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ECG interpretation for beginners – 2 Axel en Luc De Wolf RZ Tienen UZ Leuven.

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Presentatie over: "ECG interpretation for beginners – 2 Axel en Luc De Wolf RZ Tienen UZ Leuven."— Transcript van de presentatie:

1 ECG interpretation for beginners – 2 Axel en Luc De Wolf RZ Tienen UZ Leuven

2

3 INFLUENCE OF TIME-TO-TREATMENT ON THE ODDS RATIO (OR) OF MORTALITY Boersma et al. Lancet 1996; 348: 771–775. ABSOLUTE BENEFIT PER 1,000 TREATED PATIENTS TREATMENT DELAY IN HOURS PATHOPHYSIOLOGY + EPIDEMIOLOGY THROMBOLYSIS IN CLINICAL TRIALS AND REGISTRIES NEW TRIALS/ REGISTRIES MANAGEMENT OF ACUTE MI AND THE RATIONALE FOR EARLY REPERFUSION CLINICAL QUESTIONS METALYSE (+ PRESCRIBING INFORMATION) COSTS REFERENCES SYSTEM REQUIREMENTS IMPRESSUM The “golden hour”: 65 lives are saved for every 1,000 patients treated when the treatment is initiated within the first hour of symptom onset!

4 A heart Blood circulates, passing near every cell in the body, driven by this pump …actually, two pumps… Atria = turbochargers Myocardium = muscle Mechanical systole Electrical systole

5 Excitation of the Heart

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7 Cardiac Electrical Activity

8 A system Quality of ECG? Rate Rhythm Axis P wave PR interval QRS duration QRS morphology Abnormal Q waves ST segment T wave QT interval

9 A system Quality of ECG? Rate Rhythm Axis P wave PR interval QRS duration QRS morphology Abnormal Q waves ST segment T wave QT interval

10 P wave Are there P waves….? – Pointy = P pulmonale (RA hypertrophy)>2,5mm – Bifid = P mitrale (LA hypertrophy)>2,5mm Not very accurate or useful….

11 PR interval Start of P wave to start of QRS Normal = s Too short – can mean WPW syndrome (ie. an accessory pathway), or normal! Too long –means AV block (heart block) - 1 st /2 nd /3 rd degree

12 A system Quality of ECG? Rate Rhythm Axis P wave PR interval QRS duration QRS morphology Abnormal Q waves ST segment T wave QT interval

13 QRS complex Should be <0.12s duration >0.12s = BBB (either LBBB or RBBB) ‘Pathological’ Q waves can mean a previous MI (? territory) >25% size of subsequent complex Q waves are allowed in V1, aVR and III

14 BBB W I LL ia M = LBBB M a RR o W = RBBB Look at V1 and V6

15 QRS complex Is there LVH? Sum of the Q or S wave in V1 and the biggest R wave in V5 or V6 >35mm (R wave in aVL >11mm) Not actually very useful….

16 A system Quality of ECG? Rate Rhythm Axis P wave PR interval QRS duration QRS morphology Abnormal Q waves ST segment T wave QT interval

17 ST segment ST depression ◦ Downsloping or horizontal = abnormal ◦ Ischaemia (coronary stenosis) ◦ If lateral (V4-V6), consider LVH with ‘strain’ or digoxin (reverse tick sign) ST elevation ◦ Infarction (coronary occlusion) ◦ Pericarditis (widespread) These are usually in ‘territories’ eg. anterior/lateral/inferior etc. and will be present in contiguous leads

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21 T wave Peaked (hyperkalaemia or normal young man) Inverted/biphasic (ischaemia, previous infarct) Small (hypokalaemia) No pot, no tea!

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24 QT interval Don’t worry about too much… Start of QRS to end of T wave Needs to be corrected for HR Various formulae ◦ eg. Bazett’s: Computer calculated often wrong Long QT can be genetic (long QT sy.) or secondary eg. drugs (amiodarone, sotalol) Associated with risk of sudden death due to Torsades de Pointes

25 Morfologische afwijkingen Hypertrofie Voorkamer en Kamer

26 K51 – Rechter voorkamerhypertrofie Dilatatie van de rechter voorkamer Hoge spitse P toppen in afl. II & aVF (  0,25 mV) Toename initiële P voltage in afl. II, III, aVF & V1 Normale duur P golf Vaak in combinatie met tekenen van rechter kamerhypertrofie P pulmonale

27 Dilatatie van de linker voorkamer P golf > 120 ms Gehaakte P top door toename amplitude terminaal deel van P golf in afl. I, II, aVL & V6 Bifasische P golf in afl. V1 met terminaal negatief deel (  0,1 mV,  40 ms) K52 - Linker voorkamerhypertrofie Risico op atriale fibrillatie

28 (R in V5 of V6) + (S in V1 of V2) > 3,5 mV (35 mm) ST elevatie concaaf naar boven met hoge positieve T top in rechtszijdige afleidingen ST depressie convex naar boven met asymmetrisch negatieve T top in linkszijdige afleidingen Normale as K53 - Linker kamerhypertrofie

29 For more presentations Left Ventricular Hypertrophy Why is left ventricular hypertrophy characterized by tall QRS complexes? LVHECHOcardiogram Increased QRS voltage As the heart muscle wall thickens there is an increase in electrical forces moving through the myocardium resulting in increased QRS voltage.

30 For more presentations Left Ventricular Hypertrophy Criteria exists to diagnose LVH using a 12-lead ECG. – For example: The R wave in V5 or V6 plus the S wave in V1 or V2 exceeds 35 mm. However, for now, all you need to know is that the QRS voltage increases with LVH.

31 Hoge R in V1 (> 0,7 mV) met R/S ratio > 1 Vlakke R progressie Diepe S in V5-V6 ( > 0,7 mV) met R/S ratio < 1 qR of rSR’ in V1 met hoge spitse R’ (diff. diagnose RBTB) Hoge, terminale R in aVR Rechter asdeviatie (komt overeen met diepe S in I en aVL) K55 – Rechter kamerhypertrofie Kliniek van longlijden

32 Ischemie en Infarkt

33 K56 - Ischemie Wanneer een elektrode geplaatst wordt tegenover een zone van ischemie betekent - ST segment depressie: subendocardiale ischemie - ST segment elevatie: transmurale (subepicardiale) ischemie

34 Characteristic changes in AMI ST segment elevation over area of damage ST depression in leads opposite infarction Pathological Q waves Reduced R waves Inverted T waves

35 ST elevation R P Q ST Occurs in the early stages Occurs in the leads facing the infarction Slight ST elevation may be normal in V 1 or V 2

36 Deep Q wave R P Q T ST Only diagnostic change of myocardial infarction At least 0.04 seconds in duration Depth of more than 25% of ensuing R wave

37 T wave changes R P Q T ST Late change Occurs as ST elevation is returning to normal Apparent in many leads

38 Bundle branch block I II III aVR aVL aVFV1 V2 V3V4 V5 V6 I II III aVR aVL aVFV1 V2 V3V4 V5 V6 Anterior wall MI Left bundle branch block

39 Sequence of changes in evolving AMI 1 minute after onset 1 hour or so after onsetA few hours after onset A day or so after onsetLater changes A few months after AMI Q R P Q T ST R P Q P Q T R P S T P Q T R P Q T

40 Anterior infarction I II III aVR aVL aVFV1 V2 V3V4 V5 V6 Left coronary artery

41 Inferior infarction I II III aVR aVL aVFV1 V2 V3V4 V5 V6 Right coronary artery

42 Lateral infarction I II III aVR aVL aVFV1 V2 V3V4 V5 V6 Left circumflex coronary artery

43 Location of infarct combinations aVR V1 V4 I II III LATERAL INFERIOR ANT POST ANT SEPTAL ANT LAT aVL aVF V2 V3 V5 V6

44 Diagnostic criteria for AMI Q wave duration of more than 0.04 seconds Q wave depth of more than 25% of ensuing r wave ST elevation in leads facing infarct (or depression in opposite leads) Deep T wave inversion overlying and adjacent to infarct Cardiac arrhythmias


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