Transcript ECG predictors of culprit artery in acute myocardial

ECG predictors of culprit artery in
acute myocardial infarction
Dr.Deepak Raju
• North American Societies of Imaging divided
left ventricle into 4 walls–septal,anterior,
lateral and inferior and subdivided into 17
segments
• LAD- AW(1,7,13) by diagonals ,ant.septum
(2,8,14) by septal branches,RBB by 1st septal
,apex(17) &sometimes part of seg.15 as wraps
around apex(80%)
• RCA-RV,IW(4,10,15),inf.septum(3,9,15),part of
lat.wall(5,11,16)if dominant
• LCX-anterior lateral wall(6,12,16),inferior
lateral wall(5,11) part of inf wall(4)and
seg10&15 if dominant
• LV divided into two zones –anteroseptal and
inferolateral
• 12 different locations of coronary occlusions 6
in the anteroseptal zone and 6 in the
inferolateral zone can be recognised
Anteroseptal zone-LAD and branches
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Proximal to S1 & D1
Prox to D1,distal to S1
Distal to S1&D1
Prox to S1 ,distal to D1
Selective D1–D2 occlusion
Selective S1–S2 occlusion
Proximal to S1 & D1
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Large area of infarct
31% cases (Engelen et al;JACC 1999)
Injury vector points upward,anteriorly
Right or left depending on predominent septal
or diagonal invt.
Proximal to S1 & D1
ECG pattern
• ST↑ in V1 to V4−5 and aVR
• ST↓ in II, III, aVF and V5−6
• ST ↑ in aVL or aVR depending on predominent
invt. of lateral or septal
• ST dep. III+aVF≥2.5 mm s/o LAD prox to D1(Fiol
2006)
• ST elev.in aVR+V1>ST dep V6-s/o LAD prox to
S1(Fiol,2006)
• ST dep II>III
Prox to D1,distal to S1
• Injury vector upward ,anteriorly and to left
• 11% cases
• Large infarct-basal anterolateral may be
spared
Prox to D1,distal to S1
ECG pattern
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ST↑ inV2 toV5−6,I,aVL
ST ↓ in II,III,aVF
ST ↓ in III>II
Wrap around LAD-prox. to D1-Lead III ST
dep.with a positive T &ST elevation in
aVL(Porter et al 1998)
Distal to S1&D1
• Area at risk involves inferior third of LV-apical
infarction & some invt of inf wall
• Injury vector directed anteriorly,downward
and to left
• 48% of cases
Distal to S1&D1
ECG pattern
• ST↑ in V2 toV4−5,not in V1
• Slight ST↑ in II,III,aVF,not in aVR(slight ST
dep)
• ST elev.II>III
• ST elev. In V3-4> V1
• Short LAD less evident changes
Prox to S1 ,distal to D1
• 11% cases
• Injury vector downward anterior and to right
Prox to S1 ,distal to D1
ECG pattern
• ST↑ in V1 to V4, V5,aVR
• ST↑ in II, III(III>II)
• ST↓ in V6
Criteria
• Sensitivity low&specificity higher-absence of a
criteria may not help
• ST ↑ in V1 <2.5 failed to differentiate b/w
prox. and distal
• ST ↑ in a VL did not have much significance,ST
dep. helped to localise
• Q in V4-6 specific for distal to S1-presence of
septal vector facilitating Q formation
Selective D1–D2 occlusion
• Mid and apical antr. &mid and apical lateral
wall
• Injury vector –upward ,left ,anterior
Selective D1–D2 occlusion
Ecg pattern
• ST↑ in I, aVL and sometimes V2 to V5−6
• ST↓ in II, III, aVF(ST dep.III>II)
• ST↓ in V2-3 s/o D1+LCX or RCA
Selective S1 occlusion-antr.,upward
&right
Ecg pattern
• ST↑ in V1−2, aVR
• ST↓ in I, II, III, aVF, V6(ST dep.II > III)
Algorithm for localisation-ST↑ant.
leads
ST ↑in ant. &inf. leads
Inferolateral zone-LCX&RCA
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Proximal RCA occlusion
Distal RCA occlusion
Dominant RCA occlusion
Proximal LCX occlusion
OM occlusion
Dominant LCX occlusion
Proximal RCA occlusion
• Inf wall,inferior part of septum,RV
• Downward and to right
• Sagittal plane-anterior if predominent RV
invt,otherwise posterior
• Changes in right leads transient
• Lead V1 equally useful(Fiol 2004)-v1
equiphasic or elevated s/o RV invt.
Proximal RCA occlusion
Ecg pattern
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ST↑ in II, III,aVF(III > II)
ST↓ in I,aVL
ST↑ in V4R with positive T
ST isoelectric or elevated in V1
Distal RCA occlusion-downward,right
and posterior
Ecg pattern
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ST↑ in II,III,and aVF(III > II)
ST↓ in I and aVL
ST↓ in V1−3
Magnitude of ST elevation in inf leads>change
in precordial leads
Dominant RCA
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Inferolateral wall also involved
Downward and to right
Anterior or posterior depends on RV invt
ST elevation in lateral leads-local injury vector
Dominant RCA
ECG pattern
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ST↑ in II, III, aVF(III > II)
ST↓ in V1−3 < ST ↑ in II, III, aVF.
Prox.RCA occlusion-ST in V1−3 ↑/equiphasic
ST dep in V1 if distal RCA
ST ↑ in V5−6 ≥ 2mm(Nikus ,2004)
Proximal LCX
• Lateral wall and inferior wall(inferobasal seg.)
• Downward ,posteriorly and to left
Proximal LCX
Ecg pattern
• ST↓ in V1−3 greater than ST↑ in inferior
leads
• ST↑ in II, III, aVF(II >III)
• Usually ST↑ in V5−6
• ST↑ in I, aVL(I >aVL)
OM occlusion
• Anterior and posterior part of lateral wall
• Injury vector left and posteriorly
• Upward or downward depending on area of
invt.
• Diagonal –upward and anteriorly
OM occlusion
Ecg pattern
• Slight ST ↑ in I,aVL,V5−6
• Slight ST ↑ II, III,aVF may occur
• Slight ST ↓ in V1−3
Dominant LCX occlusion
• Inferior lateral and inferobasal seg
• Injury vector in frontal plane b/w +60
&+90,posteriorly
Dominant LCX occlusion
ECG pattern
• ST↑ in II,III,aVF(II≥III) greater than ST ↓ in
V1−3
• ST ↓ aVL usually not in I
• Prominent ST ↑ in V5−6
• ST elevation ≥1mm predicts RCA prox. With
accuracy90%,ST dep. ≥1mm predicts LCX invt
with 100% accuracy(Braat SH et al,1998)
• ST elevation 2mm required in inf. leads to use
this criteria
• Sensitivity of V1 ST elevation for RV 24%,specificity 100%
RCA Vs LCX
• Lead aVL S/R ratio >3 s/o RCA&<3 s/o LCX
(Assali et al,1999)
Kosuge criteria
• V3/III ratio-magnitude of ST ↓ in V3 /ST↑ in
III
– <0.5-prox.RCA
– 0.5-1.2-dist.RCA
– >1.2-LCX
ST dep in aVR
• ST dep in aVR ≥1 mm s/o LCX, < 1 mm or no
depression s/o RCA(CHEST 2002)
ST ↑inferior leads-Fiol’s algorithm
ST↑inferior leads-Tierala’s algorithm
• Both were 94% sensitive &40% specific for
RCA
• 40% sensitive &94% specific for LCX
Dominant RCA Vs LCX
• ST ↑ in V5-6 3-4 mm usually seen in LCX
• ST ↑ in II>III favour LCX
• ST ↓ in I favour RCA
Diagonal Vs OM
• D1– upward-no ST elevation in inf leads
– Anterior-ST elevation/equiphasic in ant. Leads V14
• OM
– Downward-ST elevation inf leads
– Posterior-ST dep ant leads V1-4
LMCA occlusion
• ST elevation in aVR ≥V1 s/o LMCA occlusion
(Yamaji et al;JACC 2001)
• 80% sensitivity,specificity,PPV
• ST elevation in aVR correlated with clinical
outcome
Isolated ST ↑in V7-9
• 4% of MI,20% of MI with normal 12 lead ECG
• All had mid LCX or OM occlusion(Matetzky et
al ;JACC 1999)
• THANK YOU
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Isophasic in I
II> III
ST dep in antr leads >inf leads
Prox. LCX
D/d –distal dom RCA
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Isophasic in I
II=III
ST elevation in inf leads>dep in antr leads
ST elevation In V5 2 mm
Distal dom RCA
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ST dep in I
ST dep in V1
ST dep in V6
Distal RCA,not dominent
• LAD prox to D1 &S1
• d/d-selective S1 occlusion-ST elevation not so
striking in V1-4
• Distal dominent RCA
• LAD distal to D1 and S1
• LAD prox to S1& D1
• D1 occlusion
• d/d OM occlusion(st dep in II III a VF not
suggestive)
• ST dep in V2-3 s/o additional LCX or RCA lesion
• Prox RCA, dominent
• LCX, dominent
• d/d distal RCA
• ST dep in antr leads more than ST elev. In inf
leads
• OM occlusion