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