ECG in Acute Coronary Syndromes

Muhadi MD
Div of Cardiology, Dept of Internal Med, Cipto M Hospital, FMUI
 Kompetensi Dokter Indonesia dan PPK FKTP
(SKDI 2012, KepMenKes No 514 thn 2015)

Penyakit Tingkat
Kemampuan
Angina pektoris 3B
Infark miokard 3B
ECG Components
Tahapan SKA
Sindrom Koroner Akut —
Segmen ST Elevasi
(STEMI)
Tahapan SKA
Gambar I-II STEMI

• I : timbul elevasi segmen ST

(iskemia), (0-12 jam)

• I A : Timbul gelombang Q
patologis sebagai tanda
nekrosis, (1-12 jam)
 Gel Q Patologis vs Non-patologis ??

• Gelombang Q patologis pada infark miokardium

biasanya lebih dalam dan lebar daripada gelombang Q
normal.

• Kriteria gelombang Q patologis adalah :

1.Kedalamannya ≥ ¼ tinggi gelombang R di sadapan yang
sama.
ATAU
2.Durasi gelombang Q > 0.04 detik (1 kotak kecil EKG).
Gambar I-II STEMI

• I B : Resolusi segmen ST. Segmen ST menurun

dan gel T semakin negatif

• I C : Fase subakut infark, segmen ST menjadi

isoelektrik namun gel T mengalami inversi, (2-5
hari)

• I D : Fase kronik infark, gel T menjadi positif lagi.

Tidak tampak sisa infark pada segmen ST maupun
gel T. Parut miokardium hanya tampak dalam
bentuk gel Q atau kompleks QS, (beberapa
minggu-bulan)
Sindrom Koroner Akut —
ST-depresi dan T-inverted
(NSTEMI)
Gambar III NSTEMI atau UAP

• III A : depresi ST

• III B : inversi gel T

 ST-depresi

• Bentuk depresi segmen ST yang bervariasi

 Inversi gelombang T

Inversi asimetris gelombang T biasanya terdapat pada hipertrofi

ventrikel.

Inversi simetris gelombang T ditemukan pada keadaan kematian sel

miokardium, yang terjadi biasanya pada iskemia atau miokarditis
 Gambar IV Angina Prinzmetal
(Variant angina) : kasus khusus

• Nyeri dada biasanya sebentar (15-20 min) dan timbul

saat istirahat atau sedang tidur.
• Elevasi segmen ST kembali ke isoelektrik segera setelah
gejala hilang.

• Oklusi koroner diduga akibat spasme arteri.

Lokasi ….
Anatomic Groups
(Septum)
Anatomic Groups
(Anterior Wall)
Anatomic Groups
(Lateral Wall)
Anatomic Groups
(Inferior Wall)
Anatomic Groups
(Summary)
 Regional Issues :

❖Anteroseptal MIs associated with lateral

wall involvement are associated with
extensive coronary artery disease
❖The ST segment elevation of an acute
inferior MI that is of greater amplitude in
lead III than in lead II is a strong predictor
of occlusion of the proximal right coronary
artery
 Regional Issues :

❖Acute inferior MI associated with ST

segment elevation in lead V1 is suggestive
of right ventricular infarction
❖Posterior MI can be differentiated from
septal myocardial ischemia by the presence
of an R : S wave amplitude ratio of at least 1
 Acute Inferior STEMI

hyperacute T waves with ST elevation in II, III, aVF

 Old inferior MI

Pathologic Q waves, T wave inversion in II, III, aVF

Acute inferior STEMI and the right ventricle

ST segment elevation in V4r indicative of proximal

RCA occlusion causing right ventricular infarction
 Anteroseptal STEMI

ST elevation in V1-3 before Q waves developed

Fully evolved anteroseptal MI

QS waves in V1-2, qrS complex in V3, resolving ST elevation with

deep inverted T waves
Acute extensive anterior STEMI

ST elevation V2-6, I, aVL

 Acute Left Main Sub-total Coronary Occlusion

ST depression in at least 7 leads; ST elevation aVR > any ST elevation in V1

STEMI Anterior-septal dan lateral
STEMI INFERIOR
STEMI Inferior with Right
Ventricular Infarction
63 year old man with epigastric burning, belching,
diaphoresis, and lightheadedness

SB with 1st degree AV block, acute inferior STEMI

 53 year old diabetic woman with four days of
nausea, vomiting, and lightheadedness

T-wave abnormality consistent with anterolateral NSTEMI/UAP

 43 year old man reports eight hours of left
chest and arm pain

SR, acute lateral STEMI

 62 year old woman with nine hours of chest pain
and dyspnea

SR, recent inferior STEMI with persistent ischemia

 68 year old woman with chest pain and dyspnea

SR, T-wave abnormality consistent with anteroseptal NSTEMI/UAP

 62 year old man with epigastric burning, nausea,
diaphoresis, and lightheadedness; blood pressure is 80/35

SR with 2nd degree AV block and 2:1 AV conduction, acute inferior STEMI
 57 year old man with chest pressure, dyspnea,
and nausea

SR with 1st degree AV block, acute inferior-lateral, and right ventricular (RV) STEMI
THANK YOU