ekg-materijal za studente
TRANSCRIPT
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KLINIČKA ELEKTROKARDIOGRAFIJA
Žarko Mavrić
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LITERATURA
• Braunwald E i sur. Harrison’s Principles of Internal Medicine. McGraw Hill: New York, 2001.
• Zipes D i sur. Braunwald's Heart Disease: A textbook of cardiovascular medicine. Elsevier Saunders: Philadelphia, 2005.
• Barić Lj i sur. Elektrokardiografija u praksi. Lek: Zagreb, 2003.
• Goldschlager N, Goldman MJ. Principles of clinical electrocardiography. Appleton&Lange: Norwalk/San Mateo, 1989.
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Elektrokardiografija
• EKG morfologija
– Analiza oblika (amplitude, širine, izgleda) EKG signala
• Aritmologija
– Analiza ritma (frekvencije, pravilnosti, mjesta nastanka) impulsa
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• EKG krivulja je grafički prikaz električnih potencijala koji nastaju tijekom rada srca
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Elektro-ionske promjene tijekom depolarizacije i repolarizacije
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Srčani generator
Električno polje srca
Potencijali na površini tijela
Registracija EKG-a
Interpretacija EKG-a
Slijed aktivacije
Faktori transmisije
Kablovi, pojačalo, pisač
Dijagnostički kriteriji
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Komponente EKG sustava
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Elektrokardiografski odvodi
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Bipolarni ekstremitetni i prekordijalni odvodi
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Unipolarni ekstremitetni odvodi
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Prekordijalni odvodi i dopunski torakalni odvodi
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Dipol i električno polje
• Veličina potencijala registrirana u pojedinim
točkama polja ovisi o:
– veličini potencijala u izvoru
– udaljenosti od izvora
– odnosu mjernog instrumenta prema osi dipola
Ep = m · cos α
r 2
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A = H cos α
• α = 0o cos α = 1 A = H • α = 90o cos α = 0 A = 0
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Projekcije vektora na osi odvoda
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Osi ekstremitetnih i prekordijalnih odvoda
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Heksaksijalni referentni sustav
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Komponente normalne EKG krivulje
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Normalan EKG
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• Frekvencija = 300
Broj kvadrata od 0,2 sec između
susjednih QRS kompleksa*
• 300 – 150 – 100 – 75 – 60 – 50
• Broj QRS kompleksa u 6 sec x 10
Određivanje frekvencije srca • Normalna 60 (50) - 100 min-1
• Bradikardija < 60 (50) min-1
• Tahikardija > 100 min-1
*Pri standardnoj brzini papira od 25 mm/sec, 5 velikih kvadrata=1sec.
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Srčani vektori
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Izolirano mišićno vlakno: depolarizacija
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Izolirano mišićno vlakno: repolarizacija
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Slijed aktivacije ventrikula
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Slijed depolarizacije ventrikula
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Sekvencijalni vektori depolarizacije ventrikula
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Vektokardiogram u frontalnoj ravnini
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Električna os srca
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A = H cos α
• α = 0o cos α = 1 A = H • α = 90o cos α = 0 A = 0
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Projekcije vektora na osi odvoda
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Izračunavanje srednje električne osi
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Električna os srca
60o
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Električna os srca
0o
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Električna os srca
45o
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Električna os srca
105o
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Električna os srca
135o
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Električna os srca
-45o
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Artefakti
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Zamjena elektroda (desna-lijeva ruka)
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Dekstrokardija
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Artefakti: micanje ekstremiteta (lijeva noga)
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Tremor
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Tremor (psudoundulacija atrija)
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Tremor (parkinsonizam) (desna ruka)
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Artefakti od pomaka elektrode
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Rijetki artefakti (vs pomak elektroda)
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Zamjena prekordijalnih elektroda (V1=V6)
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Normalne varijante
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Juvenilni obrazac i rana repolarizacija
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Juvenilni obrazac
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Rana repolarizacija
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Rana repolarizacija
Normalna varijanta? Perikarditis?
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Interpretacija EKG-a
• Osjetljivost i specifičnost EKG promjena
• Serijsko praćenje EKG promjena
• Usporedba s ranijim EKG nalazom u istog pacijenta
• Sistematski pristup interpretaciji:
– identifikacija pacijenta (ime i prezime)
– datum registracije
– baždarenje
– ritam
– električna os
– morfološke promjene (P, PR, QRS, ST, T, U)
– QT interval
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Abnormalnosti atrija
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Povećanje (abnormalnost) desnog i lijevog atrija
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Depolarizacija atrija
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Abnormalnost lijevog atrija Hipertrofija desnog ventrikula
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Abnormalnost lijevog atrija
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Abnormalnost lijevog atrija Blok desne grane
Infarkt prednje stjenke Hipertrofija lijevog ventrikula
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Abnormalnost desnog atrija
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Abnormalnost desnog atrija Hipertrofija desnog ventrikula
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Biatrijalna abnormalnost
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Hipertrofija ventrikula
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Hipertrofija lijevog ventrikula
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Hipertrofija lijevog ventrikula (volumno opterećenje)
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A: Hipertrofija LV – tlačno opterećenje (aortalna stenoza) B: Hipertrofija LV – volumno opterećenje (aortalna regurgitacija)
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Hipertrofija lijevog ventrikula: dijagnostički kriteriji
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Hipertrofija desnog ventrikula Biatrijalna abnormalnost
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Hipertrofija desnog ventrikula
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Emfizem pluća
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Akutno opterećenje desnog ventrikula (akutno plućno srce)
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Hipertrofija desnog ventrikula: dijagnostički kriteriji
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Dominantan R u V1 (R, Rs, rSR’)
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Smetnje intraventrikularnog provođenja
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Provodni sustav srca
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Intraventrikularni provodni sustav
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Blok desne grane i blok lijeve grane
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Blok desne grane
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Blok lijeve grane
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Blok desne grane i blok lijeve grane
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Lijevi prednji i lijevi stražnji fascikularni blok
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Lijevi prednji fascikularni blok
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Lijevi prednji fascikularni blok
A: Lijevi prednji fascikularni blok B: S1S2S3
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Devijacija električne osi ulijevo u infarktu miokarda donje stjenke
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Lijevi stražnji fascikularni blok
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Lijevi stražnji fascikularni blok
+ blok desne grane
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Lijevi stražnji fascikularni blok
+ blok desne grane i AV blok Io
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Downloaded from: Heart Disease (on 17 January 2006 07:56 PM)
© 2005 Elsevier
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Downloaded from: Heart Disease (on 17 January 2006 07:56 PM)
© 2005 Elsevier
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Downloaded from: Heart Disease (on 17 January 2006 07:56 PM)
© 2005 Elsevier
Aberantno intraventrikularno provođenje (Ashmanov fenomen)
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Ventrikularna preekscitacija
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Ventrikularna preekscitacija
• Tip WPW (Wolff-Parkinson-White):
– Akcesorni atrio-ventrikularni put (Kent)
• Tip LGL (Lown-Ganong-Levine):
– Akcesorni atrio-Hisov put
– Ubrzano provođenje kroz AV spoj
• Tip Mahaim:
– Akcesorni put između AV čvora i miokarda desnog ventrikula (nodo-ventrikularni put)
– Akcesorni put između AV čvora i desne grane (nodo-fascikularni put)
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Preekscitacija: Kentov akcesorni put (WPW)
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Preekscitacija
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Preekscitacija po tipu WPW
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Preekscitacija po tipu WPW
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Preekscitacija po tipu WPW (intermitentna)
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Ishemija, lezija i infarkt miokarda
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Ishemija – lezija – infarkt
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Promjene akcijskog potencijala u akutnoj ishemiji
- niži potencijal membrane u mirovanju
- manja amplituda AP
- skraćeno trajanja AP (patološka rana repolarizacija)
- manja brzine faze 0 AP
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Patofiziologija ST elevacije
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Subendokardijalna i transmuralna (epikardijalna) lezija
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Subendokardijalna i transmuralna (epikardijalna) ishemija
Kronična ishemija produljuje trajanje AP (faza 3 – T val)
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Negativni T valovi: diferencijalna dijagnoza
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Negativni T valovi: ishemija
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Negativni T valovi: ishemija
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Negativni T valovi: ishemija
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Hiperakutna faza infarkta miokarda prednje stjenke
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Akutni infarkt miokarda: ST elevacija i prominentni T valovi
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Infarkt miokarda: hiperakutne promjene
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Infarkt miokarda: hiperakutne promjene
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Infarkt miokarda: hiperakutne promjene
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Infarkt miokarda: hiperakutne promjene
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Evolucija infarkta miokarda prednje i donje stjenke
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Infarkt miokarda donje i stražnje stjenke
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Infarkt miokarda donje, stražnje i lateralne stjenke
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Angina pektoris Prinzmetal
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Pseudonormalizacija T valova u akutnoj ishemiji
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Akutni infarkt miokarda donje stjenke lijeve klijetke i miokarda desne klijetke
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Akutni infarkt miokarda donje stjenke lijeve klijetke i miokarda desne klijetke*
* V1 – V6 = V1R – V6R
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Akutni infarkt miokarda
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Akutni infarkt miokarda
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Akutni infarkt miokarda
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Akutni infarkt miokarda
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Akutni infarkt miokarda
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Infarkt miokarda: evolucija
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Infarkt miokarda: evolucija
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Akutni infarkt miokarda prednje stjenke uz blok desne grane
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Akutni infarkt miokarda donje stjenke uz blok lijeve grane
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Infarkt miokarda anteroseptalne stjenke uz blok lijeve grane
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Infarkt miokarda prednje stjenke uz blok lijeve grane
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Akutni infarkt miokarda donje i lateralne stjenke uz elektrostimulaciju desne klijetke
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Različite elektrokardiografske abnormalnosti
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Perikarditis
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Perikarditis
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Perikarditis
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Perikarditis
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Učinak digitalisa
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Hipo- i hiperkalcemija
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Hipokalcemija
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Hiperkalcemija
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Hiper- i hipokalemija
K 8,6 mEq/L
K 5,8 mEq/L
K 1,5 mEq/L
K 3,7mEq/L
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Hiperkalemija
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Hiperkalemija
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Hiperkalemija
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Hipokalemija
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Hipokalemija
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Hipotermija
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Totalni električni alternans (P-QRS-T)
Perikardijalni izljev s tamponadom
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Produženi QT interval
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Produženi QT interval
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Prominentni, široki, negativni T valovi
•Intrakranijalno (subarahnoidalno) krvarenje
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Negativni T valovi: diferencijalna dijagnoza
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Prominentni, široki, negativni T valovi