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BASICS OFELECTROCARDIOGRAPH
Y
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REFERENCE
Dr. Annapoorna Kalia, Associate Consultant Dept.
of Cardiology
2
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Outline
1. Review of the
conduction system
2. EKG waveforms and
intervals
3. EKG leads
4. Determining heart rate
5. Determining QRS axis
1.Review dari sistem konduksi
Bentuk gelombang
2.EKG dan interval
3.lead EKG
4.Menentukan denyut jantung
5.Menentukan sumbu QRS
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The Normal Conduction System
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Cardiac Impulse
5
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Cardiac Impulse
1. Cardiac impulse originates in the SA node
2. Traverses the atria simultaneously no specialconduction wires in atria so the delay
3. Reaches AV node the check post so delay
4. Enters bundle of His and branches throughspecialized conducting wires called Purkinjenetwork - activates both ventricles quick QRS
5. First the septum from L to R, then right ventricle and
then the left ventricle and finally the apex6. Then the ventricles recover for next impulse
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1. Impuls jantung berasal dari SA node
2. Melintasi atrium secara bersamaan - tidak ada kabel konduksi
khusus di atrium - sehingga keterlambatan
3. Capai AV node - pos pemeriksaan - sehingga menunda
4. Memasuki berkas His dan cabang - melalui kabel khusus
melakukan disebut jaringan Purkinje - mengaktifkan kedua
ventrikel - QRS cepat
5. Pertama septum dari L ke R, maka ventrikel kanan dan kemudian
ventrikel kiri dan akhirnya puncak
6. Kemudian ventrikel pulih untuk impuls berikutnya
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CARDIAC CONDUCTIO
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What is an EKG?
The electrocardiogram (EKG) is arepresentation of the electricalevents of the cardiac cycle.
Each event has a distinctive
waveform, the study of whichcan lead to greater insight into apatients cardiacpathophysiology.
Elektrokardiogram (EKG)
adalah representasi dari
peristiwa listrik dari siklus
jantung.
Setiap acara memiliki
gelombang yang khas, studi
yang dapat menyebabkan
wawasan yang lebih besar
patofisiologi jantung pasien.
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WHAT IS AN
ELECTROCARDIOGRAM? (ECG/
EKG)The ECGis a graphical recordingof the hearts electrical activity
during each of its cycles. It is the
most common investigation of the
heart performed by physicians and
is extremely useful.
EKG adalah rekaman grafis dari
aktivitas listrik jantung selama setiap
siklus nya. Ini adalah penyelidikan
yang paling umum dari jantung yangdilakukan oleh dokter dan sangat
berguna.
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What types of pathology can we identify and study
from EKGs?
Arrhythmias Myocardial ischemia and
infarction
Pericarditis
Chamber hypertrophy Electrolyte disturbances
(i.e. hyperkalemia,hypokalemia)
Drug toxicity (i.e. digoxinand drugs which prolongthe QT interval)
-aritmia
-Iskemia miokard dan infark
-pericarditis
-Chamber hipertrofi
-Gangguan elektrolit
(misalnya hiperkalemia,
hipokalemia)
-Toksisitas obat (yaitu
digoxin dan obat-obatan yang
memperpanjang interval QT)
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WHEN IS AN ECG USED?
The ECG is used to investigate suspected problemswith the electrical conduction system of the heartas
well as some other abnormalities such as metabolic
disturbances (e.g. excess potassium).
The ECG is an essential tool for health
professionals in making a diagnosis of abnormalheart rhythms when one is suspected. It is a routine
investigation in people who complain of symptoms
such as chest painas well as breathlessness.
The findings of the ECG can also have an effect on
treatment of certain conditions, for example it ishelpful in deciding some aspects of treatment in
people who have suffered from a heart attack.
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EKG ini digunakan untuk menyelidiki dugaan masalah dengan
sistem konduksi listrik jantung serta beberapa kelainan lain seperti
gangguan metabolik (misalnya kalium yang berlebih).
EKG adalah alat penting bagi para profesional kesehatan dalam
membuat diagnosis dari irama jantung abnormal ketika seseorang
dicurigai. Ini adalah investigasi rutin pada orang yang mengeluhkan
gejala seperti nyeri dada serta sesak napas.
Temuan EKG juga dapat memiliki efek pada pengobatan kondisi
tertentu, misalnya akan sangat membantu dalam menentukan
beberapa aspek dari pengobatan pada orang yang telah menderita
serangan jantung.
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HOW TO PREPARE FOR AN ECG
First reassure yourself that there is no
danger or paininvolved in performing theprocedure and try to relax breathing
steadily.
Rest your arms by your side with your legs
flat, making sure that your legs aren'ttouching one another.
Make sure that your chest is exposed as
well as your arms and legs.
The nurse should then clean your skin witha sterile wipe prior to placing the electrodes
in place
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Pertama meyakinkan diri sendiri bahwa tidak ada bahaya atau sakit
yang terlibat dalam melakukan prosedur dan mencoba untuk bersantai
bernapas mantap.
Istirahatkan tangan Anda di sisi Anda dengan kaki datar, memastikan
bahwa kaki Anda tidak menyentuh satu sama lain.
Pastikan dada Anda terkena serta lengan dan kaki.
Perawat kemudian harus membersihkan kulit Anda dengan
menghapus steril sebelum menempatkan elektroda di tempat
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WHAT CAN YOU EXPECT DURING AN
ECG? After the preparations that take place before an
ECG is performed, various electrodes with aplastic head and an adhesive gel are placed at
strategically located points on your body.
These points are shown in the diagram to the
right, and include: 6 points on your chest starting just to the right of your breast
bone extending sideways towards the left hand border of your
rib cage called V1 - V6.
4 points, one on each limb, the ones on the arms are placed
below the levels of the shoulders and on the legs they are
placed below the level of your groin (note that the closer the
electrodes are placed to your heart the more intense the
reading is, and the easier it is to interpret).
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Setelah persiapan yang berlangsung sebelum EKG dilakukan,
berbagai elektroda dengan kepala plastik dan gel perekat
ditempatkan pada titik-titik strategis yang terletak di tubuh Anda.
Titik-titik ini ditunjukkan dalam diagram di sebelah kanan, dan
meliputi:
-6 poin di dada Anda mulai hanya di sebelah kanan tulang dada Anda
memperpanjang samping menuju perbatasan kiri tulang rusuk Anda
disebut V1 - V6.
- 4 poin, satu pada setiap anggota tubuh, yang di lengan ditempatkan di
bawah tingkat bahu dan kaki mereka ditempatkan di bawah tingkatpangkal paha (perhatikan bahwa semakin dekat elektroda ditempatkan
ke jantung Anda semakin intens membaca adalah, dan semakin mudah
untuk menafsirkan).
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WHAT DOES THE ECG RECORD?
During the process of the recording the
signal is calculated and amplified from
the 10 electrodes placed on your bodyand subsequently recorded on a piece of
graph paper with specific dimensions.
Depending what 'lead' (the vector formed
between the different electrodes) you are
looking at the ECG appears different.
There are 12 such leads in a regular 12
lead ECG, each of which analyse a
different plane of the heart and are
therefore useful in diagnosing different
conditions and localising disease. The
'leads' or vectors on the chest wall arenamed V1, V2, V3, V4, V5 & V6 going
from right to left on the patient, and
therefore analyse the heart in order from
the right to the left i.e. from V1 to V6.
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Selama proses rekaman sinyal dihitung dan diperkuat dari 10 elektroda
ditempatkan pada tubuh Anda dan kemudian direkam pada selembar
kertas grafik dengan dimensi tertentu. Tergantung apa yang 'memimpin'
(vektor terbentuk antara elektroda yang berbeda) yang Anda cari di
EKG muncul berbeda.
Ada 12 lead tersebut dalam biasa 12 lead EKG, yang masing-masingmenganalisis pesawat yang berbeda dari hati dan karena itu berguna
dalam mendiagnosa kondisi yang berbeda dan melokalkan penyakit.
The 'lead' atau vektor pada dinding dada bernama V1, V2, V3, V4, V5
& V6 pergi dari kanan ke kiri pada pasien, dan karena itu menganalisis
hati dalam urutan dari kanan ke kiri yaitu dari V1 ke V6 .
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The leads on the chest are called unipolar leads
because their vector is only pointing in one direction
i.e. in a direction perpendicular to the chest wall. There are 4 electrodes on the patients limbs, but only 3
of which are used to form leads and one which is used
as an earth, just like the one found on a plug for an
electrical device.
The 3 limb electrodes used are the right arm, the leftarm and the left leg. From these 3 electrodes 6 limb
leads are formed, these are named I, II, III, aVR, aVL,
and AVF. The leads are formed by using various
combinations of the 3 leads, with leads I-III using 2
electrodes to form a vector (bipolar leads) and leads
aVR, aVL and aVF using 3 electrodes (augmented
bipolar leads).
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Mengarah pada dada disebut lead unipolar karena vektor mereka hanya
menunjuk satu arah yaitu ke arah tegak lurus terhadap dinding dada.
Ada 4 elektroda pada pasien anggota badan, tetapi hanya 3 dari yang
digunakan untuk membentuk memimpin dan salah satu yang digunakan
sebagai bumi, seperti yang ditemukan pada sebuah plug untuk perangkat
listrik.
3 elektroda ekstremitas yang digunakan adalah lengan kanan, lengan kiri dan
kaki kiri. Dari ini 3 elektroda 6 ekstremitas lead terbentuk, ini bernama I, II,
III, aVR, aVL, dan aVF. The lead dibentuk dengan menggunakan berbagai
kombinasi dari 3 lead, dengan lead I-III menggunakan 2 elektroda untuk
membentuk vektor (lead bipolar) dan mengarah aVR, aVL, dan aVF
menggunakan 3 elektroda (augmented lead bipolar).
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Bipolar leads
I = Right arm to left arm
II= Right arm to left leg
III = Left arm to left leg
Augmented bipolar leads
aVR = Right arm to left arm and left leg
aVL = Left arm to left leg and right arm
aVF = Left leg to left arm and right arm
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Usually the ECG is recorded on special graph paper that
is divided into 1-mm2boxes. Each box represents a
specific time interval since the ECG always records at a
particular velocity. By counting these boxes horizontally, the doctor is able
to discern the heart rate as well as the timings of the
different parts of the ECG.
The heart rate, the timings of the intervals (as seen in
the diagram below), the height of the recording as wellas the leads in which the abnormalities are present all
help to make a diagnosis. An ECG readout will look like
a series of 'waveforms', a single one of which is shown
below. The image also highlights the electrical activity in
the heart at the time, that causes the distinctive wave.
Depolarisation indicates that a wave of electricity has
just passed through an area of the heart such as the
ventricles of atria, causing them to contract.
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Biasanya EKG dicatat pada kertas grafik khusus yang dibagi menjadi kotak-1
mm2. Setiap kotak mewakili interval waktu tertentu sejak EKG selalu mencatat
pada kecepatan tertentu.
Dengan menghitung kotak-kotak ini horizontal, dokter mampu membedakan
denyut jantung serta timing dari bagian yang berbeda dari EKG.
Denyut jantung, timing interval (seperti terlihat dalam diagram di bawah),
ketinggian rekaman serta memimpin di mana kelainan hadir semua bantuan untuk
membuat diagnosis. Sebuah pembacaan EKG akan terlihat seperti serangkaian
'gelombang', satu pun dari yang ditunjukkan di bawah ini. Gambar juga
menyoroti aktivitas listrik di jantung pada waktu itu, yang menyebabkan
gelombang khas. Depolarisasi menunjukkan bahwa gelombang listrik baru saja
melewati daerah jantung seperti ventrikel dari atrium, menyebabkan mereka
untuk kontrak.
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WHAT CAN YOU EXPECT AFTER AN
ECG?
After the ECG recording is made, the leads will beremoved from your body and the doctor present will
attempt to make a diagnosis on the basis of what
was found.
If the ECG shows a serious abnormality, or there is
more information that is needed, other investigations
which are more interventional may be indicated, for
example an echocardiogram(an ultrasound
examination of the heart).
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Setelah rekaman EKG dibuat, lead akan dikeluarkan dari
tubuh Anda dan dokter ini akan mencoba untuk membuat
diagnosis berdasarkan apa yang ditemukan.
Jika EKG menunjukkan kelainan yang serius, atau ada
informasi lebih lanjut yang diperlukan, investigasi lain yang
lebih intervensi dapat diindikasikan, misalnya
ekokardiogram (pemeriksaan USG jantung).
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What are Some Possible Results From an
ECG and What Do These Mean?
There are a very large number of possible disorders that
can be found on an ECG, but there are some main
categories into which a majority of the abnormalities can
be grouped. Abnormalities of the Left heartAbnormalities of the Right heart
Abnormalities of the atria
Abnormally fast rates (tachycardias)
Abnormally slow rates (bradycardias and conduction
blocks)Heart attacks
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Beberapa Kemungkinan Hasil Dari EKG dan Apa Artinya ini?
Ada jumlah yang sangat besar gangguan yang mungkin yang dapatditemukan pada EKG, tetapi ada beberapa kategori utama di mana
mayoritas kelainan dapat dikelompokkan.
Kelainan jantung Kiri
Kelainan jantung kanan
Kelainan atrium
Tarif normal cepat (takikardia)
Tingkat abnormal lambat (bradycardias dan blok konduksi)
serangan jantung
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What these abnormalities Apa ini berarti kelainan tergantung pada
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What these abnormalities
mean depends on their
severity and the patient in
question. The diagnosis of an
abnormality on ECG does not
necessarily mean that an
abnormality is present, and if
there is an abnormality found
that doesn't correlate withpatients symptoms, the ECG
should be checked and
performed again. It is
important to make sure that
errors weren't made in theplacement of electrodes or in
the interpretation of results,
because there is always a
Apa ini berarti kelainan tergantung pada
tingkat keparahan dan pasien yang
bersangkutan. Diagnosis kelainan pada
EKG tidak berarti bahwa kelainan hadir,
dan jika ada kelainan yang ditemukan
yang tidak berhubungan dengan gejala
pasien, EKG harus diperiksa dandilakukan lagi. Hal ini penting untuk
memastikan bahwa kesalahan tidak
dibuat dalam penempatan elektroda atau
dalam interpretasi hasil, karena selalu
ada margin of error dengan
penyelidikan.
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IMPORTANT PRECAUTIONS Correct Lead placement and good
contact
Proper earth connection, avoid
other gadgets
Deep inspiration record of L3, aVF
Compare serial ECGs if available
Relate the changes to Age, Sex,Clinical history
Consider the co-morbidities that
may effect ECG
Make a xerox copy of the record for
future use
Interpret systematically to avoid
errors
-Memimpin penempatan yang benar dan
kontak yang baik
-Hubungan bumi yang tepat,menghindari gadget lainnya
-Catatan inspirasi yang mendalam dari
L3, aVF
-Bandingkan EKG seri jika tersedia
-Menghubungkan perubahan Age, Sex,sejarah klinis
-Pertimbangkan komorbiditas yang
dapat mempengaruhi EKG
-Membuat salinan fotokopi dari catatan
untuk penggunaan masa depan-Menafsirkan secara sistematis untuk
menghindari kesalahan
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ECG Complex
P wave
PR Interval
QRS complex
ST segment
T Wave
QT Interval
RR Interval
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ECG Complex P Wave is Atrial contraction
Normal 0.12 sec
PR interval is from the beginning
of P wave to the beginning of
QRSNormal up to 0.2 sec
QRS is Ventricular contraction
Normal 0.08 sec
ST segmentNormal Isoelectic
(electric silence)
QT IntervalFrom the beginning
of QRS to the end of T wave
Normal0.40 sec
RR IntervalOne Cardiac cycle
0.80 sec
- P Wave adalah kontraksi atrium - normal 0.12sec
- Interval PR adalah dari awal gelombang P ke
awal QRS - normal hingga 0,2 sec
- QRS adalah ventrikel kontraksi-Normal 0.08
sec
- Segmen ST - normal Isoelectic (keheningan
listrik)
- QT Interval - Dari awal QRS ke akhir
gelombang T - normal - 0.40 sec
- RR Interval - Satu siklus jantung 0.80 sec
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+
+ +
- - -
ECG BIPOLAR LIMB LEADS
R L
F
R
F
L
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Standard ECG is recorded in12 leads
Six Limb leads L1, L2, L3,
aVR, aVL, aVF
Six Chest Leads V1 V2 V3
V4 V5 and V6
L1, L2 and L3 are called
bipolar leads
L1 between LA and RA
L2 between LF and RA
L3 between LF and LA
ECG BIPOLAR LIMB LEADS
-Standard EKG tercatat dalam 12 lead
-Enam Limb memimpin - L1, L2, L3,
aVR, aVL, aVF
- Enam Dada Memimpin - V1 V2 V3
V4 V5 dan V6
-L1, L2 dan L3 disebut lead bipolar
-L1 antara LA dan RA
-L2 antara LF dan RA
-L3 antara LF dan LA
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ECG Unipolar Limb Leads
++
+
Lead aVR Lead aVL Lead aVF
R L
F
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Standard ECG is recorded in 12
leads
Six Limb leadsL1, L2, L3, aVR,
aVL, aVF
Six Chest LeadsV1 V2 V3 V4 V5
and V6 aVR, aVL, aVF are called unipolar
leads
aVRfrom Right Arm Positive
aVLfrom Left Arm Positive aVFfrom Left Foot Positive
ECG Unipolar Limb Leads
-Standard EKG tercatat Dalam, 12
lead
-Enam Limb memimpin - L1, L2, L3,
aVR, aVL, aVF
-Enam Dada Memimpin - V1 V2 V3
V4 V5 Dan V6
-L1, L2 Dan L3 disebut memimpin
bipolar
-L1 ANTARA LA Dan RA
-L2 ANTARA LF Dan RA
-L3 ANTARA LF Dan LA
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ECG Chest Leads
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Precardial (chest) Lead Position
V1 Fourth ICS, right sternalborder
V2 Fourth ICS, left sternal
border V3 Equidistant between V2 and
V4
V4 Fifth ICS, left Mid clavicularLine
V5 Fifth ICS Left anterioraxillary line
V6 Fifth ICS Left mid axillaryline
ECG Chest Leads
Precardial (dada) Posisi Memimpin
-V1 Keempat ICS, batas sternum
kanan
-V2 Keempat ICS, batas sternum
kiri-V3 Repetitively antara V2 dan V4
-V4 Kelima ICS, kiri Mid
clavicular Baris
-V5 Kelima ICS Left anterior garis
aksila-V6 Kelima ICS Kiri garis mid
aksila
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The Six Chest Leads
TRANSVERSE
PLANE
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ECG Graph Paper
X- Axis time in seconds
Y-AxisAmp
litudeinmillvolts
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X-Axis represents time - Scale X-Axis1 mm = 0.04 sec Y-Axis represents voltage - Scale Y-Axis1 mm = 0.1 mV
One big square on X-Axis = 0.2 sec (big box)
Two big squares on Y-Axis = 1 milli volt (mV)
Each small square is 0.04 sec (1 mm in size) Each big square on the ECG represents 5 small squares
= 0.04 x 5 = 0.2 seconds
5 such big squares = 0.2 x 5 = 1sec = 25 mm
One second is 25 mm or 5 big squares One minute is 5 x 60 = 300 big squares
ECG GRAPH PAPER
X Axis merupakan waktu Skala X Axis 1 mm = 0 04 detik
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- X-Axis merupakan waktu - Skala X-Axis - 1 mm = 0,04 detik
- Y-Axis merupakan tegangan - Skala Y-Axis - 1 mm = 0,1 mV
- Salah satu persegi besar di X-Axis = 0,2 detik (kotak besar)- Dua kotak besar pada Y-Axis = 1 mili volt (mV)
- Setiap kotak kecil adalah 0,04 detik (1 mm)
- Setiap persegi besar pada EKG mewakili 5 kotak kecil
= 0,04 x 5 = 0,2 detik
- 5 kotak besar seperti = 0,2 x 5 = 1sec = 25 mm
- Satu detik adalah 25 mm atau 5 kotak besar
- Satu menit adalah 5 x 60 = 300 kotak besar
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Rate Determination
Next
QRS
QRS
Rate Determination
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Rate Determination
No. of Big
Boxes
RR Interval Rate Cal. Rate
One 0.2 sec 60 0.2 300
Two 0.4 sec 60 0.4 150
Three 0.6 sec 60 0.6 100
Four 0.8 sec 60 0.8 75
Five 1.0 sec 60 1.0 60
Six 1.2 sec 60 1.2 50
Seven 1.4 sec 60 1.4 43
Eight 1.6 sec 60 1.6 37
BR
A
D
Y
T
A
C
H
Y
NO
R
M
A
L
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What is the Heart Rate ?
Answer on next slide
What is the Heart Rate ?
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To find out the heart
rate we need to know The R-R interval in
terms of # of big squares
If the R-R intervals areconstant
In this ECG the R-R
intervals are constant R-R are approximately
3 big squares apart
So the heart rate is 3003 = 100
What is the Heart Rate ?
Untuk mengetahui detak jantung
kita perlu tahu
-The R-R Interval dalam hal #
kotak besar
-Jika interval R-R adalah konstan
Dalam EKG ini interval R-R adalahkonstan
R-R adalah sekitar 3 kotak besar
terpisah
Jadi denyut jantung adalah 300 3
= 100
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What is the Heart Rate ?
Answer on next slide
What is the Heart Rate ?
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To find out the heart rate we
need to know
The R-R interval in terms
of # of big squares
If the R-R intervals are
constant
In this ECG the R-R intervals
are constant
R-R are approximately 4.5
big squares apart So the heart rate is 300 4.5
= 67
Untuk mengetahui detak
jantung kita perlu tahu
-The R-R Interval dalam
hal # kotak besar
-Jika interval R-R adalah
konstan
Dalam EKG ini interval R-
R adalah konstan
R-R adalah sekitar 4,5
kotak besar terpisah
Jadi denyut jantung adalah300 4,5 = 67
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What is the Heart Rate ?
Answer on next slide
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What is the Heart Rate ? To find out the heart ratewe need to know
The R-R interval interms of # of Big
Squares
If the R-R intervals are
constant
In this ECG the R-R
intervals are not constant
R-R are varying from 2
boxes to 3 boxes
It is an irregular rhythm Sinus arrhythmia
Heart rate is 300 2 to 3 =
150 to 100 approx
Untuk mengetahui detak jantung
kita perlu tahu The R-R Interval dalam hal #
Kuadrat Big
Jika interval R-R adalah konstan
Dalam EKG ini interval R-R tidakkonstan
R-R yang bervariasi dari 2 kotak
untuk 3 kotak
Ini adalah ritme yang luar biasa -
aritmia Sinus
Denyut jantung adalah 300 2
sampai 3 = 150-100 approx
QRS A i
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QRS Axis
SE
NENW
SW
QRS Axis
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The QRS electrical (vector) axis
can have 4 directions
Normal Axis - when it is
downward and to the left southeast quadrant from -30
to +90 degrees
Right Axis when it is
downward and to the right
southwest quadrantfrom +90to 180 degrees
Left Axis when it is upward
and to the left Northeast
quadrant from -30 to -90
degrees
Indeterminate Axiswhen it is
upward & to the right
Northwest quadrantfrom -90
to +180
QRS listrik (vektor) axis dapat
memiliki 4 arah
Axis biasa - ketika itu adalah ke
bawah dan ke kiri - kuadran
tenggara - dari -30 sampai +90
derajat
Kanan Axis - ketika itu adalah kebawah dan ke kanan - kuadran barat
daya - 90-180 derajat
Left Axis - ketika itu adalah ke atas
dan ke kiri - Timur Laut kuadran-
dari -30 sampai -90 derajat Tak tentu Axis - ketika itu atas & ke
kanan - Northwest kuadran - dari -
90 sampai +180
A i D t i ti
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Axis Determination
NORMAL RIGHT LEFT
MEET LEAVEALL UPRIGHT
A i D t i ti
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Axis Determination
Axis LI LIII oraVF
TIP
Normal Positive Positive Both Up
Right Negative Positive Meet
Left Positive Negative Leave
Indeterminate Negative Positive Meet
57
Wh t i th A i ?
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LEAD 1
LEAD 2
LEAD 3
aVR
aVL
aVF
What is the Axis ?
ECG With Normal Axis
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ECG With Normal Axis
Note the QRS voltages arepositive and upright in theleads - L1, L2, L3 and aVF
L2, L3 and aVF tell that it is
downward L1, aVL tell that it is to the
left
Downward and leftward isNormal Axis
Normal QRS axis
Catatan tegangan QRS positif dan
tegak di lead - L1, L2, L3 dan aVF
L2, L3 dan aVF mengatakan bahwa
itu adalah ke bawah
L1, aVL mengatakan bahwa itu
adalah ke kiri
Downward dan ke kiri adalahnormal Axis
Axis QRS yang normal
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Wh t i th A i ?
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LEAD 1
LEAD 2
LEAD 3
What is the Axis ?
ECG With Right Axis
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Note the QRS voltages are
positive and upright in leads L2,
L3
Negative in Lead 1
L2, L3 tell that it is downward
L1 tells that it is not to the left
but to right Downward and rightward is Right
Axis
See the RightMeet criterion
QRS in L1 and L3 meet Right Axis Deviation - RAD
- Catatan tegangan QRS positif dan tegak
dalam memimpin L2, L3
- Negatif di Lead 1
- L2, L3 mengatakan bahwa itu adalah ke
bawah
- L1 mengatakan bahwa tidak ke kiri tapi
ke kanan
- Downward dan kanan yang Tepat Axis
Lihat kriteria kanan Bertemu QRS di
L1 dan L3 bertemu
- Penyimpangan Axis Kanan - RAD
61
Wh t i th A i ?
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LEAD 1
LEAD 2
LEAD 3
aVR
aVL
aVF
What is the Axis ?
ECG With Left Axis Note the QRS voltages are
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Note the QRS voltages arepositive and upright in leadsL1and aVL
Negative in L2, L3 and aVF
L1, aVL tell that it is leftward
L2, L3, and aVF tell that it is notdown ward - instead it is
upward Upward and Leftward is Left
Axis
See the Left - Leave criterion
QRS in L1 and L3 leaveeach other
Left Axis Deviation - LAD
Catatan tegangan QRS positif
dan tegak di lead aVL L1and
Negatif di L2, L3 dan aVF L1, aVL mengatakan bahwa
itu adalah ke kiri
L2, L3, dan aVF mengatakan
bahwa itu tidak bangsal turun- tetapi itu adalah ke atas
Upward dan ke kiri adalah
Left Axis
Lihat Kiri - Tinggalkan kriteria
QRS di L1 dan L3
meninggalkan satu sama lain
Left Axis Deviation - LAD
Normal ECG
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Normal ECG
Normal ECG
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Normal ECG
Standardization10 mm (2 boxes) = 1 mV
Double and half standardization if required
Sinus RhythmEach P followed by QRS, R-R constant
P wavesalways examine for in L2, V1, L1
QRS positive in L1, L2, L3, aVF and aVL.Neg in aVR
QRS is < 0.08 narrow, Q in V5, V6 < 0.04, < 3 mm
R wave progression from V1 to V6, QT interval < 0.4
Axis normalL1, L3, and aVF all will be positive
ST Isoelectric, T waves , Normal T in aVR,V1, V2
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- Standardisasi - 10 mm (2 kotak) = 1 mV
- Double dan setengah standardisasi jika diperlukan
- Sinus Rhythm - Setiap P diikuti oleh QRS, RR konstan
- Gelombang P - selalu memeriksa untuk di L2, V1, L1
- QRS positif di L1, L2, L3, aVF dan aVL. - Neg di aVR
- QRS adalah
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Pediatric ECG
Pediatric ECG
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This is the ECG of a 6
year old child Heart rate is 100
Normal for the age
See V1 + V5 R >> 35
Not LVHNormal T in V1, V2, V3
Normal in child
Base line disturbances in
V5, V6 due tomovement by child
Ini adalah EKG seorang anak
berusia 6 tahun
Denyut jantung adalah 100 -
normal untuk usia
Lihat V1 + V5 R >> 35 - TidakLVH - normal
T di V1, V2, V3 - normal pada
anak
Gangguan garis dasar di V5, V6 -
karena gerakan oleh anak
Juvenile ECG
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Be aware of normal ECG Normal Resting ECG cannot
exclude disease
69
ECG Resting normal - tidak bisa
mengecualikan penyakit
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exclude disease
Ischemia may be covertsupply /demand equation
Changes of MI take some time todevelop in ECG
Mild Ventricular hypertrophy - notdetectable in ECG
Some of the ECG abnormalities are
non specific
Single ECG cannot give progress Need serial ECGs
ECG changes not always correlatewith Angio results
Paroxysmal events will be missedin single ECG
mengecualikan penyakit
Iskemia mungkin rahasia - supply
persamaan permintaan /
Perubahan MI mengambil beberapa
waktu untuk mengembangkan di
EKG
Mild ventrikel hipertrofi - tidak
terdeteksi di EKG Beberapa kelainan EKG yang non
spesifik
EKG tunggal tidak dapat memberikan
kemajuan - Butuh EKG seri
Perubahan EKG tidak selaluberkorelasi dengan hasil Angio
Peristiwa paroksismal akan tertinggal
dalam satu EKG
Normal Variations in ECG May have slight left axis due to
rotation of heartMungkin memiliki sumbu kiri sedikit
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rotation of heart
May have high voltage QRS simulating LVH
Mild slurring of QRS butduration < 0.09
J point depression, earlyrepolarization
T inversions in V2, V3 and V4 Juvenile T
Similarly in women also T
Low voltages in obese womenand men
Non cardiac causes of ECGchanges may occur
karena rotasi hati
Mungkin memiliki QRS tegangan tinggi -simulasi LVH
Slurring ringan QRS tapi durasi
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y p
This ECG has all normal features
The ST-T (J) Junction point is
elevated. T waves are tall, May be inverted in LIII, The ST
segment initial portion is concave. This does not signify Ischemia
Pseudo Normalization
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Pseudo Normalization
Before
Chest pain
DuringChest pain
Chest pain
Relieved
T
T
T
Atrial Waves
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Left Atrial
E l
74
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Enlargement
Left Atrial Enlargement
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g
P wave duration is 4 boxes-0.04 x 4 = 0.16
Always examine V 1 and Lead 1 for
Left Atrial Enlargement
Selalu memeriksa V 1 dan Lead 1 untuk
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LAE
Biphasic P Waves, Prolonged P
waves
P wave 0.16 sec, Downward
component
Systemic Hypertension, MS and or
MR
Aortic Stenosis and Regurgitation
Left ventricular hypertrophy with
dysfunction
Atrial Septal Defect with R to Lshunt
Selalu memeriksa V 1 dan Lead 1 untuk
LAE
Biphasic P Waves, gelombang P
berkepanjangan
P gelombang 0,16 detik, komponen
Downward Hipertensi sistemik, MS dan atau MR
Aortic Stenosis dan Regurgitasi
Hipertrofi ventrikel kiri dengan
disfungsi
Atrial Septal Defect dengan R ke L shun
Right Atrial Enlargement
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Right Atrial Enlargement
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P wave voltage is 4 boxes or 4 mm
Always examine Lead 2 for RAE
Right Atrial Enlargement
Selalu memeriksa Lead 2 untuk RAE
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Tall Peaked P Waves, Arrow
head P waves Amplitude is 4 mm ( 0.4 mV) -
abnormal
Pulmonary Hypertension,
Mitral Stenosis Tricuspid Stenosis,
Regurgitation
Pulmonary Valvular Stenosis
Pulmonary Embolism Atrial Septal Defect with L to R
shunt
Selalu memeriksa Lead 2 untuk RAE
Tinggi Gelombang P Peaked, kepala
panah gelombang P
Amplitudo 4 mm (0,4 mV) - normal
Hipertensi Paru, Mitral Stenosis
Stenosis trikuspid, RegurgitasiPulmonary Stenosis katup
Embolisme paru
Atrial Septal Defect dengan L untuk R
shunt
Ventricular Hypertrophy
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Ventricular Muscle Hypertrophy
QRS voltages in V1 and V6, L 1
and aVL
We may have to record to
standardization
T wave changes opposite to QRSdirection
Associated Axis shifts
Associated Atrial hypertrophy
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Ventricular Hypertrophy Otot
Tegangan QRS di V1 dan V6, L 1 dan aVL
Kita mungkin harus merekam standardisasi
Perubahan gelombang T berlawanan dengan arah QRS
Pergeseran Associated Axis
Associated Atrial hipertrofi
Right Ventricular Hypertrophy
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Tall R in V1 with R >> S, or
Right Ventricular Hypertrophy
-Tinggi R di V1 dengan R >> S
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R/S ratio > 1
Deep S waves in V4, V5 andV6
The DD is RVH, Posterior MI,
Anti-clock wise rotation of
Heart
Associated Right Axis
Deviation, RAE
Deep T inversions in V1, V2
and V3
Absence of Inferior MI
Tinggi R di V1 dengan R >> S,
atau rasio R / S> 1
-Jauh S gelombang di V4, V5 dan
V6
-DD adalah RVH, Posterior MI,
Anti-jam rotasi bijaksana Hati
-Associated Kanan Axis Deviation,
RAE
-Inversi T Jauh di V1, V2 dan V3
-Tidak adanya Inferior MI
84
Is there any hypertrophy ?
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Criteria of RVH
Criteria and Causes of RVH
Kriteria RVH
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Tall R in V1 with R >> S, or R/S ratio > 1
Deep S waves in V4, V5 and V6 The DD is RVH, Posterior MI, Rotation
Associated Right Axis Deviation, RAE
Deep T inversion in V1, V2 and V3
Cause of RVH
Long standing Mitral Stenosis Pulmonary Hypertension of any cause
VSD or ASD with initial L to R shunt
Congenital heart with RV over load
Tricuspid regurgitation, Pulmonary
stenosis
Tinggi R di V1 dengan R >> S, atau rasio R / S> 1
Jauh S gelombang di V4, V5 dan V6
DD adalah RVH, Posterior MI, Rotasi
Associated Kanan Axis Deviation, RAE
Jauh T inversi di V1, V2 dan V3
Penyebab RVH
Mitral Stenosis lama berdiri
Hipertensi paru sebab apapun
VSD atau ASD dengan L awal untuk R shunt
Jantung bawaan dengan RV atas beban
Regurgitasi trikuspid, stenosis pulmonal
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What is in this ECG ?
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ECG OF MS with RVH, RAE Classical changes seen are
Right ventricular hypertrophyPerubahan Klasik lihat adalah
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g yp p y
Right axis deviation
Right Bundle Branch Block
PPulmonale - Right Atrial
enlargement
PMitraleLeft Atrial
enlargement If Atrial Fibrillation developsP
disappears
Hipertrofi ventrikel kanan
Deviasi aksis ke kanan
Bundle Branch Block Kanan
P - pulmonal - Kanan Atrial
pembesaran
P - Mitrale - Left Atrial pembesaran
Jika Atrial Fibrillation berkembang -
menghilang 'P'
Left Ventricular Hypertrophy
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Left Ventricular Hypertrophy
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High QRS voltages in limb leads
R in Lead I + S in Lead III > 25 mm
S in V1 + R in V5 > 35 mm
R in aVL > 11 mm or S V3 + R aVL > 24, > 20
Deep symmetric T inversion in V4, V5 & V6
QRS duration > 0.09 sec
Associated Left Axis Deviation, LAE
Cornell Voltage criteria, Estes point scoring
90
What is in this ECG ?
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Causes of LVH
Pressure overload - SystemicHypertension, Aortic Stenosis
Causes and Criteria of LVH
Penyebab LVH
Tekanan yang berlebihan - Hipertensi sistemik
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yp ,
Volume overload - AR or MR -
dilated cardiomyopathy VSD - cause both right & left
ventricular volume overload
Hypertrophic cardiomyopathy No pressure or volume overload
Criteria of LVH
High QRS voltages in limb leads R in Lead I + S in Lead III > 25 mm
or S in V1 + R in V5 > 35 mm
R in aVL > 11 mm or S V3 + R aVL >24 , > 20
Deep symmetric T inversion in V4,V5 & V6
QRS duration > 0.09 sec,Associated Left Axis Deviation, LAE
aorta Stenosis
Volume yang berlebihan - AR atau MR kardiomiopati dilatasi
VSD - menyebabkan volume ventrikel baik
kanan & kiri yang berlebihan
Kardiomiopati hipertrofik - Tidak ada tekanan
atau volume yang berlebihan
Kriteria LVHTegangan QRS tinggi di ekstremitas lead
R di Lead I + S di Lead III> 25 mm atau S d
V1 + R di V5> 35 mm
R di aVL> 11 mm atau S V3 + R aVL> 24 ,>
20 Mendalam simetris T inversi di V4, V5 & V6Durasi QRS> 0,09 detik, Associated Left Axi
Deviation, LAE
Atrial Ectopics
92
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APC
APCAPC
APC
Note the premature
(ectopic) beats marked as
Atrial Ectopics
Perhatikan dini (ektopik) ketukan
di d i b i
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( p )
APC (Atrial PrematureContractions)
These occurred before the
next expected QRS complex
(premature) Each APC has a P wave
preceding the QRS of that
beatSo impulse has
originated in the atria The QRS duration is normal
< 0.08, not wide
ditandai sebagai
APC (Atrial Prematur Kontraksi)
Ini terjadi sebelum kompleks QRS
yang diharapkan berikutnya
(prematur)
Setiap APC memiliki gelombang P
sebelum QRS dari beat itu - Jadi
impuls telah berasal dari atrium Durasi QRS normal
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Complete RBBB Complete RBBB has a QRS duration
> 0.12 sec
R' wave in lead V1 (usually see rSR'
Lengkap RBBB memiliki durasi QRS> 0,12 sec
R 'gelombang dalam memimpin V1 (biasanya
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R' wave in lead V1 (usually see rSR'
complex) S waves in leads I, aVL, V6, R wave
in lead aVR
QRS axis in RBBB is -30 to +90
(Normal)
Incomplete RBBB has a QRS
duration of 0.10 to 0.12 sec with the
same QRS features as above
The "normal" ST-T waves in RBBB
should be oriented opposite to thedirection of the QRS
melihat RSR' kompleks)
Gelombang S di lead I, aVL, V6, R gelombang
dalam memimpin aVR
QRS axis di RBBB adalah -30 sampai +90
(Normal)
Incomplete RBBB memiliki durasi QRS dari
0,10-0,12 detik dengan fitur QRS yang sama
seperti di atas
The "normal" gelombang ST-T di RBBB harus
berorientasi berlawanan dengan arah QRS
Complete LBBB
98
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Complete LBBB Complete LBBB has a QRS duration
> 0.12 sec
Prominent S waves in lead V1, R in L
Lengkap LBBB memiliki durasi QRS> 0,12sec
Tokoh gelombang S dalam memimpin V1, RL I VL V6
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I, aVL, V6
Usually broad, Bizarre R waves are
seen, M pattern Poor R progression from V1 to V3 is
common.
The "normal" ST-T waves in LBBBshould be oriented opposite to thedirection of the QRS
Incomplete LBBB looks like LBBB
but QRS duration is 0.10 to 0.12sec, with less ST-T change.
This is often a progression of LVHchanges.
L I, aVL, V6
Biasanya luas, Bizarre gelombang R terlihat,pola M Perkembangan R miskin dari V1 ke V3
adalah umum.
The "normal" gelombang ST-T di LBBBharus berorientasi berlawanan dengan arahQRS
Lengkap LBBB terlihat seperti LBBB tapidurasi QRS adalah 0,10-0,12 detik, dengan
kurang ST-T perubahan. Ini sering merupakan perkembanganperubahan LVH.
Blood Supply of Heart
100
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LCA
RCA
LAD
LCX
RCA
Blood Supply of Heart
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Heart has four surfaces
Anterior surfaceLAD, Left Circumflex (LCx)
Left lateral surfaceLCx, partly LAD
Inferior surfaceRCA, LAD terminal portion
Posterior surfaceRCA, LCx branches
Rt. and Lt. coronary arteries arise from aorta
They are 2.5 mm at origin, 0.5 mm at the end
Coronary arteries fill during diastole
Flow - epicardium to endocardiumpoverty/plenty
Ischemia, Injury & Infarction
102
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1. Ischemia produces ST segment
depression with or without T
inversion
2. Injury causes ST segment elevation
with or without loss of R wave
voltage
3. Infarction causes deep Q waves withloss of R wave voltage.
MyocardialIschemia
Myocardial Injury
Myocardial
Infarction
Ischemia and Infarction
103
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TRANSMURAL Injury ST
Elevation
Ischemic Heart Disease (IHD)
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Blood supply Sub-endocardial Transmural
Ischemia
Transient loss
Stable
Angina
Variant
Angina
Infarction
Persistent loss
NSTEMI
ACS
STEMI
ACS
ST Segment Depressed Elevated
105
Interpret this ECG
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NSTEM
N ST MI NSTEMI N Q MI
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Non ST MI or NSTEMI, Non Q MI
Or also called sub-endocardial Infarction
Non transmural, restricted to the sub-endocardial
region - there will be no ST or Q waves
ST depressions in anterio-lateral & inferior leads
Prolonged chest pain, autonomic symptoms like
nausea, vomiting, diaphoresis
Persistent ST-segment even after resolution of
pain
107
What are these ECGs
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STEMI and QWMI
STEMI d QWMI
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STEMI and QWMI
ST signifies severe transmural myocardial injury
This is early stage before death of the muscle tissue
the infarction
Q waves signify muscle deathThey appear late in thesequence of MI and remain for a long time
Presence of either is an indication for thrombolysis
Evolution of Acute MI
109
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ANormal ST segment and T waves
BST mild and prominent T waves
CMarked ST + merging upright T
DST elevation reduced, T,Q starts
EDeep Q waves, ST segment returning to
baseline, T wave is inverted
FST became normal, T Upright, Only Q+
Critical Narrowing of LAD
110
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Normal Q waves
111
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Notice the smallNormal Q in Lead I
Pathological Q wave
112
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Notice the deep & wide
Infarction Q in Lead I
113
Very Striking
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Hyper Acute MI
Note the hyper acute elevation of ST
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Note the hyper acute elevation of ST
The R wave is continuing with ST andthe complexes are looking rectangular
Some times tall and peaked T waves in
the precardial leads may be the only
evidence of impending infarct
Sudden appearance LBBB indicates MI
MI in Dextro-cardiaright sided leads
are to be recorded
115
Severe Chest Pain Why ?
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Acute Anterio-lateral MI
Note the marked ST elevations in chest leads
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Note the marked ST elevations in chest leads
V2 to V5 and also ST in L1 & aVL
T inversions have not appeared as yet
R wave voltages have dropped markedly in V3,
V4, V5 and V6
Small R in L1 and aVL.
117
Which wall MI ?
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Note the ST elevations in Inferior
Acute Inferior wall MI
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Note the ST elevations in Inferior
leads- namely L2, L3 and aVF
T inversions yet to appear
aVL lead shows complimentary
STand T inversion
Acute True Posterior MI
119
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Due to occlusion of the distal Left circumflex
Acute True Posterior MI
5/28/2018 Ekg Basic Ttm 2013
118/118
120
artery or posterior descending or distal rightcoronary artery
Mirror image changes or reciprocal changes in
the anterior precardial leads
Lead V1 shows unusually tall R wave (it is the
mirror image of deep Q)
V1 R/S > 1, Differential Diagnosis - RVH