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Myocardial Ischemia / Injury / Infarction Localization on ECG

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

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Why Localize ? Dr. UZMA ANSARI Oct 15, 2010

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Anatomy Of heart <ul><li>Surface </li></ul><ul><ul><li>Anterior </li></ul></ul><ul><ul><li>left </li></ul></ul><ul><ul><li>Inferior </li></ul></ul><ul><ul><li>Base </li></ul></ul>Oct 15, 2010 Dr. UZMA ANSARI Apex – Left Ventricle Borders

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SURFACES OF HEART <ul><li>Anterior: Right atrium, Right ventricle partly by LV,LA. LEFT : LV,LEFT AURICLE </li></ul><ul><li>Inferior/Diaphragmatic: </li></ul><ul><li>2/3 by LV&1/3 by RV. </li></ul>Oct 15, 2010 Dr. UZMA ANSARI

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Oct 15, 2010 Dr. UZMA ANSARI

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Oct 15, 2010 Dr. UZMA ANSARI

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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

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Blood supply <ul><li>RCA </li></ul><ul><li>Smaller </li></ul><ul><li>Ant aortic sinus </li></ul><ul><li>RA </li></ul><ul><li>RV except area around anterior I V groove </li></ul><ul><li>Posterior I V Septum </li></ul><ul><li>LV:small area around posterior IV groove </li></ul><ul><li>Entire conducting system </li></ul><ul><li>LCA </li></ul><ul><li>Larger </li></ul><ul><li>Lt post aortic sinus </li></ul><ul><li>LA </li></ul><ul><li>LV except area around posterior IV groove </li></ul><ul><li>Anterior I V septum </li></ul><ul><li>RV:small area around anterior IV groove </li></ul><ul><li>Part of LBB </li></ul>Oct 15, 2010 Dr. UZMA ANSARI

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Oct 15, 2010 Dr. UZMA ANSARI

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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 <ul><li>Anterior 2/3 rd of I V septal </li></ul><ul><li>Anterior portion of LV </li></ul><ul><li>Whole apex </li></ul>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

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Dr. UZMA ANSARI Oct 15, 2010 LCX <ul><li>97% from LCA </li></ul><ul><li>2% from Separate Ostium </li></ul><ul><li>1% RCA </li></ul>Obtuse margin of heart and entire posterior wall. LA, posterior IV septum if PD arises from LCX OM <ul><li>97% LCA </li></ul>Obtuse margin of heart adjacent to LV Postero lateral branch <ul><li>80% LCA </li></ul><ul><li>20% RCA </li></ul>Posterior and diaphragm LV wall PD <ul><li>82% RCA </li></ul><ul><li>18% LCA </li></ul>Posterior IV septum and Diaphragm LV

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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

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

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

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

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

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

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Post Ischemic T wave changes <ul><li>ST elevation MI </li></ul><ul><li>Non-ST Elevation Infarction </li></ul>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

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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

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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

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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

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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

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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

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

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Septal I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 <ul><li>V1, V2 </li></ul><ul><ul><li>septum is left ventricular tissue </li></ul></ul>Dr. UZMA ANSARI Oct 15, 2010

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Septal Wall <ul><li>V1, V2 </li></ul><ul><ul><li>Along sternal borders </li></ul></ul><ul><ul><li>Look through right ventricle & see septal wall </li></ul></ul>I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Dr. UZMA ANSARI Oct 15, 2010

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Practice 2 Dr. UZMA ANSARI <ul><li>Anteroseptal MI </li></ul><ul><li>ST elevations V1, V2, V3, V4 </li></ul>Oct 15, 2010 January 2004

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Dr. UZMA ANSARI Lateral Wall <ul><li>I and aVL </li></ul><ul><ul><li>View from Left Arm  </li></ul></ul><ul><ul><li>lateral wall of left ventricle </li></ul></ul>I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Oct 15, 2010 January 2004

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Lateral Wall <ul><li>V5 and V6 </li></ul><ul><ul><li>Left lateral chest </li></ul></ul><ul><ul><li>lateral wall of left ventricle </li></ul></ul>I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Dr. UZMA ANSARI Oct 15, 2010

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Lateral Wall <ul><ul><li>I, aVL, V5, V6 </li></ul></ul><ul><ul><li>ST elevation  suspect lateral wall injury </li></ul></ul>Dr. UZMA ANSARI Lateral Wall Oct 15, 2010

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Lateral MI Dr. UZMA ANSARI Oct 15, 2010

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

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Practice 1 Dr. UZMA ANSARI <ul><li>Anterior MI with lateral involvement </li></ul><ul><li>ST elevations V2, V3, V4 </li></ul><ul><li>ST elevations II, AVL, V5 </li></ul>Oct 15, 2010 January 2004

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Dr. UZMA ANSARI Inferior Wall <ul><li>II, III, aVF </li></ul><ul><ul><li>View from Left Leg  </li></ul></ul><ul><ul><li>inferior wall of left ventricle </li></ul></ul>I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Oct 15, 2010

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Inferior MI Dr. UZMA ANSARI Oct 15, 2010

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Practice 3 Dr. UZMA ANSARI <ul><li>Inferior MI </li></ul><ul><li>ST elevation 2,3 AVF </li></ul>Oct 15, 2010 January 2004

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Practice 4 Dr. UZMA ANSARI <ul><li>Inferior lateral MI </li></ul><ul><li>ST elevations 2, 3, AVF </li></ul><ul><li>ST elevations V5 </li></ul>Oct 15, 2010 January 2004

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Posterior Leads <ul><li>Posterior leads V1, V2 </li></ul><ul><ul><li>Posterior Infarct with ST </li></ul></ul><ul><ul><li>Depressions and/ tall R wave </li></ul></ul><ul><ul><li>RCA and/or LCX Artery </li></ul></ul><ul><ul><li>ST elevation in V7,V8,V9. </li></ul></ul><ul><li>Understand Reciprocal changes </li></ul><ul><ul><li>The posterior aspect of the heart is viewed as a mirror image and therefore depressions versus elevations indicate MI </li></ul></ul><ul><ul><li>Rarely by itself usually in combo. </li></ul></ul>Dr. UZMA ANSARI Oct 15, 2010 January 2004

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Oct 15, 2010 Dr. UZMA ANSARI

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

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Anterior wall MI <ul><li>Occlusion of LAD </li></ul><ul><li>ST , V1-V6 </li></ul><ul><li>Occlusion above D1 and 1 st Septal </li></ul><ul><li>Basal portion of LV </li></ul><ul><li>Anterior and lateral wall </li></ul><ul><li>Inter-Ventricular Septum </li></ul><ul><li>ST segment vector – superiorly and to left </li></ul>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

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

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Occlusion: More distally i.e. below Septal 1 and D1 <ul><li>Basal portion spared (ST vector directed inferiorly) </li></ul><ul><li>ST segment not elevated in I, aVL/aVR </li></ul><ul><li>No depression in II, III, aVF </li></ul><ul><li>Indeed, ST segment elevation in II, III, aVF </li></ul><ul><li>ST segment elevation more prominent in V3 – V6 than V2 </li></ul>Dr. UZMA ANSARI Oct 15, 2010 January 2004

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Oct 15, 2010 January 2004 Dr. UZMA ANSARI

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Oct 15, 2010 January 2004 Dr. UZMA ANSARI

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Recommendation Dr. UZMA ANSARI Oct 15, 2010 January 2004

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Inferior MI <ul><li>ST Elevation in II,III,aVF </li></ul><ul><li>RCA OR LCX </li></ul><ul><li>ST III>II ST II>III </li></ul><ul><li>ST I,aVL ST I,aVL </li></ul>Oct 15, 2010 January 2004 Dr. UZMA ANSARI Whichever provides PD – Dominant artery

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Oct 15, 2010 January 2004 Dr. UZMA ANSARI

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Proximal RCA <ul><li>Right Ventricular Ischemia / Infarction </li></ul><ul><ul><li>ST vector directed towards right and anteriorly inferiorly </li></ul></ul><ul><ul><li>ST elevation in right anterior leads i.e. V3R, V4R, sometimes V1 </li></ul></ul><ul><ul><li>40% Associated with inferior M.I.ST elevation-V3R,V4R,V1,II,III,aVF </li></ul></ul><ul><li>V4R </li></ul><ul><li>Most commonly used right sided lead </li></ul><ul><li>Great value in diagnosing RV infarct along with IWMI </li></ul><ul><li>Useful in distinguishing between RCA and LCX involvement </li></ul><ul><li>Between proximal and distal RCA occlusion </li></ul><ul><li>V3R, V4R should be recorded as rapidly as possible because ST elevation in V3R, V4R remain for a shorter period of time in RWMI than ST elevation in extremity leads (II,III, aVF) in inferior MI </li></ul>Dr. UZMA ANSARI Oct 15, 2010 January 2004

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Inferior MI +Posterior M.I. <ul><li>Lateral / Infero Lateral / Baso Lateral MI not postero inferior MI. </li></ul><ul><li>Proximal RCA OR LCX </li></ul><ul><li>(posterior+inferior) Posterior+Inferior MI </li></ul><ul><li>+ RV infarct ST II,III,aVF,aVL,I ST II,III,aVF ST ,tall R V1,V2,V3, </li></ul><ul><li>ST I,aVL ST II>III ST V3R,V4R </li></ul><ul><li>ST III>II </li></ul>Dr. UZMA ANSARI Oct 15, 2010 January 2004

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Oct 15, 2010 January 2004 Dr. UZMA ANSARI

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Multiple infarct <ul><li>Multi vessel. Anterior+inferior inferior+posterior anterior+lateral Old+new </li></ul>Oct 15, 2010 January 2004 Dr. UZMA ANSARI

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Multiple Ischemia / Infarction / Injury <ul><li>ST depression in multiple leads in absence of elevation </li></ul><ul><li>Subendocardial ischemia / injury at multiple region due to multi vessel disease </li></ul>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

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<ul><li>In some cases, Deep T wave ( > 0.5 mV ) in V2, V3, V4 with prolong QT after an episode of chest pain without evidence of Ischemia / Injury / Infarction </li></ul><ul><li>(i.e. T wave morphology similar to CVA) </li></ul>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

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Thank You Dr. UZMA ANSARI Oct 15, 2010