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ELECTROCARDIOG

RAMA
ISCHEMIA SI INFARCTUL MIOCARDIC

Asist. Univ. Dr. Mihaela Popescu


Catedra de Cardiologie Spitalul
Universitar de Urgenta Elias

Ischemie/ Leziune
miocardica

Efectele ischemiei
PA ischemic
Depolarizare redusa
Repolarizare redusa
Durata si amplitudine
redusa
PA ischemic
PA normal
Sistola = ST
Diastola

Diastola= TP

CORESPONDENTA ECG - POTENTIAL


DE ACTIUNE

Complex QRS = Faza 0 si 1


Segment ST = Faza 2
Unda T= Faza 3
Interval TQ = Faza 4

Ischemia miocardica
Ischemia

Scaderea perfuziei miocardice - reversibila


Miocit ischemic- repolarizare precoce (+)
Ischemia subendocardica unde T negative
Ischemia transmurala unde T pozitive,
ascutite

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


negativa- curent de la normal la ischemic
In diastola (TP) regiunea ischemica este mai
pozitiva- curent de la ischemic la normal

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

Curent sistolic de leziune

Curent diastolic de leziune

Leziune subendocardica

Curent sistolic de leziune

Curent diastolic de leziune

Leziune transmurala

Curent sistolic de leziune

Curent diastolic de leziune

Ischemie/ Leziune
miocardica

Infarct miocardic

Ischemie persistenta celulele isi pierd viabilitatea=


necroza
Infarct miocardic:
cu supradenivelare de segment ST (STEMI)
fara supradenivelare de segment ST (NSTEMI)

Supra/sub denivelare ST

Criterii de diagnostic ECG in


STEMI
Supradenivelare ST :
>0.25 mV la barbati sub 40 ani
>0.20 mV la barbati peste 40 ani
> 0.15 mV la femei in V2-V3, sau > 0.1 mV in
orice alta derivatie
>0.05mV in V7-V9 (>0.01mV la barbati sub
40 ani)
avR si subdenivelare ST in 8 sau mai multe
derivatii= afectare multivasculara sau de
trunchi comun.

Supradenivelarea de
segment ST Apare precoce
R

Apare in derivatiile directe

NB: o mica supradenivelare de


segment ST poate fi normala in V1,

ST
P

V2 V3

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

Modificare diagnostica in/post infarct

Durata >0.04 secunde

Amplitudine de >25% din unda R

R
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.

Modificari ale Negativarea


undeiundei
T T -modificare
tardiva

R
ST

T
Q

Apare cand segmentul ST

incepe sa revina la normal


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.

Secventa modificarilor aspectului


ECG in infarctul miocardic acut
R

R
T

ST

ST

QS

1 minut dupa debut

1 ora de la debut

La cateva ore de la debut

R
ST

P
T

La o zi de la debut

ST

P
T

Modificari tardive

La cateva luni dupa IMA

Note subsol progresie


modificari
Sequence of changes in evolving AMI
The ECG changes that occur due to myocardial infarction do not all occur at the same time.
There is a progression of changes correlating to the progression of infarction.
Within minutes of the clinical onset of infarction, there are no changes in the QRS
complexes and therefore no definitive evidence of infarction. However, there is ST
elevation providing evidence of myocardial damage.
The next stage is the development of a new pathological Q wave and loss of the r wave.
These changes occur at variable times and so can occur within minutes or can be delayed.
Development of a pathological Q wave is the only proof of infarction.
As the Q wave forms the ST elevation is reduced and after 1 week the ST changes tend to
revert to normal, but the reduction in R wave voltage and the abnormal Q waves usually
persist.
The late change is the inversion of the T wave and in a non-Q wave myocardial infarct,
when there is no pathological Q wave, this T wave change may be the only sign of
infarction.
Months after an MI the T waves may gradually revert to normal, but the abnormal Q waves
and reduced voltage R waves persist.
In terms of diagnosing AMI in time to make thrombolysis a life-saving possibility, the main
change to look for on the ECG is ST segment elevation.

ARTERELE CORONARE

ARTERELE CORONARE

CLASIFICAREA IMA PE BAZA ASPECTULUI


ECG CORELAT CU DATELE ANGIOGRAFICE
CATEGORIA

LOCALIZAREA
OCLUZIEI

ECG LA PREZENTARE

1. ADA proximal

Proximal de prima
perforanta septala

ST in V1-V6, DI, aVL


si bloc fascicular sau
bloc de ramura

2. ADA mediu

Distal de prima
perforanta septala,
proximal de marea
diagonala

ST in V1-V6, DI, aVL

3. ADA distal sau


artera diagonala

Distal de marea
diagonala sau afectarea
primei diagonale

ST in V1-V4 sau ST
in V5-V6, DI, aVL

4. IMA inferior
moderat intins
(posterior,
lateral, de
ventricul drept)

ACD proximal sau artera


circumflexa

ST in DII, DIII, aVF si


oricare sau toate
dintre:
a) V1, V3R, V4R sau
b) V5-V6 sau
c) R>S in V1, V2

5.IMA inferior

ACD distal sau artera

ST doar in DII, DIII,

Infarct miocardic anterior


I II III

Artera descendenta anterioara

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Note de subsol IMA


anterior
Location of infarction and its relation to the ECG: anterior infarction
As was discussed in the previous module, the different leads look at different
aspects of the heart, and so infarctions can be located by noting the changes that
occur in different leads. The precordial leads (V16) each lie over part of the
ventricular myocardium and can therefore give detailed information about this
local area. aVL, I, V5 and V6 all reflect the anterolateral part of the heart and will
therefore often show similar appearances to each other. II, aVF and III record the
inferior part of the heart, and so will also show similar appearances to each other.
Using these we can define where the changes will be seen for infarctions in
different locations.
Anterior infarctions usually occur due to occlusion of the left anterior descending
coronary artery resulting in infarction of the anterior wall of the left ventricle and
the intraventricular septum. It may result in pump failure due to loss of
myocardium, ventricular septal defect, aneurysm or rupture and arrhythmias. ST
elevation in I, aVL, and V26, with ST depression in II, III and aVF are indicative
of an anterior (front) infarction. Extensive anterior infarctions show changes in V1
6 , I, and aVL.

Infarct inferior
I II III

Artera coronara
dreapta
sau a circumflexa

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Infarct inferior si de VD
I II III

Artera coronara
dreapta
sau a circumflexa

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Infarct postero inferior


lateral
I II III

Artera coronara
dreapta
sau a circumflexa

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Note subsol IMA inferior


Location of infarction and its relation to the ECG: inferior
infarction
ST elevation in leads II, III and aVF, and often ST depression in
I, aVL, and precordial leads are signs of an inferior (lower)
infarction. Inferior infarctions may occur due to occlusion of the
right circumflex coronary arteries resulting in infarction of the
inferior surface of the left ventricle, although damage can be
made to the right ventricle and interventricular septum. This type
of infarction often results in bradycardia due to damage to the
atrioventricular node.

Infarct lateral
I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

LAD distal sau a


diagonala/ a circumflexa
Location of infarction and its relation to the ECG: lateral infarction
Occlusion of the left circumflex artery may cause lateral infarction
Lateral infarctions are diagnosed by ST elevation in leads I and aV

Localizarea infarctului
I

aVR

aVL

V2

V3
III

INFERIOR

V4

SEPTAL

LATERAL
II

V1

ANT
SEPTAL

V5

ANT
V6 LAT

aVF

Location of infarction: combinations


The previous slides discussed the changes that occur in typical anterior,
inferior and lateral infarctions. However, the area infarcted is not always
limited to these areas and infarctions can extend across two regions. For
example, an anterior infarction which is also on the lateral side of the heart is
known as an anterolateral infarction.
ST segment elevation in leads I and aVL represent a lateral infarction
Anteroseptal infarctions show ST segment elevation in leads V 1 to V4.
ST elevation in V to V is typical of an anterolateral infarction

Localizarea infarctului?

IM inferior

Localizarea infarctului?

IM anterior

For more presentations


www.medicalppt.blogspot.com

IM anterolateral

Vectorul ST
Poate indica
localizarea ocluziei
arterei coronare

Diagnosticul diferential al
IMA cu supradenivelare ST
Angina Prinzmetal
Pericardita
Repolarizare precoce
Sdr. Brugada
Unda Osborne
Supradenivelarea
inghetata - anevrism

Diagnosticul diferential al
IMA cu supradenivelare ST
Anteroseptal
aneurism
Unda Osborne

Normal

Sdr. Brugada

Asocierea IM cu BRS
Anterior wall MI
I II III

aVR aVL aVF

V1 V2 V3

Left bundle branch block


V4 V5 V6

I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Bundle branch block


Bundle branch block is the pattern produced when either the right bundle or the entire left
bundle fails to conduct an impulse normally. The ventricle on the side of the failed bundle
branch must be depolarised by the spread of a wave of depolarisation through ventricular
muscle from the unaffected side. This is obviously a much slower process and usually the
QRS duration is prolonged to at least 0.12 seconds (for right bundle branch block) and 0.14
seconds (for left bundle branch block).
The ECG pattern of left bundle branch block (LBBB) resembles that of anterior infarction,
but the distinction can readily be made in nearly all cases. Most importantly, in LBBB the
QRS is widened to 140 ms or more. With rare exceptions there is a small narrow r wave (less
than 0.04 seconds) in V1 to V3 which is not usually seen in anteroseptal infarction. There is
also notching of the QRS best seen in the anterolateral leads, and the T wave goes in the
opposite direction to the QRS in all the precordial leads. This combination of features is
diagnostic. In the rare cases where there may be doubt assume the correct interpretation is
LBBB. This will make up no difference to the administration of a thrombolytic on medical
direction but for the present will be accepted as a contraindication for paramedics acting
autonomously (see later slide).
Right bundle branch block is characterised by QRS of 0.12 seconds or wider, an s wave in
lead I, and a secondary R wave (R) in V1. As abnormal Q waves do not occur with right
bundle branch block, this remains a useful sign of infarction.

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 pace-maker.

Criterii pentru detectarea unui IM vechi in prezenta BRS

Unda Q in cel putin doua dintre DI, aVL, V5, V6


Regresia undei R din V1 in V4
Incizura pe unda S in V3-V5 semnul Cabrera

Modificari reciproce (in


Localizare IM
Supradenivelare ST
Subdenivelare
oglinda)
reciproca de ST
Anterior

V1-V6 (progresie lenta a


undei R)

II, III, aVF

Lateral

DI, aVL, V5, V6

V1-V3

Inferior

II, III, aVF

DI, aVL, posibil


derivatiile anterioare

Posterior

Unde R anormal de
inalte in V1- V3

V1-V3

SUPRAINCARCAREA
ATRIALA
HIPERTROFIILE
VENTRICULARE

Supraincarcarea atriala
dreapta
Unda P >2,5mm
Morfologie: unda ascutita
In V1, V2, daca unda este bifazica, predomina componenta
pozitiva, initiala
Axa se verticalizeaza: +75 - +90
Titulatura: p pulmonar
Derivatii preferentiale: DII, DIII, aVF

Supraincarcarea atriala
dreapta
Cauze de supraincarcare atriala dreapta
Valvulopatii
Stenoza tricuspidiana
Regurgitare tricuspidiana

Hipertensiune pulmonara
BPOC
Embolii pulmonare
Apnee in somn

Boli congenitale
Stenoza pulmonara
Tetralogia Fallot

Tranzitor
Trombembolism pulmonar
Status astmaticus

NB: De obicei asociata cu HVD, exceptia stenoza tricuspidian

Supraincarcarea atriala
stanga
Unda P > 0.11 s
Morfologie: unda bifida
In V1, V2 predomina componenta
negativa
Axa se orizontalizeaza
Titulatura: p mitral
Derivatii preferentiale: DI, aVL, V5,
V6

Supraincarcarea atriala
stanga
Valvulopatii

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

Hipertrofia ventriculara
stanga
Suprasolicitarea VS cauze:
Suprasarcina de volum: IMi, IAo
Suprasarcina de presiune: HTA, SAo

valv./subvalv., CoAo, CMH

Suprasolicitarea VS efect:
Suprasarcina de volum dilatare cavitati
Suprasarcina de presiune hipertrofie, ingrosare

pereti

HVS

Criterii de apreciere a HVS


Indice Sokolow - Lyon: R (V5/V6) + S
(V1/V2) > 3.5 mV
(4.5 mV la copil)
Indicele Cornell: R (aVL) + S (V3) > 2.8
mV (B), 2 mV (F)

Scorul Romhilt - Estes

Hipertrofia ventriculara
dreapta
Etiologie:

incarcare de volum - DSV, Fallot (sunt stg. - dr.)


incarcare de presiune HTP primara, HTP secundara
(emfizem, TBC, bronsiectazii bilaterale, fibroze pulm,
SMi)
Consecinte:
balanta vectoriala VD-VS se schimba pana la
predominanta VD, in cazuri extreme de HVD
inversarea asp. normal pe ECG:R in V1, V2 + S in V5, V6
rotatie orara, catre anterior a VD + rotatie posterioara a
vf. Inimii
prin masa VD asincronism VD-VS

HVD

HVD
3 patternuri
1. fara tulburari de conducere
intraventriculare drepte
2. cu BRD incomplet
3. cu BRD complet

Criterii de apreciere a HVD


Sokolow Lyon
Unda R in V1 + unda S in V5/ V6>1.1mV
Alte criterii de apreciere:

1)
2)
3)
4)
5)
6)

deviatie axiala > 90 grd


R V1 > 7 mm
R/S V1 >1
P pulmonar
S/R V6 >1
aspect de BRD

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 deAS
SV6 >7 mm + dilatare AS
QRS >+90 + dilatare deAS (in prezenta de BRD)