Localize Myocardial Ischemia on ECG

Myocardial Ischemia / Injury / Infarction Localization on ECG

ECG Dr. UZMA ANSARI Using ECG one can localize the site of Ischemia / Injury/ Infarction. Chief diagnostic tool to identify Oct 15, 2010

Why Localize ? Dr. UZMA ANSARI Oct 15, 2010

Anatomy Of heart ,[object Object],[object Object],[object Object],[object Object],[object Object],Oct 15, 2010 Dr. UZMA ANSARI Apex – Left Ventricle Borders

SURFACES OF HEART ,[object Object],[object Object],[object Object],Oct 15, 2010 Dr. UZMA ANSARI

Anatomy of Left ventricle Dr. UZMA ANSARI According to new terminology infero posterior should be called infero basal - Source: AHA Oct 15, 2010 Base/posterior surfase

Blood supply ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Oct 15, 2010 Dr. UZMA ANSARI

Dr. UZMA ANSARI Oct 15, 2010 LMCA Entire LV, LA, except the posterior portion of IV septal and adjacent area when PD is a branch of RCA LAD ,[object Object],[object Object],[object Object],1 st D (Branch of LCA) High lateral wall of LV 2 nd D Lower lateral aspect of LV freewall 1 st Septal Superior and Anterior portion of IV septal Minor Septal Inferior and anterior 1/3 rd of septum Ramus Inter ventricularis (From LCA) Anterior aspect of apex

Dr. UZMA ANSARI Oct 15, 2010 LCX ,[object Object],[object Object],[object Object],Obtuse margin of heart and entire posterior wall. LA, posterior IV septum if PD arises from LCX OM ,[object Object],Obtuse margin of heart adjacent to LV Postero lateral branch ,[object Object],[object Object],Posterior and diaphragm LV wall PD ,[object Object],[object Object],Posterior IV septum and Diaphragm LV

Dr. UZMA ANSARI Oct 15, 2010 RCA RA and part of LA, RV, Posterio superior IV septum. SN, AV node Acute Marginal Inferior and diaphragmatic surface of RV Conus Branch Outflow track of RV SN branch RA, LA,SN RV Branch RV Atrial Branch Right Atrium

Localization - Left Coronary Artery (LCA) Dr. UZMA ANSARI Oct 15, 2010 January 2004

Localization Right Coronary Artery (RCA) Dr. UZMA ANSARI Oct 15, 2010 January 2004

Localization Summary Dr. UZMA ANSARI Oct 15, 2010 January 2004

Prevalence of Culprit Artery Dr. UZMA ANSARI 57% Oct 15, 2010 RCA 45% LCX 12% LAD 36%

Prevalence of STEMI Dr. UZMA ANSARI Oct 15, 2010 Inferior 58% Anterior 39% Other 3%

Post Ischemic T wave changes ,[object Object],[object Object],Dr. UZMA ANSARI ST depression, peaked T-waves, then T-wave inversion ST elevation & appearance of Q-waves ST segments and T-waves return to normal, but Q-waves persist Ischemia ST depression & T-wave inversion ST depression & T-wave inversion ST returns to baseline, but T-wave inversion persists Ischemia Oct 15, 2010 January 2004 Infarction Fibrosis Infarction Fibrosis

Localization Dr. UZMA ANSARI I Lateral II Inferior III Inferior aVR aVL Lateral V1 Septal aVF Inferior V2 Septal V3 Anterior V4 Anterior V5 Lateral V6 Lateral Oct 15, 2010 January 2004 The changes of ischemia/injury/infarction are seen in the leads Over lying the area involved

Localization Dr. UZMA ANSARI Inferior: II, III, AVF Septal: V1, V2 Anterior: V3, V4 Lateral: I, AVL, V5, V6 Oct 15, 2010 January 2004 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Frontal Plane Leads Dr. UZMA ANSARI aVL -30 0 I II III 0 0 aVF -aVR +90 0 +60 0 +120 0 -150 0 30 0 Oct 15, 2010

Recommendations Dr. UZMA ANSARI - AHA guidelines ‘ ECG machines should be equipped with switching systems that will allow the limb leads to be displayed and labelled appropriately in their anatomically contiguous sequence’ Oct 15, 2010 aVL, Lateral II, Inferior V1 septal V4 anterior I,Lateral aVF Inferior V2 septal V5 lateral -aVR III, inferior V3 anterior V6 lateral

Localization - Myocardial Infarct Dr. UZMA ANSARI The localisation of the occlusion can be adequately visualized using a coronary angiogram (CAG). Oct 15, 2010 Localization ST elevation Reciprocal ST depression Coronary Artery Anterior MI V1-V6 None LAD Septal Mi V1-V4, disappearance of septum Q in leads V5,V6 none LAD Lateral MI I, aVL, V5, V6 II,III, aVF (inferior leads) LCX Inferior MI II, III, aVF I, aVL (lateral lead) RCA (80%) or LCX (20%) Posterior MI V7, V8, V9 high R in V1-V3 with ST depression V1-V3 > 2mm (mirror view) RCA or LCX Right Ventricle MI V1, V4R I, aVL RCA Atrial MI PTa in I,V5,V6 PTa in I,II, or III RCA

Anterior Wall Dr. UZMA ANSARI I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Oct 15, 2010

Septal I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 ,[object Object],[object Object],Dr. UZMA ANSARI Oct 15, 2010

Septal Wall ,[object Object],[object Object],[object Object],I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Dr. UZMA ANSARI Oct 15, 2010

Practice 2 Dr. UZMA ANSARI ,[object Object],[object Object],Oct 15, 2010 January 2004

Dr. UZMA ANSARI Lateral Wall ,[object Object],[object Object],[object Object],I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Oct 15, 2010 January 2004

Lateral Wall ,[object Object],[object Object],[object Object],I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Dr. UZMA ANSARI Oct 15, 2010

Lateral Wall ,[object Object],[object Object],Dr. UZMA ANSARI Lateral Wall Oct 15, 2010

Lateral MI Dr. UZMA ANSARI Oct 15, 2010

Localization - Extensive Anterior MI Dr. UZMA ANSARI Oct 15, 2010 January 2004

Practice 1 Dr. UZMA ANSARI ,[object Object],[object Object],[object Object],Oct 15, 2010 January 2004

Dr. UZMA ANSARI Inferior Wall ,[object Object],[object Object],[object Object],I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Oct 15, 2010

Inferior MI Dr. UZMA ANSARI Oct 15, 2010

Practice 3 Dr. UZMA ANSARI ,[object Object],[object Object],Oct 15, 2010 January 2004

Practice 4 Dr. UZMA ANSARI ,[object Object],[object Object],[object Object],Oct 15, 2010 January 2004

Posterior Leads ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dr. UZMA ANSARI Oct 15, 2010 January 2004

Localization Criteria: Occluded artery to the ECG Dr. UZMA ANSARI Source: AHA Oct 15, 2010 January 2004

Anterior wall MI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dr. UZMA ANSARI Oct 15, 2010 January 2004 ST elevation ST depression V1-V4, lead I, aVL, often in aVR II, III, aVF (Inferior) often V5 aVL > aVR III > II

Occlusion: Between 1 st Septal and D1 Dr. UZMA ANSARI Oct 15, 2010 January 2004

Occlusion: More distally i.e. below Septal 1 and D1 ,[object Object],[object Object],[object Object],[object Object],[object Object],Dr. UZMA ANSARI Oct 15, 2010 January 2004

Oct 15, 2010 January 2004 Dr. UZMA ANSARI

Recommendation Dr. UZMA ANSARI Oct 15, 2010 January 2004

Inferior MI ,[object Object],[object Object],[object Object],[object Object],Oct 15, 2010 January 2004 Dr. UZMA ANSARI Whichever provides PD – Dominant artery

Proximal RCA ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dr. UZMA ANSARI Oct 15, 2010 January 2004

Inferior MI +Posterior M.I. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Dr. UZMA ANSARI Oct 15, 2010 January 2004

Multiple infarct ,[object Object],Oct 15, 2010 January 2004 Dr. UZMA ANSARI

Multiple Ischemia / Infarction / Injury ,[object Object],[object Object],Dr. UZMA ANSARI ST depression in more than / equal to 8 leads along with ST elevation in aVR and / or V1Indicates 75% chances of 3 vessel disease / LMCA stenosis Source: AHA Oct 15, 2010 January 2004

[object Object],[object Object],Dr. UZMA ANSARI CAG Severe stenosis of proximal LAD If missed and not treated, it could lead to AWMI So, If we get deeply inverted T wave (> 0.5 mV) with prolonged QT, one should suspect Severe stenosis of proximal LAD with / without CVA Appropriate treatment Oct 15, 2010 January 2004

Thank You Dr. UZMA ANSARI Oct 15, 2010

Localize Myocardial Ischemia on ECG

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Localize Myocardial Ischemia on ECG