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Asist. Univ. Dr. Mihaela Popescu

Catedra de Cardiologie Spitalul Universitar de
Urgenta Elias
Ischemie/ Leziune
Efectele ischemiei
PA ischemic
•Depolarizare redusa
•Repolarizare redusa
•Durata si amplitudine redusa

PA ischemic
PA normal
Sistola = ST
Diastola Diastola= TP

•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

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
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
• 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
• >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
• Apare in derivatiile directe

• NB: o mica supradenivelare de segment ST

ST poate fi normala in V1, 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
Deep Q wave
P The only diagnostic changes of acute
myocardial infarction are changes in the QRS
T complexes and the development of abnormal Q
waves. However, this may be a late change and
Q 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 undei T
• Negativarea undei T -modificare tardiva
• Apare cand segmentul ST incepe sa
revina la normal

T wave inversion
The T wave is the most unstable feature of the ECG
R tracing and changes occur very frequently under normal
ST circumstances, limiting their diagnostic value.
P 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
T patients presenting with MI, a T wave abnormality is the
only ECG sign.
The T wave can be lengthened or heightened by coronary
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


1 minut dupa debut 1 ora de la debut La cateva ore de la debut



La o zi de la debut Modificari tardive La cateva luni dupa IMA

Note subsol progresie
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
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
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.
1. ADA proximal Proximal de prima perforanta ↑ ST in V1-V6, DI, aVL si bloc
septala fascicular sau bloc de ramura
2. ADA mediu Distal de prima perforanta ↑ ST in V1-V6, DI, aVL
septala, proximal de marea
3. ADA distal sau Distal de marea diagonala sau ↑ ST in V1-V4 sau ↑ ST in
artera diagonala afectarea primei diagonale V5-V6, DI, aVL

4. IMA inferior ACD proximal sau artera ↑ ST in DII, DIII, aVF si

moderat intins circumflexa oricare sau toate dintre:
(posterior, lateral, de a) V1, V3R, V4R sau
ventricul drept) b) V5-V6 sau
c) R>S in V1, V2
5.IMA inferior mic ACD distal sau artera ↑ ST doar in DII, DIII, aVF
circumflexa sau ramuri din
artera circumflexa
Infarct miocardic anterior

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Artera descendenta anterioara

Note de subsol IMA
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 (V 1–6) 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 V2–6, with ST depression in II, III and aVF are indicative
of an anterior (front) infarction. Extensive anterior infarctions show changes in V 1–
6 , I, and aVL.
Infarct inferior

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Artera coronara dreapta

sau a circumflexa
Infarct inferior si de VD

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Artera coronara dreapta

sau a circumflexa
Infarct postero inferior

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Artera coronara dreapta

sau a circumflexa
Note subsol IMA inferior

Location of infarction and its relation to the ECG: inferior

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

Location of infarction and its relation to the ECG: lateral infarction
Occlusion of the left circumflex artery may cause lateral infarctions.
Lateral infarctions are diagnosed by ST elevation in leads I and aVL.
Localizarea infarctului
I aVR V1 V4



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 V1 to V4.
• ST elevation in V4 to V6 is typical of an anterolateral infarction

Localizarea infarctului?
IM inferior
Localizarea infarctului?
IM anterior
For more presentations
IM anterolateral
Vectorul ST
Poate indica localizarea
ocluziei arterei coronare
Diagnosticul diferential al
IMA cu supradenivelare ST

•Angina Prinzmetal
•Repolarizare precoce
•Sdr. Brugada
•Unda Osborne
•Supradenivelarea “inghetata” -
Diagnosticul diferential al
IMA cu supradenivelare ST
Unda Osborne

Normal Sdr. Brugada

Asocierea IM cu BRS
Anterior wall MI Left bundle branch block

I II III aVR aVL aVF V1 V2 V3 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 reciproca
de ST

Anterior V1-V6 (progresie lenta a undei II, III, aVF


Lateral DI, aVL, V5, V6 V1-V3

Inferior II, III, aVF DI, aVL, posibil derivatiile


Posterior Unde R anormal de inalte in V1-V3

V1- V3

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

• Stenoza tricuspidiana
• Regurgitare tricuspidiana

Hipertensiune pulmonara
• Embolii pulmonare
• Apnee in somn

Boli congenitale
• Stenoza pulmonara
• Tetralogia Fallot

• Trombembolism pulmonar
• Status astmaticus

NB: De obicei asociata cu HVD, exceptia stenoza tricuspidiana

Supraincarcarea atriala
•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

• 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
• Suprasolicitarea VS – cauze:
• Suprasarcina de volum: IMi, IAo

• Suprasarcina de presiune: HTA, SAo valv./subvalv., CoAo,


• Suprasolicitarea VS – efect:
• Suprasarcina de volum – dilatare cavitati

• Suprasarcina de presiune – hipertrofie, ingrosare pereti

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
• 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.
• prin masa VD asincronism VD-VS
• 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) deviatie axiala > 90 grd
• 2) R V1 > 7 mm
• 3) R/S V1 >1
• 4) P pulmonar
• 5) S/R V6 >1
• 6) 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 de AS
• SV6 >7 mm + dilatare AS
• ÅQRS >+90 + dilatare de AS (in prezenta de BRD)