急性前壁心肌梗死合并下壁导联ST段下移的临床意义

48例首次急性前壁心肌梗死患者中伴下壁导联ST段平均下移>1mm、持续时间>48h者,CK和CK-MB的平均峰值更高,核素检查左室射血分数<40％,左室下壁运动障碍、出现放射性稀疏或缺损区的发生率也更高(P<0.05或<0.01)。说明这类病人有下壁心肌缺血,且可能心肌坏死面积更广。     

急性前壁心肌梗塞时下壁导联心电图ST段变化的意义

探讨ＥＣＧ胸前导联ＳＴ段抬高伴下壁Ⅱ，Ⅲ，ａＶＦ导联ＳＴ段压低与冠状动脉病变的关系。对６０例急性前壁心肌梗塞病例进行回顾分析，所有病人于发病后４周左右行冠状动脉造影检查。结果（１）３３例前降支单支血管病狭窄达９０％－１００％组，７７．８％出现Ⅱ，Ⅲ，ａＶＦ导联ＳＴ段压低０．１≥ｍＶ，狭窄７０％８９％组仅２３．１％出现Ⅱ，Ⅲ，ａＶＦ导联ＳＴ段压低≥０．１ｍＶ，两组间在统计学差异有极显著性。（２）６０     

Concomittant ST elevation in inferior and anterior leads in acute myocardial infarction. Clinical and anatomical significance

Various instances of acute myocardial infarction that may cause concomittant ST-segment elevation in inferior and anterior leads are presented. Among the situations that produce this phenomenon are: (1) multivessel coronary artery disease or isolated disease of a dominant left anterior descending artery causing combined inferior and anterior myocardial infarction; and (2) isolated disease of a right coronary artery causing combined infarction, or isolated right ventricular myocardial infarction. The mechanisms responsible for the electrocardiographic patterns in each instance are discussed.     

急性下壁心肌梗死心电图胸前导联V1-3 ST段抬高的临床意义

目的 探讨急性下壁心肌梗死患者心电图胸前导联ST段抬高与冠状动脉造影所示冠状动脉病变的关系及其临床意义.方法 187例急性下壁心肌梗死患者,按入院时18导心电图胸前导联ST段改变分为2组,ST段抬高组（16例）和非ST段压低组（171例）.所有患者均行冠状动脉造影术,病变适合行经皮腔冠状动脉成型术并检测B型钠尿肽（BNP）.结果 急性下壁心肌梗死伴胸前导联ST段抬高时多为右冠状动脉近段闭塞,尤其是圆锥支闭塞（P＜0.01）,且伴有右心功能不全和血流动力学障碍,与下壁右室心梗相比BNP差异有统计学意义（P＜0.01）.结论 急性下壁心肌梗死合并胸前导联ST抬高表明为右冠状动脉近段或开口闭塞且多伴右室心肌梗死和心功能不全.     

Clinical significance of precordial ST segment depression during acute inferior myocardial infarction

To investigate the mechanisms and clinical significance of precordial (V1-V4) ST segment depression during acute inferior myocardial infarction, stress thallium-201 scintigrams and coronary angiograms were obtained within four to eight weeks after the onset of myocardial infarction in 37 patients experiencing their first acute inferior myocardial infarction. Among 18 patients with precordial ST depression (group 1), 11 with concomitant disease of the left anterior descending artery (LAD) had positive results on exercise test, whereas in seven patients without LAD lesion, only two had positive exercise test (p less than 0.01). In 19 patients without precordial ST depression (group 2), 11 had severe stenosis in the LAD. However, among these 11 patients, only two had positive exercise tests. Patients with precordial ST depression demonstrated a higher frequency of positive exercise tests than those without it (p less than 0.01). On stress thallium-201 scintigraphy, a perfusion defect involving the inferior wall was present in all patients, but additional anterior wall ischemia was present in only five of the 18 patients in group 1. These five patients had chest pain on exercise tests and a severe stenosis greater than 90% in the LAD. There was no significant difference in the frequency of additional posterolateral wall infarction between groups 1 and 2. In 18 patients in group 1, sigma ST (total degrees of ST segment depression in leads V1, V2, V3, and V4 in the acute stage) was significantly greater in 11 patients with LAD lesion than in seven without (p less than 0.05), and sigma ST greater than five mm was observed in 12 of 13 patients who had additional anterior wall ischemia and posterolateral wall infarction on stress thallium-201 scintigraphy (p less than 0.05). Myocardial revascularization, such as aortocoronary bypass surgery or percutaneous transluminal coronary angioplasty (PTCA), was performed in six of the 18 patients in group 1 in the chronic stage, but in only one of the 19 patients in group 2. Thus, in patients with initial acute inferior myocardial infarction, those with precordial ST depression seemed to be a high-risk group. It was suggested that, during the early stage of myocardial infarction, this abnormality on electrocardiograms is related to the summation of effects of anterior wall ischemia and posterolateral wall infarction. Furthermore, the sigma ST evaluation is useful in differentiating a mirror image of inferior wall infarction from anterior wall ischemia and posterolateral wall infarction as the mechanism of precordial ST depression.     

急性前壁心肌梗死下壁导联ST段压低的临床价值

目的 探讨急性前壁透壁性心肌梗死时下壁导联ST段压低的临床价值。方法 比较任一下壁导联ST段压低≥1.0mm的17例与压低均＜1．0mm的16例的CK－MB值、超声心动描记术、冠状动脉造影等结果。结果 前组CK－MB值更高,射血分数减低更显著,左室收缩与舒张末期容积更大,造影术示致梗死狭窄病变多位于左前降支近端或呈多支病变。结论 急性前壁心肌梗死下壁导联ST段压低≥1.0mm时,其梗死面积较大,会发生较严重的左室射血功能损害及左心室重构。     

Mechanism of anterior ST segment depression during acute inferior myocardial infarction. Observations during coronary thrombolysis

Anterior ST segment depression, found in 13 of 17 patients with acute inferior myocardial infarctions, resolved promptly in all 11 patients whose occluded right coronary arteries were opened with an infusion of streptokinase. Failure of streptokinase to open the artery produced no change in the electrocardiogram. Five of the patients with anterior ST segment depression had normal left anterior descending coronary arteries. In the other patients opening the right coronary artery normalized the anterior ST segments without resulting in collateral flow to the anterior wall, or changing blood pressure or heart rate. Anterior ST depression was a manifestation of the inferior infarction and was not due to anterior ischemia.     

急性前壁心肌梗死伴下壁导联ST段下移的临床意义

目的　探讨急性前壁心肌梗死患者入院时心电图下壁导联 ST段下移与临床预后及左冠状动脉前降支“罪犯”血管病变部位之间的关系。方法　选择 1998年 1月～ 2 0 0 2年 10月住院诊治并行冠状动脉造影的急性前壁心肌梗死患者 5 9例 ,依据冠状动脉造影所示左前降支“罪犯”血管病变部位与第一对角支起始部的关系分成两组 , 组 36例病变部位位于第一对角支发出前 , 组 2 3例病变位于第一对角支发出后。结果　 组 36例占 6 1.0 1% , 组 2 3例占 38.98%。 组病人多数合并下壁导联 ST段下移≥ 1mm ,在 、 、a VF导联分别为 81% ,92 % ,79%。 组多数 ST段位于等电位线或 ST段下移 <1m m,在 、 、a VF导联分别为 6 0 % ,6 1% ,5 3%。结论　急性前壁心肌梗死患者入院时心电图下壁导联 ST段下移可以预测“罪犯”血管病变部位位于第一对角支起始部近端 ,而 ST段位于等电位线或 ST段下移 <1mm预示病变部位位于前降支远端     

急性广泛前壁心肌梗死并Ⅱ、Ⅲ、avF导联ST段压低的临床意义

目的　探讨急性前壁心肌梗死并心电图 、 、av F导联 ST段压低的临床意义。方法　随机选取 5 5例急性广泛前壁心肌梗死病人 ,根据入院时心电图 、 、av F ST段是否压低分为 ST段压低组 (n=35 )与 ST段无压低组 (n=2 0 )。 1月内作冠状动脉造影和心电图 ,比较两组病人合并其它冠状动脉病变的发生率、心功能及严重心律失常的发生率。结果　 ST段压低组合并其他冠状动脉病变的发生率为 77.14 % ,其中单支病变右冠状动脉 2 2 .86% ,左回旋支 17.14 % ,合并双支病变 37.14 % ,而无 ST段压低组合并其它冠状动脉病变的发生率为 15 .0 %。在广泛前壁加高侧壁心肌梗死 、 、av F ST段压低时合并其它冠状动脉病变的发生率为 12 .5 0 %。结论　急性广泛前壁心肌梗死伴 、 、av F ST段压低时多提示合并右冠状动脉和左回旋支病变 ,而广泛前壁加高侧壁心肌梗死并出现 、 、av F ST段压低更可能是一种对应性变化     

Electrocardiographic predictors of culprit artery in acute inferior ST elevation myocardial infarction

Background

In acute inferior ST-segment elevation myocardial infarction (STEMI), multiple electrocardiographic algorithms have been proposed to predict the culprit artery. Our purpose is to review these and compare them to ST depression in lead aVR to predict culprit artery in inferior STEMI.

Methods

In 106 patients with acute inferior STEMI who underwent emergent coronary angiography, we correlated electrocardiographic and angiographic findings pertaining to the culprit artery. We then reviewed the algorithms proposed by Fiol et al and Tierala et al, and applied them and our own from Kanei et al using ST depression in aVR for predicting the left circumflex artery (LCx) as the culprit, to the population. Finally, we compared the sensitivities and specificities of the respective algorithms for predicting the culprit artery.

Results

The sensitivity and specificity of ST depression in lead aVR to predict LCx as the culprit were 53% and 86%, respectively, and 86% and 55%, respectively for predicting the right coronary artery (RCA) as the culprit. When their algorithms were applied to our population, the sensitivities and specificities of Fiol et al and Tierala et al were slightly higher.

Conclusion

Compared to other proposed algorithms, ST depression in aVR is a simple method with satisfactory sensitivity and specificity to predict the culprit artery in inferior STEMI.     

Clinical significance of glycated hemoglobin in the acute phase of ST elevation myocardial infarction

In population-based studies,including diabetic and nondiabetic cohorts,glycated hemoglobin A1c(HbA1c) has been reported as an independent predictor of allcause and cardiovascular disease mortality.Data on the prognostic role of HbA1c in patients with acute myocardial infarction(MI) are not univocal since they stem from studies which mainly differ in patients' selection criteria,therapy(thrombolysis vs mechanical revascularization) and number consistency.The present review is focused on available evidence on the prognostic significance of HbA1c measured in the acute phase in patients with ST-elevation myocardial infarction(STEMI) submitted to primary percutaneous coronary intervention(PCI).We furthermore highlighted the role of HbA1c as a screening tool for glucose intolerance in patients with STEMI.According to available evidence,in contemporary cohorts of STEMI patients submitted to mechanical revascularization,HbA1c does not seem to be associated with short and long term mortality rates.However,HbA1c may represent a screening tool for glucose intolerance from the early phase on in STEMI patients.On a pragmatic ground,an HbA1c testhas several advantages over fasting plasma glucose or an oral glucose tolerance test in an acute setting.The test can be performed in the non-fasting state and reflects average glucose concentration over the preceding 2-3 mo.We therefore proposed an algorithm based on pragmatic grounds which could be applied in STEMI patients without known diabetes in order to detect glucose intolerance abnormalities from the early phase.The main advantage of this algorithm is that it may help in tailoring the follow-up program,by helping in identifying patients at risk for the development of glucose intolerance after MI.Further validation of this algorithm in prospective studies may be required in the contemporary STEMI population to resolve some of these uncertainties around HbA1c screening cutoff points.     

女性急性ST段抬高型心肌梗死患者的临床特点

目的探讨女性急性ST段抬高型心肌梗死患者的临床特点。方法选取2014年9月至2016年12月首都医科大学附属北京天坛医院心血管内科诊断为急性ST段抬高型心肌梗死并行急诊冠状动脉造影的患者452例,按性别分为两组,女性组102例,男性组350例。回顾性分析患者一般临床资料、冠状动脉造影、实验室检查、心脏功能和结构及住院期间病死率。结果与男性组相比,女性组发病年龄大[(66.4±10.6)岁比(58.4±11.1)岁,P0.001],就诊时间晚[(4.6±4.9)h比(2.6±1.9)h,P0.001],GRACE评分高(206.5±45.1比186.7±50.5,P0.001)。此外,女性单支血管病变比例低(14.7%比32.6%,P=0.037),术后发生慢血流及使用IABP比例高(11.8%比4.6%,P=0.008;11.8%比5.4%,P=0.026)。女性组的肌酸激酶同工酶MB、高敏肌钙蛋白I和B型利钠肽峰值均显著高于男性组,超声心动图显示左心室射血分数显著低于男性组(53.9%±10.3%比57.9%±8.2%,P0.001)。女性组的住院期间病死率显著高于男性组(7.8%比2.3%,P=0.013)。结论女性急性ST段抬高型心肌梗死患者发病年龄大,就诊时间晚,冠状动脉造影显示病变重,血管开通后发生慢血流比例高,术后心功能差,住院病死率高。     

急性下壁心肌梗死伴胸导联ST段压低的临床意义

目的探讨急性下壁心肌梗死伴胸导联ST段压低的临床意义。方法观察64例急性下壁心肌梗死胸导联ST段压低与常规及24h动态心电图检查结果的关系。结果①单纯下壁心肌梗死不伴胸导联ST段改变显著多于伴胸导联ST段改变(P<0.01),下壁伴正后壁心肌梗死伴胸导联ST段改变显著多于不伴胸导联ST段改变(P<0.01),而下壁伴右心室心肌梗死与胸导联ST段改变无明显区别(P>0.05)。②伴胸导联ST段改变者严重室性心律失常与房室传导阻滞的发生率均较不伴胸导联ST段改变者高(P<0.05)。结论急性下壁心肌梗死伴胸导联ST段压低表明心肌梗死广泛,严重室性心律失常和房室传导阻滞的发生率明显增多。     

Angiographic correlates of anterior ST segment depression in acute inferior wall myocardial infarction.

This study was conducted prospectively to assess the correlation between the pattern of anterior ST segment depression on the admission electrocardiogram and the in-hospital morbidity and mortality in patients with acute inferior wall myocardial infarction. Coronary angiography was also done to assess its correlation, if any, with pattern of anterior ST segment depression. Our study cohort comprised of 165 consecutive patients with acute inferior wall myocardial infarction divided into four groups based on admission electrocardiogram. Group I (n = 33): patients with no anterior ST segment depression; group II (n = 16): patients with ST segment depression in leads V1-V3; group III (n = 71): patients with ST segment depression in leads V4-V6, I and aVF, and; group IV (n = 45): patients with ST segment depression in all anterior leads (V1-V6, I, aVL). The outcomes were analysed in terms of high grade atrioventricular block, Killip class II or higher failure, and in-hospital mortality. Coronary angiography was performed to analyse coronary anatomy. Group IV patients had increased incidence of complete heart block (37.8% vs 15.2% in the total group) (p < 0.001) and increased mortality (11.1% vs 4.2% in the total group) (p < 0.05). This group also had greater incidence of triple vessel disease (76.7%) (p < 0.001). Group II patients had greater incidence of double vessel disease (88.9%) (p < 0.05) and had no triple vessel disease. Group III patients had double vessel disease (76.5%) (p < 0.05) or triple vessel disease (23.5%) (p = NS) and no single vessel disease. Coronary angiography in group II showed greater incidence of involvement of left circumflex artery and right coronary artery while in group III there was left anterior descending artery and right coronary artery disease. We conclude that patients with anterior ST segment depression in group III and group IV categories are in high risk subset with acute inferior wall myocardial infarction.     

The relationship of ST elevation to eventual QRS loss in acute inferior myocardial infarction

The electrocardiographic changes of ST-segment elevation in acute myocardial infarction are related to the region of infarction. The authors examined body surface map data in 70 patients with acute inferior infarction to determine the exact relationship of the initial ST elevation to the eventual loss of QRS. The patients had no evidence of previous myocardial infarction and no subsequent infarction and did not receive thrombolytic therapy or other acute interventions, such as surgery. Maps were recorded on admission to the hospital, during the hospital admission and again at follow-up examination 6-48 months after infarction. The region of ST elevation of the initial body surface map was compared to a QRS loss region derived by subtracting the follow-up map, integrated over the 80 msec after the onset of the QRS, from a "QRS loss region" derived from 381 normal patients using the same interval. In 76% of patients there was a direct relationship between the position of the ST elevation and the QRS loss region (mean correlation coefficient, 0.49). In a further 15% of patients there was a general relationship without specific features, and in the remaining 8% the difference maps were not related to the position of ST elevation. The region of ST elevation predicts the eventual QRS loss in the majority of patients and may be useful for monitoring interventions in acute myocardial infarction.     

急性前壁心肌梗死时下壁导联ST段压低的临床意义

目的 :探讨急性前壁心肌梗死合并下壁导联 ST段压低的临床意义。方法 :回顾性分析2 2例首发急性前壁心肌梗死患者的心电图、冠状动脉及左室造影资料。结果 :急性前壁心肌梗死时下壁导联 ( 、 、a VF) ST段下移≥ 0 .0 5 m V组与 <0 .0 5 m V组的 、a VL导联 ST80 值有显著性差异 ( P <0 .0 5 ) ;两组的左前降支 6段 ( LAD6 )或 LAD始部病变的发生率也有显著性差异 ( P <0 .0 5 ) ;下壁导联 ST段压低≥ 0 .0 5 m V对 L AD6 或 LAD始部病变预测价值的敏感性及特异性分别是 : 导联 5 9%、5 0 % ; 导联 83%、70 % ;a VF导联 83%、70 %。结论 :急性前壁心肌梗死时下壁导联ST段压低预示 LAD6 或 L AD始部病变是高前侧壁发生透壁性心肌缺血的“镜像”反应 ,表现为 、a VL导联 ST段抬高 ;它与右冠状动脉、左旋支、多支病变以及胸前导联 ST段抬高程度无关