心肌梗死部位与危险因素及预后的相关性探讨

急性心肌梗死的部位是决定心肌梗死预后的重要因素,为此作者研究了１７９例急性前壁和下壁心梗（包括非Ｑ波性心梗）梗死部位与危险因素的差别及对住院病死率和并发症的影响。本文结果提示前壁心梗患者中,不吸烟者较下壁心梗患者中多,且前壁心梗患者中有高血压和高血脂者多,机械并发症多,预后差,病死率高。房室传导阻滞多见于下壁心梗,非Ｑ波心梗并发症少于有Ｑ波心梗患者。     

提高对无Q波心肌梗死的认识

提高对无Ｑ波心肌梗死的认识钱贻简在讨论急性心肌梗死的预后时，有必要再谈谈无Ｑ波心肌梗死（无Ｑ心梗），因其发病机理、病理变化、临床表现及治疗处理均与Ｑ波心肌梗死（Ｑ波心梗）有所不同。特别是其预后，在急性期较Ｑ波心梗好，而在远期则较差。表现在病死率及梗死...     

心肌梗塞的部位和类型的预后意义:前壁心肌梗塞具有独立的不良影响

心(肌)梗(塞)的部位(前壁对下壁)和类型(Q波型对非 Q 波型)的相对预后意义迄今仍无定论。本研究以 MILIS 中471例首次心梗患者为对象,平均随访30.8(0～48)个月。依心梗部位划分:前壁心梗253例,下壁心梗218例。依心梗类型划分:Q波型心梗323例,非 Q 波型心梗148例。依心梗部位和类型划分:前壁 Q 波型心梗190例,前壁非 Q 波型心梗63例,下壁 Q 波型心梗133例,下壁非 Q 波型心梗85例。前壁心梗组的住院期和随访期的临床病程均较下壁心梗组为差:梗塞范围较大(21.2对14.9gEg/m~2[MB CK],p<0.001),入院时左室喷血分数较     

急性下壁心肌梗死伴右室梗死的临床表现和预后分析

目的探讨急性下壁心肌梗死(心梗)不伴或伴右室心梗患者的临床特征、治疗和预后。方法回顾既往6年住我院的103例急性下壁心梗患者,比较下壁心梗不伴右室心梗(65例)和伴右室心梗(38例)两组患者的临床特征和院内死亡率。结果发生低血压、心源性休克、快速心律失常(阵发性心房颤动,非持续性室性心动过速)、缓慢心律失常(包括窦性心动过缓,Ⅲ度房室传导阻滞)在下壁伴右室心梗组高于下壁心梗组,两组比较有显著性差异(P<0.05)。两组左心室射血分数(LVEF)及经皮冠脉介入(PCI)治疗患者的院内病死率比较无显著差异(P>0.05)。结论血流动力学障碍和心律失常是右室心梗住院并发症高的主要因素,右室心梗是独立于左室功能损害的危险因素,早期介入治疗能改善住院死亡率。     

影响急性心肌梗死患者近期预后的相关因素分析

目的探讨影响急性心肌梗死(AMI)近期预后的相关因素。方法回顾性分析651例AMI患者近期(1个月)病死率与患者性别、年龄、发病就诊时间、梗死部位、治疗方法、危险因子等的关系。结果急性心肌梗死患者的近期病死率与患者性别、年龄、发病就诊时间、梗死部位、治疗方法、吸烟、高脂血症等密切相关,女性、高龄、前壁心肌梗死、就诊时间大于6 h患者近期病死率更高,接受急诊介入治疗的AMI患者病死率较溶栓治疗组低,吸烟、高脂血症可能是影响AMI预后的独立危险因素。结论急性心肌梗死近期预后受多因素影响,可通过选择有效治疗方法、控制危险因素来改善患者近期预后。     

心电图诊断心肌梗死的当今评价：酷似心肌梗死的心电图改变

临床上常见到一些不是心肌梗死的病例,却有着酷似心肌梗死的心电图改变,往往给初诊带来困难,因此,进行心电图的鉴别就显得十分重要。非Ｑ波心梗（既往称不透壁或心内膜下心梗）本身的心电图诊断特异性差,必须结合临床、心肌酶等才能作出诊断。ＳＴ段下移与异常Ｔ波常见于各种非心肌梗死的心脏病与非心脏病,病因诊断困难。Ｔ波高耸作为急性心梗超急性期的表现不具特异性,亦见于低体温状态、高钾血症、左室肥厚、左束支阻滞及心脏电复律后;Ｔ波深倒也并非Ｑ波心梗所独有,可见于心尖肥厚型心肌病、心脏复苏后与急性颅内疾患等。因此,…     

253例急性心肌梗死病人梗死部位分析

目的调查总结急性心肌梗死病人梗死的常见部位及其与病死率的相关性.方法回顾性分析病历,将符合诊断标准的住院病人按照不同发病部位分组,了解不同发病部位的构成比以及发病部位与病死率的关系.结果符合条件病例共253例,前壁急性心肌梗死(前壁、前间壁及广泛前壁)占总发病的58.6%,其次是急性下壁心肌梗死占29.3%,急性前壁合并下壁组心肌梗死病例病死率与其他部位梗死病死率有统计学意义(P＜0.05).结论急性心肌梗死以前壁或下壁为主,急性前壁合并下壁心肌梗死的病死率显著高于急性心肌梗死平均病死率.     

急性非Q波心肌梗死合并多器官功能衰竭抢救成功一例

急性非Ｑ波心肌梗死合并多器官功能衰竭抢救成功一例梁岩章友华黄红袁贤奇朱俊宋有城１临床资料患者男性，７７岁，因急性前壁非Ｑ波心肌梗死、左心功能不全于１９９７年５月１日急诊入院。既往有陈旧性下后壁心肌梗死、糖尿病、高血压病史。入院后仍反复发作心绞痛。于入...     

陈旧性前壁心肌梗死R波递增不良的研究

目的探讨心电图R波递增不良（pRwP）在陈旧性前壁心肌梗死（MI）中的发生率及与心肌灌注断层显像前壁心肌放射性缺损节段数和分布的关系。方法回顾性分析2000—2006年北京医院核医学科连续进行三磷酸腺苷负荷心肌灌注断层显像检查诊断前壁心肌梗死病例的心电图，应用常规心电图R波递增不良的诊断标准对药物负荷检查前卧位标准12导联心电图进行分析诊断，将陈旧性前壁心梗不同心电图表现同药物负荷心肌灌注断层显像前壁心肌放射性缺损节段数和分布进行比较。结果心肌灌注断层显像检出前壁心梗106例，90例符合入选标准，前壁Q波心肌梗死26例，前壁非Q波心肌梗死64例，前壁非Q波心肌梗死患者R波递增不良发生率为20．3％～42．2％，前壁Q波心肌梗死心肌灌注断层显像前壁心肌放射性缺损节段数显著多于非Q波心肌梗死，R波递增不良前壁非Q波心肌梗死前壁心肌放射性缺损节段数多于R波递增不良阴性前壁非Q波心肌梗死。前壁心肌核素放射性缺损节段分布：R波递增不良前壁非Q波心肌梗死中部前壁、前间壁显著多于R波递增不良阴性前壁非Q波心肌梗死，而R波递增不良阴性前壁非Q波心肌梗死基底部前侧壁显著多于R波递增不良前壁非Q波心肌梗死（Zema标准）。结论陈旧性前壁心梗R波递增不良非常常见，不同心电图表现同心肌灌注断层显像前壁心肌放射性缺损节段数和分布相关。     

老年人急性脑血管意外并发心肌梗死22例临床分析

目的探讨老年人急性脑血管意外并发心肌梗死的临床特征，为临床治疗提供指导。方法回顾性分析了２２例急性脑血管意外并发心肌梗死的老年患者的临床资料。结果２２例患者心肌梗死均发生于脑血管意外后６小时～８天。其中下壁７例，前壁５例，前壁＋下壁４例，前间壁３例，下壁＋侧壁２例，无Ｑ波型１例。入院前，１５例患者有各种基础疾病。住院期间１６例患者出现各种并发症，死亡９例（４０．９％）。结论此类患者心肌梗死症状不典型、并发症多，且治疗存在矛盾。     

Aetiological and prognostic correlates of site of myocardial infarction

This is a study of the relationship between the site of infarctionand both risk factors and in-hospital outcome in 745 consecutivepatients admitted with a first myocardial infarction. Patients with anterior infarctions were significantly more likelynever to have smoked than patients with inferior infarctions.They had a higher prevalence of hypertension and a higher meancholesterol level. In hospital prognosis was worse in anteriorinfarctions, with significantly higher rates of death and complications.Atrioventricular blocks were more common in inferior infarctions.Non-Q-wave infarctions had a lower incidence of complicationsthan Q-wave infarctions. There was no difference in risk factorlevels between Q-wave and non-Q-wave infarctions. Anterior andinferior infarctions were of similar size. Non-Q-wave infarctionswere significantly smaller.A logistic regression showed a negativerelationship between in-hospital mortality and smoking, anda positive one with peak cardiac enzyme levels. Any effect ofsite of infarction on mortality was eliminated when correctedfor these factors. Our data indicate that the adverse prognosisassociated with anterior myocardial infarction is related todifferences in aetiology rather than to infarction size.     

右胸头胸导联心电图病理性Q波意义探讨

描记１３５例（正常人２２例，心绞痛１４例，非Ｑ波梗塞１０例，前壁梗塞２５例，下壁右室梗塞３６例）右胸头胸导心电图ＨＶ３Ｒ－ＨＶ７Ｒ，发现前３组共４６例右胸心电图正２２例（８８％），３例有左前降支冠脉闭塞，左室扩大合并心室壁瘤患者，ＨＶ３Ｒ，ＨＶ４Ｒ出现Ｑ波，ＨＶ５Ｒ－ＨＶ７Ｒ正常。下壁梗塞组心电图正常５例（１８％），Ｑ波主要分布在ＨＶ５Ｒ－ＨＶ７Ｒ。下壁合并右室梗塞组全部病例ＨＶ６Ｒ，ＨＶ７Ｒ均含     

Natural course of electrocardiographic components and stages in the first twelve hours of acute myocardial infarction

Time course evolution of R, Q, T and ST components of the electrocardiogram during the first 12 hours of an acute myocardial infarction was studied. A comparison between anterior-extensive and anteroseptal wall infarctions (anterior group), and inferior-extensive and inferior wall infarction (inferior group) showed appearance of significant Q waves within two hours in both groups. R wave loss was nearly a mirror image of Q wave development in both groups. T waves became negative and ST more isoelectric earlier in the inferior than in the anterior group. When combined variations of the four electrocardiographic components were analyzed, four stages of acute infarction were delineated. Stage I--tall R, no Q, ST elevation and positive T; Stage II--significant Q wave appearance; Stage III--negativity of T waves; and Stage IV--ST isoelectric. The inferior group reached stages III-IV within 12 hours; the anterior group remained mostly in stage II. An early appearance of Q waves correlated well with rapid progression to stages III-IV within 12 hours in both infarction groups.     

Prognostic significance of location and type of myocardial infarction: independent adverse outcome associated with anterior location

To determine the relative prognostic significance of location (anterior or inferior) and type (Q wave or non-Q wave) of infarction, the hospital course and follow-up outcome (mean duration 30.8 months) of 471 patients with a first infarction were analyzed. Analyses were performed grouping the patients according to infarct location (anterior, n = 253; inferior, n = 218), infarct type (Q wave, n = 323; non-Q wave, n = 148), and both location and type (inferior non-Q wave, n = 85; inferior Q wave, n = 133; anterior non-Q wave, n = 63; and anterior Q wave, n = 190). Patients with anterior infarction had a substantially worse in-hospital and follow-up clinical course compared with those with inferior infarction, evidenced by a larger infarct size (21.2 versus 14.9 g Eq/m2 creatine kinase, MB fraction [MB CK], p less than 0.001), lower admission left ventricular ejection fraction (38.1 versus 55.3%, p less than 0.001) and higher incidence of heart failure (40.7 versus 14.7%, p less than 0.001), serious ventricular ectopic activity (70.2 versus 58.9%, p less than 0.05), in-hospital death (11.9 versus 2.8%, p less than 0.001) and total cumulative cardiac mortality (27 versus 11%, p less than 0.001). Patients with Q wave infarction similarly experienced a worse in-hospital course compared with patients with non-Q wave infarction, evidenced by a larger infarct size (20.7 versus 12.7 MB CK g Eq/m2, p less than 0.001), lower admission left ventricular ejection fraction (43.7 versus 50.6%, p less than 0.001), and a higher incidence of heart failure (31.9 versus 21.6%, p less than 0.05) and in-hospital death (9.3 versus 4.1% p less than 0.05). However, there was no increased rate of reinfarction or mortality in hospital survivors with non-Q wave infarction compared with those with Q wave infarction, and total cardiac mortality was similar (16 versus 21%, p = NS). To evaluate the role of infarct location and type independent of infarct size, patients were grouped according to quartile of infarct size, and outcome was reanalyzed within each group. Patients with anterior infarction demonstrated a lower left ventricular ejection fraction on admission and after 10 days than did patients with inferior infarction, even after adjustment for infarct size, as well as a higher incidence of congestive heart failure and cumulative cardiac mortality.(ABSTRACT TRUNCATED AT 400 WORDS)     

Q-wave prediction of myocardial infarct location, size and transmural extent at magnetic resonance imaging

OBJECTIVE: We investigated how pathologic Q waves or equivalents predict location, size and transmural extent of myocardial infarction (MI). METHODS: MI characteristics, detected by contrast-enhanced magnetic resonance imaging, were compared with 12-lead electrocardiogram in 79 patients with previous first MI. RESULTS: Q waves involved only the anterior leads (V1-V4) in 13 patients: in all patients MI involved the anterior and anteroseptal walls and apex; 81% of scar tissue was within these regions. Q waves involved only the inferior leads (II, III, aVF) in 13 patients: in 12 of these patients MI involved the inferior and inferoseptal walls; however, only 59% of scar occupied these regions. Q waves involved only lateral leads (V5, V6, I, aVL) in 11 patients: in nine of these patients MI involved the lateral wall but only 27% of scar tissue was within this wall. Q waves involved two electrocardiogram locations in 42 patients. In the 79 patients as a whole, the number of anterior Q waves was related to anterior MI size (r=0.70); however, the number of inferior and lateral Q waves was only weakly related to MI size in corresponding territories (r=0.35 and 0.33). A tall and broad R wave in V1-V2 was a more powerful predictor of lateral MI size than Q waves. Finally, the number of Q waves accurately reflected the transmural extent of the infarction (r=0.70) only in anterior infarctions. CONCLUSION: Q waves reliably predict MI location, size and transmural extent only in patients with anterior infarction. A tall and broad R wave in V1-V2 reflects a lateral MI.     

Exercise four hour redistribution thallium-201 single photon emission computed tomography and exercise induced ST segment elevation in detecting the viable myocardium in patients with acute myocardial infarction

OBJECTIVE: To investigate the specificity and sensitivity of the combination of redistribution in exercise thallium-201 single photon emission computed tomography (SPECT) and exercise induced ST elevation for detecting the viable myocardium in patients with acute myocardial infarction. DESIGN: 37 patients were studied within seven weeks of onset of Q wave myocardial infarction (anterior in 22, inferior in 15). All patients underwent exercise four hour redistribution thallium-201 SPECT and positron emission tomography using fluorine-18-fluorodeoxyglucose (FDG) and nitrogen-13 ammonia under fasting conditions. RESULTS: Sixteen patients showed exercise induced ST elevation >/= 1.5 mm, and 15 of these had increased FDG uptake in the infarct region. Eleven of 16 patients (10 of 11 patients with anterior infarctions) with irreversible thallium-201 defects and increased FDG uptake showed exercise induced ST elevation. The sensitivity, specificity, and predictive accuracy of redistribution, exercise induced ST segment elevation, or both for detecting increased FDG uptake were 82%, 75%, and 67% (94%, 75%, and 91% for anterior infarctions), respectively. CONCLUSIONS: In patients with acute Q wave myocardial infarction, the combination of redistribution in exercise thallium-201 SPECT and exercise induced ST elevation can detect the viable myocardium in the infarct region with high sensitivity and specificity, especially in patients with anterior infarctions.     

The prognostic significance of first myocardial infarction type (Q wave versus non-Q wave) and Q wave location. The Multicenter Diltiazem Post-Infarction Research Group

The prognostic significance of the type of first acute myocardial infarction (Q wave versus non-Q wave) and Q wave location (anterior versus inferoposterior) was determined from a multicenter data base involving 777 placebo-treated patients who were participants in the Multicenter Diltiazem Post-Infarction Trial. There were 224 patients (29%) with a non-Q wave infarction, 326 (42%) with an inferoposterior Q wave infarction and 227 (29%) with an anterior Q wave infarction. Mean left ventricular ejection fraction was significantly (p less than 0.001) lower in patients with an anterior Q wave infarction than in the other two groups (anterior Q wave 0.39; inferior Q wave 0.52; non-Q wave 0.53). Nevertheless, the total cardiac mortality rate during the follow-up period (average 25 months per patient) was only marginally higher (p = 0.42) in the anterior Q wave group (8.4%) than in the other two groups (inferoposterior Q wave 7.1%; non-Q wave 6.3%). The total first recurrent cardiac event was somewhat higher (p = 0.08) in the anterior Q wave group (18.1%) than in the other two groups (inferoposterior Q wave 11.7%; non-Q wave 15.6%). Survivorship analyses extending over 3 years revealed that electrocardiographic classification of the type of first infarction and Q wave location did not make significant independent contributions to the risk of postinfarction cardiac death or first recurrent cardiac event, either before or after adjustment for baseline clinical variables.     

Correlation between ST Elevation and Q Waves on the Predischarge Electrocardiogram and the Extent and Location of MIBI Perfusion Defects in Anterior Myocardial Infarction

Background: The common electrocardiographic subclassification of anterior acute myocardial infarction (AMI) is not reliable in presenting the exact location of the infarct. We investigated the relationship between predischarge electrocardiographic patterns and the extent and location of perfusion defects in 55 patients with first anterior AMI. Methods: Predischarge electrocardiogram was examined for residual ST elevations and Q waves which were correlated with technetium‐99m‐sestamibi function and perfusion scans. Results: Patients with ST elevations in V2–V4 and Q waves in leads V3–V5 had worse global perfusion scores. Perfusion defects in the apex inferior segment were significantly less frequent in patients with Q waves in leads I and aVL (11% vs 54%, P = 0.027; and 22% vs 60%, P = 0.011, respectively). Patients with Q wave in aVF had more frequently involvement of the apex inferior segment (80% vs 40%; P = 0.035). Patients with Q wave in lead II had significantly more frequent perfusion defects in the inferior wall. ST elevation in V3 and V4 was associated with perfusion abnormalities of the infero‐septal segments. ST elevation in V5 and V6 and Q wave in V5 were associated with regional perfusion defects in apical inferior segment (73% vs 30%, P = 0.002), extending into the mid inferior segment (55% vs 18%, P = 0.005 for Q wave in V5). Q wave in lead aVL is associated with less apical and inferior involvement. Q waves in leads II and aVF are a sign of inferior extension of the infarction. Conclusions: Residual ST elevation in leads V3 and V4 are more frequently associated with involvement of the apical‐inferoseptal segment rather than the anterior wall. Residual ST elevation and Q waves in V5 are related to a more inferior rather than a lateral involvement.     

A method of diagnosis in posterior myocardial infarct

Based on the results of examination of 58 patients with myocardial infarction, the authors propose a method for diagnosing posterior myocardial infarction by abdominal electrocardiographic mapping. The anterior abdominal wall shows the area from which one may record the direct markers of posterior myocardial infarction: abnormal Q wave, R wave regression, abnormal QS complex, as well as ST segment elevation which is typical of acute myocardial infarction. The anterior abdominal wall also defines the areas from which direct signs of inferior and lateral myocardial infarctions may be recorded.     

Residual myocardial jeopardy in patients with Q-wave and non-Q-wave infarctions

The correlation between the presence of areas of jeopardized myocardium and the electrocardiographic patterns of anterior and inferior Q-wave and non-Q-wave infarctions was studied in 486 patients who had had stable symptoms for at least six months after a single myocardial infarction. Myocardial jeopardy was identified on a ventriculogram in the right anterior oblique position if normal or hypokinetic wall motion was seen in all segments distal to a lesion that caused stenosis of greater than 50% and less than 100% in the proximal or mid left anterior descending coronary artery (anterior jeopardy), or in the proximal or mid right coronary artery or proximal circumflex coronary artery in a left dominant circulation (inferior jeopardy). Patients with non-Q-wave anterior infarctions had a significant increase in the frequency of jeopardized myocardium when compared with patients with Q-wave inferior or anterior infarctions. The group with non-Q-wave anterior infarction also had a significantly lower percentage of myocardial segments with absent wall motion in the area of infarction than all other groups. This combination of coronary narrowing with retained wall motion may contribute to the increased frequency of reinfarction seen in some studies of non-Q-wave infarction.