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Elektrokardiofisiologi
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Cardiac Muscle Contraction
Heart muscle:
Is stimulated by nerves and is self-excitable
(automaticity)
Contracts as a unit
Has a long (2! ms) absolute refractory
"eriod
Cardiac muscle contraction is similar tos#eletal muscle contraction
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$xtrinsic Innervation of t%e Heart
Heart is stimulated
by t%e sym"at%etic
cardioacceleratory
center
Heart is in%ibitedby t%e
"arasym"at%etic
cardioin%ibitory
center
Figure 18.15
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Heart &%ysiology: Intrinsic
Conduction 'ystem utor%yt%mic cells:
Initiate action "otentials
Have unstable resting "otentials called
"acema#er "otentials
se calcium influx (rat%er t%an sodium) for
rising "%ase of t%e action "otential
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Cell *e"olari+ation
,lo of sodium ions into cell during activation
*e"ol .e"ol/ .estoration of
ionic balance
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&acema#er and ction
&otentials of t%e Heart
Figure 18.13
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Heart Physiology: Sequence of
Excitation
'inoatrial (') node generates im"ulses
about 0 times1minute
trioventricular () node delays t%e
im"ulse a""roximately !/3 second
Im"ulse "asses from atria to ventricles via
t%e atrioventricular bundle (bundle of His)
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Heart Physiology: Sequence
of Excitation
bundle s"lits into to "at%ays in t%e
interventricular se"tum (bundle branc%es)
4undle branc%es carry t%e im"ulse toard t%ea"ex of t%e %eart
&ur#in5e fibers carry t%e im"ulse to t%e %eart
a"ex and ventricular alls
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Heart &%ysiology: 'e6uence of
$xcitation
Figure 18.14a
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7ormal Im"ulse Conduction
'inoatrial node
node
4undle of His
4undle 4ranc%es
&ur#in5e fibers
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Im"ulse Conduction 8 t%e $C9
'inoatrial node
node
4undle of His
4undle 4ranc%es
&ur#in5e fibers
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Cardiac Cycle
Cardiac cycle refers to all events
associated it% blood flo t%roug% t%e
%eart
'ystole contraction of %eart muscle
*iastole relaxation of %eart muscle
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&%ases of t%e Cardiac Cycle
entricular filling mid-to-late diastole
Heart blood "ressure is lo as blood enters atria
and flos into ventricles valves are o"en t%en atrial systole occurs
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&%ases of t%e Cardiac Cycle
entricular systoletria relax
.ising ventricular "ressure results in closing of
valves Isovolumetric contraction "%ase
entricular e5ection "%ase o"ens semilunar
valves
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&%ases of t%e Cardiac Cycle
Isovolumetric relaxation early diastole
entricles relax
4ac#flo of blood in aorta and "ulmonary trun#
closes semilunar valves
*icrotic notc% brief rise in aortic "ressure
caused by bac#flo of blood rebounding off
semilunar valves
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&%ases of t%e Cardiac Cycle
Figure 18.20
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What is an ECG?
;%e electrocardiogram ($C9) is a
re"resentation of t%e electrical events of t%e
cardiac cycle/
$ac% event %as a distinctive aveform t%e
study of %ic% can lead to greater insig%t
into a "atient
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BASC !E"#$%&%G'
rr%yt%mia: bnormal r%yt%m
4aseline:,lat straig%t isoelectric line
=aveform: Movement aay from t%e baseline
u" or don
'egment: line beteen aveforms
Interval: aveform "lus a segment
Com"lex: Combination of several
aveforms
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32 $C9 >$*'
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$C9 >imb >eads
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$C9 ugmented >imb >eads
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$C9 &recordial >eads
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;%e $C9 &a"er
Hori+ontally
?ne small box - !/!@ s
?ne large box - !/2! s
ertically
?ne large box - !/ m
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;%e $C9 &a"er (cont)
$very A seconds (3 large boxes) is
mar#ed by a vertical line/ ;%is %el"s %en calculating t%e %eart rate/
7?;$:t%e folloing stri"s are not mar#ed
but all are B seconds long/
3 sec 3 sec
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Electrocardiogra(hy
$lectrical activity is recorded byelectrocardiogram ($C9)
& ave corres"onds to de"olari+ation of ' node
.' com"lex corres"onds to ventricularde"olari+ation
; ave corres"onds to ventricular re"olari+ation
trial re"olari+ation record is mas#ed by t%e
larger .' com"lex
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$lectro"%ysiology
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Cardiac Current ,lo
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Cardiac Current ,lo
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$C9 'ignal Heart be%aves as a syncytium:
a "ro"agating ave t%at onceinitiated continues to "ro"agateuniformly into t%e region t%at isstill at rest/
;%e de"olari+ation avefrontdefines a dividing line beteenactivated and resting cells/
$lse%ere t%e signal is +ero
=ill "ro"agate along conduction"at%s sinus node node bundle branc%es &ur#in5ie
fibers
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7ormal $C9 'ignal
& atrial
de"olari+ation
.' com"lex
ventricularde"olari+ation
; ventricular
re"olari+ation
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$lectrocardiogra"%y
Figure 18.16
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$lectrocardiogram
7ormal & ave %asam"litude of D !/2 m
ave is firstdonard deflection
after & aveE signalsstart of ventricularde"olari+ation
. ave is "ositive
deflection after ave ' ave is negative
deflection "receded by or . aves
; ave follos .'
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$C9 'ignal ;%e excitation begins at t%e
sinus (') node and s"readsalong t%e atrial alls
;%e resultant electric vector
is s%on in yello Cannot "ro"agate across t%e
boundary beteen atria and
ventricle
;%e "ro5ections on >eads I II
and III are all "ositive
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$C9 'ignal
trioventricular () node
located on atria1ventricle
boundary and "rovides
conducting "at% &at%ay "rovides a delay to
allo ventricles to fill
$xcitation begins it% t%ese"tum
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$C9 'ignal
*e"olari+ation continues to"ro"agate toard t%e a"ex of
t%e %eart as t%e signal moves
don t%e bundle branc%es
?verall electric vector "oints
toard a"ex as bot% left and
rig%t ventricles de"olari+e
and begin to contract
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$C9 'ignal *e"olari+ation of t%e rig%t
ventricle reac%es t%ee"icardial surface
>eft ventricle all is t%ic#er
and continues to de"olari+e s t%ere is no com"ensating
electric forces on t%e rig%t
t%e electric vector reac%es
maximum si+e and "oints left 7ote t%e atria %ave
re"olari+ed but signal is not
seen
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$C9 'ignal
*e"olari+ation front
continues to "ro"agate to t%e
bac# of t%e left ventricular
all $lectric vector decreases in
si+e as t%ere is less tissue
de"olari+ing
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$C9 'ignal
*e"olari+ation of t%e
ventricles is com"lete and
t%e electric vector %asreturned to +ero
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$C9 'ignal entricular re"olari+ation
begins from t%e outer side oft%e ventricles it% t%e left
being slig%tly dominant
7ote t%at t%is "roduces an
electric vector t%at is in t%esame direction as t%e
de"olari+ation traveling in t%e
o""osite direction
.e"olari+ation is diffuse and
generates a smaller and longer
signal t%an de"olari+ation
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$C9 'ignal
"on com"lete
re"olari+ation t%e %eart is
ready to go again and e
%ave recorded an $C9 trace
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Heart Excitation "elated to ECG
Figure 18.17
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$lectro"%ysiology
=%en myocardial muscle is com"letely
"olari+ed or de"olari+ed t%e $C9 ill not
record any electrical "otential but rat%er a
flat line isoelectric line/
fter de"olari+ation myocardial cells
undergo re"olari+ation to return to
electrical state at rest/
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$lectro"%ysiology
& ave re"resents de"olari+ation of atria %ic%causes atrial contraction
.e"olari+ation of atria not normally detectable on
an $C9
$xcitation of bundle of His and bundle branc%es
occur in middle of &. interval
.' com"lex reflects de"olari+ation of ventricles
; ave reflects re"olari+ation of muscle fibers inventricles
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$C9 ;ime 8 oltage
$C9 mac%ines can run at ! or 2 mm1sec/ Ma5or grid lines are mm a"art at standard
2 mm1s mm corres"onds to !/2!
seconds/ Minor lines are 3 mm a"art at standard 2
mm1s 3 mm corres"onds to !/!@ seconds/
oltage is measured on vertical axis/ 'tandard calibration is !/3 m "er mm of
deflection/
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# i .'
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#sis .'
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A "e)ie* %f !he Wa)es+ nter)als %f !he E,G
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;%e & =ave
;%e & =ave Is ;%e 'ignal ;%at $lectrical&otential Has >eft ;%e ' 7ode 'e"t
cross ;%e tria 8 Has Initiated trial
Contraction/
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=%at Is 7ormal & =ave F
*uration : ;%e 7ormal *uration ?f &
=ave is 2/! - 2/ mm (/!@ - /3 sec)
If It Is 9reater ;%an 2/0 mm (/33 sec) ItIs Considered ;o 4e n bnormal &
=ave/
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m"litude
7ormal m"litude ,or
& =ave Is 2-A mm/
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;%e & =ave '%ould lays 4e 9ently
.ounded - 7ever &ointed ?r &ea#ed/ bnormal m"litude ?f ;%e & =ave Is
?ften 'een In Cor &ulmonale - alve*isease Hy"ertension 8 In &atients =it%Congenital Heart *isease
& =aves =it%in ;%e 'ame >ead ;%at reMultiformic Indicate ;%e &resence ?f
More ;%an ?ne &acema#er In ;%e .ig%ttrium/
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In ;%e 'ix >imb >eads Generally& =aves
in t%e u"rig%t "osition exce"t In a. 8 3
;%ey are negatively deflected/
4i"%asic & =aves fre6uently seen in
lead III lead 2 8 occasionally in leada>/
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4i&%asic & =ave In 3
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!he P" nter)al
fter ;%e & =ave ;%ere Is G'ilent
&eriod =%ere 7ot%ing Is Ha""ening In
;%e $9 ;racing/ ;%is uiescent &eriod
Is Called ;%e &. Interval/
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;%e &. Interval Is ;ime >ag nd
.e"resents ;%e &eriod *uring =%ic%;%ere Is 7odal Ca"ture ?f ;%e '
7ode 'ignal/
;%e &. Interval llos ;%e tria ;oContract (atrial systole) =%ic% G;o"s ?ff
;%e entricles =it% 4lood - n $vent
CalledAtrial Kick/
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;%e &. interval is measured from t%e
beginning of t%e & ave to t%e
beginning of t%e ave ort%e
beginning of t%e . ave if t%e ave
is absent/
;%e &. interval re"resents t%e time"eriod encom"assing atrial
de"olari+ation u" to but not including
t%e start of ventricular de"olari+ation/
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*uration : ;%e adult &. interval is
normally beteen A- mm or !/32 -!/2!
seconds in duration/ some cardiologists
ill say it is normal out to !/22 seconds (
312 mm)
If t%e &. interval is longer t%an mm it is
called a "rolonged &. interval 8 may
indicate t%e "resence of an 4loc#/
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;%e &. interval s%ortens during exercise
because of t%e sym"at%etic tone t%at
"redominates over t%e %eart/
If t%e &. Interval could not s%orten
along it% ot%er segments in t%e $C9
t%en acceleration of %eart rate duringexercise ould be difficult if not
im"ossible/
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In young c%ildren ;%e &. Interval is s%orter
t%an in adults/ t%e c%ild
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in c%ildren 32 years of age t%e &.
interval at rest ill be !/3@ seconds or
about A/ mm/
In dults 3J Kears ?f ge nd ?lder ;%e
&-. Interval t .est =ill 4e A- mm In
>engt%/ &rolonged &-. Intervals re 'ym"tomatic
?f : 4loc#s *ue ;o Coronary *isease
8 .%eumatic ,ever/
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;%e =ave
*efinition : ;%e ave is t%e first donard
deflection after t%e & ave 8 before t%e .
ave/
'ometimes aves are "resent 8sometimes t%ey are absent de"ending on
t%e lead/
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It is common to normally see aves in
leads I II a> and in @-B/ normal ave is not ider in duration
t%an !/ mm or about !/!2 seconds/ its
normal am"litude is L 3 mm/ aves are an indication of ventricular
se"tal all de"olari+ation/
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;%ey a""ear before t%e .' com"lex
because t%e fascicle t%at conducts t%esignal is %ig%er t%an t%e rig%t and left
bundle branc% t%at give you t%e .'
com"lex/
aves of normal si+e %ave no
diagnostic meaning in normal %earts
exce"t t%at t%e se"tum %as de"olari+ed/
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;%e . =ave
*efinition : ;%e . ave is t%e first u"ard
deflection after t%e & ave/
In t%e "recordial c%est leads t%ere s%ouldbe an . ave "rogression - i/e/ - an ever
increasing am"litude of t%e . ave from
3 t%roug% B
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. ave "rogression occurs because t%e
"recordial c%est leads see" across t%e
t%oracic cage loo#ing from t%e t%inner
rig%t ventricle across to t%e t%ic#er left
ventricle/
>oss of t%e . ave "rogression is
abnormal and signals t%e "ossible
"resence of bundle branc% bloc#s or t%e
occurrence of a myocardial infarction/
'
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;%e ' =ave
*efinition : ;%e s ave is defined as t%efirst donard deflection after t%e . ave/
;%ere is a normal "rogressive decrease in
t%e si+e of t%e ' ave in t%e "recordialleads
3 t%roug% 2 s%ould %ave large ' avesit% a decreasing a""earance of ' t%roug%
and B/
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-"S Co.(lex Generalities
Mostly "ard *eflected .' Com"lexesre ,ound In >eads I II III a, a> @ and B/
Mostly *onard *eflected .'Com"lexes =ill 4e 'een In >eads a.
nd 32 nd 'ometimes A/
;%e .' Com"lex 'ignals ;%e
*e"olari+ation ?f ;%e entricles/
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normal .' com"lex %as a duration of
!/!B - !/32 'ec/ or about 3/ - A/! mm/
If t%e .' Is NAmm t%ere is an abnormal
intraventricular conduction "at%ay/
;% '; ' t
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;%e '; 'egment
;%e '; segment is t%e "ause after t%e.' Com"lex - t%e interval beteen t%e
end of t%e .' com"lex 8 t%e beginning
of t%e ; ave/ it symboli+es t%e end of ventricular
de"olari+ation to t%e start of
ventricular re"olari+ation/
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It is during t%is "%ase of t%e $C9 %en
t%e %eart is being "assively "erfused
;%e '; segment slo"es gently u" toard
t%e isoelectric line from t%e O "oint andends at t%e beginning of t%e ; ave/
;%e '; 'egment
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;%e '; 'egment
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7ormal $9 1 O &oint In a>
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7ormal u" slo"ing of t%e '; segment may
be 3-2 mm in sian-$uro"eans and as muc%as @ mm in frican-mericans
;%e normal duration of t%e '; segment is
about 2-A mm/
'; ' t $l ti
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'; 'egment $levation
=%en t%e '; segment is elevated in
"atient it% #non disease it is usually
sign of an evolving transmural
infarction - an MI in "rogress/
'; segment elevations ill be seen in
t%e lateral c%est leads - >eads I a>
and and B/
'; ' t $l ti
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'; 'egment $levation
'; ' t $l ti
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'; 'egment $levation
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;%e Classic 'igns ?f n cute MI In
&rogress re :
$levated '; 'egment
Inverted ; =ave
&resence ?f =ave
'; ' t * i
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'; 'egment *e"ression
=%en ;%e '; 'egment Is *e"ressed
;%en It Is sually 'ign ?f Cardiac
Isc%emia/
;y"es ?f
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y
'; 'egment *e"ression
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'; 'egment *e"ression May 4e
&ermanent &art ?f ;%e $9 ;racing/ t .est ;%e &atient May Have 7ormal
'; 'egment/ Hoever It May 4ecome
*e"ressed s ;%e &ersonevel Is Increased bove ;%e Heart
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;%e '; segment de"ression ill begin
to a""ear as t%e %eart becomesisc%emic
It ill continue to be more de"ressed
t%e more isc%emic t%e %eart becomes/
;% '; t ill li t%
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;%e '; segment ill normali+e once t%e
exercise intensity is reduced to a level in
%ic% t%e %eart receives enoug% "erfusionto su""ort t%e or# t%at is being
demanded/
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;%e ; =ave
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;%e ; =ave
;%e ; =ave .e"resents .e"olari+ation?f ;%e entricles/
.e"olari+ation &roceeds ,rom ;%e "ex
?f ;%e Heart ;o ;%e 4ase ?f ;%e Heart/ In 7ormal Hearts ;%e ; =ave Is sually
"rig%t In >eads I II III a, a> 8 2-
B/
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In normal %earts t%e ; ave ill usually
be u"side don in a. and 3/
;%e normal duration of t%e ; ave is
about 3-2 mm/
7ormal am"litude for t%e ; ave is %ig%ly
variable/
; aves get taller during exercise/
; =aves *uring Infarction
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; =aves *uring Infarction
=it% infarction t%e ; ave usuallybecomes tall and narro - referred to
as G"ea#ing/
=it% time and t%e onset of isc%emia
t%e ; ave ill invert/
;%e ; Interval
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;%e ; Interval
;%e ; Interval $ncom"asses ;%e ;ime,rom ;%e 4eginning ?f ;%e ?r . =ave;%roug% ;%e $nd ?f ;%e ; =ave/
;%e ; Interval .e"resents @!P ?f ;%e7ormal Cardiac Cycle =%et%er t .est ?r*uring $xercise/
;%e ; Interval 4ecomes '%orter s ;%e
Heart .ate Increases/
Su..ary %f /urations +
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y
A.(litudes %f !he P0-"S0!
& =aves
7ormal *uration : 2/ mm
7ormal m"litude : 2-A mm
&. Intervals
7ormal *uration : A- mm
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=aves
7ormal *uration : L / mm
7ormal m"litude : L2P of .am"litude or 3/! mm
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.' Com"lex7ormal *uration : L A/! mm
7ormal m"litude : ariable
'; 'egment
7ormal m"litude : 3-2 mm7ormal *uration : 2-A mm
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; =ave
7ormal *uration : 2 mm
7ormal m"litude : L mm in >imb
>eads 8 L 3! mm in &recordial
>eads
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&ola Membaca $9
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&ola Membaca $9
Irama .ate .'
#sis .'
Morfologi 9elombang &
Interval &.
*urasi .' Morfologi .'
*eviasi 'egmen ';
Morfologi 9elombang ;
Morfologi 9elombang
>ain-lain (>H> 'train444; interval)
esim"ulan $9
$ilai $or.al :
nter)al P" 123455 s6d 124155
/urasi -"S 121755 s6d 123455
Aksis $or.al 0 811 s6d 9 3311
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7/25/2019 EKG Abdurap
106/119
$9 bnormal
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7/25/2019 EKG Abdurap
107/119
$9 bnormal
&enya#it Oantung oroner
'indroma oroner #ut
;a#iaritmia
4radiaritmia 9angguan $le#trolit
elainan 'tru#tur Oantung : elainan atu"
&embesaran .uang Oantung $fusi &eri#ard"enya#it 5antung baaan/
.%yt%m nalysis
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7/25/2019 EKG Abdurap
108/119
.%yt%m nalysis
'te" 3: Calculate rate/
'te" 2: *etermine regularity/
'te" A: ssess t%e & aves/
'te" @: *etermine &. interval/ 'te" : *etermine .' duration/
'te" 3: Calculate .ate
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7/25/2019 EKG Abdurap
109/119
'te" 3: Calculate .ate
?"tion 3
Count t%e Q of . aves in a B second r%yt%m
stri" t%en multi"ly by 3!/
.eminder: all r%yt%m stri"s in t%e Modules are
B seconds in lengt%/
Inter"retationF9 x 10 = 90 bpm
3 sec 3 sec
'te" 3: Calculate .ate
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7/25/2019 EKG Abdurap
110/119
'te" 3: Calculate .ate
?"tion 2 ,ind a . ave t%at lands on a bold line/
Count t%e Q of large boxes to t%e next .
ave/ If t%e second . ave is 3 large box
aay t%e rate is A!! 2 boxes - 3! A boxes -
3!! @ boxes - 0 etc/ (cont)
R wave
'te" 3: Calculate .ate
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7/25/2019 EKG Abdurap
111/119
'te" 3: Calculate .ate
?"tion 2 (cont) Memori+e t%e se6uence:
A!! - 3! - 3!! - 0 - B! - !
Inter"retationF
8
1
1
3
1
3
1
1
;