右胸V_4R导联ST段抬高在急性前壁ST段抬高型心肌梗死的临床价值分析
|
摘要
目的:分析右胸V_4R导联ST段抬高在急性前壁ST段抬高型心肌梗死(ST-elevation myocardial infarction,STEMI)的临床价值。方法:入选2017年1月至2018年7月在我院住院的接受经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗的急性前壁STEMI的患者96例,其中男性82例,女性14例,平均年龄(56±11)岁。根据患者入院时心电图右胸V_4R导联抬高程度分V_4R ST段抬高≥1.0 mm与V_4R ST段抬高<1.0 mm 2组,观察2组患者心脏超声、冠状动脉造影结果及主要不良事件(包括PCI术前室性心动过速/心室颤动及住院期间心力衰竭及心血管死亡)的发生情况。结果:与V_4R ST段抬高<1.0 mm组患者相比,V_4R ST段抬高≥1.0 mm患者收缩压及射血分数偏低,全球急性冠状动脉事件注册(global registry of acute coronary events,GRACE)评分及心肌梗死溶栓(thrombolysis in myocardial infarction,TIMI)评分较高,Killip分级>1患者比例、心脏前间壁中段运动障碍比例及合并多血管病变比例较高(均P<0.05)。V_4R ST段抬高≥1.0 mm组患者发生PCI术前室性心动过速/心室颤动、住院期间出现心力衰竭及复合事件的比例均高于V_4R ST段抬高<1.0 mm组(均P<0.05)。多因素Logistic回归分析显示与V_4R ST段抬高<1.0 mm患者相比,V_4R ST段抬高≥1.0 mm患者PCI术前室性心动过速/心室颤动增加2.76倍,住院期间心力衰竭增加3.29倍,复合事件增加5.88倍。结论:急性前壁STEMI患者右胸V_4R导联ST段抬高≥1.0 mm是患者住院期间发生不良事件的危险因素,预后较差。
Objective To explore the significance of right precordial lead(V_4R) ST-segment(V_4RST) elevation in diagnosis of acute anterior ST-segment elevation myocardial infarction(STEMI). Methods A total of 96 patients, including82 males and 14 females, with acute anterior STEMI were enrolled from January 2017 through July 2018. The average age of patients was(56±11) years. Patients were divided into two groups based on V_4R ST elevation of either ≥1.0 mm or <1.0 mm. The results of cardiac ultrasound and coronary angiography were assessed. The adverse events including ventricular tachycardia(VT) or ventricular fibrillation(VF) occurring before coronary intervention, acute heart failure occurrence and cardiovascular death during hospitalization. Results Patient with V_4R ST elevation(≥1.0 mm) had a lower systolic blood pressure and left ventricular ejection fraction, higher global registry of acute coronary events(GRACE) score and thrombol-ysis in myocardial infarction(TIMI) score, and higher proportion of Killip class >1 and middle anteroseptal segmental wall motion abnormality. The incidences of VT/VF before coronary intervention and acute heart failure were significant higher in patient with V_4R ST≥1.0 mm(P<0.05). Multivariable Logistic regression analyses revealed significant association of V_4R ST elevation with VT/VF events prior coronary intervention [hazard ratio(HR) 2.76, 95% confidence interval(CI): 0.96 to 10.19, P=0.021] and acute heart failure(HR 3.29, 95% CI: 0.83 to 13.09, P=0.032) independently, and combined(HR5.88, 95% CI: 2.61 to 28.8, P =0.011). Conclusions Right precordial lead V_4R ST elevation is associated with adverse events in patients with acute anterior STEMI.
Objective To explore the significance of right precordial lead(V_4R) ST-segment(V_4RST) elevation in diagnosis of acute anterior ST-segment elevation myocardial infarction(STEMI). Methods A total of 96 patients, including82 males and 14 females, with acute anterior STEMI were enrolled from January 2017 through July 2018. The average age of patients was(56±11) years. Patients were divided into two groups based on V_4R ST elevation of either ≥1.0 mm or <1.0 mm. The results of cardiac ultrasound and coronary angiography were assessed. The adverse events including ventricular tachycardia(VT) or ventricular fibrillation(VF) occurring before coronary intervention, acute heart failure occurrence and cardiovascular death during hospitalization. Results Patient with V_4R ST elevation(≥1.0 mm) had a lower systolic blood pressure and left ventricular ejection fraction, higher global registry of acute coronary events(GRACE) score and thrombol-ysis in myocardial infarction(TIMI) score, and higher proportion of Killip class >1 and middle anteroseptal segmental wall motion abnormality. The incidences of VT/VF before coronary intervention and acute heart failure were significant higher in patient with V_4R ST≥1.0 mm(P<0.05). Multivariable Logistic regression analyses revealed significant association of V_4R ST elevation with VT/VF events prior coronary intervention [hazard ratio(HR) 2.76, 95% confidence interval(CI): 0.96 to 10.19, P=0.021] and acute heart failure(HR 3.29, 95% CI: 0.83 to 13.09, P=0.032) independently, and combined(HR5.88, 95% CI: 2.61 to 28.8, P =0.011). Conclusions Right precordial lead V_4R ST elevation is associated with adverse events in patients with acute anterior STEMI.
引文
[1]Zehender M,Kasper W,Kauder E,et al.Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction[J].N Engl J Med,1993,328(14):981-988.
[2]Braat SH,de Zwaan C,Brugada P,et al.Right ventricular involvement with acute inferior wall myocardial infarction identifies high risk of developing atrioventricular nodal conduction disturbances[J].Am Heart J,1984,107(6):1183-1187.
[3]Braat SH,Gorgels AP,B?r FW,et al.Value of the ST-Tsegment in lead V4R in inferior wall acute myocardial infarction to predict the site of coronary arterial occlusion[J].Am J Cardiol,1988,62(7):140-142.
[4]Wellens HJ.The value of the right precordial leads of the electrocardiogram[J].N Engl J Med,1999,340(5):381-383.
[5]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志,2015,45(5):380-393.
[6]Thygesen K,Alpert JS,Jaffe AS,et al.Fourth universal definition of myocardial infarction(2018)[J].J Am Coll Cardiol,2018,72(18):2231-2264.
[7]Mann DL,Zipes DP,Libby P,et al,Braunwald’s heart disease:a textbook of cardiovascular medicine[M].10th ed,Philadelphia:Saunders,2014:201-204.
[8]Ponikowski P,Voors AA,Anker SD,et al.2016 ESCGuidelines for the diagnosis and treatment of acute and chronic heart failure:the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC).Developed with the special contribution of the Heart Failure Association(HFA)of the ESC[J].Eur J Heart Fail,2016,18(8):891-975.
[9]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.中国心力衰竭诊断和治疗指南2014[J].中华心血管病杂志,2014,42(2):98-122.
[10]Mehta SR,Eikelboom JW,Natarajan MK,et al.Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction[J].J Am Coll Cardiol,2001,37(1):37-43.
[11]Kanovsky J,Kala P,Novotny T,et al.Association of the right ventricle impairment with electrocardiographic localization and related artery in patients with ST-elevation myocardial infarction[J].J Electrocardiol,2016,49(6):907-910.
[12]Barsheshet A,Hod H,Oieru D,et al.Right precordial lead(V4R)ST-segment elevation is associated with worse prognosis in patients with acute anterior myocardial infarction[J].J Am Coll Cardiol,2011,58(5):548-549.
[13]Yoshida K,Yokokawa M,Desjardins B,et al.Septal involvement in patients with post-infarction ventricular tachycardia:implications for mapping and radiofrequency ablation[J].J Am Coll Cardiol,2011,58(24):2491-2500.
[14]Isner JM,Roberts WC.Right ventricular infarction complicating left ventricular infarction secondary to coronary heart disease.Frequency,location,associated findings and significance from analysis of 236 necropsy patients with acute or healed myocardial infarction[J].Am JCardiol,1978,42(2):885-894.
[15]Andersen HR,Falk E,Nielsen D.Right ventricular infarction:frequency,size and topography in coronary heart disease:a prospective study comprising 107 consecutive autopsies from a coronary care unit[J].J Am Coll Cardiol,1987,10(6):1223-1232.
[16]Cabin HS,Clubb KS,Wackers FJ,et al.Right ventricular myocardial infarction with anterior wall left ventricular infarction:an autopsy study[J].Am Heart J,1987,113(1):16-23.
[17]Bodi V,Sanchis J,Mainar L,et al.Right ventricular involvement in anterior myocardial infarction:a translational approach[J].Cardiovasc Res,2010,87(3):601-608.
[18]Masci PG,Francone M,Desmet W,et al.Right ventricular ischemic injury in patients with acute ST-segment elevation myocardial infarction:characterization with cardiovascular magnetic resonance[J].Circulation,2010,122(14):737-742.
[19]Ben-Gal T,Herz I,Solodky A,et al.Acute anterior wall myocardial infarction entailing ST-segment elevation in lead V1:electrocardiographic and angiographic correlations[J].Clin Cardio,1998,21(6):399-404.
[20]Ben-Gal T,Sclarovsky S,Herz I,et al.Importance of the conal branch of the right coronary artery in patients with acute anterior wall myocardial infarction:electrocardiographic and angiographic correlation[J].J Am Coll Cardiol,1997,29(3):506-511.
[21]Ghaffari S,Taban Sadeghi M,Sayyadi MH,et al.The association of right coronary artery conus branch size and course with ST segment elevation of right precordial leads and clinical outcome of acute anterior myocardial infarction[J].J Cardiovasc Thorac Res,2017,9(1):49-53.
[22]Loukas M,Patel S,Cesmebasi A,et al.The clinical anatomy of the conal artery[J].Clin Anat,2016,29(9):371-379.
[23]Jensen LO,Terkelsen CJ,Horváth-PuhóE,et al.Influence of multivessel disease with or without additional revascularization on mortality in patients with ST-segment elevation myocardial infarction[J].Am Heart J,2015,170(1):70-78.
[2]Braat SH,de Zwaan C,Brugada P,et al.Right ventricular involvement with acute inferior wall myocardial infarction identifies high risk of developing atrioventricular nodal conduction disturbances[J].Am Heart J,1984,107(6):1183-1187.
[3]Braat SH,Gorgels AP,B?r FW,et al.Value of the ST-Tsegment in lead V4R in inferior wall acute myocardial infarction to predict the site of coronary arterial occlusion[J].Am J Cardiol,1988,62(7):140-142.
[4]Wellens HJ.The value of the right precordial leads of the electrocardiogram[J].N Engl J Med,1999,340(5):381-383.
[5]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志,2015,45(5):380-393.
[6]Thygesen K,Alpert JS,Jaffe AS,et al.Fourth universal definition of myocardial infarction(2018)[J].J Am Coll Cardiol,2018,72(18):2231-2264.
[7]Mann DL,Zipes DP,Libby P,et al,Braunwald’s heart disease:a textbook of cardiovascular medicine[M].10th ed,Philadelphia:Saunders,2014:201-204.
[8]Ponikowski P,Voors AA,Anker SD,et al.2016 ESCGuidelines for the diagnosis and treatment of acute and chronic heart failure:the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology(ESC).Developed with the special contribution of the Heart Failure Association(HFA)of the ESC[J].Eur J Heart Fail,2016,18(8):891-975.
[9]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.中国心力衰竭诊断和治疗指南2014[J].中华心血管病杂志,2014,42(2):98-122.
[10]Mehta SR,Eikelboom JW,Natarajan MK,et al.Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction[J].J Am Coll Cardiol,2001,37(1):37-43.
[11]Kanovsky J,Kala P,Novotny T,et al.Association of the right ventricle impairment with electrocardiographic localization and related artery in patients with ST-elevation myocardial infarction[J].J Electrocardiol,2016,49(6):907-910.
[12]Barsheshet A,Hod H,Oieru D,et al.Right precordial lead(V4R)ST-segment elevation is associated with worse prognosis in patients with acute anterior myocardial infarction[J].J Am Coll Cardiol,2011,58(5):548-549.
[13]Yoshida K,Yokokawa M,Desjardins B,et al.Septal involvement in patients with post-infarction ventricular tachycardia:implications for mapping and radiofrequency ablation[J].J Am Coll Cardiol,2011,58(24):2491-2500.
[14]Isner JM,Roberts WC.Right ventricular infarction complicating left ventricular infarction secondary to coronary heart disease.Frequency,location,associated findings and significance from analysis of 236 necropsy patients with acute or healed myocardial infarction[J].Am JCardiol,1978,42(2):885-894.
[15]Andersen HR,Falk E,Nielsen D.Right ventricular infarction:frequency,size and topography in coronary heart disease:a prospective study comprising 107 consecutive autopsies from a coronary care unit[J].J Am Coll Cardiol,1987,10(6):1223-1232.
[16]Cabin HS,Clubb KS,Wackers FJ,et al.Right ventricular myocardial infarction with anterior wall left ventricular infarction:an autopsy study[J].Am Heart J,1987,113(1):16-23.
[17]Bodi V,Sanchis J,Mainar L,et al.Right ventricular involvement in anterior myocardial infarction:a translational approach[J].Cardiovasc Res,2010,87(3):601-608.
[18]Masci PG,Francone M,Desmet W,et al.Right ventricular ischemic injury in patients with acute ST-segment elevation myocardial infarction:characterization with cardiovascular magnetic resonance[J].Circulation,2010,122(14):737-742.
[19]Ben-Gal T,Herz I,Solodky A,et al.Acute anterior wall myocardial infarction entailing ST-segment elevation in lead V1:electrocardiographic and angiographic correlations[J].Clin Cardio,1998,21(6):399-404.
[20]Ben-Gal T,Sclarovsky S,Herz I,et al.Importance of the conal branch of the right coronary artery in patients with acute anterior wall myocardial infarction:electrocardiographic and angiographic correlation[J].J Am Coll Cardiol,1997,29(3):506-511.
[21]Ghaffari S,Taban Sadeghi M,Sayyadi MH,et al.The association of right coronary artery conus branch size and course with ST segment elevation of right precordial leads and clinical outcome of acute anterior myocardial infarction[J].J Cardiovasc Thorac Res,2017,9(1):49-53.
[22]Loukas M,Patel S,Cesmebasi A,et al.The clinical anatomy of the conal artery[J].Clin Anat,2016,29(9):371-379.
[23]Jensen LO,Terkelsen CJ,Horváth-PuhóE,et al.Influence of multivessel disease with or without additional revascularization on mortality in patients with ST-segment elevation myocardial infarction[J].Am Heart J,2015,170(1):70-78.