心电向量在心电图教学中的作用及应用

依据心电向量理论为基础,研究心电图教学方法,其核心就是用综合心电向量在导联体系中的投影来解释各种心电现象。具体方法：首先复习心脏的相关解剖知识及心脏电生理的知识,熟悉心脏除极顺序,心电图的导联及导联轴;通过额面和水平面六轴系统与心脏解剖结构建立相应关系,使心电图导联体系与心脏解剖相结合,弄清心电向量与导联体系的联系;由心脏电生理过渡到心电向量,由心电向量过渡到综合心电向量,实现概念之间的自然过渡。然后将心电除极过程的综合心电向量,简化为心电主除极（最大除极）方向,并与额面和水平面六轴系统结合起来,将心脏的解剖位置应用其中,用主除极强度和方向在不同导联体系中的投影来解释具体的心电现象,讨论阐明内涵,尤其是方向性所反映的内涵。此教学方法形象具体,生动直观,教学思路清晰,教学过程简化,教师演示讲解的可操作性强,可直观快速分析复杂抽象的心电图波形,便于学生理解记忆,提高学生快速诊断能力,在有限的学时内能达到预期的教学效果。     

Respiratory sinus arrhythmia and carotid baroreflex control of heart rate in endurance athletes and untrained controls

The purpose of this study was to compare the magnitude of the respiratory sinus arrhythmia, an index of cardiac vagal tone, and carotid baroreflex control of heart rate in endurance-trained athletes (n = 12, aged 20 +/- 1 years, means +/- SE) and untrained control subjects (n = 12, aged 22 +/- 1 year). Average R-R interval (ECG) and its variability were determined at rest under controlled breathing conditions, and the changes in R-R interval in response to brief applications of suction (-10, -25, -40 mmHg) and pressure (10 and 30 mmHg) to the carotid sinus region of the neck were also measured. The average R-R interval at rest was greater in the athletes vs. controls (1150 +/- 45 vs. 854 +/- 44 ms, P less than 0.001), but the standard deviation of the R-R intervals was similar in the two groups (72 +/- 15 vs. 70 +/- 9 ms). The magnitude of the tachycardia in response to neck pressure was also similar in the athletes and controls. Although the heart rate responses to neck suction were not significantly different between the two groups, there was a strong trend for attenuated bradycardic responses in the athletes at the two highest stimulus levels (70 +/- 14 vs. 97 +/- 25 ms and 86 +/- 14 vs. 145 +/- 38 ms for the -25 and -40 mmHg levels, respectively, P greater than 0.1). The results of this study do not support the postulate that cardiac vagal tone is enhanced in the endurance-trained state.(ABSTRACT TRUNCATED AT 250 WORDS)     

New approaches to the analysis of ECG data

Recently, techniques for analyzing computerized ECG data have been developed in time domain, frequency domain and micro level analysis of signals. In body surface ECG mapping, reverse problem analysis from body surface to cardiac surface was investigated, but findings were not sufficient to be clinically useful. Heart rate variability analysis from Holter ECG tapes showed the utility for determination of autonomic nervous function by time and frequency domain analysis. Late ventricular potentials recorded by Signal Averaged ECG have been beneficial for predicting malignant ventricular tachyarrhythmias, as well as delayed potentials in atrial activity. QT dispersion from 12-lead ECG has been studied as one of the indicators of ventricular instability and there was some difficulty in detecting the end points of QT intervals such as that in patients with flat T waves. The recently developed automatic analysis of the Least square fit method for detecting terminal points of T wave might be optimal compared with the other methods. Micro volt T wave alternans by spectrum frequency analysis of T wave in consecutive heart beats is a unique technique for predicting cardiac sudden death, however the mechanism remains obscure.     

Non-contact monitoring of heart rate variability using medical radar for the evaluation of dynamic changes in autonomic nervous activity during a head-up tilt test

Abstract

Electrocardiography (ECG) is a mandatory standard for monitoring electrical activity of the heart in many clinical settings such as intensive care and emergency units. However, in situations wherein the skin is damaged, such as acute burn injuries, it is impossible to efficiently attach electrodes to the skin. In this study, we developed a non-contact cardiac monitoring system using a 24-GHz medical radar for directly measuring the beat-to-beat heart mechanical activity at a distance from a subject. The heart rate variability (HRV) was analysed using an autoregressive model (AR) from the measured beat-to-beat intervals during a head-up tilt test. To investigate the feasibility of the proposed system, we compared medical radar and ECG recording by using Lin’s correlation coefficient and Bland–Altman analysis, which showed a negligible mean difference from the substantial agreement of Lin’s correlation coefficient of 0.9 between the radar and ECG. The non-contact radar clearly monitored dynamic changes in HRV indices induced by the head-up tilt test. This type of non-contact HRV-sensing technique as an alternative approach has significant potential for advancing personal healthcare in both clinical and out-of-hospital settings.     

心电向量图对犬心肌梗塞诊断特异性的研究

目的:利用心电向量图(VCG)与心电图(ECG)两种方法同步描记犬出现心肌梗塞时的15路体表心电信号,通过对VCG和ECG两种诊断指标的对比,确定VCG和ECG诊断犬心肌梗塞的差异,并验证VCG对犬心肌梗塞诊断的特异性。方法:通过对30只正常犬的冠状动脉结扎,人为造成心肌梗塞,记录犬出现心肌梗塞时的15路体表心电信号,并进行对比分析。结果:VCG对犬心肌梗塞的诊断敏感,诊断指标提前出现,诊断特异性明显地高于ECG。结论:对犬心肌梗塞的早期诊断,采用VCG和ECG两种诊断方法,VCG的特异性高于ECG。     

Recent progress in electrocardiography

Recent advances in electrocardiography (ECG) have revealed new and useful information concerning the electrophysiologic properties of the normal and diseased heart. 1) Evaluation of the frequency of ventricular premature contractions (VPCs) as a function of underlying heart rate with Holter ECG recordings is a useful approach to elucidate the mechanisms of ventricular arrhythmias and to predict the response of ventricular arrhythmias to antiarrhythmic agents. 2) Decreased heart rate variability, presence of late potential, prolonged QT interval, increased QT interval dispersion, and T wave alternans indicate lethal ventricular tachyarrhythmias and sudden cardiac death. 3) The multiple reentrant wave hypothesis has been widely accepted for the mechanism of atrial fibrillation (AF). Recently, spontaneous initiation of AF by ectopic beats originating from the superior vena cava and the pulmonary veins has been reported. Radiofrequency ablation of the focal source of AF completely prevented the recurrence of AF.     

Autonomic activity and baroreflex sensitivity in patients submitted to carotid stenting

Arterial baroreflex and cardiac autonomic control play important roles in hemodynamic instability after carotid artery stenting (CAS). Spontaneous baroreflex sensitivity (BRS), heart rate variability (HRV) and blood pressure variability (BPV) are established tools for the assessment of arterial baroreflex and cardiac autonomic activity. Aim of the study was to evaluate cardiac autonomic activity (by means of HRV, BPV and BRS) after CAS and to explore the impact of internal carotid artery stenosis on BRS changes after CAS. 37 patients (68±10.45 years) with internal carotid stenosis underwent CAS. HRV, BPV and BRS were measured in all subjects before and at 1 and 72h after CAS. ANOVA was performed to compare BRS, HRV and BPV parameters before and after CAS. Spearman analysis was performed to determine a possible correlation between carotid stenosis degree (or carotid plaque diameter) and BRS changes (ΔBRS). LF/HF (index of sympatho-vagal balance) decreased during postoperative period, in comparison with baseline (2.32±1.70 vs 1.65±1.40, p<0.05). There was a significant negative correlation between carotid stenosis degree and ΔBRS (r=-0.35, p=0.03) and between carotid plaques thickness and ΔBRS (r=-0.36, p=0.02). CAS procedure may cause an alteration of carotid wall mechanical properties, increasing baroreflex sensitivity. BRS does not increase in all the patients, because arterial wall damage and nerve destruction determined by atherosclerotic plaque may reduce ΔBRS.     

Estimation of the respiratory frequency using spatial information in the VCG

A new method for extracting respiratory signals from the ECG/VCG is presented. The method is based on the alignment of an observed VCG loop to a reference loop with respect to the transformations of rotation and time synchronisation. The resulting series of estimated rotation angles reflects respiratory-induced changes in the electrical axis of the heart. The respiratory frequency is estimated by power spectral analysis of the derived respiration signal. The value of respiratory modulation of the heart rate is considered by analysing the cross power spectrum of the signals related to rotation angles and heart rate. For comparison, a respiratory signal derived from the QRS area of two different leads is implemented. The performance of the methods is validated on a database with simultaneously recorded VCG and respiratory signals acquired from 20 healthy subjects. The agreement between the respiratory frequencies obtained from the derived and the respiratory signals is presented. The angle-based respiratory signal is found to produce the best agreement with a gross median error of only 4.2%.     

Identification of myocardial infarction (MI) using spatio-temporal heart dynamics

Cardiovascular disorders, such as myocardial infarction (MI) are the leading causes of mortality in the world. This paper presents an approach that uses novel spatio-temporal patterns of the vectorcardiogram (VCG) signals for the identification of various types of MI. In contrast to the traditional electrocardiogram (ECG) approaches, the 3D cardiac VCG signal is partitioned into 8 octants for localized analysis of the heart's electrical activities. The proposed method was tested using the PhysioNet PTB database for 368 MIs and 80 healthy control (HC) recordings, each of which includes 12-lead ECG and 3-lead VCG. Significant differences are found in the VCG spatial distribution between MI and HC groups. Furthermore, classification and regression tree (CART) analysis was used to demonstrate that VCG octant features can distinguish MIs from HCs with a sensitivity (accuracy of MI identification) of 97.28% and a specificity (accuracy of HC identification) of 95.00%, which is promising compared to the previously reported results using other ECG databases. The results indicate that the present approach provides an effective way for monitoring, post-processing, and interpretation of ECG data, and hopefully can impact the current cardiac diagnostic practice.     

Validation of a cardiac monitor for measuring heart rate variability in adult female pigs: accuracy, artefacts and editing

Autonomic regulation of cardiac activity during stress has not been clearly defined in farm animals. In part, this is due to the limited availability of affordable ambulatory cardiac monitors capable of accurately monitoring and storing large amounts of data that meet the criteria necessary for heart rate variability analysis. Our objectives were to measure the accuracy of a 24-h Polar RR monitor using gold standard ECG, to examine and categorise any occurring anomalies and to ascertain their impact on the outcome of heart rate variability analysis. Five 1-year-old female pigs (gilts) were socially isolated from their pen mates and cardiac activity was simultaneously measured using two systems, a 24-h Polar RR Recorder and a Telemetric ECG system. The Polar data were manually assessed both against and in isolation of the ECG data to identify anomalous beats, which were then assigned to one of five identified error categories. The anomalies in the Polar data were corrected and statistical comparisons were performed among the three data sets to evaluate the effects of anomalies on heart rate variability analysis. Bland-Altman analysis was used to measure the level of agreement among the ECG, Uncorrected Polar and Corrected Polar data. No anomalies or ectopies were found in the ECG data but 46 anomalies (0.81% of total interbeat intervals [IBI]) were found in the Polar Uncorrected data. Manual identification and editing procedures reduced this error to 0.018%. Most mean heart rate and IBI parameters were unaffected by error (P>.05). Standard deviation (S.D.) and root mean square of successive differences (RMSSD) were 45% and 50% higher when anomalies were present in the data. Artefacts affected the magnitude of the frequency domain indices and overestimated total and parasympathetic activity and underestimated sympathetic activity. The mean difference between ECG and Uncorrected Polar data was 1.36 ms (limits of agreement -69.03 to 71.74 ms). This was greatly improved to 0.36 ms (limits of agreement -5.37 to 6.10 ms) after editing. Overall, even a small proportion of error biased the outcome of heart rate variability analysis. This bias was greatly reduced by correcting the anomalous beats. Bland-Altman analysis demonstrated that when there was error present in the Polar data, it could not be used interchangeably with the ECG data. However, if there were no anomalies present in the data or if they were classified and corrected using the approach in this study, then the two systems could be used interchangeably.     

Cardiac function abnormalities and biochemical changes in myocardial ischemia

The relationship between myocardial ischemia and biochemical changes has been well documented. For example, hyperlipidemia is one of the largest risk factors for the development of coronary artery disease. Decreased coronary blood flow produces various changes in cardiac metabolism, which cause severe cardiac function abnormalities, including heart failure and arrhythmias. Many biochemical markers have been used for both diagnosis and evaluation of the severity of myocardial infarction. In this symposium the speakers have discussed: 1) the relationship between the changes in the ionic environments in the intra- and extra-cellular spaces and the genesis of cardiac arrhythmias, with special reference to the role of increased intracellular resistance in conduction delay during ischemia (Dr. Takao Fujino), 2) metabolic basis of ECG abnormalities in ischemic heart disease and the role of intra-coronary ECG recordings in the evaluation of cardiac ischemia (Dr. Tetsunori Saikawa), and 3) biochemical changes associated with exercise and other stresses, with special reference to the roles of increased catecholamines and decreased blood fluidity in the genesis of cardiac abnormalities (Dr. Takehiko Fujino). Prof. Takeshi Kanno gave a special lecture entitled "Approaches from clinical laboratory to hereditary variants". He showed an excellent model of approach from clinical laboratory medicine to detect important biochemical abnormalities which may be overlooked by routine daily analyses in the clinical laboratory.     

Present and future of cardiac function tests: electrophysiologic tests]

Various electrocardiographic and physiologic tests have been developing for almost 100 years since Einthoven established the standard 12 lead electrocardiogram(ECG) system. Recently, interest has focused on the new developing parameters associated with cardiac ventricular repolarization, such as transmural dispersion of repolarization, T wave alternans and QT dispersion. QT dispersion, measured as interlead difference of QT interval, has been suggested to reflect regional variation of ventricular repolarization. However, still unsolved basic problems give difficulties for clinical acceptance of this parameter. On the other hand, it is generally accepted that heart rate variability obtained from Holter ECG is useful tool to assess the autonomic tone. Head-up tilt test is a valuable diagnostic tool to identify patients with neurally mediated syncope and also useful for assessment of reflex cardiac autonomic function, such as baroreflex sensitivity. The number of electrophysiologic study(EPS) dramatically increased together with increase of radiofrequency catheter ablation. A new three-dimensional nonfluoroscopic electroanatomical mapping system(CARTO) is an exciting development in catheter ablation treatment. Transtelephonic ECG and its computer-assisted answering system are also useful for diagnose and treatment in the patients of paroxysmal cardiac symptoms.     

Electrophysiological tests in clinical laboratory]

We briefly described recently developed methods for testing cardiac electrophysiological phenomena such as 24-hour Ambulatory ECG, high resolution ECG, body surface mapping ECG, heart rate variability, QT and QT dispersion, and T wave alternans. Of these methods ambulatory ECG monitoring is important and useful for detecting malignant arrhythmias and ischemia attacks, especially in cases of vasospastic angina. Using this method, it is possible to quantitatively analyze arrhythmia and elucidate the pathophysiology of vasospastic angina. The monitoring system is useful not only for diagnosis, but also for assessing treatment efficacy. Heart rate variability is currently used for analyzing the autonomic nervous system; however, the exact meaning of each index still remains to be confirmed. The concept of QT dispersion was recently introduced as an index for detecting dispersion of ventricular repolarization and QT dispersion is still controversial. T wave alternans monitoring has been recently introduced as a new method of assessing the microvolt level of T wave alternans, which has been hypothesized to correlate with the occurrence of arrhythmic events in myocardial infarction. The possible roles of these methods and their applications for clinical practice are discussed.     

Use of dynamic time warping for accurate ECG signal timing characterization

Dynamic time warping techniques have been used to characterize the timing variation of the constituent components of the human electrocardiogram (ECG). Lead II ECG recordings were obtained in 21 subjects, 10 male and 11 female aged between 13–65 years. The fiducial points in each cardiac cycle were identified in the recordings across the range of heart rate from 46–184 beats/min. A set of second order equations in the square root of the cardiac cycle time was obtained to describe the duration each of the constituent components in the ECG signal. The accuracy of the dynamic time warping technique was verified against professionally annotated clinical recordings in the on-line PhysioNet? database. The equations obtained allow a Lead II ECG signal to be synthesized in which the variation with heart rate of the profile of each in the signal mirrors the true in-vivo behaviour.     

Use of vectorcardiography in determination of the left ventricular muscle mass

Many studies have investigated different ECG and vectorcardiographic (VCG): criteria for diagnosis of left ventricular hypertrophy (LVH). In some investigations VCG was more sensitive than ECG in this respect. This study was performed to elucidate whether it is possible also to determine the degree of LVH using VCG. Eighty cardiovascularly healthy subjects aged 15-39 were investigated with ECG, VCG (Frank system) and echocardiography. The echocardiographic left ventricular (LV) mass has been shown by others to correlate closely to the anatomical and the angiographically determined LV mass and was used as reference standard. Thirty-eight of the subjects were endurance sportsmen and had a LV mass above standard reference limits. The measured ECG variables were R-amplitude in a VL, I, V5, V6, S-amplitude in V1 and SV1 + RV5/V6 and the VCG variables were QRS spatial area and circumference and left maximal spatial vector. The sensitivity and specificity of single criteria tested were similar for ECG and VCG in the quantitative determination of LVH. The correlations between ECG-amplitudes and the magnitude of the LV mass were weak. The correlations were higher with the VCG-variables, QRS spatial circumference being superior to the others, but not good enough to permit an estimation of the LV mass in individual subjects. In conclusion, normal VCG variables were highly specific for a normal LV mass but in individuals with LVH, VCG was not useful for the estimation of the LV mass.     

自主呼吸状态下光电容积脉搏波法对 健康人群心率变异性的分析

目的 分析自主呼吸状态下光电容积脉搏波法对健康人群心率变异性。方法 选取2016年10月~2018年9月我校本科生健康志愿者64名,所有志愿者均行心电图（ECG）及光电容积脉搏波法（PPG）检测,比较3 min的ECG与PPG检测HRV时的RR间期标准差（SDNN）、RR间期差值均方根值（RMSSD）、低频功率与标准化高频功率的比值（LF/HF）,并分析ECG与PPG检测的心率变异性参数的相关性与一致性。结果 64例志愿者3 min的ECG与PPG心率变异性参数比较,差异无统计学意义（P＞0.05）。经Pearson相关性分析发现,PPG检测SDNN、RMSSD、LF/HF与ECG各指标呈正相关（SDNN:r=0.999,P＜0.001;RMSSD:r=0.998,P＜0.001;LF/HF:r=0.998,P＜0.001）;经可靠性分析发现,PPG用于检测健康人群心率变异性与ECG一致性较高（ICC=0.915,95% CI:0.878~0.943,P＜0.001）。结论 健康人群自主呼吸状态下光电容积脉搏波法可用于心率变异性的检测,临床上有较好的应用价值。     

Vectorcardiogram more sensitive than 12-lead ECG in the detection of inferior myocardial infarction

The vectorcardiogram (VCG) is commonly stated to be more sensitive than the 12-lead electrocardiogram (ECG) for the diagnosis of inferior myocardial infarction. However, a recent study indicated that VCG is not superior to ECG for this diagnosis. The purpose of this study was to compare the performance of VCG and ECG criteria and to indicate possible explanations for the disagreement between earlier studies. Accordingly, we studied 65 patients with inferior myocardial infarction verified by left ventriculography or 201-TI myocardial scintigraphy and 351 normal subjects. Sensitivity was 69% (45/65) and 43% (28/65) for the VCG and ECG criteria, respectively. This difference was highly significant (P less than 0.001). Among the normal subjects there were only three with false positive ECG. We conclude that both VCG and ECG criteria for the diagnosis of inferior myocardial infarction are highly specific and that VCG criteria have greater sensitivity than ECG criteria.     

Effect of Carotid Sinus Stimulation on Cardiac Output and Peripheral Vascular Resistance during Changes in Blood Volume Distribution in Man

In ten healthy subjects (mean age 29.6 years) the hemodynamic response to carotid sinus stimulation (neck suction - 40 mmHg) was studied under control conditions and during peripheral pooling of blood (lower body negative pressure). Heart rate, arterial and central venous pressure, cardiac output and forearm blood flow were measured. The time sequence of the heart rate response was studied separately in six healthy subjects. During control conditions, carotid sinus stimulation induced a significant decrease in arterial pressure and heart rate. The blood pressure decrease mainly reflected a reduction in cardiac output, total peripheral vascular resistance being essentially unchanged. However, in the skeletal muscle, represented by a forearm segment, vascular resistance decreased significantly. During lower body negative pressure (LBNP) the same stimulation of the carotid sinus induced a significantly greater fall in mean arterial pressure even though the reduction in cardiac output was slightly smaller on the average than in the control condition. The heart rate increased, probably secondary to a time dependent increase in heart rate elicited by the continuous LBNP stimulus. Total peripheral vascular resistance decreased significantly during LBNP, the reaction likewise differing significantly from that in the control condition. Thus the augmented blood pressure response was due to a more pronounced vasodilatation when the carotid sinus was stimulated during lower body negative pressure. The results indicate that the hemodynamic changes elicited by carotid sinus stimulation are modified by changes in the distribution of blood volume and in the tone of resistance vessels.     

The electrocardiomultigraphimeter in the variability analysis

The electrocardiomultigraphimeter (ECXGM) is a software package for clinical research in many branches of electrocardiography. The ECXGM makes available a set of conversions and representations of the ECG signal that are usually implemented in clinical practice on different instruments such as electrocardiographs, vectorcardiographs and spectrum analysers. This paper analyses the tools offered by the ECXGM for macro and microscopic variability analysis: graphic processing (contourograms, superimposed VCG loops), wave recognition programs, measuring and measurement synthesis: histograms and statistical diagrams.