7
Myocardial ischemia &
Myocardial infarction
Dr Ghazi Ahmad Radaideh
MD, FRCP
Rashid Hospital
Dubai - UAE
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Introduction
When myocardial blood supply is abruptly reduced to
a region of the heart, a sequence of injurious events
occur :
Ischemia ( subendocardial or
transmural)
Injury
Necrosis, and eventual fibrosis
(scarring) if the blood supply
isn't restored in an appropriate
period of time.
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Ischemia:
T wave inversion or elevation,
ST elevation or depression
Injury:
ST elevation or depression
Necrosis:
Abnormal Q wave
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Hyperacute T waves
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ST segment changes
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localization of infarction
septal : V1-2
anterior : V3-4
anteroseptal : V1-4
high lateral : I, aVL
lateral : I, aVL, V6
anterolateral : I, aVL, V3-6
extensive anterior V1-6, I,
aVL
apical (anteroinferior) : II,
III, aVF, one or more of V1
inferior : II, III, aVF
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localization of infarction
Posterior : reciprocal changes
in V1-V2
prominent R wave and ST
depression, upward T in V1-2
(mirror image of anterior),
usually associated with inferior
or lateral infarction
RV infarction : changes in
right-sided chest leads :
ST elevation in V1-V4R,
usually associated with inferior
infarction
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Hyperacute Anteroseptal MI :
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Anteroseptal MI
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Lateral MI
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Extensive ant MI
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Inferior MI
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Inferolateral MI
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Posterior MI
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True posterior MI
ECG changes are seen in anterior precordial leads
V1-V3, ( mirror image of an anteroseptal MI):
Increased R wave amplitude and duration ("pathologic R
wave" is a mirror image of a pathologic Q)
R/S ratio in V1 or V2 >1
Hyperacute ST-T wave changes: i.e., ST depression and
large,inverted T waves in V1-3
Late normalization of ST-T with symmetrical upright T
waves in V1-3
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Rt ventricular MI
RCA
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Right Ventricular MI
only seen with proximal right
coronary occlusion; i.e., with
inferior family MI's.
ECG findings usually require
additional leads on right chest
(V1R to V6R)
ST elevation, >1mm, in right
chest leads, especially V4R
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MI & LBBB
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The Pseudoinfarcts
(Differential Diagnosis)
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Pericarditis
Concave upwards ST elevation in most leads
except aVR lasting 5-10 days.
PR-segment depression and sticks up like a
"knuckle. in aVR
Diffuse T wave inversion 10-15 days after
onset of acute pericarditis.
No reciprocal ST segment depression (except
in aVR)
Electrical alternans and low voltage if a
large pericardial effusion is present.
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Pericarditis
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Brugada syndrome
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Miscellaneous Abnormalities of
the QRS
The differential diagnosis of these QRS
abnormalities depend on other ECG
findings as well as clinical patient
information.
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Tall R in V1
R/S ration >1 in V1 or V2
True posterior MI (look for inferior MI)
RVH (RAD and/or P-pulmonale, RV strain)
Complete or incomplete RBBB (look for rSR'
in V1, S wave in leads I and V6)
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Tall R in V1
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