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ECG interpretation for ECG interpretation for beginnersbeginners
Part 4 – Acute coronary Part 4 – Acute coronary syndromessyndromes
Paul WilliamsCardiology Specialist Registrar
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Normal ECG!Normal ECG!
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MI diagnosisMI diagnosisUse your systemDon’t forget rate, rhythm etc.
Need to have basic understanding of:◦Pathology of heart attacks
◦Coronary arteries and regions of heart
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Coronary arteriesCoronary arteries2 coronary arteries come off aortaTotal of 3 main coronary arteries
LCA◦LMS branches into:◦Left anterior descending (LAD)◦Circumflex (Cx)
RCA
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Left ventricle supplyLeft ventricle supply
LAD – Supplies anterior wall, septum +- lateral walls(60%)
Cx – Supplies lateral wall (15%)RCA – Supplies inferior and
posterior walls (25%). Also supplies RV & conducting tisse
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Inferior
Lateral
Lateral
Septal
Anterior
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Other territoriesOther territoriesInferior MI – can have RV
involvement◦RV leads - V4R
Posterior MI – Usually ST depression V1-V3
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The hallmark of acute ischaemia is ST segment shift
ST elevation = complete blockage = STEMI
ST depression = partial blockage = NSTEMI/USA
Generally only occurs when patient has symptoms: ACS are dynamic
If real, usually have changes in contiguous leads
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STEMISTEMIOccluded coronary arteryEmergency = myocardium is
dying!
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STEMISTEMIChanges evolve:
◦Often “hyperacute” T waves initially◦T wave inversion◦Q waves
Dynamic - repeat ECGs if not sure
What territory is it?◦Two contiguous leads◦Can get reciprocal ST depression◦Remember posterior & RV involvement
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DifferentialDifferentialPericarditis
◦Widespread concave upsloping ST depression
◦Would involve multiple coronary arteries if MI
◦PR depression (II)◦Look at the patient – common sense
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Management of STEMIManagement of STEMIABCCardiac monitor (can go into VF)AnalgesiaAspirinClopidogrelReperfusion therapy
◦ Thrombolysis◦ Primary PCI
Medical Rx
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Inferior
Lateral
Lateral
Septal
Anterior
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Old MIsOld MIsOld STEMIs can leave permanent
Q wavesTerritories are the same
(anterior, inferior lateral etc.)Poor R wave progression can also
indicate an old anterior STEMI
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ST depressionST depression
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ST depressionST depressionOften get T wave inversion as wellRemember your territoriesGenerally ST depression only
occurs during acute ischaemia
Differential◦Digoxin (downsloping lateral: V4-V6, I,
aVL)◦LVH (downsloping lateral)
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Management of Management of NSTEMI/USANSTEMI/USAABCCardiac monitorAnalgesiaInitial medical Rx
◦Aspirin◦Clopidogrel◦Beta-blocker◦Statin◦LMWH
IP angiography
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Question 1Question 1
What are the ECG abnormalities?What is the differential?
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Question 2Question 2
What are the ECG abnormalities?What sort of ACS?What territory is affected?
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Question 3Question 3
What are the ECG abnormalitiesWhat sort of ACS?What territory?
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Question 4Question 4
What are the ECG abnormalities?Give 3 possible differentials
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Question 5Question 5
• What are the ECG abnormalities?• What sort of ACS?What territory?