curs 2 ekg ima, hipertrofii
TRANSCRIPT
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ELECTROCARDIOGRAMA
ISCHEMIA SI INFARCTUL MIOCARDIC
Asist. Univ. Dr. Mihaela PopescuCatedra de Cardiologie Spitalul
Universitar de Urgenta Elias
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Ischemie/ Leziune miocardica
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Efectele ischemiei
PA ischemicPA normal
Sistola = STDiastola= TPDiastola
PA ischemic •Depolarizare redusa•Repolarizare redusa•Durata si amplitudine
redusa
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CORESPONDENTA ECG - POTENTIAL DE ACTIUNE
Complex QRS = Faza 0 si 1Segment ST = Faza 2Unda T= Faza 3Interval TQ = Faza 4
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Ischemia◦ Scaderea perfuziei miocardice - reversibila◦ Miocit ischemic- repolarizare precoce (+)◦ Ischemia subendocardica – unde T negative◦ Ischemia transmurala – unde T pozitive, ascutite
Ischemia miocardica
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Diferenta de potential intre zonele normale si cele ischemice: mic curent= curent de leziune
Flux de ioni de K dinspre zona mai pozitiva spre cea mai negativa
In sistola (ST) regiunea ischemica este mai negativa- curent de la normal la ischemic
In diastola (TP) regiunea ischemica este mai pozitiva- curent de la ischemic la normal
Curentul de leziune
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Curentul de leziune
ST- curent de la regiunea normala spre cea ischemicaTP – curent de la regiunea ischemica spre cea normala
STTP
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Curent de leziune
Curent sistolic de leziune Curent diastolic de leziune
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Leziune subendocardica
Curent sistolic de leziune Curent diastolic de leziune
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Leziune transmurala
Curent sistolic de leziune Curent diastolic de leziune
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Ischemie/ Leziune miocardica
Infarct miocardic◦ Ischemie persistenta – celulele isi pierd viabilitatea= necroza◦ Infarct miocardic:
cu supradenivelare de segment ST (STEMI) fara supradenivelare de segment ST (NSTEMI)
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CATEGORIA LOCALIZAREA OCLUZIEI
ECG LA PREZENTARE
1. ADA proximal Proximal de prima perforanta septala
↑ ST in V1-V6, DI, aVL si bloc fascicular sau bloc de ramura
2. ADA mediu Distal de prima perforanta septala, proximal de marea diagonala
↑ ST in V1-V6, DI, aVL
3. ADA distal sau artera diagonala
Distal de marea diagonala sau afectarea primei diagonale
↑ ST in V1-V4 sau ↑ ST in V5-V6, DI, aVL
4. IMA inferior moderat intins (posterior, lateral, de ventricul drept)
ACD proximal sau artera circumflexa
↑ ST in DII, DIII, aVF si oricare sau toate dintre:a) V1, V3R, V4R saub) V5-V6 sauc) R>S in V1, V2
5.IMA inferior mic
ACD distal sau artera circumflexa sau ramuri din artera circumflexa
↑ ST doar in DII, DIII, aVF
CLASIFICAREA IMA PE BAZA ASPECTULUI ECG CORELAT CU DATELE ANGIOGRAFICE
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Infarct miocardic anterior
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Artera descendenta anterioara
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Infarct inferior
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Artera coronara dreapta sau a circumflexa
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Infarct inferior si de VD
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Artera coronara dreapta sau a circumflexa
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Infarct postero inferior lateral
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Artera coronara dreapta sau a circumflexa
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Infarct lateral
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
LAD distal sau a diagonala/ a circumflexa
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Localizarea infarctului
aVR V1 V4I
II
III
LATERAL
INFERIOR
SEPTAL
ANT SEPTAL
ANTLAT
aVL
aVF
V2
V3
V5
V6
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Vectorul STPoate indica localizarea ocluziei arterei coronare
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Supradenivelarea de segment ST
R
P
Q
ST
• Apare precoce• Apare in derivatiile directe
• NB: o mica supradenivelare de segment ST poate fi normala in V1, V2 V3
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Unda Q patologica
R
P
QT
ST
• Modificare diagnostica in infarct• Durata >0.04 secunde• Amplitudine de >25% din unda
R
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Modificari ale undei T
R
P
QT
ST
• Negativarea undei T -modificare tardiva
• Apare cand segmentul ST incepe sa revina la normal
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Secventa modificarilor aspectului ECG in infarctul miocardic acut
1 minut dupa debut 1 ora de la debut La cateva ore de la debut
La o zi de la debut Modificari tardive La cateva luni dupa IMA
Q
R
P
QT
STR
P
Q
ST
P
QT
ST
R
P
S
T
P
QT
ST
R
P
Q
T
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Diagnosticul diferential al IMA cu supradenivelare ST
•Angina Prinzmetal•Pericardita•Repolarizare precoce•Sdr. Brugada•Unda Osborne•Supradenivelarea “inghetata” - anevrism
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Diagnosticul diferential al IMA cu supradenivelare ST
Unda Osborne
Normal Sdr. Brugada
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Asocierea IM cu BRS
I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6
Anterior wall MI Left bundle branch block
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Asocierea IM cu BRS
•↑ ST > 1mm in derivatii cu QRS pozitiv -5 puncte •↓ ST > 1 mm in V1-V3 -3 puncte •↑ ST > 5 mm in derivatii cu QRS negativ – 2 puncte
La un scor cumulativ de 3 puncte – specificitate de peste 90% de a detecta infarctul miocardic acut in prezenta blocului de ramura stang sau a unui ritm de pace-maker.
•Unda Q in cel putin doua dintre DI, aVL, V5, V6•Regresia undei R din V1 in V4•Incizura pe unda S in V3-V5 –semnul Cabrera
Criteriile Sgarbossa (pt IMA cu BRS)
Criterii pentru detectarea unui IM vechi in prezenta BRS
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Modificari reciproce (in oglinda)Localizare IM Supradenivelare ST Subdenivelare
reciproca de ST
Anterior V1-V6 (progresie lenta a undei R)
II, III, aVF
Lateral DI, aVL, V5, V6 V1-V3
Inferior II, III, aVF DI, aVL, posibil derivatiile anterioare
Posterior Unde R anormal de inalte in V1- V3
V1-V3
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SUPRAINCARCAREA ATRIALA
HIPERTROFIILE VENTRICULARE
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Supraincarcarea atriala dreapta•Unda P >2,5mm•Morfologie: unda ascutita•In V1, V2, daca unda este bifazica, predomina componenta pozitiva, initiala•Axa se verticalizeaza: +75° - +90°•Titulatura: p pulmonar•Derivatii preferentiale: DII, DIII, aVF
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Supraincarcarea atriala dreapta
Valvulopatii • Stenoza tricuspidiana • Regurgitare tricuspidiana
Hipertensiune pulmonara• BPOC • Embolii pulmonare• Apnee in somn
Boli congenitale• Stenoza pulmonara• Tetralogia Fallot
Tranzitor • Trombembolism pulmonar• Status astmaticus
Cauze de supraincarcare atriala dreapta
NB: De obicei asociata cu HVD, exceptia stenoza tricuspidiana
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Supraincarcarea atriala stanga•Unda P > 0.11 s•Morfologie: unda bifida•In V1, V2 predomina componenta negativa•Axa se orizontalizeaza•Titulatura: p mitral•Derivatii preferentiale: DI, aVL, V5, V6
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Supraincarcarea atriala stanga
Valvulopatii
•Stenoza mitrala•Regurgitare mitrala
Complianta scazuta a VS
•Hipertensiune arteriala•Cardiomiopatie obstructiva•Stenoza aortica•Regurgitare aortica•Boli infiltrative - amiloidoza
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Criterii pentru ambele tipuri de dilatari V1: unda larga bifazica
◦ componenta pozitiva > 1,5 mm◦ componenta negativa >1 mm, >0.04s
DII:◦ Unda > 2.5 mm◦ Unda > 0,12 sec
Dilatare biatriala
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Suprasolicitarea VS – cauze:◦ Suprasarcina de volum: IMi, IAo◦ Suprasarcina de presiune: HTA, SAo valv./subvalv.,
CoAo, CMH
◦Suprasolicitarea VS – efect:◦ Suprasarcina de volum – dilatare cavitati◦ Suprasarcina de presiune – hipertrofie, ingrosare
pereti
Hipertrofia ventriculara stanga
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HVS
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Indice Sokolow - Lyon: R (V5/V6) + S (V1/V2) > 3.5 mV
(4.5 mV la copil) Indicele Cornell: R (aVL) + S (V3) > 2.8 mV
(B), 2 mV (F) Scorul Romhilt - Estes
Criterii de apreciere a HVS
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Etiologie: ◦ incarcare de volum - DSV, Fallot (sunt stg. - dr.)◦ incarcare de presiune – HTP primara, HTP secundara
(emfizem, TBC, bronsiectazii bilaterale, fibroze pulm, SMi)
Consecinte:◦ balanta vectoriala VD-VS se schimba pana la
predominanta VD, in cazuri extreme de HVD◦ inversarea asp. normal pe ECG:R in V1, V2 + S in V5,
V6◦ rotatie orara, catre anterior a VD + rotatie posterioara a
vf. Inimii◦ prin masa VD asincronism VD-VS
Hipertrofia ventriculara dreapta
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HVD
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3 patternuri◦ 1. fara tulburari de conducere intraventriculare
drepte ◦ 2. cu BRD incomplet◦ 3. cu BRD complet
HVD
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Sokolow Lyon◦ Unda R in V1 + unda S in V5/ V6>1.1mV
◦ Alte criterii de apreciere: 1) deviatie axiala > 90 grd 2) R V1 > 7 mm 3) R/S V1 >1 4) P pulmonar 5) S/R V6 >1 6) aspect de BRD
Criterii de apreciere a HVD
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SV1 + RV5(sau V6) >35 mm (indice Sokolov pozitiv) combinat cu deviere ax frontal QRS la dreapta +90
SV6 >7 mm (fara BRD) probabil cel mai bun semn este combinatia
de pattern de HVD tipic cu dilatare de AS (durata p >=120 ms)
◦ S/R>1 in V5/V6 +dilatare de AS◦ SV6 >7 mm + dilatare AS◦ ÅQRS >+90 + dilatare de AS (in prezenta de BRD)
Hipertrofie biventriculara