ECG 導(dǎo)聯(lián)-文檔資料

1、ICUHInstitute of Cardiology Union Hospital1導(dǎo)聯(lián)的連接 I 右上左上 avR 正極連右上 II 右上左下 avL 正極連左上 III 左上左下 avF 正極連左下 胸導(dǎo) V1 4肋間胸骨右 V2 4肋間胸骨左 V3 V2-V4中點 V4 5肋間左鎖骨中線 V5 腋前線V4水平 V6 腋中線V4水平Einthoven三角與六軸系統(tǒng)ICUHInstitute of Cardiology Union Hospital2Einthoven triangleLead I= LA-RALead II=LF-RALead III=LF-LA Lead I + Lea

2、d III= Lead II the left arm, right arm, and left leg form the apexes of an equilateral triangle, while the heart, an electrical point, is assumed to be the center of the triangle. The sides of the triangle are analogous to the three standard limb leads and called lead axes. Transposing the three sid

3、e of the triangle ( lead I, II, III ) to a common central point of zero potential forms the triaxial reference system of Bayley. ICUHInstitute of Cardiology Union Hospital3ICUHInstitute of Cardiology Union Hospital4The Concept of a LeadLeads I II III+-RARALL+-LALLLALEAD IILEAD ILEAD IIIRemember, the

4、 RLis always the groundICUHInstitute of Cardiology Union Hospital5The horizontal or transverse planeICUHInstitute of Cardiology Union Hospital6hexaxial frontal plane額面六軸系統(tǒng)額面六軸系統(tǒng)horizontal planeICUHInstitute of Cardiology Union Hospital7ICUHInstitute of Cardiology Union Hospital8心室肥厚心室肥厚 The resultan

5、t vector points to the left, positeriorly, and inferiorly. Marked increment of the posterior and leftward forces during ventricular depolarization. Increased forces anteriorly and to the right High-amplitude R wave in left chest leads (V5,V6 ) Deep S wave in right chest leads (V1,V2 )Tall R wave in

6、lead V1Deep S wave in V5, V6 ICUHInstitute of Cardiology Union Hospital9 左室肥大 左室的位置及特點 左后方 厚于右側(cè) ECG表現(xiàn) QRS電壓增高 胸導(dǎo)：Rv5，v62.5mv Rv5+Sv14.0(男)或3.5mv(女) 肢導(dǎo)：R 1.5mv RaVL1.2mv RaVF2.0mv R + S 2.5mlICUHInstitute of Cardiology Union Hospital10電軸左偏QRS時間延長0.100.11s，但0.12s以R波為主的導(dǎo)聯(lián)可出現(xiàn)ST-T的改變 QRS電壓高，同時有ST-T改變， 稱為

7、左室肥大合并勞損ICUHInstitute of Cardiology Union Hospital11ICUHInstitute of Cardiology Union Hospital12 右室肥大特點 1/3左室厚 ECG改變改變 V1導(dǎo)聯(lián)R/S1，V5 R/S1 或 S波加深， 重者V1為qR型 Rv1+Sv51.05mV，avR R/q或R/S1， R0.5mv 電軸右偏+90 ST-T改變ICUHInstitute of Cardiology Union Hospital13ICUHInstitute of Cardiology Union Hospital14 雙側(cè)心室肥大 大致

8、正常心電圖 向量相抵 單側(cè)心室肥大 一側(cè)掩蓋另側(cè) 雙側(cè)心室肥大ICUHInstitute of Cardiology Union Hospital15The ECG of biventricular hypertrophyTall R wave in left chest leads plusRight axis deviation , Tall R wave in V1ICUHInstitute of Cardiology Union Hospital16Outline 4. Ischemia and ST-T changes5. Myocardial infarctionICUHInsti

9、tute of Cardiology Union Hospital174. Myocardial ischemia, and ST-T changes心肌缺血與心肌缺血與ST-T改變改變ICUHInstitute of Cardiology Union Hospital18Inferior portion of the heartand the right ventriclethe ventricular septum and a large part of the left ventricular free walllateral wall of the left ventricleICUH

10、Institute of Cardiology Union Hospital19The occlusion of the coronary artery in experimental canine studies After clamping coronary artery, the initial ECG changes was an inversion of T wave. Ischemia is a reversible process unassociated with histologic changes. The clamp was left on the coronary ar

11、tery, the ischemia pattern persisted and the ST segment become elevated. The clamp was not released after the appearance of the injury stage, the elevated ST segment persisted, and the R wave disappeared and was replaced by Q wave. control clamping releasecontrol clamping clamping release control cl

12、amping clamping clamping release1. Ischemia stage ( reversible change )2. Injury stage ( reversible change )3. Infarction stage ( irreversible change )ICUHInstitute of Cardiology Union Hospital20心肌缺血（myocardial ischemia)心肌缺血主要影響心室復(fù)極（ST-T） ST-T的改變起決于缺血程度，持續(xù)時間和部位 表現(xiàn)為缺血型和損傷型 缺血型波改變 心內(nèi)膜下缺血波高尖 機(jī)理缺血使心內(nèi)膜復(fù)極

13、更慢，心內(nèi)膜向量 減弱，心外膜波向量相對增加 心外膜下心肌缺血(含透壁) 波倒置 冠狀波 機(jī)理心外膜缺血時，外膜復(fù)極緩慢，內(nèi)膜相對較早復(fù)極，故復(fù)極順序發(fā)生變化，由內(nèi)向外，故波方向與正常相反，缺血導(dǎo)聯(lián)記錄到倒置波。ICUHInstitute of Cardiology Union Hospital21The ischemia ECG ( T wave change ) Subendocardial ischemia tall and upright T wave with prolonged Q-T interval Subepicardial ischemia deeply and symme

14、trically inverted T wave Transmural ischemia ( both subendo and subepicardial) the same as subepicardial ischemia ICUHInstitute of Cardiology Union Hospital22 缺血引起缺血引起T波改變的機(jī)制波改變的機(jī)制subendocardial ischemia Tall and upright T wave with prolonged Q-T interval exploring electrode; repolarization directio

15、n; T vector Subepicardial ischemiaepicardiumendocardiumNormal repola. Repola. delayed a time after the opposing repola. potentials from subepic. Repola. is delayed in subepicardium as compared to the subendocardium. The direction of the repola. process is reversed ( from endoc. To epic.) T.ICUHInsti

16、tute of Cardiology Union Hospital23損傷性損傷性ECG ( ST 段改變段改變 )心內(nèi)膜心內(nèi)膜 a horizontal depression of the ST segment Subepicardial injury the ST segment elevation Transmural injury ( both subendo and subepicardial injury ) the same as the subepicardial injure ICUHInstitute of Cardiology Union Hospital24損傷型 表現(xiàn)

17、為ST段壓低或抬高 心內(nèi)膜損傷：ST段壓低 機(jī)理輕度損傷鉀內(nèi)流增加細(xì)胞內(nèi)外鉀濃度差加大細(xì)胞過度極化靜息時損傷部電位較高T-P上抬，除極后損傷與正常部位無電位差，恢復(fù)等電位線，相對地ST段壓低。 心外膜損傷： ST段抬高 機(jī)理 心肌損傷較重，細(xì)胞膜通透性增加，鉀外逸，細(xì)胞內(nèi)外鉀濃度差減小，細(xì)胞極化不足，靜息時損傷部電位較低，T-P下移，除極后損傷與正常部位無電位差，恢復(fù)等電位線，相對地ST段抬高。ICUHInstitute of Cardiology Union Hospital25Interpretation of injury pattern The injury ( ST ) vector

18、 points from normal area toward the injury area. Subendocardial injury The ST vector points from the epicardial toward the endocardial surface with ST segment depression.Subepicardial injury The ST vector points from the endocardial toward the epicardium surface with ST segment elevation.endocardium

19、epicardiumExploring electrodeICUHInstitute of Cardiology Union Hospital26ICUHInstitute of Cardiology Union Hospital27損傷型損傷型 ECG ( ST 改變改變 ) The acute phase:ST elevations and sometimes tall positive (hyperacute) T waves in certain leads. ICUHInstitute of Cardiology Union Hospital28ST-T改變的臨床意義改變的臨床意義l

20、冠脈灌注不足冠脈灌注不足 心絞痛的發(fā)作（短時間心絞痛的發(fā)作（短時間ST-T 改變改變 通常為壓低通常為壓低) 慢性冠脈缺血慢性冠脈缺血 (持續(xù)性持續(xù)性ST-T 改變改變 ) 變異性心絞痛變異性心絞痛( ST段抬高段抬高)lST 段抬高與壓低相比，可能提示更為嚴(yán)重的缺血段抬高與壓低相比，可能提示更為嚴(yán)重的缺血l鑒別診斷鑒別診斷 非特異性非特異性 ( 繼發(fā)性繼發(fā)性) ST-T 改變改變 原發(fā)性原發(fā)性ST-T 改變改變( 缺血缺血 ) ICUHInstitute of Cardiology Union Hospital29Angina pectoris 心絞痛心絞痛 a patient who co

21、mplained of chest pain while being examinedFive minutes later, after the patient was given sublingual nitroglycerin, the ST segments have reverted to normal, with relief of angina.the ECG with classic or typical angina often shows the pattern of subendocardial ischemia with ST segment depressions.IC

22、UHInstitute of Cardiology Union Hospital30Angina pectoris 心絞痛心絞痛 A Baseline rhythm strip from the positive exercise test of a patient with coronary artery disease.Notice the marked ST depressions with increased heart rate. ICUHInstitute of Cardiology Union Hospital31Variant angina pectoris 變異性心絞痛Sev

23、eral hours later, (after nitroglycerin ) completely normal ECG recurrent chest pain at rest, marked elevation of the ST in leads II, III, aVF, by reciprocal ST depression in leads I, and aVL. Non-specific ST-Tchange inferior leadsTheir angina is atypical because, they have ST segment elevations.ICUH

24、Institute of Cardiology Union Hospital32Other conditions can produce ST-T changes Secondary T wave change : myocarditis, cardiomyopathy, pericarditis, electrolyte imbalance, drug use, ventricular hypertrophy, bundle-branch block, W-P-W syndrome, et al. Primary T wave change : characteristic ECG find

25、ings of myocardial ischemia ICUHInstitute of Cardiology Union Hospital33Other conditions can produce ST-T changesST segment elevation, usually most marked in the chest leads, is sometimes seen as a normal variant. This so-called early repolarization pattern may be confused with the ST segment elevat

26、ions of acute myocardial infarction or pericarditis.ICUHInstitute of Cardiology Union Hospital34Characteristic morphologic features of secondary and primary T wave changes J pointICUHInstitute of Cardiology Union Hospital35Myocardial infarction心肌梗死心肌梗死ICUHInstitute of Cardiology Union Hospital36心肌梗死

27、（myocardial infarction）心肌梗死是冠心病的嚴(yán)重類型，為心肌的缺血性壞死。其發(fā)生包括缺血，損傷和壞死三個類型，在ECG上有特征性的演變過程。缺血型改變 表現(xiàn)為T波的高尖（內(nèi)膜）或倒置（外膜） 機(jī)理同前損傷型改變 由于損傷嚴(yán)重，故表現(xiàn)為ST段上抬 機(jī)理 舒張期損傷電流學(xué)說 （同前） 除極波受阻學(xué)說 損傷除極不完全（表面電位為正）而此時正常心肌表面電位為負(fù)，損傷部電位較高，面對損傷部的電極出現(xiàn)ST抬高 ICUHInstitute of Cardiology Union Hospital37損傷型損傷型 ECGConvex upward ST elevation In trans

28、mural AMI, ST change is the same finding as a pure subepicardial injury ( monophasic wave ). Plateau shapeDome shape Monophasic waveICUHInstitute of Cardiology Union Hospital38Interpretation of injury patternSystolic current of injury收縮期損傷電流Diastolic current of injury舒張期損傷電流ICUHInstitute of Cardiolo

29、gy Union Hospital39Two theories to explain ST elevation1. 舒張期損傷電流學(xué)說舒張期損傷電流學(xué)說 ( the resting state ): diastolic current of injury The normal area of completed polarization. (+) The injured area of incomplete polarization. ()The exploring lead facing opposite to the injury vector; Injury deflection bel

30、ow the baseline 2. 除極受阻學(xué)說除極受阻學(xué)說 ( 去極化去極化 ): systolic currentThe normal area of complete depolarization. ()The injury area of blocking of depolarization. (+) The ST vector points to the exploring lead, an elevated ST is produced.Reciprocal ST depressions can appear in leads sensing the contralateral

31、surface of the heart. Resting depolarization repolarization Resting depolarization repolarizationBase lineBase lineICUHInstitute of Cardiology Union Hospital40壞死型改變壞死型改變MI診斷的標(biāo)志診斷的標(biāo)志 abnormal Q wave and diminished amplitude or absence of the R wave in the leads facing the necrotic or scarred myocardi

32、um.壞死型壞死型Q 波的診斷標(biāo)準(zhǔn)波的診斷標(biāo)準(zhǔn) Width of Q wave 0.04 sec Depth of Q wave R waveICUHInstitute of Cardiology Union Hospital41壞死型壞死型Q波的發(fā)生機(jī)理波的發(fā)生機(jī)理 infracted Q wave is the resultant vector of both infracted and uninfracted myocardium. Most MI are located in the LV free wall and the ventricular septum. The initia

33、l vector of myocardial depolarization changes. Sequence of depolarization in the normal myocardium Sequence of depolarization in infarcted myocardium An initial q wave ( septal depolarization ) is part of the normal LV morphology. Resultant vector of the free both ventricular wall Necrotic zone beco

34、mes electrically inactive , the resultant vector points away from the necrotic zone.qICUHInstitute of Cardiology Union Hospital42Q 和和 QR 取決于記錄電極的位置取決于記錄電極的位置 The exploring electrode is placed directly over a transmural infarcted area, no R wave, but QS wave. The exploring electrode is placed over an

35、 area where the endocardial surface is infarcted, but epicardial surface is not . So a QR wave is present, and the amplitude of the R wave is small.ICUHInstitute of Cardiology Union Hospital43直接的心表電極記錄直接的心表電極記錄ICUHInstitute of Cardiology Union Hospital44 胸導(dǎo)聯(lián)記錄胸導(dǎo)聯(lián)記錄 Precordial lead close to ischemic

36、and injured zone Precordial lead close to necrotic, injured and ischemic zoneICUHInstitute of Cardiology Union Hospital45心肌梗死ECG的演變及分期分期 時間 心電圖表現(xiàn)早期（超急性期） 數(shù)分 ST抬高T高大無Q急性期 小時日周 T下降倒置 ST抬高下降 Q波出現(xiàn)近期（亞急期） 數(shù)周月 ST段正常Q波 T波改變陳舊期（愈合期） 3-6月后 ST-T正?；騎稍異常Q波ICUHInstitute of Cardiology Union Hospital46 Evolution o

37、f MI 心肌梗死的演變心肌梗死的演變 Minutes later, perisiting hours Tall, peaked, broad T wave;ST elevation.Hours or days later, perisiting weeks Abnormal Q or Qs; ST elecvation; inverted T. weeks monthsAbnormal Q or QS;ST retuning to base line;Deeply inverted T.36 months after MI.Q may or may not disappear;T norma

38、l or inverte.Onset of AMINormal hyperacute acute stage subacute (recent ) stage old stageICUHInstitute of Cardiology Union Hospital47Clinical significance of evolution of MIThe characteristic Q, ST, and T changes of MI frequently do not occur simultaneously in the same ECG and should be followed by

39、the means of serial tracings, which are extremely important for accurate diagnosis of AMI.Progressive changes in the ST, T, QRS configuration are the hallmark of AMI.ICUHInstitute of Cardiology Union Hospital48心肌梗死的定位根據(jù)Q波出現(xiàn)的導(dǎo)聯(lián)定位ICUHInstitute of Cardiology Union Hospital49Inferior portion of the hear

40、tand the right ventriclethe ventricular septum and a large part of the left ventricular free walllateral wall of the left ventricleICUHInstitute of Cardiology Union Hospital50the anterior portion of the left ventriclethe inferior portion of the left ventricle Localization of infarctionICUHInstitute

41、of Cardiology Union Hospital51 Localization of infarctionDetermined by recognizing abnormalities ( abnormal Q or QS ) in the leads facing the damaged area.Expressed for the diagnosis of MI three major locations anterior（前壁）（前壁）, inferior ( diaphramatic )（下壁）（下壁）, posterior（后壁）（后壁）. anterior MI furth

42、er divided into anteroseptal（前間壁）（前間壁）, localized anterior（前壁）（前壁）, anterlateral（前側(cè)壁）（前側(cè)壁）, extensive anterior （廣泛前壁）（廣泛前壁） The electrocardiographic locations of MI do not correlate precisely with pathologic findings.ICUHInstitute of Cardiology Union Hospital52導(dǎo)聯(lián) 前間壁 前壁 前側(cè)壁 高側(cè)壁 廣泛前壁 下壁 后壁 右室 V1 + +

43、V2 + + + V3 + + + V4 + + + V5 + + V6 + + V7 + V8 + V9 + + + + + avL + + aVF + V3R + V4R + V5R + V6R +ICUHInstitute of Cardiology Union Hospital53Localization of anterior infarctionsaVL Anteroseptal MI 前間壁前間壁 V1 3 Anterior ( localized ) MI 前壁前壁 V2 4 Anterolateral MI 前側(cè)壁前側(cè)壁 I, aVL, V4 6 High lateral M

44、I 高側(cè)壁高側(cè)壁 I, aVL Extensive anterior MI 廣泛前壁廣泛前壁 I, aVL, V16左心室高側(cè)心尖高間中間右心室V3V2V1V4V5V6IICUHInstitute of Cardiology Union Hospital54ECG sequence with anterior wall Q wave infarctionA, Acute phase of an anterior wall infarction: ST elevations and new Q waves. B, Evolving phase: deep T wave inversions. C

45、, Resolving phase: partial or complete regression of ST-T changes (and sometimes of Q waves). In A and B, notice the reciprocal ST-T changes in the inferior leads (II, III, and aVF). ICUHInstitute of Cardiology Union Hospital55ECG sequence with inferior wall Q wave infarction A, Acute phase of an in

46、ferior wall myocardial infarction: ST elevations and new Q waves. B, Evolving phase: deep T wave inversions. C, Resolving phase: partial or complete regression of ST-T changes (and sometimes of Q waves). In A and B, notice the reciprocal ST-T changes in the anterior leads (I, aVL, and V2). ICUHInsti

47、tute of Cardiology Union Hospital56Evolution of acute anterior wall MI TTTTQ STQ STSTSTSTIn the earliest phase of the infarctionSeveral hours laterICUHInstitute of Cardiology Union Hospital57Evolution of acute extensive anterior MIICUHInstitute of Cardiology Union Hospital58Evolution of acute inferi

48、or MI12 Hours after onset of chest pain24 Hours later5 Days later Markedly elevated ST in leads II, III, aVF. Reciprocal ST depression in leads ( I, aVR, aVL, V14 ) facing the undamaged area during the acute phase. Q wave and inverted T waves in II，III，aVF ICUHInstitute of Cardiology Union Hospital5

49、9Recent inferior MIThis patient sustained a myocardial infarction 1 month previouslyICUHInstitute of Cardiology Union Hospital60Old inferior MI Notice the prominent Q waves in leads II, III, and aVF from a patient who had a myocardial infarction 1 year previously. The ST-T changes have essentially r

50、everted to normal. ICUHInstitute of Cardiology Union Hospital61Anterior wall and inferior MINotice the slow R wave progression and QS complexes in chest leads V1 to V5, as well as the QS waves in leads II, III, and aVF.ICUHInstitute of Cardiology Union Hospital62Non-Q wave myocardial infarctionSuben

51、docardial infraction markedly depressed ST in many leads The ECG changes: ST elevation or depression; T wave inverted; without abnormal Q wave; ST T evolution. NonQ wave infarction in a patient who complained of severe chest pain. Subsequently, the patients cardiac enzyme levels were elevated. Notic

52、e the marked, diffuse ST depressions in leads I, II, III, aVL, aVF, and V2 to V6, in conjunction with the ST elevation in lead aVR. These findings are consistent with severe subendocardial ischemia. ICUHInstitute of Cardiology Union Hospital63MI complicated by ventricular aneurysm 室壁瘤Notice the prominent Q waves in leads V1 to V3 and aVL, the persistent ST elevations in these leads, and the reciprocal ST depressions in the inferior leads (II, III, and aVF).The diagnosis is confirmed by cardiac catheterization. ICUHInstitute of Cardio