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中华临床医师杂志(电子版) ›› 2018, Vol. 12 ›› Issue (10) : 546 -551. doi: 10.3877/cma.j.issn.1674-0785.2018.10.003

所属专题: 文献

专题笔谈

急性ST段抬高型心肌梗死的非典型心电图改变
李浩1, 韩清华1,()   
  1. 1. 030001 太原,山西医科大学第一医院心内科
  • 收稿日期:2018-04-05 出版日期:2018-05-15
  • 通信作者: 韩清华

Atypical electrocardiogram changes in acute ST-segment elevation myocardial infarction

Hao Li1, Qinghua Han1,()   

  1. 1. Department of Cardiology, The First Hospital of Shanxi Medical University, Taiyuan 030001, China
  • Received:2018-04-05 Published:2018-05-15
  • Corresponding author: Qinghua Han
  • About author:
    Corresponding author: Han Qinghua, Email:
引用本文:

李浩, 韩清华. 急性ST段抬高型心肌梗死的非典型心电图改变[J]. 中华临床医师杂志(电子版), 2018, 12(10): 546-551.

Hao Li, Qinghua Han. Atypical electrocardiogram changes in acute ST-segment elevation myocardial infarction[J]. Chinese Journal of Clinicians(Electronic Edition), 2018, 12(10): 546-551.

心电图是广泛使用和容易获得的最初诊断工具。急性心肌梗死(AMI)的治疗有赖于其临床表现、心电图及心肌坏死标志物的综合判断。识别高危心电图及其微妙变化将使患者早期血运重建明显获益。本文主要对非典型的心电图诊断相当于急性ST段抬高型心肌梗死(STEMI)的一些规律,包括左束支传导阻滞(LBBB)满足Sgarbossa标准、Wellens′综合征、QRS波终末变形、超急性T波、de Winter征和aVR导联抬高等进行综述。

Electrocardiogram (ECG) is widely used and flexible to obtain as an initial diagnostic tool. Optimal treatment of acute myocardial infarction (AMI) relies on the comprehensive diagnosis based on clinical manifestations, ECG changes, and myocardial necrosis markers. Identifying subtle high-risk ECG changes will bring obvious benefit to early revascularization in AMI patients. This review mainly discusses atypical STEMI-equivalent ECG changes, including left bundle branch block (LBBB) satisfying the standard of Sgarbossa criteria, Wellens′ syndrome, terminal QRS distortion, hyperacute T-waves, De Winter pattern, and elevation in lead aVR.

1
Welch RD, Zalenski RJ, Frederick PD, et al. Prognostic value of a normal or nonspecific initial electrocardiogram in acute myocardial infarction [J]. JAMA, 2001, 286(16):1977-1984.
2
Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction [J]. J Am Coll Cardiol, 2012, 60(16):1581-1598.
3
Macfarlane PW, Browne D, Devine B, et al. Modification of ACC/ESC criteria for acute myocardial infarction [J]. J Electrocardiol, 2004, 37 Suppl:98-103.
4
Schmitt C, Lehmann G, Schmieder S, et al. Diagnosis of acute myocardial infarction in angiographically documented occluded infarct vessel : limitations of ST-segment elevation in standard and extended ECG leads [J]. Chest, 2001, 120(5):1540-1546.
5
Tran V, Huang HD, Diez JG, et al. Differentiating ST-elevation myocardial infarction from nonischemic ST-elevation in patients with chest pain [J]. Am J Cardiol, 2011, 108(8):1096-1101.
6
Das MK, Khan B, Jacob S, et al. Significance of a fragmented QRS complex versus a Q-wave in patients with coronary artery disease [J]. Circulation, 2006, 113(21):2495-2501.
7
梁芳,沈春莲,张伟, 等. 心电图碎裂QRS波在急性心肌梗死诊断中的价值 [J]. 中国循环杂志, 2011, 26(5):363-366.
8
Rituparna S, Suresh S, Chandrashekhar M, et al. Occurrence of ″J waves″ in 12-lead ECG as a maker of acute ischemia and their cellular basis [J]. Pacing Clin Electro, 2007, 30(6):817-819.
9
Fesmire FM, Percy RF, Bardoner JB, et al. Usefulness of automated serial 12-lead ECG monitoring during the initial emergency department evaluation of patients with chest pain [J]. Ann Emerg Med, 1998, 31(1):3-11.
10
Khan AR, Golwala H, Tripathi A, et al. Impact of total occlusion of culprit artery in acute non-ST elevation myocardial infarction: a systematic review and meta-analysis [J]. Eur Heart J, 2017, 38(41):3082-3089.
11
Pride YB, Tung P, Mohanavelu S, et al. Angiographic and clinical outcomes among patients with acute coronary syndromes presenting with isolated anterior STsegment depression: a TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel-Thrombolysis In Myocardial Infarction 38) substudy [J]. JACC Cardiovasc interv, 2010, 3(8):806-811.
12
Martí D, Mestre JL, Salido L, et al. Incidence, angiographic features and outcomes of patients presenting with subtle ST-elevation myocardial infarction [J]. Am Heart J, 2014, 168(6):884-890.
13
Miranda DF, Lobo A, Walsh B, et al. New Insights into the Use of the 12-lead Electrocardiogram for Diagnosing Acute Myocardial Infarction in the Emergency Department [J]. Can J Cardiol, 2018, 34(2):132-145.
14
Rokos IC, French WJ, Mattu A, et al. Appropriate cardiac cath lab activation: optimizing electrocardiogram interpretation and clinical decision-making for acute ST elevation myocardial infarction [J]. Am Heart J, 2010, 160(6):995-1003.
15
Birnbaum Y, Bayés de Luna A, Fiol M, et al. Common pitfalls in the interpretation of electrocardiograms from patients with acute coronary syndromes with narrow QRS: a consensus report [J]. J Electrocardiol, 2012, 45(5):463-75.
16
Nikus K, Pahlm O, Wagner G, et al. Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology [J]. J Electrocardiol, 2010, 43(2):91-103.
17
Nikus K, Birnbaum Y, Eskola M, et al. Updated electrocardiographic classification of acute coronary syndromes [J]. Curr Cardiol Rev, 2014, 10(3):229-236.
18
Al Rajoub B, Noureddine S, El Chami S, et al. The prognostic value of a new left bundle branch block in patients with acute myocardial infarction: a systematic review and meta-analysis [J]. Heart Lung, 2017, 46(2):85-91.
19
Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators [J]. N Engl J Med, 1996, 334(8):481-487.
20
Smith SW, Dodd KW, Henry TD, et al. Diagnosis of ST elevation myocardial infarction in the presence of left bundle branch block with the ST elevation to S-wave ratio in a modified Sgarbossa rule [J]. Ann Emerg Med, 2012, 60(6):766-776.
21
Meyers HP, Limkakeng AT Jr, Jaffa EJ, et al. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study [J]. Am Heart J, 2015, 170(6):1255-1264.
22
Dodd KWZ, D. L. Elm K, Hart M, et al. Performance Characteristics of the Modified Sgarbossa Criteria for Diagnosis of Acute Coronary Occlusion in Emergency Department Patients with Ventricular Paced Rhythm and Symptoms of Acute Coronary Syndrome [J]. Academic Emergency Medicine, 2017, 24(S1):S36.
23
Armstrong EJ, Kulkarni AR, Bhave PD, et al. Electrocardiographic criteria for ST elevation myocardial infarction in patients with left ventricular hypertrophy [J]. Am J Cardiol, 2012, 110(7):977-983.
24
Jothieswaran A, Body R. BET 2:Diagnosing acute myocardial infarction in the presence of ventricular pacing: can Sgarbossa criteria help? [J]. Emerg Med J, 2016, 33(9):672-673.
25
de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction [J]. Am Heart J, 1982, 103(4 Pt 2):730-736.
26
de Zwaan C, Bar FW, Janssen JH, et al. Angiographic and clinical characteristics of patients with unstable angina showing an ECG pattern indicating critical narrowing of the proximal LAD coronary artery [J]. Am Heart J, 1989, 117(3):657-665.
27
Haines DE, Raabe DS, Gundel WD. Anatomic and prognostic significance of new T-wave inversion in unstable angina [J]. Am J Cardiol, 1983, 52(1):14-18.
28
郭继鸿. 中国心律学[M]. 北京: 人民卫生出版社, 2010: 72-76.
29
Stober T, Kunze K. Electrocardiographic alterations in subarachnoid haemorrhage. Correlation between spasm of the arteries of the left side on the brain and T inversion and QT prolongation [J]. J Neurol, 1982, 227(2):99-113.
30
Van Bree, Roos YB, van der Bilt IA, et al. Prevalence and characterization of ECG abnormalities after intracerebral hemorrhage [J]. Neurocrit Care, 2010, 12(1):50-55.
50
Daly MJ, Finlay DD, Scott PJ, et al. Prehospital body surface potential mapping improves early diagnosis of acute coronary artery occlusion in patients with ventricular fibrillation and cardiac arrest [J]. Resuscitation, 2013, 84(1):37-41.
31
Lipinski MJ, Mattu A, Brady WJ. Evolving Electrocardiographic Indications for Emergent Reperfusion [J]. Cardiol Clin, 2018, 36(1):13-26.
32
Walsh BM, Smith SW. Differences in Electrocardiographic Findings Between Acute Isolated Right Ventricular Myocardial Infarction and Acute Anterior Myocardial Infarction [J]. JAMA Intern Med, 2016, 176:1875-1876.
33
Lee DH, Walsh B, Smith SW. Terminal QRS distortion is present in anterior myocardial infarction but absent in early repolarization [J]. Am J Emerg Med, 2016, 34(11):2182-2185.
34
杨晓云. 超急性期T波改变 [J]. 临床心电学杂志, 2017, 26(1):16-18.
35
Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction [J]. Ann Emerg Med, 2012, 60(1):45-56.e2.
36
de Winter RJ, Verouden NJ, Wellens HJ, et al. Interventional cardiology group of the academic medical C. A new ECG sign of proximal LAD occlusion [J]. N Engl J Med, 2008, 359(19):2071-2073.
37
Li RA, Leppo M, Miki T, et al. Molecular basis of electrocardiographic ST-segment elevation [J]. Circ Res, 2000, 87(10):837-839.
38
38 Smith SW. Updates on the Electrocardiogram in Acute Coronary Syndromes [J]. Current Emergency and Hospital Medicine Reports, 2013, 1(1):43-52.
39
Stone GW, Sabik JF, Serruys PW, et al. Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease [J]. N Engl J Med, 2016, 375(23):2223-2235.
40
Widimsky P, Rohac F, Stasek J, et al. Primary angioplasty in acute myocardial infarction with right bundle branch block: should new onset right bundle branch block be added to future guidelines as an indication for reperfusion therapy? [J]. Eur Heart J, 2012, 33(1):86-95.
41
Fiol M, Carrillo A, Rodriguez A, et al. Electrocardiographic changes of ST-elevation myocardial infarction in patients with complete occlusion of the left main trunk without collateral circulation: differential diagnosis and clinical considerations [J]. J Electrocardiol, 2012, 45(5):487-490.
42
Driver BE, Khalil A, Henry T, et al. A new 4-variablemformula to differentiate normal variant ST segment elevation in V2-V4 (earlynrepolarization) from subtle left anterior descending coronary occlusion-Adding QRS amplitude of V2 improves the model [J]. J Electrocardiol, 2017, 50(5):561-569.
43
Smith SW. T/QRS ratio best distinguishes ventricular aneurysm from anterior myocardial infarction [J]. Am J Emerg Med, 2005, 23(3):279-287.
44
Klein LR, Shroff GR, Beeman W, et al. Electrocardiographic criteria to differentiate acute anterior ST-elevation myocardial infarction from left ventricular aneurysm [J]. Am J Emerg Med, 2015, 33(6):786-790.
45
Bischof JE, Worrall C, Thompson P, et al. ST depression in lead aVL differentiates inferior ST-elevation myocardial infarction from pericarditis [J]. Am J Emerg Med, 2016, 34(2):149-154.
46
Sarda L, Colin P, Boccara F, et al. Myocarditis in patients with clinical presentation of myocardial infarction and normal coronary angiograms [J]. J Am Coll Cardiol, 2001, 37(3):786-792.
47
Sclarovsky S, Birnbaum Y, Solodky A, et al. Isolated mid-anterior myocardial infarction: a special electrocardiographic sub-type of acute myocardial infarction consisting of ST-elevation in nonconsecutive leads and two different morphologic types of ST-depression [J]. Int J Cardiol, 1994, 46(1):37-47.
48
Birnbaum Y, Hasdai D, Sclarovsky S, et al. Acute myocardial infarction entailing ST-segment elevation in lead aVL: electrocardiographic differentiation among occlusion of the left anterior descending, first diagonal, and first obtuse marginal coronary arteries [J]. Am Heart J, 1996, 131(1):38-42.
49
Iwasaki K, Kusachi S, Kita T, et al. Prediction of isolated first diagonal branch occlusion by 12-lead electrocardiography: ST segment shift in leads I and aVL [J]. J Am Coll Cardiol, 1994, 23(7):1557-1561.
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