ECG Basics
Acute Myocardial Infarction
Views of the Heart
Some leads get a good view of the: Lateral portion of the heart
Anterior portion of the heart
Inferior portion of the heart
Infarct , injury and ischaemic
Normal
Progression of an Acute Myocardial Infarction
An acute MI is a continuum that extends from the normal state to a full infarction: IschemiaLack of oxygen to the cardiac tissue, represented by ST segment depression, T wave inversion, or both InjuryAn arterial occlusion with ischemia, represented by ST segment elevation InfarctionDeath of tissue, represented by a pathological Q wave
Ischemia
Injury
Infarction
Figure. a. Acute infarction: correlation between the electrocardiogram (ECG) and the stage of myocardial ischemia. Monophasic ST deformation /transmural lesion = lesion / injury. b. Subacute infarction. Correlation between the ECG and the stage of myocardial ischemia (ST elevation = lesion, plus pathologic Q wave = necrosis, plus negative T wave = ischemia). c. Evolution of subacute infarction to chronic infarction
Figure 9.3. The evolution of an inferior wall myocardial infarction, as seen in lead III of a 55-year-old white male. Note that the admission tracing shows only ST elevation. A Q wave is beginning to form by 1 hour, and ST elevation is on the way down. By 24 hours, Q wave formation is complete, and the T wave is fully inverted. By 1 year, a pathologic Q wave is the only remaining evidence of infarction.
Myocard infark : 1. 2. 3. 4. Hyperacute T wave ST segment changes Pathological Q wave Resolution of changes of ST segment and T wave 5. Reciprocal ST segment depression
T wave changes associated with ischaemia
Ishemia Injury - Infarct
Accurate ECG interpretation in a patient with chest pain is critical. Basically, there can be three types of problems - ischemia is a relative lack of blood supply (not yet an infarct), injury is acute damage occurring right now, and finally, infarct is an area of dead myocardium. It is important to realize that certain leads represent certain areas of the left ventricle; by noting which leads are involved, you can localize the process. The prognosis often varies depending on which area of the left ventricle is involved (i.e. anterior wall myocardial infarct generally has a worse prognosis than an inferior wall infarct).
V1-V2 V3-V4 V5-V6 anteroseptal wall anterior wall anterolateral wall
II, III, aVF
I, aVL V1-V2
inferior wall
lateral wall posterior wall (reciprocal)
b
Hubungan antara lokasi infark dan oklusi arteri koroner (panah), dan lead elektrocardiogram. a. Anteroseptal infark. b. Anterior infark Extensive (anterolateral infarction) c. Infark lateral isolatedction
Figure. ST, QRS, and T vectors in myocardial infarction. a. ST injury vector. b. b. QRS vector in necrosis. c. c. T ischemia vector
Diagnosing a MI
To diagnose a myocardial infarction you need to go beyond looking at a rhythm strip and obtain a 12-Lead ECG.
12-Lead ECG
Rhythm Strip
The 12-Lead ECG
The 12-Lead ECG sees the heart from 12 different views. Therefore, the 12-Lead ECG helps you see what is happening in different portions of the heart. The rhythm strip is only 1 of these 12 views.
The 12-Leads
The 12-leads include: 3 Limb leads (I, II, III) 3 Augmented leads (aVR, aVL, aVF) 6 Precordial leads (V1- V6)
ST Elevation
One way to diagnose an acute MI is to look for elevation of the ST segment.
ST Elevation (cont)
Elevation of the ST segment (greater than 1 small box) in 2 leads is consistent with a myocardial infarction.
Anterior View of the Heart
The anterior portion of the heart is best viewed using leads V1- V4.
Anterior Myocardial Infarction
If you see changes in leads V1 - V4 that are consistent with a myocardial infarction, you can conclude that it is an anterior wall myocardial infarction.
Putting it all Together
Do you think this person is having a myocardial infarction. If so, where?
Interpretation
Yes, this person is having an acute anterior wall myocardial infarction.
Other MI Locations
Now that you know where to look for an anterior wall myocardial infarction lets look at how you would determine if the MI involves the lateral wall or the inferior wall of the heart.
Other MI Locations
First, take a look again at this picture of the heart.
Lateral portion of the heart
Anterior portion of the heart
Inferior portion of the heart
Other MI Locations
Second, remember that the 12-leads of the ECG look at different portions of the heart. The limb and augmented leads see electrical activity moving inferiorly (II, III and aVF), to the left (I, aVL) and to the right (aVR). Whereas, the precordial leads see electrical activity in the posterior to anterior direction.
Limb Leads
Augmented Leads
Precordial Leads
Other MI Locations
Now, using these 3 diagrams lets figure where to look for a lateral wall and inferior wall MI.
Limb Leads Augmented Leads Precordial Leads
Anterior MI
Remember the anterior portion of the heart is best viewed using leads V1- V4.
Limb Leads Augmented Leads Precordial Leads
Lateral MI
So what leads do you think the lateral portion of the heart is best viewed?
Limb Leads Leads I, aVL, and V5- V6 Precordial Leads
Augmented Leads
Inferior MI
Now how about the inferior portion of the heart?
Limb Leads Leads II, III and aVF Precordial Leads
Augmented Leads
Putting it all Together
Now, where do you think this person is having a myocardial infarction?
Inferior Wall MI
This is an inferior MI. Note the ST elevation in leads II, III and aVF.
Putting it all Together
How about now?
Anterolateral MI
This persons MI involves both the anterior wall (V2-V4) and the lateral wall (V5-V6, I, and aVL)!
End of Module
Acute Myocardial Infarction
