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Macstrak Project ECG The Acute Coronary Syndromes.

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Presentation on theme: "Macstrak Project ECG The Acute Coronary Syndromes."— Presentation transcript:

1 Macstrak Project ECG The Acute Coronary Syndromes

2 Macstrak Project Reviewing ECG for changes related to ACS ECGs evolve over time, during and after ACO ECG interpretation linked to management decisions Systematic approach to reading ECGs Principles discussed and examples of Macstrak ECG data capture ECG - Acute Coronary Syndromes

3 Macstrak Project ECG can provide answers to: Acute Coronary Occlusion (ACO) Is the vessel open or closed? How long was it closed? What territory is at risk? Threatened ACO (TACO) Is there a risk of an occlusion event? Consequences of an occlusion event? ACS - early assessment

4 Macstrak Project ECG assessed in conjunction with history at presentation – e.g. prolonged chest pain? Artery open/closed? ST elevation means closed Duration of occlusion: ST resolution artery may have opened Q waves present long duration of closure ST elevation shape convex early occlusion ST elevation shape concave late occlusion ACO - early assessment

5 Macstrak Project Each lead looks at specific area of myocardium Grouped leads represent heart muscle territory TerritoryLeadsCoronary inferiorII,III,aVFRCA or Circ anteriorV 1 -V 4 LAD lateralI,aVLDiagonal or OM apicalV 5 -V 6 LAD posteriorV 7 -V 9 Circ Inferior STUp requires a right sided ECG RVV 4 R RCA ACO - early assessment

6 Macstrak Project RCA LAD Circ LM

7 Macstrak Project TACO (Threatened ACO) arteries have unstable plaque or partial occlusion that is at risk for complete closure Risk of occlusion event is greater if: pain is cardiac; troponins +ve; ST’s, T’s changing pain at presentation or recent prolonged > brief episodes (>2 min) pain present despite therapy (ASA, clopidogrel, heparin, GP2b/3a inhib., IABP) TACO - early assessment

8 Macstrak Project Consequences of occlusion event: What is the territory at risk ? anterior large inferior with RV involvement previous infarction – Q waves Clinical assessment during ischemia hypotension, pulmonary edema TACO - early assessment

9 Macstrak Project Approach: Rhythm: 1.Is it NSR? If not – intervention for brady/tachy? 2.Is morphology valid? P wave - in sync with QRS QRS width >.12 RBBB V 1 - rSR, V 6 - RS LBBB V 1 - QS, V 6 - RR ACS - ECG interpretation

10 Macstrak Project Approach: The ECG can be used to look for ACS changes when none of the following conditions are present: LBBB Paced VT Accelerated idioventricular rhythm (AIVR) ACS - ECG interpretation

11 Macstrak Project Approach: Morphology: ST’s - Up or down - ST Up - 1 mm, except V mm - ST Down 1 mm (flat) Q’s-.04 wide (one box) T’s- inversion (where QRS is positive) V 4 R- ST Up - 1 mm V 7 -V 9 - ST Up - 1 mm ACS - ECG interpretation

12 Macstrak Project ECG Case Studies

13 Macstrak Project Patient arrived in the ER with complaint of severe chest pain and diaphoresis. The pain had been present for 30 minutes.

14 Macstrak Project Using the approach presented P wavematches QRS QRS width0.10 Will morphology be valid? YES

15 Macstrak Project x x x x

16 Patient presented to a hospital with PCI capabilities and underwent a primary PCI. This is his ECG the next day.

17 Macstrak Project Using the approach presented P wavematches every QRS QRS width0.08 Will morphology be valid? YES

18 Macstrak Project x x x

19 These are the pictures from the patient’s PCI. The top picture shows an acute total occlusion of the RCA. The bottom, shows restored blood flow to the area supplied by the RCA.

20 Macstrak Project Patient presented with a history of on and off chest pain yesterday that became continuous and more intense about 3 hours ago.

21 Macstrak Project Using the approach presented P waveone with QRS QRS width0.12 Will morphology be valid? YES Note: First three beats are ectopic atrial – not NSR but morphology is valid

22 Macstrak Project x x x x

23 The picture on the left side shows an occlusion of the proximal RCA. The right side picture shows the open RCA after PCI.

24 Macstrak Project Patient presented with chest pain, diaphoresis, and dizziness. Blood pressure was 100/60.

25 Macstrak Project Using the approach presented P wavewith every QRS QRS width0.10 Will morphology be valid? YES

26 Macstrak Project x x x

27 R XX V8 XX V9 Since the previous ECG showed an acute inferior MI, the staff completed a 15 lead ECG 2 minutes after the original one.

28 Macstrak Project R XX V8 XX V9 Using the approach presented P wavewith each QRS, PAC’s QRS width0.10 Will morphology be valid? YES

29 Macstrak Project x x x x x x XX V8 XX V9

30 Macstrak Project Patient presents with waxing and waning chest tightness. He has been having mild tightness for 10 minutes. No other symptoms.

31 Macstrak Project Using the approach presented P wavewith every QRS QRS width0.08 Will morphology be valid? YES

32 Macstrak Project x x

33 Patient was given NTG spray and is currently pain free. A repeat ECG is done.

34 Macstrak Project Using the approach presented P wavewith every QRS QRS width0.08 Will morphology be valid? YES

35 Macstrak Project x

36 Two hours after the initial episode, the patient c/o chest tightness that is a bit more intense. He says its been there for 10 minutes but he thought it would go away so he didn’t bother the nurse.

37 Macstrak Project Using the approach presented P wavewith each QRS QRS width0.10 Will morphology be valid? YES

38 Macstrak Project x x x x

39 Culprit lesion at ostium of a large intermediate branch, successful PCI

40 Macstrak Project Patient presents 1 day after experiencing chest pain after shovelling snow. He is diaphoretic, short of breath and dizzy. His BP is 95/50.

41 Macstrak Project Using the approach presented P wavewith each QRS QRS width Will morphology be valid? YES - RBBB, V1 mostly +, V6 mostly -, S wave

42 Macstrak Project x x x x x

43 More examples

44 Macstrak Project

45 x x

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47 x

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49 x x x x x x x x

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51 x x x x

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53 x

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55 x x x

56 Acute occlusion of proximal LAD, opened with Primary PCI

57 Macstrak Project

58 x

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60 x x x Moving baseline, should repeat ECG

61 Macstrak Project

62 x x x x

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64 x x x x x Morphology only from narrow beats

65 Macstrak Project

66 x Note RBBB


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