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7/25/2019 EKG Abdurap

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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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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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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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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
http://ecg/15/15x/1504x.htm


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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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'; ' t $l ti


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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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$9 bnormal


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$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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.%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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?"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



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?"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



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?"tion 2 (cont) Memori+e t%e se6uence:

A!! - 3! - 3!! - 0 - B! - !

Inter"retationF

8

1

1

3

1

3

1

1

;

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