Special electrocardiographic manifestations of culprit vessel occlusion in patients with non-ST elevation myocardial infarction
-
摘要: 目的探讨非ST段抬高型心肌梗死(NSTEMI)患者罪犯血管闭塞的心电图特征，并分析其预测罪犯血管闭塞的准确性。方法回顾性收集2016年8月—2020年12月于河北省人民医院心内科318例诊断为NSTEMI患者临床资料，根据有无罪犯血管闭塞分为闭塞组和非闭塞组，比较其临床特征、心电图及与罪犯血管关系，分析特殊心电图征象对罪犯血管闭塞的预测准确性。结果① 闭塞组与非闭塞组R波递增不良、N波、V1导联R波直立发生率无统计学差异(P>0.05)。闭塞组病理性Q波、孤立ST段压低、胸前导联T波失衡发生率高于非闭塞组，Wellens综合征发生率低于非闭塞组(P < 0.05)；②Wellens综合征主要出现在罪犯血管为左前降支患者中，孤立ST段压低主要出现在左回旋支，病理性Q波主要出现在右冠状动脉，具有统计学差异(P < 0.05)；胸前导联T波失衡在各罪犯血管中无统计学差异(P>0.05)。③各种特殊心电图表现联合预测罪犯血管闭塞的AUC=0.615(0.549~0.681)，灵敏度46.0%，特异度73.1%，具有统计学意义(P < 0.05)。结论特殊心电图征象可以预测NSTEMI患者罪犯血管闭塞，特异度较高而灵敏度较低。
-
关键词:
- 非ST抬高型心肌梗死 /
- 血管闭塞 /
- 心电图 /
- 心肌梗死
Abstract: ObjectiveTo explore characteristics of ECG of culprit artery occlusion in patients with Non-ST elevation myocardial infarction(NSTEMI) and analyze its predictive accuracy.MethodsClinical data of 318 patients diagnosed with NSTEMI retrospectively were collected in August 2016 to December 2020 in Cardiology Department of Hebei General Hospital. According to the presence of culprit artery occlusion they were divided into occluded group and non occluded group. We compared the clinical characteristics, ECG and the relationship with the culprit artery, and analyze predictive accuracy of special ECG signs of culprit artery occlusion.Results1) There was no significant difference in the incidence of N wave and V1R upright between occluded group and non-occluded group(P>0.05). The incidence of pathological Q-wave, isolated ST segment depression and T-wave precordial instability in occluded group was higher than those in non-occluded group, while the incidence of Wellens syndrome was lower than that in non-occluded group(P < 0.05). 2) Wellens syndrome was mainly found in patients with LAD as culprit artery, isolated ST segment depression was mainly found in LCX, and pathological Q wave was mainly found in RCA, with statistical differences(P < 0.05). There was no statistical difference in T-wave precordial instability among each culprit artery(P>0.05). 3) The AUC, sensitivity and specificity of all types of special ECG signs to predict culprit artery occlusion were 0.615(0.549-0.681), 46.0% and 73.1%, with statistically significant(P < 0.05).ConclusionSpecial ECG signs can predict culprit artery occlusion in patients with NSTEMI with high specificity and low sensitivity.-
Key words:
- non-ST elevation myocardial infarction /
- culprit artery /
- ECG /
- myocardial infarction
-
-
表 1 NSTEMI患者罪犯血管闭塞组与非闭塞组临床特征比较
Table 1. Comparison of clinical characteristics between two groups in NSTEMI patients
例(%), X±S 项目 闭塞组(113例) 非闭塞组(205例) t/χ2值 P值 男性 83(73.5) 146(71.2) 0.671 0.386 年龄/岁 60.9±12.0 62.3±11.4 1.518 0.130 高血压 73(71.6) 128(66.0) 0.958 0.328 糖尿病 27(29.3) 59(34.7) 0.777 0.378 高脂血症 20(19.6) 46(23.7) 0.650 0.420 吸烟 49(48.0) 93(47.9) 0.000 0.987 既往MI 16(17.4) 22(12.9) 0.953 0.329 家族史 12(11.8) 10(5.2) 4.246 0.039 LVEF/% 50.0±13.7 52.9±15.4 1.541 0.124 LDL-C/(mmol·L-1) 2.82±0.72 2.89±0.82 0.795 0.427 eGFR/[mL·min-1·(1.73m2)-1] 86.2±18.7 86.0±27.9 0.054 0.957 发病-CAG时间/h 92.2±103.0 118.2±117.8 1.890 0.060 Killip≥2级/% 14(12.4) 18(8.8) 1.048 0.306 GRACE评分/分 124.5±32.2 127.8±32.4 0.857 0.392 罪犯血管 17.842 0.001 LAD 39(34.5) 80(39.0) LCX 40(35.4) 56(27.3) RCA 33(29.2) 41(20.0) LM 1(0.9) 12(5.9) 无 0(0) 16(7.8) 
下载: 导出CSV
表 2 NSTEMI患者罪犯血管闭塞组与非闭塞组特殊心电图征象比较
Table 2. Comparison of special ECG signs between two groups in NSTEMI patients
例(%) 指标 闭塞组(113例) 非闭塞组(205例) χ2值 P值 R波递增不良 18(15.9) 23(11.2) 1.439 0.230 Wellens综合征 4(3.5) 22(10.7) 5.019 0.025 N波 28(24.8) 52(25.4) 0.013 0.908 病理性Q波 14(16.0) 8(3.9) 10.983 0.001 孤立ST段压低 13(11.5) 8(3.9) 6.826 0.009 V1导联R波直立 18(15.9) 26(12.7) 0.644 0.422 胸前导联T波失衡 30(26.5) 33(16.1) 5.008 0.025
下载: 导出CSV
表 3 NSTEMI患者特殊心电图征象与罪犯血管分布
Table 3. Special ECG signs and culprit vessel distribution in NSTEMI patients
例(%) 指标 LAD LCX RCA LM 无 χ2值 P值 Wellens综合征(26例) 18(69.2) 2(7.7) 1(3.8) 1(3.8) 4(15.4) 23.030 < 0.001 孤立ST段压低(21例) 2(9.5) 16(76.2) 3(14.3) 0(0) 0(0) 23.268 < 0.001 病理性Q波(24例) 4(16.7) 6(25.0) 14(58.3) 0(0) 0(0) 19.302 0.001 胸前导联T波失衡(63例) 20(31.7) 25(39.7) 16(25.4) 1(1.6) 1(1.6) 6.229 0.183
下载: 导出CSV
表 4 NSTEMI患者特殊心电图征象预测罪犯血管闭塞
Table 4. Specific ECG signs predict culprit vessel occlusion in NSTEMI patients
指标 AUC(95%CI) P值 灵敏度/% 特异度/% Wellens综合征* 0.536(0.471~0.601) 0.288 10.7 96.5 孤立ST段压低 0.538(0.471~0.605) 0.262 26.5 96.1 病理性Q波 0.551(0.484~0.619) 0.130 14.2 96.1 胸前导联T波失衡 0.552(0.485~619) 0.123 26.5 83.9 *Wellens综合征预测罪犯血管非闭塞的AUC(95%CI)、P值、灵敏度、特异度。
下载: 导出CSV
-
[1] Hung CS, Chen YH, Huang CC, et al. Prevalence and outcome of patients with non-ST segment elevation myocardial infarction with occluded "culprit" artery-a systemic review and meta-analysis[J]. Crit Care, 2018, 22(1): 34. doi: 10.1186/s13054-018-1944-x
[2] 石磊, 陈万, 李庆宽, 等. 非ST段抬高型急性心肌梗死高危患者早期及晚期介入治疗对长期预后的影响[J]. 临床急诊杂志, 2021, 22(4): 252-255, 260. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC202104006.htm
[3] Wiśniewski P, Rostoff P, Gajos G, et al. Predictive value of electrocardiographic ST-segment elevation myocardial infarction equivalents for detecting acute coronary artery occlusion in patients with non-ST-segment elevation myocardial infarction[J]. Kardiol Pol, 2019, 77(6): 624-631. doi: 10.33963/KP.14815
[4] Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction(2018)[J]. Circulation, 2018, 138(20): e618-e651.
[5] Schröder LC, Holkeri A, Eranti A, et al. Poor R-wave progression as a predictor of sudden cardiac death in the general population and subjects with coronary artery disease[J]. Heart Rhythm, 2022, 19(6): 952-959. doi: 10.1016/j.hrthm.2022.02.010
[6] Zhou L, Gong X, Dong T, et al. Wellens' syndrome: incidence, characteristics, and long-term clinical outcomes[J]. BMC Cardiovasc Disord, 2022, 22(1): 176. doi: 10.1186/s12872-022-02560-6
[7] 付鹏, 陈洁, 张琳, 等. 心电图有无N波对左回旋支罪犯血管导致的急性心肌梗死患者的临床意义[J]. 中国循环杂志, 2018, 33(11): 1064-1068. doi: 10.3969/j.issn.1000-3614.2018.11.006
[8] Pride YB, Tung P, Mohanavelu S, et al. Angiographic and clinical outcomes among patients with acute coronary syndromes presenting with isolated anterior ST-segment 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. doi: 10.1016/j.jcin.2010.05.012
[9] Bayés de Luna A, Rovai D, Pons Llado G, et al. The end of an electrocardiographic dogma: a prominent R wave in V1 is caused by a lateral not posterior myocardial infarction-new evidence based on contrast-enhanced cardiac magnetic resonance-electrocardiogram correlations[J]. Eur Heart J, 2015, 36(16): 959-964. doi: 10.1093/eurheartj/ehv035
[10] 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. doi: 10.1016/j.annemergmed.2012.02.015
[11] 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. doi: 10.1093/eurheartj/ehx418
[12] Kobayashi A, Misumida N, Aoi S, et al. Prevalence and clinical implication of Wellens' Sign in patients with non-ST-segment elevation myocardial infarction[J]. Cardiol Res, 2019, 10(3): 135-141. doi: 10.14740/cr856
[13] Meyers HP, Bracey A, Lee D, et al. Ischemic ST-segment depression maximal in V1-V4(Versus V5-V6) of any amplitude is specific for occlusion myocardial infarction(Versus Nonocclusive Ischemia)[J]. J Am Heart Assoc, 2021, 10(23): e022866. doi: 10.1161/JAHA.121.022866
[14] Rovai D, Di Bella G, Rossi G, et al. A prominent R wave in V(1) but not in V(2) is a specific sign of a large lateral transmural infarction[J]. Rev Esp Cardiol(Engl Ed), 2012, 65(12): 1101-1105. doi: 10.1016/j.recesp.2012.05.018
[15] Yang T, Chen J, Liu X, et al. Non-ST-elevated myocardial infarction with "N" wave on electrocardiogram and culprit vessel in left circumflex has a risk equivalent to ST-elevated myocardial infarction[J]. Clin Cardiol, 2020, 43(5): 491-499. doi: 10.1002/clc.23334
[16] Rostoff P, Wisniewski P, Gajos G, et al. Electrocardiographic identification of the culprit coronary artery in acute non-ST-elevation myocardial infarction: predictive value of N-wave and T-wave precordial instability[J]. Coron Artery Dis, 2020, 31(7): 590-596. doi: 10.1097/MCA.0000000000000918
[17] 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. doi: 10.1016/j.annemergmed.2012.02.015
[18] Wiśniewski P, Rostoff P, Gajos G, et al. Predictive value of electrocardiographic ST-segment elevation myocardial infarction equivalents for detecting acute coronary artery occlusion in patients with non-ST-segment elevation myocardial infarction[J]. Kardiol Pol, 2019, 77(6): 624-631. doi: 10.33963/KP.14815
[19] 隗沫, 顾伟, 李昭, 等. 心电图aVR导联对急性非ST段抬高型心肌梗死的病变血管的预测价值及预后评估[J]. 临床急诊杂志, 2021, 22(7): 487-490. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC202107010.htm
[20] Aslanger E, Yıldırımtürk Ö, Şimşek B, et al. A new electrocardiographic pattern indicating inferior myocardial infarction[J]. J Electrocardiol, 2020, 61: 41-46. doi: 10.1016/j.jelectrocard.2020.04.008
[21] Meyers HP, Bracey A, Lee D, et al. Comparison of the ST-elevation myocardial infarction(STEMI) vs. NSTEMI and occlusion MI(OMI) vs. NOMI paradigms of acute MI[J]. J Emerg Med, 2021, 60(3): 273-284. doi: 10.1016/j.jemermed.2020.10.026
-