缺血性胸痛时的动态心电图表现_徐金义.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,缺血性胸痛时的动态心电图表现,河南省人民医院心功能科 徐金义,1,缺血性胸痛的概念,心肌缺血引起的胸部疼痛,胸痛时不一定心肌缺血,(,其他原因引起的胸痛,),心肌缺血时也不一定胸痛,(,无症状性心肌缺血,),通过,DCG,捕捉到的异常,ST,段同时伴有的胸部疼痛*,是急性心肌缺血时的临床表现,2,异常,ST,段,一定形态,的,ST,段抬高或压低超过正常标准及平直延长时，称为,ST,段异常，常伴或不伴,T,波改变。,ST,段形态,:,水平型 下斜,/,垂型 弓背向下,/,上型 上斜型,ST,段压低：,ST,段抬高：,ST,段平直延长：,ST,段在基线上持续时间,120ms,时,3,动态心电图自动,ST,段测量点,E,点：等电位点，,PR,段中点,J,点：,QRS,波与,ST,段交点,L,点：,ST,段测量点 因频率不同而变化,1.HR120bpm,时取,J,点后,50ms,4,动态心电图对,ST,段压低型心肌缺血的诊断标准,1984,年美国国立心肺研究院的,3,个,1,标准：,1.ST,段水平或下斜型压低,1mm,（,原有压低者，再压低,1mm,）,2.,持续时间,1min,3.,两次压低间隔时间,1min,测量点：,J,点后,80ms,为,L,点,1999,年,ACC/AHA,建议将两次下移间隔,1min,改为,5min,5,动态心电图对,ST,段抬高型心肌缺血的诊断标准：,1.,基础,ST,段在等电位线上者,ST,段抬高,1mm,（,基础,ST,段已有抬高者再抬高,1mm,）,2.,持续时间,1min,3.,两次下移间隔,1min,测量点：,J,点后,80ms,为,L,点,6,缺血性胸痛的动态心电图表现：病例一,ST,段压低型心肌缺血：,胸痛发作前,ST,段正常,心率增快、胸痛发作时多数导联,ST,段下斜型压低,7,女,53,岁,2007,年,04,月,07,日,17:50:11,1mv=10mm,HR=75bpm,8,女,53,岁,2007,年,04,月,07,日,18:30:44,1mv=10mm,HR=95bpm,9,女,53,岁,2007,年,04,月,07,日,18:58:54,1mv=10mm,HR=75bpm,10,缺血性胸痛的动态心电图表现：病例二,ST,段压低型心肌缺血：,胸痛发作前多数导联,ST,段水平或下斜型压低,心率增快、胸痛发作时多导联,ST,段较前下斜型压,低,1mm,11,女,49,岁,2007,年,07,月,29,日,18:16:17,HR=71bpm,12,2007,年,07,月,29,日,18:29:56,HR=86bpm,13,2007,年,07,月,29,日,18:33:07,HR=86bpm,14,缺血性胸痛的动态心电图表现：病例三,ST,段抬高型心肌缺血：,胸痛发作前,ST,段正常,胸痛发作时少数导联,ST,段弓背向下型抬高,1mm,心率变化不明显,恢复过程中出现室性早搏,15,孙跃停 男,46,岁,2009,年,11,月,13,日,03:28:24,16,孙跃停 男,46,岁,2009,年,11,月,13,日,03:31:29,17,孙跃停 男,46,岁,2009,年,11,月,13,日,03:32:45,18,孙跃停 男,46,岁,2009,年,11,月,13,日,03:33:43,19,孙跃停 男,46,岁,2009,年,11,月,13,日,03:48:01,20,孙跃停 男,46,岁,2009,年,11,月,13,日,03:52:01,21,缺血性胸痛的动态心电图表现：病例四,A,ST,段抬高型心肌缺血：,胸痛发作前,ST,段正常,胸痛发作时一组导联,ST,段弓背型抬高,1mm,伴心率减慢,22,男,53,岁 变异性心绞痛,2010,年,03,月,07,日,10:06:13,23,男,53,岁 变异性心绞痛,2010,年,03,月,07,日,10:09:03,24,男,53,岁 变异性心绞痛,2010,年,03,月,07,日,10:09:58,25,缺血性胸痛的动态心电图表现：病例四,B,ST,段抬高型心肌缺血：,ST,段的演变 多伴,T,波的演变,指示性改变、对应性改变并存,26,男,53,岁 变异性心绞痛,2010,年,03,月,07,日,21:15:49,27,男,53,岁 变异性心绞痛,2010,年,03,月,07,日,21:19:02,28,男,53,岁 变异性心绞痛,2010,年,03,月,07,日,21:21:32,29,男,53,岁 变异性心绞痛,2010,年,03,月,08,日,21:21:52,30,缺血性胸痛的动态心电图表现：病例四,C,ST,段抬高型心肌缺血：,一过性、可逆性 符合“全”或“无”的规律,持续时间：,1,分钟至数分钟,31,男,53,岁 变异性心绞痛,2010,年,03,月,08,日,03:48:19,32,男,53,岁 变异性心绞痛,2010,年,03,月,08,日,03:50:52,33,男,53,岁 变异性心绞痛,2010,年,03,月,08,日,03:51:16,34,缺血性胸痛的动态心电图表现：病例五,ST,段抬高型心肌缺血：伴,QRS,波、,U,波的改变,胸痛发作前：,ST,段正常、,QRS,波正常、,U,波不显,胸痛发作时：多数导联,ST,段弓背型抬高,出现巨型,R,U,波倒置,35,男,56,岁,2007,年,06,月,21,日,10:08:30,10mm/mv,10mm/mv,HR=83bpm,36,男,56,岁,2007,年,06,月,21,日,10:16:58,10mm/mv,10mm/mv,HR=93bpm,37,男,56,岁,2007,年,06,月,21,日,10:17:49,10mm/mv,10mm/mv,HR=79bpm,38,男,56,岁,2007,年,06,月,21,日,10:18:49,10mm/mv,10mm/mv,HR=77bpm,39,缺血性胸痛的动态心电图表现：病例六,ST,段抬高型心肌缺血：,发生于多个导联,发生于心率增快,发生于各个时间段 不论白昼,40,男,56,岁,2007,年,06,月,21,日,10:21:32,10mm/mv,41,HR=71bpm,男,56,岁,2007,年,06,月,21,日,10:21:51,10mm/mv,42,HR=86bpm,男,56,岁,2007,年,06,月,21,日,15:19:18,10mm/mv,10mm/mv,43,HR=92bpm,男,56,岁,2007,年,06,月,21,日,19:01:42,5mm/mv,44,HR=90bpm,男,56,岁,2007,年,06,月,22,日,02:05:58,5mm/mv,45,HR=75bpm,男,56,岁,2007,年,06,月,22,日,07:27:58,5mm/mv,46,HR=83bpm,男,56,岁,2007,年,06,月,22,日,08:20:23,5mm/mv,47,HR=94-75bpm,男,56,岁,2007,年,06,月,22,日,09:18:00,5mm/mv,48,HR=110bpm,缺血性胸痛的动态心电图表现：病例七,ST,段抬高型心肌缺血,伴发恶性心律失常：二联律室早、成对室早,IIII,型房室阻滞,49,女,33,岁,2009,年,06,月,17,日,11:55:57,50,女,33,岁,2009,年,06,月,17,日,11:57:54,51,女,33,岁,2009,年,06,月,17,日,11:58:48,52,女,33,岁,2009,年,06,月,17,日,11:58:51,53,女,33,岁,2009,年,06,月,17,日,12:00:05,54,女,33,岁,2009,年,06,月,17,日,12:00:21,55,女,33,岁,2009,年,06,月,17,日,12:00:56,56,女,33,岁,2009,年,06,月,17,日,12:01:08,57,缺血性胸痛的动态心电图表现：病例八,ST,段抬高型心肌缺血,伴发致命性心律失常：,VT,Vf,58,男,55,岁,2005,年,9,月,27,日,00:41:00,59,HR=61bpm,男,55,岁,2005,年,9,月,27,日,05:06:23,60,HR=71-96bpm,男,55,岁,2005,年,9,月,27,日,05:07:15,61,HR=101bpm,男,55,岁,2005,年,9,月,27,日,05:08:23,62,HR=100-90bpm,男,55,岁,2005,年,9,月,27,日,05:09:23,63,HR=79bpm,男,55,岁,2005,年,9,月,27,日,05:53:33,64,HR=83bpm,男,55,岁,2005,年,9,月,27,日,05:53:56,65,男,55,岁,2005,年,9,月,27,日,05:54:58,66,男,55,岁,2005,年,9,月,27,日,05:55:18,67,男,55,岁,2005,年,9,月,27,日,05:55:29,68,缺血性胸痛时的动态心电图特征（小结）,符合“全”或“无”规律,一过性、可逆性；,指示性改变与对应性改变并存,持续时间：持续,1-15min,最多不超过,30min,两种类型,ST,段偏移：损伤型抬高 损伤型压低,69,ST,段偏移程度与缺血程度相关，且较无症状性重,ST,段抬高多于,ST,段降低的发生率 且更有诊断意义,男多于女，多在中年以上,可发作于各个时间段 不论昼夜,可发作于活动时也可见于静息时,心肌缺血时的心率变化：增快、减慢、不明显,70,伴室性心律失常者少见，一旦出现，后果严重,抬高或压低的,ST,段有时发生于一组导联、有时发生于多组导联,抬高或压低的,ST,段有时伴,:1.QRS,波,的改变,2.T,波,的改变,3.U,波的改变,偶见,ST,段,无偏移但,T,波增高时伴胸痛，缺血性胸痛时的动态心电图表现实则,ST,段抬高型或非,ST,段抬高型急性冠脉综合征的心电图表现,71,总而言之：,缺血性胸痛时的动态心电图表现实则为,ST,抬高型或非,ST,抬高型,ACS,的心电图演变,动态心电图可以一览心肌缺血的全过程,对缺血性胸痛的诊断和鉴别具有重要的临床意义！,72,