准确测量QT间期是**步，关键是如何修正？

2018-05-19 人间世医学界心血管频道

xujie.L

医生/

QT间期的准确测量只是第一步，随后我们还需要对其进行一定的修正，才能真正完成其对心脏复极的精确评估。

QT间期的准确测量只是第一步，随后我们还需要对其进行一定的修正，才能真正完成其对心脏复极的精确评估。

1.第一步：QT间期的心率调整

从心脏电活动和机械活动角度讲，QT间期实际上相当于心室的收缩期，而心室收缩期会随心率的变化而变化，即心率越快，心室收缩期越短，这也就意味着心率越快，QT间期越短。那么，不同心率下的哪一个QT间期才是真正代表了心脏复极呢？

于是就有了许多根据心率校正的QT间期（QTc）计算公式，目前应用最多的是Bazett公式，即QTc=QT / RR1/2 [sec]，其中QT就是我们所测量的QT间期，RR代表的是相邻QRS之间的时间，以秒记作单位。

图1：心电图示QT间期=366ms，心率=74次/分，RR间期=0.81s

比如图1示：心率=74次/分，QT间期=366ms，RR=0.81，那么我们，计算所得的QTc=366/(0.81)1/2=406ms。但是这个Bazett计算公式也并不是万能的，它主要适用于心率60-100次/分时的QT间期的校正，若心率过快或过慢，其准确性会下降。而线性Framingham校正公式QTc=QT+0.154（1-RR）的适用心率范围会相对宽泛一些。

多说一句，QT间期随心率增加而减少的特性也被应用于长QT综合征的治疗-快速起搏。

2.第二步：宽QRS波的QT间期校正

也许你会觉得根据心率校正完QT间期算是万事大吉了，但是事实总是比你想象的要更复杂，比如说图2，我们测量的QT间期=515ms，心率=69次/分，RR= 0.87s，根据Bazett公式可得QTc= 552ms，那这个QTc就真的代表心脏复极时间吗？

图2：心电图示：QT间期=515ms，心率=69次/分，RR间期= 0.87s，QRS波时限=160ms

显然不是，原因在于该心电图是一个完全型右束支阻滞，其QRS波是明显增宽的，而我们测的QT间期延长可能是QRS延长所致，所以此时计算所得的QTc就会受到代表心脏除极的QRS波的干扰，并不能有效反映心脏复极。那怎么办呢？

目前针对宽QRS波下的QT间期校正，主要采用的公式是JTc=QTc-QRS，比如该患者计算所得得QTc= 552ms，QRS=160ms，那么JTc= 392ms。因此，如果忽略了QRS波宽度，我们可能会极其显着地误判心脏复极情况。有学者认为JTc间期是能够在不同QRS波群、不同心率条件下，较正确反映心室复极时间的可比指标。

3.第三步：QTc的正常范围

经过最初的测量和上述的校正，我们最终取得的一个相对准确的QTc结果，但是万里长征还差最后一步，就是QTc多少才算正常呢？很可惜的是现在并没有一个简单的数值能把正常人和长QT综合征/短QT综合征患者有效地区分开来。

但是总得有个范围吧，目前采用的是2.5%原则，即位于人群的上限或下限的2.5%则被认为是异常的，具体数值是男性QTc参考范围为350-450ms，女性QTc参考范围为360-460ms。但是对于长QT综合征患者的一级亲属而言， QTc＞430ms就可以认为是异常的了。另外QTc过长，大于500ms时，发生恶性心律失常（尖端扭转型室速）的风险会明显增高。

我们经常强调心电图阅图中不要忘了QT间期，其实这个QT间期并不那么简单，需要我们通过一系列步骤才能得到我们所想要的QTc。

原始出处：

[1] Pieter GP， et al. The Measurement of the QT Interval [J]. Current Cardiology Reviews， 2014；10： 287-94.

[2] Hofman N， et al. Diagnostic criteria for congenital long QT syndrome in the era of moleculargenetics: do we need a scoring system？ [J]. Eur Heart J 2007； 28： 575-80.

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2018-05-20 xinmeili

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2018-05-20 smartxiuxiu

好

74 0
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2018-05-19 易水河

学习学习.不错

88 0
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2018-05-19 lietome2

好文.值得点赞!认真学习.应用于实践!谢谢分享给广大同好!

69 0
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2018-05-19 1ddf0692m34(暂无匿称)

学习了.长知识

68 0
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2018-05-19 紫迎馨

学习

23 0
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2018-05-19 sunfeifeiyang

阅

24 0
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2018-05-19 龙胆草

学习谢谢分享

21 0
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createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Sat May 19 08:31:01 CST 2018, time=2018-05-19, status=1, ipAttribution=)]
2018-05-19 明月清辉

谢谢分享.学习了

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