PHYSICIANS MEETPROF.DR.DHANDAPANI’S UNIT
AN INTERESTING ECG
DR D SUBBURAJ
• 65/M presented with substernal chest discomfort , lasted for 15 mins
• Not radiating • Ass. With nausea & diaphoresis• No h/o DM or SHT• o/e - diaphoretic, BP- 90/60mmHg, PR-54bpm CVS- S1 S2 +, No murmur
RS - NVBS + , Other systems- normal
LIMB LEADS
Chest leads
v1
ECG FINDINGS• Sinus rhythm• Rate-54• PR-252ms• Cardiac axis 2 degrees• QTc-399 ms• ST elevation II,III,a VF,V5,V6. depression I,a VL,V2,V3• P Ta elevation II,III,a VF,V5 ,V6, depression in V1,V2
Pta SEGMENT ELEVATED IN II,III , aVF.
CHEST LEADS
ATRIAL INFARCT WITH INFERO POST LATERAL WALL INFARCT & FIRST DEGREE HEART BLOCK
ATRIAL INFARCTION
• Seen in upto 10% of patients with STEMI.• Rt atrial 81-98% Biatrial 19-24% Lt atrial 2-19%• Often clinically unrecognized because of its
subtle ECG changes.
DIAGNOSIS
• The diagnosis of atrial infarction is usually made from elevation of P-Ta segment in the clinical setting of MI.
• The diagnosis may be entertained when the P-Ta segment is minimally elevated, i.e. in the same direction as the p wave. (Schamroth)
P-Ta segmentFrom end of P wave to beginning of QRS
DIAGNOSTIC CRITERIA
1. PTa segment elevation >0.5 mm in leads v5,v6 with reciprocal PTa segment depression in leads v1,v2.
2. PTa segment elevation >0.5 mm in lead I with reciprocal PTa segment depression in leads II,III
3 PTa segment depression >1.5 mm in precordial leads .
4 PTa segment depression >1.2 mm inleads I,II,III and in associaton with any atrial arrhythmias.
5 Abnormal p wave: flattening of p wave in M pattern, flattening of p wave in W pattern,
irregular or notched p wave according to lieu et alaccording to lieu et al
COMPLICATIONS
• Arrhythmias :61-74% AF, SVT, atrial premature beats• Thromboembolism: 8484% systemic, pulmonary• Atrial rupture :4-5%• Hemodynamic disturbances
RCA• RCA SUPPLIES SA node,AV node, RV , posteromedial
papillary muscle ,inf part of LV, variabily post&lat segments of LV.
• RV BRANCH –from proximal seg of RCA• RCA OCCLUSION-SA NODE- sinus bradycardiaAVNODE-AV nodal blockRV-Cardiogenic shockPAPILLARY MUSCLE-MRINFERO POST LATERAL MI
RCA OR CX ?RCA OR CX ?RCA ST elevation III>IIST depression aVL> IST dep in I
CX ST elevation in II>III ST isoelectric LEAD I
avLaVR
III
II
PROXY OR DISTAL
• RV branch is from proxymal seg• PROXYMAL OCCULSION- ST ELEVATION &
POSITIVE T in V4R,
• DISTAL- ISOELECTRIC ST,POSITIVE T.• NEGATIVE T- CX OCCULSIONNEGATIVE T- CX OCCULSION• ATRIAL INFARCT – PROXYMAL OCCLUSIONATRIAL INFARCT – PROXYMAL OCCLUSION
ANOTHER ECG OF RCA OCCLUSIONANOTHER ECG OF RCA OCCLUSION
I
II
III
aVF
aVL
aVRV1
V2
V3
V4
V5
V6
REF : HURST 11th edition SCHAMROTH
THANK YOU