myocardial ishcemia and infarction chapter 8: st segment elevation ischemia and q wave infarct...
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Myocardial Ishcemia and
InfarctionChapter 8: St Segment Elevation Ischemia
and Q Wave Infarct Patterns
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Terminology1. Ischemia
2. Angina Pectoris
3. Necrosis
4. Myocardial Infarction
5. Epicardium
6. Subendocardium
7. TransmuraL
8. three major coronary arteries
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Transmural Ischemia
Acute Phase
St segment elevation
Sometimes tall T waves in certain leads
Acute phase may last hours to days
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Transmural Ischemia
Evolving phase
T wave inversion in the leads where the previously showed ST segment elevation
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Transmural Ischemia
Location
Anterior
Leads V1 - V6, I and aVl
Inferior
Leads II, III and aVf
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Anterior MI
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Inferior MI
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Recipocity
Compare the anterior leads (V1 -
V6, I and aVl)to the inferior
leads (II, III and aVf)
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Anterior MI Inferior MI
Early Phase
ST elevationTall T waves
V1-V6, I and aVl
ST elevationTall T wavesII, III and aVf
ST Depression in II, III and aVf
St Depressionin V1-V6, I and
aVl
Evolving PhaseInverted T
waves in V1-V6, I and aVl
Inverted T waves in II, III
and aVf
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ST Elevation
The ST elevation seen with acute MI is called a “Current of injury”
ST segment elevations are the earliest ECG signs of acute MI
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Q WavesQ waves are characteristic markers of infarction. (But not all transmural infarcts lead to Q waves.)
New Q waves of an MI generally appear with the first day or two
With an Anterior MI, these Q waves are seen in one of more of leads V1-V6, I and aVl
With an Inferior MI, these Q waves are seen in one of more of leads II, III and aVf
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Normal Q Waves
large Q waves
Small Q waves
Small Q waves
Small Q waves
Small Q wavesHorizontal Axis
Small Q wavesVertical Axis
Small Q wavesHorizontal Axis
Small Q wavesVertical Axis
Small Q wavesVertical Axis
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Tall T waves in V2-V5
Abnormal Q waves in V1
and V2
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Normal and Abnormal Q Waves
Normal
Narrow (less than 0.04 sec), Low amplitude
Abnormal if greater than 0.04 sec in leads I, II, III, aVf or leads V3 - V6.
Wider Q waves in V1, V2, III, and aVf can be normal
Not all Q waves are abnormal, Not all Q waves are the result of MI.
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Anterior InfarctionsAnterior MI show loss of R wave progression in the chest leads
Anterospetal Infarcts: Loss of R waves in V1 and V2
“Strictly” Anterior Infarcts: Loss of R waves in V3 and V4
Anterolateral or Anteroapical infarcts: abnormal Q waves in V5 and V6
FYI
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Inferior Infarctions
Abnormal Q waves in leads II, III, and aVF
FYI
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OtherPosterior Infarctions
Right Ventricular Infarctions
Ventricular Aneurysm
Multiple Infarctions
“Silent” MI
MI with Bundle Branch Block
FYI
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Myocardial Ischemia and Infarction
Chapter 9: St Segment Depression Ischemia and non-Q Wave Infarct Patterns
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Subendocardial Ischemia
Inner layer
St Segment depression
Anterior leads (I, aVl and V1-V6)
Inferior leads (II, III, and aVf)
May see ST segment elevation in aVr
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Subendocardial Ischemia
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Subendocardial IschemiaTransient ST segment depression
ST segment depression often occurs with angina, which generally returns to baseline when the angina subsides
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Subendocardial Ischemia
Exercise
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Subendocardial Ischemia
ST segment depression criteria
1 mm or more
horizontal or downward
lasts 0.08 seconds
depression of only the J point with rapid upward sloping are considered normal.
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Subendocardial Ischemia
False-Positive
ST depression without disease
False-Negative
Disease without ST depression
Silent Myocardial ischemia
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Subendocardial InfarctionPersistent ST depression
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T wave inversion
Subendo-cardial Infarction
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Non-Specific ST-T changes
Subtle changes
slight flattening of T wave
minimal T wave inversion
FYI
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Prinzmetal’s Angina
Transient ST segment elevation with angina
No Q waves, no T wave inversion
Angina may occur at rest or at night
Coronary artery spasm
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