PHAN TCH MOT

BAN IEN TIM CACH TIEP CAN

CO HE THONG
BS Nguyen xuan Tuan Anh
Bo mon Noi - HYD

Hoat ong ien hoc cua

tim
Nut xoang
Bo noi nh
that
Bo His
Cac nhanh
Mang
Purkinje

S hnh hanh P-QRS-T

Song P : kh cc
nh.
Phc bo QRS :
kh cc that
Song T : hoi cc
that

NH DANH SONG

Cac chuyen ao
Chuyen ao
lng cc chi I II
III
Chuyen ao n
cc chi aVR, aVL,
aVF
Chuyen ao
trc tim V1 V6

Tiep can co he thong

1-Tan so (RATE)
2- Nhp (RHYTHM)
3- Cac khoang cach (INTERVAL
PR/QRS/QT)
4- Truc (AXIS)
5- Ph ai (HYPERTROPHY)
6- Nhoi mau (THAY OI QRST)

1- RATE & RHYTHM

Phan tch 5 iem

Song P ?
QRS bnh thng hay rong ?
Nhp co eu hay khong ?
Tng quan gia song P va QRS
Tan so tim.

1.2 - TAN SO TIM : Cach

tnh
LUAT 300 : Khi
nhp eu, tan so
tim c tnh bang
cach lay 300 chia
cho so o ln
gia khoang RR.
Khi giay chay vi
van toc 25
mm/sec, 1 o nho
la 0.04 va 1 o
ln la 0.2
(5X0.04).

1.3 NHP XOANG/CAC ROI

LOAN NHP

Nhp xoang : song P D I , D II luon

luon dng.
Neu song P D I khong dng
khong phai nhp xoang (tr dextrocardia
hoac mac sai ien cc).

Nhp xoang BT : eu , 60-90 nhp/phut

Nhp cham xoang : eu , <60/p
Nhp nhanh xoang : eu , >= 100 /p
Loan nhp xoang : khong eu, normal variant.

Loan nhp xoang do ho

hap

Mac sai ien cc

1.4 RLNT TREN THAT : phc

bo hep
Tren that : xung
ong phat xuat
ngay tai hoac pha
tren nut AV
Cac RLNT tren that
thng gap la :
Rung nh
Flutter nh (cuong nh).
Cn nhp nhanh kch
phat tren that.
Nhp bo noi

1.4.1 RUNG NH
Loan nhp hoan toan, ng
ang ien uon ln thanh song
f lan tan (fibrillation)
RN ap ng that nhanh : tan so
that > 120/p
RN ap ng that co kiem soat : 70110/p
RN ap ng that cham : < 60/p

Rung nh (atrial fibrillation) :

song f lan tan, loan nhp
hoan toan

1.4.2 FLUTTER NH
Song F rang ca,
tan so 300 .
ap ng that :
2:1 thng gap
nhat tan so
that la 150
(300/2).
4:1 tan so
that la 75.
Thay oi : nhp
khong eu

Flutter nh : dan truyen

2:1

1.4.3 CN NHP NHANH KCH

PHAT TREN THAT
Nhp eu, tan so 150-240
lan/phut
Song P kho thay
C che vong vao lai tai bo noi
nh that
Con goi la AVNRT : AV Nodal
Reentry Tachycardia

PSVT : paroxysmal
supraventricular tachycardia

1.4.4 NHP BO NOI

Nhp eu, hoat ong nh bat nguon

t bo noi nh that.
Song P D II hoac am (khi ng
trc hay sau QRS) hoac khong thay
(lan vao QRS)
Nhp thoat bo noi : hoat ong nut xoang
b suy yeu. Tan so 40-60 lan/phut.
Nhp bo noi gia toc : nhp phat t bo noi
tang len t 61-99 lan/phut, nam quyen
ch huy tao nhp.
Nhp nhanh bo noi : >100 lan/phut

Nhp thoat bo noi : song P

am i sau phc bo QRS II,
III, aVF, aVL.

1.5 NGOAI TAM THU

NTT la nhng phc bo QRS en sm
xen vao nhp c ban
NTT nh : nhat bop en sm co nguon
goc t mot v tr nh thay v la nut xoang
( P thay oi hnh dang)
NTT bo noi : nguon goc t nut nh that (P
am hoac khong thay D II).
NTT that : phc bo QRS gian rong, d dang,
nguon goc t tam that

Ngoai tam thu tren that, co

luc nhp oi

Ngoai tam thu that nhp

oi

1.6 ROI LOAN NHP THAT :

Phc bo rong
Nguon goc xung ong t that : phc
bo rong d dang.
QRS khong lien he vi song P, khong
thay P hoac P retrograde.
Nhp thoat t that : 20-40 lan/phut
Nhp t that gia toc : nhp > 40 nhng
khong qua 110-120/phut.
Nhanh that : > 12130 lan /phut. Cup
quyen ch huy.

NHANH THAT

2- O CAC KHOANG
Khoang PR
Phc bo QRS
Khoang QT

2.1 KHOANG PR
Tnh t au kh cc nh
(au song P) en au
kh cc that (au QRS).
o tot nhat D II . BT :
0.12-0.20
PR ngan : < 0.12 H/c
kch thch sm , dan
truyen qua ng phu.
PR dai : > 0.22 . Block AV
o I.

2.2 Phc bo QRS- BLOCK

NHANH
Khoang QRS : thi gian kh cc
tam that. ngi ln, nhp
xoang thi gian nay khong qua
0.10
o bat ky au trong 12 chuyen
ao. La chuyen ao nao co QRS
dai nhat.
Phc bo QRS gian rong khi vut
qua 0.10 hay o ln.

2.3 KHI PHC BO QRS GIAN

RONG
Neu nhp la nhp tren that
(khong phai la nhanh that), QRS
gian rong (khong do WPW) th co
3 ly do :
Block nhanh phai.
Block nhanh trai.
Cham dan truyen noi that (IVCD
intra vaentricular conduction delay).
Xem D I, V1 va V6.

BLOCK NHANH PHAI

V1 : rSr
D I, V6 : song S pha sau gian rong.
QRS > 0.11

Block nhanh P : right bundle

branch block (RBBB) rsR V1, S
rong D I

BLOCK NHANH TRAI

QRS > 0.12
D I va V6 : R dng, co moc,
KHONG CO SONG Q.
QRS am V1 (rS hay QS)

Block nhanh trai (left bundle

branch block LBBB) S sau
V1,V2,V3- R rong co moc va
mat q V4-V6.

IVCD
Thng la hau qua cua mot
tien trnh benh ly tai c tim nh
NMCT, x hoa, benh c tim, tim
ln.
QRS gian rong > 0.11
Khong co dang block nhanh phai
hay block nhanh trai ien hnh D I,
V1 va V6.

WPW
Mot ngoai le khi nhp tim la nhp
xoang bnh thng nhng khong
thuoc ba dang tren la h/c WOLFFPARKINSON-WHITE.
QRS rong.
Song delta.
PR ngan lai

H/C WPW : PR ngan lai va

song delta I, II , V3, V4.

2.3 KHOANG QT
o t au song Q (hoac R neu
khong co Q) en cuoi song T.
Neu nhp tim < 100 lan/phut, QT
keo dai khi no ln hn khoang
RR.
Chon chuyen ao nao thay ro
phan ket thuc cua song T va
co QT dai nhat.

QT Interval (QTc < 0.40 sec)

Bazett's Formula: QTc = (QT)/SqRoot RR (in seconds)
Poor Man's Guide to upper limits of QT: For HR = 70 bpm, QT<0.40 sec; for
every 10 bpm increase above 70 subtract 0.02 sec, and for every 10 bpm
decrease below 70 add 0.02 sec. For example:
QT < 0.38 @ 80 bpm
QT < 0.42 @ 60 bpm

H/c QT dai

3- TRUC IEN TIM VA BLOCK

PHAN NHANH
12 chuyen ao nhn trai
tim theo nhng goc nhn
khac nhau.
3 chuyen ao chuan
chi la I, II, III. Moi chuyen
ao cach nhau 60 o
(tam giac eu Einthoven).
3 chuyen ao n cc chi
la avR, aVL, aVF cach
nhau 120 o, vi aVL
-30 o va aVF 90 o

CACH TNH TRUC IEN TIM

Da vao 2 chuyen
oa D I va aVF v
chung vuonggoc
nhau. D I v tr 0
o va aVF v tr
+90 o.
Truc BT : 0-90
Truc lech trai : 0-90
Truc lech phai :90180
Truc bat ng : 180270

CACH TNH NHANH

- D I va aVF co tong bien o
tng t nhau : truc 45 o.
- D I dng va co bien o ln hn
aVF : truc gan D I hn (gia 0-40
o).
- aVF dng va co bien o ln
hn : truc gan aVF hn (50-90 o).
- Truc se vuong goc vi chuyen
ao nao co tong bien o bang 0
(pha am bang pha dng).

TRUC LECH TRAI BENH

LY
- Block phan nhanh trai trc
(LAH) thng gap hn block
phan nhanh trai sau (LPH)
- Thc hanh ta chan oan LAH
khi co truc lech trai benh ly
ngha la khi truc QRS am hn
-30 o.
- Nhn D II , neu am : chac
chan truc > -30 o.

 Tan so 72,
PR=0.16,
QRS=0.09,
QT=0.36
Truc QRS = -70 o
(truc lech trai).
Nhp xoang BT, dan
truyen nut
xoang va AV BT.
rS II, III, aVF.
KL : ECG bat
thng- Block
phan nhanh trai
trc

4- LN CAC BUONG TIM

Ph ai that trai :
Song S sau nhat
V1/V2 cong song
R cao nhat V5/V6
> 35 mm va/hoac R
aVL > 12 mm.
B/n tren 35 tuoi.
Hnh anh tang
ganh that trai.

Ph ai that trai : SV2 + RV5

> 35mm
Tang ganh
that T

Ln tam nh
-Nhp xoang BT :
song P dng D II.
P co the +, - hay hai
pha V1.
-Ln nh phai : P cao
nhon. P pulmonale
xem II, III, aVF.
-Ln nh trai : P
lng lac a va
gian rong >0.12. P
mitrale xem I, II, aVL
va hoac pha am
cua song P V1 sau.

Ln nh P : P cao II

LN NH TRAI
P > 0.12
P co 2 nh cach
nhau 0.04
P terminal force : pha
am song P V1
rong hn 0.04 va
sau hn 1 mm.

PH AI THAT PHAI
Kho chan oan.
Gi y khi ket hp nhieu yeu to :
Truc lech P hoac bat nh.
Ln nh P.
Dang block nhanh P khong hoan toan
rSR
ien the thap (kh phe thung).
Song S ton tai tat ca cac chuyen
ao trc tim.
Tang ganh that P.
R cao V1.

RVH
Truc P
Ln nh P
R cao V1
S V5,V6

Ph ai that P : ln nh P.
truc 105 o, R V1 > 6 mm, R
aVR > 5 mm. R V1 + S V5/V6 >
10 mm.

RVH : RAD 120 , qR V1, R/S

V6 < 1

5- THAY OI QRST va
NHOI MAU C TIM
- Khau quan trong nhat cua viec
phan tch mot ECG chnh la viec
anh gia cac thay oi cua Q-RST-T.
- Can phai anh gia mot cach
co he thong e khong bo sot
bat c mot thay oi nao.

ANH GIA CAC THAY OI QR-S-T

- Co the bo qua chuyen ao aVR.
- Scan tat ca 11 leads con lai e tm
song Q. Ghi nhan cac lead co song
Q.
- Xem co R wave progression
Chuyen ao trung gian co v tr BT ?
Co song R cao (hoac rSr) V1 khong ?

- Scan tat ca cac lead (tr aVR)

cac thay oi cua oan ST (chenh
len hay chenh xuong )- va/hoac
cac thay oi cua song T

Chuyen ao trc tim

1- Vector kh cc au
tien la kh cc vach
lien that t T sang P
(r/V1 va q/V6)
2- Sau o. vector kh
cc chnh se i t P sang
T (do khoi c that trai
u the) song am
V1, V2 va dng V5,V6.
3- Song R tang dan va
chuyen ao trung gian
se V3,V4

CAC NHOM CHUYEN AO

Cac
Cac
Cac
Cac

lead
lead
lead
lead

DUI : II, III, aVF.

VACH : V1, V2.
TRC : V2, V3, V4.
BEN :

V4-V6
Ben cao : I, aVL

R WAVE PROGRESSION
- Bnh thng R tang cao dan t P
sang T.
- Poor R wave progression : R t V1
en V3-V4 khong gia tang bien o
hoac tang rat t.

LVH, RVH, benh phoi (COPD, hen)

NMCT thanh trc hay trc vach
Cac RL dan truyen ( LBBB, LAHB< IVCD).
Benh c tim.
Bat thng thanh ngc, normal variant.

POOR R WAVE PROGRESSION

SONG Q/SONG T AO-BNH

THNG
Mot vai lead bnh thng co song
Q hay T ao.
III, aVF, aVL, avR,V1

Song Q va T : nhng ieu

can nh
Song q (kh cc vach) thng thay
cac chuyen ao ben (I, aVL, V5,V6) tren
ngi BT.
Hep (<0.04) va nho (<25% bien o song R)

Song q thng thay D I va aVL khi truc

pha trai cua 60 o va II, III, aVF khi
truc pha phai cua 60 o.
Song T ao n oc III,aVF hoac aVL
thng khong mang y ngha thieu mau c
tim khi QRS cung am cac lead o.

ST-T : nhng eu can nh

oan ST bat au t iem J (cuoi QRS) i
lai cao dan len hoa lan vao sn len
cua song T, sau khi en nh, no ha
nhanh xuong ng an ien hoac noi
qua song U khong co phan cach ro
rang gia ST-T (smooth), song T khong
oi xng
Song T BT cung chieu vi QRS (tr
chuyen ao ben P)
T luon luon dng I, II, V3,V4,V5,V6.
T luon luon am aVR.

HNH DANG CUA ST

CHENH LEN
ST chenh len dang cong
lom (concave) thng la
lanh tnh gap ngi
BT (tai cc sm).
IEU NAY CH UNG
KHI BENH NHAN KHONG
CO AU NGC
ST chenh len dang cong
loi (convex) thng do
ton thng c tim cap
(NMCT).

Early repolarisation

Convex ST elevation :
II,III,avF

ST CHENH XUONG
Thieu mau c tim.
Tang ganh that.
Digitalis.
Giam K/Mg.
Thay oi lien quan nhp tim.
Bat ky mot ket hp nao cua
cac n/n tren.

Cac dang ST chenh xuong

NHOI MAU C TIM

anh gia new onset chest pain
Nhng thay oi cap tnh
Co nhoi mau c tim cu hay khong

Benh nhan nay co b NMCT hay

khong ?
Neu co th b vung nao, mc o lan
rong, co kem theo cac RL g khac hay
khong (RLNT, block nh that )
Co can phai can thiep mach vanh
khong ?

ECG TRONG NMCT

1- ST chenh len.
2- Song T am (ao).
3- Xuat hien Q benh ly.
4- ST chenh xuong chuyen ao
soi gng.

DIEN TIEN CUA NMCT

CAP
- A va B : BT , normal q septal
wave
- C : g toi cap . Song T
rong ra, nho cao len nh
muon keo an St len.
Thoang qua.
- D : ST chenh len va xuat
hien Q hoai t.
- E va F : Q sau hn , ST
chenh len toi a, xuat
hien T ao.
- G : cac thay oi ST- T tr
lai bnh thng, ton tai Q
hoai t.

NMCT thanh di : Q, ST
chenh len T ao II, III, avF

NMCT cu thanh di : Q II,

III, aVF

NMCT trc vach

anteroseptal : V1,V2,V3 Q benh
ly va thay oi ST-T

NMCT : Q benh ly va ST
chenh len V2-V6, DI, aVL.

SYSTEMIC APPROACH
1- RATE : LUAT 300
2- RHYTHM : P luon dng DI, II. eu ?, lien
he P va QRS, QRS rong hay hep.
3- INTERVALS : PR dai > 0.2, QRS rong > 0.10,
QT dai > RR. Neu QRS rong RBBB, LBBB,
IVCD, WPW.
4- AXIS : xem D I va aVL. BT, RAD, LAD, bat
nh
5- HYPERTROPHY : that trai (35,12), that P (R
cao V1, truc P, S sau V6_, nh P (P phe > 2.5),
nh trai (P mitrale, 2 nh, >0.12).
6- INFARCT

Q wave : normal septal q (I, L, V5,6) - q III, aVF.

R wave progression.
ST segment : convex / concave.
T waves : Co the am III, aVF, aVL va V1.