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Efectele ischemiei
PA ischemic
Depolarizare redusa
Repolarizare redusa
Durata si amplitudine redusa
PA ischemic
PA normal
Sistola = ST
Diastola
Diastola= TP
Unda T= Faza 3
Interval TQ = Faza 4
Ischemia miocardica
Ischemia
Curentul de leziune
Diferenta de potential intre zonele normale si cele
ischemice: mic curent= curent de leziune
Flux de ioni de K dinspre zona + spre In sistola (ST) regiunea ischemica este mai negativacurent de la normal la ischemic
Curentul de leziune
ST- curent de la regiunea normala spre cea ischemica
TP curent de la regiunea ischemica spre cea normala
ST
TP
Curent de leziune
Leziune subendocardica
Leziune transmurala
Supra/sub denivelare ST
Supradenivelarea de segment ST
ST
P
Apare precoce
ST elevation
ST segment elevation usually occurs in the early stages of infarction, and may exhibit
quite a dramatic change.
ST elevation is often upward and concave, although it can appear convex or horizontal.
These changes occur in leads facing the infarction.
ST elevation is not unique to MIs and therefore is not confirming evidence. Basic
requirements of ST changes for diagnosis are: elevation of at least 1 mm in two or more
adjoining leads for inferior infarctions (II, III, and aVF), and at least 2 mm in two or more
precordial leads for anterior infarction. You should be aware that ST elevation can be
seen in leads V1 and V2 normally. However, if there is also elevation in V3 the cause is
unlikely to be physiological
Unda Q patologica
ST
P
T
Q
Deep Q wave
The only diagnostic changes of acute
myocardial infarction are changes in the QRS
complexes and the development of abnormal Q
waves. However, this may be a late change and
so is not useful for the diagnosis of AMI in the
pre-hospital situation.
Remember that Q waves of more than 0.04
seconds , or 1 little square, are not generally
seen in leads I, II or the precordial leads.
R
ST
T
Q
T wave inversion
The T wave is the most unstable feature of the ECG
tracing and changes occur very frequently under normal
circumstances, limiting their diagnostic value.
Subtle changes in T waves are often the earliest signs of
myocardial infarction. However, their value is limited for
the reason above, but for approximately 20 to 30% of
patients presenting with MI, a T wave abnormality is the
only ECG sign.
The T wave can be lengthened or heightened by coronary
insufficiency.
T wave inversion is a late change in the ECG and tends to
appear as the ST elevation is returning to normal. As the
ST segment returns towards the isoelectric line, the T wave
also decreases in amplitude and eventually inverts.
ST
ST
P
Q S
P
T
1 ora de la debut
R
ST
ST
P
T
La o zi de la debut
P
T
Modificari tardive
ARTERELE CORONARE
ARTERELE CORONARE
LOCALIZAREA OCLUZIEI
ECG LA PREZENTARE
1. ADA proximal
2. ADA mediu
ST in V1-V4 sau ST in
V5-V6, DI, aVL
4. IMA inferior
moderat intins
(posterior, lateral, de
ventricul drept)
V1 V2 V3
V4 V5 V6
Infarct inferior
I II III
V1 V2 V3
V4 V5 V6
Infarct inferior si de VD
I II III
V1 V2 V3
V4 V5 V6
V1 V2 V3
V4 V5 V6
Infarct lateral
I II III
V1 V2 V3
V4 V5 V6
Localizarea infarctului
I
aVR
aVL
V2
V3
III
INFERIOR
V4
SEPTAL
LATERAL
II
V1
ANT
SEPTAL
V5
V6
ANT
LAT
aVF
Localizarea infarctului?
IM inferior
Localizarea infarctului?
IM anterior
IM anterolateral
Vectorul ST
Poate indica localizarea
ocluziei arterei coronare
Unda Osborne
Supradenivelarea inghetata anevrism
Normal
Sdr. Brugada
Asocierea IM cu BRS
Anterior wall MI
I II III
V4 V5 V6
I II III
V1 V2 V3
V4 V5 V6
Asocierea IM cu BRS
Criteriile Sgarbossa (pt IMA cu BRS)
ST > 1mm in derivatii cu QRS pozitiv -5 puncte
ST > 1 mm in V1-V3 -3 puncte
ST > 5 mm in derivatii cu QRS negativ 2 puncte
La un scor cumulativ de 3 puncte specificitate
de peste 90% de a detecta infarctul miocardic acut in
prezenta blocului de ramura stang sau a unui ritm de pacemaker.
Supradenivelare ST
Subdenivelare reciproca
de ST
Anterior
Lateral
V1-V3
Inferior
Posterior
V1-V3
SUPRAINCARCAREA ATRIALA
HIPERTROFIILE
VENTRICULARE
Valvulopatii
Stenoza tricuspidiana
Regurgitare tricuspidiana
Hipertensiune pulmonara
BPOC
Embolii pulmonare
Apnee in somn
Boli congenitale
Stenoza pulmonara
Tetralogia Fallot
Tranzitor
Trombembolism pulmonar
Status astmaticus
Titulatura: p mitral
Derivatii preferentiale: DI, aVL, V5, V6
Stenoza mitrala
Regurgitare mitrala
Complianta scazuta a VS
Hipertensiune arteriala
Cardiomiopatie obstructiva
Stenoza aortica
Regurgitare aortica
Boli infiltrative - amiloidoza
Dilatare biatriala
Criterii pentru ambele tipuri de dilatari
V1: unda larga bifazica
componenta pozitiva > 1,5 mm
componenta negativa >1 mm, >0.04s
DII:
Unda > 2.5 mm
Unda > 0,12 sec
CMH
Suprasolicitarea VS efect:
Suprasarcina de volum dilatare cavitati
Suprasarcina de presiune hipertrofie, ingrosare pereti
HVS
HVD
HVD
3 patternuri
1. fara tulburari de conducere intraventriculare drepte
2. cu BRD incomplet
3. cu BRD complet
Hipertrofie biventriculara
SV1 + RV5(sau V6) >35 mm (indice Sokolov pozitiv)
combinat cu deviere ax frontal QRS la dreapta +90
SV6 >7 mm (fara BRD)
probabil cel mai bun semn este combinatia de
pattern de HVD tipic cu dilatare de
AS (durata p >=120 ms)
S/R>1 in V5/V6 +dilatare de AS
SV6 >7 mm + dilatare AS
QRS >+90 + dilatare de AS (in prezenta de BRD)