摘要
目的:通过与冠状动脉造影(CAG)结果比较,分析急性心肌梗死患者(AMI)的十二导联或十五导联心电图(ECG)改变的特点,特别是加压单极肢体导联(aVR、aVL、aVF)ST段和QRS波群的改变特点,总结体表心电图在定位急性心肌梗死(AMI)梗死相关动脉(IRA)中的作用。
方法:收集南昌大学第一附属医院2007年～2009年收治的急性心肌梗死患者的心电图及冠状动脉造影结果进行回顾性分析,总结其心电图特点。要求入选的病例在患者胸痛发作十二小时内记录心电图并于患者入院一星期之内行冠状动脉造影术。共收集到患者132例,其中ST段抬高性心肌梗死(STEMI)107例,非ST段抬高性心肌梗死(NSTEMI)25例。
结果:急性下壁心肌梗死时右冠状动脉闭塞组和左回旋支闭塞组在Ⅰ、aVL、V1、V6导联上ST段偏移程度有具有统计意义的差别,其中Ⅰ、aVL导联的ST段压低在右冠状动脉闭塞组较明显(P值分别为0.035、0.001),V1导联ST段压低在左回旋支闭塞组较明显(P=0.001),而aVR导联ST段的改变在两组中没有差别(P=0.357),同时得出急性下壁心肌梗死时aVL导联ST段压低、STⅢ↑>STⅡ↑和STaVL↓>STⅠ↓提示右冠状动脉闭塞(P均为0.001),下壁心肌梗死时如同时伴有V6导联ST段抬高对诊断左回旋支闭塞的敏感度为50﹪,特异度为97﹪,准确度为86﹪,阳性预测值为85﹪,阴性预测值为88﹪。用ROC曲线来分析上述改变对区别急性下壁心肌梗死时罪犯血管的优劣,得出aVL导联ST段压低最具诊断价值,其曲线下面积达到0.915。右冠状动脉闭塞组aVL导联ST段压低者38例(压低>1mm有28例),左回旋支闭塞组ST段压低共8例(压低>1mm有0例)。右冠状动脉闭塞时,胸前六导联有ST段压低的导联数目在近段闭塞组和远段闭塞组之间有显著性差异(χ2=16.009,P=0.007),当有连续四个及以上的导联出现ST段压低时多见于右冠状动脉近段闭塞,V1、V2导联ST段压低也常见于右冠状动脉近段闭塞组。.右室导联(V3R、V4R、V5R)ST段抬高对诊断右冠状动脉闭塞有重要意义,特异度达到100﹪,且几乎均为右冠状动脉近段闭塞。左前降支闭塞引起急性前壁心肌梗死时,如Ⅰ、aVR、aVL导联ST段抬高和Ⅱ、aVF导联ST段压低提示闭塞部位为左前降支近段(P值分别为0.004、0.007、0.015、0.022、0.004),十二导联ST段总偏移数在两组之间有显著差异(P=0.000),用ROC曲线来分析以上因素在区别左前降支近段闭塞和远段闭塞中的优劣,得出十二导联ST段总偏移数最能够提示左前降支近段闭塞,曲线下面积为0.899。aVL导联出现Q波见于左前降支近段闭塞和左主干闭塞。对诊断左前降支近段闭塞的敏感度为36﹪,特异度为89﹪,准确度为55﹪,阳性预测值为87﹪,阴性预测值为43﹪。非ST段抬高型心肌梗死多见于多支病变,与ST抬高型心肌梗死有明显统计差异(χ~2=5.945,P=0.017)。
结论:急性下壁心肌梗死时aVL导联ST段压低>1mm、STⅢ↑>STⅡ↑和STaVL↓>STⅠ↓提示右冠状动脉闭塞。急性下壁心肌梗死时如同时伴有V6导联ST段抬高提示左回旋支闭塞。右冠状动脉闭塞时,四个及以上的胸导联出现ST段偏移提示右冠状动脉近段闭塞。右室导联的ST段抬高提示右冠状动脉近段闭塞。急性前壁心肌梗死时Ⅰ、aVR、aVL导联ST段抬高和Ⅱ、aVF导联ST段压低或aVL导联出现病理性Q波提示左前降支近段或左主干闭塞。急性前壁心肌梗死时十二导联ST段总偏移程度>10mm提示左前降支近段闭塞。非ST段抬高型心肌梗死患者多存在两支或三支血管病变。
Objective: To assess the characters of 12-leads or 15-leads electrocardiogram ST-segment and QRS wave group changing, especially augmented unipolar limb lead (aVR, aVL, aVF) and predict the infarct-related artery in the acute myocardial infarction.
Method: Collecting the electrocardiogram and the coronary angiography of the patients with acute myocardial infarction in the first affiliated hospital of Nanchang University from 2007 to 2009 and retrospectively analyzed. The electrocardiogram was registered within 12 hours after the acute episode, and underwent coronary angiography within one week. 132 patients were collected, which included 107 with ST-segment elevation myocardial infarction (STEMI), 25 with Non-ST-segment elevation myocardial infarction (NSTEMI).
Results: The acute inferior myocardial infarction from right coronary artery occlusion group and the left circumflex artery occlusion group in theⅠ, aVL, V1, V6 leads ST segment deviation on the degree of statistically significant differences,Ⅰ, aVL leads ST-segment depression in the right coronary artery occlusion group were significantly (P values were 0.035 and 0.001), V1 ST-segment down in the left circumflex artery occlusion group was more apparent (P=0.001), and aVR ST-segment changes in the two groups did not differ (P = 0.357), also obtain aVL lead ST-segment depression ,STⅢ↑> STⅡ↑and STaVL↓> STⅠ↓strongly suggests the infarct-related artery of acute inferior myocardial infarction is right coronary artery . Inferior myocardial infarction if accompanied V6 ST-segment elevation in the diagnosis of left circumflex artery occlusion had a sensitivity of 50%, specificity was 97%, and accuracy was 86%, positive predictive value 85% negative predictive value of 88%. Using ROC curve analysis of these changes on the difference between the value of the two groups suggest the culprit vessel, come aVL lead ST-segment depression diagnostic value of most, the area under the curve to 0.915. Right coronary artery occlusion group aVL ST-segment depression in 38 patients (depression >1mm, 28 cases),left circumflex artery occlusion group were 8 cases of ST-segment depression (depression>1mm 0 case).When the infarct-related artery is right coronary artery, the chest leads ST segment deviation in the number of occlusion in the proximal and distal occlusion between the two groups was significant difference (χ~2=16.009,P=0.007),when more than four leads and the more common proximal right coronary artery occlusion. V1, V2 ST-segment depression is also common in the right coronary artery proximal occlusion group. . Right ventricular leads (V3R, V4R and V5R) ST segment elevation on the diagnosis of right coronary occlusion is important, the specificity 100%, and almost all proximal occlusion of right coronary artery. Anterior myocardial infarctionⅠ, aVR, aVL leads ST-segment elevation andⅡ、aVF leads ST-segment depression prompt for the left anterior descending artery occlusion in the proximal (P values were 0.004, 0.007, 0.015,0.022,0.004), 12 leads ST-segment total number of shifts between the two groups were significantly different. With ROC curve analysis of these changes on the difference between the values of two blocking parts of the tips, which come 12 leads ST-segment total number of shifts in the best position to suggest proximal left anterior descending artery occlusion, area under the curve to 0.899. Pathologic Q wave in lead aVL is seen occur proximal left anterior descending artery occlusion and left main coronary artery occlusion, diagnosis of left anterior descending artery proximal occlusion of the sensitivity was 36%, specificity was 89%, accuracy was 55%, positive predictive value of 87%, negative predictive value of 43%. Non-ST segment elevation myocardial infarction more common in multi-vessel disease, with ST elevation myocardial infarction with significant statistical difference (χ2 = 5.945, P = 0.017).
Conclusion: The acute inferior myocardial infarction aVL lead ST-segment depression>1mm, STⅢ↑> STⅡ↑and ST aVL↓> STⅠ↓tips right coronary artery occlusion. Acute inferior myocardial infarction accompanied by ST segment elevation in lead V6 tips left circumflex artery occlusion. Right coronary artery occlusion, and over four chest leads ST-segment deviation suggests proximal occlusion of right coronary artery. Right ventricular leads ST-segment elevation prompt proximal right coronary artery occlusion. Acute anterior myocardial infarctionⅠ, aVR, aVL ST-segment elevation andⅡ、aVF leads ST-segment depression or pathologic Q wave aVL lead prompt appears proximal left anterior descending artery or left main coronary artery occlusion. Acute anterior myocardial infarction 12 ST-segment level of the total offsets> 10mm prompted proximal left anterior descending artery occlusion. Non-ST segment elevation myocardial infarction there is more than two or three vessel disease.
引文
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