ECG IN STEMI.ppt
- 1. ECG IN STEMI DR AZERIN OTHMAN HRPZ II KOTA BHARU STEMIWORKSHOP
- 2. • Diagnosis of acute STEMI • Correlate ECG changes and candidate for reperfusion therapy • Assess the success of reperfusion therapy • Correlate location of MI & extent of myocardial injury - stratification/prognostication/complications - optimal treatment ROLES OF ECG IN STEMI
- 4. CLINICAL DIAGNOSIS OF ACUTE STEMI 1.Chest pain or equivalent symptoms or events suggestive ischaemic in origin. + 2.ECG changes : Any of the followings (on its own or in any combinations): ST elevation in 2 or more contiguous leads of standard 12 lead ECG as follows: Posterior Infarction RV Infarction New onset LBBB + 3.Elevated cardiac markers 4 - ≥ 1mm limb leads : I, aVL, II, III, aVF. - ≥ 1mm precordial leads : V4 - V6. - ≥ 2 mm precordial leads : V1 - V3 .
- 5. Other causes of raised cardiac markers – CKMB & Troponin
- 6. ECG CHANGES IN STEMI 1.HYPERACUTE PEAK T WAVE - HYPERACUTE T WAVE - T waves tall, symmetrical & peaked - usually present 5- 30 minutes after the onset of MI later followed by ST changes.
- 7. ECG CHANGES IN STEMI 2.ST SEGMENT ELEVATION - HYPERACUTE ST ELEVATION - commonly seen - usually within hours after onset of MI - occurs in the leads facing the infarction
- 8. ECG CHANGES IN STEMI 3. PATHOLOGICAL Q WAVE - FULLY EVOLVED PHASE - at least 0.04 seconds in duration - depth of more than 25% of ensuing R wave - usually after 9 hours, occasionally after 24 hours after onset of MI - evidence of myocardial necrosis - loss of R wave after 12 hours
- 9. ECG CHANGES IN STEMI 4.RESOLUTION OF ST ELEVATION & T WAVE INVERSION - RESOLUTION PHASE - ST segment elevation diminishes and T wave inverted. - occurs around 1 week
- 10. ECG CHANGES IN STEMI 5.RESOLUTION OF ST ELEVATION & T WAVE INVERSION - CHRONIC PHASE - persistent Q wave or reduced /poor R wave - T wave normalised. - occurs after months-years
- 11. SEQUENCE OF ECG CHANGES IN STEMI
- 13. ST ELEVATION IN ACUTE STEMI ST elevation in 2 or more contiguous leads of standard 12 lead ECG as follows: - ≥ 1mm limb leads : I, aVL, II, III, aVF. - ≥ 1mm precordial leads : V4 - V6. - ≥ 2 mm precordial leads : V1 - V3 .
- 14. Inferior STEMI • ST elevation: II,III,aVF • Reciprocal ST depression : I,aVL • Infarct artery: RCA (80%) LCX (20%)
- 15. Anteroseptal STEMI • ST elevation: V1-V4 • Can have reciprocal ST depression inferior leads • Infarct artery : LAD
- 16. Extensive Anterior STEMI • ST elevation: I,aVL, V1-V6. • Can have reciprocal ST depression inferior leads • Infarct artery : LAD
- 17. Anterior STEMI • ST elevation: V1-V6. • Can have reciprocal ST depression inferior leads • Infarct artery : LAD
- 18. Lateral STEMI • ST elevation: I,aVL , V5-V6. • Can have reciprocal ST depression inferior leads • Infarct artery : LCX
- 19. Posterior infarction • Usually associated with inferior and/or lateral and or RV STEMI • 4% occur alone - called true/isolated posterior STEMI • ECG of posterior infarction are : ST depression ≥ 1mm (0.1mv) with upright T wave precordial leads : V1 - V4 and / or ST elevation ≥ 1mm (0.1mv) in the posterior leads : V7 - V9 and / or Tall R wave and duration ≥ 0.04s precordial leads : V1 or V2 and / or The ratio of the R / S wave > 1 precordial leads : V1 or V2 *Some use ST elevation ≥ 0.5mm in V7-V9 for diagnosis of posterior MI
- 20. True posterior STEMI ST depression ≥ 1mm (0.1mv) with uprightT wave precordial leads : V1 –V3
- 21. If we flip or view ECG posteriorly ST depression ≥ 1mm (0.1mv) with uprightT wave precordial leads : V1 –V3 ST elevation when view ECG posteriorly
- 23. ST depression ≥ 1mm (0.1mv) in leads : V1-V3 ST elevation ≥ 1mm (0.1mv) in leads : V7-V9
- 24. Other posterior leads placement…. LEADV1 → LEAD V7 LEAD V2 → LEAD V8 LEAD V3 → LEAD V9
- 25. ECG-POSTERIOR STEMI Tall R wave and duration ≥ 0.04s precordial leads : V1 or V2 The ratio of the R / S wave > 1 precordial leads : V1 or V2 Flip back OTHER CAUSES OFTALL R -V1-V2
- 26. TRUE POSTERIOR INFARCTION • ST depression + upright T: V1-V4 and/or • ST elevation : V7-V9 and/or • Tall R wave and duration ≥ 0.04s precordial leads : V1 or V2 and /or • The ratio of the R / S wave > 1 precordial leads : V1 or V2 • Infarct artery : LCX POSTERIOR LEADS
- 27. Infero - lateral - posterior STEMI • ST elevation : II,III,aVF V4-V6 • ST depression: V1-V3 • Infarct artery : RCA ST depression ≥ 1mm (0.1mv) with uprightT wave precordial leads : V1 –V2
- 28. RV INFARCTION • Usually with inferior STEMI & ST elevation is transient, disappearing in less than 10 hours following its onset in half of patients. • Do right sided ECG in all inferior STEMI • ECG of RV infarction is
- 29. Do right sided ECG
- 30. • ST elevation : RV3 ,RV4 • Usually asstd : inferior STEMI • Infarct artery : RCA
- 31. LBBB AND STEMI • New onset LBBB - as STEMI presentation • STEMI AS LBBB - higher hospital mortality • Guidelines new LBBB STEMI reperfusion RX • Beside STEMI many other causes of LBBB • LBBB obscure classical STEMI ECG-Q wave & ST-T changes • How do we predict the likelihood of LBBB as true STEMI ( the best & goal standard is coronary angiogram !!) BUT…. PCI NOT READILY AVAILABLE EVERYWHERE & WITHIN TIME ?? ENSURE GIVE FIBRINOLYSIS TO “TRUE “ STEMI…
- 32. LBBB IN STEMI LBBB can be associated with STEMI in the following ways • True STEMI - with massive myocardial damage • Preexisting LBBB with acute STEMI • Transient ischemic LBBB during STEMI • Rate dependent LBBB (Usually tachycardia related ) • STEMI in pacemaker rhythms CAUSES OF LBBB - STEMI - HYPERTENSION - AORTIC VALVE DISEASE - EXTENSIVE CAD - DEGENERATIVE DISEASE - CONGENITAL HEART DISEASE - PACEMAKER RHYTHM
- 33. So we analyse with …. SGARBOSSA CRITERIA
- 34. SGARBOSSA CRITERIA CRITERIA 1: ST ELEVATION > 1MM IN ANY CONCORDANT LEAD ( POSITIVEQRS) SCORE : 5 - MOST PREDICTIVE CRITERIA 2: ST DEPRESSION > 1MM IN ANY LEAD V1-V3 SCORE : 3 CRITERIA 3: ST ELEVATION > 5MM IN ANY DISCORDANT LEAD ( NEGATIVE QRS) SCORE : 2 - LEAST PREDICTIVE SCORE ≥ 3 : 90% SPECIFIC FOR STEMI & CUTPOINT USED
- 35. LBBB + INFERIOR STEMI LBBB + ST > 1mm in lead with a positiveQRS complex ( lead II) → score 5 likely STEMI as score ≥ 3
- 36. LBBB + ANTERIOR MI LBBB + ST elevation > 1mm in leads with positive QRS complex ( V4-V5)→ score 5 likely STEMI as score ≥ 3
- 37. LBBB LBBB + ST elevation > 5mm in leads with negative QRS complex (V1-V3) → score 2 unlikely STEMI as score < 3
- 38. LBBB AND PROBABILITY OF STEMI
- 39. CLINICAL ASSESSMENTOF SUCCESSFUL REPERFUSION RESOLUTION OF CHEST PAIN ABSOLUTE RESOLUTION OF ST ELEVATION OR REDUCTION OF ≥ 50% OF ST ELEVATION EARLY PEAK CARDIAC ENZYME IDIOVENTRICULAR RHYTHM TWAVE INVERSION WITHIN 4 HOURS
- 40. PRE REPERFUSION RX POST REPERFUSION RX-90 MIN CLINICAL ASSESSMENT OF SUCCESSFUL REPERFUSION
- 41. Correlation location of STEMI & clinical outcome