V_(4)与Ⅲ导联ST段、QRS波时限鉴别急性下壁心肌梗死并存左前降支受累的临床意义  

Clinical significance of ST-segment and QRS duration in leads V4 andⅢin identifying acute inferior myo-cardial infarction with left anterior descending artery lesion

作　　者：郑晓斌 张昭福 ZHENG Xiaobin;ZHANG Zhaofu(Depart-ment of Cardiovascular Medicine,1.Shanxi Cardiovascular Hospital,Taiyuan Shanxi 030000;Xinxiang Central Hospital,Xinxiang Henan 453000,China)

机构地区：[1]山西省心血管病医院心血管内科,山西太原030000 [2]新乡市中心医院心血管内科,河南新乡453000

出　　处：《实用心电学杂志》2022年第4期272-279,共8页Journal of Practical Electrocardiology

摘　　要：目的研究V_(4)、Ⅲ导联ST段改变及QRS波时限鉴别急性下壁ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者左前降支不同受累情况的临床价值。方法回顾性分析行冠状动脉造影的下壁STEMI患者189例,将其中64例存在单一罪犯血管(右冠状动脉或左回旋支)并存左前降支不同阻塞的病例,分为左前降支闭塞组(阻塞程度≥99%,n=17)、左前降支狭窄组(50%<阻塞程度<99%,n=21)、左前降支正常组(无阻塞,n=26)。比较三组患者的临床资料,根据受试者工作特征(receiver operating characteristic,ROC)曲线确定V_(4)、Ⅲ导联ST段偏移量与QRS波时限相关界值。结果左前降支正常组患高血压、脑梗死者占比低于左前降支闭塞组与左前降支狭窄组;左前降支闭塞组患糖尿病及心功能KillipⅢ—Ⅳ级者占比高于左前降支正常组(P均<0.05)。左前降支闭塞组左心室射血分数较其他两组显著降低(P<0.01),左前降支正常组血清NT-proBNP水平明显低于左前降支闭塞组(P<0.01)。在心电图方面,左前降支闭塞组与左前降支狭窄组患者V_(4)导联ST段压低(ST_(V_(4))↓)数值、V_(4)导联ST段压低与Ⅲ导联ST段抬高差值(ST_(V_(4))↓-ST_(Ⅲ)↑)、V_(4)导联QRS波时限(QRSV_(4))均高于左前降支正常组(P均<0.05);与左前降支正常组相比,左前降支闭塞组Ⅲ导联QRS波时限增宽(P<0.05)。ROC曲线分析显示,ST_(V_(4))↓-ST_(Ⅲ)↑>-1.46 mm(敏感性83.3%,特异性57.1%),QRSV_(4)>97.38 ms(敏感性68.4%,特异性80.8%)对下壁心肌梗死患者并存左前降支受累(包括左前降支闭塞或狭窄)有较高的预测价值,且二者联合诊断性能更优(敏感性76.3%,特异性84.6%)。结论下壁STEMI并存左前降支受累患者合并疾病较多,特别是左前降支闭塞时患者心功能更差,而ST_(V_(4))↓-ST_(Ⅲ)↑、QRSV_(4)能够为下壁STEMI合并左前降支病变提供诊断线索。Objective To study the clinical value of ST-segment changes and QRS duration in leads V_(4) and Ⅲ in identifying different involvements of the left anterior descending(LAD)artery among patients with acute inferior ST-segment elevation myocardial infarction(STEMI).Methods Retrospective analysis was performed on 189 pa-tients with inferior STEMI who had undergone coronary angiography.Among these patients,64 were divided into LAD occlusion group(LAD obstruction≥99%,n=17),LAD stenosis group(50%<LAD obstruction<99%,n=21)and normal LAD group(without LAD obstruction,n=26)according to different degrees of LAD obstruction in a single culprit vessel(the right coronary artery or left circumflex artery).The clinical data of the three groups were compared;the receiver operating characteristic(ROC)curve was utilized to determine the related cut-off va-lues of ST-segment deviation and QRS duration in leads V_(4)andⅢ.Results The proportion of patients with hyper-tension or cerebral infarction in the normal LAD group is lower than that in the LAD occlusion group and the LAD stenosis group;the proportion of patients with diabetes or cardiac function of KillipⅢ-Ⅳin the LAD occlusion group is higher than that in the normal LAD group(P<0.05).The left ventricular ejection fraction in the LAD occlusion group is significantly lower than that in the other two groups(P<0.01),and the serum NT-proBNP level of the normal LAD group is the lowest(P<0.01).In terms of electrocardiogram,the deviation of ST-segment depression in lead V_(4)(ST_(V_(4))↓),the difference between ST-segment depression in lead V_(4)and ST-segment elevation in leadⅢ(ST_(V_(4))↓-ST_(Ⅲ)↑),and QRS duration in lead V_(4)(QRSV_(4))of patients in the LAD occlusion and LAD stenosis groups are higher than those of patients in the normal LAD group(P<0.05).QRS duration of leadⅢin the LAD occlusion group is widened as compared to the normal LAD group(P<0.05).ROC curve analysis indicates that ST_(V_(4))↓-ST_(Ⅲ)↑>-1.46 mm and QRSV_(4)>97.38 ms are of high

关 键 词：下壁心肌梗死 急性ST段抬高型心肌梗死 左前降支 心电图 QRS波时限 多支病变 

分 类 号：R542.22[医药卫生—心血管疾病]