CORONARY INSUFFICIENCY

BY DR.MANSI GANDHI

LA RA V1 V2 V3 V4 V5 V6 V5 V4 V1 V2 V3 LV RV V6

6.5

Lateral I, AVL, V5-V6 Anterior / Septal V1-V4

Inferior II, III, aVF

RCA:
II, I,

Inferior myocardium Lateral myocardium

III, aVF aVL, V5, V6

LCA: LAD:

Anterior/Septal myocardium
V1-V4

 ACS

includes spectrum of clinical presentations

Unstable NSTEMI STEMI

angina

 Condition

where there is inadequate supply of the blood to a portion of myocardium. It may be present at all times or it may be relativeblood flow being adequate at rest but inadequate when myocardial demand is increased by exercise or coronary vasospasm

 Abnormalities

of repolarization (earliest ; M.C.being abn. of ST segment esp. DEPRESSION) of depolarizatrion

Abnormalities

Abnormal

relationship between repolarization and depolarization.

 Abnormalities

of ST segment Depression of ST segment Elevation of ST segment

 ST

segment normally leaves baseline immediately after QRS complex ; hence very little of it is isoelectric

MECHANISM : INJURY TO SUBENDOCARDIAL REGION OF LEFT VENTRICLE (Depression in V5 , V6)

Isoelectric for 0.12 sec (3 mm) or



longer

No depression below the baseline Depression of distal part of ST segment

Depression

of a horizontal ST segment Sharp angled ST T junction

Reflects severe form of impaired coronary blood flow

J-point is the point where S wave becomes isoelectric and joins the T wave. ST segment elevation or depression is measured 2 small boxes away from the J-point and then, up or down the isoelectric line.

Point at which potential of ECG is exactly zero is called J point.

ST Q

S J point

One way to diagnose an acute MI is to look for elevation of the ST segment.

Elevation of the ST segment (greater than 1 small box) in 2 leads is consistent with a myocardial infarction.

Mechanism TRANSMURAL EPICARDIAL INJURY

Slide 11

T wave deflection may occur withHyperventilation, heavy meals, smoking, drinking cold water, decrease in blood pressure,anxiety

Inverted Symmetrical Sharply pointed

After exercise,if height of T-wave in V4 is 5mm or more than resting value coronary insufficiency suspected

 Increasing

QRS-T angle in both frontal and horizontal planes suggest coronary insufficiency

 Small

rounded deflexion occurring just after T wave Same direction as T wave V2-V4 Inverted U wave cardiac ds ( CAD, HTN) If after exercise ischaemia

Chest pain caused by transient myocardial ischemia due to an imbalance between myocardial oxygen supply and demand.

Angina

pectoris of effort with FIXED effort threshold Reproducibility of critical level substrate for angina pectoris is ORGANIC STENOSIS CLASSIC FORM k/a HEBERDENS ANGINA ST DEPRESSION D/T acute subendocardial injury Angina pectoris of effort with VARIABLE effort threshold Cold induced Nocturnal (DECUBITUS ANGINA) Emotionally triggered Angina pectoris AT REST

Variant

form of angina pectoris AT REST(PRINZMETALS ANGINA) Variant form of angina pectoris ppt by EFFORT Unstable angina(ACCELERATED / CRESCENDO / PREINFARCTION ANGINA PECTORIS / INTERMEDIATE CORONARY SYNDROME)

1. Stable Angina .
The commonest cause is ADVANCED ATHEROSCELEROSIS
Retrosternal pain Radiating to left arm & shoulder Lasting less than 15 min.

Stable Angina
Anginal pain is often associated with Depression of ST segment
Exercise ECG showing typical severe down sloping ST segment :

Standing

1 min.

3 min.

7 min.

9 min.

In between attacks : ECG is entirely NORMAL

2. Unstable Angina .
Increased frequency, severity or frequency, duration of pain in a patient of Stable Angina
N.B. Pain occurs with less exertion or at rest
Myocardial infarction may occur in 10-20% of 10patients.

Angina . (Prinzmetal)
3. Variant
Chest pain at rest due to coronary artery spasm ECG changes: changes:
With chest pain , marked ST segment elevation Return of the ST segment to the baseline after nitroglycerin administration

The baseline ECG

Acute elevation of ST segment

 Slope-elevation

of ST (V2 V6) concave or upward sloping configuration ; Tall and widened T; Increased VAT Diminution in depth of S wave

During attack of chest painreflects features of Prinzmetals -ST elevation -tall T waves

Following cessation of chest pain

AT REST

AFTER EFFORT

B-slope elevation of ST segment -increased amplitude of T waves -increased amplitude of R wave -diminished amplitude of S wave -inverted U wave

About

4 mm in amplitude Monophasic deflexion (R ,ST ,T WAVE blends) Higher the ST elevation, the more severe the CAD