12 Lead ECG Interpretation

PART I
The Basics

Dana Yost, Senior Paramedic

Paramedic Training
King County, WA

1. I guarantee you will have the tools to interpret 12 Lead ECGs

2. I guarantee you will be able to Interpret the 12 Lead ECG with
reasonable accuracy
3. I guarantee WE will stay here until you can

OBJECTIVES

Basic Anatomy and Blood Supply of the Heart

Understand the difference between Myocardial Ischemia, Injury and

Infarction

How a 12 Lead ECG looks at the heart

Learn to interpret the 12 Lead ECG

Localize Ischemia, Injury or Infarction and predict the Artery involved

Conditions that are AMI Imitators

Special Considerations

Opportunity for Practice

Which is different?

Acute Coronary
Syndromes
Definition:
Sudden ischemic disorders of the heart

Include unstable angina and acute

myocardial infarction
Represent a dynamic disease process

Acute Coronary
Syndromes
Unstable angina (USA)
Non ST Segment Myocardial Infarction (NON-STEMI)
ST Segment Myocardial Infarction (STEMI)

Initiating Events
Plaque rupture

Thrombus formation
Vasoconstriction

Plaque Rupture
Stable

Lipid Core

Vulnerable

Lipid Core
Lumen

Lumen
Fibrous Cap

Fibrous Cap

Plaque Rupture

Lipid Core
Fibrous Cap

Lumen

Thrombus Formation

Platelets Adhere
Lipid Core

Fibrous Cap

Thrombus Formation

Lipid Core
Platelet Aggregation

Thrombus Formation

Lipid Core

Platelet Aggregation
Fibrin

Vasoconstriction

Acute Coronary Syndromes

Acute Coronary Syndromes
ACS

Unstable Angina
USA

NON-STEMI

STEMI

Acute Coronary
Syndromes
All have sudden ischemia
Can not be differentiated in the first hours
All have the same initiating events

Anatomy of the Heart

The layers of the heart muscle

Endocardium
(inner most)

Myocardium
(muscle mass)
Epicardium
(outer most)

Evolution of Myocardial Infarction

A Dynamic Process

Anatomy of the Heart

Right Atrium
Left Atrium
Left Ventricle
Right Ventricle
Septum

Anatomy of the Heart

Coronary Arteries
Left Coronary Artery (LCA)
Right Coronary Artery (RCA)
Distal
Proximal

Anatomy of the Heart

Coronary Arteries
Left Coronary Artery (LCA)
Septal branch feeds the bundles
Left coronary artery
Circumflex
LAD

Lateral
Branches
Septal Branch
POSTERIOR

Right

Left

Anatomy of the Heart

Coronary Arteries
Right Coronary Artery (RCA)
feeds the SA and AV Nodes in 80% - 90% of Population

Right coronary Artery

Posterior branch

Right
Inferior branch

Left

The Three Is
Ischemia
lack of oxygenation
ST depression or T inversion
Injury
prolonged ischemia
ST elevation
Infarct
death of tissue
may or may not show in Q wave

Well Perfused Myocardium

Epicardial Coronary Artery

Lateral Wall of LV

Septum
Left
Ventricular
Cavity

Positive Electrode
Interior Wall of LV

Evolution of Myocardial Infarction

Ischemia
Blood flow to a certain area is insufficient to
meet oxygen requirements

Ischemia
Epicardial Coronary Artery
Lateral Wall of LV

Septum
Left
Ventricular
Cavity

Positive Electrode
Interior Wall of LV

Evolution of Myocardial Infarction

Injury
If Ischemia is prolonged, injury follows. This is the
hyper-acute phase of infarction

Injury
Thrombus

Ischemia

Evolution of Myocardial Infarction

Infarction
Dead Myocardium
Irreversible damage

Infarction
Infarcted Area
Electrically Silent

Depolarization

Many infarcts do not develop Q waves

Q Wave
First negative deflection

R Wave
First positive Deflection

S Wave
Negative deflection following R wave

Anatomy of the QRS

J-Point

ECG Changes
ST Segment is measured from the end of
the QRS complex (J point) to the
beginning of the T wave.

ST is the beginning of ventricular

repolarization.

ST Segment

ST Segment
Compare to TP segment

ST

TP

ECG Changes
T waves

ST segment

Q waves

ST Segment Elevation
The hallmark of Myocardial Injury

Normal ST is on the isoelectric line or less than 1mm above or below

isoelectric line.
Elevated ST of > 1mm above isoelectric line = Acute Injury

Depression & T Wave Inversion

Myocardial Ischemia

Depressed ST of more than 1 mm below isoelectric line = Ischemia

Inverted Ts = Ischemia

Practice
Find J-points and ST segments

Practice
Find J-points and ST segments

Practice
Find J-points and ST segments

Physiologic Q waves
< .04 sec (40ms)

Pathologic Q
>.04 sec (40 ms)

Pathologic Qs = Old MI (scar)

ECG Changes
ECG changes during Evolution of Myocardial Injury

Normal

Minutes -

T Waves become tall

First Hour -

ST elevates

First Hour -

T inversion

Hours to Days -

Q waves form

Days - ST & T become normal - Qs remain

A normal 12-lead ECG in itself DOES NOT rule out AMI

Break