ΗΚΓ ΚΑΙ ΣΝ Γ Ε Ω Ρ Γ Ι Ο Σ Γ Ι ΑΝ Ν Ο Π Ο Υ Λ Ο Σ Ε Π Ι Μ Ε Λ Η Τ Η Σ Β Κ Α Ρ Δ Ι Ο Λ Ο Γ Ι Α Σ Γ Ν Α «Γ. Γ Ε Ν Ν Η Μ Α Τ Α Σ»

ΗΚΓ ΚΑΙ ΣΝ Γ Ε Ω Ρ Γ Ι Ο Σ Γ Ι ΑΝ Ν Ο Π Ο Υ Λ Ο Σ Ε Π Ι Μ Ε Λ Η Τ Η Σ Β Κ Α Ρ Δ Ι Ο Λ Ο Γ Ι Α Σ Γ Ν Α «Γ. Γ Ε Ν Ν Η Μ Α Τ Α Σ»

ΑΝΔΡΑΣ 48 ΕΤΩΝ ΜΕ ΑΛΓΟΣ ΕΠΙΓΑΣΤΡΙΟΥ ΚΑΙ ΝΑΥΤΙΑ

ECG evidence of myocardial ischaemia in the distribution of a left circumflex artery is often overlooked. Isolated ST-segment depression 0.5 mm in leads V1 V3 may indicate left circumflex occlusion and can best be captured using posterior leads at the fifth intercostal space (V7 at the left posterior axillary line, V8 at the left mid-scapular line and V9 at the left paraspinal border).

ΔΥΝΑΜΙΚΌ ΕΝΕΡΓΕΊΑΣ

ΤΟ ΈΜΦΡΑΓΜΑ ΣΤΟ ΗΚΓ

LMA OCCLUSION Widespread horizontal ST depression, most prominent in leads I, II and V4-6 ST elevation in avr 1mm ST elevation in avr V1

LEFT BUNDLE BRANCH BLOCK ΑΠΟΚΛΕΙΣΜΟΣ ΑΡΙΣΤΕΡΟΥ ΣΚΕΛΟΥΣ

LBBB CRITERIA QRS duration of > 120 ms Dominant S wave in V1 Broad monophasic R wave in lateral leads (I, avl, V5-V6) Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in avl) Prolonged R wave peak time > 60ms in left precordial leads (V5-6)

Appropriate discordance: the ST segments and T waves always go in the opposite direction to the main vector of the QRS complex Poor R wave progression in the chest leads Left axis deviation

Ann Emerg Med 2008;52:329-336.e1. J Am Coll Cardiol 2012;60:96-105.

MODIFIED SGARBOSSA S CRITERIA Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med 2012;60:766-76

79 bpm 60 bpm

Cabrera E, Friedland C. La onda de activacion ventricular en el bloqueo de rama izquierda con infarto: un nuevo signo electrocardiografico. Arch Inst Cardiol Mex. 1953;23:441 460.

ΤΟ ΗΚΓ ΣΤΗΝ ΙΣΧΑΙΜΙΑ ST depression can be either upsloping, downsloping, or horizontal (see diagram below). Horizontal or downsloping ST depression 0.5 mm at the J-point in 2 contiguous leads indicates myocardial ischaemia. ST depression 1 mm is more specific and conveys a worse prognosis. ST depression 2 mm in 3 leads is associated with a high probability of NSTEMI and predicts significant mortality (35% mortality at 30 days). Upsloping ST depression is non-specific for myocardial ischaemia.

T WAVE

ΥΠΕΡΟΞΕΑ Τ

T wave inversion may be considered to be evidence of myocardial ischaemia if: At least 1 mm deep Present in 2 continuous leads that have dominant R waves (R/S ratio > 1) Dynamic not present on old ECG or changing over time

Inverted T waves Normal finding in children Persistent juvenile T wave pattern Myocardial ischaemia and infarction Bundle branch block Ventricular hypertrophy ( strain patterns) Pulmonary embolism Hypertrophic cardiomyopathy Raised intracranial pressure or stroke

ΝΕΑΡΟΣ ΑΝΔΡΑΣ, ΠΡΟΑΘΛΗΤΙΚΟΣ ΕΛΕΓΧΟΣ

ΓΥΝΑΊΚΑ 56 ΕΤΏΝ, ΚΑΠΝΊΣΤΡΙΑ, ΜΕ ΔΙΑΛΕΊΠΟΝ ΘΩΡΑΚΙΚΌ ΆΛΓΟΣ ΑΠΌ 3 ΕΒΔΟΜΆΔΩΝ

ΣΎΝΔΡΟΜΟ WELLENS Deeply-inverted or biphasic T waves in V2-3 (may extend to V1-6) Isoelectric or minimally-elevated ST segment (< 1mm) No precordial Q waves Preserved precordial R wave progression Recent history of angina ECG pattern present in pain-free state Normal or slightly elevated serum cardiac markers

DE WINTER S T WAVES Tall, prominent, symmetric T waves in the precordial leads Upsloping ST segment depression >1mm at the J- point in the precordial leads Absence of ST elevation in the precordial leads ST segment elevation (0.5mm-1mm) in avr Normal STEMI morphology may precede or follow the dewinter pattern

ΔΙΑΤΑΡΑΧΕΣ ST-T ΔΕΝ ΕΊΝΑΙ ΠΑΝΤΑ ΙΣΧΑΙΜΙΑ

Type 1 (Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave)

Υπάρχει κατάσπαση του ST σε κάποια απαγωγή εκτός των AVR και V1; STEMI Οι ανασπάσεις είναι με το κυρτό προς τα πάνω ή οριζόντιες; STEMI Η ανάσπαση στην III είναι μεγαλύτερη από τη II; STEMI Κατάσπαση του PR σε πολλαπλές απαγωγές; Περικαρδίτιδα

Spiked Helmet sign