Electrocardiograma. Conf. dr. Adelina Vlad. UMF Carol Davila Bucuresti Disciplina Fiziologie II

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1 Electrocardiograma Conf. dr. Adelina Vlad UMF Carol Davila Bucuresti Disciplina Fiziologie II

2 Este metoda standard folosita in clinica pentru a investiga activitatea electrica a cordului Este neinvaziva, ieftina si versatila Permite identificarea Aritmiilor Tulburarilor de conducere Ischemiei miocardice Hipertrofiei si dilatarii cavitatilor cordului Diselectrolitemiilor Susceptibilitatii crescute pt moarte subita (interval QT prelungit)

3 voltaj Electrocardiograma reprezinta inregistrarea grafica a potentialelor electrice generate de fibrele miocardice de lucru Cordul este suspendat intr-un mediu bun conducator electric; semnalele electrice sunt culese cu ajutorul electrozilor metalici plasati pe tegument, amplificate si inregistrate apoi de electrocardiograf timp

4 Electrod negativ Voltmetru Inregistrarea Undelor de Depolarizare si Repolarizare Electrod pozitiv Depolarizarea (- +) avanseaza catre electrodul pozitiv generand o unda pozitiva (A) Repolarizarea (+ -), care progreseaza catre electrodul pozitiv, genereaza o unda negativa (C) Absenta unei diferente de potential intre cei doi electrozi conduce la inregistrarea unei linii izoelectrice (B,D)

5 Caracteristici ale ECG Normale Electrocardiograma normala este formata dintr-un numar de unde, pozitive si negative, conectate prin segmente de linii izoelectrice Undele corespund depolarizarii si repolarizarii versantului extracelular al sarcolemei miocardiocitelor de lucru pe parcursul ciclului cardiac

6 Unda P depolarizarea atriala Segmentul PQ intervalul de timp dintre sfarsitul activarii atriale si inceputul depolarizarii ventriculare Complexul QRS activarea ventriculara Unda T repolarizarea ventriculara

7 Relatia dintre PA Ventricular si Undele QRS T pe ECG Potential de actiune (PA) monofazic inregistrat intr-o fibra miocardica ventriculara Inregistrare ECG realizata simultan: QRS apare la inceputul PA, iar unda T la sfarsitul acestuia Cand miocardul ventricular este in intregime polarizat ori depolarizat pe electrocardiograma se inregistreaza o linie izoelectrica

8 Depolarizarea rapida (faza 0 a PA) corespunde complexului QRS Factori care scad panta fazei 0 prin diminuarea influxului Na+ (flecainida, procainamida ori hiperpotasemia) tind sa prelungeasca durata complexului QRS Faza de platou (faza 2) corespunde segmentului izoelectric ST Conditii care prelungesc faza 2 (amiodarona, hipocalcemie) cresc durata segmentului ST Scurtarea fazei 2 (digitala, hipercalcemie) scade durata segmentului ST Repolarizarea activa (faza 3) corespunde undei T

9 The electrical cardiac cycle generates fast changing potentials throughout the heart Curentii electrici care se propaga prin miocard sunt produsi de - fibre ale tesutului excitoconducator - fibre miocardice de lucru ECG inregistreaza numai curentii extracelulari produsi de miocardul de lucru atrial si ventricular

10 Undele de depolarizare si repolarizare miocardica genereaza dipoli electrici care pot fi reprezentati vectorial vectori cardiaci, caracterizati prin directie, sens, magnitudine ECG inregistreaza suma spatiala si temporala a potentialelor electrice (vectori) produse de fibre miocardice multiple, care sunt transmise la suprafata corpului Limitari inerente: De sensibilitate activitatea anumitor regiuni poate fi anulata sau diminuata, devenind prea slaba pentru a putea fi inregistrata De specificitate aceeasi rezultanta vectoriala poate fi generata prin inregistrarea unor semnale selective sau prin anularea partiala a fortelor orientate in sensuri opuse

11 Vectori Cardiaci Activitatea electrica a cordului intr-un anumit moment poate fi aproximata printr-un singur dipol si reprezentata printr-un vector, numit vector cardiac Localizarea, orientarea si magnitudinea vectorilor cardiaci variaza odata cu paternul campului electric miocardic dintr-un anumit moment

12 Inregistrarea Activitatii Electrice a Cordului Activitatea electrica a cordului poate fi masurata cu voltmetre conectate la suprafata corpului prin electrozi negativ nul pozitiv

13 Sistemul Derivatiilor Electrocardiografice Electrozii sunt configurati sub forma mai multor derivatii electrice O derivatie inregistreaza fluctuatii ale voltajului extracelular generat intre electrozii sai Electrocardiograma standard foloseste 12 derivatii: 6 in planul frontal 3 derivatii bipolare sau derivatiile standard ale membrelor 3 derivatii unipolare modificate (amplificate) ale membrelor 6 in planul transversal derivatiile unipolare precordiale

14 O derivatie bipolara Consta din doi electrozi plasati in doua puncte diferite Inregistreaza diferenta de potential intre cele doua puncte (valoarea absoluta a potentialului la oricare dintre cei doi electozi nu este cunoscuta) Un electrod este considerat pozitiv, celalalt negativ O derivatie unipolara Masoara potentialul absolut intr-un singur punct Necesita un potential de referinta Potentialul este inregistrat de un electrod unic electrodul inregistrator sau activ, considerat pozitiv fata de potentialul de referinta

15 Willem Einthoven Premiul Nobel pentru Fiziolgie sau Medicina in 1924

16 New Diagnostic Tools - Electrocardiographic Imaging (ECGI) Application of the ECGI vest used for imaging the electrical activity of the heart. Body Surface Potential Maps (BSPM) are displayed on the monitor. These BSPM are used to reconstruct the electrical activity on the heart surface noninvasively. The existing method for noninvasive diagnosis of cardiac rhythm disorders is the traditional electrocardiogram (ECG). ECG measures electrical signals from six to twelve electrodes placed on the surface of the chest. These signals reflect the electrical excitation of the heart as seen from remote observation points, located on the body surface. Traditional ECG is very limited in resolution since it samples the entire body surface electric potential at only six or twelve points, leaving out very important information. Completing the missing data is analogous to completing a puzzle of several hundred pieces when only six or twelve pieces are available. Advances in electronics and computers have made it possible to cover the torso with hundreds of electrodes to obtain the total body surface ECG. This approach is known as body surface potential mapping (BSPM). Currently, we use 250 body-surface electrodes embedded in a vest that facilitates rapid and convenient application.

17 Derivatiile Bipolare Standard Derivatia I Electrodul negativ este plasat pe bratul drept, cel pozitiv, simetric pe bratul stang Defineste in planul frontal o axa la 0 Derivatia II negativa la bratul drept, pozitiva la piciorul stang Defineste in planul frontal o axa la +60 Derivatia III Conexiunea negativa la bratul stang, pozitiva la piciorul stang Defineste in planul frontal o axa la +120 Inregistreaza diferenta de potential intre doua membre, in plan frontal

18 Triunghiul lui Einthoven Este delimitat de axele celor trei derivatii standard ale membrelor Legea lui Einthoven: daca potentialele electrice inregistrate de oricare doua din cele trei derivatii bipolare ale membrelor sunt cunoscute la un moment dat, valoarea potentialului inregistrat de cea de-a treia poate fi determinat matematic prin insumarea primelor doua (teorema lui Kirchhoff) Tinand cont de semnele + si ale derivatiilor, legea lui Einthoven devine: I + III = II - +

19 Derivatiile Unipolare (Amplificate) ale Membrelor Derivatii ale planului frontal, compara potentialul inregistrat de un electrod al membrelor (brat stang, brat drept, picior stang) cu media celorlalti doi (metoda Goldberger) Doi electrozi sunt conectati la borna negativa a electrocardiografului prin intermediul unor rezistente electrice, iar cel de-al treilea, considerat electrod activ, inregistrator, este conectat la borna pozitiva a aparatului

20 avr (augmented voltage right) Electrodul pozitiv este plasat pe bratul drept Axa derivatiei este orinetata in planul frontal la avl (augmented voltage left) Electrodul pozitiv este plasat pe bratul stang Axa derivatiei este orientata in planul frontal la avf (augmented voltage foot) Electrodul pozitiv este plasat pe piciorul stang Axa derivatiei este orientata in planul frontal la + 90

21 Sistemul Hexaxial Rezulta prin suprapunerea axelor celor 6 derivatii ale planului frontal Cele 6 axe ale derivatiilor divid planul frontal in 12 segmente, care subantind unghiuri de 30

22 Vectorii Cardiaci Sunt Tridimensionali

23 Derivatiile Precordiale In mod obisnuit sunt utilizate sase derivatii precordiale unipolare: V 1 : electrodul este plasat in spatiul patru intercostal parasternal drept V 2 : spatiul patru intercostal parasternal stang V 4 : spatiul cinci intercostal pe lina medioclaviculara V 3 : la jumatatea distantei dintre V 2 si V 4 V 6 : spatiul cinci intercostal pe linia axilara medie V 5 : la jumatatea distantei dintre V 4 si V 6.

24 Derivatiile precordiale sunt orientate in planul transversal, perpendicular pe planul derivatiilor frontale Suprafata cordului este situata in proximitatea peretelui toracic Fiecare derivatie precordiala inregistreaza cu predilectie potentialul electric al miocardului din imediata sa vecinatate Anomalii ventriculare relativ discrete, mai ales ale peretelui ventricular anterior, pot produce modificari electrocardiografice importante in derivatiile precordiale

25 Borna Wilson Cate un electrod explorator este plasat in fiecare dintre cele 6 pozitii descrise si conectat la borna pozitiva a sistemului de inregistrare Potentialul de referinta (borna Wilson) este realizat astfel: Electrozii membrelor sunt conectati impreuna, prin intermediul unor rezistente de 5000 W, la borna negativa a electrocardiografului fiecare derivatie precordiala inregistreaza potentialul la una dintre pozitiile precordiale relativ la media potentialelor celor trei membre Potentialul de referinta ramane relativ constant pe parcursul ciclului cardiac potentialul inregistrat de derivatia precordiala reflecta strict activitatea electrica a zonei in care este amplasat electrodul explorator

26

27

28 Perspective Asupra Cordului Miocardul anterior Derivatiile V1 V4 Miocardul lateral Derivatiile I, avl, V5, V6 Miocardul inferior Derivatiile II, III, avf

29 Vedere inferioara Vedere anterioara Vedere laterala

30 avf Reprezentarea Vectoriala a Lead I vector Derivatiilor Vectorii derivatiilor sunt orientati astfel: Pentru derivatiile bipolare: de la electrodul negativ catre cel pozitiv Pentru derivatiile unipolare: de la jumatea distantei dintre electrozii care sunt conectati impreuna pt a forma referinta, catre electrodul activ (pozitiv)

31 Vectori Cardiaci Activitatea electrica a cordului intr-un anumit moment poate fi aproximata printr-un singur dipol si reprezentata printr-un vector, numit vector cardiac Localizarea, orientarea si magnitudinea vectorilor cardiaci variaza potrivit patternului campului electric miocardic dintr-un anumit moment

32 De la Vactori Cardiaci la Unde Electrocardiografice Amplitudinea si polaritatea undelor ECG inregistrate intr-o derivatie sunt proportionale cu magnitudinea si sensul proiectiei vectorilor cardiaci pe axa acelei derivatii a. Daca vectorul cardiac este orientat catre polul pozitiv al derivatiei aparatul inregistreaza un potential pozitiv unda pozitiva in derivatia respectiva b. Daca vectorul cardiac este orientat in sens opus fata de polul pozitiv al derivatiei aparatul inregistreaza un potential negativ unda negativa in acea derivatie a b

33 Undele ECG reflecta fluctuatii ale voltajului extracelular inregistrate de fiecare derivatie A vector cardiac corespunzator activarii ventriculare B, C, D proiectii ale A pe axele derivatiilor I, II si III, cu ilustrarea undelor R inregistrate pe ECG

34 Geneza ECG Normala

35 Unde Morfologie Polaritate Axa Amplitudine (mv) Durata (s) Criterii de Evaluare Segmente Este pe linia izoelectrica sau nu? Durata Intervale Durata

36 avf Depolarizarea Atriala si Unda P AD AS V6 Lead I vector V1 P bifazic in V1 Plan frontal Plan orizontal

37 Forma Unda P - Caracteristici In dom; uneori bifazica (V1, V2), sau discret bifida (V5, V6, avl), datrita ansincronismului partial al activarii atriale Polaritate pozitiva in derivatiile I,II, avl, avf, V4 V6 negativa in avr Axa: 0 75 Durata: < 0.12 s Amplitudinea: < 0.25 mv in derivatiile membrelor Deflexiunea negativa terminala in V1 < 0.1 mv in adancime

38 1 mv 1 mm = 0.04 s

39 Repolarizarea Atriala si Unda Ta Repolarizarea atriala incepe in proximitatea NSA Vectorul repolarizarii atriale are aceeasi directie dar sens opus vectorului depolarizarii Unda de amplitudine mica si polaritate opusa undei P (Ta) In ECG normala Ta este mascata de complexul QRS

40 Segmentul PR Conducerea prin NAV si Segmentul PR Este linia izoelectrica dintre sfarsitul undei P si debutul complexului QRS Durata: s Punte temporala intre activarea atriala si cea ventriculara! Depolarizarea NAV, a fasciculului His, a ramurilor acestuia si a retelei Purkinje genereaza potentiale care sunt prea mici pentru a fi inregistrate la suprafata corpului de un aparat ECG standard

41 Intervalul PR Intervalul PR = unda P + segmentul PR Reprezinta timpul dintre initierea activarii atriale si debutul activarii ventriculare Durata: s, variaza cu frecventa cardiaca si cu varsta

42 avf Depolarizarea Ventriculara si Complexul QRS Lead I vector 1. Activarea septala V1, V2, avr = derivatii ventriculare drepte unde pozitive de amplitudine mica, r I, avl, V5, V6 = derivatii ventriculare stangi unde negative cu amplitudine mica, q

43 avf 2. Depolarizarea apexului ventricular V1, V2, avr tranzitia catre unda negativa, S I, avl, V5, V6 tranzitia catre unda pozitiva, R Lead I vector

44 avf Lead I vector 3. Activarea peretelui ventricular stang vectorul dominant al activarii ventriculare V1, V2, avr unda negativa cu amplitudine mare, S I, avl, V5, V6 unda pozitiva cu amplitudine mare, R

45 avf Lead I vector 4. Activarea ariilor posterobazale ale vetriculului stang V1, V2, avr parte terminala a ascendenta a undei negative S (o readuce la linia izoelectrica) I, avl, V5, V6 mica deflexiune negativa, s

46 avf QRS in Derivatiile Membrelor Lead I vector

47 QRS in Derivatiile Precordiale rs qrs

48 Vectocardiograma Depolarizarii Ventriculare Vectocardiograma ilustreaza progresia paternului depolarizarii sau repolarizarii miocardice reprezentat vectorial moment de moment (infasuratoarea tuturor vectorilor momentani ai depolarizarii ventriculare, spre exemplu) Vectocardiograma QRS

49 Nomenclatura: Unda Q Complexul QRS Prima unda negativa a complexului Durata: < s; exceptie: in derivatiile V1, V2 orice Q este anormal Amplitudine: < ¼ R wave, < mv Unda R Prima unda pozitiva a complexului Forma si dimensiunea nu sunt clar standardizate; amplitudinea cea mai mare in V5 si/ sau V6 O a doua unda pozitiva este notata R Unda S A doua unda negativa a complexului daca exita unda Q, sau prima unda negativa in caz contrar Durata: < 0.04 s Amplitudinea cea mai mare in V1 si/ sau V2

50 qrs qr R bifid rsr QS QS bifid Undele cu amplitudine mare sunt notate cu majuscule

51 Complexul QRS - Caracteristici Morfologie: R/S < 1 in V1 V2; orice unda Q este anormala in aceste derivatii R/S > 1 in V5 V6 Axa QRS = vectorul rezultant al activarii ventriculare in planul frontal Limite normale: Deviatie axiala stanga: Deviatie axiala dreapta:

52 Durata QRS: < 0.11 s masurata in derivatia cu cel mai larg complex Deflexiunea intrinsecoida: - Masoara durata activarii transmurale in dreptul electrodului pozitiv al unei derivatii precordiale (V1, V2, V5, V6) - Se determina de la varful ultimei unde R pana la punctul de debut al complexului QRS - Valori normale: < s in V1, V2 si < s in V5, V6 QRS ID ID

53 Amplitudinea QRS = suma algebrica a amplitudinilor undelor componente > 1 mv intr-una dintre derivatiile precordiale, > 0.5 mv intr-o derivatie standard Amplitudinea undelor R si S este importanta pentru diagnosticul hipertrofiei ventriculare stangi: Indice Sokolow-Lyon: Sv1 + (Rv5 or Rv6) > 3.5 mv Criteriile de voltaj Cornell: Sv3 + SaVL 2.8 mv la barbat, 2.0 la femeie sau drepte: Sv1 > 0.7 mv, RV5 or V6 > 0.7 mv etc.

54

55 Segmentul ST Izoelectric, miocardul ventricular este depolarizat in intregime Variatii de < 1mm (< 2 mm in V1,2) sunt considerate normale

56 Repolarizarea Ventriculara Incepe in ariile epicardice ale miocardului ventricular si la nivelul apexului Vectorul repolarizarii ventriculare este orientat catre apex Unda T are aceeasi polaritate cu a complexului QRS precedent

57 Morfologie Caracteristicile Undei T Asimetrica, are panta ascendenta lina, panta descendenta abrupta, si varf rotunjit Polaritate Pozitiva in I, II, avl, avf, V5, V6 negativa in avr variabla in III, V1 - V3 Axa 0-90 ; Formeaza un unghi < 60 cu axa QRS, numit unghi QRST Durata Indeterminabila, debutul undei T neputand fi localizat cu precizie Amplitudine 1/3 din amplitudinea undei R precedente

58 Apare uneori dupa unda T Unda U Are aceeasi polaritate cu unda T si o amplitudine mai mica de 0.1 mv Substratul sau electrofiziologic este discutabil; poate fi determinat de o repolarizare tardiva a celulelor mezomiocardice (cu PA de durata mai lunga) sau a cardiomiocitelor din arii cu relaxare mecanica intarziata ST interval ST segment PQ segment PQ interval Isoelectric line QT interval

59 Intervalul QT Cuprinde complexul QRS, segmentul QT si unda T Acopera durata activarii si repolarizarii ventriculare (correspunde duratei PA ventricular) Se determina in derivatia cu cel mai lung interval QT si fara unde U Este caracterizat de durata

60 Durata intervalului QT Variaza cu frecventa cardiaca (scade cand frecventa creste intrucat durata PA se scurteaza la cresterea frecventei de stimulare) Ecuatia Bazzet: QTc = QT/ RR, unde QTc inseamna QT corectat iar RR reprezinta durata dintre doua unde R consecutive (un ciclu cardiac). Este dependenta de derivatie = dispersia QT; variatii normale < 0.05 s, cel mai lung in V2, V3; accentuarea dispersiei intervalului QT este un semn de variabilitate crescuta a repolarizarii si de risc aritmogen Valori normale: QTc < 0.44 s; poate fi usor prelungit la femei

61

62 Interpretarea Electrocardiogramei 1) Calibrarea 2) Determinarea frecventei cardiace 3) Determinarea ritmului 4) Determinarea axei QRS 5) Determinarea duratei intervalelor 6) Analiza morfologiei si a interrelatiei dintre elementele electrocardiogramei (P, P-Q, Q, QRS, ST, T, QT) in derivatiile frontale si precordiale sau 6) Identificarea elementelor definitorii pt. hipertrofie 7) Identificarea semnelor de ischemie/ infarct miocardic

63 1) Calibrarea de Voltaj si de Timp Pe verticala 1 mm (un patrat mic) = 0.1 mv 10 mm (doua patrate mari) = 1mV Pe orizontala Un patrat mic = 0.04 s Un patrat mare = 0.20 s

64 2) Calculul Frecventei Cardiace Metoda directa Frecventa cardiaca (FC) = nr. cicluri cardiace/ min = 60 s/ durata unui ciclu cardiac Un ciclu cardiac corespunde intervalului dintre doua unde ECG de acelasi tip, de pilda unui interval R-R R R = 16 x 0.04 = 0.64 FC = 60/ 0.64 = 94 batai/min

65 Calculul FC R wave Metoda rapida Se alege o unda R care se suprapune pe o linie groasa Se numara patratele mari pana la urmatoarea unda R. Daca a doua unda R este la 1 patrat mare de precedenta, FC este de 300 bpm, la 2 patrate mari 150 bpm, la 3 patrate mari 100 bpm, la 4 patrate mari 75 bpm, etc. In exemplul nostru, un pic sub 100 bpm 94 bpm

66 3) Determinarea Ritmului Cardiac Ritm cardiac = ritmul de activare a ventriculilor Intrebari la care se raspunde pentru a stabili ritmul inimii: Unde este localizat pacemakerul cardiac? Care este calea de conducere de la pacemaker pana la ultima celula ventriculara? Pacemakerul functioneaza regulat si are o frecventa de descarcare corecta?

67 Pasul 1: Pasul 2: Pasul 3: Pasul 4: Pasul 5: Se calculeaza frecventa cardiaca Se determina regularitatea activarii ventriculare Se analizeaza undele P, pt a verifica daca pacemakerul cardiac este localizat in AD, la nivelul NSA Se determina intervalul PR, pt a evalua durata depolarizarii atriale si a intarzierii PA la nivelul NAV Se determina durata complexului QRS, pt a evalua conducerea PA prin miocardul venricular

68 Pasul 2: Determinarea regularitatii R R Se verifica egalitatea intervalelor R-R (folosind o rigla sau semne de marcare pe o hartie) Ritmul este regulat (R-R sunt echidistante)? Ocazional neregulat? Neregulat, dar respecta un anumit patern repetitiv? Neregulat, fara a respecta vreun patern? In exemplul nostru? Ritm regulat

69 Pasul 3: Analiza undelor P Undele P sunt prezente? Toate undele P au acelasi aspect si polaritate corecta? Undele P apar la intervale regulate? Fiecare complex QRS este precedat de o unda P? Interpretarea exemplului: Unde P normale cu 1 unda P inaintea fiecarui complex QRS

70 Pasul 4: Analiza intervalului PR Normal: secunde. (3-5 mm) Interpretare? 0.12 secunde

71 Pasul 5: Durata QRS Normal: secunde (1-3 mm) Interpretare? 0.08 secunde

72 Analiza Ritmului Cardiac Frecventa Regularitate Unde P Interval PR Durata QRS bpm regulat normale 0.12 s 0.08 s Interpretare? Ritm sinusal normal

73 Parametrii Ritmului Sinusal Normal FC Regularitate Unde P Interval PR Durata QRS bpm regulat normale s s Orice abatere de la acesti parametri indica prezenta unei aritmii cardiace

74 4) Determinarea Axei QRS (Axa Electrica a Inimii) Axa electrica a inimii reprezinta vectorul rezultant al depolarizarii ventriculare in planul frontal Se obtine prin insumarea vectorilor momentani ai activarii ventriculare (corespunzatori activarii septului, apexului, peretilor liberi si a bazelor)

75 Se determina prin analiza complexelor QRS in oricare doua derivatii ale planului frontal Sunt posibile doua abordari: Metoda geometrica, precisa dar elaborata Metoda inspectiei, rapida si usor de realizat, suficient de precisa pentru practica clinica

76 Se noteaza pe hexaxa +2 unitati pe derivatia II si +1 unitate pe avr 2 3 Se ridica perpendiculare pe derivatiile I si pe avr din punctele notate aterior 4 Se conecteaza centrul cercului cu intersectia celor doua perpendiculare 1 Se masoara amplitudinea rezultanta a QRS in oricare doua derivatii ale planului frontal (D II si avr in exemplul nostru) Se estimeaza axa sagetii galbene (la aprox. 95 ) 5 Metoda geometrica

77 Fiecare unda a complexului QRS intr-o derivatie reprezinta proiectia unui moment vectorial al depolarizarii ventriculare (activarea septului, apexului etc) pe acea derivatie Suma algebrica a amplitudinilor undelor complexului QRS intr-o derivatie a planului frontal reprezinta proiectia vectorului rezultant al activarii ventriculare (axa QRS sau axa electrica a cordului) pe acea derivatie Perpendicularele ridicate din varful proiectiilor vectorului rezultant al activarii ventriculare pe doua derivatii ale planului frontal (reprezentate ca parte a hexaxei) se intersecteaza intr-un punct care marcheaza varful vectorului rezultant al depolarizarii ventriculare Conectand centrul hexaxei cu intersectia celor doua perpendiculare va rezulta axa complexului QRS, numita si axa electrica a inimii; valori normale: intre - 30 si + 90 de grade

78 Metoda Inspectiei 1 Se identifica derivatia in care amplitudinea QRS este nula derivatia avl in acest exemplu (sageata verde pe hexaxa) 2 Se identifica derivatia perpendiculara pe cea in care amplitudinea QRS este minima derivatia II in cazul nostru (sageata galbena pe hexaxa. Daca amplitudinea QRS este +, axa va fi orientata la + 60º, daca este -, axa este orientata la - 120º. In exemplul dat, axa este orientata la + 60º

79 Axa QRS este perpendiculara pe derivatia planului frontal cu amplitudinea neta a complexului QRS minima sau chiar nula; un complex echidifazic este usor vizibil pe traseul ECG, si are amplitudinea neta 0 Axa QRS este paralela cu derivatia planului frontal in care amplitudinea QRS are valoarea cea mai mare Cele doua derivatii implicate in demersurile descrise mai sus sunt perpendiculare intre ele

80 +50

81 +30

82 Daca nu exista nici o derivatie in care amplitudinea QRS este nula sau aproape nula, cel mai probabil axa QRS formeaza bisectoarea a doua derivatii separate printr-un unghi de 30, pe care rezultanta QRS are proiectia maxima si egala +15

83 0

84 +120

85 Orientatarea Axei QRS Limitele normale ale axei QRS sunt cuprinse intre - 30 o si + 90 o. O axa QRS situata intre - 30 o si - 90 o este anormala si numita deviatie axiala stanga. Deviatia axiala dreapta este definita de orientarea axei QRS intre + 90 o si o abnormal and called -150 o 180 o 150 o -120 o 120 o O axa QRS localizata intre o si - 90 o defineste deviatia axiala superioara dreapta. o -90 o o 90 o -60 o 60 o -30 o 30 o 0 o

86 Deviatia Axiala Stanga Deviatia axiala stanga la cordul hipertensiv (hipertrofie ventriculara stanga). Observati si prelungirea discreta a duratei complexului QRS. Deviatia axiala stanga produsa de blocul de ram stang. Durata complexului QRS este considerabil crescuta

87 Deviatia Axiala Dreapta Stenoza congenitala a valvei pulmonare cu hipertrofie ventriculara dreapta. Deviatie dreapta superioara a axei QRS, cu o prelungire discreta a duratei complexului QRS Deviatie axiala dreapta indusa de blocul de ram drept. Se observa cresterea considerabila a duratei complexului QRS.

88 Intervalele de interes sunt PR si QT, dar si durata complexelor QRS Intervalul PR 5) Masurarea Intervalelor < 0.12 s s > 0.20 s Eliberare crescuta de catecolamine Sindrom Wolff- Parkinson-White Normal Blocuri ale NAV Wolff-Parkinson-White 1st Degree AV Block

89 Complexul QRS < 0.10 s s > 0.12 s Normal Hemiblocuri Bloc complet de ram drept sau stang Extrasistole ventriculare Ritmuri ventriculare Incomplete bundle branch block 3 rd degree AV block with ventricular escape rhythm

90 Intervalul QTc < 0.44 s > 0.44 s Long QT Normal QT lung Torsades de Pointes Un QT prelungit poate fi deosebit de periculos, indica predispozitia la un tip de tahiaritmie ventricualra numit torsada varfurilor. Cauze posibile: medicamente, tulburari electrolitice, afectiuni ale SNC, infarct miocardic, afectiuni cardiace congenitale.

91 QT = 0.40 s RR = 0.68 s Square root of RR = 0.82 QTc = 0.40/0.82 = 0.49 s Intervalul PR? Durata QRS? Intervalul QTc? 0.16 secunde 0.08 secunde 0.49 secunde Interpretare: PR si QRS normale, QT lung

92 RR 23 boxes 17 boxes 10 boxes QT 13 boxes Normal QT Long QT QTc = QT/ RR Inainte sa calculam QTc, putem face urmatoarea estimare rapida: Un QT > jumatate din intervalul RR este probabil lung

93 6) Hipertrofia ECG permite diagnosticarea: Dilatarii atriale drepte Dilatarii atriale stangi Hipertrofiei ventriculare drepte (HVD) Hipertrofiei ventriculare stangi (HVS)

94 Hipertrofia Ventriculara Este indusa de presiuni sau volume crescute Modificari ECG Unde R, S cu amplitudine crescuta Deviatia axei QRS Cresterea deflexiunii intrinsecoide Inversarea undei T

95 7) Modificari ECG Induse de Infarctul Miocardic Urmarim urmatoarele: Unde Q anormale Supra sau subdenivelari ale segmentului ST Unde T ascutite, aplatizate ori inversate Supra sau subdenivalarea segmentului ST in cel putin doua derivatii este semnul ECG cel mai precoce si mai relevant in cursul unui infarct miocardic acut (IMA)

96 Supradenivelarea segmentului ST Supradenivelarea segmentuli ST in cel putin 2 derivatii este un indiciu pertinent pentru diagnosticul IMA Intrucat perfuzia miocardului este regionala, aria infarctata este la randul sau regionala derivatii ECG specifice permit estimarea localizarii zonei lezate

97 IMA Anterior

98 IMA Inferior Segmentul ST este supradenivelat in derivatiile II, III si avf

99 IMA Anterolateral In acest caz sunt afectati atat peretele anterior (V 2 -V 4 ) cat si cel lateral (V 5 -V 6, I si avl)!

100 8) Alte patologii diagnosticabile prin ECG Efectul unor medicamente (digitala, antiaritmice din clasele 1 si 3, medicamente psihotrope etc.) Anomalii electrolitice si metabolice (Ca, K, Mg, ph etc.) Etc

101 Teste ECG Speciale Folosirea unor derivatii suplimentare utile in diagnosticul IMA peretelui ventricular drept si posterior (V1R V6R; V8, V9) Derivatii esofagiene pentru o mai buna inregistrare a activitatii atriale sau pentru monitorizarea intraoperatorie a ischemiei miocardice Monitorizarea Holter intregistrarea ECG, a presiunii arteriale ori a amandurora timp de h; ECG evalueaza aritmii intermitente Inregistrarea evenimentelor patologice sporadice pana la 30 de zile, poate surprinde tulburari de ritm infrecvente care ar putea scapa monitorizarii Holter; sistemul de inregistrare este activat de pacient cand apar simptomele Monitorizarea continua a segmentului ST detectia precoce a ischemiei si a unor forme grave de aritmii (monitorizare intra- si postoperatorie, etc)

102 Bibliografie Boron and Boulpaep, Fiziologie Medicala, editia a 3-a, Hipocrate 2017 (pag ) Dan Dobreanu Fiziologia Inimii, Targu-Mures University Press, 2007 (pag ) Guyton and Hall, Tratat de Fiziologie a Omului, editia a 11-a, Editura Medicala Calisto, 2007 (pag ) Bara Constantin, Electrocardiografie clinica in chestionare explicative, Editura Medicala 1993 (pag )

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