ECG cardiac infarction and ischemia

An electrocardiogram - an ECG - or the dutch and german version of the word - elektrokardiogram or EKG, is a tool used to visualize “gram” the electricity “electro” that flows through the heart “cardio”.

An ECG tracing specifically shows how the depolarization wave moves during each heartbeat - which is a wave of positive charge - looks from the perspective of different sets of electrodes.

This particular set of electrodes is called lead II, with one electrode on the right arm and the other on the left leg, so essentially when the wave’s moving toward the left leg electrode, you get a positive deflection, like this big positive deflection correspond to the wave moving down the septum.

To read an ECG there are a few key elements to keep in mind, one of them includes figuring out if part of the heart has is suffering from ischemia or has undergone an infarction.

The term ischemia means that blood flow to a tissue has decreased, which results in hypoxia, or insufficient oxygen in that tissue, whereas infarction goes one step further and means that blood flow has been completely cut off, resulting in necrosis, or cellular death. That typically happens if blood flow has been cut off for about 20 minutes.

In the heart, ischemia and infarction can be transmural, affecting the entire thickness of the myocardium, or subendocardial, affecting just the innermost part of the myocardium - the part just beneath the endocardium.

Out of all four chambers of the heart, the ECG is most sensitive to transmural or subendocardial ischemia or infarction in the left ventricle because that’s the chamber with the thickest walls and therefore has the most cardiac tissue.

Alright, let’s start with subendocardial ischemia, which might happen when there’s incomplete blockage - let’s say 70% - in a coronary artery.

In that situation, at rest there’s enough blood flowing through to meet the demand of the myocardium, but during exercise there’s not enough to meet the increased demand of the myocardium.

In that situation, the subendocardial tissue get ischemic because it’s the last bit of tissue to get blood from the tiny branches of the coronary arteries as they make their way through the ventricular wall from outside to inside.

This condition is called stable angina, because there’s ischemia which causes chest pain with exercise and it disappears with rest.