ecg 1 - unife.it · matteo bertini, md, phd e-mail: [email protected] cardiology department s....
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Matteo Bertini, MD, PhD
E-mail: [email protected]
Cardiology Department
S. Anna Hospital
University of Ferrara, Italy
ECG 1
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Attività elettrica del cuore
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Il sistema di conduzione atrio-
ventricolare è costituito da:
Nodo Atrio-Ventricolare
Fascio di His
Branca destra e Branca sinistra
Rete di Purkinje
Principi Generali di Elettrofisiologia Cardiaca
Le Basi dell’ Elettrocardiogramma
Nodo del seno
Ventricoli
Atri
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Elettrocardiogramma = registrazione dalla superficie
corporea delle correnti generate dal cuore
L’Elettrocardiogramma di superficie registra solo le grandi correnti
provenienti da atri e ventricoli, NON quelle provenienti dal sistema
di eccito-conduzione
- +
Elettrocardiografo = Galvanometro
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I Principali Elementi di un ELETTROCARDIOGRAMMA
Attivazione
atriale
Sistole
atriale
Diastole
atriale
Attivazione
ventricolare
Sistole
ventricolare
Diastole
ventricolare
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Il Potenziale di Azione
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PQRS
T
PQ ST
Atri
Ventricoli
Attivazione del sistema di conduzione atrioventricolare
Tratto isoelettrico PQ
Attivazione Atriale: Onda P
Attivazione Ventricolare: Complesso QRS
Ripolarizzazione Ventricolare: onda T
Elettrofisiologia Cardiaca d’ Organo
Le Basi dell’ Elettrocardiogramma
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P
Q
R
S
T
PQ QT
J
ST
Linea
isoelettrica
I Principali Elementi di un ELETTROCARDIOGRAMMA
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1 cm = 1 mV
Unità di Ampiezza in Elettrocardiografia
Amplificazione Elettrocardiografica Convenzionale
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1 mm = 40 msec
5 mm = 200 msec
Unità di Tempo in Elettrocardiografia
alla velocità di scorrimento convenzionale di 25 mm / sec
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PQQRS
PQ = 120-200 msec (3-5 mm)
QRS = 80-120 msec (2-3 mm)
Valori Normali
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Il Tracciato Elettrocardiografico Standard (12 derivazioni)
Derivazioni Periferiche Derivazioni Precordiali
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Derivazioni Bipolari degli arti (Eintoven):
Definiscono esattamente un Vettore sul Piano
Frontale
D1
D2D3
+
-
++
-
-0°+180°
60°120°
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Derivazioni Unipolari degli arti
+
++
+
aVLaVR
aVF
+90°
°
-30°-150°
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Derivazioni Periferiche
D1
D2D3
aVF
+
-
++
++
+
-
-
Bipolari
Unipolari
Derivazioni
degli arti+90°
+180° 0°
aVLaVR
-30°-150°
+60°
+120°
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L’asse elettrico del cuore nelle derivazioni periferiche
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Principi di Elettrocardiografia:
il Vettore di Attivazione di una Camera Cardiaca
Elettrocardiografo = Galvanometro
- +
+
+
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+
+
-
-
D1
aVF
0°
+90°
+180°
Determinazione rapida dell’asse elettrico
cardiaco sul piano frontale
Quadrante
Inferiore SinistroQuadrante
Inferiore Destro
Quadrante
Superiore Destro
Quadrante
Superiore Sinistro
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+
+-
D1
aVF
D1
aVF
+
+-D1
aVF
+
+-D1
aVF
+
+-
A B C D
D1
aVF
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V1V3
V4
V5
V6
V2
V7
V8
SnDxSnDx
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V1V3
V4
V5
V6
V2
V1
V3-4
V6
SnDx
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22
D1
D2D3
aVLaVR
aVF
+
-
++
++
+
-
-0°
-90°
+90°
+180 °
Derivazioni Bipolari ed
Unipolari degli arti
40V1
V3
V4
V5
V6
V2
SnDx
Derivazioni
precordiali
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Percorso di conduzione
SA node
AV node His bundle
Purkinje fibers
R
P
QS
TP
0 second
atrial systole
(0.1 second) atrial diastole (0.7 second)
cardiac cycle 0.8 second
ventricular systole (0.35 second) ventricular diastole (0.45 second)
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Attività elettrica (ECG)
P int.
80 ms.QRS int.
80 ms.T int.
160 ms.
PR int.
120:200 ms.QT int.
300:400 ms.
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Myocardial Action Potential
mV
-100
+40
0
4
0
1 2
3
4
ECG
AP
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AP ECG
• Measured in the Cardiac Cell
• Resting Potential = -90mV
• Depolarization = Phase 0
• Repolarization = Phase 3
• Measured at the Skin Surface
• Resting Potential = Isoelectric Line
• Depolarization = +/-deflection
• Repolarization = “T-Wave”
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Myocardial Action Potential
mV
-100
+40
0
4
0
1 2
3
4
ECG
AP
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ECG Basics
• ECG graphs:
– 1 mm squares
– 5 mm squares
• Paper Speed:
– 25 mm/sec standard
• Voltage Calibration:
– 10 mm/mV standard
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ECG Paper: Dimensions5 mm
1 mm
0.1 mV
0.04 sec
0.2 sec
Speed = rate
Voltage
~Mass
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Calcolo della Frequenza Cardiaca
FC = 300numero di quadrati grandi compresi tra due QRS
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Cardiac Cycle:
ECG WAVES• Normal ECG
formation / conduction:
– P Wave: Atrial depolarization/contraction
– QRS Waves: Ventricular depolarization/contraction
– T Wave: Ventricular Repolarization
– PR and QT Intervals…conduction problems
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ECG: Cardiac Cycle
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Cardiac Cycle Basics:
• Begins with SA Node
depolarization
• P – P = 1 Cycle
• Heart rate (pulse) is determined by
ventricle depolarization/contraction
• R – R = 1 heart beat
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Calculating Heart Rates
from ECG’s: Step One
• Sinus Rhythm: Each QRS complex is preceded by P wave
• NSR: Within the intrinsic rate of the SA Node: 60-100 bpm
• Tachycardia: >100 bpm
• Bradycardia: < 60 bpm
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Rhythm ID: Algorithm
• P-Wave: What is the atrial rhythm? < 0.12 sec (3 mm)
• QRS: What is the ventricular rhythm? <0.10 sec (<3 mm)
• P-R Interval: Is AV conduction normal? 0.12-0.20 sec (3-5 mm)
• Any unusual complexes?
• IS IT DANGEROUS?
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Rhythms Involving Errors in
Formation: P and QRS
• Normal and Ectopic Rhythms
– Sinus: “Normal”
– Atrial: “Ectopic”
• Junctional Rhythms: “Escape”
– Retrograde Atrial Depolarization
• Ventricular Rhythms:
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P-Wave: • 1.SA Node “fires”
• 2. Right and Left
Atria Depolarize
• 3. AV Node “fires”
• Questions:
– P waves present?
– Regular rhythm?
– 1/QRS?
SA Node
LA/RA
Depol
AV
Node
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Ritmo sinusale normale
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Ritmo sinusale “normale”
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Bradicardia sinusale
Sintomi:
•Nessuno
•Vertigini
•Stanchezza
•Dispnea
•Palpitazioni
•Perdita di memoria
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Ritmo giunzionale
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Step Two:
• Count the number of small squares
between R – R waves (X):
• Divide 1500 by X:
• Rate = 1500 / X
Example: X = 20
1500 / 20 =75
Rate = 75 bpm
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Why “1500 / X”?
• Paper Speed: 25 mm/ sec
• 60 seconds / minute
• 60 X 25 = 1500 mm / minute
• Take 6 sec strip (30 large boxes)
• Count the P/R waves X 10
OR