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ECGs: Ischemia and Infarction

ECGs: Ischemia and Infarction. AFAMS Resident Orientation 26 March 2012. Outline. Terminology. Injury Acute MI ST elevation in 2 contiguous leads Reciprocal ST depression Ischemia ST depression, T wave inversion Infarct Q waves. EKG Stages of MI. Hyperacute T waves (A)

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ECGs: Ischemia and Infarction

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  1. ECGs: Ischemia and Infarction AFAMS Resident Orientation 26 March 2012

  2. Outline

  3. Terminology • Injury • Acute MI • ST elevation in 2 contiguous leads • Reciprocal ST depression • Ischemia • ST depression, T wave inversion • Infarct • Q waves

  4. EKG Stages of MI • Hyperacute T waves (A) • ST elevation (B) • Q waves – usually within 6-12h (C) • T wave inversions (D) • ST-T wave resolution • Q waves persist European Heart Journal 2007; 28, 2985-2991

  5. EKG Stages of MI • Hyperacute T waves

  6. Sinus tachycardia, Inferior MI – recent, Nonspecific ST-T wave changes

  7. NSR, Biatrial Enlargement, Old inferior MI

  8. Localization of MI • Anteroseptal • ST elevation in V1-V3 • Anterior • ST elevation in V2-V4 • Lateral • ST elevation in I, AVL, V5-6 • Inferior • ST elevation in II,III,AVF

  9. 47 year old male with chest pain NSR with anteroseptal myocardial infarction

  10. 65 year old male with chest tightness NSR with acute anterior myocardial infarction

  11. 62 year old female with shortness of breath and chest discomfort Sinus Tachycardia with Lateral Myocardial Infarction

  12. 45yo wm with 2 hours of SSCP that started during exertion NSR with PVC, LAD, Acute anterolateral MI

  13. Middle age white male awoke from sleep with chest pain Sinus tachycardia, Acute Inferior MI

  14. Right Sided ECG • Who? • Any patient with inferior ST elevation MI • Why? • Investigate infarct involvement of RV • How? • Reverse Precordial Leads • Where to Look? • ST elevation in V4R

  15. Right Sided EKG

  16. Not all ST changes are ischemia • While ischemia and infarction are the most concerning causes of ST changes, other causes exist • Use the clinical history to help you • Recognize patterns

  17. 20 year old asymptomatic male Sinus bradycardia, Early repolarization-> Normal variant

  18. NSR, PACs, LVH – voltage criteria, repolarizationabnormality  HCM

  19. 59yo female presents to the ER with CP NSR, Acute pericarditis (Diffuse ST elevation and PR depression), and Pericardial effusion (electrical alternans)

  20. 26 year old male with syncope NSR, RBBB, Long QT-> Brugada Syndrome

  21. Differential Diagnosis of ST elevation • STEMI • LV aneurysm • Left Ventricular Hypertrophy • Pericarditis / Myocarditis • Early Repolarization • Normal variant • Hyperkalemia • BrugadaSyndrome • ARVD

  22. Examples of ST Elevations NEJM 2003: 349:2128-35

  23. Conclusions • ST changes often represent ischemia, injury or infarction • Many other possible diagnoses • Use clinical information to narrow down the list • When you are unsure, call a cardiologist

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