急性后间壁心肌梗死心电图诊断标准商榷

目的　对 4例下壁急性心肌梗死 (AMI)伴V1 3 和V3R 5R导联ST段抬高入院诊断为下壁、右室合并前间壁AMI的梗死部位进行探讨 ,藉以商榷急性后间壁心肌梗死诊断标准。方法　根据心电图及核素心肌灌注显像和冠状动脉造影资料进行分析。结果　 4例患者心电图表现为Ⅱ、Ⅲ、aVF、V1 3 和V3R 5RST段抬高 ,其中V1导联ST段抬高最显著 ,放射性核素99mTc MIBI心肌灌注缺损部位在下壁和后间壁 ,4例患者梗死相关动脉均为右冠状动脉。结论　根据以上发现我们提出后间壁AMI的心电图诊断标准如下 :①下壁AMI同时伴V1导联ST段明显抬高≥ 2mm ;②ST段抬高的幅度呈V1>V2 >V3 和V1>V3R>V4R,同时具备以上两个条件即可诊断为下壁、后间壁AMI。     

常规心电图在心肌梗死诊断中的价值

目的 在心肌梗死患者中，观察心电图改变与梗死相关冠脉(IRA)病变之间的相关性。方法 51例入选分析。所有病例均接受冠脉造影。结果 以左前降支(LAD)为梗死相关冠脉(IRA)，单次梗死者，最常累及的导联是V2导联，无论单支病变还是双支和三支病变，部分病例都累及右胸导联和下壁导联；以右冠(RCA)或左回旋支(LCX)为IRA，均可累及下壁和右胸导联，但LCX可累及高侧壁或侧壁。结论 在心肌梗死患者中，分析常规12导联心电图，有助对冠脉病变的推测，在此基础上加选用导联，能更精确推测冠脉病变。     

Acute anterior wall myocardial infarction entailing ST-segment elevation in lead V3R, V1 or aVR: electrocardiographic and angiographic correlations

Background

The correlation between ST-segment elevation (ST↑) in lead V₃R (ST↑_V3R), lead V₁ (ST↑_V1), and lead aVR (ST↑_aVR) during anterior wall acute myocardial infarction (AMI) and the culprit lesion site in the left anterior descending (LAD) coronary artery and the nature of the conal branch of the right coronary artery has not been throughly described.

Methods

One hundred forty-two patients with first anterior wall AMI were included. The 15-lead electrocardiogram with the standard 12 leads plus leads V₃R through V₅R showing the most pronounced ST-segment deviation before initiation of reperfusion therapy was evaluated and correlated with the exact LAD occlusion site in relation to the first septal perforator (S1) and the nature of the conal branch of the right coronary artery as determined by coronary angiography.

Results

ST-segment elevation in lead aVR, ST↑_V1 of at least 2 mm, and ST↑_V3R of at least 1 mm were more prevalent among patients with occlusions proximal to S1 than patients with occlusions distal to S1 (41.7% vs 4.9%, P < .01; 30.0% vs 7.3%, P < .01; and 91.7% vs 4.9%, P < .01, respectively). Of the 60 patients with occlusions proximal to S1, 20 patients had a small conal branch (18 patients with ST↑_aVR and 15 patients with ST↑_V1 ≥2 mm), and 24 patients had a large conal branch (all patients with non-ST↑_aVR and ST↑_V1 <2 mm; P < .01). The sensitivity of ST↑_V1 of more than 1 mm, of at least 2 mm, ST↑_V3R of at least 1.5 mm, and ST↑_aVR for detecting a small conal branch was 65.1%, 81.8%, 84.0%, and 90%, respectively; the specificity was 68.5%, 64%, 66.7%, and 64.9%, respectively.

Conclusions

In patients with anterior wall AMI, ST↑_V3R of at least 1 mm combined with ST↑ in leads V₂ through V₄ were strongly predictive of LAD occlusion proximal to S1; furthermore, ST↑_aVR and ST↑_V1 of at least 2 mm were found to be useful in identifying LAD occlusion proximal to S1. ST↑_aVR, ST↑_V3R of at least 1.5 mm, and ST↑_V1 of at least 2.0 mm were also associated with the presence of a small conal branch not reaching the intraventricular septum during anterior wall AMI.     

判断急性下壁心肌梗死冠状动脉堵塞位置心电图新标准的探讨

目的 :评价判断急性下壁心肌梗死 (AIMI)梗死相关血管的心电图新标准。方法 :将 1999年 11月～ 2 0 0 1年 8月我科收治的 76例AIMI患者 ,依V3 导联ST段压低与Ⅲ导联ST段抬高的比值 (STV3 /Ⅲ )分为 3组 :V3 /Ⅲ <0 .5 ,V3 /Ⅲ≥ 0 .5～≤ 1.2 ,V3 /Ⅲ >1.2。通过冠状动脉造影 (CAG)观察三组患者梗死相关血管是右冠状动脉 (RCA)近段、RCA远段还是左回旋支 (LCX)。结果 :V3 /Ⅲ <0 .5组梗死相关血管是RCA近段 ,V3 /Ⅲ≥0 .5～≤ 1.2组梗死相关血管是RCA远段 ,V3 /Ⅲ >1.2组梗死相关血管是LCX。结论 :STV3 /Ⅲ是判断AIMI冠状动脉堵塞位置较好标准 ,同时它还能帮助判断RCA堵塞是位于近段还是远段     

Validation of electrocardiographic criteria for identifying left ventricular dysfunction in patients with previous myocardial infarction

BackgroundEleven criteria correlating electrocardiogram (ECG) findings with reduced left ventricular ejection fraction (LVEF) have been previously published. These have not been compared head‐to‐head in a single study. We studied their value as a screening test to identify patients with reduced LVEF estimated by cardiac magnetic resonance (CMR) imaging.MethodsECGs and CMR from 548 patients (age 61 + 11 years, 79% male) with previous myocardial infarction (MI), from the DETERMINE and PRE‐DETERMINE studies, were analyzed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each criterion for identifying patients with LVEF ≤ 30% and ≤ 40% were studied. A useful screening test should have high sensitivity and NPV.ResultsMean LVEF was 40% (SD = 11%); 264 patients (48.2%) had LVEF ≤ 40%, and 96 patients (17.5%) had LVEF ≤ 30%. Six of 11 criteria were associated with a significant lower LVEF, but had poor sensitivity to identify LVEF ≤ 30% (range 2.1%–55.2%) or LVEF ≤ 40% (1.1%–51.1%); NPVs were good for LVEF ≤ 30% (range 82.8%–85.9%) but not for LVEF ≤ 40% (range 52.1%–60.6%). Goldberger''s third criterion (RV4/SV4 < 1) and combinations of maximal QRS duration > 124 ms + either Goldberger''s third criterion or Goldberger''s first criterion (SV1 or SV2 + RV5 or RV6 ≥ 3.5 mV) had high specificity (95.4%–100%) for LVEF ≤ 40%, although seen in only 48 (8.8%) patients; predictive values were similar on subgroup analysis.ConclusionsNone of the ECG criteria qualified as a good screening test. Three criteria had high specificity for LVEF ≤ 40%, although seen in < 9% of patients. Whether other ECG criteria can better identify LV dysfunction remains to be determined.     

急性前壁心肌梗死时核素心梗面积与U波的关系

目的探讨急性前壁心肌梗死时胸前导联U波倒置的意义。方法对67例首次发病24h内，无对心电图U波有影响并发症及其它疾病者入院时的心电图进行分析，并测定其核素心肌梗死面积和核素心功能。结果67例患者U波倒置组25例，无U波倒置组42例；U波倒置组核素心梗面积为（33±7）％，左室射血分数（LVEF）（44±4）％，前1／3充盈分数（1／3FF）（0.32±0．07）％，病理性Q波导联数（2．1±1．0）；而无U波倒置组核素心梗面积为（49±9）％，LVEF（35±6）％，1／3FF（0．21±0．09）％，病理性Q波导联数（3．1±1．2）；两者比较差异有显著性（P＜0．05）。结论急性前壁心肌梗死患者入院时胸前导联U波倒置的出现预示心肌梗死面积相对较小，其LVEF亦可能＞40％。     

Recovery of left ventricular function after primary angioplasty for acute myocardial infarction.

AIMS: To study recovery of segmental wall thickening (SWT), ejection fraction (EF), and end-systolic volume (ESV) after acute myocardial infarction (AMI) in patients who underwent primary stenting with drug-eluting stents. Additionally, to evaluate the predictive value of magnetic resonance imaging (MRI)-based myocardial perfusion and delayed enhancement (DE) imaging. METHODS AND RESULTS: Twenty-two patients underwent cine-MRI, first-pass perfusion, and DE imaging 5 days after successful placement of a drug-eluting stent in the infarct-related coronary artery. Regional myocardial perfusion and the transmural extent of DE were evaluated. A per patient perfusion score was calculated and consisted of a summation of all segmental scores. Myocardial infarct size was quantified by measuring the volume of DE. At 5 months after AMI, cine-MRI was performed and SWT, EF, and ESV were quantified. EF increased from 48+/-11 to 55+/-9% (P<0.01). SWT at 5 months was inversely related to baseline segmental DE scores (P<0.001) and segmental perfusion scores (P<0.001). EF and ESV at 5 months were related to acute infarct size (R(2)=0.65; P<0.001 and R(2)=0.78; P<0.001, respectively) and the calculated perfusion score (R(2)=0.23; P=0.02 and R(2)=0.14; P=0.09, respectively) at baseline. CONCLUSION: Marked recovery of left ventricular function was observed in patients receiving a drug-eluting stent for AMI. DE imaging appears to be a better prognosticator than perfusion imaging.     

Does the electrocardiographic presence of Q waves influence the survival of patients with acute myocardial infarction?

AIMS: To compare the outcome of short- and long-term survival of patients with Q wave vs non-Q wave myocardial infarction. METHODS: A total of 6676 patients with acute myocardial infarction were enrolled on the TRAndolapril Cardiac Evaluation (TRACE) register between 1990 and 1992. Medical history, electrocardiographic diagnosis of Q wave and non-Q wave myocardial infarction, echocardiographic estimation of left ventricular systolic function determined as wall motion index, infarct complications, and survival were documented. The factors influencing the postmyocardial infarction outcome of these patients were studied after 30 days and after 8 years of follow-up, respectively. RESULTS: Cox proportional-hazard models demonstrated that the electrocardiographic Q waves had significant influence on survival during the first 30 days [risk ratio 1.4 (95% confidence limits 1.2-1.7)] but no influence thereafter [1.0 (0.9-1.1)]. The result was the same in univariate and multivariate analyses. Subgroup analysis defined by age, sex, wall motion index, presence of congestive heart failure, diabetes mellitus, arterial hypertension, subsequent myocardial infarctions and use of thrombolytic therapy did not disclose importance of Q waves on mortality. CONCLUSION: The electrocardiographic presence of Q waves is associated with increased mortality during the initial 30 days after a myocardial infarction, but has no influence thereafter.     

ST段抬高急性心肌梗塞胸导联心电图变化对心功能的预测

目的：探讨急性心肌梗塞（AMI）时左胸导联心电图变化对急性期及恢复期心功能的预测价值。方法：对42例胸导联ST段抬高急性AMI（STEAMI）患者进行体表12导联心电图（ECG）同步记录．观察心肌梗塞急性期V1-V6导联ST段抬高的导联数（NOSTE）及AMI恢复期原有R波振幅减少≥50％及演变成Q波的导联数（NORWA）；并在AMI急性期及恢复期进行Killip及NYHA心功能分级。结果：AMI急性期NOSTE≥4时，Killip心功能≤2级和≥3级者分别占13％和87％；NOSCE3≤时，Killip心功能≤2级和≥3级者分别占100％和0（P=0．000）；AMI恢复期NORWA≥4时，NYHA心功能≤2级和≥3级者分别占56％和44％；NORWA≤3时，NYHA心功能≤2级和≥3级者分别占100％和0（P=0．008）。结论：胸导联心电图变化有助于预测ST段抬高AMI患者急性期及恢复期的心功能。     

Transient giant R waves in the early phase of acute myocardial infarction: Association with ventricular fibrillation

An unusual electrocardiographic (ECG) pattern was observed in five patients who suffered an acute anterior myocardial infarction. Early in their illness and following resuscitation from ventricular fibrillation (three patients), in the midst of recurrent ventricular irritability prior to development of ventricular fibrillation (one patient), and following a period of seizures (one patient), the ECG showed ST-segment elevation, marked increase in the R-wave amplitude, disappearance of S waves and merging of QRS complexes with the elevated ST segments. ECG patterns noted in these patients were similar to the ones recorded from dogs immediately after ligation of a large coronary artery, and from patients with severe episodes of variant angina. Although these early electrocardiographic changes probably reflect either marked regional transmural blood flow deprivation or its aftermath, they could not be taken as indices of eventual massive myocardial necrosis since in most of these patients the alterations were followed by development of nontransmural myocardial infarction. The possible mechanisms and the implications of such discrepancy between early and late electrocardiographic indicators of injury or necrosis is discussed.     

急性前壁心梗心电图与TIMI分级和核素心梗面积的关系

目的探讨心电图预测首次急性前壁心肌梗死病人冠脉再通、梗死面积和左室功能的价值。方法观察４７例急性前壁心肌梗死患者第３周时心电图ＳＴ段和Ｔ波与冠脉造影ＴＩＭＩ分级、核素梗死面积和心功能的关系。结果梗死后第３周心电图Ｖ２～Ｖ４导联ＳＴ段回复至等电位线和Ｔ波倒置者冠脉再通率高于ＳＴ段抬高和Ｔ波直立者梗死面积前者小于后者,ＳＴ段在等电位线和Ｔ波倒置组亦有相对好的左室功能。结论结果提示首次急性前壁心肌梗死后第３周时心电图胸导联Ｖ２～Ｖ４ＳＴ段和Ｔ波能较好地预测冠状动脉再通状态、梗死面积和心功能     

体表心电图错误判断或无法判断梗死相关动脉的原因分析

目的 将体表心电图(ECG)预测的梗死相关动脉(IRA)与冠状动脉造影结果 进行对比分析,以了解判断错误的原因和可能机制.方法 搜集2004年10月至2009年7月就诊的急性ST段抬高心肌梗死(STEMI)患者,入选发病时间≤12 h并且术前有≥2份18导联ECG,排除既往有陈旧性心肌梗死、冠状动脉旁路移植术后、起搏器置入术后或ECG显示有左束支传导阻滞的患者.所有患者入院后都在2 h内施行了急诊冠状动脉造影.采用最常用的ECG标准判断IRA,并与冠状动脉造影结果 进行对比分析.结果 入选STEMI患者1024例,其中854例能够通过ECG判断IRA,96例判断错误,74例无法判断.判断错误和无法判断的170例患者中有76例(44.7%)IRA为左回旋支,66例(38.8%)为右冠状动脉,20例(11.8%)为左前降支,7例(4.1%)为中间支,1例(0.6%)为左主干;27例(15.9%)合并双支病变,47例(27.6%)合并三支病变;8例(4.7%)合并早期复极综合征;6例(3.5%)患者冠状动脉造影提示小分支闭塞.结论 侧支循环影响ECG对IRA的判断.ECG无法判断IRA时最常见于左回旋支病变.解剖变异、早期复极综合征或小分支闭塞也会影响IRA的判断.     

The entry ECG in the early diagnosis and prognostic stratification of patients with suspected acute myocardial infarction

475 patients with suspected uncomplicated myocardial infarction(MI) were divided into 3 groups based on their entry ECG: group1 — significant ST elevation; group 2a — ST depressionor T inversion, group 2b — normal ECG. Infarction wasconfirmed in 99.7% of group 1, 68.5% of group 2a and 39.7% ofgroup 2b patients. Despite similar clinical, haemodynamic andhistorical variables at presentation, group 1 patients had significantlylarger MI, more in-hospital complications and a higher short-termand longterm mortality (P<0.005) than group 2 patients. The entry ECG of patients with suspected MI is an excellentand simple predictor of those who are most likely to have anMI confirmed and identifies a group of patients at high riskof death or developing complications.     

缺血性J波者的流行病学及J波预测急性心肌梗死预后的临床价值

目的分析J波与心肌梗死预后的关系,探讨缺血性J波者的流行病学及其J波预测急性心肌梗死预后的临床价值。方法将120例急性心肌梗死患者根据心电图是否存在J波分为观察组与对照组各60例,两组患者首先均采用常规12导联心电图（ECG）检测,再采用动态心电记录器和十二导联动态心电图仪进行24小时动态监测。结果在流行病学上,两组患者的性别、年龄、舒张压比较,差异均无显著性（P〉0．05）,两组患者的收缩压以及多血管病变率比较,差异有显著性（P〈0．05）。两组患者心肌梗死事件差异总体比较差异无显著性（P〉0．05）,但是个别项目差异有显著性。J波呈顿挫型、振幅高、持续时间长者提示发生心脏事件危险性增加。同时J波振幅高,持续时间长,预示发生急性心肌梗死的危险性大。结论心肌梗死合并J波综合征可能出现在心肌梗死的急性期,心电图中对J波综合征的诊断可以早期发现高危人群,提高对心源性猝死的防范。     

Smartphone ECG for evaluation of ST-segment elevation myocardial infarction (STEMI): Design of the ST LEUIS International Multicenter Study

In patients experiencing an ST-elevation myocardial infarction (STEMI), rapid diagnosis and immediate access to reperfusion therapy leads to optimal clinical outcomes. The rate-limiting step in STEMI diagnosis is the availability and performance of a 12–lead ECG. Recent technology has provided access to a reliable means of obtaining an ECG reading through a smartphone application (app) that works with an attachment providing all 12–leads of a standard ECG system. The ST LEUIS study was designed to validate the smartphone ECG app and its ability to accurately assess the presence or absence of STEMI in patients presenting with chest pain compared with the gold standard 12–lead ECG. We aimed to support the diagnostic utility of smartphone technology to provide a timely diagnosis and treatment of STEMI. The study will take place over 12 months at five institutions. Approximately 60 patients will be enrolled per institution, for a total recruitment of 300 patients.     

墓碑型心电图改变急性前壁心肌梗死患者临床特点的探讨

目的 :探讨墓碑型ECG改变与急性前壁心肌梗死 (AMI)临床表现之间的关系。方法 :2 0 0 1年 1月～ 2 0 0 3年 12月连续进行急诊冠状动脉介入诊疗的首次前壁AMI患者 2 0 3例 ,墓碑组 73例 ,非墓碑组 130例。对比分析两组一般特征、临床特征、冠状脉造影表现和血管重建方法。结果 :墓碑组肌酸激酶 MB峰值、住院并发症 (死亡、心力衰竭、心源性休克和心室颤动 )、经血运重建治疗 (溶栓和经皮冠脉介入治疗 )明显高于非墓碑组 (P<0 .0 5～ 0 .0 1) ;住CCU时间显著延长 ,LVEF明显降低 (P <0 .0 5 )。而典型症状、心绞痛史、心率、血压、血脂指标、血尿酸、血糖、急性肺水肿、室性心动过速、心房颤动、高度房室阻滞、住院总天数和冠状动脉造影特征两组间差异无统计学意义 (P >0 .0 5 )。结论 :在前壁首次AMI患者 ,墓碑型心电图改变者虽然再灌注治疗明显增多 ,但预后不良 ,提示墓碑型ECG改变的机制可能与微血管病变有关     

Association between cine CMR-based radiomics signature and microvascular obstruction in patients with ST-segment elevation myocardial infarction

BackgroundIn the process of percutaneous coronary intervention (PCI), patients with ST-segment elevation myocardial infarction (STEMI) may receive large doses of the iodine contrast agent. Some adverse events may be aroused if the patients receive the gadolinium agents. We investigate the association between cine cardiac magnetic resonance (CMR)-based radiomics signature and microvascular obstruction (MVO) in patients with STEMI.MethodsA total of 116 STEMI patients who received continuous CMR within 6 days after PCI were retrospectively included in this study. According to the late gadolinium enhancement (LGE) of CMR, the myocardial infarction (MI) was divided into with and without MVO. Radiomic features were extracted from cine CMR images and the least absolute shrinkage and selectionator operator (LASSO) algorithm was used for features selection and radiomic signatures construction. Binary logistic regression was used to assess association between radiomic signatures and MVO with adjusted for baseline clinical characteristics.ResultsOf 116 patients with STEMI, MI with MVO was found in 50 patients and MI without MVO was found in 66 patients. LASSO regression selected five radiomics features for radiomics signature construction. Logistic regression revealed that radiomics score, high sensitivity C-reactive protein (hs-CRP) and creatine phosphokinases (CPK) were independent risk factors for MVO with odds ratio (OR) of 4.41 (95% CI: 2.26–9.93), 1.018 (95% CI: 1.006–1.034) and 1.0007 (95% CI: 1.0004–1.0012), respectively. Area under curve (AUC) of receiver operating characteristic (ROC) of radiomics score to predict MVO was 0.75 (95% CI: 0.68–0.85).ConclusionsCine CMR-based radiomics signature was an independent predictive factor of MVO in patients with STEMI, which showed the potential of this contrast free radiomics signature to be an imaging biomarker for MVO.