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急性冠脉综合征不典型心电图识别

2021-10-20 朱晓晓心电资讯 朱晓晓心电资讯

心电图识别
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波形特殊、部位特殊、等位性Q波、多部位梗死、合并其他异常......

波形特殊、部位特殊、等位性Q波、多部位梗死、合并其他异常......

 

冠状动脉粥样硬化可引起心肌的缺血、损伤及梗死，除临床表现外，心电图的特征性改变及其演变规律也是临床医生确定诊断和评估病情的重要依据。

 

但是临床中我们常常会遇见一些病情复杂、心电图表现不典型的病人，给疾病的及时诊治带来了许多困难。

复旦大学附属中山医院心内科的副主任医师孔令秋老师，制作了本期《急性冠脉综合征不典型心电图识别》课程，为我们详细讲解临床中可能碰到的不典型的急性心梗心电图表现。
 
一、波形特殊
1.De winter 综合征

  • 前壁导联J点下移1~3mm，T波高尖，整个ST段呈上斜型压低。

  • 患者可有aVR导联ST段轻度上抬。

  • 部分患者可出现胸前导联R波递增不良。

  • QRS波通常不宽或轻度增宽。

图片

 图1 De winter综合征心电图表现
2.Wellens 综合征
T波双向或T波对称性倒置，与症状往往不匹配。

图片

图2 Wellens综合征心电图表现
3.冠状动脉痉挛综合征
可合并传导阻滞、室速、室颤等改变，改变多为动态的、可恢复的。

图片

图3 冠状动脉痉挛综合征心电图表现
4.缺血性J波

冠状动脉狭窄或痉挛引起严重的急性心肌缺血时，心电图可出现新发J波或在原有基础上J波振幅增高或时限延长，称为缺血性J波。

图片

图4 缺血性J波心电图表现
5.巨R波心肌梗死

R波增高、增宽，S波减少、消失，ST段明显抬高（呈下斜型），J点消失，R波降支与ST-T融合成一斜线下降，使QRS波、ST段与T波形成单个三角形的宽波，难以辨认各波段的交界。

 

GRWS改变出现在ST段明显抬高的导联（缺血损伤区导联）；在ST段压低的导联（背离损伤区导联）酷似宽大的S波。

图片

图5 巨R波心梗心电图表现
 

二、部位特殊

1.急性正后壁心肌梗死
（1）典型案例
V1、V2、V3导联ST段压低，I、II导联抬高，需高度警惕后壁异常，加做V7、V8、V9见ST段明显抬高，正后壁心梗诊断明确。
 

图片

图6 急性正后壁心梗心电图表现
（2）为何正后壁心梗ST段抬高不明显？
心脏前壁贴近胸壁，发生梗死时ST段抬高幅度很高。但心脏后壁并不正对后胸壁，所以后壁梗死患者V7~V9的ST段抬高幅度一般较小。
 

图片

图7 心脏与导联位置对应示意图

三、等位性Q波

等位性Q波指心肌梗死发生时，因各种原因导致体表心电图没有表现出典型的病理性Q波，而形成与病理性Q波意义相同的各种特征性QRS波改变，包括小q波、进展性Q波、Q波区、QRS起始部切迹/顿挫、R波丢失、对应R波增高、新消失的间隔q波、心电图一过性伪正常化。
1.小q波
（1）产生原因

  • 梗死面积≤2.5cm2。

  • 左室面积＜10％。

  • 左室除极起始40ms处。

（2）形态特点
左胸导联q波未达到病理性Q波标准，但宽度和深度超过下一个胸导联q波，即qV3＞qV4，qV4＞qV5，qV5＞qV6或V1~V3均出现q波，需排除右室肥厚、左前分支阻滞，多提示前间壁MI。
 

图片

图8 小q波心电图表现
2.进展性Q波
对同一患者在相同体位、导联位置一致的前提下进行观察，若Q波出现动态改变，如Q波加深或加宽，原无Q波的导联出现小q波等，则称为进展性Q波。
 

图片

图9 进展性Q波心电图表现
3.R波丢失
两个连续胸导联R波振幅相差≥50%，同一导联R波振幅进行性下降，RIII、aVF振幅≤0.25mV伴II导联病理性Q波，提示大面积心肌细胞坏死，往往合并室壁瘤改变。

图片

图10 R波丢失心电图表现

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    2022-05-17 赛华佗

    #急性冠脉综合征##心电图#

    0

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    2022-06-05 yaanren

    #不典型#

    0

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    2021-10-22 zhouqu_8

    #综合征#

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1220445, encodeId=32a11220445a4, content=<a href='/topic/show?id=ab99522007b' target=_blank style='color:#2F92EE;'>#急性冠脉综合征#</a><a href='/topic/show?id=7e215120544' target=_blank style='color:#2F92EE;'>#心电图#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52200, encryptionId=ab99522007b, topicName=急性冠脉综合征), TopicDto(id=51205, encryptionId=7e215120544, topicName=心电图)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=赛华佗, createdTime=Tue May 17 16:51:03 CST 2022, time=2022-05-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1898666, encodeId=2b141898666d7, content=<a href='/topic/show?id=e5062028978' target=_blank style='color:#2F92EE;'>#不典型#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=102a153, createdName=yaanren, createdTime=Sun Jun 05 12:14:30 CST 2022, time=2022-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1432167, encodeId=77ed143216e6d, content=<a href='/topic/show?id=f9b9e9124a8' target=_blank style='color:#2F92EE;'>#综合征#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79124, encryptionId=f9b9e9124a8, topicName=综合征)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Fri Oct 22 13:14:30 CST 2021, time=2021-10-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1062487, encodeId=7c64106248e7b, content=不典型心电图, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ece61961273, createdName=雲深無迹, createdTime=Thu Oct 21 08:22:37 CST 2021, time=2021-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1062474, encodeId=fa2010624e4bd, content=好好学习，天天向上, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210612/4cac76eb29134c3aa63a2560971ec878/648fa1cb22cd430380c051eb0a8f6259.jpg, createdBy=7a8d5519826, createdName=呼吸科小医生, createdTime=Thu Oct 21 07:40:04 CST 2021, time=2021-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1062439, encodeId=2434106243912, content=总结的太好了, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4e7a5560026, createdName=丁荣伟, createdTime=Thu Oct 21 06:13:30 CST 2021, time=2021-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1062437, encodeId=9869106243ea9, content=学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210511/e9408422a23545ef9738dd674abfc4ff/c719925083844b82986bc39d43051172.jpg, createdBy=8eb14795142, createdName=与狼共舞, createdTime=Thu Oct 21 06:09:15 CST 2021, time=2021-10-21, status=1, ipAttribution=)]
    2021-10-21 雲深無迹

    不典型心电图

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1220445, encodeId=32a11220445a4, content=<a href='/topic/show?id=ab99522007b' target=_blank style='color:#2F92EE;'>#急性冠脉综合征#</a><a href='/topic/show?id=7e215120544' target=_blank style='color:#2F92EE;'>#心电图#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=100, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=52200, encryptionId=ab99522007b, topicName=急性冠脉综合征), TopicDto(id=51205, encryptionId=7e215120544, topicName=心电图)], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20220519/c2ab253484ee4527a2d4e9589a4821ac/45de9bf494a54becb2ea4369c9d11e85.jpg, createdBy=7a3710, createdName=赛华佗, createdTime=Tue May 17 16:51:03 CST 2022, time=2022-05-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1898666, encodeId=2b141898666d7, content=<a href='/topic/show?id=e5062028978' target=_blank style='color:#2F92EE;'>#不典型#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=102a153, createdName=yaanren, createdTime=Sun Jun 05 12:14:30 CST 2022, time=2022-06-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1432167, encodeId=77ed143216e6d, content=<a href='/topic/show?id=f9b9e9124a8' target=_blank style='color:#2F92EE;'>#综合征#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79124, encryptionId=f9b9e9124a8, topicName=综合征)], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/aLGWoFXAyMbIu3qymFOyheQLjPSX3OUs5GmkyBlcCOwTPIeq3why9NGibxxUqYo6hcx8qZLHZFgNPnBK1yzWeOFpyg2OnWOt0/0, createdBy=fa4716, createdName=zhouqu_8, createdTime=Fri Oct 22 13:14:30 CST 2021, time=2021-10-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1062487, encodeId=7c64106248e7b, content=不典型心电图, beContent=null, objectType=article, channel=null, level=null, likeNumber=57, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=ece61961273, createdName=雲深無迹, createdTime=Thu Oct 21 08:22:37 CST 2021, time=2021-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1062474, encodeId=fa2010624e4bd, content=好好学习，天天向上, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210612/4cac76eb29134c3aa63a2560971ec878/648fa1cb22cd430380c051eb0a8f6259.jpg, createdBy=7a8d5519826, createdName=呼吸科小医生, createdTime=Thu Oct 21 07:40:04 CST 2021, time=2021-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1062439, encodeId=2434106243912, content=总结的太好了, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=4e7a5560026, createdName=丁荣伟, createdTime=Thu Oct 21 06:13:30 CST 2021, time=2021-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1062437, encodeId=9869106243ea9, content=学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210511/e9408422a23545ef9738dd674abfc4ff/c719925083844b82986bc39d43051172.jpg, createdBy=8eb14795142, createdName=与狼共舞, createdTime=Thu Oct 21 06:09:15 CST 2021, time=2021-10-21, status=1, ipAttribution=)]
    2021-10-21 呼吸科小医生

    好好学习，天天向上

    0

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    2021-10-21 丁荣伟

    总结的太好了

    0

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    2021-10-21 与狼共舞

    学习学习

    0