The Electrocardiography of Myocardial Infarction and Ischemia
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1 The Electrocardiography of Myocardial Infarction and Ischemia Pai-Feng Kao MD Cardiology division Taipei Medical University-Wan Fang Hospital Date:
2 Schema of the ischemic cascade
3 Acute Myocardial Infarction
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5 The 12-Leads The 12-leads include: 3 Limb leads (I, II, III) 3 Augmented leads (avr, avl, avf) 6 Precordial leads (V 1 - V 6 )
6 Electrocardiogram (ECG) Composite of all action potentials of nodal and myocardial cells detected, amplified and recorded by electrodes on arms, legs and chest
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15 Significance of ECG waveforms P-wave: signature of atrial excitation QRS-complex: signature of ventricular excitation T-wave: signature of ventricular repolarization Atrial repolarization is buried in QRS-complex and thus not detectable
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25 myocardial ischemia 可分為 1. subendocardial ischemia 2. subepicardial ischemia (=transmural ischemia) myocardial injury 也可分為 1. subendocardial injury 2. subepicardial injury (=transmural injury)
26 Myocardial ischemia and ST-T changes 正常狀況下, 心室去極化是由 endocardium 到 epicardium, 再極化剛好相反, 由 epi 到 endocardium, 但再極化跟去極化電性相反, 所以心室去極化跟再極化的電氣方向 (polarity) 大致相同 ( 所以 QRS 方向跟 T 的方向大多相近 ) 但 ischemia 時, Na-K pump 失去活性 (reduced ATP production), 所以再極化的速度減慢, 或根本形成 partial depolarization status, 於是 ST segment and/or T wave 會有變化
27 其心電圖特徵為 : Subendocardial ischemia: prolonged QT interval or increased amplitude of the T wave or both Subepicardial or transmural ischemia: inversion of the T waves Subendocardial injury: ST segment depression Subepicardial or transmural injury: ST segment elevation
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30 Two cause of ST segment deviation during myocardial ischemia Shortening and decreased amplitude of the action potential Depolarization (i.e. a less negative resting membrane potential) ----Potential differences ----Systolic current of injury
31 Depolarization creates potential differences, resulting in a diastolic current of injury
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36 Ischemia 時為何 T wave 會 inversion (I) 正常狀況下, 心室去極化是由 endocardium 到 epicardium, 再極化剛好相反, 由 epi 到 endocardium, 但再極化跟去極化電性相反, 所以心室去極化跟再極化的電氣方向 (polarity) 大致相同 ( 所以 QRS 方向跟 T 的方向大多相近 ) Ischemia 時, Na-K pump 失去活性 (reduced ATP production), 所以再極化的速度減慢, 或根本形成 partial depolarization status, 於是 ST segment and/or T wave 會有變化
37 Ischemia 時為何 T wave 會 inversion (II) Recovery is more delayed in the subepicardial layers, and the subendocardial muscle fibers seem to recover first----transmural 或是 subepicardial ischemia 時為何 T wave 會 inversion
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40 Electrocardiography of Myocardial Ischemia
41 T wave changes associated with ischaemia
42 Tall T waves in leads V2 and V3 in patient with recent inferoposterior myocardial infarction, indicating posterior ischaemia Copyright 2002 BMJ Publishing Group Ltd. Channer, K. et al. BMJ 2002;324:
43 Tall T waves in myocardial ischaemia
44 Arrowhead T wave inversion in patient with unstable angina
45 Biphasic T waves in man aged 26 with unstable angina
46 ST changes with ischaemia showing normal wave form (A); flattening of ST segment (B), making T wave more obvious; horizontal (planar) ST segment depression (C); and downsloping ST segment depression (D)
47 Subtle ST segment change in patient with ischaemic chest pain: when no pain is present (top) and when in pain (bottom)
48 Substantial ST segment depression in patient with ischaemic chest pain
49 Widespread ST segment depression in patient with unstable angina
50 Non-ischaemic ST segment changes: in patient taking digoxin (top) and in patient with left ventricular hypertrophy (bottom)
51 Different Kinds of ST-T Changes
52 Normalisation of longstanding inverted T waves in patient with chest pain
53 Reversible ST segment changes in patient with chest pain; the ST segment elevation returns to normal as the chest pain settles
54 R on T, giving rise to ventricular fibrillation
55 Acute myocardial infarction with complete heart block
56 Electrocardiography of Myocardial Infarction
57 Acute injury pattern Abnormal ST levation in 2 or more adjacent leads (except lead avr) The term derived from an injury current flowing between an injred (i.e. depolarized ) tissue and a normally polarized tissue. Most common cause of injury current and the corresponding injury pattern Acute myocardial ischemia (During thrombotic, embolic, or spastic coronary occlusion
58 Transient injury current producing a similar ECG injury pattern may result from pressure exerted by pericardial fluid during acute pericarditis
59 Long lasting or permanent under various circumstances Myocardial dyskinesis or ventricular aneurysm Pressure exerted by fibrin or calcification during chronic pericarditis Pressure exerted by a cardiac tumor Variant pattern in a normal heart with excessive asynchrony of early repolarization
60 Pericarditis The presence of effusion Injury of the superficial myocardium by pressure of fluid or fibrin Superficial myocarditis
61 Action potentials in a model cardiac cell simulating Brugada syndrome and conduction disease.
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64 Diagnostic Criteria of AMI by ECG 1. ST elevation > 1.0 mm 2 adjacent limb leads V4-V6 2. ST elevation > 2.0 mm V1-V3
65 One way to diagnose an acute MI is to look for elevation of the ST segment. ST Elevation
66 Elevation of the ST segment (greater than 1 small box) in 2 leads is consistent with a myocardial infarction. ST Elevation (cont)
67 Sequence of changes seen during evolution of myocardial infarction Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
68 Myocardial Infarction 1. Evolution * Hyperacute: Tall, peaked T- wave * Injury: ST elevation * Necrosis: Pathologic Q - wave (Q 0.04 sec and 25% R) * Ischemia: T inversion
69 Hyperacute T waves Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
70 Sometimes the QRS complex, the ST segment, and the T wave fuse to form a single monophasic deflection, called a giant R wave or tombstone Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
71 Pathological Q waves in inferior and anterior leads
72 Long standing ST segment elevation and T wave inversion associated with a previous anterior myocardial infarction (echocardiography showed a left ventricular aneurysm) Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
73 An inferolateral myocardial infarction with reciprocal changes in leads I, avl, V1, and V2 Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
74 Reciprocal changes: presence of widespread ST segment depression in the anterolateral leads strongly suggests that the subtle inferior ST segment elevation is due to acute infarction Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
75 Coronary Vessels Anterior ---LAC RPM---
76 Coronary Vessels Posterior ---LAC RPM---
77 Left coronary artery Coronary Circulation 1. anterior interventricular artery supplies interventricular septum + anterior walls of ventricles 2. circumflex artery passes around left side of heart in coronary sulcus, supplies left atrium and posterior wall of left ventricle Right coronary artery 1. posterior interventricular artery supplies posterior walls of ventricles 2. marginal artery supplies lateral R atrium + ventricle Remember: a heart that doesn t work will- LAC RPM Cornory arteries- Left Anterior Interventricular, circumflex and Posterior Interventricular and marginal Right
78 Location Anatomical relationship of leads Inferior wall Leads II, III, and avf Anterior wall Leads V1 to V4 Lateral wall Leads I, avl, V5, and V6 Nonstandard leads Right ventricle Right sided chest leads V1R to V6R Posterior wall Leads V7 to V9
79 Views of the Heart Some leads get a good view of the: Lateral portion of the heart Anterior portion of the heart Inferior portion of the heart
80 Salient Features of Acute Myocardial Infarction 1. Indicative changes (Q, ST elevation) in leads 2. Reciprocal changes in leads 3. Progressive changes in pattern from day to day
81 Anterior View of the Heart The anterior portion of the heart is best viewed using leads V 1 - V 4.
82 Other MI Locations First, take a look again at this picture of the heart. Lateral portion of the heart Anterior portion of the heart Inferior portion of the heart
83 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. Limb Leads Augmented Leads Precordial Leads
84 Other MI Locations Now, using these 3 diagrams let s figure where to look for a lateral wall and inferior wall MI. Limb Leads Augmented Leads Precordial Leads
85 Anterior MI Remember the anterior portion of the heart is best viewed using leads V 1 - V 4. Limb Leads Augmented Leads Precordial Leads
86 Acute anteroseptal wall MI
87 Acute anterior wall MI
88 Acute anterior wall MI
89 Lateral MI So what leads do you think the lateral portion of the heart is best viewed? Leads I, avl, and V 5 - V 6 Limb Leads Augmented Leads Precordial Leads
90 Anterolateral MI This person s MI involves both the anterior wall (V 2 -V 4 ) and the lateral wall (V 5 -V 6, I, and avl)!
91 Inferior MI Now how about the inferior portion of the heart? Leads II, III and avf Limb Leads Augmented Leads Precordial Leads
92 Acute inferior wall MI
93 Acute inferior and septal wall MI
94 Acute inferior wall MI with RV infarct
95 Copyright 2002 BMJ Publishing Group Ltd. Morris, F. et al. BMJ 2002;324:
96 Posterior AMI a. V1 & V2 - tall R wave - tall & wide T-wave - ST depression b. ± inferior changes of AMI c. absence of other cause for V1R
97 Isolated posterior infarction with no associated inferior changes (note ST segment depression in leads V1 to V3) Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
98 Position of V7, V8, and V9 on posterior chest wall Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
99 ST segment elevation in posterior chest leads V8 and V9 Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
100 RV Infarction NB: ST elevation > 1mm in any of V4-6R ~ 90% specific in the presence of inferior AMI
101 Placement of right sided chest leads
102 Acute inferior myocardial infarction with associated right ventricular infarction Morris, F. et al. BMJ 2002;324: Copyright 2002 BMJ Publishing Group Ltd.
103 Acute inferior wall MI with RV infarct
104 AMI & LBBB Data from the GUSTO I trial factors independently predictive of AMI with LBBB, 1. ST elevation concordant with QRS > 1 mm 5 pts 2. ST depression in V1-2-3 > 1 mm 3 pts 3. ST elevation discordant with QRS > 5 mm 2 pts
105 Left bundle branch block
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107 Inferior MI + RBBB (note Q's in II, III, avf and rsr' in lead V1)
108 Anteroseptal MI with RBBB (note Q's in leads V1- V3, terminal R wave in V1, fat S wave in V6)
109 Timetable of ECG Change In AMI
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111 Secondary ST-T change WPW syndrome Hypertrophic cardiomyopathy Left Ventricular Hypertrophy Right Ventricular Hypertrophy Complete or incomplete LBBB
112 Secondary ST-T change Pneumothorax Pulmonary emphysema and cor pulmonale Left anterior fascicular block Acute pericarditis Central nervous system disease
113 Factors affecting the ST-T and U wave configuration include:i Intrinsic myocardial disease (e.g., myocarditis, ischemia, infarction, infiltrative or myopathic processes) Drugs (e.g., digoxin, quinidine, tricyclics, and many others) Electrolyte abnormalities of potassium, magnesium, calcium
114 Factors affecting the ST-T and U wave configuration include:ii Neurogenic factors (e.g., stroke, hemorrhage, trauma, tumor, etc.) Metabolic factors (e.g., hypoglycemia, hyperventilation) Atrial repolarization (e.g., at fast heart rates the atrial T wave may pull down the beginning of the ST segment) Ventricular conduction abnormalities and rhythms originating in the ventricles
115 Electrocardiograms Showing Normal ST-Segment Elevation and Normal Variants.
116 Electrocardiograms Showing ST-Segment Elevation in Various Conditions. 1 LVH 2 LBBB 3 Acute pericarditis 4 hyperkalemia 5 acute ASMI 6 acute ASMI with RBBB 7 Brugada syndrome
117 Ventricular tachycardia
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119 Hyperkalemia
120 Hyperkalemia
121 Hyperkalemia
122 Hyperkalemia
123 Digoxin effect
124 Pericarditis
125 Thanks for Your Attention
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