Principles of ECG Diagnosis

7
Myocardial ischemia &
Myocardial infarction
Dr Ghazi Ahmad Radaideh
MD, FRCP
Rashid Hospital
Dubai - UAE

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Reading 12-Lead ECG step-by-step

(RAWIHI)
1. Rate, Rhythm and Regularity
2. Determine the QRS Axis
3. Evaluate the Waves (P,QRS,T ),
Intervals (PR,ST,QT)
4. Evaluate for chamber Hypertrophy
5. Look for myocardial Infarction and Ischemia
6. Interpret the ECG
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Introduction
When myocardial blood supply is abruptly reduced to
a region of the heart, a sequence of injurious events
occur :
Ischemia ( subendocardial or
transmural)
Injury
Necrosis, and eventual fibrosis
(scarring) if the blood supply
isn't restored in an appropriate
period of time.
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The changes of ECG in relation to

myocardial blood supply during MI

Ischemia:
T wave inversion or elevation,
ST elevation or depression

Injury:
ST elevation or depression

Necrosis:
Abnormal Q wave
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Hyperacute T waves

The earliest signs of acute myocardial infarction

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ST segment changes

Sometimes the QRS complex, the ST

segment, and the T wave fuse to form a
single monophasic deflection, called a giant
R wave or "tombstone"
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5.Reciprocal ST Segment Depression.

Defined as:
ST Depression
in leads that are
separate and distinct
from leads
manifesting STE.
Seen in up to 70% of inferior and 30% of anterior infarctions.
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localization of infarction
septal : V1-2
anterior : V3-4
anteroseptal : V1-4
high lateral : I, aVL
lateral : I, aVL, V6
anterolateral : I, aVL, V3-6
extensive anterior V1-6, I,
aVL
apical (anteroinferior) : II,
III, aVF, one or more of V1
inferior : II, III, aVF

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localization of infarction
Posterior : reciprocal changes
in V1-V2
prominent R wave and ST
depression, upward T in V1-2
(mirror image of anterior),
usually associated with inferior
or lateral infarction

RV infarction : changes in
right-sided chest leads :
ST elevation in V1-V4R,
usually associated with inferior
infarction
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Anterior group of myocardial

infarctions

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Hyperacute Anteroseptal MI :

ST elevation in the anterior leads V1 - 4, & reciprocal

ST depression in the inferior leads)
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Hyperacute MI with Giant R

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Anteroseptal MI

Q, QS, or qrS complexes in leads V1-V3 (V4)

Evolving ST-T changes
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Lateral MI

Diagonal branches of LAD and anterolateral

marginal (OM)branches of CXA
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Extensive ant MI

LAD and anterolateral marginal (OM) branches of

CXA
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Inferior group of myocardial

infarctions

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Inferior MI

Posterior left ventricular branches from RCA or CXA

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Inferolateral MI

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Posterior group of myocardial

infarctions

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Posterior MI

Distal CXA and/or posterolateral marginal branches

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True posterior MI
ECG changes are seen in anterior precordial leads
V1-V3, ( mirror image of an anteroseptal MI):
Increased R wave amplitude and duration ("pathologic R
wave" is a mirror image of a pathologic Q)
R/S ratio in V1 or V2 >1
Hyperacute ST-T wave changes: i.e., ST depression and
large,inverted T waves in V1-3
Late normalization of ST-T with symmetrical upright T
waves in V1-3

Often seen with inferior MI (i.e., "inferoposterior

MI")
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Right ventricular myocardial

infarctions

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Rt ventricular MI

RCA
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Right Ventricular MI
only seen with proximal right
coronary occlusion; i.e., with
inferior family MI's.
ECG findings usually require
additional leads on right chest
(V1R to V6R)
ST elevation, >1mm, in right
chest leads, especially V4R
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Myocardial Infarction in special

situation

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Anterior MI & RBBB

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MI + Left Bundle Branch Block

Often a difficult ECG diagnosis
because:
in LBBB the right ventricle is
activated first. and
left ventricular infarct Q waves may
not appear at the beginning of the
QRS complex (unless the septum
is involved).

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Suggested ECG features for acute

MI the presence of LBBB
ST segment elevation >= 1 mm and
concordant with QRS complex in at least 1
lead. (5 points)
ST segment depression >= 1 mm in leads
V1 V2 or V3(3points)
ST segment elevation >= 5 mm and
discordant with QRS complex in at least 1
lead(2points)
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MI & LBBB

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Non-ST Elevation Infarction

Recognized by evolving ST-T changes over time
without the formation of pathologic Q waves
Evolving ST-T changes may include any of the
following patterns:
Convex downward ST segment depression
only (common)
Convex upwards or straight ST segment
elevation only (uncommon)
Symmetrical T wave inversion only (common)
Combinations of above changes
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Anterolateral ST-T wave changes

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The Pseudoinfarcts
(Differential Diagnosis)

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The Pseudoinfarcts (1)

WPW preexcitation (negative delta wave
may mimic pathologic Q waves)

IHSS (septal hypertrophy may make normal

septal Q waves "fatter" thereby mimicking
pathologic Q waves)
LVH (may have QS pattern or poor R wave
progression in leads V1-3)
RVH (tall R waves in V1 or V2 may mimic
true posterior MI)
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The Pseudoinfarcts (2)

Left anterior fascicular block (may see
small q-waves in anterior chest leads)
Complete or incomplete LBBB (QS waves
or poor R wave progression in leads V1-3)
Pneumothorax (loss of right precordial R
waves)
Pulmonary emphysema and cor pulmonale
(loss of R waves V1-3 and/or inferior Q
waves with right axis deviation)
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The Pseudoinfarcts (3)

Acute pericarditis (the ST segment
elevation may mimic acute transmural
injury)
Brugada Syndrome

Central nervous system disease (may

mimic non-Q wave MI by causing diffuse
ST-T wave changes)

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Pericarditis
Concave upwards ST elevation in most leads
except aVR lasting 5-10 days.
PR-segment depression and sticks up like a
"knuckle. in aVR
Diffuse T wave inversion 10-15 days after
onset of acute pericarditis.
No reciprocal ST segment depression (except
in aVR)
Electrical alternans and low voltage if a
large pericardial effusion is present.
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Pericarditis

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Brugada syndrome

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Miscellaneous Abnormalities of
the QRS
The differential diagnosis of these QRS
abnormalities depend on other ECG
findings as well as clinical patient
information.

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Poor R Wave Progression

Defined as loss of, or no R waves in leads
V1-3 (R <2mm):

Normal variant (if the rest of the ECG is normal)

LVH
LBBB (increased QRS duration)
LAFB (LA Deviation)
Anterior or anteroseptal MI
Emphysema and COPD (R/S ratio in V5-6 <1)
Diffuse infiltrative or myopathic processes
WPW preexcitation (delta waves, short PR)

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Poor R progression in COPD

& RAH

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Tall R in V1
R/S ration >1 in V1 or V2
True posterior MI (look for inferior MI)
RVH (RAD and/or P-pulmonale, RV strain)
Complete or incomplete RBBB (look for rSR'
in V1, S wave in leads I and V6)

WPW (look for delta waves, short PR)

Dextrocardia
Normal variant in children (if rest of the ECG
is normal- Diagnosed by exclusion)

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Tall R in V1

Inferoposterior MI 2days from the onset

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