平板运动试验aVR导联ST段抬高对冠状动脉左主干病变的诊断价值

目的探讨平板运动试验aVR导联ST段抬高对冠状动脉左主干病变及前降支近段病变诊断价值。方法选取18例平板运动试验阳性并伴aVR导联ST段抬高者,2周内行冠状动脉造影(CAG),以冠状动脉内径狭窄≥50%者为CAG阳性。结果左主干病变13例,前降支近段病变3例,右冠状动脉中段狭窄1例,冠状动脉造影阴性1例。平板运动试验阳性并伴aVR导联ST段抬高对左主干病变的阳性预测值为72.22%(13/18);对冠状动脉左主干及前降支近段病变的预测值为88.89%(16/18)。结论平板运动试验阳性并aVR导联ST抬高≥0.1mv对诊断冠状动脉左主干及前降支近段病变有较高的阳性预测价值。     

心电图aVR导联变化对严重左主干狭窄病变的诊断意义

【】 目的 探讨冠状动脉左主干慢性严重狭窄病变的心电图特点。方法 单中心前展性连续选取典型心绞痛发作时12导联心电图aVR导联ST段抬高≥1mm,其他导联ST段压低或不抬高者作为研究对象,心绞痛缓解后aVR导联ST段抬高≥1mm恢复到等电位线。符合这一标准者共计76例住院急性冠脉综合症患者。依冠状动脉造影结果,分析左主干病变特点和其他冠状动脉病变特征。目测狭窄程度≥70%,为严重左主干狭窄病变。结果 单纯左主干严重狭窄54例(54/76, 71.1%),左主干病变 前降支近端近开口病变6例(6/76,7.9%);单纯左回旋支狭窄3例(3/76,3.9%); 其他复杂三支血管病变13例(13/76,17.1%)。冠状动脉正常者为零。左主干严重狭窄患者,aVR导联ST段抬高比非左主干患者更明显(0.25±0.10mV vs 0. 20±0.11mV, P<0.001); ST段压低导联多见于II III aVF和V3-V6导联,左主干严重狭窄患者,ST压低导联ST段压低程度比非左主干患者更明显(p<0.001)。这一特点诊断左主干严重狭窄的敏感性为72.7%, 假阳性54.4%,特异性45.4%,符合率61.9%。     

aVR、V1导联心电图对左主干及前降支近端明显狭窄的诊断价值

目的探讨aVR、V1导联对冠状动脉左主干及前降支近端狭窄诊断的阳性预测价值。方法对比分析120例冠造结果为左主干病变患者典型aVR、V1导联心电图改变的几率，对比分析120例心电图有典型变化患者的冠脉造影结果。结果①有68例（占56．7％，68／120，）的左主干病变患者出现了典型的aVR、V1导联心电图表现，即典型“左主干”心电图对左主干病变诊断的敏感性为56．7％；②有31例（占37.3％，31／83）典型aVR、V1导联心电图患者冠造结果为左主干病变，有81例（占97．6％，81／83）的典型aVR、V1导联心电图患者冠造结果为左主干及前降支病变，37例患者未检查冠造，典型“左主干”心电图对左主干病变的阳性预测价值为37.3％．而对左主干及／或前降支近段狭窄病变的预测价值为97．6％，二者的差异有显著性（p〈0．001）。结论心电图出现aVR、V1导联ST抬高〉1mm，且aVR导联ST段抬高〉V1导联，V4-6导联ST段下移≥2mm，Ⅱ、Ⅲ、aVF导联ST段下移≥1mm对诊断左主干或前降支近段明显狭窄有很好的阳性预测价值。     

静息状态下心电图指标对冠心病多支病变诊断价值的比较

目的探讨静息状态下常规十二导联心电图对冠心病患者（非急性心肌梗死、无胸痛发作状态）冠状动脉（冠脉）多支病变的诊断价值。方法观察分析1999年11月至2006年1月于济南市第四人民医院心内科入院拟诊不稳定型心绞痛行冠状动脉造影（CAG）患者（104例）的造影资料及CAG前ECG资料。选择性多体位左、右冠状动脉造影,以左主干、前降支、回旋支、右冠状动脉中任一支狭窄≥50%者为阳性,将患者分为阴性组（8例）、多支病变组[30例,LAD+LCX+RCA和（或）左主干病变]和非多支病变组（66例,单支病变+双支病变）。其中,左主干病变14例（可并发单支、双支或3支病变）。计数各组病例心电图aVR导联ST段抬高病例数、异常导联数、ST段移位绝对值之和、异常导联数+ST段移位绝对值之和、ST段时间,进行统计学分析。结果异常导联数+ST移位、异常导联数、ST段时间、aVR导联ST段抬高,多支病变组与非多支病变组比较有显著差异。异常导联数+ST移位、异常导联数和ST移位的敏感性显著高于aVR导联ST抬高,异常导联数+ST移位的敏感性明显高于ST移位。aVR导联ST抬高和ST移位特异性最好,两者之间无明显差异。结论异常导联数+ST移位、异常导联数、ST移位是诊断冠心病多支病变的敏感指标,且均优于aVR导联ST抬高;异常导联数+ST移位的敏感性明显高于ST移位。     

aVR导联对前壁急性心肌梗死相关血管的诊断、预后价值

目的探讨前壁急性心肌梗死（AMI）aVR导联ST段抬高对冠状动脉左主干及左前降支近段病变的诊断及预后价值。方法将61例前壁AMI者的心电图和冠状动脉造影（CAG）及临床资料进行对比分析,根据aVR导联有无ST段变化分为抬高组（A组）及ST段无抬高组（B组）。结果①梗死相关血管为左主干病变的A组及B组分别为5例（19.2%）及1例（2.8%）,两组统计有显著性差异（P〈0.01）。②梗死相关血管为左前降支近段病变的A组及B组分别为20例（76.9%）及5例（14.2%）两组统计有显著性差异（P〈0.01）。③发生心脏事件的A组及B组分别为10例（37.1%）、4例（11.4%）,两组统计有显著性差异（P〈0.01）。结论前壁AMIaVR导联ST段抬高对诊断左主干、左前降支近段病变及预后有很好的预测价值。     

aVR导联ST段改变对急性非ST段抬高型心肌梗死相关血管的判定及临床意义

目的探讨体表心电图a VR导联ST段改变对急性非ST段抬高型心肌梗死病人梗死相关血管(IRA)的判定及临床意义。方法回顾性分析230例临床确诊为急性非ST段抬高型心肌梗死病人的临床资料、心电图及冠状动脉造影结果。依据心电图a VR导联ST段变化将病例分为A组(ST抬高组)、B组(ST下移组)和C组(ST无偏移组)。结果冠状动脉造影结果:ST抬高组左主干病变、左前降支病变的发生率明显高于ST下移组和ST无偏移组,差异有统计学意义(P0.05);ST下移组左回旋支病变及右冠状动脉病变的发生率明显高于ST抬高组和ST无偏移组,差异有统计学意义(P0.05);ST抬高组和ST下移组双支病变及三支病变的发生率明显高于ST无偏移组,差异均有统计学意义(P0.05)。a VR导联ST段抬高组、下移组主要不良心血管事件发生率均明显高于ST无偏移组(P0.05)。结论急性非ST段抬高型心肌梗死病人如果伴有a VR导联ST段抬高或下移可能提示梗死相关血管为左主干病变、左前降支病变、左回旋支病变、右冠状动脉病变或严重的多支病变,且住院期间不良心血管事件发生率增高。a VR导联ST段改变对急性非ST段抬高型心肌梗死病人梗死相关血管的判定及临床预后均具有重要的临床指导意义。     

心电图表现为aVR导联下斜型ST段抬高的急性左主干病变1例

急性左主干病变病情严重,危险程度等同于急性ST段抬高型心肌梗死,需尽快行冠状动脉介入治疗.本文报道1例急性左主干病变的急性心肌梗死病例,心电图表现为aVR导联ST段下斜型抬高,Ⅰ、aVL导联ST段弓背向下抬高,Ⅱ、Ⅲ、aVF、V4—V6导联ST段压低,并探讨了aVR导联ST段抬高对预测左主干病变的意义.     

急性心肌梗死左主干与前降支近段病变心电图ST段压低的对照分析

目的探讨12导联心电图ST段压低在急性心肌梗死左主干与前降支近段病变鉴别中的价值。方法选取因急性心肌梗死住院的患者,依冠状动脉造影结果,分为冠状动脉左主干病变(LM组)和左前降支近端病变(LAD组)。回顾性分析患者入院即刻的12导联心电图,比较两组ST段压低改变的特点。结果入选符合标准的患者共74例,LM组15例,LAD组59例。LM组Ⅰ、Ⅲ、aVL和aVF导联ST段压低比例显著高于LAD组(P均<0.05),V2～6ST段压低比例两组亦有差异(P均<0.01)。同时,V2～6导联ST段改变值两组亦有差异。多元分析表明Ⅲ、V2和V6导联ST段压低对急性左主干病变有预测价值(P均<0.001),其诊断的敏感度为26.7%、特异度100%、阳性预测值100%和准确度85.1%。结论Ⅲ、V2和V6导联ST段压低有助于鉴别急性左主干与左前降支近段病变。     

静息心电图在诊断冠状动脉病变中的作用

目的探讨常规12导联心电图指标对静息状态下冠状动脉病变的预测价值。方法回顾性分析1998年3月～2006年1月拟诊不稳定型心绞痛并行冠状动脉造影患者（104例）的造影资料及冠脉造影前心电图。以左主干、前降支、回旋支、右冠状动脉中任一支狭窄≥50％者为阳性，将患者分为阴性组（8例）、单支病变组（41例）、双支病变组（25例）、三支病变组（16例）、左主干病变组（14例，可合并单支、双支或三支病变）。各组病例的年龄、性别、化验检查等指标进行统计学分析；计数各组病例心电图aVR导联ST段抬高病例数、异常导联数、ST段移位绝对值之和、异常导联数＋ST段移位绝对值之和、ST段时间，在单支病变组、双支病变组、三支病变组和左主干组之间进行统计学分析。结果①年龄：单支病变组与左主干病变组比较有显著性差异（P〈0.05），其它各组间比较无显著性差异（p〉0．05）。（参avR导联ST段抬高、异常导联数、ST移位、异常导联＋ST段移位：单支病变组与三支病变组、左主干病变组之间比较有显著性差异（P〈0．05）；ST段改变时间：单支病变组与左主干病变组之间比较有显著性差异（p〈0.05），但与三支病变组比较无显著性差异（P〉0．05）。③aVR导联抬高、ST段移位、异常导联＋ST段移位：双支病变组与三支病变组、左主干组比较有显著性差异（p〈0．05）；异常导联，双支病变组与三支病变组、左主干病变组比较无显著性差异（p〉0．05）；ST段时间：双支病变组与左主干病变组比较有显著性差异（p〈0．05），而与三支病变组比较无显著性差异（p〉0．05）。结论aVR导联抬高、ST段移位、异常导联＋ST段移位是识别单支病变或双支病变与三支病变或左主干病变的敏感指标；ST段时间是识别单支病变或双支病变与左主干病变的敏感指标，但对识别三支病变不敏感；异常导联数对识别单支病变与三支病变或左主干病变敏感，但对识别双支病变与三支病变或左主干病变不敏感。     

运动诱发ST段抬高的意义

目的观察运动诱发心电图ST段抬高的无心肌梗死（MI）者6例,探讨其冠状动脉（冠脉）病变特点。方法对无MI而运动诱发心电图ST段抬高的患者进行静息心电图、运动试验及冠脉造影检查,运动试验采用Bruce方案。结果在3002例行运动试验检查者中,有6例未患MI而运动诱发心绞痛伴心电图ST段抬高,发生率为0．2％。相应导联ST段抬高0．1～0．6mV,停止运动后心绞痛症状消失,ST段恢复正常。6例中,1例冠状动脉正常;余5例冠脉均有严重狭窄（70％～95％）,ST段抬高导联与缺血相关血管有良好的对应关系,近期内行冠脉介入治疗效果良好,术后症状消失。多次复查运动试验,结果均阴性。结论无MI者运动诱发心电图ST段抬高多提示心肌透壁缺血,冠脉病变重,应采取积极的治疗措施。     

Clinical characteristics of patients with exercise-induced ST-segment elevation without prior myocardial infarction.

BACKGROUND: Exercise-induced ST-segment elevation is a relatively uncommon problem and occurs more frequently in patients who have had a myocardial infarction. Data is limited on the characteristics of Taiwanese patients without prior myocardial infarction who develop exercise-induced ST-segment elevation. METHODS AND RESULTS: Exercise-induced ST-segment elevation developed in 9 of 6,147 consecutive patients without myocardial infarction who underwent treadmill exercise testing at out institution over a 4-year period. The clinical and angiographic characteristics of these patients were studied. Angiographically normal coronary arteries with coronary vasospasm were found in 5 patients, hemodynamically significant coronary stenosis was found in 3 patients, and coexisting spasm in angiographically normal coronary arteries combined with hemodynamically significant coronary stenosis in the different vessel was found in 1 patient. During a median follow-up of 71 months, 2 patients with coronary vasospasm developed recurrent angina after self-discontinuation of calcium antagonists and 2 patients (1 with coronary vasospasm and 1 with hemodynamically significant coronary stenosis) died of cardiac causes before arrival at the emergency department. CONCLUSION: Coronary vasospasm was a more common underlying pathology of exercise-induced ST-segment elevation in this Taiwanese cohort. Coronary angiography +/- intracoronary ergonovine provocation testing is necessary in these patients to identify the underlying pathology and appropriate treatment.     

急性前壁心肌梗死患者心电图下壁导联ST段改变与其冠状动脉病变的关系

目的　探讨急性前壁心肌梗死患者心电图下壁导联 ST段改变与冠状动脉病变的关系。方法　对 81例冠状动脉左前降支 (L AD)单支病变所致急性前壁心肌梗死患者 ,依其早期心电图下壁导联 ST段改变的形态将患者分为 3组 ,即压低组、抬高组、无改变组 ,并与冠状动脉造影结果进行比较和分析。结果　下壁导联 ST段压低组中73.3%患者为 L AD非优势近端病变 ;抬高组中 6 2 .5 %患者为 L AD优势远端病变 ;无改变组中 L AD优势近端病变与 L AD非优势远端病变所占比例近似。结论　急性前壁心肌梗死患者下壁导联 ST段改变与 L AD形态及病变的部位有关。     

Acute myocardial infarction with significant left main coronary artery stenosis, significant 3-vessel coronary artery disease and elevated troponin-I at admission

Exercise-induced ST-segment elevation in lead aVR accompanied by ST-segment elevation in lead V1 might be a specific finding of left main coronary artery (LMCA) stenosis. Lead aVR and lead v1 ST segment elevation has been reported, during an attack of chest pain, in patients with LMCA disease with ST segment depression in leads V3, V4 and V5 (with maximal depression in V4). ST-segment elevation in lead aVR in patients with angina at rest can be related to transmural ischemia of the basal part of the interventricular septum, frequently due to LMCA or multivessel coronary disease too. 3-vessel coronary artery disease (CAD) and LMCA disease show a frequent combination of leads with abnormal ST segments during chest pain with ST-segment depression in leads I II V4-V6, and ST-segment elevation in lead aVR. When ST-segment status in lead aVR combines with troponin T, ST-segment elevation in lead aVR and positive troponin T on admission are useful predictors of LMCA or 3-vessel CAD. We present a case of acute myocardial infarction with significant left main coronary artery stenosis, significant 3-vessel coronary artery disease and elevated troponin I at admission in an 83-year-old Italian woman. Also this case focuses attention on the importance of the recognition of the patterns suspected for LMCA and/or 3-vessel coronary disease.     

Stress-induced ST-segment elevation in patients without prior Q-wave myocardial infarction

Background

Stress-induced ST-segment elevation is an uncommon finding that usually occurs in patients with prior myocardial infarction (MI). Our purpose was to assess the angiographic and clinical significance of this finding in patients without prior MI.

Methods

Of the 29 002 consecutive ambulatory patients who underwent stress myocardial perfusion imaging over a 5-year period, 205 (0.7%) developed stress-induced ST-segment elevation, of whom 39 (19%) had no Q-wave MI in leads showing ST-segment elevation during either exercise (n = 31) or dipyridamole (n = 8) stress myocardial perfusion imaging. All 39 patients were hospitalized and underwent coronary angiography.

Results

Significant coronary artery disease was found in all 39 patients: 87% had critical (≥90%) stenosis, and 59% had multiple vessel disease. During hospitalization, 37 patients (95%) underwent revascularization.

Conclusions

In patients without prior Q-wave MI, stress-induced ST-segment elevation is associated with critical coronary artery disease. Therefore, these patients should be considered for early coronary investigation.     

急性前壁心肌梗塞下壁导联ST段压低的临床意义

对44例急性前壁心肌梗塞患者,将冠脉造影结果与体表心电图ST段改变进行比较分析.结果发现急性前壁心肌梗塞患者38.6%有下壁导联ST段压低,这些导联ST段压低与多支血管病变无关,而与前降支近端病变有关,可能反映高侧壁导联心肌缺血时心电图对应性改变.     

Coronary spasm-induced acute myocardial infarction associated with intracoronary thrombosis]

A 63-year-old man was admitted with an acute anteroseptal myocardial infarction. Coronary angiography performed 3 hours after the onset of chest pain revealed 99% stenosis of the proximal left anterior descending coronary artery (LAD) with delayed filling and intraluminal thrombus distal to the stenosis. After the intracoronary injection of isosorbide dinitrate, the delayed filling disappeared and a subsequent intracoronary urokinase partially dissolved the thrombus. Repeat coronary angiography in the chronic phase disclosed 75% stenosis of the LAD and disappearance of the thrombus. Intracoronary acetylcholine provoked a coronary spasm at the stenotic site of the LAD, concomitantly with chest pain and ST-segment elevation in the anterior leads. The present case demonstrated that coronary spasm plays an important role in thrombus formation and acute myocardial infarction. To date, the concept has been postulated that a dynamic interaction between atherosclerosis, platelet aggregation and spasm may work to cause coronary thrombosis and subsequently lead to acute myocardial infarction. Our report shed light on the importance of coronary spasm in the pathogenesis of myocardial infarction.     

Wellens' syndrome and other electrocardiographic changes in a patient with a left anterior descending artery subocclusion associated with a left main coronary artery subocclusion

Changing axis deviation has been reported also during atrial fibrillation or atrial flutter. Changing axis deviation has been also reported during acute myocardial infarction associated with atrial fibrillation too or at the end of atrial fibrillation during acute myocardial infarction. Patients with unstable angina have a higher incidence of left main coronary artery (LMCA) and proximal left anterior descending (LAD) coronary artery disease compared to patients with stable angina pectoris. In 1982, Wellens and colleagues described two electrocardiographic patterns that were predictive of critical narrowing of the proximal LAD artery, and were subsequently termed Wellens' syndrome. The criteria were: a) prior history of chest pain, b) little or no cardiac enzyme elevation, c) no pathologic precordial ST segment elevation, d) no loss of precordial R waves, and e) biphasic T waves in leads V2 and V3, or asymmetric, often deeply inverted T waves in leads V2 and V3. The ECG changes are best recognized outside the episode of anginal pain. Lead aVR and lead v1 ST segment elevation, during chest pain, has been reported in patients with LMCA disease with ST segment depression in leads V3, V4 and V5 (with maximal depression in V4).We present a case of changing axis deviation in a 37-year-old Italian man with a LAD coronary artery subocclusion associated with a LMCA subocclusion. This case focuses attention on the importance of the recognition of the patterns suspected for LAD coronary artery disease or for LMCA disease.     

11例急性单纯后壁心肌梗死心电图及梗死相关动脉特点分析

目的 分析急性单纯后壁心肌梗死（不包括同时合并下壁及右室心肌梗死）的心电图及冠状动脉造影特点。方法 总结自2001年至2006年门、急诊收治的急性单纯后壁心肌梗死患者11例,随访心电图特点,并行冠状动脉造影确定梗死相关动脉。结果 11例患者除了V7-V9导联ST段有典型的弓背向上抬高1．0—2．0mm外,9例（81．8％）V1-V2导联R／S≥1,5例（45．5％）V1-V4导联ST段压低1．0—2．0mm,4例（36．4％）Ⅰ、aVL导联ST段抬高0．5-1．5mm,5例（45．5％）V5-V6导联ST段抬高0．5—1．5mm。冠状动脉造影显示梗死相关动脉均为左回旋支（LCX）。梗死部位1例在第一钝缘支（OM1）发出前,为95％管状狭窄;6例（54．5％）在OM1发出后,其中4例为100％闭塞,1例为99％次全闭塞,1例为90％长段狭窄;4例（36．4％）在OM1,其中2例为100％闭塞,1例为99％次全闭塞,1例为95％局限性狭窄。单支病变3例（27．3％）,合并左前降支（LAD）病变4例（36．4％）,合并右冠状动脉（RCA）病变2例（18．2％）,同时合并LAD及RCA病变2例（18．2％）。结论12导联心电图,如有V1-V2导联R／S≥1,V1-V4导联ST段压低等特点时,结合临床与心肌酶学改变,高度怀疑急性后壁心肌梗死,需做后壁导联和冠状动脉造影加以证实,而梗死相关动脉多为左回旋支。     

Implications of inferior ST-segment elevation accompanying anterior wall acute myocardial infarction for the angiographic morphology of the left anterior descending coronary artery morphology and site of occlusion.

Inferior ST-segment elevation during anterior wall acute myocardial infarction (AMI) due to left anterior descending (LAD) coronary artery occlusion is unusual and was not previously investigated. This study tested the hypothesis that inferior ST-segment elevation during anterior AMI predicts a specific angiographic morphology that satisfies 2 necessary conditions: (1) mass of ischemic anterior wall myocardium is relatively small, resulting in a weaker anterior injury current and less reciprocal inferior ST-segment depression; and (2) there is concomitant inferior wall transmural ischemia that further shifts the inferior ST segments upward. The study group consisted of 42 consecutive patients with anterior AMI undergoing angiography at 4.1 days (range 0 to 14). Coronary angiograms were examined for 3 features: (1) site of LAD artery occlusion (a distal obstruction implying a smaller mass of ischemic anterior wall myocardium), (2) LAD artery extension onto inferior wall of left ventricle (termed a "wrap around" vessel), and (3) collateral flow from LAD artery to inferior wall. The latter 2 features would be expected to contribute to inferior wall transmural ischemia. Acute inferior ST-segment elevation (sum of ST-segment deviation in leads II, III and aVF greater than or equal to 3.0 mm) was seen in 7 patients (16%). A greater number of LAD artery branches proximal to the site of occlusion was significantly correlated with less inferior ST-segment depression (r = 0.59, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)