aVR导联S T段抬高预测非S T段抬高型急性心肌梗死的临床价值

目的：探讨aVR导联ST段抬高对非ST段抬高型急性心肌梗死的预测价值。方法选取27例心电图改变为ST段压低≥0．1 mV伴aVR导联ST段抬高者作为观察组,另选50例ST段压低≥0．1 mV但不伴aVR导联ST段抬高者作为对照组,追踪观察2组非ST段抬高型急性心肌梗死的发生率。结果临床确诊为非 ST 段抬高型心肌梗死者观察组为7例（25．9％）,对照组为1例（2％）;2组比较差异有统计学意义（P＜0．05）。结论 aVR导联ST段抬高对非ST段抬高型急性心肌梗死具有一定的预测价值,临床应给予重视。     

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.     

急性左主干闭塞心电图1例分析并文献复习

急性左主干闭塞是临床上较常见的心血管急危重症，掌握其心电图特征，有利于快速、准确地识别高危患者，选择合适的治疗方案。根据2011年ESC NSTE-ACS患者管理指南，可以通过典型心电图改变早期识别发现左主干病变，主要表现为aVR导联ST段抬高＞0.1 mV。此外，急性左主干闭塞病变心电图的早期诊断可能具备以下三个特征之一：①Ⅰ、Ⅱ、V4～V6导联ST段压低伴aVR导联ST段抬高；②发病后12 h内心电图同时有aVR和V1导联ST段抬高且抬高程度aVR＞V1导联（ST aVR↑＞ST V1↑）；③Ⅱ、Ⅲ、aVF导联ST段压低＋aVR导联ST段抬高。     

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。     

aVR导联ST段抬高在预测非ST段抬高型急性心肌梗死患者预后中的价值

目的探讨aVR导联ST段抬高在预测首次非ST段抬高型急性心肌梗死患者短期预后中的价值。方法分析426例非ST段抬高型急性心肌梗死患者入院心电图。结果aVR导联无ST段抬高(n=281)、抬高0.05~0.1mV(n=68)和抬高≥0.1mV(n=77)患者的住院死亡率分别是1.8%、7.4%和15.6%。调整基线预测因子和入院时ST段压低的影响,aVR导联ST段抬高0.05~0.1mV和抬高≥0.1mV患者死亡的优势比分别是4.2(95%可信区间为1.4~13.5;P<0.001)和6.1(95%可信区间为2.4~17.3;P<0.001)。住院期间复发心肌缺血事件和心力衰竭发生率随aVR导联ST段抬高程度增加而增加,而不同程度aVR导联ST段抬高患者血清肌酸激酶和肌酸激酶同工酶相似。aVR导联无ST段抬高、抬高0.05~0.1mV和抬高≥0.1mV患者左主干或3支血管病变发生率分别为16.9%、37.1%和56.2%(P<0.001)。结论首次非ST段抬高型急性心肌梗死伴aVR导联ST段抬高患者预后较差,而这种差的预后与严重的冠状动脉病变有关,对这些患者进行早期介入治疗也许有重要的益处。     

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导联ST段抬高对急性心肌梗死预后的价值

目的探讨心电图aVR导联ST段抬高对急性前壁心肌梗死患者预后的价值。方法首次入院急性前壁心肌梗死患者57例，对其心电图和冠状动脉造影及临床资料进行对比分析。根据心电图aVR导联ST段变化分为抬高组、无偏移组。结果梗死相关血管为左主干病变的ST段抬高组、ST段无偏移组分别为5例（21．7％）、1例（2．9％），两组统计有显著性差异（p〈0．01）；病变范围为多支病变ST段抬高组、ST段无偏移组分别为10例（43．4％）、8例（23．5％），两组统计有显著性差异（p〈0．05）；发生心脏事件ST段抬高组、ST段无偏移组分别为8例（34.8％）、3例（8．8％），两组有显著性差异（p〈0．01）。结论aVR导联ST段抬高对预测急性前壁心肌梗死患者的预后有重要的价值，应高度重视。     

左主干闭塞所致急性心肌梗死的心电图特点

目的分析急性左主干(LM)闭塞的常规心电图(ECG)表现,总结其ECG特点。方法1999年1月至2004年8月,10例急性心肌梗死(AMI)患者经急诊冠状动脉造影证实为急性LM闭塞(LM组),回顾性分析其急诊ECG表现。并选取同时期30例经急诊造影证实为左前降支(LAD)近段闭塞的AMI患者(LAD组),比较两组造影前的急诊ECG表现,以求总结急性LM闭塞的常规ECG特点。结果LM组心率快于LAD组,在心律失常发生率方面两组差异无统计学意义。LM组中9例患者存在aVR导联ST段抬高(≥0·05mV),发生率明显高于LAD组(分别为90%和36·7%,P=0·002),同时LM组aVR导联ST段抬高幅度亦明显大于LAD组。而LM组胸前导联V1-3的ST段抬高程度则明显低于LAD组。aVR导联ST段抬高>0·05mV诊断急性LM闭塞的敏感性为90%,特异性为63·3%。如果同时再满足V1 V2 V3导联ST段抬高程度<0·5mV,其诊断急性LM闭塞的敏感性为90%,特异性达到86·7%。结论aVR导联ST段抬高>0·05mV,同时伴有V1~V3导联ST段抬高不明显、甚至压低是急性LM闭塞区别于LAD闭塞的ECG特点,结合临床表现,分析ECG特点可能有助于造影术前预测此类患者和风险评价。     

左主干病变心电图分析

目的分析左主干病变冠心病心绞痛患者的心电图改变。方法30例冠脉造影诊断为左主干病变的患者,对其心绞痛发作时各导联ST段的变化及临床资料进行分析。结果30例中除7例急性心肌梗死患者呈现典型心电图演变外,有20例患者ST段广泛压低(5个导联以上)。17例患者胸痛发作的心电图中可见STaVR抬高,其中13例STV1也可见抬高,但是程度均低于aVR导联。结论左主干病变引起心肌缺血的心电图改变表现为广泛导联ST段压低及aVR导联ST段抬高。     

急性心肌梗死时体表心电图预测左主干闭塞的临床意义

目的:分析急性冠状动脉左主干(LM)闭塞的常规心电图(ECG)表现,总结其ECG特点.方法:15例急性心肌梗死(AMI)患者经冠状动脉造影证实为急性LM闭塞(LM组),回顾性分析其急诊ECG表现.并选取同时期30例左前降支(LAD)近段闭塞的AMI患者(LAD组),比较2组造影前的急诊ECG表现,以求总结急性LM闭塞的常规ECG特点.结果:LM组心率快于LAD组,心律失常发生率2组差异无统计学意义.LM组中13例患者存在aVR导联ST段抬高(≥0.05 mV),发生率明显高于LAD组(分别为86.7%和36.7%,P＜0.01),同时LM组aVR导联ST段抬高幅度亦明显大于LAD组.而LM组胸前导联V1～3的ST段抬高程度则明显低于LAD组.aVR导联ST段抬高＞0.05 mV诊断急性LM闭塞的敏感性为90%,特异性为63.3%.如果同时再满足V1～3导联ST段抬高程度＜0.5 mV,其诊断急性LM闭塞的敏感性为90%,特异性达到86.7%.结论:aVR导联ST段抬高≥0.05 mV,同时伴有V1～3导联ST段抬高不明显、甚至压低是急性LM闭塞区别于LAD闭塞的ECG特点,结合临床表现,分析ECG特点可能有助于造影前预测此类患者和进行风险评价.     

Identification of the optimal electrocardiographic leads for detecting acute epicardial injury in acute myocardial infarction

Current coronary care electrocardiographic (ECG) monitoring techniques are aimed at detection of cardiac arrhythmias rather than myocardial ischemia. However, in patients with acute myocardial infarction (AMI) who undergo reperfusion therapy, monitoring ST-segment deviation could provide an early noninvasive indicator of coronary artery reocclusion. In this study, the admission 12-lead ECGs of patients with initial AMI were used to propose optimal lead locations for ST-segment monitoring. The study population was selected from consecutive Duke University Medical Center admissions during 1965 to 1981 who met the following inclusion criteria: chest pain for no more than 8 hours, initial AMI documented by ECG and 3 of 4 enzyme criteria, greater than or equal to 0.1 mV (1 mV = 10 mm) of ST elevation in at least 1 of the standard 12 leads (not aVR) on admission ECG, and no ECG evidence of conduction disturbances, ventricular hypertrophy or tachycardia. ST-segment deviation was quantified; AMI location was assigned based on the lead with maximal deviation. Of the 80 patients who had an inferior AMI, lead III was both the most frequent location for ST elevation (94%) and the most common site with maximal ST deviation. Lead V2 had the highest incidence of ST-segment depression (60%). In the 68 patients who had an anterior AMI, lead V2 had the highest frequency of ST elevation (99%). Leads V2 and V3 were the most common sites of maximal elevation. Thus, for monitoring ST deviation, leads III and V2 may be superior to leads II and V1, which are commonly used in arrhythmia monitoring.(ABSTRACT TRUNCATED AT 250 WORDS)     

临床心电图和外周血管超声对冠状动脉病变预测价值的临床研究

目的 探讨心电图和外周血管超声对冠状动脉病变的预测价值.方法 回顾性分析168例冠心病患者联合心电图和外周血管超声与冠状动脉造影（CAG） 资料.根据CAG确定病变范围,通过分析心电图,多导联ST-T改变,如aVR 导联ST 段抬高＞0.05 mV,且合并≥6个导联ST段压低（幅度越大预测性越高）或aVR导联ST 抬高大于V1导联ST 段抬高,联合颈动脉和股动脉超声检测,提示外周动脉硬化积分与冠状动脉硬化狭窄积分呈正相关.结果 ①多支病变组心电图改变特点与非多支病变组差异有统计学意义（P＜0.05）.②与非冠心病组比较,冠心病组颈股动脉内膜增厚和斑块形成率增高（P＜0.05）.冠状动脉多支病变组颈股动脉斑块形成率高于其他两组（P＜0.05）.③冠状动脉多支病变组颈股动脉粥样硬化IMT与对照组比较差异有统计学意义（P＜0.01）,与单支病变组比较差异亦有统计学意义（P＜0.05）.结论 联合心电图和外周血管超声检测预测冠状动脉多支血管病变、左主干病变准确性高,临床检测方便,适合基层推广.     

ST-segment depression in lead aVR: a useful predictor of impaired myocardial reperfusion in patients with inferior acute myocardial infarction

STUDY OBJECTIVE: During inferior acute myocardial infarction (AMI), the ECG lead aVR is frequently ignored, and therefore its clinical significance remains unclear. We examined the relation between ST-segment deviation seen in lead aVR on ECGs obtained at hospital admission and myocardial reperfusion in patients who have experienced recanalized inferior AMIs. DESIGN AND SETTING: Retrospective study. PATIENTS: A total of 225 patients with inferior AMIs in whom Thrombolysis in Myocardial Infarction grade 3 flow was achieved within 6 h after symptom onset. MEASUREMENTS AND RESULTS: Patients were classified as follows according to ST-segment deviation in lead aVR on an ECG obtained at hospital admission: group A, 103 patients with no ST-segment depression; group B, 80 patients with ST-segment depression of < or = 1.0 mm; and group C, 42 patients with ST-segment depression of > 1.0 mm. There were no differences in time from symptom onset to hospital admission or in the culprit lesion among the three groups. The degree of ST-segment elevation in leads II, III, aVF, V5, or V6, the degree of ST-segment depression in leads V1 to V4, and the sum of ST-segment deviation in these leads were lowest in group A and highest in group C. In groups A, B, and C, the incidence of impaired myocardial reperfusion, defined as myocardial blush grade 0/1, was 2%, 23%, and 67%, respectively (p < 0.001). The sensitivity and negative predictive values of ST-segment depression in lead aVR for impaired myocardial reperfusion were higher than those based on other ECG variables. Multivariate analysis showed that the degree of ST-segment depression in lead aVR was an independent predictor of impaired myocardial reperfusion (odds ratio 8.41; 95% confidence interval, 2.96 to 23.9; p < 0.001). CONCLUSIONS: We conclude that the degree of ST-segment depression in lead aVR is a useful predictor of impaired myocardial reperfusion in patients who have experienced inferior AMIs.     

aVR导联ST段回落对非ST段抬高型急性冠脉综合征患者短期预后的评估价值

目的探讨aVR导联ST段抬高回落在非ST段抬高型急性冠脉综合征（NSTE-ACS）患者短期预后中的评估价值。方法纳入NSTE-ACS aVR导联抬高的患者45例;根据入院6h后aVR导联ST段是否回落分为ST段回落组（n=20）与非ST段回落组（n=25）;分析入选患者一般临床资料、心电图、冠状动脉造影结果,并对不良心脏事件的危险因素进行Logistic回归分析。结果 aVR导联ST段无回落组左主干＋三支血管病变率、30d内再发心肌梗死率、急诊PCI及冠脉旁路移植术比例均高于ST段回落组患者,具有统计学差异（P〈0.05）。Logistic回归分析显示,aVR导联ST段无回落是入院后30d内不良心脏事件（死亡、心肌梗死及行血运重建术）独立预测因子（OR=18.54,95%CI：3.57～96.1,P〈0.001）。结论 aVR导联ST段抬高无回落的NSTE-ACS患者其预后差于ST段抬高回落者,aVR导联ST段无回落是NSTE-ACS不良心血管事件的独立预测因子。     

ECG discrimination between right and left circumflex coronary arterial occlusion in patients with acute inferior myocardial infarction: value of old criteria and use of lead aVR

STUDY OBJECTIVES: Prior studies have proposed several ECG criteria for identifying the culprit artery in patients with acute inferior myocardial infarction (MI). We applied each criterion to our patients to assess its utility. In doing so, we discovered a previously unreported, but highly useful, criterion utilizing lead aVR. STUDY DESIGN: Retrospective review. PATIENTS: Thirty consecutive patients with symptoms of acute MI, ST-segment elevation in the inferior ECG leads, an appropriate rise and fall of creatine kinase and troponin I levels, and coronary arteriography within 7 days of the onset of symptoms. MEASUREMENTS: The ECG recorded within 24 h of the onset of symptoms that had the most prominent ST-segment changes was analyzed. In the 12 standard leads and in lead V(4)R, ST-segment elevation or depression was measured 0.06 s after the J point. RESULTS: Four previously described criteria were useful in identifying the right coronary artery (RCA) or the left circumflex coronary artery (LCX) as the culprit: ST-segment elevation in lead I, ST-segment more or less elevated in lead II than in lead III, ST-segment elevation >or= 0.5 mm in lead V(4)R, and various combinations of ST-segment elevation or depression in leads V(1) and V(2). A new criterion was found to be at least as useful as any previously described: the presence and amount of ST-segment depression in lead aVR. CONCLUSIONS: At least five different ST-segment criteria help to identify the RCA or the LCX as the culprit artery in patients with acute inferior MI. One of these, the amount of ST-segment depression in lead aVR, has not been reported previously and needs validation in a larger study.     

ST-segment elevation resolution in lead aVR: a strong predictor of adverse outcomes in patients with non-ST-segment elevation acute coronary syndrome.

BACKGROUND: The impact of ST-segment elevation resolution in lead aVR on outcomes in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) is unclear. METHODS AND RESULTS: Electrocardigrams (ECGs) were recorded on admission and 6 h later in 367 patients with NSTE-ACS. ST-segment deviation >or=0.5 mm was considered significant: 92 patients had ST-segment elevation in lead aVR on admission ECG (ST upward arrowaVR), and 275 did not. Among patients with ST upward arrowaVR, 50 had ST resolution, defined as a reduction >50% in the degree of ST-segment elevation in lead aVR from admission to 6 h later, and 42 did not. ST upward arrowaVR without ST resolution was associated with older age, greater ST-segment depression in other leads on admission and 6 h later, higher rates of positive troponin T, left main and/or 3-vessel coronary disease, and adverse events such as death, (re)infarction, or urgent revascularization within 30 days after admission. Multivariate analysis showed that ST upward arrowaVR without ST resolution was the strongest independent predictor of death or (re)infarction within 30 days after admission (hazard ratio 5.62, p=0.018). CONCLUSIONS: ST upward arrowaVR without ST resolution is a strong predictor of 30-day adverse outcomes and correlates with the extent and severity of coronary artery disease in patients with NSTE-ACS.     

ST-segment depression in lead aVR predicts predischarge left ventricular dysfunction in patients with reperfused anterior acute myocardial infarction with anterolateral ST-segment elevation.

BACKGROUND: Patients with an anterolateral acute myocardial infarction (AMI) have a worse prognosis, and those with additional inferolateral wall involvement might be higher risk because of more extensive area at risk. Lead -aVR obtained by inversion of images in lead aVR has been reported to provide useful information for inferolateral lesion. METHODS: We examined the relation between ST-segment deviation in lead aVR on admission electrocardiogram (ECG) and left ventricular function in 105 patients with an anterolateral AMI undergoing successful reperfusion < or = 6 hours after onset. Patients were classified according to ST-segment deviation in lead aVR on admission ECG: group A, 23 patients with ST elevation of > or = 0.5 mm; group B, 47 patients without ST deviation; and group C, 35 patients with ST depression of > or = 0.5 mm. RESULTS: There were no differences among the 3 groups in age, sex, or site of the culprit lesion. In groups A, B, and C, the peak creatine kinase level was 3661 +/- 1428, 4440 +/- 1889, and 6959 +/- 2712 mU/mL, and the left ventricular ejection fraction (LVEF) measured by predischarge left ventriculography was 54% +/- 9%, 48% +/- 7%, and 37% +/- 9%, respectively(P < .01). During hospitalization, congestive heart failure occurred more frequently in group C than in groups A or B (P < .05). ST-segment depression in lead aVR had a higher predictive accuracy than other ECG findings in identifying patients with predischarge LVEF < or = 35%. CONCLUSIONS: We conclude that in patients with an anterolateral AMI, ST-segment depression in lead aVR on admission ECG is useful for predicting larger infarct and left ventricular dysfunction despite successful reperfusion.     

Effects of thrombolytic therapy in acute inferior myocardial infarction with or without right ventricular involvement

Objectives. This study assessed the prognostic impact of right ventricular involvement (RVI) in streptokinase-treated patients with inferior acute myocardial infarction (AMI) stratified for small or large AMI.Background. Only scant data exist from small studies about the impact of reperfusion therapy on survival in patients with RVI during inferior AMI.Methods. Right ventricular involvement was assessed by ST-segment elevation ≥0.1 mV in lead V₄R and infarct size by the extent of ST-segment deviation on the baseline electrocardiogram: small AMI = sum ST-segment elevation ≤0.8 mV and no precordial ST-segment depression (small ST); large AMI = presence of precordial ST-segment depression or sum ST-segment elevation >0.8 mV (large ST) in 522 inferior AMI patients of the Hirudin for Improvement of Thrombolysis (HIT-4) Trial. In 187 patients, 90-min coronary angiography was performed.Results. Right ventricular involvement was present in 169 patients (32%). Higher 30-day cardiac mortality rates with RVI (5.9% vs. 2.5%) were related to larger infarct size rather than to RVI. For large ST, a proximal right coronary artery lesion was observed in 52% with and in 23% without RVI. Patency rates at 90 min were similar (54% vs. 52%). In the 28% of patients who had small ST, cardiac mortality was less than 1% irrespective of the presence of RVI. Coronary artery lesions were mostly located distally. Patency rates were 27% with and 80% without RVI.Conclusions. ST-segment elevation of ≥0.1 mV in V₄R in inferior AMI patients is associated with larger infarct size and higher 30-day mortality rates. Right ventricular involvement is not an independent predictor of survival. In patients with small ST, cardiac mortality is low, even if ST V₄R is ≥0.1 mV.     

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.