心电图缺血分级与急诊PCI术后心血管事件

目的心电图缺血分级(GI)已被证实可以预测急性ST段抬高型心肌梗死(STEMI)溶栓患者的预后,但尚不清楚心电图缺血分级对急诊经皮冠状动脉介入术(PPCI)的STEMI患者院内心血管事件的预测价值,本研究旨在探讨初始心电图缺血分级对已接受PPCI的STEMI患者住院期间心血管事件的影响。方法本研究纳入2008年7月至2011年8月在本中心诊断为STEMI并且接受PPCI的患者188例。患者按心电图表现分为两组:2级缺血组(GI2,ST段抬高不伴有QRS终末部分扭曲)和3级缺血组(GI3,在ST段≥2个相邻导联抬高伴有QRS终末部分扭曲)。观察终点为院内心血管事件(死亡、非致命性再次心肌梗死、心力衰竭和恶性心律失常)。结果 GI3组患者心律失常发生率、心力衰竭或者心源性休克等心血管事件的发生率均高于GI2组,差异有统计学意义。结论尽管已经接受急诊经皮冠状动脉介入治疗,初始心电图3级缺血仍然是STEMI患者住院期间心血管事件的独立预测因子。     

ST段抬高型急性心肌梗死患者入院时心电图表现的临床意义

目的:评价ST段抬高型急性心肌梗死(STEMI)患者入院时心电图缺血程度(ST段抬高和QRS波终末扭曲)对梗死范围和住院期间病死率判断的价值。方法:入选STEMI患者122例,发病时间均在12h以内,根据入院时心电图表现分为非QRS波终末扭曲组(n=73)和QRS波终末扭曲组(n=49),住院期间记录一般临床特征、动态监测肌酸激酶(CK)和肌酸激酶同工酶(CK-MB)水平,并记录住院期间死亡例数。结果:QRS波终末扭曲组发病年龄较大(P=0.001),ST段抬高导联数多(P=0.025)及入院时Killp分级>1者例数多(P=0.044),有较高的CK[(1526.5±1180.4)IUvs(2129.7±1414.1)IU,P=0.012]和CK-MB[(137.1±109.0)IUvs(184.9±117.0)IU,P=0.023]水平。2组住院期间病死率分别为6.8%vs20.4%,Logistic回归证实住院期间病死率与QRS波终末扭曲呈明显的相关性(OR值7.14,95%可信区间1.17～43.60,P=0.016)。结论:入院时心电图QRS波终末扭曲对STEMI患者梗死范围大小和住院期间病死率有独立的预测价值。     

老年急性ST段抬高心肌梗死患者的心肌缺血分级

目的探讨老年急性ST段抬高心肌梗死患者心肌梗死缺血分级。方法选择86例老年急性ST段抬高心肌梗死患者,根据心电图QRS波群进行心肌缺血分级,其中Ⅱ级缺血40例,Ⅲ级缺血46例,并对两组患者入院12 h内进行溶栓治疗,比较两组患者治疗前后的心电图、心功能及心律失常等指标。结果与治疗前相比,两组患者治疗后的ST段抬高幅度均显著下降(P0.05),但Ⅲ级心肌缺血患者治疗前和溶栓2 h后的ST段抬高幅度均显著高于Ⅱ级心肌缺血患者(P0.05),且溶栓2 h后,Ⅲ级心肌缺血患者的ST段回降≥50%的比例显著低于Ⅱ级心肌缺血患者的比例(P0.05);与Ⅱ级心肌梗死患者相比,Ⅲ级心肌梗死患者的心肌梗死面积、肌酸激酶同工酶(CK-MB)峰值、肌钙蛋白(c TNI)峰值、N端-脑纳肽前体(NT-pro BNP)、心律失常等并发症的发生率等均显著增加,但左心室射血分数(LVEF)显著降低(P0.05)。结论加强对心肌缺血分级的研究,对于老年急性ST段抬高心肌梗死患者的临床预后有积极的临床意义。     

急性ST段抬高型心肌梗死QRS波终末变形与冠状动脉病变程度的关系

目的探讨急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者心电图QRS波终末变形与冠状动脉病变程度的相关性。方法根据入院心电图将STEMI患者(n=80)分为QRS波终末变形阳性(3级缺血)组、QRS波终末变形阴性(2级缺血)组。两组均行冠状动脉介入治疗,以冠状动脉病变狭窄程度SYNTAX评分,分为高分组(≥22分)、低分组(22分)。结果 3级缺血组29例、2级缺血组51例,其中高分组27例、低分组53例。3级缺血组SYNTAX评分明显高于2级缺血组,差异有统计学意义[(20.2±8.3)分vs.(13.5±6.8)分,P0.001)]。高分组心电图3级缺血现象明显多于低分组,差异有统计学意义(50.4%vs.20.9%,P0.001)。多因素回归分析显示,3级缺血(P0.001)、年龄(P=0.017)、糖尿病(P=0.014)、前壁心肌梗死(P=0.012)是冠状动脉病变SYNTAX评分高的独立预测因素。结论 QRS波终末变形阳性可能与冠状动脉病变严重程度相关。3级缺血冠心病患者冠状动脉SYNTAX评分高可能有助于解释3级缺血与预后差的联系。对STEMI患者以心电图3级缺血来预测冠状动脉高SYNTAX评分,可能有助于选择最合适的血运重建策略。     

终末QRS变形与ST段测量估测急性前壁心肌梗死面积以及溶栓疗效的临床价值

利用SelvesterQRS计分系统,比较ST段测量与QRS终末变形对急性前壁心肌梗死(简称心梗)患者最后梗死面积和溶栓治疗效果的影响。选择644例第一次急性前壁心梗患者,其中398例接受溶栓治疗,246例未接受溶栓治疗。从入院时首次稳定心电图上估计ST段抬高的导联数目、ST段抬高的幅度(∑ST)及QRS终末形态。根据QRS终末变形存在与否将患者分为两组:QRS终末变形(QRS+)组,QRS终末无变形(QRS-)组。利用修改的SelvesterQRS计分系统,从出院前心电图上估计最后梗死面积。结果:接受与未接受溶栓治疗者QRS+组∑ST、ST段抬高导联数大于QRS-组,差异有显著性(P<0.05)。在QRS-和QRS+者,溶栓治疗均能减少Selvester计分;但最后梗死面积的减少仅在QRS-的患者有意义(P<0.01)。ST段抬高的幅度与最后梗死面积之间无相关性;ST段抬高导联数仅与溶栓治疗者的最后梗死面积有关(r=0.25141,P≤0.05)。溶栓组QRS+者无复灌流率较QRS-者高。结论:QRS终末变形较ST段测量能更好地估测急性前壁心梗患者的最后梗死面积和溶栓治疗的效果。     

QRS终末扭曲对急性ST段抬高型心肌梗死患者病情及预后的评估价值

目的探讨QRS终末扭曲对急性ST段抬高型心肌梗死(STEMI)患者病情及预后的评估价值。方法选择2016年6月至2017年6月于湖北省第三人民医院心功能科收治的STEMI患者139例为研究对象,按心电图特征将患者分为QRS终末扭曲组(n=61)、非QRS终末扭曲组(n=78),对两组患者的一般临床资料(性别、年龄、合并症、心肌梗死位置、病程、溶栓治疗比例、ST段抬高导联数、QRS积分、心肌酶、肌酸激酶、左室射血分数)以及预后指标(心血管事件发生率、死亡率、Killip心功能分级)进行比较。结果两组患者一般资料比较,在性别、合并症、心肌梗死位置、溶栓治疗比例、ST段抬高导联数目等方面无显著差异(P0.05)。QRS终末扭曲组患者年龄、病程、QRS积分、心肌酶和肌酸激酶水平均高于非QRS终末扭曲组,而左室射血分数低于非QRS终末扭曲组(P0.05)。QRS终末扭曲组患者的不良心血管事件发生率和死亡率均高于非QRS终末扭曲组,Killip心功能Ⅲ级和Ⅳ级患者比例高于非QRS终末扭曲组,差异有统计学意义(P0.05)。结论通过评估STEMI患者QRS波形扭曲程度,可实现对STEMI患者的病情及预后效果的判断。     

心电图QRS波群形态缺血分级与ST段抬高型心肌梗死患者严重心律失常及靶血管的关系研究

背景 目前,心电图QRS波群形态缺血分级与ST段抬高型心肌梗死(STEMI)患者严重心律失常发生风险及靶血管的关系尚未完全明确.目的 探讨心电图QRS波群形态缺血分级与STEMI患者严重心律失常及靶血管的关系.方法 选取2016年7月—2019年11月内江市第一人民医院收治的126例STEMI患者作为研究对象,按照入院...     

碎裂QRS波与急性心肌梗死血管再通的研究

目的通过观察急性ST段抬高型心肌梗死行急性血管再通及未行血管再通治疗的心电图碎裂QRS波(Fragmented QRS complex,fQ RS)变化,探讨fQ RS评估急性ST段抬高型心肌梗死血管再通的临床价值。方法观察急性ST段抬高型心肌梗死行急诊溶栓、行急诊经皮冠状动脉介入治疗(percutaneous transluminal coronary intervention,PCI)血管再通患者、未行急诊血管再通治疗患者心电图fQ RS发生率。结果 STEMI溶栓后冠脉血管再通组fQ RS波发生率明显低于未通组(p0.01);STEMI行急诊PCI后fQ RS波发生率明显低于未行急诊PCI组(p0.01);STEMI行急诊PCI术前组与术后组fQ RS发生率比较无明显差异(p0.05)。结论碎裂QRS波对评估急性ST段抬高型心肌梗死冠脉血管再通具有重要临床价值。     

QRS波终末改变在STEMI危险分层中的应用

目的 对急性ST段抬高心肌梗死(STEMI)患者心电图QRS波终末改变情况、危险分层情况探讨.方法 选取我院2019年3月至2020年3月接受检查的STEMI患者76例,均进行心电图检查,根据有无QRS波终末改变分为对照组(n=48),观察组(n=28).分析各危险分层患者QRS波终末部分改变患者的检出情况、比较两组各...     

急性ST段抬高心肌梗死QRS波群形态对溶栓后心功能及预后的影响

本文通过对急性ST段抬高型心肌梗死(STEMI)患者入院时心电图表现进行缺血分级,采用溶栓进行早期再灌注治疗,观察心电图变化、左心室功能和住院并发症,探讨心肌缺血分级的临床意义.     

Grade 3 ischemia on the admission electrocardiogram predicts rapid progression of necrosis over time and less myocardial salvage by primary angioplasty

BACKGROUND: Among patients with ST-elevation acute myocardial infarction, those with terminal QRS distortion (grade 3 ischemia) have higher mortality and larger infarct size (IS) than patients without QRS distortion (grade 2 ischemia). METHODS: We assessed the relation of baseline electrocardiographic ischemia grades to area at risk (AR) and myocardial salvage [100 (AR-IS)/AR] in 79 patients who underwent primary angioplasty for first ST-elevation acute myocardial infarction and had technetium Tc 99m sestamibi single-photon emission computed tomography before angioplasty (AR) and at predischarge (IS). Patients were classified as having grade 2 ischemia (ST elevation without terminal QRS distortion in any of the leads, n = 48), grade 2.5 ischemia (ST elevation with terminal QRS distortion in 1 lead, n = 16), or grade 3 ischemia (ST elevation with terminal QRS distortion in >2 adjacent leads, n = 15). RESULTS: Time to treatment was comparable among groups. AR was comparable among groups (38% +/- 20%, 33% +/- 23%, and 34% +/- 23%, respectively; P = .70). There were no differences among groups in residual myocardial perfusion (severity index 0.28 +/- 0.12, 0.29 +/- 0.16, and 0.30 +/- 0.15 in grades 2, 2.5, and 3 ischemia, respectively; P = .97). In contrast, there was a trend toward lower myocardial salvage (45% +/- 32%) in the grade 3 group than in the grade 2 (65% +/- 33%) and grade 2.5 (65% +/- 40%) groups ( P = .16). Salvage was dependent on time only in the grade 3 group. Spearman rank correlation coefficients between time to treatment and percentage salvage were 0.003 ( P = .99), -0.24 ( P = .38), and -0.63 ( P = .022) for grades 2, 2.5, and 3, respectively. CONCLUSIONS: Patients with grade 3 ischemia have rapid progression of necrosis over time and less myocardial salvage. This admission pattern is a predictor of myocardial salvage by primary angioplasty.     

Grade 3 ischemia on admission electrocardiogram and chest pain duration predict failure of ST-segment resolution after primary percutaneous coronary intervention for acute myocardial infarction

Objectives

ST resolution (STR) is a surrogate marker of myocardial tissue reperfusion and a predictor of outcome after primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI). Terminal QRS distortion (grade 3 ischemia) has been shown to predict failure of STR after thrombolysis for STEMI, but the ability of grade 3 ischemia to predict STR with pPCI is unclear.

Methods

We retrospectively analyzed 155 patients who underwent pPCI and compared grade 2 ischemia (ST elevation without terminal QRS distortion; n = 89) to grade 3 ischemia (n = 66) on admission for baseline characteristics, in-hospital course, and STR immediately after pPCI and at 18 to 24 hours.

Results

Patients with grade 3 ischemia were older (60 ± 12 vs 56 ± 11 years; P = .018), had more anterior STEMI (42% vs 17%; P = .0004), and were less often smokers (41% vs 90%; P = .004). The grade 3 ischemic group had significantly less complete STR (35% vs 75% [P < .00001] immediately after pPCI and 33% vs 79% [P < .00001] 18-24 hours after pPCI), a longer hospital stay (6.4 ± 4.1 vs 4.9 ± 1.9 days; P = .008), and higher peak CKMB (292 ± 231 vs 195 ± 176 ng/mL; P = .0005). Duration of symptoms before pPCI (odds ratio [OR], 0.838; 95% confidence interval [CI], 0.724-0.969; P = .017) and grade 3 ischemia (OR, 0.181; 95% CI, 0.068-0.480; P < .001) were negative predictors of complete STR, whereas nonanterior STEMI (OR, 5.95; 95% CI, 2.154-16.436; P < .001) and initial sum of ST elevation (OR, 3.132; 95% CI, 1.140-8.605; P = .027) were positive predictors.

Conclusion

Grade 3 ischemia on presentation of STEMI and duration of chest pain are strong independent predictors of failure to achieve complete STR after pPCI.     

Grade III ischemia on presentation with acute myocardial infarction predicts rapid progression of necrosis and less myocardial salvage with thrombolysis

We assessed the relation between baseline electrocardiographic ischemia grades and initial myocardial area at risk (AR) and final infarct size (IS) in 49 patients who had undergone (99m)Tc sestamibi single-photon emission computed tomography before and 6 +/- 1 days after thrombolysis. Patients were classed as having grade III ischemia (ST segment elevation with terminal QRS distortion, n = 19) or grade II ischemia (ST elevation but no terminal QRS distortion, n = 30). We compared AR and IS by baseline ischemia grade and treatment (adenosine vs. placebo) and assessed relations of infarction index (IS/AR ratio x100) to time to thrombolysis, baseline ischemia grade, and adenosine therapy. Time to thrombolysis was similar for grade II and grade III. For placebo- treated patients, the median AR did not differ significantly between grade II (38%) and grade III patients (46%, p = 0.47), nor did median IS (16 vs. 40%, p = 0.096), but the median infarction index was 66 vs. 90% (p = 0.006). For adenosine-treated patients, median AR (21 vs. 26%, p = 0.44), median IS (5 vs. 17%, p = 0.15), and their ratio (31 vs. 67%, p = 0.23) did not differ significantly between grade II and grade III patients. The infarction index independently related to grade III ischemia (p = 0.0121) and adenosine therapy (p = 0.045). Infarct size related to baseline ischemia grade and was reduced by adenosine treatment. Necrosis progressed slowlier with baseline grade II versus III ischemia, which could offer more time for myocardial salvage with reperfusion.     

Grade 3 ischemia on the admission electrocardiogram is associated with severe microvascular injury on cardiac magnetic resonance imaging after ST elevation myocardial infarction

Background

Grade 3 ischemia during ST elevation myocardial infarction (STEMI) is defined as ST elevation with distortion of the terminal portion of the QRS on electrocardiogram (ECG). The aim of this study was to evaluate the effect of ischemic grade on cardiac magnetic resonance (CMR) imaging infarct characteristics such as infarct size, microvascular obstruction (MVO), intramyocardial hemorrhage (IMH), and myocardial salvage.

Methods

Patients with STEMI treated with primary percutaneous coronary intervention had a 12-lead ECG on presentation for analysis of ischemic grade. Gadolinium-enhanced CMR imaging was performed within 7 days to assess infarct size, MVO, IMH, and myocardial salvage.

Results

Of the 37 patients enrolled in the study, grade 3 ischemia was present in 32%. Those with grade 3 ischemia had higher peak troponin I levels (P = .013), more MVO (P < .001), more IMH (P < .001), larger infarct size (P = .025), and less myocardial salvage (P = .012). Regression analysis found that grade 3 ischemia, infarct size, and peak troponin I level were significantly associated with MVO and IMH.

Conclusion

Grade 3 ischemia on the admission ECG during STEMI is closely associated with the development of severe microvascular damage on CMR imaging.     

The Initial Electrocardiographic Pattern in Acute Myocardial Infarction

Background: The ECG is the most widely used accessory for early diagnosis and risk stratification of patients with acute myocardial infarction (AMI). Previous studies have concentrated on the association between either the number of leads with ST segment deviation (elevation and depression) or the total amount of ST segment elevation and/or depression and prognosis. However, the results are conflicting. Methods: A different method is to use the grades of ischemia as an estimate of infarct or size and prognosis. Grade I ischemia is defined as tall peak T waves with < 0.1 mV ST segment elevation; grade II as ST segment elevation with positive T waves, without distortion of the terminal portion of the QRS; and grade III as ST segment elevation, positive T waves, and distortion of the terminal portion of the QRS. Grade III ischemia on the admission ECG is associated with larger final infarct size and increased mortality. Results: In patients with inferior wall AMI, especially those with prior infarction, the pattern of precordial ST segment depression is even more important and maximal ST depression in V4-V6 is associated with high mortality. Moreover, meticulous interpretation of the initial ECG pattern provides information about the probable site of the culprit obstructive coronary lesion. Conclusion: Thus, the admission ECG of AMI can assist not only in diagnosis, but also in estimation of infarct size, correlation with the underlying coronary anatomy and risk stratification.     

The Impact of Preinfarction Angina on Electrocardiographic Ischemia Grades in Patients with Acute Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention

Objective: Grade 3 ischemia (G3I) is defined as ST elevation with distortion of the terminal portion of the QRS (emergence of the J point >50% of the R wave in leads with qR configuration, or disappearance of the S wave in leads with an Rs configuration). Patients with G3I on the presenting electrocardiogram (ECG) had worse prognosis than the patients with lesser (grade 2‐G2I) ischemia. The aim of this study is to examine the effects of preinfarct angina (PIA) on electrocardiographic ischemia grades. Methods: One hundred forty‐eight consecutive patients with ST‐segment myocardial infarction (STEMI) were included in this study. All patients underwent primary percutaneous coronary intervention. The admission ECGs was analyzed retrospectively for electrocardiographic ischemia grades and compared with the presence of PIA. Results: Study population consisted of 110 patients with G2I (88 men, mean age = 63 ± 6 years) and 38 patients with G3I (32 men, mean age = 61 ± 8 years). Baseline characteristics of the groups were the same except for patients with G3I had significantly longer pain to balloon time and higher admission creatine kinase MB isoenzyme (CK‐MB) levels. Tissue myocardial perfusion grade (TMPG) was better in patients with G2I. While 18 patients (47%) with G3I had PIA, 81 patients (70%) with G2I had PIA (P = 0.005). Although pain to balloon time and admission CK‐MB were independent predictor of worse electrocardiographic ischemia grade (OR 1.69, 95% CI 1.09–2.62; P = 0.01; OR 1.01, 1.00–286 Conclusion: PIA is one of the most important clinical predictors of better ischemia grades especially when combined with the pain to balloon time, LVEF, and admission CK‐MB levels in patients with STEMI. This study provided another evidence for the protective effects of PIA.     

Terminal QRS distortion on admission is better than ST-segment measurements in predicting final infarct size and assessing the Potential effect of thrombolytic therapy in anterior wall acute myocardial infarction.

We assessed predicting final infarct size (using predischarge Selvester score) by 3 electrocardiographic variables in 267 patients with first anterior wall acute myocardial infarction (AMI) undergoing (n = 86) or not undergoing (n = 181) thrombolysis. Patients with previous AMI or inverted T waves in leads with ST elevation were excluded. The sum (sigma) of ST elevation, the number of leads with ST elevation, and the initial electrocardiographic pattern were determined on the admission electrocardiogram (absence (QRS-) or presence (QRS+) of distortion of the terminal portion of the QRS in > or =2 leads (J point > or =0.5 of the R-wave amplitude in leads I, aVL, V4 to V6, or presence of ST elevation without S waves in leads V1 to V3). There was no association between sigmaST elevation and final infarct size in patients who did or did not receive thrombolytic therapy. Analysis of covariance showed that the number of leads with ST elevation (F = 19.6), thrombolysis (F = 25.2), and QRS+ initial pattern (F = 19.5) were all associated with final infarct size (p <0.0001 for all). Among patients who did not receive thrombolytic therapy, the average Selvester score was 19.7+/-9.9 for the QRS- patients and 26.1+/-10.4 for the QRS+ patients (p = 0.02). Among patients who received thrombolytic therapy, the average Selvester score was 11.7+/-9.8 for the QRS- patients and 24.2+/-10.1 for the QRS+ patients (p <0.0001). Thrombolysis reduced final Selvester score only in the QRS- group (p <0.00001), but not in the QRS+ group (p = 0.45). It is concluded that (1) final Selvester score in anterior wall AMI can be predicted by the number of leads with ST elevation, the initial electrocardiographic pattern, and thrombolysis, and (2) thrombolysis reduces final Selvester score only in patients with QRS- pattern.     

Prediction of the extent and severity of left ventricular dysfunction in anterior acute myocardial infarction by the admission electrocardiogram

BACKGROUND: The grade of ischemia, as detected by the relation between the QRS complex and ST segment on the admission electrocardiogram, is associated with larger infarct size and increased mortality rates in acute myocardial infarction. METHODS: We assessed the correlation between left ventricular function and the admission electrocardiogram in 151 patients with first anterior acute myocardial infarction who received thrombolytic therapy and underwent cardiac catheterization at 90 minutes and before hospital discharge. The number of leads with ST elevation, sum of ST elevation, maximal Selvester score, and the presence of severe (grade 3) ischemia were determined in each electrocardiogram. Left ventricular ejection fraction, the number of chords with wall motion abnormalities, and the severity of dysfunction (SD/chord) were determined. RESULTS: At 90 minutes, the 39 ischemia grade 3 patients had lower ejection fraction than the 112 grade 2 patients. Both at 90 minutes and at hospital discharge, the grade 3 group had more chords with wall motion abnormalities and more severe regional dysfunction (SD/chord). However, the number of leads with ST elevation, sum of ST elevation, and maximal Selvester score had no correlation with ejection fraction at 90 minutes and only mild correlation with the extent of dysfunction (number of chords) at 90 minutes. There was no correlation between either the number of leads with ST elevation or the sum of ST elevation and the severity of regional dysfunction. CONCLUSIONS: The number of leads with ST elevation, sum of ST elevation, and maximal Selvester score had only mild correlation with the extent of myocardial dysfunction but not with the severity of dysfunction. Grade 3 ischemia is predictive of more extensive myocardial involvement and greater severity of regional dysfunction.     

LVH and the diagnosis of STEMI - how should we apply the current guidelines?

Left ventricular hypertrophy (LVH) induces changes in the depolarization and repolarization of the heart that alter the resting electrocardiogram (ECG). These changes include widening of the QRS duration, an increase in the QRS amplitude and secondary changes in the ST segment and T waves. Typically, there is ST segment depression and T wave inversion (or biphasic T waves) in the lateral leads and ST segment elevation (STE) in the precordial leads V1-V3. However, other patterns of ST-T changes may occur. These changes may vary over time and may not necessarily reflect acute ischemia. The ST-T changes secondary to LVH interfere with ECG interpretation and may affect our accuracy in diagnosing STEMI and other forms of active ischemia. The current guidelines specify thresholds for STE in patients without LVH for whom acute reperfusion therapy is indicated; however, there are no such thresholds for patients with LVH.