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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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