ECG:Acute coronary syndromes

Cardiovascular disease

• Commonest cause of death

• ACS Common admissions

• 33,623 in year 2000

• Increase with age

Coronary artery disease

ATHERO-SCLEROSIS ATHERO-THROMBOSIS

Plaque disruptionAccelerated progression

YEARS MINUTES

CHRONIC ACUTE

Acute coronary syndromes

Sudden Cardiac Death

Asymptomatic

Silent ischaemia

Stable angina

RISK FACTORS

ACUTE CORONARY SYNDROME (ACS)

NO ST ELEVATION ST ELEVATION

NSTEMI STEMI*

UNSTABLE ANGINA

NQMI QwMI

Myocardial Infarction

SPECTRUM OF ACS

Modified from Antman EM, Braunwald E. Acute myocardial infarction

Acute Coronary Syndrome in Young patients under 45 years old

Electrocardiography• ST elevation:

– Limb > 1 mm;

– Precordial > 2 mm

– LBBB new or presumably new• ST segment depression > 0.05 mV• T-wave inversion – marked >0.2 mV symmetrical T-wave

inversion in precordial leads• Bundle branch block• Arrhythmias• Serial assessment

– Rest vs. Exercise– At time of symptom vs. absence

Hallmark of ischaemia-infarction

“Rule in AMI” ECG criteria

These 3 characteristics have independent predictive value and prognostic value;

Recommended for rapid triage:

• ST elevation ≥0.1mV (1mm) in leads (+)QRS• ST depression ≥0.1mV (1mm) in V1-V3• ST elevation ≥0.5mV (5mm) in leads with (–)QRS

New or presumably new LBBB coupled with typical ischaemic history

Superior (aVR, aVL)

Inferior II, III, avF

Lateral I, aVL

(Medial-RV) V3R-V6R

Anterior V1-V3Posterior V7-V9 (V1-V3)

Apical V5-V6

Beyond standard “12-lead-ECG”V7V8V9

V5R

V4R

V3R

V7 Post-Axillary

V8 Mid-scapular

V9 Para-vertebral

ACS: ECG can be “normal”

50yo hypertensive, smoker

1-2 hr of “stuttering” chest discomfort, palpitation

ECG changes can be subtle!

• 45yo female diabetic-5yr• Woken up at 4am with SOB, nausea

Dynamic changes: T waves

• 75yr female hypertensive• “Atypical” chest discomfort at rest and exertion

Previous inferior AMI: Q waves

• 52yo male smoker, hypercholesterolaemia, FHx• 1 hr chest discomfort on exertion, similar episode 3 days ago, pain

partially relieved by GTN

Dynamic changes: ST segment

• 40yr smoker executive• Chest tightness during company meeting, on-off for 2 hours, 5-10min

STEMI in evolution

• 53yr woken at 5.00am with “choking”• Arrive at hospital within 30minutes (no traffic jam!)

Tachycardia ↔ Ischaemia

• 75yo hypertensive diabetic• 1hr of subacute breathlessness and palpitation

ST-T changes: ACS?

80yr hypertensive“Off-her-feet” for 1-2week, found in confused state this morning.

Chest pain after exertion

• 60yo smoker, FHx, 2mo of anginal chest pain• Undergoes EST, terminated after chest discomfort at Stage 2, relief

partially with GTN….

STEMI in evolution

• Admitted an hour ago … for chest “squeezing”, worse on exertion, while in CCU…more chest pain

Elevated J point ?STEMI

• 38yo athlete, smoker, FHx• Chest discomfort after involved in motor vehicle accident

STEMI? NSTEMI?

• 68yo smoker, hypercholesterolaemia• Fainted after chest pain at coffee shop, arrived at A&E with chest

pain and sweating.

Acute or old infarct?

• 70yo right inguinal hernia, • Pre-operative ECG, repeat…..

ST segments elevation

• 56yo acute chest discomfort on-and-off for 5 days

ST segments elevation

• 24yo non-smoker, FHx• Chest discomfort

ST segments elevation

• 69yo pensioner• “Gray-out” while boarding bus, brought in by passerby• Fully conscious, laceration forehead

STEMI?

• 54yo MA complaint of acute shoulder and chest pain while lifting O2 cylinder; Rested for 10minutes, still feel “unwell”.

STEMI?

• 43yo man acute chest tightness on way to work, drove to nearest Clinic in town….

Acute or Old infarct?

76yo male heavy smoker, hypertension, history of MI 1year agoAcute onset chest pain started 6 hours ago..

“Tombstones & Graves”

Acute chest pain ~ 1 hourInfarct territory? Infarct related vessel?

STEMI arrhythmia

Syncope after chest pain…Infarct territory? Infarct related vessel?

STEMI arrhythmia

Arrhythmia?Infarct territory? Infarct related vessel?

STEMI arrhythmia

Arrhythmia?Infarct territory? Infarct related vessel?

“Tombstones & Graves”

Acute chest pain ~ 1 hourInfarct territory? Infarct related vessel?

Right sided praecordial leads ECG

V6R----V3R

Sites for right-sided leads are the mirror image of those for the usual left-sided leads: in the fifth right intercostal space, lead V4R is at the midclavicular line, lead V5R is at the anterior axillary line and lead V6R is at the midaxillary line.

“Tombstones & Graves”

• Infarct territory, vessel?

Acute or old infarct?

Incidental finding during routine ECG…No recall of chest pain, history of dyspepsia…

STEMI arrhythmia

• Infarct territory? Infarct related artery?

STEMI complications

• Chest pain and lower back pain• Onset 2 hours ago, during dinner..

Thank You