Snyder J W, Basta L L, Woolson R F
J Electrocardiol. 1975;8(2):95-102. doi: 10.1016/s0022-0736(75)80016-1.
We reviewed 144 consecutive patients with symptomatic high grade atrioventricular block. Cases due to congenital heart disease, acute myocardial infarction, cardiac surgery or digitalis toxicity were excluded. Of the remaining, we chose 71 patients in whom atrioventricular conduction was observed either intermittently during complete heart block (CHB) or in electrocardiograms taken within two years prior to documentation of CHB. The mean age was 69 years, with the peak incidence in the seventh decade in 43 men and eight decade in 28 women. Bundle branch block (BBB) was present in 76% of patients as follows: 47% had right BBB (20% with normal QRS axis, 20% with left axis deviation and 7% with right axis deviation), 17% had left BBB (11% with normal QRS axis and 6% with left axis deviation) and 12% had either alternating BBB, right BBB with alternating axis deviation or atypical BBB. "Trifascicular block" patterns accounted for 21% of the total group of CHB. We also studied the prevalence of various patterns of BBB in a group of 2000 random hospital patients of comparable age and sex exclusive of those with acute myocardial infarction and heart surgery. The risk of CHB for the various patterns of BBB was calculated relative to normal intraventricular conduction. All patterns of BBB carried a considerably increased relative risk of CHB, (P smaller than .01). The relative risk was highest for RBBB with left axis deviation and lowest for LBBB with normal or left axis deviation. In the men, 74% had QRS patterns of "bifascicular" or "trifascicular" block during atrioventricular conduction. By contrast, 71% women had atrioventricular beats showing either no BBB or right BBB with normal QRS axis. QRS pattern during CHB was unchanged from that during atrioventricular conduction in 52% if cases (rabge 38%-76% with different QRS patterns) suggesting idiojunctional pacemaker. CHB in these cases was thought to be due probably to coexistent disease in the AV node or His bundle. Although the concept of uni-, bi- and trifascicular block patterns has been useful in identifying patients at greater risk of CHB, the predictability of the electrocardiogram has obvious limitations, particularly in women.
我们回顾了144例连续性有症状的高度房室传导阻滞患者。排除先天性心脏病、急性心肌梗死、心脏手术或洋地黄中毒所致病例。在其余患者中，我们选择了71例，这些患者在完全性心脏传导阻滞（CHB）期间房室传导呈间歇性，或在记录CHB前两年内的心电图中观察到房室传导。平均年龄为69岁，发病高峰在70年代，男性43例，80年代女性28例。76%的患者存在束支传导阻滞（BBB），情况如下：47%为右束支传导阻滞（20% QRS电轴正常，20%左偏，7%右偏），17%为左束支传导阻滞（11% QRS电轴正常，6%左偏），12%为交替性束支传导阻滞、右束支传导阻滞伴交替性电轴偏移或不典型束支传导阻滞。“三分支阻滞”模式占CHB总病例组的21%。我们还研究了2000例年龄和性别相仿的随机住院患者（不包括急性心肌梗死和心脏手术患者）中各种束支传导阻滞模式的患病率。计算各种束支传导阻滞模式相对于正常室内传导的CHB风险。所有束支传导阻滞模式的CHB相对风险均显著增加（P小于0.01）。左偏右束支传导阻滞的相对风险最高，正常或左偏左束支传导阻滞的相对风险最低。男性中，74%在房室传导期间有“双分支”或“三分支”阻滞的QRS模式。相比之下，71%的女性房室搏动无束支传导阻滞或为QRS电轴正常的右束支传导阻滞。52%的病例（不同QRS模式下为38%-76%）CHB期间的QRS模式与房室传导期间相同，提示交界性起搏点。这些病例中的CHB可能被认为是由于房室结或希氏束并存疾病所致。尽管单分支、双分支和三分支阻滞模式的概念在识别CHB风险较高的患者方面很有用，但心电图的可预测性有明显局限性，尤其是在女性中。
