值得重视的aVR导联的特殊作用

约100年之前,临床心电图学之父Einthoven首先提出等边三角理论,并由此创用心电图I、Ⅱ、Ⅲ标准导联。此后,Wilson又创用单极加压肢体导联即aVR、aVL、aVF,形成六轴导联体系,延用至今。在这六轴系统中,位于额面右上方位的探查电极只有aVR导联,其负极置于左下30°处,位于I和Ⅱ导联之间。这一导联当时设置时是具有其特殊意义的,但以后由于胸导联的出现和普遍重视I、Ⅱ导联,aVR导联常被疏忽。其实,aVR导联有不容忽视的重要价值,值得复习。一、对心室肥大的诊断价值心脏在胸腔中,可由于各种原因而转位。例如在顺钟向与逆钟向转位时,由于膈…     

aVR导联对心律失常的定位意义

1942年Goldberger对Wilson于1934年创立的单极导联作了改进,并提出加压单极肢体导联后,aVR导联被临床广泛采用。美国心脏病学会（AHA）于1954年将其作为规范化的导联之一。在额面六轴系统中探查电级位于额面的右上方只有aVR导联。随着心电学的发展,近年来已日益证实aVR导联在心律失常定位方面有着不容忽视的重要价值。     

心电图aVR导联在急性心肌梗死中的诊断价值(附126例急性心肌梗死心电图分析)

目的探讨aVR导联在急性心肌梗死中的诊断价值。方法回顾性分析急性心肌梗死患者126例心电图,参照患者冠状动脉造影资料,了解aVR导联心电在不同部位心肌梗死中的变化。结果在右冠状动脉（right coronary artery,RCA）及RCA伴多支病变,aVR导联多出现初始r波。aVR导联sT段压低,亦多出现在RCA及RCA伴多支病变时。aVR导联ST抬高在3支病变、左主干伴多支病变时发生率较高。结论aVR导联在诊断急性心肌梗死部位有一定的价值。     

aVR导联临床应用的新视点

aVR导联是一个经常被忽略的导联,但是,近几年的研究显示aVR导联在诸多方面都发挥着重要的作用。aVR导联经典的临床应用包括窦性心律的确认、电轴的确定、右位心和左右手反联及心室肥厚的诊断。其临床应用的新发现包括:急性冠脉综合征时,aVR导联ST段抬高提示左主干、左前降支近端或三支病变;在ST段抬高型心肌梗死中aVR导联ST段抬高或下移是住院患者死亡率的独立预测因子,可用于危险分层;分析心律失常时,aVR导联可用于鉴别宽QRS型、窄QRS型心动过速;体表心电图的aVR导联结合V1、V2导联可以估算右房房颤周长,并且aVR导联P波振幅是心脏手术术后房颤发生的强有力的预测因子;Brugada综合征时出现"aVR征"有助于危险分层;右室负荷过重时,aVR导联ST段抬高是急性肺栓塞的死亡预测因子(单变量回归分析)和并发症的预测因子;aVR导联R波延迟是慢性右室压力负荷过重的独立预测因子且多见于肺动脉狭窄患者;特发性肺动脉高压的患者中,aVR导联R波>4mm,结合V1导联R波>6mm、R/SV1>1,R/SV5与R/SV1比值<0.04,Ⅱ导联P波>2.5mm可以诊断右室肥厚;当疑似预激综合征时,利用体表心电图同时出现PR间期≤120ms和PR离散度≥20ms、aVR导联缺少初始正向波(间隔R波)和V1导联水平面QRS移行提前这3步可识别心室预激,且具有较高的特异性和敏感性;连续监测aVR导联R波和R/S比例有助于预测三环类抗抑郁药物中毒时意识的恢复;急性心包炎时,aVR导联ST段压低、PR段抬高形成了急性心包炎的特征性表现,即"关节征",并且可能是急性心包炎最早甚至是唯一的心电图改变,具有早期诊断价值。     

食管心脏电生理技术与临床应用（2）--食管导联心电图

1.4无创性心房标测心脏标测是确定心脏最早激动点或激动顺序的电生理检查技术,通常采用常规导管电极直接标测心腔内各部位的电位,同时结合记录体表多导联心电图的方法来了解心脏电活动。目前,新一代心脏电生理标测系统,如心脏激动电磁标测系统（CARTO）和非接触球囊标测系统（EnSite 3000）已经广泛应用于临床。心脏激动顺序的心内膜导管法标测包括：（1）窦性心律标测;（2）异位节律标测;（3）心脏起搏标测;（4）心动过速标测等,可了解心脏正常顺向激动与逆向激动顺序、发生心律失常时异常激动顺序、激动起源部位的定位等。无创性心房标测是测量体表各导联,尤其是V1 P波（PV1,代表右心房激动）与食管导联P波（PE,代表左心房激动）的时间,以及各导联的P波形态等。通常采用50mm～100mm/s的纸速,能更加准确测量时距。在窦性心律或心律失常时根据PV1与PE的时间可了解左、右心房的激动顺序,以明确心律失常的性质。1.4.1窦性心律标测窦性频率较快时心房激动常起始于高位右心房,窦性频率相对慢时心房最早激动点多位于右心房中部侧壁,心腔内标测时这些部位的A波最早出现。在心房传导顺序正常的情况下,窦性激动从该处传导至低位右心房、希氏束部位,最后到达左心房。无创性心房标测时,体表各导联出现窦性P波,V1 P波早于食管导联P波出现。1.4.2异位节律标测当心脏某部位出现异位节律时,无创性心房标测可初步了解心脏的激动顺序：（1）起源于右心房的期前收缩,V1 P波早于食管导联P波出现;起源于左心房的期前收缩,食管导联P波早于V1 P波出现。结合Ⅱ、Ⅲ、aVF P波直立或倒置,还可判断期前收缩起源于心房上部或下部。（2）房室交接性期前收缩时,心房激动顺序为逆行性,P波在Ⅱ、Ⅲ、aVF倒置。间隔部先激动,同时向左、右心房呈放射性传播,V1 P波与食管导联P波几乎同时出现。（3）室性期前收缩如果能逆传至心房,提前的宽大畸形QRS波群后出现P-波,从房室结逆传的心房激动顺序与房室交接性期前收缩相似,但R-P-间期长于后者。1.4.3起搏标测创伤性心脏电生理检查可在心腔内各个不同部位进行起搏标测,常见有右心房、冠状窦及右心室起搏。无创性心房标测主要通过经食管心房起搏,改变刺激频率或期前刺激偶联间期来了解：（1）刺激引起的心房激动顺序;（2）刺激诱发的单次折返或心动过速时的心房激动顺序;（3）心房期前收缩顺传心室形成的QRS波群,可视为室性期前收缩。观察QRS波群后各导联的R-P-间期与P波形态,可了解心室激动沿不同途径逆传至心房的激动顺序（图7）。     

将AVR导联作为常规多导心电图的节律导联在心律失常诊断中意义的探讨

目的探讨将aVR导联作为常规多导联心电图的节律导联在心律失常诊断中的价值。方法收集我院自2007年1月至2009年7月间收治心律失常患者1874例,均设置aVR导联为节律导联之一进行常规多导心电图检查,结合心内电生理检查结果进行对比分析,观察aVR导联在基本心律起源的诊断及各型心律失常的鉴别诊断中的作用。结果各型心律失常(各类早搏1119例,房颤并宽QRS波87例,室上速59例,宽QRS心动过速29例,各类逸搏273例,其他307例)均可由aVR导联记录并准确定位。结论将aVR导联替代II导联作为常规多导联心电图的节律导联用于分析基本心律起源和心律失常起源更合理。     

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 段改变对不同冠脉血管病变的诊断及鉴别诊断意义

冠状动脉左主干及其主要分支病变均可引起心电图 aVR 导联 ST 段的抬高或压低,但不同血管病变所致心肌缺血或梗死的危险分层及临床预后却相差甚远,因此对不同冠脉血管病变的诊断及鉴别诊断非常重要。这其中 aVR 导联 ST 段的改变具有重要的临床意义,其诊断及鉴别诊断价值高于其他任何单一或多个导联。本文就 aVR 导联 ST 段的抬高或压低对不同冠脉血管病变的诊断及鉴别诊断意义、诊断标准及国外近年来的研究进展进行综述。     

aVR导联表现的临床意义

常规心电图检查简便易行,aVR导联的不同改变对临床诊断一些心律失常、左右心室肥大、冠状动脉不同部位的闭塞或狭窄等都有一定的意义,这对基层医院特别重要。在大型医院,又可反过来指导和验证我们的心脏电生理和冠状动脉造影位置。     

心电图aVR导联的临床应用价值

以往aVR导联常常不被人们重视，据调查仅有6％～20％的心电图分析者会注意分析aVR导联，大多数心电工作者及临床医师认为aVR导联仅能反映心脏左侧导联（如II、aVL、V”V。导联）相对应的心电变化，诊断价值有限，形成了心电学诊断的一个误区。本文就其临床应用价值作如下综述。     

Twelve-lead electrocardiogram: the advantages of an orderly frontal lead display including lead -aVR

BACKGROUND: It is possible that efforts in ECG review by both young experienced clinicians are currently discouraged-and risk to be completely dismissed-by the conventional (ie, disorderly) display of the frontal plane leads, with lead aVR at -150 degrees. METHODS: We reviewed studies on the usefulness of leads aVR and -aVR as well as on the history of the frontal leads in electrocardiography. RESULTS: Lead aVR and particularly, lead -aVR, provide useful information when systematically analyzed. In addition, if lead -aVR is examined in its anatomically logical sequence, ie, aVL, I, -aVR, II, aVF, and III, the frontal plane of the 12-lead ECG is more easily understood. This "panoramic" or "orderly" display is in common use in countries such as Sweden, but it is rarely seen in the United States. CONCLUSIONS: ECG interpretation would be enhanced by displaying the limb leads in an orderly arrangement that starts with lead aVL and ends with lead III, and many ECG changes would be ideally displayed by a lead -aVR at 30 degrees.     

Clinical Value of Lead aVR

Lead aVR is the only lead in the surface ECG that does not face the “typically” relevant walls of the left ventricle. Historically, its value has been neglected most likely due to its unusual configuration and direction, which appeared to have little correlation with other more congruous and easily diagnostic frontal leads. The isolation of the unipolar leads in the Standard surface ECG presentation may also have played an important role. Even with this “unfair” neglect, we know nowadays that it is very sensitive to locate obstructed epicardial coronary arteries. Besides helping distinguishing the culprit lesion of an infarct, lead aVR also helps recognizing other conditions that could be of clinical significance such as pericarditis, Brugada syndrome, fascicular blocks of the right branch, ectopic left atrial rhythms, etc. The purpose of this review is to revise the clinical value of lead aVR in the recognition of frequent and not so frequent clinical conditions. Ann Noninvasive Electrocardiol 2011;16(3):295–302     

Limb leads of the electrocardiogram: sequencing revisited

The six limb leads are normally presented in a format the logic of which is traditional rather than anatomical and does not allow visual interpolation such as is customary with the six chest leads. The sequence: a VL, I, -aVR, II, aVF, III was suggested years ago, and is used in some European countries, particularly Sweden. It provides a better impression of the extent of the changes of inferior infarction and makes the rather neglected lead aVR much more useful, though reversed in polarity. It also provides a more direct indication of the electrical axis, and simplifies comparisons with the frontal plane vectorcardiogram. Because modern digital electrocardiographs can provide the sequenced format, this seems a good time to review the advantages of adopting it.     

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。     

aVR导联ST段抬高对非ST段抬高型急性心肌梗死的意义

目的：探讨aVR导联ST段抬高（ ST segment elevation ,STSE）对于非STSE型急性心肌梗死（ acute myocardial infarction , AMI ）的预测价值。方法回顾性分析425例非STSE 型AMI患者的心电图资料,并观察各导联ST段压低情况及是否存在T波倒置。对所测定数据进行整理和统计学处理。结果 aVR导联STSE多见于完全性右束支阻滞、左心室肥厚以及V1导联STSE的患者,在其他导联广泛ST段压低的患者中也较为多见;此类情况在T波倒置患者中较少见。本研究中,22例在住院时死亡,其中5例死于心源性休克。患者住院死亡率的不断升高和aVR导联STSE的等级不断上升相关。多重变量分析表明,aVR导联STSE已经成为预测住院死亡的独立重要变量。 aVR导联STSE大都与住院患者的心肌缺血时间以及发生心力衰竭相关,但是与血清肌酸激酶或肌酸激酶同工酶 MB 的水平高低没有相关性。结论如果aVR导联STSE和严重冠状动脉病变之间的联系,能够在大样本非STSE型AMI患者群体中得到进一步验证,那么aVR导联STSE就可以成为选择早期介入治疗患者的一个较为有用的指标。     

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.     

急性下壁心肌梗死aVR导联QRS波的形态分析

目的探讨下壁心肌梗死时心电图aVR导联QRS波群形态的改变。方法分析89例急性下壁心肌梗死患者心梗前、后以及1年后的心电图和100例经冠状动脉造影证实的无冠心病患者的心电图,分析aVR导联QRS波群形态的变化。结果急性下壁心肌梗死前和无冠心病患者的心电图aVR导联QRS波群多呈q(Q)r型(89.2%),少数呈QS型(10.8%);下壁心肌梗死后及1年后心电图aVR导联QRS波群多呈rs(S)型(86.21%),少数呈QS型(12.77%),极少数呈Qr型(1.02%)。结论下壁心肌梗死后心电图aVR导联QRS波群多呈r(sS)型。     

Prognostic Significance of T‐Wave Amplitude in Lead aVR on the Admission Electrocardiography in Patients with Anterior Wall ST‐Elevation Myocardial Infarction Treated by Primary Percutaneous Intervention

Background: T‐wave positivity in aVR lead patients with heart failure and anterior wall old ST‐segment elevation myocardial infarction (STEMI) are shown to have a higher frequency of cardiovascular mortality, although the effects on patients with STEMI treated with primary percutaneous coronary intervention (PCI) has not been investigated. In this study, we sought to determine the prognostic value of T wave in lead aVR on admission electrocardiography (ECG) for in‐hospital mortality in patients with anterior wall STEMI treated with primary PCI. Methods: After exclusion, 169 consecutive patients with anterior wall STEMI (mean age: 55 ± 12.9 years; 145 men) undergoing primary PCI were prospectively enrolled in this study. Patients were classified as a T‐wave positive (n = 53, group 1) or T‐wave negative (n = 116, group 2) in aVR based upon the admission ECG. All patients were evaluated with respect to clinical features, primary PCI findings, and in‐hospital clinical results. Results: T‐wave positive patients who received primary PCI were older, multivessel disease was significantly more frequent and the duration of the patient's hospital stay was longer than T‐wave negative patients. In‐hospital mortality tended to be higher in the group 1 when compared with group 2 (7.5% vs 1.7% respectively, P = 0.05). After adjusting the baseline characteristics, positive T wave remained an independent predictor of in hospital mortality (odds ratio: 4.41; 95% confidence interval 1.2–22.1, P = 0.05). Conclusions: T‐wave positivity in lead aVR among patients with an anterior wall STEMI treated with primary PCI is associated with an increase in hospital cardiovascular mortality.     

镜像右位心的F导联心电图特征读析

目的 探讨F导联心电图诊断镜像右位心的特征。方法 在健康体检中应用F导联采集镜像右位心心电图并解读。结果 F导联检测到13例(0.018%)镜像右位心。在镜像右位心中Ⅰ导联各波形态均倒置,即P、QRS及T波均倒置;F2(Ⅱ)与F6(Ⅲ)导联、F3(aVR)与F1(aVL)导联波形互换;V3R、V5R导联波形类似正常时的V3、V5导联,代表左室波形;V1和V2导联代表右室波形。结论 镜像右位心的特征显示:P波F1(aVL)、F2(Ⅰ)导联显示镜像QRS波形;F1(aVL)、F2(Ⅰ)、F3(-aVR)、F4(Ⅱ)导联P-QRS-T波群均主波向下,呈rS型,其R波波幅递增;QRS波F5(aVF)不变;胸导联V1～V6呈rS型,其R波波幅递减,其S波呈逐渐相对增深,R/S比例逐渐减小的规律;V1导联R波高尖;常伴有其他心电图改变。