Yip Hon-Kan, Chen Mien-Cheng, Wu Chiung-Jen, Chang Hsueh-Wen, Yu Teng-Hung, Yeh Kuo-Ho, Fu Morgan
Division of Cardiology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China.
Chest. 2003 Apr;123(4):1170-80. doi: 10.1378/chest.123.4.1170.
Simultaneous ST-segment elevation in the precordial and inferior leads is a rare ECG finding in patients with acute myocardial infarction (AMI) and its clinical implications rarely have been reported. The purpose of this study was to evaluate the clinical features of this distinctive ECG manifestation and its impact on clinical outcome.
Between May 1993 and July 2001 in our hospital, direct percutaneous coronary intervention (dPCI) was performed in 924 patients with AMI. Of these 924 consecutive patients, 37 patients (4.0%) who had simultaneous ST-segment elevation (> or = 1 mm) in the precordial and inferior leads were retrospectively analyzed. Eight of these 37 patients who had a wrapped left anterior descending artery (LADA) occlusion were placed into group 1 (ie, wrapped LADA). Twenty-nine of the 37 patients who had anatomic lesions other than a wrapped LADA in the coronary arteries were placed into group 2 (ie, "nonwrapped" LADA). Group 2 patients had significantly higher incidences of cardiogenic shock (58.6% vs 0%, respectively; p = 0.004), pulmonary edema (43.8% vs 0%, respectively; p = 0.02), and sustained sudden cardiac death due to malignant ventricular tachyarrhythmias (44.8% vs 0%, respectively; p = 0.03) than did group 1 patients. Group 1 patients usually had ST-segment elevations of < 2 mm the inferior leads. However, group 2 patients always had ST-segment elevations of > or = 2 mm in the inferior leads. Univariate analysis demonstrated that the mean (+/- SD) ST-segment elevation in the inferior leads was significantly higher in group 2 patients than in group 1 patients (11.08 +/- 4.18 vs 2.95 +/- 0.92 mm, respectively; p = 0.0001). Coronary angiography demonstrated that the incidence of multivessel disease (93.1% vs 37.5%, respectively; p = 0.002) and the incidence of severe obstructive two-vessel disease (ie, stenosis of > 85%) [93.1% vs 0%, respectively; p = 0.0001] were significantly higher in group 2 than in group 1 patients. Although there was no significant difference in the rate of unsuccessful reperfusion (24% vs 13%, respectively; p = 0.38) between group 2 and group 1 patients, the 30-day mortality rate was significantly higher in group 2 patients than in group 1 patients (48.3% vs 0%, respectively; p = 0.015).
AMI with ECG manifestation of simultaneous ST-segment elevation in precordial and inferior leads can be caused by either a wrapped LADA occlusion or a nonwrapped LADA occlusion. While patients with wrapped LADA occlusions usually have favorable clinical outcomes, patients with nonwrapped LADA occlusions usually have serious clinical presentations and unfavorable clinical outcomes. Specific clinical and ECG features identifying high-risk patients in this clinical setting would be extremely important for early, aggressive, and appropriate management.
急性心肌梗死（AMI）患者胸前导联和下壁导联同时出现ST段抬高是一种罕见的心电图表现，其临床意义鲜有报道。本研究旨在评估这种独特心电图表现的临床特征及其对临床结局的影响。
1993年5月至2001年7月期间，我院对924例AMI患者进行了直接经皮冠状动脉介入治疗（dPCI）。在这924例连续患者中，对37例（4.0%）胸前导联和下壁导联同时出现ST段抬高（≥1mm）的患者进行了回顾性分析。这37例患者中，8例左前降支（LADA）血管呈包裹状闭塞的患者被归入第1组（即包裹状LADA组）。37例冠状动脉病变为非包裹状LADA的患者中的29例被归入第2组（即“非包裹状”LADA组）。第2组患者的心源性休克发生率（分别为58.6%和0%；p = 0.004）、肺水肿发生率（分别为43.8%和0%；p = 0.02）以及因恶性室性心律失常导致的持续性心源性猝死发生率（分别为44.8%和0%；p = 0.03）均显著高于第1组患者。第1组患者下壁导联ST段抬高通常<2mm。然而，第2组患者下壁导联ST段抬高总是≥2mm。单因素分析显示，第2组患者下壁导联ST段抬高的平均值（±标准差）显著高于第1组患者（分别为11.08±4.18mm和2.95±0.92mm；p = 0.0001）。冠状动脉造影显示，第2组患者多支血管病变发生率（分别为93.1%和37.5%；p = 0.002）以及严重阻塞性双支血管病变发生率（即狭窄>85%）[分别为93.1%和0%；p = 0.0001]均显著高于第1组患者。尽管第2组和第1组患者再灌注未成功的比例无显著差异（分别为24%和13%；p = 0.38），但第2组患者30天死亡率显著高于第1组患者（分别为48.3%和0%；p = 0.015）。
胸前导联和下壁导联同时出现ST段抬高心电图表现的AMI可由包裹状LADA闭塞或非包裹状LADA闭塞引起。包裹状LADA闭塞的患者通常临床结局良好，而非包裹状LADA闭塞的患者通常临床表现严重且临床结局不佳。识别这种临床情况下高危患者的特定临床和心电图特征对于早期、积极和适当的治疗极为重要。
