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ECG interpretation for beginners Part 4 – Acute coronary syndromes Paul Williams Cardiology Specialist Registrar.

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Presentation on theme: "ECG interpretation for beginners Part 4 – Acute coronary syndromes Paul Williams Cardiology Specialist Registrar."— Presentation transcript:

1 ECG interpretation for beginners Part 4 – Acute coronary syndromes Paul Williams Cardiology Specialist Registrar

2 Normal ECG!

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4 MI diagnosis Use your system Don’t forget rate, rhythm etc. Need to have basic understanding of: ◦ Pathology of heart attacks ◦ Coronary arteries and regions of heart

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8 Coronary arteries 2 coronary arteries come off aorta Total of 3 main coronary arteries LCA ◦ LMS branches into: ◦ Left anterior descending (LAD) ◦ Circumflex (Cx) RCA

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10 Left ventricle supply LAD – Supplies anterior wall, septum +- lateral walls(60%) Cx – Supplies lateral wall (15%) RCA – Supplies inferior and posterior walls (25%). Also supplies RV & conducting tisse

11 Inferior Lateral Septal Anterior

12 Other territories Inferior MI – can have RV involvement ◦ RV leads - V4R Posterior MI – Usually ST depression V1- V3

13 The hallmark of acute ischaemia is ST segment shift ST elevation = complete blockage = STEMI ST depression = partial blockage = NSTEMI/USA Generally only occurs when patient has symptoms: ACS are dynamic If real, usually have changes in contiguous leads

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15 STEMI Occluded coronary artery Emergency = myocardium is dying!

16 STEMI Changes evolve: ◦ Often “hyperacute” T waves initially ◦ T wave inversion ◦ Q waves Dynamic - repeat ECGs if not sure What territory is it? ◦ Two contiguous leads ◦ Can get reciprocal ST depression ◦ Remember posterior & RV involvement

17 Differential Pericarditis ◦ Widespread concave upsloping ST depression ◦ Would involve multiple coronary arteries if MI ◦ PR depression (II) ◦ Look at the patient – common sense

18 Management of STEMI ABC Cardiac monitor (can go into VF) Analgesia Aspirin Clopidogrel Reperfusion therapy ◦ Thrombolysis ◦ Primary PCI Medical Rx

19 Inferior Lateral Septal Anterior

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23 Old MIs Old STEMIs can leave permanent Q waves Territories are the same (anterior, inferior lateral etc.) Poor R wave progression can also indicate an old anterior STEMI

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25 ST depression

26 Often get T wave inversion as well Remember your territories Generally ST depression only occurs during acute ischaemia Differential ◦ Digoxin (downsloping lateral: V4-V6, I, aVL) ◦ LVH (downsloping lateral)

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28 Management of NSTEMI/USA ABC Cardiac monitor Analgesia Initial medical Rx ◦ Aspirin ◦ Clopidogrel ◦ Beta-blocker ◦ Statin ◦ LMWH IP angiography

29 Question 1 What are the ECG abnormalities? What is the differential?

30 Question 2 What are the ECG abnormalities? What sort of ACS? What territory is affected?

31 Question 3 What are the ECG abnormalities What sort of ACS? What territory?

32 Question 4 What are the ECG abnormalities? Give 3 possible differentials

33 Question 5 What are the ECG abnormalities? What sort of ACS? What territory?


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