1, 2 &

3
• QRS lebar (>0.12 • RBBB & LBBB
ms)
 QRS sempit : Supraventricular origin

QRS sempit

Irama
Irama Teratur
Tidak teratur

Supraventricular
Sinus Tachycardia Atrial Fibrillation
Tachycardia

Atrial Flutter
 QRS Lebar : Ventricular origin

QRS lebar

Irama
Irama Teratur
tidak teratur

Ventricular Ventricular
Tachycardia Fibrillation
SVT
AF rapid
VT
VT
VF
Torsade de Pointes
 Artefak (bukan gelombang EKG)

EKG (pasien bergerak, masih dapat dihitung)

75
76
77
Bradyarrhytmia
(rate < 60 x/min)

Failure of impulse AV conduction

formation abnormalities
 Sinus Bradycardia  1st and 2nd AV Block

 Sick Sinus Syndrome  Total AV Block

 BBB (Bundle Branch
Block)
First-degree AV block

Rhythm : Regular
Rate : Usually normal
P wave : Sinus P wave present; one P wave to each QRS
PR : Prolonged ( greater than 0.20 seconds )
QRS : Normal
Second -degree AV block, Mobitz I

Rhythm : Irregular
Rate : Usually slow but can be normal
P wave : Sinus P wave present;
some not followed by QRS complexes
PR : Progressively lengthens
QRS : Normal
Second-degree AV block, Mobitz II

Rhythm : Regular usually;

can be irreguler if conduction ratios vary
Rate : Usually slow
P wave : Two, three, or four P waves before each QRS
PR : PR interval of beat with QRS is constant;
PR interval may be normal or prolonged
QRS : Normal if block in His bundle;
wide if block involves bundle branches
Third-degree AV block

Rhythm : Regular
Rate : 40 – 60 if block in His bundle;
30 – 40 if block involves bundle branches
P wave : Sinus P wave present; bear no relationship to QRS;
can be found hidden in QRS complexes and T waves
PR : Varies greatly
QRS : Normal if block in His bundle;
wide if block involves bundle branches
Sick Sinus Syndrome
LBBB
Latihan ….
Menentukan Axis
Electrical Position

94
Menentukan Axis (Electrical Position)

95
96
Determining the Mean Electrical Axis (QRS axis)

Lead I : 4 – 0 = 4
Lead aVF : 12 – 2 = 10

97
 Lead I : 4 – 0 = 4
- = 270°
Lead aVF : 12 – 2 = 10

- = 180° I
+ = 0°/360°

aVF

+ = 90° 98
99
100
101
ARTI KLINIS AKSIS QRS

Differential Diagnosis
LVH, left anterior fascicular block, inferior wall
MI, PVC from the right ventricle, WPW
Left axis deviation syndrome activating the right ventricle,
Pregnancy, Ascites, Abdominal tumor,
exhalation.
RVH, left posterior fascicular block, lateral
wall MI, PVC from the left ventricle, WPW
Right axis deviation
syndrome activating the left ventricle,
Emphysema, Inhalation

102
103
104
 Gelombang P
 Menggambarkan aktivitas depolarisasi atria
 Arah gelombang P normal selalu positif di II & selalu negatif
di aVR
 Nilai Normal :
• Tinggi < 3mm
• Lebar < 3mm

105
P pulmonal
P Pulmonale
P Mitrale
109
110
Hipertrofi
atrium ka
nan
Biatrial
Hipertrofi
atrium kiri

111
RVH
 Gelombang Q
Menggambarkan awal fase depolarisasi ventrikel
Ciri – ciri Q patologis :
1. Lebarnya sama atau lebih dari 1mm (0,04 detik)
2. Dalamnya lebih dari 25 % amplitudo gelombang R
Kepentingan : menentukan adanya nekrosis miokard (infark miokard)

Gelombang T
Menggambarkan repolarisasi ventrikel
Arah normal : sesuai arah gelombang QRS
Amplitudo normal
• Kurang dari 10 mm di sandapan dada
• Kurang dari 5mm di sandapan ekstremitas
• Minimum 1 mm
Kepentingan :
1. menandakan infark atau iskemik
2. Menandakan kelainan elektrolit , dll 113
114
Extremely tall, pointed T
waves seen in
hyperkalemia

115
T Inverted
T inverted
118
 Interval P-R

Batas normal : 0,12 – 0,20 detik

Kepentingan :
1. Interval P-R < 0,12 detik : terdapat pada hantaran dipercepat
(WPW syndrome)
2. Interval P-R > 0,20 detik : terdapat pada blok AV
3. Interval P-R berubah – ubah : terdapat pada wandering
pacemaker

QRS interval = 0.06 – 0.10 sec

QT interval = 0.32 – 0.43 sec
119
Interval QRS

120
Gelombang R

121
 Criteria for the

ECG diagnosis of

left ventricular

hypertrophy

(LVH)

122
123
Criteria for the ECG diagnosis of right ventricular hypertrophy (RVH

124
2. Ventrikel : a. Ventrikel kiri

b. Ventrikel kanan

c. Biventrikel
a. Ventrikel kiri
•1. LVH: (Left ventricular hypertrophy).
a. Gelombang S (terbesar) di V1 atau V2
(dlm mm) ditambah gelombang R
(terbesar) di V5 atau V6 (dlm mm) >
35mm. ("voltage criteria“)
b. Gelombang R > 12 mm di aVL (LVH is
more likely with a "strain pattern"
which is asymmetric T wave inversion
in those leads showing LVH).

Summary :
• S wave V1 or V2 or R wave V5 or V6
of 30mm or greater.
• LAD
• QRS duration upper limit of normal
• Shift in the ST segment or T wave
(strain pattern) V5 and V6 125
b. Ventrikel kanan

•RVH: (Right ventricular hypertrophy).

Gelombang R > gelombang S di V1
dan Gelombang R menurun dari V1
sampai V6.

Summary of Criteria for RVH

Remember, again, that the electrocardiographic criteria for chamber enlarge-
ment have both low sensitivity and specificity. In summary, these are the
things to look for when trying to diagnose RVH:
1. R to S ratio of >1.0 in V1 or V2
2. RAD
3. Normal QRS duration
4. Strain pattern V1 or V2 and in limb leads with the tallest R wave 126
c. Biventrikel
Merupakan gabungan kriteria RVH dan LVH

ARTI KLINIS HIPERTROFI JANTUNG :

1. Pembesaran atrium kanan : ASD, PAPVR, Ebstein anomali
2. Pembesaran atrium kiri : Mitral stenosis, Mitral regurgitasi
3. Hipertrofi ventrikel kiri : Hipertensi, Aortic stenosis, Aortic regurgitasi,
Mitral regurgitasi, VSD, PDA
4. Hipertrofi ventrikel kanan : PPOK, ASD, Pulmonal stenosis

127
RAE LAE 128
RVH LVH

129
 V1 V6

RBBB

LBBB

130
131
INTRAVENTRICULAR
CONDUCTION DELAY

1. RIGHT BUNDLE BRANCH BLOCK (RBBB)

2. LEFT BUNDLE BRANCH BLOCK (LBBB)
3. LEFT ANTERIOR HEMI BLOCK (LAH)
4. LEFT POSTERIOR HEMI BLOCK (LPH)
BUNDLE BRANCH BLOCK :
1. KOMPLIT : - kanan : RIGHT BUNDLE BRANCH BLOCK
(>0,12”) - kiri : LEFT BUNDLE BRANCH BLOCK
2. INKOMPLIT : - kanan : INCOMPLETE RIGHT BUNDLE BRANCH BLOCK
132
(<0,12”) - kiri : INCOMPLETE LEFT BUNDLE BRANCH BLOCK
133
Diagnostic criteria for right bundle branch block
1. QRS duration >0.12 s
RIGHT BUNDLE
2. A secondary R wave (R’) in V1 or V2 BRANCH BLOCK (RBBB)
3. Wide slurred S wave in leads I, V5, and V6
Associated feature
4. ST segment depression and T wave inversion
in the right precordial leads 134
 LEFT BUNDLE
BRANCH BLOCK
(LBBB)

Diagnostic criteria for left bundle branch block

1. QRS duration of >0.12 s
2. Broad monophasic R wave in leads 1, V5, and V6
3. Absence of Q waves in leads V5 and V6
Associated features
4. Displacement of ST segment and T wave in an opposite direction to the
dominant deflection of the QRS complex (appropriatediscordance)
5. Poor R wave progression in the chest leads
6. RS complex, rather than monophasic complex, in leads V5 and V6 135
7. Left axis deviation—common but not invariable finding
KRITERIA LAH :
1. LAD, sering mendekati −60 derjats
2. Gelombang R kecil di lead III
3. Gelombang Q kecil di lead I
4. Normal QRS durasi

LEFT ANTERIOR
HEMIBLOCKS

136
KRITERIA LPH :
1. RAD, sering mendekati +120 derjats
2. Gelombang Q kecil di lead III
3. Gelombang R kecil di lead I
4. Normal QRS durasi

LEFT POSTERIOR
HEMIBLOCKS

137
S-T Segment

 Need reference point

 Compare to TP segment
 DO NOT use PR segment as reference!

ST TP
S-T Segment

139
Waveform Components:
Practice
 Find J-points and ST segments
Waveform Components:
Practice
 Find J-points and ST segments
 Primary Causes of ST
Segment Elevation
•Early repolarization (normal
variant in young adults)
• Pericarditis
• Ventricular aneurysm
• Pulmonary embolism
• Intracranial hemorrhage
Primary Causes of ST Segment
Depression
• Myocardial ischemia
• Left ventricular hypertrophy
• Intraventricular conduction
defects
• Medication (e.g., digitalis)
• Reciprocal changes in leads
opposite the area of acute injury
142
143
144
Inferior Wall
 II, III, aVF
 View from Left Leg 
 inferior wall of left ventricle

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Inferior Wall
 Posterior View
 portion resting on diaphragm
 ST elevation  suspect
inferior injury

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6 Inferior Wall
Lateral Wall
 I and aVL
 View from Left Arm 
 lateral wall of left ventricle

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Lateral Wall
 V5 and V6
 Left lateral chest
 lateral wall of left ventricle

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Lateral Wall
 I, aVL, V5, V6
I aVR V1 V4
 ST elevation  suspect
lateral wall injury II aVL V2 V5

III aVF V3 V6

Lateral Wall
Anterior Wall
 V3, V4
 Left anterior chest
  electrode on anterior
chest

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Anterior Wall
 V3, V4
 ST segment elevation 
suspect anterior wall
injury

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Septal Wall
 V1, V2
 Along sternal borders
 Look through right ventricle & see
septal wall

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
Septal
 V1, V2
 septum is left
ventricular tissue

I aVR V1 V4
II aVL V2 V5
III aVF V3 V6
PROGRESIFITAS MYAKARD INFARK AKUT

154
Figure. ST, QRS, and T vectors in
myocardial infarction.
a. ST injury vector.
b. b. QRS vector in necrosis.
c. c. T ischemia vector
a b

Hubungan antara lokasi

infark dan oklusi arteri
koroner (panah), dan lead
elektrocardiogram.
a. Anteroseptal infark.
b. Anterior infark
Extensive (anterolateral
infarction)
c. Infark lateral
isolatedction
c
 d. Infark Inferior f. Right ventricular
“infarction” (combined
to inferior infarction)
d

e e. Infark Posterior f
NON-TRANSMURAL = SUB ENDOCARDIAL = non Q-WAVE M.I.

depresion
TRANSMURAL = MYOCARDIAL = Q-WAVE M.I.

elevation
Figure.
a. Acute infarction: correlation between
the electrocardiogram (ECG) and the
stage of myocardial ischemia.
Monophasic ST deformation
/“transmural” lesion = lesion / injury.
b. Subacute infarction. Correlation
between the ECG and the stage of
myocardial ischemia (ST elevation =
lesion, plus pathologic Q wave =
necrosis, plus negative T wave =
ischemia).
c. Evolution of subacute infarction to
chronic infarction
Figure V3 lead: Evolution of QRS and ST/T morphologies in STEMI due to
occlusion of LAD.
(a) Few minutes; (b) 1 hour; (c) 1 day; (d) 1 week.
Figure 9.3. The evolution of an inferior
wall myocardial infarction, as seen in
lead III of a 55-year-old white male. Note
that the admission tracing shows only
ST elevation. A Q wave is beginning to
form by 1 hour, and ST elevation is on
the way down. By 24 hours, Q wave
formation is complete,
and the T wave is fully inverted. By 1
year, a pathologic Q wave is the only
remaining evidence of infarction.
Nonpathologic (nonischemic) and pathologic (ischemic) ST-segment and T-
wave changes.
A, Characteristic nonischemic ST-segment change called J-depression; note
that the ST slope is upward.
B and C, Examples of pathologic ST-segment changes; note that the
downward slope of the ST segment (B) or the horizontal segment is
sustained (C).
(From Park MK, Guntheroth WG: How to Read Pediatric ECGs, 4th ed. Philadelphia, Mosby, 2006.)
Myocard infark :
1. Hyperacute T wave
2. ST segment changes
T wave changes associated
3. Pathological Q wave with ischaemia
4. Resolution of changes of ST segment
and T wave
5. Reciprocal ST segment depression
The ECG shows:
• Sinus rhythm
• Normal axis
• Q waves in leads V2-V4
• Raised ST segments in leads V2-V4
• Inverted T waves in leads I, VL, V2-V6
The ECG shows:
• Sinus rhythm
• Normal axis
• Small Q waves in leads II, III, VF
• Biphasic T waves in leads II, V6; inverted Twaves in leads III, VF
• Markedly peaked T waves in leads V1-V2
 Tiga tanda infark
miokard akut :

• Elevasi segment ST
• T Inversi
• Q formasi

167
 PJK
 ISCHEMIA : ST depresi atau T inverted / flat
(datar)

 INFARCT : ST Elevasi

 NECROSIS (OLD INFARCT) :

gel. Q patologis atau QS

CONTOH

172
CONTOH

173
CONTOH

174
CONTOH

175
176
ST Depresi
178
179
180
181
 Latihan
Normal Sinus Rhythm

Rhythm : Regular
Rate : 60 – 100
P wave : Normal in configuration; precede each QRS
PR : Normal ( 0. 12 – 0.20 seconds )
QRS : Normal ( less than 0.12 seconds )
 Pembacaan EKG
Nama : …. Unuk soal 1- 13
Usia : …. Pembacaan sesuai standart
Diagnosa : ….
Tanggal (Dilakukan EKG) : ………. Jam : ……….

Ritme : sinus / aritmia

VR : …. x/i AR : …. x/i
Axis : …..
Gel P : .... mV ; ….. mm/sec
Gel Q : Lead …..
P – R interval : …. mm/sec
QRS complex : …. mm/sec
S – T segment : ……….
R : …..
S : …..
T : …..

Kesimpulan : (Dr ……….)

…………………………… 183
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190
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Latihan no 12
Latihan no 13
Wassalamualaikum ww

197