Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Anterior Wall MI
An anterior wall myocardial infarction (AWMI) occurs when anterior myocardial tissue usually supplied by the left anterior descending artery (LAD) dies due to lack of blood supply. When an AWMI extends to the septal and lateral regions as well, the culprit lesion is usually more proximal in the LAD or even in the left main coronary artery. This large MI is termed an "extensive anterior". The ECG findings of an acute AWMI include: 1) ST segment elevation in the anterior leads (V3 and V4) and sometimes in septal and lateral leads depending on the extent of the MI. This ST elevation is concave downward and frequently overwhelms the T wave producing a "tombstoning" type appearance. 2) Reciprocal ST segment depression in the inferior leads (II, III and aVF). The ECG findings of an old AWMI includes: 1) Loss of anterior forces leaving Q waves in leads V1 and V2. This is sometimes termed "poor R wave progression" or PRWP. Note: To dinstinctly say that an old anterior wall MI is present on the ECG, there must be no identifiable R wave in lead V1 and usually V2 as well. If there is an R wave in V1or V2, the term PRWP can be used, but not an old anterior wall MI. 2) On rare occasions, persistant ST elevation may be seen in V1 and/or V2indicating a ventricular aneurysm (see the ventricular aneurysm section)
MI. The ECG findings of an acute posterior wall MI include: 1) ST segment depression (not elevation) in the septal and anterior precodial leads (V1 to V4). This occurs since these EKG leads will see the MI backwards (since the leads are placed anteriorly, but the MI is posterior). 2) The ratio of the R wave to the S wave in leads V1 or V2 is > 1. 3) ST elevation in the posterior leads of a posterior EKG (leads V7 to V9). Suspicion for a posterior MI must remain high, especially if inferior ST elevation is also present. 4) ST elevation in the inferior leads (II, III, and aVF) may be seen if an inferior MI is also present.
Myocardial Ischemia
Myocardial ischemia (not infarction) has two distinct ECG findings: 1) ST segment depression (not elevation) 2) Symmetric T wave inversions The lead in which these findings are seen will help to determine the area of myocardial ischemia.
Specifically,. 2nd degree AV block type I is characterized by progressingly increasing delay of AV nodal conduction until a P wave fails to conduct through the AV node. Thus, the PR interval becomes progressively longer from beat-to-beat until a P wave is not conducted.
Atrial fibrillation
Atrial fibrillation occurs when many sites in the atria rapidly fire action potentials. The result is a VERY fast atrial rate (about 400-600 beats per minute). Since the atrial rate is so fast and the action potentials produced are of such low amplitude, P waves will NOT be seen on the ECG in patients with atrial fibrillation. The atrial action potentials all attempt to conduct through the AV node, however the AV node becomes intermittently refractory and will only allow a certain number of atrial action potentials to reach the ventricles. This is why the ventricular rate is NOT also 400-600, but rather around 100-200 beats per minute. Since the AV node is intermittently (and not regularly) refractory, the QRS complexes that are produced when an atrial action potential does reach the ventricles will occur in an irregular pattern.
Thus an ECG showing atrial fibrillation will have NO visible P waves and an irregularly irregular QRS complex. The ventricular rate is frequently fast unless the patient is on AV node blocking drugs (such as beta-blockers). When the ventricular rate is greater than 100 in the presence of atrial fibrillation, the person is said to have atrial fibrillation with a "rapid ventricular response" or "RVR". Atrial fibrillation is sometimes abbreviated as "Afib". Thus a "rapid afib" or atrial fibrillation with RVR is sometimes abbreviated as "afib with RVR".
Atrial Flutter
Atrial flutter occurs when a "reentrant circuit" is present causing a repeated loop of electical activity to depolarize the atrium at rate of about 300-400 (remember the atrial rate in atrial fibrillation is 400-600). This produces a characteristic "sawtooth" pattern of the P waves, unlike atrial fibrillation in which the atrial rate is so fast that the P waves are not identifiable. Just as in atrial fibrillation, not all of the P waves are able to conduct through the AV node. Thus the ventricular rate will not be as fast as the atrial rate. Typically, the atrial rate will be about 300 per minute and only every other atrial depolarization will be conducted through the AV node. In this situation, the ventricular (QRS) rate will be exactly 150 beats per minute. Clinical Pearl: A narrow comlpex tachycardia at a ventricular rate of exactly 150 beats per minute is very commonly atrial flutter. Atrial flutter with variable conduction of the P waves can also occur. In this situation there may be 3 P waves to 1 QRS complex, then a quick change to 2 P waves to 1 QRS complex etc. Any combination of P waves to QRS complexes can occur.
will resume exactly 2 P to P intervals after the last normal sinus beat. Ventricular bigeminy occurs when every other beat is a PVC.
Ventricular Tachycardia
Ventricular tachycardia (VT) occurs when multiple ectopic ventricular beats occur in succession. If all of the QRS complexes appear the same or very similar, then it is termed monomorphic VT. If the QRS complexes appear different from beat-to-beat, then it is termed polymorphic. Another name for polymorphic VT is "Torsades de Pointes". VT can be hemodynamically unstable resulting in syncope and can degenerate into the universally fatal rhythm ventricular fibrillation. When describing ventricular tachycardia, the following should be mentioned: 1) Monomorphic versus polymorphic (Torsades) 2) Sustained versus non-sustained (sustained defined as > 30 seconds in duration or symptomatic) 3) The heart rate at which it is occurring (electrophysiologist use the "cycle length" or the number of milliseconds between the QRS complexes) The Brugada Criteria for determining if the rhythm is indeed VT is below, only 1 is required to establish a diagnosis of VT: 1) The absence of an R-S complex on ALL of the precordial leads (aka "concordance"). Meaning all of the QRS complexes are either all positive or all negative, no in betweens. 2) R-S interval > 100 ms in ANY precordial lead 3) The presence of atrioventricular dissociation (try to identify P waves amongst the QRS complexes going at a different rate, if present then you have AV dissociation and VT is the rhythm) 4) Specific morphology criteria for the QRS complexes
Ventricular Fibrillation
Ventricular fibrillation is often a fatal arrhythmia. It occurs when the ventricular rate exceeds 400. In this setting, virually no forward cardiac output occurs. Advanced Cardiac Life Support (ACLS) should be instituted immediately.
Asystole
Asystole occurs when no electical activity of the heart is seen. Obviously, this may be a fatal arrythmia. Emergent implementation of Advanced Cardiac Life Support (ACLS) is crucial.
Pericarditis
Pericarditis, or inflammation of the pericardium, has typical ECG findings. These findings occur in progressive stages, all of which are seen in about 50% of cases of pericarditis. Stage I (acute phase): Diffuse concave upward ST segment elevation in most leads, PR depression in most leads (may be subtle), and sometimes notching at the end of the QRS complex. Stage II: ST segment elecation and PR depression have resolved. T waves may be normal or flattened. Stage III: T waves are inverted and the ECG is otherwise normal. Stage IV: The T waves return to the upright position thus the EKG is back to normal. Note: The EKG changes of pericarditis must be distinguished from those of early repolarization. The ST elevation seen in early replarization is very similar; diffuse and concave upward. However three things may help to distinguish pericarditis from early repolarization: 1) The ratio of the T wave amplitude to the ST elevation should be > 4 if early repolarization is present. In other words, the T wave in early repolatization is usually 4 times the amplitude of the ST elevation. Another way to describe this would be that the ST elevation is less than 25% of the T wave amplitude in early repolarization. 2) The ST elevation in early repolarization resolves when the person exercises. 3) Early replarization, unlike pericarditis, is a benign ECG finding that should not be associated with any symptoms.