Ecg Pathology 02

Electrocardiography
Changes
Sutomo Kasiman, MD, FIHA, FACC

Departemen Kardiologi & Kedokteran
Vaskuler FKUSU
OVERVIEW
ECG Changes
•Rhythm
•Frequency
Diagnosing ECG
Electrical conduction
Sinoatrial
Node
Atrioventricular
Node
Cardiac Physiology Electrocardiography Diagnosis
P T
Q
S
R 1 sec
P T
Q
S
0.5 Sec
ECG Normal
Rhythm (Irama)
• Sinus
• Arrythmia
Frequency
• Normal
• Tachycardia
• Bradycardia
Morphology
• Axis
• Besaran depolarisasi
Arrythmia
SK
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 ms) • RBBB & LBBB

Tachyarrhythmia
• Tachyarrhythmia could be secondary to cardiac,

pulmonary or dysmetabolic diseases
• Treatment must be directed not only to the

arrhythmia but – when present – to its cause
• Our primary objective is to treat the patient

and not only the arrhythmia
CAUSE OF CARDIAC ARRHYTHMIAS :
• Disturbances in automaticity : bertambah cepat

atau bertambah lambatnya suatu daerah otomatisitas.
Misal di sinus node, AV node, abnormal beats/
depolarisasi atrium, AV junction, ventrikel, VT, dll.
• Disturbances in conduction : konduksi terlalu cepat

(WPW) atau terlalu lambat (blok AV).
• Combinations of altered automaticity and conduction.

Approach to
electrocardiographic diagnosis
• Duration of QRS
• Regularity of QRS
• P wave ??
QRS complex
Regular / irregular ?
QRS complex
Normal-looking QRS complex?
Wide / narrow ?
P wave ?
Relationship between P and QRS ?

narrow-QRS tachycardia :
Supraventricular origin
narrow-QRS
Regular rhythm Irregular rhythm
Supraventricular
Sinus Tachycardia Atrial Fibrillation
Tachycardia
Atrial Flutter
Atrial Flutter :
-The result of a re-entry circuit within
the atria
-Irregular / regular QRS rate
-Narrow QRS complex
-Rapid P waves (300x/min), “sawtooth”
Atrial Flutter
Supraventricular Tachycardia ( SVT )
reentry via accessory pathway
PSVT :
-due to re-entry mechanism
-narrow QRS complex
-regular
-retrograde atrial depolarization
-P wave ?
PSVT (Paroxysmal SupraVentricular Tachyradia)
SVT
SVT
Atrial Fibrillation :
-from multiple area of re-entry within atria

-or from multiple ectopic foci
-irregular, narrow QRS complex
-very rapid atrial electrical activity
(400-700 x/min).
-no uniform atrial depolarization
narrow-QRS tachycardia :
Supraventricular origin
narrow-QRS
Supraventricular
Sinus Tachycardia Atrial Fibrillation
Tachycardia
Atrial Flutter
Atrial Fibrillation :
-from multiple area of re-entry within atria

-or from multiple ectopic foci
-irregular, narrow QRS complex
-very rapid atrial electrical activity
(400-700 x/min).
-no uniform atrial depolarization
Rapid AF
Junctional rhythm:
-AV junction can function as a pace maker
(40-60 x/min).
-due to the failure of sinus node to initiate time
impulse or conduction problem.
-normal-looking QRS.
-retrograde P wave.
-P wave may preceede, coincide with, or
follow the QRS
Preventricular Contractions
• Coffee
• Cigarettes
• Sleep deprivation
• Pathology
Normal ECG
ECG with Preventricular Contractions

VENTRICLE EXTRA SYSTOLE
SR
VES
VES Unifocal
Bentuk VES sama, fokus impuls timbul dari

tempat yang sama
VES multifocal
Bentuk VES berbeda, fokus impuls timbul dari

tempat yang berbeda
VES bigemini
Setiap satu irama sinus diikuti oleh satu VES

VES Trigemini
Setiap dua irama sinus diikuti oleh satu VES

VES Quadrigemini
Setiap tiga irama sinus diikuti oleh satu VES

VES consecutive
VES timbul dua atau tiga kali berturut-turut

R on T
Terdapat gel R berada pada gel T

Sinus rhythm
with
Multifocal VES
VES VES
SR SR
SR SR SR SR
Sinus rhythm with VES couplet
Sinus Rhythm with VES, R on T
wide-QRS tachycardia :
Supraventricular and Ventricular origin
wide-QRS
Ventricular
SVT + BBB
Fibrillation
SVT + acc. pathway
Ventricular
Tachycardia
Ventricular Tachycardia
VT
VT
VT
wide-QRS tachycardia :
Supraventricular and Ventricular origin
wide-QRS
Ventricular
SVT + BBB
Fibrillation
SVT + acc. pathway
Ventricular
Tachycardia
Ventricular Fibrillation
Normal ECG
ECG during Ventricular Fibrillation

Ventricular Fibrilation
• Ischemia
• Electric Shock
VF
Torsade de pointes
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)
Sick Sinus Syndrome
ATRIO-VENTRICULAR BLOCK
Atrioventricular Block
• Ischemia
• Nodal Compression
• Nodal Inflamation
• Extreme Stimulation
ATRIO-VENTRICULAR BLOCK
1st degree AV block
Prolonged PR interval
2ND AV Block Type 1 :
Wenkebach
Missing QRS
2nd degree AV block, type 1
Missing QRS Missing QRS

2ND AV Block Type 2 :
Mobitz
2nd degree AV block, type 2
Missing QRS
Normal ECG
ECG with Atrioventricular Block

Total AV Block /
( 3rd degree AV block )
QRS QRS QRS
P P P P P P P
LBBB
The
Deadly
Rhythms
PEA
VT VF (Pulseless
Electrical
Activity)
A systole
Summary
Cardiac Arrthythmias
• Tachycardia: abnormally fast heart rate
• Bradycardia: Abnormally slow heart rate
• Incomplete Atrioventricular Block:
Prolonged P-R interval
• Complete Atrioventricular Block: P waves
and QRS complexes become dissociated
• Fibrillation: Complete lack of coordination
SUMMARY
• Atria
• Ventricles
Cardiac Physiology
• Nodes
Electrocardiography • Electrical
Propagation
Diagnosing Heart Conditions

SUMMARY
• ECG
Measurement
Cardiac Physiology • P-Wave
• QRS-Complex
Electrocardiography • T-Wave

SUMMARY
• AV Block
Cardiac Physiology • PVCs
• V-Fib
Electrocardiography

Myocardial Ischemia
• ST segment depression
• T wave inversion
Topography Chest leads
Myocardial Ischemia
Myocardial Infarction
• ST segment elevation
• Q wave
Anterior Infarction
Inferior Infarction
Hypertrophy
• Left ventricle hypertrophy

• Right ventricle hypertrophy
Left Ventricle Hypertrophy
R wave V5-6 > 2.6 mV

S wave V1 n R V5-6>3.5 mV
ST dep n inv T wave V5-6
QRS comp.V5-6 >0.1 sec
Right ventricle Hypertrophy
R wave exag V1-2

S wave exag V5-6
Right axis >1100
Selamat menjalani
Kepaniteraan Klinik
Positions of normal heart

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Electrocardiography

Sutomo Kasiman, MD, FIHA, FACC

• QRS sempit (<0.12 ms) • AV blok derajat 1, 2 & 3

• QRS lebar (>0.12 ms) • RBBB & LBBB

• Tachyarrhythmia could be secondary to cardiac,

• Treatment must be directed not only to the

• Our primary objective is to treat the patient

• Disturbances in automaticity : bertambah cepat

• Disturbances in conduction : konduksi terlalu cepat

• Combinations of altered automaticity and conduction.

Relationship between P and QRS ?

Regular rhythm Irregular rhythm

-from multiple area of re-entry within atria

Regular rhythm Irregular rhythm

-from multiple area of re-entry within atria

ECG with Preventricular Contractions

Bentuk VES sama, fokus impuls timbul dari

Bentuk VES berbeda, fokus impuls timbul dari

Setiap satu irama sinus diikuti oleh satu VES

Setiap dua irama sinus diikuti oleh satu VES

Setiap tiga irama sinus diikuti oleh satu VES

VES timbul dua atau tiga kali berturut-turut

Terdapat gel R berada pada gel T

Regular rhythm Irregular rhythm

SVT + acc. pathway

Regular rhythm Irregular rhythm

SVT + acc. pathway

ECG during Ventricular Fibrillation

Failure of impulse AV conduction

Missing QRS Missing QRS

ECG with Atrioventricular Block

QRS QRS QRS

Diagnosing Heart Conditions

Diagnosing Heart Conditions

Diagnosing Heart Conditions

• Left ventricle hypertrophy

R wave V5-6 > 2.6 mV

R wave exag V1-2

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