ACS and ECG

8/16/2019 ACS and ECG

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ACUTE CORONARYSYNDROMES

Dr. Ravi Kant

Assistant Professor Department of General Medicine


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LECTURE OUTLINE

• INTRODUCTION –EPIDEMIOLOGY/PREVALENCE/DEFINITION

•PATHOPHYSIOLOGY OF ACUTE CORONARYSYNDROMES

• APPROACH TO SUSPECTED ACUTECORONARY SYNDROME – GUIDELINEUPDATE

• TREATMENT/MANAGEMENT UPDATE


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INTRODUCTION

• Coronary Artery Disease – ea!in" #a$se o%&or'i!ity ( &ortaity in in!$striai)e!nations*

• At+o$"+ !e#rease in #ar!io,as#$ar

&ortaity sti &a-or #a$se o% &or'i!ity( '$r!en o% !isease*


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DEFINITIONS

• CAD is a #ontin$$& o% !isease.*• An"ina 0 $nsta'e an"ina 0 AMI 0

s$!!en #ar!ia# !eat+

• A#$te #oronary syn!ro&e en#o&1asses$nsta'e an"ina2 NSTEMI2 STEMI

• Sta'e an"ina – transient e1iso!i# #+est1ain !/t &yo#ar!ia is#+ae&ia2

re1ro!$#i'e2 %re3$en#y #onstant o,erti&e*$s$ay reie,e! 4it+ rest/NTG*

• Cassi5#ation o% an"ina – CanadianCardiovascular Society classication.


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Canadian Cardiovascular AssociationClassifcation o Angina

CLASS 1 NO PAIN WITH ORDINARYPHYSICAL ACTIVITY

CLASS 2 SLIGHT LIMITATION OF PHYSICAL

ACTIVITY –PAIN OCCURS WITH

WALKING, CLIMBINGSTAIRS,STRESS

CLASS 3 SEVERE LIMITATION OF DAILY

ACTIVITY – PAIN OCCURS ON

MINIMAL EXERTION

CLASS 4 UNABLE TO CONDUCT ANY

ACTIVITY WITHOUT PAIN, PAIN AT

REST


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UNSTABLE ANGNA

• Pain o##$rrin" at rest – !$ration 0 67&in24it+in one 4ee8 o% 5rst ,isit

• Ne4 onset an"ina – 9 Cass 6 se,erity2onset 4it+ ast 6 &ont+s

• :orsenin" o% #+est 1ain – in#rease 'y ateast ; #ass2 in#reases in %re3$en#y2!$ration

• An"ina 'e#o&in" resistan#e to !r$"s t+at1re,io$sy "a,e "oo! #ontro*

• N07*?&&@2 T 4a,e #+an"es


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ACUTE MYOCARDALN!ARCTON

• ECC/ACC DEFN –rise an! %a in #ar!ia#en)y&es 4it+ one or &ore o% t+e %oo4in"

• Is#+ae&i# ty1e #+est 1ain/sy&1to&s

• ECG #+an"es – ST #+an"es2 1at+oo"i#a B4a,es

• Coronary artery inter,ention !ata

• Pat+oo"i#a 5n!in"s o% an a#$te MI

• NSTEMI UNSTA


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A""ROAC#

• I!enti%yin" t+ose 4it+ #+est 1ain s$""esti,e o%IHD/ACS*

• T+oro$"+ +istory re3$ire!

• C+ara#ter o% 1ain

• Onset an! !$ration

• Lo#ation an! ra!iation

• A""ra,atin" an! reie,in" %a#tors

• A$tono&i# sy&1to&s• TY"CAL $S ATY"CAL #STORY

• Fai$re to re#o"nise sy&1to&s ot+er t+an

#+est 1ain 0 a11ro 6 +r !eay in see8in"


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C#ARACTERSTCS O! TY"CAL ANGNAL C#EST"AN %ADA"TED !ROM ROSEN&S' EMERGENCYMEDCNE(

CHARACTERISTIC SUGGESTIVE OFANGINA

LESS SUGGESTIVE OFANGINA

TYPE OF PAIN DULL

PRESSURECRUSHING

PAIN

SHARPSTABBING

DURATION 2!" MIN, #2$ MIN SECONDSTOHOURSCONTINUOUS

ONSET GRADUAL RAPID

LOCATION/CHEST

WALL TENDERNESS

SUBSTERNAL, NOT

TENDER TO PALP%

LATERAL CHEST

WALLTENDER TO PALP%

REPRODUCIBALITY WITH

EXERTIONACTIVITY

WITH

BREATHINGMOVING

AUTONOMIC

SYMPTOMS

PRESENT USUALLY ABSENT


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TOOLS USED N RS)STRAT!CATON

• HISTORY

• ECG

•


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ECG

• First 1oint o% entry into ACS a"orit+&

• A'nor&a or nor&a

• Neit+er ;77 sensiti,e or ;77 s1e#i5#%or AMI

• Sin"e ECG %or AMI – sensiti,ity o% 72s1e#i5#ity J7

Nor&a ECG !oes not e#$!e ACS – ;1ro,en to +a,e AMI2 K $nsta'e an"ina


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• GUDELNES*

• Initia ;6 ea! ECG – "oa !oor to ECG ti&e

;7&in2 rea! 'y e1erien#e! !o#tor*

• I% ECG not !ia"nosti#/+i"+ s$s1i#ion o% ACS –

seria ECGs initiay ;? 7 &in inter,as*

• ECG a!-$n#ts – ea!s V –VJ2 RV K

• Contin$o$s ;6 ea! ECG &onitorin"reasona'e aternati,e to seria ECGs*


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T+an,ing You


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Ee#tro#ar!io"ra1+y

Dr* Ra,i ant

Assistant Pro%essor

De1art&ent o% GeneraMe!i#ine


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Intro!$#tion

• An ee#tro#ar!io"ra& >ECG or EG@ is a"ra1+i# re#or!in" o% ee#tri# 1otentias"enerate! 'y t+e +eart*

• T+e si"nas are !ete#te! 'y &eans o% &etaee#tro!es atta#+e! to t+e etre&ities an!#+est 4a an! t+en are a&1i5e! an!re#or!e! 'y t+e ee#tro#ar!io"ra1+*

• ECG leads a#t$ay !is1ay t+einstantaneo$s diferences in 1otentia'et4een t+e ee#tro!es*


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av. or/s annt.rvals

• T+e ECG 4a,e%or&s area'ee! a1+a'eti#ay2'e"innin" 4it+ t+e P4a,e2 4+i#+ re1resentsatria !e1oari)ation *

• T+e BRS #o&1ere1resents ,entri#$ar!e1oari)ation2 an! t+eSTTU #o&1e

re1resents ,entri#$arre1oari)ation*


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• T+e 1oint is t+e -$n#tion 'et4eent+e en! o% t+e BRS #o&1e an! t+e

'e"innin" o% t+e ST se"&ent*• T+e BRST 4a,e%or&s o% t+e s$r%a#e

ECG #orres1on! in a "enera 4ay 4it+

t+e !ierent 1+ases o% si&$taneo$syo'taine! ,entri#$ar action potentials2t+e intra#e$ar re#or!in"s %ro&

sin"e &yo#ar!ia 5''ers*


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• Con!itions t+at 1roon" 1+ase 6>a&io!arone2 +y1o#a#e&ia@ in#reaset+e BT inter,a*

• In #ontrast2 s+ortenin" o% ,entri#$arre1oari)ation >1+ase 6@2 s$#+ as 'y!i"itais a!&inistration or

+y1er#a#e&ia2 a''re,iates t+e STse"&ent


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ECG Lea!s

• T+e ;6 #on,entiona ECG ea!s re#or! t+e!ieren#e in 1otentia 'et4een ee#tro!es1a#e! on t+e s$r%a#e o% t+e 'o!y*

• T+ese ea!s are !i,i!e! into t4o "ro$1s

si i&' >etre&ity@ ea!s an! si #+est>1re#or!ia@ ea!s*

• T+e i&' ea!s re#or! 1otentias

trans&itte! onto t+e rontal plane an! t+e#+est ea!s re#or! 1otentias trans&itte!onto t+e horizontal plane


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Genesis o% t+e Nor&a ECG

• P :a,e

• T+e nor&a atria !e1oari)ation ,e#tor is oriente! !o4n4ar! an!to4ar! t+e s$'-e#ts e%t2 reQe#tin" t+e s1rea! o% !e1oari)ation%ro& t+e sin$s no!e to t+e ri"+t an! t+en t+e e%t atria&yo#ar!i$&*

• Sin#e t+is ,e#tor 1oints to4ar! t+e 1ositi,e 1oe o% ea! II an!to4ar! t+e ne"ati,e 1oe o% ea! aVR2 t+e nor&a P 4a,e 4i 'e1ositi,e in ea! II an! ne"ati,e in ea! aVR* ne"ati,e in ea! II2 1ositi,e in ea! aVR@*• T+e nor&a P 4a,e in ea! V; &ay 'e 'i1+asi# 4it+ a 1ositi,e

#o&1onent reQe#tin" ri"+t atria !e1oari)ation2 %oo4e! 'y as&a >; &&6@ ne"ati,e #o&1onent reQe#tin" e%t atria!e1oari)ation*


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BRS Co&1e

• Nor&a ,entri#$ar !e1oari)ation 1ro#ee!s as a ra1i!2#ontin$o$s s1rea! o% a#ti,ation 4a,e %ronts*

• T+is #o&1e 1ro#ess #an 'e !i,i!e! into t4o &a-or se3$entia1+ases2 an! ea#+ 1+ase #an 'e re1resente! 'y a &ean,e#tor

• T+e 5rst 1+ase is !e1oari)ation o% t+e inter,entri#$ar se1t$&%ro& t+e e%t to t+e ri"+t an! anteriory >,e#tor ;@*

• T+e se#on! res$ts %ro& t+e si&$taneo$s !e1oari)ation o%t+e ri"+t an! e%t ,entri#es it nor&ay is !o&inate! 'y t+e&ore &assi,e e%t ,entri#e2 so t+at ,e#tor 6 1oints e%t4ar!

an! 1osteriory*

• T+ere%ore2 a ri"+t 1re#or!ia ea! >V;@ 4i re#or! t+is 'i1+asi#

!e1oari)ation 1ro#ess 4it+ a s&a 1ositi,e !eQe#tion >se1tar 4a,e@ %oo4e! 'y a ar"er ne"ati,e !eQe#tion >S 4a,e@*


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T :a,e an! U :a,e

• Nor&ay2 t+e &ean T4a,e ,e#tor is oriente! ro$"+y #on#or!ant 4it+t+e &ean BRS ,e#tor >4it+in a'o$t K? in t+e %ronta 1ane@* Sin#e!e1oari)ation an! re1oari)ation are ee#tri#ay o11osite 1ro#esses2t+is nor&a BRS–T4a,e ,e#tor #on#or!an#e in!i#ates t+atre1oari)ation nor&ay &$st 1ro#ee! in t+e re,erse !ire#tion %ro&!e1oari)ation >i*e*2 %ro& ,entri#$ar e1i#ar!i$& to en!o#ar!i$&@*

• T+e nor&a U 4a,e is a s&a2 ro$n!e! !eQe#tion >; &&@ t+at %oo4st+e T 4a,e an! $s$ay +as t+e sa&e 1oarity as t+e T 4a,e*

• An a'nor&a in#rease in U4a,e a&1it$!e is &ost #o&&ony !$e to!r$"s >e*"*2 !o%etii!e2 a&io!arone2 sotao2 3$ini!ine2 1ro#aina&i!e2!iso1yra&i!e@ or to +y1o8ae&ia*

• Very 1ro&inent U 4a,es are a &ar8er o% in#rease! s$s#e1ti'iity tot+e torsades de pointes ty1e o% ,entri#$ar ta#+y#ar!ia In,ersion o%t+e U 4a,e in t+e 1re#or!ia ea!s is a'nor&a an! &ay 'e a s$'tesi"n o% is#+e&ia*


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Ma-or ECG A'nor&aities


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Car!ia# Enar"e&ent an! Hy1ertro1+y

• Ri"+t ,entri#$ar +y1ertro1+y !$e to a 1ress$re oa! >as %ro&1$&oni# ,a,e stenosis or 1$&onary artery +y1ertension@ is#+ara#teri)e! 'y a reati,ey ta R 4a,e in ea! V; >R S 4a,e@2

$s$ay 4it+ ri"+t ais !e,iation aternati,ey2 t+ere &ay 'e a3R 1attern in V; or VR* ST !e1ression an! T4a,e in,ersion in

t+e ri"+tto&i!1re#or!ia ea!s are aso o%ten 1resent*

• T+is 1attern2 %or&ery #ae! ri"+t ,entri#$ar strain2 isattri'$te! to re1oari)ation a'nor&aities in a#$tey or#+roni#ay o,eroa!e! &$s#e*

• Pro&inent S 4a,es &ay o##$r in t+e e%t atera 1re#or!ia

ea!s* Ri"+t ,entri#$ar +y1ertro1+y !$e to osti$& se#$n!$&–ty1e atria se1ta !e%e#ts2 4it+ t+e a##o&1anyin" ri"+t,entri#$ar ,o$&e o,eroa!2 is #o&&ony asso#iate! 4it+ anin#o&1ete or #o&1ete ri"+t '$n!e 'ran#+ 'o#8 1attern 4it+a ri"+t4ar! BRS ais*


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Cini#a Inter1retation o%t+e ECG

• A##$rate anaysis o% ECGs re3$ires t+oro$"+ness an! #are*

• T+e %oo4in" ;K 1oints s+o$! 'e anay)e! #are%$y in e,ery ECG

• ; stan!ar!i)ation >#ai'ration@ an! te#+ni#a %eat$res >in#$!in" ea!1a#e&ent an! arte%a#ts@

• 6 r+yt+&

• +eart rate

• K PR inter,a/AV #on!$#tion• ? BRS inter,a

• BT/BT# inter,a

• &ean BRS ee#tri#a ais

• W P 4a,es

• J BRS ,ota"es

• ;7 1re#or!ia R4a,e 1ro"ression

• ;; a'nor&a B 4a,es

• ;6 ST se"&ents

• ; T 4a,es

• ;K U 4a,es


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Myo#ar!ia Is#+e&ia an!In%ar#tion

• T+e ECG is a #ornerstone in t+e !ia"nosis o% a#$te an! #+roni# is#+e&i# +eart!isease*

• Is#+e&ia eerts #o&1e ti&e!e1en!ent ee#ts on t+e ee#tri#a 1ro1ertieso% &yo#ar!ia #es* Se,ere2 a#$te is#+e&ia o4ers t+e restin" &e&'rane1otentia an! s+ortens t+e !$ration o% t+e a#tion 1otentia*

• T+ese #$rrents o% in-$ry are re1resente! on t+e s$r%a#e :+en t+e a#$te

is#+e&ia is transmural2 t+e ST ,e#tor $s$ay is s+i%te! in t+e !ire#tion o% t+eo$ter >e1i#ar!ia@ ayers2 1ro!$#in" ST ee,ations an! so&eti&es2 in t+eeariest sta"es o% is#+e&ia2 ta2 1ositi,e so#ae! +y1era#$te T 4a,es o,ert+e is#+e&i# )one* :it+ is#+e&ia #on5ne! 1ri&ariy to t+e subendocardium2t+e ST ,e#tor ty1i#ay s+i%ts to4ar! t+e s$'en!o#ar!i$& an! ,entri#$ar#a,ity2 so t+at o,eryin" >e*"*2 anterior 1re#or!ia@ ea!s s+o4 STse"&ent!e1ression >4it+ ST ee,ation in ea! aVR@* M$ti1e %a#tors ae#t t+ea&1it$!e o% a#$te is#+e&i# ST !e,iations* Pro%o$n! ST ee,ation or!e1ression in &$ti1e ea!s $s$ay in!i#ates ,ery se,ere is#+e&ia* Fro& a#ini#a ,ie41oint2 t+e !i,ision o% a#$te &yo#ar!ia in%ar#tion into STse"&entee,ation an! nonST ee,ation ty1es is $se%$ sin#e t+e eX#a#y o% a#$tere1er%$sion t+era1y is i&ite! to t+e %or&er "ro$1


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ECG se3$en#e 4it+ anterior3 4a,e in%ra#tion


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ECG se3$en#e 4it+ in%erior 3 4a,ein%ra#tion

C t i !


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Co&1$teri)e!Ee#tro#ar!io"ra1+y

• Co&1$teri)e! ECG syste&s are 4i!ey$se! %or i&&e!iate retrie,a o% t+o$san!so% ECG re#or!s*

• Co&1$ter inter1retation o% ECGs sti +as&a-or i&itations*

• In#o&1ete or ina##$rate rea!in"s are&ost i8ey 4it+ arr+yt+&ias an! #o&1e

a'nor&aities* T+ere%ore2 #o&1$teri)e!inter1retation s+o$! not 'e a##e1te!4it+o$t #are%$ #ini#ian re,ie4*

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ACS and ECG