Localization on ECG

Myocardial
Ischemia /
Injury /
Infarction

9-Oct-14

ECG
Chief diagnostic tool to identify

Ischemia

Injury

infarction

Using ECG one can localize the site of Ischemia / Injury/ Infarction.

Dr. UZMA ANSARI

9-Oct-14

Why Localize ?

Culprit Artery

To decide
further
management.

Dr. UZMA ANSARI

Anatomy Of
heart

9-Oct-14

Borders
Surface

Upper

Left

Right

Inferior

Anterior
left
Inferior
Base

Apex Left Ventricle

Dr. UZMA ANSARI

9-Oct-14

SURFACES OF HEART
Anterior:

Right
atrium, Right
ventricle partly by
LV,LA.

Inferior/Diaphragmatic:
2/3

RV.

by LV&1/3 by

LEFT: LV,LEFT

AURICLE

Dr. UZMA ANSARI

9-Oct-14

Dr. UZMA ANSARI

9-Oct-14

LA and small
part by RA.
Four
pulmonary veins &
IVC&SVC.

Dr. UZMA ANSARI

Anatomy of Left
ventricle

Location

Central left
part of thorax
(lying on
diaphragm)
Oriented
anteriorly with
apex directed
forward from
right to left

9-Oct-14

Cone Shaped

Apex

4 wall
Septal
Anterior
Lateral
Inferior

According to new terminology infero

posterior should be called infero basal
- Source: AHA

Base/posterior surfase

Dr. UZMA ANSARI

Blood supply
RCA
Smaller
Ant aortic sinus
RA
RV except area
around anterior I V
groove
Posterior I V Septum
LV:small area around
posterior IV groove
Entire conducting
system

9-Oct-14

LCA
Larger
Lt post aortic sinus
LA
LV except area
around posterior IV
groove
Anterior I V septum
RV:small area
around anterior IV
groove
Part of LBB

Dr. UZMA ANSARI

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9-Oct-14

Dr. UZMA ANSARI

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9-Oct-14

LMCA

Entire LV, LA, except the posterior portion of IV

septal and adjacent area when PD is a branch of
RCA

LAD

Anterior 2/3rd of IV septal

Anterior portion of LV
Whole apex

1st D (Branch of
LCA)

High lateral wall of LV

2nd D

Lower lateral aspect of LV freewall

1st Septal

Superior and Anterior portion of IV septal

Minor Septal

Inferior and anterior 1/3rd of septum

Ramus Inter
ventricularis
(From LCA)

Anterior aspect of apex

Dr. UZMA ANSARI

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9-Oct-14

LCX

97% from LCA

2% from Separate Ostium
1% RCA

Obtuse margin of
heart and entire
posterior wall. LA,
posterior IV septum if
PD arises from LCX

OM

97% LCA

Obtuse margin of
heart adjacent to LV

Postero lateral 80% LCA

branch
20% RCA

Posterior and
diaphragm LV wall

PD

Posterior IV septum
and Diaphragm LV

82% RCA
18% LCA

Dr. UZMA ANSARI

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9-Oct-14

RCA

RA and part of LA, RV,

Posterio superior IV septum.
SN, AV node

Acute Marginal

Inferior and diaphragmatic

surface of RV

Conus Branch

Outflow track of RV

SN branch

RA, LA,SN

RV Branch

RV

Atrial Branch

Right Atrium

Dr. UZMA ANSARI

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9-Oct-14January 2004

Localization - Left Coronary Artery (LCA)

Left Main
(proximal
LCA)
occlusion
Extensive
Anterior injury

Left
Circumflex
(LCX)
occlusion
Lateral injury

Left Anterior
Descending
(LAD)
occlusion
Anteroseptal
injury

Dr. UZMA ANSARI

15

9-Oct-14January 2004

Localization
Right Coronary Artery (RCA)

Proximal
RCA
occlusion
Posterior
descending
artery (PDA)
occlusion

Right Ventricle injured

Posterior wall of left ventricle injured
Inferior wall of left ventricle injured
Inferior wall of left ventricle injured

Dr. UZMA ANSARI

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9-Oct-14January 2004

Localization Summary
Left Coronary Artery
Septal

Right Coronary Artery

Anterior
Lateral

Right Ventricular Infarct

Possibly Inferior

Inferior
Posterior

Dr. UZMA ANSARI

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9-Oct-14

Prevalence of Culprit Artery

RCA

45%

LCX

12%

LAD

36%

57%

Dr. UZMA ANSARI

18

9-Oct-14

Prevalence of STEMI
Inferior

58%

Anterior

39%

Other

3%

Dr. UZMA ANSARI

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9-Oct-14January 2004

Post Ischemic T wave changes

ST elevation MI
Ischemia

Infarction

Fibrosis

ST depression, peaked Twaves, then T-wave

inversion
ST elevation &
appearance of Q-waves
ST segments and T-waves
return to normal, but Qwaves persist

Non-ST Elevation
Infarction
Ischemia

ST depression &
T-wave inversion

Infarction

ST depression &
T-wave inversion

Fibrosis

ST returns to
baseline, but Twave inversion
persists

Dr. UZMA ANSARI

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9-Oct-14January 2004

Localization
The changes of ischemia/injury/infarction are seen in the leads
Over lying the area involved

I Lateral

aVR

II Inferior

aVL Lateral

III Inferior

aVF Inferior

V1 Septal

V4 Anterior

V2 Septal

V5 Lateral

V3 Anterior

V6 Lateral
Dr. UZMA ANSARI

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9-Oct-14January 2004

Localization

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

Inferior: II, III, AVF

Septal: V1, V2
Anterior: V3, V4
Dr. UZMA V5,
ANSARI V6
Lateral: I, AVL,

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9-Oct-14

Frontal Plane Leads

aVL
-300

-1500

I
00

-aVR
300

III
+1200
aVF
+900

II
+600
Dr. UZMA ANSARI

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aVL,
Lateral

Recommendations

9-Oct-14

II,
Inferior

V1
septal

V4 anterior

I,Lateral aVF
Inferior

V2
septal

V5 lateral

-aVR

V3
anterior

V6 lateral

III,
inferior

ECG machines should be equipped with switching systems that will

allow the limb leads to be displayed and labelled appropriately in
their anatomically contiguous sequence

- AHA guidelines
Dr. UZMA ANSARI

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9-Oct-14

Localization - Myocardial Infarct

Localization

ST elevation

Reciprocal
ST depression

Coronary Artery

Anterior MI

V1-V6

None

LAD

Septal Mi

V1-V4,
disappearance of
none
septum Q in leads
V5,V6

LAD

Lateral MI

I, aVL, V5, V6

II,III, aVF (inferior leads) LCX

Inferior MI

II, III, aVF

I, aVL (lateral lead)

RCA (80%) or LCX

(20%)

Posterior MI

V7, V8, V9

high R in V1-V3 with ST

depression V1-V3 >
2mm (mirror view)

RCA or LCX

Right Ventricle MI

V1, V4R

I, aVL

RCA

Atrial MI

PTa in I,V5,V6

PTa in I,II, or III

RCA

The localisation of the occlusion can be adequately visualized using

a coronary angiogram (CAG).
Dr. UZMA ANSARI

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9-Oct-14

Anterior Wall
V3,
V4

Left anterior
chest
Positive
electrode on
anterior chest

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6
Dr. UZMA ANSARI

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9-Oct-14

Septal

V1, V2
septum is left
ventricular tissue

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6

Dr. UZMA ANSARI

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9-Oct-14

Septal Wall

V1, V2
Along sternal borders
Look through right ventricle & see
septal wall

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6
Dr. UZMA ANSARI

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9-Oct-14January 2004

Anteroseptal MI

ST elevations V1, V2, V3, V4

Dr. UZMA ANSARI

Practice 2

29

9-Oct-14January 2004

Lateral Wall

I and aVL
View from Left Arm
lateral wall of left ventricle

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6
Dr. UZMA ANSARI

30

9-Oct-14

Lateral Wall

V5 and V6
Left lateral chest
lateral wall of left ventricle

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6
Dr. UZMA ANSARI

Lateral Wall
I,

31

9-Oct-14

aVL, V5, V6

ST

elevation
injury

suspect lateral wall

Lateral Wall
Dr. UZMA ANSARI

Lateral MI

32

9-Oct-14

Dr. UZMA ANSARI

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9-Oct-14January 2004

Localization - Extensive Anterior MI

Evidence in
septal, anterior,
and lateral leads

Often from
proximal LCA
lesion
Complications
common

Left ventricular failure

CHF / Pulmonary
Edema
Cardiogenic Shock

Dr. UZMA ANSARI

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9-Oct-14January 2004

Practice 1

Anterior MI with lateral

involvement

ST elevations V2, V3, V4

ST elevations II, AVL, V5

Dr. UZMA ANSARI

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9-Oct-14

Inferior Wall

II, III, aVF

View from Left Leg
inferior wall of left ventricle

aVR

V1

V4

II

aVL

V2

V5

III

aVF

V3

V6
Dr. UZMA ANSARI

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9-Oct-14

Inferior MI

Dr. UZMA ANSARI

37

9-Oct-14January 2004

Practice 3

Inferior MI

ST elevation 2,3 AVF

Dr. UZMA ANSARI

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9-Oct-14January 2004

Practice 4

Inferior lateral MI

ST elevations 2, 3, AVF

ST elevations V5

Dr. UZMA ANSARI

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9-Oct-14January 2004

Posterior Leads

Posterior leads V1, V2

Posterior Infarct with ST

Depressions and/ tall R wave
RCA and/or LCX Artery

ST elevation in V7,V8,V9.
Understand Reciprocal changes
The posterior aspect of the heart is
viewed as a mirror image and
therefore depressions versus
elevations indicate MI
Rarely by itself usually in combo.

Dr. UZMA ANSARI

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9-Oct-14

Dr. UZMA ANSARI

41

9-Oct-14January 2004

Localization Criteria:
Occluded artery to the ECG
Source: AHA

Dr. UZMA ANSARI

Anterior wall MI

42

9-Oct-14January 2004

Occlusion of LAD
ST , V1-V6
Occlusion above D1 and 1st Septal
Basal portion of LV
Anterior and lateral wall
Inter-Ventricular Septum
ST segment vector superiorly and to left
ST elevation

ST depression

V1-V4, lead I, aVL, often

in aVR

II, III, aVF (Inferior) often

V5

aVL > aVR

III > II

Dr. UZMA ANSARI

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9-Oct-14January 2004

Occlusion: Between 1st Septal and D1

Basal IV septum spared (ST
segment in lead V1 will not
be elevated)

ST segment vector
directed towards aVL
ST segment elevation : aVL
ST segment depression: III
Dr. UZMA ANSARI

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9-Oct-14January 2004

Occlusion: More distally i.e.

below Septal 1 and D1
Basal portion spared (ST vector directed
inferiorly)
ST segment not elevated in I, aVL/aVR
No depression in II, III, aVF

Indeed, ST segment elevation in II, III, aVF

ST segment elevation more prominent in V3

V6 than V2

Dr. UZMA ANSARI

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9-Oct-14January 2004

Dr. UZMA ANSARI

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9-Oct-14January 2004

Dr. UZMA ANSARI

47

9-Oct-14January 2004

Recommendation

I, aVL, V1-V4 Extensive

anterior wall infarction due to
occlusion of proximal LAD

V3 V6, II, III aVF AWMI due

to mid / distal occlusion of
LAD

Dr. UZMA ANSARI

48

Inferior MI

9-Oct-14January 2004

ST Elevation in II,III,aVF
RCA
ST III>II
ST I,aVL

OR

LCX

Whichever provides PD
Dominant artery

ST II>III
ST I,aVL

Dr. UZMA ANSARI

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9-Oct-14January 2004

Dr. UZMA ANSARI

Proximal RCA

50

9-Oct-14January 2004

V4R

Right Ventricular
Ischemia / Infarction

1.
2.
3.

ST vector directed
towards right and
anteriorly inferiorly
ST elevation in right
anterior leads i.e. V3R,
V4R, sometimes V1
40% Associated with
inferior M.I.ST elevationV3R,V4R,V1,II,III,aVF

4.
5.

Most commonly used right sided

lead
Great value in diagnosing RV
infarct along with IWMI
Useful in distinguishing between
RCA and LCX involvement
Between proximal and distal RCA
occlusion
V3R, V4R should be recorded as
rapidly as possible because ST
elevation in V3R, V4R remain for a
shorter period of time in RWMI
than ST elevation in extremity
leads (II,III, aVF) in inferior MI

Dr. UZMA ANSARI

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9-Oct-14January 2004

Inferior MI +Posterior M.I.

Lateral / Infero Lateral / Baso Lateral MI not postero
inferior MI.

Proximal RCA
(posterior+inferior)
+ RV infarct
ST II,III,aVF
ST I,aVL
ST V3R,V4R
ST III>II

OR

LCX
Posterior+Inferior MI
ST II,III,aVF,aVL,I
ST ,tall R V1,V2,V3,
ST II>III

Dr. UZMA ANSARI

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9-Oct-14January 2004

Dr. UZMA ANSARI

53

9-Oct-14January 2004

Multiple infarct
Multi vessel.
Anterior+inferior
inferior+posterior
anterior+lateral
Old+new

Dr. UZMA ANSARI

54

9-Oct-14January 2004

Multiple Ischemia / Infarction / Injury

ST depression in
multiple leads in
absence of elevation

2 Situations

During treadmill test

Subendocardial
ischemia / injury at
multiple region due to
multi vessel disease

At Rest

Stable angina

Unstable angina

Multiple vessel
involved

Severe multi vessel

disease or LMCA
involvement

ST depression in more than / equal to 8 leads along with ST elevation in aVR and / or
V1Indicates 75% chances of 3 vessel disease / LMCA stenosis
Dr. UZMA
ANSARI
Source:
AHA

55

9-Oct-14January 2004

In some cases, Deep T wave ( > 0.5 mV ) in V2, V3,

V4 with prolong QT after an episode of chest pain
without evidence of Ischemia / Injury / Infarction
(i.e. T wave morphology similar to CVA)
CAG
Severe stenosis of proximal LAD
If missed and not treated,
it could lead to AWMI

Appropriate treatment
So, If we get deeply inverted T wave (> 0.5 mV) with prolonged QT,
one should suspect Severe stenosis of proximal LAD with / without CVA
Dr. UZMA ANSARI

56

9-Oct-14

Thank You

Dr. UZMA ANSARI