ECG CBMI 2012
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Transcript of ECG CBMI 2012
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El ECG normalCátedra de Patología Médica I
Juan Beloscar
5 de setiembre de 2012
FAC
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VD
VI
N.A.V.N.S.
Ac tiva c ió n Auric ula r
Nódulo Sinusal: tiene una frecuencia de descarga automática entre 60-100 impulsos por minuto. Es el marcapasos.
Nódulo Auriculoventricular : Encargado de retardar la conducción. Es junto al haz de His la única vía eléctrica normal por la cual llegan los impulsos de la aurícula a los ventrículos.
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AD
VD
VI
AI
HAZ de HIS
Activación Septal (1° Vector)
Haz de His: tiene automatismo propio con una frecuencia entre 40-60 impulsos por minuto,
Q
Activación Septal (1er Vector)
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VD
AI
AD
VI
Activación de paredes libresde los ventrículos (2° vector)
Red de Purkinje: tiene automatismo propio con una frecuencia menor a 40 impulsos por minuto.
El músculo cardíaco normalmente no tiene automatismo.
R
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VD
AI
AD
VI
Activación de la porciónPosterobasal (3° vector)
S
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VD
AI
ADVI
12
3VA
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VD
AI
ADVI
12
3VA
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1
2
3
Vectores
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PASO 4: Onda P: PASO 5: Intervalo PRPASO 6: Onda Q: PASO 7: QRSPASO 8: Intervalo QTPASO 9: Segmento STPASO 10: Onda T:
SegmentosIntervalos
intervalo QT (en seg.)
Distancia R a R en seg.QT corregido=
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Ritmo
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Onda P
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Onda P
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Frecuencia
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Eje eléctrico
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DI (-) 01 2 3 4 5 6 7 8 9 1011 12131415
1 2 3 4 5
6 7 8 9
10 11 12 13 14 15 16 17
(-) 180(+)180
(-) 90
DI (+) 0
aVF (+) 90
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DI (-) 01 2 3 4 5 6 7 8 9 1011 12131415
1 2 3 4 5
6 7 8 9
10 11 12 13 14 15 16 17
(-) 180(+)180
(-) 90
DI (+) 0
aVF (+) 90
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DI (-) 0
aVF (+) 90
1 2 3 4 5 6 7 8 9 1011 12131415
1 2 3 4 5
6 7 8 9
10 11 12 13 14 15 16 17
(-) 180(+)180
(-) 90
D I
+90°
+0-0
-90°
+180
-180DI
DIIDIII
1
2
3
Vectores
DI (+) 0
Eje aprox.: (+)80
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Intervalo QT
intervalo QT (en seg.)
Distancia R a R en seg.QT corregido=
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Segmento ST
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Onda T
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El ECG en las sobrecargasCátedra de Patología Médica I
Juan Beloscar12 de julio de 2012
FAC
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VD
VI
N.A.V.N.S.
Activación Auricular
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Sobrecarga de Aurícula Derecha
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Onda P en la Sobrecarga Auricular Derecha
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Sobrecarga de Aurícula Izquierda
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Onda P en la Sobrecarga Auricular Izquierda
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1
2
3
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Sobrecarga de Ventrículo Izquierdo
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Sobrecarga de Ventrículo Izquierdo
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Criterios Diagnósticos
para Hipertrofia Ventricular Izquierda.
1 Índice de Sokolow-Lion: la suma de la onda S en V1 más la Onda R en V5 o V6 > 35mm en adultos y 40mm en niños y jóvenes.
2 Índice de Cornell: la onda R de aVL más la onda S de V3 > 26mm
3 La suma de la onda R máxima más la onda S máxima > 45mm
4 La amplitud de la onda R en V5 o V6 > 26mm
5 La suma de la onda R de DI más la onda S de DIII > 25mm
6 Amplitud de la onda R en aVL > 12mm
7 Amplitud de la onda r en aVF > 21mm
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Criterios para el ST-T
-Onda T y ST oponentes al QRS (onda T negativa asimétrica e infradesnivel del ST y punto J en DI, aVL, V5 y V6) vale 3 puntos.
-Igual al anterior pero bajo impregnación Digitálica vale 2 puntos.
-T plana o negativa, onda U negativa, ST plano sin infradesnivel del punto J, valen 1 punto.
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Sobrecarga de Ventrículo Derecho
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Sobrecarga de Ventrículo Derecho
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ECG Clínica de los CVD
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ECG Clínica de losCrecimientosVentriculares
Derechos
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Criterios Diagnósticos
para Hipertrofia Ventricular Derecha.1-Retardo de la deflexión intrinsecoide en V1 >30mseg.
2- Ensanchamiento del QRS > 90mseg.
3- Eje eléctrico Vertical en el plano Frontal superando los +90º.
4- La suma de la onda R en V1 más la S en V5 o V6 11mm.
5- En ausencia de hemibloqueos, ondas S 7mm en V5-V6 con R/S de V1 > 1.
6- Ondas R en V5-V6 < 5mm en ausencia de cardiopatía coronaria
7- Presencia de Complejos S1, S2, y S3 (sumado a otros indicios). Puede constituir una variante normal.
8- Ondas R altas en V1, con QRS de duración normal <100mseg, con S profundas en V2 y R predominante en V3R
9- Altos voltajes de R o R´ en V1, V2 y V3R, con depresión del segmento ST, e inversión de la onda T en V1, V2 y V3
10- Altos voltajes de R o R´ con QRS de duración normal , con depresión del segmento ST, acompañados de ondas T negativas en V1, V2 y V3
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El ECG en los Bloqueos de RamaCátedra de Patología Médica I
Juan Beloscar12 de julio de 2012
FAC
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BLOQUEO COMPLEO DE RAMA IZQUIERDA
Primero se activa el septum derecho y pared libre de VD, luego el vector B (septum bloqueado) presenta una diferencia de potencial entre el ventrículo activado (-) y el bloqueado (+),presentando despolarización lenta de la parte septal izquierda y de la pared libre del VI, se verá complejos QRS alargados y empastados, esencialmente negativos en V1 y positivos en V5-V6
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Complejos QRS empastados y alargados, onda R pura, manchada y mellada en DI, aVL, V5 y V6. Complejos QS en V1. Segmento ST y onda T opuestas a los complejos QRS.
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BLOQUEO COMPLETO DE RAMA DERECHA
La activación del lado izquierdo del septum interventricular (1e) lo realiza normalmente; se inscribe una pequeña onda r en V1 y pequeña onda q en V6.
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Durante la activación de la pared libre del VI aparecen fuerzas opuestas dependientes de la activación del septum bloqueado y como consecuencia disminución del voltaje de la onda S en V1 de la onda R en V6.
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Al terminar la despolarización de VI se manifiesta ampliamente el vector B, inscribiéndose rápidamente una onda R’ en V1 y S en V6. finalmente se activa el vector septal derecho
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*Complejos QRS de 0.13 seg de duración, onda R empastada en V1 y onda S empastada en V6
*Sobrecarga VI *Onda T negativa en V6 sugiere isquemia subepicárdica
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1)Interpretación del ECG Normal y sus variantes
II CURSO UNIVERSITARIO DE POSGRADO EN CARDIOLOGÍA
Facultad de Ciencias Médicas de la UNR
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“Variantes” de la normalidad
RSR´ o rSr´ en V1
# QRS < 0,12”
# 2,4 % normales
# activación de la Crista SV
Topol, 2003
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“LOS HEMIBLOQUEOS” ( adaptado de Rosenbaum, 1972 )
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“Los 4 tiposde HBAI”
Prof Mariani1972
I:Standard
II: H & H
III:Vertical
IV:& HVI
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V1 V6V2 V4V3 V5
D1 D3 aVR aVL aVFD2
PP, 65- Cardiopatía HipertensivaAI:62 mm; VI: 58 x 38 mm; SIV, PP: 18 mm; FEVI 60 %
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DC 24; nadador olímpico, 1988
CAI ?CVI ?ST- T ?
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RL 21 años, rugbier. CIMED 1986
rSr’CVI ?ST- T ?
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UN ECG NORMAL EXCLUYE DISFUNCIÓN SISTÓLICA VENTRICULAR IZQUIERDA
Un ECG anormal…S 94 % E 61 %VPP 35 % VPN 98 % Davie AP. BMJ 1996; 312: 222
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El ECG en la Cardiopatía IsquémicaCátedra de Patología Médica I
Juan Beloscar12 de julio de 2012
FAC
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Lentitud repolarizaciónISQUEMIA
ISQUEMIASUBEPICARDICA
T
IMAGEN RECIPROCA
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Despolarización diastólica parcialLESION
LESIÓNSUBEPICARDICA
ST
IMAGEN RECIPROCA
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Despolarización Diastólica acentuadaNECROSIS
NECROSISSUBEPICARDICA
Q
IMAGEN RECIPROCA
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DIAGNÓSTICO1º) DE CERTEZA
2º) TOPOGRÁFICO
3º) DE PERÍODO EVOLUTIVO
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DIAGNÓSTICO DE CERTEZA:
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DIAGNÓSTICO TOPOGRÁFICO DEL IM
GUSTO IIB NEJM 1996
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DIAGNÓSTICO TOPOGRÁFICO: V1- V2: Septum 1/3 medio V3- V4: Septum 1/3 inferior V5- V6: PLVI, paraseptal baja DI- aVL: PLVI, paraseptal altaDII- DIII- aVF: Inferior D Sodi Pallares
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DIAGNÓSTICODE PERÍODO EVOLUTIVO
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DIAGNÓSTICO: SUPRADESNIVEL ST:SÍ:
SCA con SSTTRATAMIENTO:
REPERFUSIÓN con TROMBOLISIS o ANGIOPLASTIA
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DIAGNÓSTICO: SUPRADESNIVEL ST:NO:
SCA sin SSTTRATAMIENTO:
MÉDICO o INTERVENCIONISTA
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DIAGNÓSTICO: SUPRADESNIVEL ST:
NO:SCA sin SST
# infradesnivel ST# inversión T# normal !?
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Redefinición del IM: CONSENSO ESC & ACCJACC 2000 (36): 959- 69
CAMBIOS INDICATIVOS
DE IM ESTABLECIDO
Dx. Inicial
ECG al Ingreso
ECG en la Evolución
IM Q IM no Q: (ST-T) Ang. Inestable
Elevación ST Sin Elevación ST: (ST-T)CAMBIOS INDICATIVOS DE ISQUEMIA MIOCARDICA
QUE PUEDEN PROGRESAR AL IM
Sindrome Coronario Agudo
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“Al Maestro con Cariño…”