ECG CHANGES IN ACUTE MYOCARDIAL
INFRACTION
NORMAL CONDUCTION SYSTEM
ECG LEADS
•
The standard EKG has 12
–
leads: 3 Standard Limb Leads
–
3 Augmented Limb Leads 6
–
Precordial Leads
ECG LIMB LEADS
• Leads are electrodes which measure the difference in electrical potential
either:between
1. Two different points on the body (bipolar leads)
2. One point on the body and a virtual reference point with zero electrical
potential,
located in the center of the heart (unipolar
leads) RECORDING OF THE ECG
Limb leads are I, II, II.
•
Each of the leads are bipolar; i.e., it requires two sensors on the skin to make a
•
lead. If one connects a line between two sensors, one has a vector.
•
There will be a positive end at one electrode and negative at the other.
• The positioning for leads I, II, and III were first given by Einthoven
(Einthoven’s
triangle).
ECG LIMB LEADS:
PRECORDIAL LEADS:
CONTIGUOUS LEADS:
•
Lateral wall: I, aVL, V5, V6 Inferior wall: II, III, avF Septum: V1 and V2
•
Anterior wall: V3 and V4
•
Posterior wall: V7-V9 (leads placed on the patient’s back 5th intercostal
• space
•
creating a 15 lead
EKG)
CORONARY CIRCULATION
•Coronary arteries and veins
•Myocardium extracts the largest amount of oxygen as blood moves into general
circulation
•Oxygen uptake by the myocardium can only improve by increasing blood flow
through the coronary arteries
•If the coronary arteries are blocked, they must be reopened if circulation is going to
be restored to that area of tissue supplied
ST SEGMENT
•
Connects the QRS complex and T wave
•
Duration of 0.08-0.12 sec (80-120 msec) T
waves
V1
I
NORMAL
ELEVATED
V3
DEPRESSED
T WAVES
•Represents repolarization or recovery of ventricles
•Interval from beginning of QRS to apex of T is referred to as the absolute refractory
period
T WAVE MORPHOLOGY:
I UPRIGHT
aVR INVERTED
DEFINITION OF ACUTE MYOCARDIAL INFARCTION:
The term acute myocardial infarction (MI) should be used when there is
acute
myocardial injury with clinical evidence of acute myocardial ischemia and with
detection of a rise and/or fall of cTn (Cardiac troponin ) values with at least one value
above the 99th percentile URL (upper range of limit) and at least one of the following:
•Symptoms of myocardial ischemia
•New ischemic electrocardiographic (ECG) changes
•Development of pathologic Q waves
•Imaging evidence of new loss of viable myocardium or new regional wall
motion abnormality in a pattern consistent with an ischemic etiology
•Identification of a coronary thrombus by angiography or autopsy
Acute Coronary Syndrome Based On ECG And Cardiac
Enzymes:
ECG
ST ELEVATION
NO ST ELEVATION
DO CARDIAC BIOMARKER
STEMI
CARDIAC BIOMARKER NORMAL CARDIAC BIOMARKER RISE
UNSTABLE ANGINA (UA) NSTEMI
EVALUATING FOR ST SEGMENT ELEVATION
•Locate the J-point
•Identify/estimate where the isoelectric line is noted to be
•Compare the level of the ST segment to the isoelectric line
•Elevation (or depression) is significant if more than 1 mm (one small box) is seen in 2
or more leads facing the same anatomical area of the heart
THE J POINT
• J point – where the QRS complex and ST segment meet
• ST segment elevation - evaluated 0.04 seconds (one small box) after J
point
Coved shape usually indicates
acute injury Concave shape is
usually benign especially if
patient
is asympto- matic
Significant ST Elevation
•
ST segment elevation measurement :starts 0.04 seconds after J
•
point ST elevation
–
> 2mm (2 small box /0.2 mV) in V2 or V3
–
>1mm (1 small box/0.1 mV) in other leads
ECG IN STEMI:
-Q waves , ST elevations, hyper acute T waves; followed by T wave
inversions.
–-Clinically
> 2mm significant ST/0.2
(2 small box segment
mV) inelevations:
V2 or V3
– >1mm (1 small box/0.1 mV) in other
leads
Note: LBBB and pacemakers can interfere with diagnosis of MI on
ECG
ersions ( 1.0 mm at least) without Q
w R/S ratio >1.
ECG IN NSTEMI:
-ST depressions (0.5 mm at least) or T wave inv aves
in 2 contiguous leads with prominent R wave
or LAD stenosis,>2mm inversions in
–Isolated T wave inversions:
•
can correlate with increased risk for MI
•
may represent Wellen’s syndrome:
anterior precordial leads)
(critical
EVOLUTION OF AMI
A - pre-infarct (normal)
B - Tall T wave (first few minutes of infarct) C - Tall
T wave and ST elevation (injury)
D - Elevated ST (injury), inverted T wave
(ischemia), Q wave (tissue death)
E - Inverted T wave (ischemia), Q wave
(tissue death)
F - Q wave (permanent marking)
ST SEGMENT ELEVATION
ANATOMIC
GROUPS
LATERAL WALL MI
INFERIOR WALL MI
SEPTAL MI
ANTERIOR WALL MI
POSTERIOR MI RECIPROCAL
CHANGES ST DEPRESSION IN V1 V2
V3
MI- FEW ECGS
EVOLUTION OF ACUTE ANTERIOR MYOCARDIAL INFARCTION AT 3
HOURS
LATERAL MI
INFERIOR WALL MI
