Ecg in Coronary Insufficiency

8/3/2019 Ecg in Coronary Insufficiency

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CORONARYINSUFFICIENCY

BY

DR.MANSI GANDHI


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V1

V1

V2

V2

V3

V3

V4

V4

V5

V5

V6

V6

RA

LA

LV

RV

6.5


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Inferior

II, III, aVF

Lateral

I, AVL,

V5-V6

Anterior /

Septal

V1-V4


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RCA: Inferior myocardium

II, III, aVFLCA: Lateral myocardium

I, aVL, V5, V6

LAD: Anterior/Septalmyocardium

V1-V4


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ACS includes spectrum of clinical presentations

Unstable anginaNSTEMI

STEMI


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Condition where there is inadequate supply

of the blood to a portion of myocardium.

It may be present at all times or it may be

relative-blood flow being adequate at rest

but

inadequate when myocardial demand

is increased by exercise or coronary

vasospasm


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Abnormalities of repolarization (earliest ;

M.C.being abn. of ST segment esp.

DEPRESSION)

Abnormalities of depolarizatrion

Abnormal relationship between

repolarization and depolarization.


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Abnormalities of ST segment

Depression of ST segment

Elevation of ST segment


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ST segment normally leaves baseline

immediately after QRS complex ; hence very

little of it is isoelectric


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MECHANISM : INJURY TO SUBENDOCARDIALREGION OF LEFT VENTRICLE(Depression in V5 , V6)


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Isoelectric for 0.12 sec (3 mm) or longer

No depression below the baselineDepression of distal part of ST segment


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Depression of a horizontal ST segment

Sharp angled ST T junction

Reflects severe form of impaired coronaryblood flow


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J-point is the point where S wave becomes isoelectric and joins the T wave.

ST segment elevation or depression is measured 2 small boxes away from

the J-point and then, up or down the isoelectric line.


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Point at which potential of ECG is exactly

zero is called J point.


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J point

Q

S

ST


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One way to

diagnose an acute

MI is to look forelevation of the

ST segment.


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Elevation of the ST

segment (greater

than 1 small box) in 2leads is consistent

with a myocardial

infarction.


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Mechanism

TRANSMURAL EPICARDIAL INJURY


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Slide 11


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T wave deflection may occur with-

Hyperventilation, heavy meals, smoking,drinking cold water, decrease in bloodpressure,anxiety

Inverted

Symmetrical

Sharply pointed

After exercise,if height of T-wave in V4 is 5mmor more than resting value coronaryinsufficiency suspected


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Increasing QRS-T angle in both frontal and

horizontal planes suggest coronary

insufficiency


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Small rounded deflexion occurring just afterT wave

Same direction as T wave

V2-V4

Inverted U wave cardiac ds ( CAD,

HTN)

If after exercise ischaemia


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Chest pain caused by transient

myocardial ischemia due to an

imbalance between myocardial

oxygen supply and demand.

Chest pain caused by transient

myocardial ischemia due to an

imbalance between myocardial

oxygen supply and demand.


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Angina pectoris of effort with FIXED effortthreshold

Reproducibility of critical level substrate forangina pectoris is ORGANIC STENOSIS

CLASSIC FORM k/a HEBERDENS ANGINAST DEPRESSION

D/T acute subendocardial injury

Angina pectoris of effort with VARIABLE effort

thresholdCold inducedNocturnal (DECUBITUS ANGINA)Emotionally triggeredAngina pectoris AT REST


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Variant form of angina pectoris AT REST(PRINZMETALSANGINA)

Variant form of angina pectoris ppt by EFFORT

Unstable angina(ACCELERATED / CRESCENDO /

PREINFARCTION ANGINA PECTORIS / INTERMEDIATE

CORONARY SYNDROME)


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1.1. Stable Angina .The commonest cause isThe commonest cause is ADVANCEDADVANCED

ATHEROSCELEROSISATHEROSCELEROSIS

Retrosternal painRetrosternal pain

Radiating to left armRadiating to left arm

&& shouldershoulder

Lasting less than 15Lasting less than 15min.min.


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Stable Angina

AnginalAnginal pain is often associated withpain is often associated withDepression ofDepression of STST segmentsegment

Exercise ECG showing typical severe down slopingExercise ECG showing typical severe down sloping

STsegmentSTsegment ::

Standing 1 min. 3 min. 7 min. 9 min.

In between attacksIn between attacks :: ECG is entirelyECG is entirelyNORMALNORMAL


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2.2. Unstable Angina .

IncreasedIncreased frequencyfrequency,, severityseverity orordurationduration ofof painpain inin aa patientpatient ofof StableStable

AnginaAngina

N.B.N.B.Pain occurs with lessPain occurs with lessexertion or at restexertion or at rest

Myocardial infarction may occur in 10Myocardial infarction may occur in 10--20%of20%of

patients.patients.


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3.3. Variant Angina .

(Prinzmetal)Chest pain at rest due toChest pain at rest due to

coronary artery spasmcoronary artery spasm

ECGECGchangeschanges::

The baseline ECGWith chest pain ,

marked ST segmentelevation

Acute elevation ofAcute elevation of STST

segmentsegment

Return of the ST segment tothe baseline after

nitroglycerin administration


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Slope-elevation of ST (V2 V6) concave orupward sloping configuration ;

Tall and widened T;

Increased VAT

Diminution in depth of S wave


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During attack ofchest pain-reflects featuresofPrinzmetals-ST elevation

-tall T waves

Followingcessation ofchest pain


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AT REST

AFTEREFFORT

B-slope elevation of ST segment-increased amplitude of T waves-increased amplitude of R wave-diminished amplitude of S wave

-inverted U wave


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About 4 mm in amplitude

Monophasic deflexion (R ,ST ,T WAVEblends)

Higher the ST elevation, the moresevere the CAD


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Ecg in Coronary Insufficiency

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