aVR导联四步法对宽QRS波心动过速的诊断价值

目的 探讨avR导联四步法对宽QRS波心动过速(WQRST)的诊断价值.方法 运用avR导联四步法对41例WQRST患者常规心电图aVR导联进行分析,同时以Brugada诊断法加以对照.结果 41例WQRST患者中室性心动过速(VT)24例,室上性心动过速(SVT) 17例.aVR导联四步法和Brugada诊断法对VT诊断的敏感性、特异性、准确度分别为95.8％( 23/24)、88.2％ (15/17)、92.6％(38/41)与87.5％ (21/24)、82.3％ (14/17)、85.4％ (35/41),两种方法对VT诊断结果的差异具有统计学意义(x2=4.37,P＜0.05).结论 aVR导联四步法对WQRST诊断的敏感性、特异性和准确度高于Brugada诊断法,并且分析流程更为简捷,值得临床应用.     

Vereckei新四步法在房颤伴宽QRS波群中的鉴别诊断意义

目的:评估Vereckei新四步法在房颤伴宽QRS波群中的鉴别诊断意义.方法:分析100例房颤伴有宽QRS渡群患者的心电图表现.结果:63例房颤伴室性早搏中19例aVR导联初始为R波,aVR导联初始r波或q波＞40 ms7例,QRS负向波起始有挫折11例;Vi/Vt比值≤1为23例;aVR导联初始为R波19例中有7例宽QRS波心电轴位于无人区,房颤伴差传中无一例aVR导联初始为R波;Vereckei新四步法诊断63例心房颤动伴室性早搏阳性指标有60例,37例房颤伴室内差异传导阳性指标只有12例,两者有统计学意义(P=0.003 6).结论:Vereckei新四步法在房颤伴宽QRS波群的鉴别诊断中简单、方便、实用、正确率高,值得推广应用.     

aVR导联在阵发性室上性心动过速中的鉴别诊断价值

目的分析心电图aVR导联形态在阵发性室上性心动过速中的鉴别诊断价值。方法选取泰达国际心血管病医院行射频消融的室上性心动过速患者157例,男69例,女88例,年龄13~74岁,平均（41.9±19.2）岁,以心内电生理检查结果为金标准,分为慢快型房室结折返性心动过速组（SF-AVNRT组,n=89）和左侧房室旁路参与的房室折返性心动过速组（AVRT组,n=68）,入选者在窦性心律和室上性心动过速时无束支传导阻滞。结果与窦性心律时相比,SF-AVNRT组aVR导联QRS波终末部形态改变（假性r波或粗顿）的发生率73.0%,AVRT组aVR导联QRS波终末部形态改变（假性r波或粗顿）的发生率为1.5%,差异有统计学意义（P〈0.01）;与窦性心律时相比,SF-AVNRT组aVR导联ST段抬高、水平型移行或T波降支切迹的发生率为2.2%,AVRT组aVR导联ST段抬高、水平型移行或T波降支切迹的发生率为89.7%,差异有统计学意义（P〈0.05）。结论与窦性心律时相比,SF-AVNRT和AVRT在aVR导联具有不同的心电图特点,aVR导联QRS波终末部形态和ST段形态对判断室上性心动过速的类型具有重要意义,需高度重视aVR导联在室上性心动过速中的鉴别诊断价值。     

左室特发性室速误诊为室上性心动过速5例分析

目的 :分析起源于左室后间隔特发性室速的临床及电生理特点 ,探讨其误诊为室上性心动过速的原因及两者的鉴别要点。方法 :回顾分析 1999～ 2 0 0 2年住院的左室特发性室速 5例 ,平均年龄 2 7岁 ,男 4例 ,女 1例 ,心动过速均有突发突止 ,不伴血流动力学障碍 ,且对异搏定敏感的特点 ,均在外院误诊为室上性心动过速伴差异性传导 ,射频消融未成功。结果 :本组 5例电生理检查心室程控刺激诱发心动过速 ,伴有室房分离 ,ECG显示右束支传导阻滞 ,有时合并左前分支阻滞 ,电轴不偏或左偏 ,在左后间隔最提前的 P电位处消融后心动过速不能被诱发。结论 :起源于左后间隔的特发性室速临床表现与室上速相似 ,但 ECG V1 和 V6 导联的形态有助于和室上性心动过速伴差异性传导相鉴别     

新的Brugada法对150例宽QRS波心动过速的分析及体会

目的　评价Brugada方案在宽QRS波心动过速的心电图中对室速诊断的准确性、特异性、敏感性及实用性。方法　用Brugada新的四步鉴别诊断法对 15 0例宽QRS波心动过速的体表心电图进行回顾性分析及诊断。结果　室速占宽QRS波心动过速的 77% ,Brugada方案对室速的正确诊断率为 97% ,特异性为91 7% ,敏感性 98 2 %。结论　宽QRS波心动过速中室速的发生率很高 ,应用Brugada法鉴别宽QRS波心动过速的实用性强 ,误差小。结合病史及发作前后的心电图 ,观察心房与心室除极的关系等因素综合评判 ,可提高鉴别诊断的准确率     

aVR导联ST段抬高对窄QRS波心动过速的鉴别及旁道定位作用

目的:观察aVR导联ST段抬高对窄QRS波心动过速的鉴别及旁道定位作用。方法:120例窄QRS波心动过速均经心内电生理和射频消融证实,分析其心动过速发作时体表12导联心电图aVR导联ST段抬高程度及持续时间。结果:120例窄QRS波心动过速中有58例房室折返性心动过速(AVRT),62例房室结折返性心动过速(AVNRT)。aVR导联ST段抬高在AVRT发生率为67.2%,AVNRT为16.1%(P<0.05),诊断AVRT的敏感性、特异性和准确性分别是67.2%、83.9%和75.8%。在39例aVR导联ST段抬高的AVRT中,有28例位于左旁道,7例位于右旁道,3例位于后间隔,1例位于前间隔。aVR导联ST段抬高定位左侧旁道的敏感性、特异性、阳性预测值和准确性分别是77.8%、50.0%、71.8%和76.5%。结论:aVR导联ST段抬高有助于鉴别窄QRS波心动过速及旁道定位。     

宽QRS波心动过速患者食管电生理检查误漏诊分析

目的 分析宽QRS波心动过速患者食管电生理检查误漏诊的原因.方法 回顾性分析宽QRS波心动过速食管电生理误漏诊2例的临床资料.结果 本文2例均以心悸就诊,行食管调搏检查,例1诊断为隐匿性房室旁道并房室折返性心动过速伴室内差异性传导,例2诊断为左室阵发性室上性心动过速合并左侧隐匿旁管并房室折返性心动过速.后经心内电生理检查,例1确诊为右侧马海姆（Mahaim）纤维参与的逆向性房室折返性心动过速;例2漏诊室性心动过速.均经射频消融术治疗痊愈.结论 食管电生理是临床诊断快速心律失常的常用方法,对复杂少见的宽QRS波心动过速应尽量将食管心房调搏资料收集齐全,使心动过速的机制明朗化,避免临床误漏诊的发生.     

食管心房调搏在急诊中的应用

食管心房调搏在急诊中的应用江苏省南通市第一人民医院急诊科（２２６００１）翟瑜，翟明之本文主要报告食管心房调博在急诊中的应用，终止室上性心动过速，诊断、鉴别诊断及对各种缓慢心律失常在抢救中的应用体会。１临床资料１．１一般资料：本组共３２例，男性１８例，...     

新方案对阵发性室上性心动过速的诊断意义

房室结折返性心动过速（AVNRT）和房室折返性心动过速（AVRT）是最常见的阵发性室上性心动过速（PSVT）,两者共约占95％以上。近年来,射频消融手术的开展使AVNRT、AVRT得到明确诊断,通过射频消融术达到根治,术后复发率低,并发症少。部分患者难以耐受食管心房调搏术,难以在术前对两者进行鉴别。     

aVR导联的临床诊断价值

aVR 导联是标准12 导联的构成导联之一,但多年来临床上一直未予足够的重视.很多人认为这是一个没有临床价值的导联,然而近年来随着临床研究的增多,aVR导联被人们重新认识,无论在窦性心律的判定、室上性心动过速的鉴别诊断、宽QRS 波心动过速的鉴别诊断、预激的旁道定位、恶性室性心律失常的预测、冠心病判断病变血管及估计预后等都有较高的临床价值.在心电图诊断中不应忽视aVR 导联.     

A modified electrocardiographic algorithm for differentiating typical atrioventricular node re-entrant tachycardia from atrioventricular reciprocating tachycardia mediated by concealed accessory pathway

Non-invasive prediction of tachycardia mechanism is becoming clinically important in the era of catheter ablation for curing supraventricular tachycardia. Twelve-lead electrocardiograms (ECGs) during sinus rhythm and atrioventricular node re-entrant tachycardia (AVNRT) or atrioventricular reciprocating tachycardia (AVRT) with a narrow QRS complex were obtained from 154 consecutive adult patients who had received successful radiofrequency catheter ablation. The ECGs of initial 104 patients were analysed by three observers without knowledge of the electrophysiological diagnosis. The two arrhythmias were accurately diagnosed in 68% of cases. Three criteria were found to be discriminators of tachycardia mechanism by univariable analysis. Pseudo r/Q/S waves predicated AVNRT in 92% of cases (sensitivity 71%; specificity 95%). Retrograde P wave predicated AVRT in 86% of cases (sensitivity 75%; specificity 85%), RP interval > or =100 ms in 93% (sensitivity 71%; specificity 94%) and ST-segment elevation in lead aVR in 83% (sensitivity 71%; specficity 83%). According to the initial results, we proposed a modified stepwise ECG algorithm which used pseudo r/S/Q waves, RP interval and ST-segment elevation in lead aVR during tachycardia. Two observers assessed the modified algorithm in the remaining 50 patients. The algorithm was able to correctly diagnose the tachycardia mechanism in 84% and 87%, respectively. Using the modified algorithm can improve the accuracy and simplify the differential diagnosis between typical AVNRT and AVRT via concealed accessory pathway in adult patients.     

体表心电图V1和aVL/aVR导联对房室结折返性心动过速的诊断价值

目的探讨体表心电图V1联合aVL或aVR导联对房室结折返性心动过速(AVNRT)的诊断价值。方法143例窄QRS心动过速患者的体表心电图,含窦性心律和心动过速心电图。由两位未知心动过速类型的心电生理医师进行诊断,记录包括V1导联假r′波、aVL导联末端切迹、心动过速RP′间期≥100 ms等指标,心动过速类型由心内电生理检查确定。结果AVNRT患者年龄较大(P<0.01),女性较多(72.4% vs 50.0%,P<0.01)。aVL导联末端切迹对于诊断AVNRT具有较高敏感度（60.9%）和特异度（89.3%）,高于传统V1导联假r′和下壁导联假s波（P均小于0.05）;联合V1导联假r′和aVL导联末端切迹或aVR导联假r′波明显提高AVNRT诊断敏感度至78.2%和74.7%,而阳性预测值无明显降低。RP′间期≥100 ms诊断顺向型房室折返性心动过速(AVRT)具有较高敏感度和特异度(敏感度69.6%, 特异度87.4%),联合aVR导联ST段J点后80 ms下斜型抬高超过1.5 mV指标,明显提高AVRT诊断敏感度（89.2%）。结论体表心电图V1和aVL或aVR导联可提高AVNRT诊断价值。     

Comparison of two diagnostic algorithms for regular broad complex tachycardia by decision theory analysis

Sensitivity and specificity are two inversely related properties of a diagnostic test and it is often practically infeasible to secure a high value for both simultaneously. Decision theory analysis shows that the utility of a diagnostic test depends not only on its sensitivity and specificity but also on the prevalence of the intended target disorder: when prevalence is low, a high specificity is more important than a high sensitivity, whereas when prevalence is high, a high sensitivity is more important than a high specificity. The significance of this principle is illustrated by two popular algorithms for the electrocardiographic diagnosis of regular broad complex tachycardia (BCT), of which the two main differential diagnoses are ventricular tachycardia (VT) and supraventricular tachycardia with aberrant conduction (SVTAG). Brugada et al. focused on criteria highly specific for VT and used them to build a four-step algorithm. In contrast, Griffith et al. first selected criteria highly sensitive for VT and then criteria highly specific for VT to build a simple two-step algorithm. It can be objectively demonstrated that the Griffith algorithm is more efficient and effective than the Brugada algorithm in terms of clinching the final diagnosis and improving overall diagnostic accuracy. The main reason for this is that VT is more common than SVTAC as the cause of regular BCT, and the Griffith algorithm adhered to the aforementioned principle governing the choice between sensitivity and specificity according to prevalence in its design. The Griffith algorithm also embodies an additional important principle, namely, it is easier and more efficient to choose alternatively between criteria highly specific and highly sensitive for the intended target disorder than concentrating on just one or the other in designing a multiple-step sequential diagnostic algorithm.     

Wide-complex Tachycardia: Continued Evaluation of Diagnostic Criteria

OBJECTIVE: To evaluate the accuracy of the Brugada algorithm for analysis of wide-complex tachycardia (WCT) when applied by board-certified emergency physicians and board-certified cardiologists. METHODS: A database consisting of 157 electrocardiograms of WCTs were evaluated in a blinded fashion using the Brugada criteria to determine the presence of ventricular tachycardia (VT) or supraventricular tachycardia with aberrancy. These results were then compared with the electrophysiologically proven diagnosis for each tracing. Sensitivity and specificity of the Brugada criteria for diagnosis of VT were calculated. Two board-certified emergency physicians and two board-certified cardiologists analyzed each tracing, and interobserver agreement was determined using the kappa statistic. RESULTS: Sensitivity and specificity for the determination of VT using the Brugada algorithm were 85% [95% confidence interval (95% CI) = 79% to 91%] and 60% (95% CI = 43% to 78%) for cardiologist 1 (C 1) and 91% (95% CI = 86% to 96%) and 55% (95% CI = 37% to 72%) for C 2. Emergency physician (EP 1) achieved a sensitivity of 83% (95% CI = 78% to 91%) and a specificity of 43% (95% CI = 25% to 59%), while EP 2 attained 79% (95% CI = 73% to 87%) and 70% (95% CI = 51% to 84%), respectively. The original authors achieved a sensitivity of 98.7% and specificity of 96.5% when determining VT in their study population. Interobserver agreement for the emergency physicians and the cardiologists in determining VT was 82% and 81%, respectively. CONCLUSIONS: Neither the emergency physicians nor the cardiologists were able to achieve a sensitivity or specificity as high as that reported by the original investigators when using the Brugada algorithm to determine the presence of VT.     

Wide QRS complex tachycardia: ECG differential diagnosis.

Wide QRS complex tachycardias (WCT) present significant diagnostic and therapeutic challenges to the emergency physician. WCT may represent a supraventricular tachycardia with aberrant ventricular conduction; alternatively, such a rhythm presentation may be caused by ventricular tachycardia. Other clinical syndromes may also demonstrate WCT, such as tricyclic antidepressant toxicity and hyperkalemia. Patient age and history may assist in rhythm diagnosis, especially when coupled with electrocardiographic (ECG) evidence. Numerous ECG features have been suggested as potential clues to origin of the WCT, including ventricular rate, frontal axis, QRS complex width, and QRS morphology, as well as the presence of other characteristics such as atrioventricular dissociation and fusion/capture beats. Differentiation between ventricular tachycardia and supraventricular tachycardia with aberrant conduction frequently is difficult despite this clinical and electrocardiographic information, particularly in the early stages of evaluation with an unstable patient. When the rhythm diagnosis is in question, resuscitative therapy should be directed toward ventricular tachycardia.     

Comparison of the performance of three diagnostic algorithms for regular broad complex tachycardia in practical application

The authors previously proposed a Bayesian approach to the electrocardiographic diagnosis of regular broad complex tachycardia (BCT), which can be due to VT or supraventricular tachycardia with aberrant conduction (SVTAC). They also published an account comparing the theoretical merits in the design of two of the most commonly used diagnostic algorithms for the same purpose, those of Brugada et al. and Griffith et al. In this study, a direct head-to-head comparison was performed on the practical performances of the three algorithms in this study. A set of 111 ECGs showing regular BCT (77 VT, 34 SVTAC) whose diagnoses were confirmed by electrophysiological study was shown to five internists in general medicine at a district general hospital. The observers were asked to comment on whether the ECG criteria in the three algorithms tested were fulfilled or not, and a computer program then derived the corresponding diagnoses. The sensitivity and specificity for VT achieved by the Brugada algorithm were 92% and 44%, 92% and 44% by the Griffith algorithm, and 97% and 56% by the Bayesian algorithm. The Bayesian algorithm achieved a higher sensitivity and specificity than the other two algorithms, but the differences are not statistically significant (P = 0.6583 and P = 0.5334, respectively). The Brugada, Griffith, and Bayesian algorithms show comparable performances in terms of overall sensitivity and specificity when tested in practice. Of the three algorithms, the Griffith algorithm excels in simplicity and is the easiest to implement in practice. The Bayesian algorithm achieved slightly higher values for sensitivity and specificity than the Brugada and Griffith algorithms but may be more suitable for automated computer-aided diagnosis of ECG due to its complexity.     

aVR导联QRS波形态对下壁心肌梗死的鉴别诊断意义

目的 探讨aVR导联QRS波形态对下壁心肌梗死的鉴别诊断意义.方法 分析52例Ⅲ、aVF导联均为病理性Q波患者的aVR导联QRS波形态,并与选择性冠状动脉造影结果对照.结果 aVR导联QRS波呈rS(s)型、QS(qs)型和Q(q)r型的患者分别为13例、10例和29例,三种形态与冠状动脉造影结果比较显示右冠状动脉或左回旋支有狭窄、闭塞病变的患者分别为12例、4例和0例,差异有统计学意义(χ2=35.56,P=0.000).结论 aVR导联QRS波形态对Ⅲ、aVF导联均为病理性Q波患者具有鉴别诊断意义.aVR导联QRS波呈Q(q)r型,可排除陈旧性下壁心肌梗死;aVR导联QRS波呈rS(s)型,可基本确定有陈旧性下壁心肌梗死.     

An algorithm to predict the site of origin of focal atrial tachycardia

Background: Only a few algorithms for predicting the site of origin of focal atrial tachycardia (AT) have been reported. We aimed to develop a new and more effective algorithm. Methods: Surface 12‐lead electrocardiograms were collected during tachycardia and sinus rhythm in 61 patients who received successful radiofrequency ablation. P‐wave polarities, durations, and amplitudes were analyzed. Predictive values of the most significant parameters were determined. An algorithm was then developed and prospectively evaluated in 30 new consecutive AT patients. Results: Thirty‐six percent (22/61) of the foci were located at the ostium of coronary sinus (CS). Other common foci included pulmonary veins (PVs, n = 15), right atrial appendage (RAA, n = 7), parahisian area (n = 7), and crista terminalis (CT, n = 3). Positive P waves in inferior leads (II, III, and aVF) and a negative P wave in lead aVR indicated high atrial origins (high CT, superior PVs, and RAA, defined as Area A), with a sensitivity of 95% and a specificity of 90%. Negative P waves in inferior leads and a positive P wave in lead aVR suggested right low septal origins (CS ostium and inferior tricuspid annulus, defined as Area B), with good sensitivity and specificity (88% and 89%, respectively). This new P‐wave diagnostic algorithm correctly identified the site of origin in 90% of AT cases. Conclusion: Combination of data from multiple leads and regrouping of sites of origin provides a better predictive value. (PACE 2011; 34:414–421)     

The differential diagnosis of wide QRS complex tachycardia

Wide complex tachycardia is defined as a cardiac rhythm with a rate greater than 100 beats/min (bpm) and a QRS complex duration greater than 0.10 to 0.12 seconds (s) in the adult patient; wide complex tachycardia (WCT) in children is defined according to age-related metrics. The differential diagnosis of the WCT includes ventricular tachycardia and supraventricular tachycardia with aberrant intraventricular conduction, including both relatively benign and life-threatening dysrhythmias. This review focuses on the differential diagnosis of WCT with a discussion of strategies useful in making the appropriate diagnosis, when possible.