Department of Cardiology and Vascular Medicine

Faculty of Medicine University of Indonesia

National Cardiovascular Center Harapan Kita
ECG CHANGES IN
ISCHEMIA, INJURY AND
INFARCTION
Daniel Tobing, MD, FIHA
The Electrocardiogram ( ECG )
No ST Elevation ST Elevation
Acute Coronary Syndrome
Unstable Angina NQMI
Qw MI
NSTEMI
Myocardial Infarction
Davies MJ
Heart 83:361, 2000
Ischemic Discomfort
Presentation
Working Dx
ECG
Biochem.
Marker
Final Dx
Hamm Lancet 358:1533,2001
Visualization of the generation of
the Left Ventricular portion of
the ECG complex in Lead II
1. Septum depolarizes from the
inside out and resulting
depolarization wave moves
away from the electrode
recording Lead II
2. The rest of the ventricle
depolarizes counter-clockwise
from the inside out and creates
the (large arrow)
which is essentially, the algebraic
sum of all of the small depolarization
vectors. This vector is, in a normal
heart, almost always moving directly
toward Lead II, generating a mostly
positive QRS complex

main cardiac vector
Lead II electrode
60 downward
rotation angle
from the horizontal 0
o
o
60
o
Note: compared to
the left ventricle, the
right ventricle is much
smaller and contributes
little to the overall main
vector of depolarization
(DEPOLARIZATION)
3. Repolarization can be thought of as
beginning where depolarization left off
and proceeding clockwise from the lateral
wall back to the septum..
4. The repolarization process proceeds at
a much slower rate than depolarization
so the wave inscribed (T-wave) is wide
and rounded. The repolarization vector is
moving away from the Lead II electrode
so the inscribed T-wave is always positive
the Left Ventricular portion of
the ECG complex in Lead II
(REPOLARIZATION)
Visualization of the generation of
ISCHEMIA
Imbalance between metabolic needs of the
myocardium (demand) and the flow of
oxygenated blood to it (supply)
Affects the generation and impulse conduction
delays in depolarization and repolarization
ST and T changes (on ECG)
Significant ST depression, if
ST segment depression >0.05 mVolt at a point 0.04
second to the right of J point.
In two or more leads facing the same anatomic area
INJURY
Prolonged ischemia more than few minutes will
cause injury
Injured cells are still alive but will infarct (die) if
ischemia is not corrected
Do not depolarize completely, electrically more
positive than the uninjured areas
viewed on ECG as ST segment elevation

Significant if: elevated > 1 mm in two or more
contiguous leads
INFARCTION
Occurs when blood flow to the heart
muscle stops or suddenly decreased
Infarcted (dead) cells are without function
and can not respond to electrical stimuli
Q wave on ECG
ST depresi dan perubahan gelombang T

ST depresi dianggap bermakna bila > 0.05 mVolt
Titik J didefinisikan sebagai akhir kompleks QRS dan permulaan segmen ST


Bentuk segmen ST :

up-sloping ( tidak spesifik )
horizontal ( lebih spesifik untuk iskemia )
down-sloping ( paling terpercaya untuk iskemia )
Perubahan gelombang T pada
iskemia kurang begitu spesifik

Gelombang T hiperakut
kadang2 merupakan satu-satunya
perubahan EKG yang terlihat
ECG CHANGES OF ISCHEMIA
J point
SPESIFISITAS DEPRESI SEGMEN ST PADA ISKEMIA
VARIASI SEGMEN ST
Unstable angina DD/ Acute NSTEMI
Tn AS, 65 th, nyeri dada khas infark
ECG CHANGES OF INJ URY (ACUTE MYOCARDIAL INFARCTION)
CONCEPT OF RECIPROCITY

ECG CHANGES OF OLD INFARCTION

Recent Inferior MCI with T-wave inversions
Tn DS, 56 th, riwayat nyeri dada khas infark 2 minggu yang lalu

LOCATING
THE MYOCARDIAL INFARCTION




Sandapan V1 dan V2 menghadap septal area ventrikel kiri

Sandapan V3 dan V4 menghadap dinding anterior ventrikel kiri

Sandapan V5 dan V6 ( ditambah I dan avL ) menghadap
dinding lateral ventrikel kiri

Sandapan II, III dan avF menghadap dinding inferior ventrikel kiri
Anatomi Koroner dan EKG 12 sandapan
LOCATING THE MYOCARDIAL INFARCTION
Mid LAD occlusion
after the first septal
perforator (arrow)
ECG : large anterior MI
Proximal large RCA occlusion
ST elevation in leads II, III, aVF, V
5
, and V
6

with precordial ST depression
Small inferior distal RCA occlusion
ECG changes in leads II, III, and aVF
Subendocardial ischemia.
Anterolateral ST-segment depression
Acute anteroseptal myocardial infarction.
Hyperacute T-wave changes are noted
Acute anterolateral myocardial infarction
Lateral myocardial infarction
Inferior myocardial infarction.
Inferior Q waves with T-wave inversions
Acute inferoposterior myocardial infarction
RBBB + Anterior Infarction
Left bundle branch block
Pseudo Infarct Patern
W P W
negative delta wave II,III,aVF
Early repolarization
Left ventricular aneurysm