心肌梗死的心电图诊断新进展.ppt

,中国医科大学附属第一医院,孙英贤,心肌梗死的心电图,诊断,新,进展,1979,年，,WHO,制定,AMI,诊断标准：,典型心肌缺血症状 典型心电图变化 血清心肌酶升高 符合以上至少两项即可诊断,2007,年,ESC,、,ACCF,、,AHA,、,WHF,心梗全球定义：,心肌坏死的生化标志物（最好是,cTn,）升高超过参考值上限（,URL,）,99,百分位值并有动态变化，伴有以下一项：,1.,缺血性症状,2.ECG,提示新发的缺血性改变、,3.,心电图提示病理性,Q,波形成,4.,影像学证据提示新发节段性室壁运动异常或存活心肌丢失。,新定义带来新挑战,如何为急性心肌梗死患者做出心电图的诊断,内,容,1.,急性心肌梗死,心电图,最新诊断标准,2.,陈旧性心肌梗死诊断：碎裂电位,3.,急性心肌梗死的定位诊断,急性心肌梗死的心电图诊断标准,2009,年,AHA,、,ACCF,、,HRS,在,心电图标准化与解析建议,中提出了心肌缺血,/,梗死心电图诊断新标准。,S-T 段,T 波,Q波,ST,段及,T,波动态变化,基础：损伤电流,ST,段抬高：新发,V2-V3,男性,0.2mv,（,40,岁内,0.25mv,）,女性,0.15mv,和（或）,其他导联,0.1mv,V3R-V4R,男性,0.05mv,（,30,岁内,0.1mv,）,女性,0.05mv,；,V7-9,0.05mv,。,ST,段压低和,T,波改变：,相邻,2,个导联新发,ST,段水平或下斜性压低,0.05mv,和（或）相邻,2,个导联,T,波倒置,0.1mv,合并高达,R,或,R/S1,缺血,/,梗死后,T,波改变,心肌缺血,/,梗死后，在,ST,段抬高导联会出现,T,波一过性倒置（,T,波演变）或持续性倒置（浅倒置）。,部分患者在,V2-4,（偶有,V5,）导联可出现,T,波深倒置（,0.5mV,）伴,QT,间期延长，但无进展为心肌梗死的心电图证据。冠脉造影常为前降支近段严重狭窄伴有侧支循环形成。,坏死性,Q,波,ECG,标准,具备下列三者之一即可诊断：,V2-V3,导联出现,0.02 s,的,Q,波,;,、,、,aVL,、,aVF,、或,V4-V6,导联任何两个相邻的导联组出现,Q,波宽度,0.03 s,，深度,0.1 mV;,V1-V2,导联导联,R,波,0.04 s,，,R/S1,，伴随正向,T,波，无传导障碍。,陈旧性心肌梗死诊断新进展：,碎裂电位,急性冠脉综合征治疗的新模式,Q,波型心肌梗死的发生率从原来,66.6%,下降到,37.5%,Q,波型心肌梗死患者,Q,波的消失率从过去的,6%,上升到,25%,63%,非,Q,波型心肌梗死和非,ST,段抬高型心肌梗死的发生率相应增加,发生过,Q,波或非,Q,波型心肌梗死的患者中,高达,2/3,的人经,12,导联心电图不能得到陈旧性心梗的诊断。,更有效的溶栓治疗和更早期的冠脉介入治疗,ECG,的新变化,碎裂,QRS,波是心电图领域又一个等位性,Q,波样改变,碎裂,QRS,波,fragmented QRS complex,，,fQRS,定义：指心电图新出现或已存在,QRS,波的三相波或多相波,有或无病理性,Q,波,排除完全或不完全性束支阻滞及室内阻滞,多见于冠心病陈旧心肌梗死患者，少见于心肌病等器质性心脏病患者，如：心脏结节病、致心律失常右室发育不良心肌病（,ARVD/C,）、,Brugada,综合症等。,QRS,波群呈,RSR,波、,rSr,波、,rSR,波（,三相波,）、,多个,R,波（,多相波,）、呈碎片状、或,S,波有切迹，,不同导联，可表现为,不同形态,心,电,图,特,征,除外完全或不完全性束支阻滞及室内阻滞,QRS,时限多数,15%,and 30%of the myocardium)and location(global,anterior,inferior,and lateral walls).,Q-waves were present in 38(30%)patients,and fQRS were present in 74(59%)patients.Of patients without DCH,51%had fQRS(specificity=49%)and 18%had Q-waves(specificity=82%).In patients with any DCH,67%had fQRS(sensitivity=67%)and 43%had Q-waves(sensitivity=43%).When only large infarcts were considered(volume of DCH 15%of total myocardial volume),fQRS sensitivity increased to 78%and specificity remained unchanged at 49%.For these larger myocardial scars,the sensitivity of Q-waves increased to 53%,and specificity remained at 79%.Sensitivity and specificity were similar when assessing regional myocardial scar.,Fig.1.fQRS compared to Q-waves in specificity and sensitivity,using CMR as the gold standard,in patients with total myocardial scar greater than 15%of total volume.,Our data do not completely agree with previously published reports,1,of the sensitivity and specificity of fQRS.We do agree that the sensitivity of fQRS is better than that of Q-waves.On the other hand,the specificity of fQRS was unacceptably low,approaching 50%.Thus,a patient with no DCH had a 50-50 chance of having fQRS.This difference may in part reflect the difference in patient population(stable outpatients vs.ACS patients)and reflect the“gold standard”used(CMR vs.nuclear imaging).It should be noted that while criteria such as the Minnesota Code,2,for abnormal Q-waves have existed for years,criteria for fQRS are not well established,and the possibility of inter-reader variability may limit its utility.,The presence of fQRS in half of the patients with no myocardial scar(50%false-positive rate)suggests that fQRS are not a useful standard in assessing the presence of myocardial infarct.,Georgetown University,fQRS,的质疑：,146,例心肌梗死诊断：,敏感性优于,Q,波,假阳性率达到,50,是否实用？,总,结,fQRS,是一项无创心电学的,新指标,用于诊断,陈旧心肌梗死,及,ACS,并预测预后及死亡率,有可能用于对心脏病患者进行,危险分层,和,判断预后,急性心肌梗死的定位诊断,下壁心肌梗死罪犯血管的判断：,根据梗死面积大小分为中,-,大面积心肌梗死和小面积下壁心肌梗死,.,右冠状动脉闭塞,OR,左回旋支闭塞？,右冠优势,OR,左冠优势？,85%,以上的人为右冠优势,8%,左右的人为左冠优势,7%,为均衡型,右冠脉闭塞引起下壁心肌梗死,心电图,ST/ST1,提示右室梗死存在,反映右冠状动脉闭塞。,I,、,aVL,导联,ST,段压低,1 mm,。右冠状动脉闭塞早期常出现,I,、,aVL,导联,ST,段压低,有时出现于,II,、,III,、,aVF,导联,ST,段抬高之前,成为早期诊断的重要线索。,右胸导联,(V4R)ST,段抬高。,V4R,导联,ST,段抬高,1mm,伴,T,波直立,提示右室梗死,反映右冠状动脉近段闭塞。,胸前导联,V1V3ST,压低与下壁导联,ST,段抬高的关系。右冠状动脉近端闭塞引起的下壁心肌梗死,STV1V3/STII,、,III,、,aVF12,+,+aVF,+,+aVR,-150,+aVL,-30,+90,+60,0,+120,+,左前降支远端闭塞,V1-4ST,段抬高，,下壁,ST,抬高，,STIISTIII,，下壁,ST,压低，,ST,段压低，,ST,段压低幅度低于前降支近段闭塞。,前降支近段闭塞,位于第一间隔支和第一对角支发出之前：,梗死部位：左室基底部、前壁、侧壁和室间隔,ECG,：,V1-4,、,I,、,aVL(,常伴有,aVR),导联,ST,抬高,、,、,aVF(,及,V5),导联,ST,压低,其中，,aVL,比,aVR,导联,ST,段抬高明显,比,导联,ST,段压低明显,位于第一间隔支和第一对角支之间时：,室间隔基底部没有受累及，故,V1,导联,ST,段一般不抬高，,aVL,导联抬高更明显，,导联,ST,段明显压低。,+,+aVF,+,+aVR,-150,+aVL,-30,+90,+60,0,+120,+,左主干闭塞,近年来临床研究发现左主干闭塞除表现为广泛前壁心肌梗死外,当其为次全闭塞可表现为“,6+2”,心电图改变,即,I,、,II,、,aVL,、,V4V6,导联,ST,段明显压低伴有,aVR,、,V1,导联,ST,段抬高,(1 mm,aVRV1),。,第一间隔支闭塞：,avR,导联,ST,段抬高，可伴新的右束支传导阻滞；,第一对角支闭塞：,I,、,avL,导联,ST,段抬高，,avL,、,V2,导联,ST,段抬高，伴,III,、,avF,导联,ST,段压低,正后壁心肌梗死,主要为,V1V3,导联,ST,段压低、,V7V9,导联,ST,段抬高。,在左冠优势,左回旋支钝缘支闭塞往往是正后壁心肌梗死的罪犯动脉,而在右冠优势,右冠状动脉近端闭塞可引起右室及下后壁心肌梗死。,谢谢！,