4. penyakit jantung koroner

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  • Anatomi Koroner dan EKG 12 sandapan

    Sandapan V1 dan V2 menghadap septal area ventrikel kiri

    Sandapan V3 dan V4 menghadap dinding anterior ventrikel kiri

    Sandapan V5 dan V6 ( ditambah I dan avL ) menghadap dinding lateral ventrikel kiri

    Sandapan II, III dan avF menghadap dinding inferior ventrikel kiri

  • Lokalisasi Dinding Ventrikel PadaEKG (Ventrikel Kiri)

    Anteroseptal : V1-V4 Anterior ekstensif : V1-V6, I dan aVL Anterolateral : V4-V6, I dan aVL Anterior terbatas : V3-V5 Inferior : II, III dan aVF Lateral tinggi : I dan aVL Posterior murni : bayangan cermin V1, V2,

    V3 pada garis horisontal

    ISCHEMIA : ST depresi atau T inverted

    INFARCT : ST Elevasi

    NECROSIS (OLD INFARCT) : gel. Q patologis atau QS

  • Iskemia Depresi ST Inversi T Inversi U

    ST depresi dan perubahan gelombang T

    ST depresi dianggap bermakna bila > 1 mm di bawah garis dasar PT di titik J Titik J didefinisikan sebagai akhir kompleks QRS dan permulaan segmen ST

    Bentuk segmen ST :

    up-sloping ( tidak spesifik ) horizontal ( lebih spesifik untuk iskemia ) down-sloping ( paling terpercaya untuk iskemia )

    Perubahan gelombang T padaiskemia kurang begitu spesifik

    Gelombang T hiperakutkadang2 merupakan satu-satunyaperubahan EKG yang terlihat

  • Nonpathologic (nonischemic) and pathologic (ischemic) ST-segment and T-wave changes. A, Characteristic nonischemic ST-segment change called J-depression; note

    that the ST slope is upward. B and C, Examples of pathologic ST-segment changes; note that the

    downward slope of the ST segment (B) or the horizontal segment is sustained (C).

    (From Park MK, Guntheroth WG: How to Read Pediatric ECGs, 4th ed. Philadelphia, Mosby, 2006.)

    Iskemia Inversi T

    Gelombang T yang negatif(vektor T berlawanan arahdengan vektor QRS)

    Tanda ini tidak terlalu spesifikYang lebih spesifik gelombang

    T ini simetris dan berujung lancip

  • Inversi T pada iskemia miokarda. Inversi T : kurang spesifik untuk iskemiab. Inversi T berujung lancip & simetris (ujung anak

    panah) : spesifik untuk iskemia

  • 7/21/2010 13

    ST Depresi

    7/21/2010 14

    T Inverted

  • Infark miokard

  • Progression of an Acute Myocardial Infarction

    An acute MI is a continuum that extends from the normal state to a full infarction:

    IschemiaLack of oxygen to the cardiac tissue, represented by ST segment depression, T wave inversion, or both

    InjuryAn arterial occlusion with ischemia, represented by ST segment elevation

    InfarctionDeath of tissue, represented by a pathological Q wave

    Normal

    Ischemia

    Injury

    Infarction

    Figure. ST, QRS, and T vectors in myocardial infarction.

    a. ST injury vector. b. b. QRS vector in necrosis. c. c. T ischemia vector

  • Hubungan antara lokasiinfark dan oklusi arterikoroner (panah), dan lead elektrocardiogram. a. Anteroseptal infark.b. Anterior infark

    Extensive (anterolateralinfarction)

    c. Infark lateral isolatedction

    a b

    c

    d

    e f

    d. Infark Inferior

    e. Infark Posterior

    f. Right ventricular infarction (combined to inferior infarction)

  • Ishemia Injury - InfarctAccurate ECG interpretation in a patient with chest pain is critical. Basically, there can be three types of problems - ischemia is a relative lack of blood supply (not yet an infarct), injury is acute damage occurring right now, and finally, infarct is an area of dead myocardium. It is important to realize that certain leads represent certain areas of the left ventricle; by noting which leads are involved, you can localize the process. The prognosis often varies depending on which area of the left ventricle is involved (i.e. anterior wall myocardial infarct generally has a worse prognosis than an inferior wall infarct).

    V1-V2 anteroseptal wallV3-V4 anterior wallV5-V6 anterolateral wallII, III, aVF inferior wallI, aVL lateral wall

    V1-V2 posterior wall (reciprocal)

    depresion

    elevation

    NON-TRANSMURAL = SUB ENDOCARDIAL = non Q-WAVE M.I.

    TRANSMURAL = MYOCARDIAL = Q-WAVE M.I.

  • Figure. a. Acute infarction: correlation between

    the electrocardiogram (ECG) and the stage of myocardial ischemia. Monophasic ST deformation /transmural lesion = lesion / injury.

    b. Subacute infarction. Correlation between the ECG and the stage of myocardial ischemia (ST elevation = lesion, plus pathologic Q wave = necrosis, plus negative T wave = ischemia).

    c. Evolution of subacute infarction to chronic infarction

    Figure V3 lead: Evolution of QRS and ST/T morphologies in STEMI due to occlusion of LAD.(a) Few minutes; (b) 1 hour; (c) 1 day; (d) 1 week.

  • Figure 9.3. The evolution of an inferior wall myocardial infarction, as seen in lead III of a 55-year-old white male. Note that the admission tracing shows only ST elevation. A Q wave is beginning to form by 1 hour, and ST elevation is on the way down. By 24 hours, Q wave formation is complete,and the T wave is fully inverted. By 1 year, a pathologic Q wave is the only remaining evidence of infarction.

  • Mid LAD occlusion after the first septalperforator (arrow) ECG : large anterior MI

  • Proximal large RCA occlusion

    ST elevation in leads II, III, aVF, V5, and V6with precordial ST depression

  • Small inferior distal RCA occlusion

    ECG changes in leads II, III, and aVF

  • 7/21/2010 33

    ST Elevasi

    7/21/2010 34

  • Fase Evolusi Lengkap

    Elevasi ST spesifik : konveks keatas

    T negatif dan simetris Q patologis

    36

  • 7/21/2010 38

    Qs Patologis

  • 7/21/2010

    Early Repolarisasi

    LATIHAN

  • Unstable angina

    Subendocardial ischemia. Anterolateral ST-segment depression

  • Acute anteroseptal myocardial infarction. Hyperacute T-wave changes are noted

    Acute anterolateral myocardial infarction

  • Lateral myocardial infarction

    Inferior myocardial infarction

  • Inferior myocardial infarction. Inferior Q waves with T-wave inversions

    Acute inferoposterior myocardial infarction

  • Right bundle branch block

    RBBB + Anterior Infarction

  • Left bundle branch block

    Thank you