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Traseul 2
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Infarctul miocardic acut cu şi fără
supradenivelarea ST
• Când circulaţia coronariană este brusc redusă sau
întreruptă într-o regiune a inimii are loc o succesiune de
evenimente:
– Ischemie – perfuzie insuficientă a miocardului;
– Leziune – hipoxia severă induce leziuni celulare reversibile;
– Necroză – moartea celulelor miocardice din zona neperfuzată;
– Fibroza ţesutului afectat - cicatrice în aria infarctizată
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Aspecte ECG ale IMA
Unda T
Apare unda Q
patologică
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Aspecte ECG ale IMA
Există două pattern-uri Non-ST Elevation
distincte ale modificărilor
ECG, în funcţie de zona
interesată:
•Subendocardic
– Absenţa
supradenivelării ST
şi a undei Q ST Elevation
•Transmural
– ST supradenivelat
– Undă Q
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ST Elevation Infarction
Here’s a diagram depicting an evolving infarction:
A. Normal ECG prior to MI
B. Ischemie – în urma ocluziei unei
artere coronare şi a instalării
hipoxiei, rezultă: ST uşor
supradenivelat si undă T înaltă
ascuţită, largă;
C. Leziune – suferinţă metabolică
intensă – ST intens
supradenivelat;
D/E. Ischemie + Leziune + Necroza -
apare Q patologic iar unda T se
inversează;
F. Fibroză (după câteva luni) – undă
Q persistentă, cu segment ST şi
unda T normale Explorări Funcţionale
Supradenivelarea ST (cont)
Supradenivelarea
segmentului ST
mai mare de 1
mm) în 2
derivatii
semnifică un
infarct miocardic.
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CIRCULATIA CORONARIANA– caracteristici anatomice
Regiunea anatomică a inimii Arterele coronare care iriga aceste
regiuni
Anteroseptala A. descendenta anterioara stanga ← Relatia cea
mai frecventa dintre
Anteroapicala A. descendenta anterioara stanga ramurile arterelor
coronare si teritoriul
Antero-laterala A. circumflexa irigat.
Question:
What ECG
changes do
you see?
Look at the
inferior leads (II,
III, aVF).
ST elevation
and Q-waves
Extra credit:
What is the
rhythm?
Atrial fibrillation
Non-ST Elevation Infarction
What do you
see in the
inferior
leads?
ST elevation,
Q-waves and
T-wave
inversion
http://www.ndsu.
edu/pubweb/~gri
er/eheart.html 34
Relaţia dintre derivaţiile membrelor şi pereţii inimii
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Relaţia dintre derivaţiile precordiale şi pereţii inimii
• Cum “văd” inima,
diferitele derivaţii • VARIANTE
precordiale?
• Peretele anterior
• Peretele anterior al al inimii:
inimii: Derivaţiile Derivaţiile V1, V4;
V3, V4;
• Peretele anterior
• Septul al inimii:
interventricular: Derivaţiile V3, V4;
Derivaţia V1, V2; • Porţiunea antero-
• Peretele lateral al septală a inimii:
Derivaţiile V1 - V4;
VS: Derivaţiile
V5,V6. • Septal leads = V1-2
• Anterior leads = V3-
4 Explorări Funcţionale 37
• Lateral leads = V5-6
Ghidul societăţii Europene de Cardiologie pentru
IMA cu supradenivelare de ST (STEMI), 2015
Derivatiile cu aceeasi culoare
din tabelul din dreapta culeg
informatii despre aceleasi zone
din miocard. Ne ajuta sa
intelegem localizarea Infarctului
Acut de miocard.
Anterior View of the Heart
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IMA?
Localizaţi!
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Interpretare
DA
IMA anteroseptal
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Other MI Locations
First, take a look again Lateral portion
at this picture of the of the heart
heart.
Anterior portion
of the heart
Inferior portion
of the heart
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Other MI Locations
Second, remember that the 12-leads of the ECG look at different
portions of the heart. The limb and augmented leads “see” electrical
activity moving inferiorly (II, III and aVF), to the left (I, aVL) and to the
right (aVR). Whereas, the precordial leads “see” electrical activity in
the posterior to anterior direction.
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Other MI Locations
Now, using these 3 diagrams let’s figure where to look
for a lateral wall and inferior wall MI.
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Anterior MI
Remember the anterior portion of the heart is best
viewed using leads V1- V4.
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Lateral MI
So what leads do you think the
lateral portion of the heart is
best viewed? Leads I, aVL, and V5- V6
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Inferior MI
Now how about the inferior
portion of the heart? Leads II, III and aVF
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Now, where do you think this person is having a
myocardial infarction?
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Inferior Wall MI
This is an inferior MI. Note the ST elevation in
leads II, III and aVF.
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http://www.unm.edu/~lkravitz/EKG/localizationMIs.html
How about now?
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Anterolateral MI
This person’s MI involves both the anterior wall (V2-
V4) and the lateral wall (V5-V6, I, and aVL)!
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http://www.unm.edu/~lkravitz/EKG/localizationMIs.html
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http://www.unm.edu/~lkravitz/EKG/localizationMIs.html
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Non-ST Elevation Infarction
The ECG changes seen with a non-ST elevation infarction are:
Note the ST
depression
and T-wave
inversion in
leads V2-V6.
Question:
What area of
the heart is
infarcting?
Anterolateral
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IMA POSTERIOR
• Infarctul posterior se întâlneşte în 15-20% dintre infarctele cu supradenivelare
de ST, de obicei în contextul unui infarct inferior sau lateral.
• IMA posterior izolat apare rar, în cca. 3-11% dintre infarcte.
• extinderea posterioră al unui infarct inferior sau lateral implică o suprafață mult
mai mare de leziuni miocardice, cu un risc crescut de disfuncție ventriculară
stângă și deces
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IMA POSTERIOR - continuare
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Explicaţia modificărilor ECG din V1-3 în IMA posterior
• derivaţiile anteroseptale V1-3 sunt orientate de la aria precordială anterioara
către suprafața interioară a miocardului posterior;
• deoarece activitatea electrica posterioră este înregistrată de pe partea anterioară
a inimii, modelul tipic de leziune şi necroză cu ST supradenivelat și unde Q, devine
inversat:
– supradenivelarea ST devine subdenivelare ST;
– undele Q devin unde R;
– T inversat (negativ) devine T pozitiv şi înalt;
• dezvoltarea progresivă a undelor R patologice din IMA posterior "undă
echivalentul lui Q" reflectă dezvoltarea undelor Q în IMA anteroseptal (imagine în
oglindă)
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Patient S.A., 52 years old presenting with chest pain:
• The ST depression and upright T waves in V2-3 suggest posterior MI.
• There are no dominant R waves in V1-2, but it is possible that this ECG was
taken early in the course of the infarct, prior to pathological R-wave
formation.
• There are also some features suggestive of early inferior infarction, with
hyperacute T waves in II, III and aVF.
An ECG of the same patient taken 30 minutes later:
• There is now some ST elevation developing in V6.
• With the eye of faith there is perhaps also some early ST
elevation in the inferior leads (lead III looks particularly
abnormal).
The same patient with posterior leads recorded:
• Posterior infarction is confirmed by the presence of ST
elevation > 0.5mm in leads V7-9.
In this ECG, posterior MI is suggested by the presence of:
• ST depression in V2-3
• Tall, broad R waves (> 30ms) in V2-3
• Dominant R wave (R/S ratio > 1) in V2
• Upright terminal portions of the T waves in V2-3
• The ECG changes extend out as far as V4, which may reflect superior-medial
misplacement of the V4 electrode from its usual position.
The same patient, with posterior leads recorded:
• Posterior infarction is diagnosed based on the presence of ST segment
elevation >0.5mm in leads V7-9.
• Note that there is also some inferior STE in leads III and aVF (but no Q
wave formation) suggesting early inferior involvement.
Another example of hyperacute STEMI?
• There are hyperacute T-waves in V2-6 (most marked in V2 and V3) with loss of R wave
height.
• The rhythm is sinus with 1st degree AV block.
• There are premature atrial complexes (beat 4 on the rhythm strip) and multifocal
ventricular ectopy (PVCs of two different types), indicating an “irritable” myocardium at risk
A ECG of the same patient taken around 40-50 minutes later:
• There is progressive ST elevation and Q wave formation in V2-5
• ST elevation is now also present in I and aVL.
• There is some reciprocal ST depression in lead III.
• This is an acute anterior STEMI – this patient needs urgent reperfusion!
Right Ventricular Infarction
• Right ventricular infarction complicates up to 40% of inferior STEMIs. Isolated RV
infarction is extremely uncommon.
• Patients with RV infarction are very preload sensitive (due to poor RV
contractility) and can develop severe hypotension in response to nitrates or
other preload-reducing agents.
• Hypotension in right ventricular infarction is treated with fluid loading, and
nitrates are contraindicated.
• The ECG changes of RV infarction are subtle and easily missed!
• The first step to spotting RV infarction is to suspect it… in all patients with
inferior STEMI!
• In patients presenting with inferior STEMI, right ventricular infarction is
suggested by the presence of:
• ST elevation in V1 – the only standard ECG lead that looks directly at the right
ventricle.
• ST elevation in lead III > lead II – because lead III is more “rightward facing”
than lead II and hence more sensitive to the injury current produced by the right
ventricle.
• Other useful tips for spotting right ventricular MI:
Right Ventricular Infarction
• The first step to spotting RV infarction is to suspect it… in all
patients with inferior STEMI!
• In patients presenting with inferior STEMI, right ventricular
infarction is suggested by the presence of:
• ST elevation in V1 – the only standard ECG lead that looks
directly at the right ventricle.
• ST elevation in lead III > lead II – because lead III is more
“rightward facing” than lead II and hence more sensitive to
the injury current produced by the right ventricle.
• Other useful tips for spotting right ventricular MI:
• ST elevation in V1 > V2.
• ST elevation in V1 + ST depression in V2 (= highly specific for
RV MI).
• Isoelectric ST segment in V1 with marked ST depression in V2.
Right Ventricular Infarction
continued
• Right-sided leads
• There are several different
approaches to recording a right-sided
ECG:
• A complete set of right-sided leads is
obtained by placing leads V1-6 in a
mirror-image position on the right
side of the chest (see diagram,
below).
• It may be simpler to leave V1 and V2
in their usual positions and just
transfer leads V3-6 to the right side
of the chest (i.e. V3R to V6R).
• The most useful lead is V4R, which is
obtained by placing the V4 electrode NB. ST elevation in the right-sided
in the 5th right intercostal space in
leads is a transient phenomenon,
the midclavicular line.
lasting less than 10 hours in 50% of
• ST elevation in V4R has a sensitivity
of 88%, specificity of 78% and patients with RV infarction.
diagnostic accuracy of 83% in the
diagnosis of RV MI.
• Inferior STEMI. Right ventricular infarction is suggested by:
• ST elevation in V1
• ST elevation in lead III > lead II
• Repeat ECG of the same patient with V4R electrode position:
• There is ST elevation in V4R consistent with RV infarction
Internare/ Durere
Prezentare la spital toracica
Crestere/ Troponina
scadere a normala
Biochimie troponinei
≤ 10 • Timpul de la primul
contact medical (PCM) la
min ECG si diagnostic
≤ 30 • Timpul de la PCM la
fibrinoliza
min
≤ 90 • Timpul de la PCM la interventie coronariana
percutanata primara (fara fibrinoliza in
prealabil) daca se poate efectua in Spital. Daca