ECG in coronary artery disease. By Sura Boonrat Central Chest Institute

Transcription

1 ECG in coronary artery disease By Sura Boonrat Central Chest Institute

2 EKG P wave = Atrium activation PR interval QRS = Ventricle activation T wave= repolarization J-point EKG QT interval Abnormal repolarization of ventricle = ST segment

3 2015 ESC Guideline for management of ACS in patients presenting without ST-segment elevation TYPE OF CORONARY ARTERY DISEASES

4 Type of coronary artery diseases Unstable angina Non-ST elevation myocardial infarction ST elevation myocardial infarction Other cardiac diseases ; e.g. coronary emboli, coronary dissection 2015 ESC Guideline for management of ACS in patients presenting without ST-segment elevation

5 George J. Tayor, MD, 150 Practice ECGs: Interpretation and Review, ISBN 13: Sub endocardial ischemia Transmural ischemia

6 DIAGNOSIS OF MI ; ECG ROLE Detection of rise and / or fall of cardiac troponin T values with at least one of the following 1. Symptoms of acute myocardial ischemia 2. New ischemic ECG change 3. Development of pathological Q waves 4. Imaging evidence of new loss of viable myocardium or new regional wall abnormality in pattern consistent with an ischemic etiology 5. Identification of a coronary thrombus by angiography including intracoronary imaging or by autopsy Fourth universal definition of myocardial infarction, EHJ (2018) 00,1-33

7 STEMI Life threatening condition Plaque rupture Acute obstruction of infarct artery (s) Immediate management is essential Mortality is higher if a greater number of ECG leads show ST elevation Ragavendra R. Baliga, MD, MaGraw-Hill Specialty Board Review, ISBN

8 Management Early diagnosis Early treatment Time = myocardium

9 ECG evaluation ECG recording as soon as possible If the ECG is equivocal, repeat ECGs and compared with previous recording Monitor ECG with defibrillator capacity FMC = First medical contract 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

10 ECG manifestations suggestive of acute MI ( in the absence of LVH and BBB ) Fourth universal definition of myocardial infarction, EHJ (2018) 00,1-33

11 ST Elevation Localizing Infarcts on the 12 lead ECG Lateral - Cx Prox LAD or LM Ant sep - LAD Anterior - LAD Inferior - RCA Lateral - Cx Ant sep - LAD Lateral - Cx Inferior - RCA Inferior - RCA Anterior - LAD Lateral - Cx

12 Coronary blood supply and conduction system as ECG lead SA node ; RCA in 55-60% AV node ; RCA 90%

13 Anterior wall STEMI

14 Tombstone STEMI Tombstoning, grave sign

15 VENTRICULAR FIBRILLATION COMPLICATION OF STEMI

16 Inferior wall STEMI

17 Right ventricular infarction

18 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation V 3 R, V 4 R LEAD V 3 R, V 4 R LEAD

19 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation Francis Morris, ABC of clinical electrophysiology, BMJ book, ISBN V 3 R, V 4 R lead

20 Right ventricular infarction The diagnosis of right ventricular infarction is important as it may be associated with hypotension Treatment with nitrates or diuretics may compound the hypotension, though the patient may respond to fluid challenge Francis Morris, ABC of clinical electrophysiology, BMJ book, ISBN

21 Posterior wall STEMI

22 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation V7-V9 = Posterior leads 22

23 V7 V9 POSTERIOR LEAD V7 V8 V9 V7 V9 POSTERIOR LEAD

24 Mirror test Dale Dubin, MD, Rapid interpretation of EKG s

25 Posterior wall MI Should be managed as a STEMI 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation

26 NSTEMI Clinical spectrum of acute coronary syndrome sub-total occlusion of coronary vessel Current guideline emphasize risk stratification of UA/NSTEMI patients with respect to selecting a conservative versus an early invasive approach Ragavendra R. Baliga, MD, MaGraw-Hill Specialty Board Review, ISBN

27 ECG manifestations suggestive of acute MI ( in the absence of LVH and BBB ) ST depression T wave inversion Fourth universal definition of myocardial infarction, EHJ (2018) 00,1-33

28 Downsloping and horizontal ST depression are more specific for sub-endocardial ischemia George J. Tayor, MD, 150 Practice ECGs: Interpretation and Review, ISBN 13:

29 Horizontal ST/T segment depression in V4-V6

30 NSTEMI ECG role ECG without acute ischemic changes have a reduced risk of MI and a very low risk of in-hospital life threatening complications Marked symmetrical precordial T-wave inversion ( 2 mm [0.2 mv]) suggests critical stenosis of LAD Nonspecific ST-T changes (usually defined as ST deviation of < 0.5 mm [0.5 mv] or T-wave inversion of < 2 mm [0.2 mv]) are less helpful diagnostically normal ECG in a patient with chest pain does not exclude ACS 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes

31 Significant Q wave Dale Dubin, MD, Rapid interpretation of EKG s