Modificari

electrocardiografice in
ischemia miocardica acuta

Ioan Tiberiu Nanea FESC

Bucuresti
Cascada Ischemica In ocluzia coronariana
modificarile ECG anunta simptomatologia

Electrocardiography in Ischemic Heart Disease: Clinical and Imaging ... Antoni Bayes de Luna
et al 2008
• Ischemia miocardica acuta se refera la
imposibilitatea ( brusc dezvoltata) a fluxului
sanguin coronarian de a oferi o cantitate
adecvata de oxigen in conditii de
suprasolicitare ( sau nu) a miocardului
• (Ischemia miocardica acuta reversibila sau devine
ireversibila)
 Manifestari ECG ale ischemiei
miocardice acute

Ischemia/ leziunea/ necroza miocardica

Nontransmurala
subendocardica/subepicardica
Transmurala

Repolarizare anormala
Depolarizare anormala
Manifestari ECG ale ischemiei miocardice acute

~Anomalii ale undei T

inversarea undei
pseudonormalizarea
amplitudine crescuta
~Anomalii ale segmentului ST
supradenivelare
subdenivelare
~Anomalii ale complexului QRS
unda q
cresterea amplitudinii
scaderea amplitudinii
~Anomalii ale undei U
negativarea
~Anomalii ale intervalului QT
prelungirea intervalului QT
micsorarea intervalului QT
 Manifestari ECG ale ischemiei
miocardice acute

1 Angina pectorala stabila sau instabila, Angina

microvasculara ( episod simptomatic)
Leziune subendocardica
subdenivelare ST

2 Angina Prinzmetal, sindromTakotsubo

Leziune transmurala ( non necrotica) +/- ischemie subepicardica
supradenivelare tranzitorie ST, cresterea amplitudinii undei R, unde T
inversate,pseudonormalizarea undelor T

3 Infarct miocardic acut fara supradenivelare ST

Leziune subendocardica sau ischemie subepicardica
subdenivelare ST sau unde T negative
 Manifestari ECG ale ischemiei
miocardice acute
4 Infarct miocardic acut cu supradenivelare ST
Ischemie subendocardica leziune subendocardica leziune
subepicardica necroza ischemie subepicardica
unde T pozitive hipervoltate, subdenivelare ST, supradenivelare ST, unde
Q de necroza, unde T negative, scaderea amplitudinii undei R,

5 Ischemia miocardica silentioasa

total asimptomatica,asociata cu episoade de ischemie documentate)
Ischemie subendocardica
subdenivelare ST

6 Intervalul QT marker precoce al ischemiei acute and

tranzitorii
Prognostic Value of the Admission Electrocardiogram in
Acute Coronary Syndromes
12,142 patients who reported
symptoms of cardiac ischemia
at rest within 12 hours of
admission
ECG, 22% of patients
had T-wave inversion,
28% had ST-segment
elevation, 35% had ST-
segment depression,
and 15% had a
combination of ST-
segment elevation and
depression
MORTALITY GUSTO-IIb
JAMA. 1999;281(8):707-713.
ISCHEMIA subendocardica
LEZIUNEA subendocardica

ISCHEMIA subepicardica

LEZIUNEA subepicardica

NECROZA transmurala
caz personal
 Personal case (2)
Detection of ischemic changes identifies a high risk patient
continuous ST segment monitoring

Coronary angiography: LAD occlusion, segment 2

 Significance of initial ST segment elevation changes for
thrombolytic treatment in first inferior myocardial infarction

study comparing streptokinase with placebo

initial sum -
stratified by the NOT
ONLY LEADS EXTENSION - ST segment
elevation (sigma ST) of 0.8 mV or less and

greater than 0.8 mV

Heart. 1997 Jun;

77(6): 506–511
 Aspecte ECG in infarctul
miocardic acut
+ leziune

+ leziune

Marimea IMAcut electrocardiografic

ar trebui apreciata prin numarul derivatiilor
cu supradenivelare de segment ST dar
si prin amplitudinea segmentului ST Schema ITN Concept

Amplitudinea ar depinde de grosimea peretelui lezionat

( NB leziunea epicardica nontransmurala se exprima tot cu supradenivelare ST )
Spitalul Caritas

Amplitudinea
supradenivelarii
segmentului ST
IM transmural

caz personal
Amplitudinea supradenivelarii
de segment ST

caz personal
Supradenivelarea de segment ST in aVR

caz personal
 Infarct miocardic acut
VS Posterior

caz personal + DD
IM acut
inferior
de VS +

IM acut de
VD
cu ruptura
peretelui
anterior

caz personal
Durere coronariana prelungitaST ?

caz personal
Durere coronariana prelungita Circumflexa rudimentara
ocluzionata
Absenta SUPRADENIV ST

caz personal
BRS si infarctul miocardic acut

caz personal
Personal case
Durere coronariana iradiata
la bazele pulmonare

caz personal + DD
Supradenivelare tranzitorie de ST
SPASM coronarian

Caz personal
Supradenivelare de ST ( magnitudine variabila, SPASM
Subdenivelare
segment ST
episod silentios

caz personal
 Wellens Syndrome
Biphasic T waves in V2 and V3 Symmetric
Deeply inverted T waves in V2 and V3 biphasic T waves in V2
and in V2 and V3
•chest pain.
•Normal / minimally elevated cardiac enzymes.
•No pathological Praecordial Q waves.
•Minimal / no ST elevation.
•No loss of praecordial R waves.

ECG pattern : >50% stenosis of the left anterior

descending coronary artery (mean = 85%), with
complete or near complete occlusion in almost 60%

N Engl J Med 2015; 372:66

 Sindrom WELLENS

caz personal
 Mortality in stroke types and its
relation with electrocardiogram (ECG)
changes

J Nat Sci Biol Med. 2014 Jul-Dec; 5(2): 434–436.

Unda U
negativa

caz personal
 Cumulative mortality as estimated by Kaplan-Meier method QT
dispersion QT dispersion was defined as maximum minus minimum QT interval

Bente Brendorp et al. Circulation. 2001;103:831-835

 Relatia dintre intervalul QT si
severitatea ischemiei

• Prolonged QT interval on EKG in coronary

ischemia is sign to consider ischemic risk in
acute coronary syndrome
• Prolonged QT interval, following acute MI-
higher risk of sudden death.
• It is a risk marker for ventricular arrhythmias
at the time of the acute ischemic event,

Electrocardiography in Ischemic Heart Disease: Clinical and Imaging ... Antoni Bayes de Luna et al
2008
 Relatia dintre intervalul QT si severitatea
ischemiei

• A corrected QT interval peak of at least 480 ms

in the acute phase of ST-elevation myocardial
infarction is an independent predictor of
cardiovascular death. Its association with
reduced ejection fraction (≤35%) increases risk
stratification accuracy

J Cardiovasc Med (Hagerstown). 2016 Jun;17(6):440-5.

Prelungirea intervalului QT(+ST-)

caz personal
Micsorarea intervalului QT

Decreases in ECG, R-Wave

Amplitude and QT Interval
Predict Myocardial Ischemic
Infarction in Rhesus
Monkeys with Left Anterior
Descending Artery Ligation

PLoS One. 2013; 8(8): e7187

 Incidenta Ischemiei Miocardice Silentioase

Silent ST-segment depression during ambulatory ECG monitoring occurs more often
than symptomatic ST-segment depression

• General Population2-4%
• Stable Angina  40-50%
• After Miocardial Infarction50%
• Sudden Death 100%
• Diabetes 50%
• After PTCA 22%

Arenja AJM, 2013

https://www.escardio.org/.../Fri-SMI-Gutterman
Unadjusted odds ratios and 95% confidence interval
characteristics. for 30-day mortality by different ECG

8772 patients
(53.4% women,
median 78 years
presenting with
acute heart
failure to 86
hospital
emergency
departments in
Ontario, Canada,
Q-waves, T-wave
inversion, or ST-
depression were
present in 51.8%
of subjects.

Douglas Greig et al. Circ Heart Fail. 2014;7:986-993

 Causes of ST Segment and T wave
abnormalities
• Acute Pericarditis • Left Ventricular
• Benign Early Aneurysm
Repolarization • Brugada Syndrome
• Left Bundle Branch • Hyper- Hipo-kalemia
Block with AMI • Hyper- Hipo-calcemia
(Sgarbossa et al’s • Hypothermia
criteria)
• CNS pathologies
• Left Ventricular
Hypertrophy • Post electrical
cardioversion
2014 ECG tutorial: ST and T wave changes up to date Jordan M Prutkin
 Repolarizare precoce
caz personal

V1

V6

repaus ECG efort Post efort

Personal case
Repolarizare precoce
caz personal
Sindrom Brugada

caz personal
 Pericardita ACUTA

I aVR V1 V4

II aVL V2 V5

III aVF V3 V6

caz personal
 Hiperpotasemia
Unde T inalte ascutite,
Potasemie 7,2 mEq/L complexe QRS largi
prelungirea intervaluluiPR
aplatizare unde P
FV
Asistola

caz personal
Hipopotasemia

Potasemie 2,2 mEq/L

Unde T aplatizate
Subdenivelare ST
Largirea QRS
Aritmii A sau V
Hipercalcemia Hipocalcemia
• Alungirea intervalului
• Scurtarea intervalului QT QT
• Supradeniv ST
• Unde R inalte
• Aplatizare sau
• Supradeniv ST negativarea undei U
• Unde U si J

caz personal
 Concluzii
• Simptomatologia coronariana acuta identifica modificari de
unda T , segment ST, complex QRS,unda U,interval QT
reversibile sau ireversibile

• Modificarile electrocardiografice induse de ischemia acuta

permit stratificarea riscului in relatie cu spectrul
sindroamelor coronariene
Predicted vs observed 30-day mortality rates according to risk deciles of Emergency Heart
failure Mortality Risk Grade ST-depression (EHMRG30-ST) model.

Douglas Greig et al. Circ Heart Fail. 2014;7:986-993

Copyright © American Heart Association, Inc. All rights reserved.

8772 patients
(53.4%
women,
median 78
years [Q1, Q3:
68,84])
presenting
with acute
heart failure
to 86 hospital
emergency
departments
in Ontario,
Canada, Q-
waves, T-
wave
inversion, or
ST-depression
were present
in 51.8% of
subjects.
Unda U NEGATIVA

Accident vascular cerebral

acut trombotic
hemiplegie

Angina instabila
Case exemple - ECG

RR 40 years
N.T. Collection
 Infarct miocardic vechi anterolateral cu BRS
(recidiva IM acut) – caz particular

MR 68 ani
Angina instabila
BRS cronic

Durere tipica
anginoasa,
prelungita
TnT ↑
BRS + gradient alterat + unda Q DI, V5-V6 = IM acut CK-MB ↑
 IMA cu supradenivelare de ST (cazuri particulare)
I V1
I V1

V2
II II
V2

III IMA anterior III

V3 IMA anterior
(1 ora) – LAD
V3 (3 zile) cu
proximal de
expansiune septala
prima septala
aVR – LAD proximal de
aVR V4 perforanta
marea diagonala,
BRD major,,
V4 distal de prima
HBAS
septala
aVL aVL
Reinfarctizare,
V5 V5 supradeniv. noua de
ST V4-V6, DI, aVL

aVF V6 aVF
Sp. Caritas V6
Sp. Caritas
Sectia Cardiologie Sectia Cardiologie
• The left main coronary artery (LM) originates from the left coronary sinus
• of Valsalva and gives origin to the left anterior descending coronary artery
• (LAD) and left circumflex coronary artery (LCX). The LAD courses in the
• anterior epicardial ventricular septum and gives origin to various diagonals
• and septal perforators. The LAD is divided into proximal, mid, and distal
• segments. The first septal perforator generally divides the proximal and
• mid-segments of the LAD. The diagonals are varied in number and caliber
• and are labeled from proximal to distal, D1, D2, D3, and so forth. anterior descending coronary artery
(LAD) occlusion site in relation to the first septal perforator (S1) and/or the first diagonal branch (D1)
The LCX
• runs in the left atrial–ventricular sulcus and gives origin to obtuse marginal
• branches (OM). The OMs are labeled from proximal to distal, OM1, OM2,
• OM3, and so forth. Ostium refers to the segment of origin of the artery
• (Figure 1.1A–Z).
• The right coronary artery (RCA) originates from the right coronary sinus
• and is divided in proximal, mid, and distal segments. The proximal segment
• of the RCA is from the ostium to the origin of the first acute marginal artery.
• In the majority of patients, the conus artery originates from the ostium of
• the RCA or separately from the right coronary sinus and is generally the
• first visualized branch. The conus artery has a superior and anterior course.
• The sinoatrial (SA) artery is generally the second artery to be visualized
• and originates from the proximal RCA and has a posterior course. The
• RCA gives origin to acute marginal (AM) branches, which vary in size and
• number and are labeled from proximal to distal, AM1, AM2, AM3, and
• so forth.
• Dominance refers to whether the posterior descending artery (PDA)
originates
• from the RCA (right dominant), LCX (left dominant), or both
(codominant).
• Approximately 80% of humans are right dominant. In right
• dominance, the distal RCA at the level of the crux of the heart typically
• bifurcates into the PDA and a posterolateral branch. The PDA courses in
• the posterior ventricular septum giving origin to the SA nodal artery and
• posterior ventricular branch. In left dominance, the PDA originates from
• the distal LCX. In co-dominance, there are right and left PDAs originating
• from the RCA and LCX.
• The coronary venous system is variable. Generally, the great cardiac vein
• (GCV) and the middle cardiac (MCV) vein are present. The GCV runs
• parallel to the LAD and then courses superiorly, crossing the LCX and
• posteriorly draining into the coronary sinus. The MCV runs inferiorly at
• midline parallel to the PDA and drains into the coronary sinus
Value of the electrocardiogram in localizing the occlusion site in the left
anterior descending coronary artery in acute anterior myocardial infarction
J Am Coll Cardiol. 1999;34(2):389-395. doi:10.1016/S0735-1097(99)00197-7
26.04.2015
• The ST segment represents ventricular
repolarization. Repolarization follows upon
contraction and depolarization. During
repolarization the cardiomyocytes elongate and
prepare for the next heartbeat. This process takes
much more time than the depolarization. The
elongation that takes place during repolarization
is not passive; it is an active process during which
energy is consumed. On the ECG, the
repolarization phase starts at the junction, or j
point, and continues until the T wave.
 Introduction
• ST segment of the cardiac cycle represents the
period between depolarization and
repolarization of the left ventricle
• In normal state, ST segment is isoelectric
relative to PR segment
Uncomplicated and complicated LBBB

Uncomplicated LBBB

Riera P et al. 2006

• they also occur in association with several other
• disease processes, such as left ventricular hypertrophy,
• hypokalaemia, and digoxin therapy.
• T wave changes
• Myocardial ischaemia can affect T wave morphology in a variety
• of ways: T waves may become tall, flattened, inverted, or
• biphasic. Tall T waves are one of the earliest changes seen in
• acute myocardial infarction, most often seen in the anterior
• chest leads. Isolated tall T waves in leads V1 to V3 may also be
• due to ischaemia of the posterior wall of the left ventricle (the
• mirror image of T wave inversion).
• Electrocardiography is not sufficiently
• specific or sensitive to be used without a
• patient's clinical history
• There are four major situations where ST segment elevation can be
seen on an ECG when there is no STEMI present, but many other
causes of ST elevation on the ECG. The four most common causes
of ST elevation that mimic STEMI will be reviewed here. A good
mnemonic to remember all of the causes of ST elevation on the
ECG is "ELEVATION"
• Electrolyte abnormalities
Left bundle branch block
Aneurysm of left ventricle
Ventricular hypertrophy
Arrhythmia disease (Brugada syndrome, ventricular tachycardia)
Takotsubo/Treatment (iatrogenic pericarditis)
Injury (myocardial infarction or cardiac contusion)
Osborne waves (hypothermia or hypocalcemia)
Non-atherosclerotic (vasospasm or Prinzmetal’s angina)
Definition of Risk Groups by Max STE
 Use of initial ST-segment deviation for prediction of final
electrocardiographic size of acute myocardial infarcts

• This study developed formulas from 68

anterior and 80 inferior AMI patients using the
extent of initial ST-segment deviation (STΔ) to
predict the final AMI size estimated by the
Selvester QRS score in a population not
receiving reperfusion therapy

Am J Cardiol, 61, 10, 1988, Pages 749–753

• Abnormalities are manifest in the ST-segment,
T wave, and QRS complex. However, the ECG
may be normal or nonspecific in these
patients
• Abnormalities are manifest in the ST-segment,
T wave, and QRS complex. However, the ECG
may be normal or nonspecific in these
patients
ISCHEMIE subendocardica LEZIUNE subepicardica
necroza transmurala
Predictiveness curve for 30-day mortality based on
Emergency Heart failure Mortality Risk Grade ST-
depression (EHMRG30-ST) model.

8772 patients
(53.4% women,
median 78 years
presenting with
acute heart
failure to 86
hospital
emergency
departments in
Ontario, Canada,
Q-waves, T-wave
inversion, or ST-
depression were
present in 51.8%
of subjects.

Douglas Greig et al. Circ Heart Fail. 2014;7:986-993

 La prezentare

IMA Inferior
Dupa coronarografie (24 ore)

caz personal
Marimea IMAcut
electrocardiografic
ar trebui apreciata prin
numarul derivatiilor
cu supradenivelare de
segment ST dar
si prin amplitudinea
segmentului ST

Amplitudinea ar depinde de
grosimea peretelui lezionat
( NB leziunea epicardica
nontransmurala se exprima
tot cu supradenivelare ST )
I aVR
V1 V4 V3R
IM inferior si
de VD
II aVL V2 V4R
V5

III aVF V3 V6

Cazuri personale
 aVR
I V1 V4 V3R

II aVL V2 V4R
V5

III aVF V3 V6

Spitalul Caritas
 aVR
I V1 V4 V3R

II aVL V2 V4R
V5

III aVF V3 V6
 ISCHEMIA subendocardica
LEZIUNEA subendocardica
ISCHEMIA subepicardica
LEZIUNEA subepicardica
NECROZA transmurala

caz personal
 ISCHEMIA subendocardica
LEZIUNEA subendocardica
ISCHEMIA subepicardica
LEZIUNEA subepicardica
NECROZA transmurala

caz personal
 ISCHEMIA subendocardica
LEZIUNEA subendocardica
ISCHEMIA subepicardica
LEZIUNEA subepicardica
NECROZA transmurala

caz personal
 ISCHEMIA subendocardica
LEZIUNEA subendocardica
ISCHEMIA subepicardica
LEZIUNEA subepicardica
NECROZA transmurala

caz personal
V7

V8

V9
Durere coronariana iradiata la bazele pulmonare

caz
personal
+ DD
Durere coronariana
iradiata la bazele
pulmonare

caz personal + DD
Marimea IMAcut electrocardiografic
ar trebui apreciata prin numarul
derivatiilor
cu supradenivelare de segment ST dar
si prin amplitudinea segmentului ST

Amplitudinea ar depinde de grosimea

peretelui lezionat
( NB leziunea epicardica
nontransmurala se exprima tot cu
supradenivelare ST )

BMJ: 324.2002 modificat

Supradenivelare de ST ( magnitudine variabila, SPASM
\
Unadjusted odds ratios and 95% confidence interval
characteristics. for 30-day mortality by different ECG

8772 patients
(53.4% women,
median 78 years

?
presenting with
acute heart
failure to 86
hospital
emergency
departments in
Ontario, Canada,
Q-waves, T-wave
inversion, or ST-
depression were
present in 51.8%
of subjects.

Douglas Greig et al. Circ Heart Fail. 2014;7:986-993

 Unde T inalte ascutite,
Hiperpotasemia complexe QRS largi
prelungirea intervaluluiPR
aplatizare unde P
FV
Potasemie 7,2 mEq/L Asistola

caz personal
Sindrom Brugada

caz personal
 Repolarizare precoce

caz personal
 ISCHEMIA subendocardica
LEZIUNEA subendocardica
ISCHEMIA subepicardica
LEZIUNEA subepicardica
NECROZA transmurala

caz personal
From: Course and prognostic implications of QT interval and QT interval variability after primary coronary
angioplasty in acute myocardial infarction
J Am Coll Cardiol. 2001;37(1):44-50. doi:10.1016/S0735-1097(00)01061-5

Figure Legend:

Kaplan-Meier survival curve representing cumulative event-free estimate for major arrhythmic events within a one-year follow-up.

Date of download: 10/3/2016 Copyright © The American College of Cardiology. All rights reserved.
Aspecte ECG in
infarctul
miocardic acut

Schema ITN Concept

Amplitudinea supradenivelarii
de segment ST

caz personal
Electrocardiograms (ECGs) in long OT syndrome, short OT syndrome, Brugada syndrome,
arrhythmogenic right ventricular cardiomyopathy, hypertrophic cardiomyopathy WPW
syndrome

EHRA/HRS/APHRS Expert Consensus on

Ventricular Arrhythmias 2014
Subdenivelar
e segment ST
( episod
silentios )

caz personal