Nikus Kjell, Pahlm Olle, Wagner Galen, Birnbaum Yochai, Cinca Juan, Clemmensen Peter, Eskola Markku, Fiol Miquel, Goldwasser Diego, Gorgels Anton, Sclarovsky Samuel, Stern Shlomo, Wellens Hein, Zareba Wojciech, de Luna Antoni Bayés
Department of Cardiology, Heart Center, Tampere University Hospital, Biokatu 6, Tampere, Finland.
J Electrocardiol. 2010 Mar-Apr;43(2):91-103. doi: 10.1016/j.jelectrocard.2009.07.009. Epub 2009 Nov 14.
The electrocardiogram (ECG) remains the most immediately accessible and widely used diagnostic tool for guiding emergency treatment strategies. The ECG recorded during acute myocardial ischemia is of diagnostic, therapeutic, and prognostic significance. In patients with myocardial ischemia as a result of decreased blood supply, the initial 12-lead ECG typically shows (1) predominant ST-segment elevation (STE) as part of STE acute coronary syndrome (STE-ACS), or (2) no predominant STE, that is, non-STE ACS (NSTE-ACS). Patients with predominant STE are classified as having either aborted myocardial infarction (MI) or ST-elevation MI (STEMI) based on the absence or presence of biomarkers of myocardial necrosis. The MI may be aborted either by spontaneous or therapeutic reperfusion of the ischemic myocardium before development of myocardial cell necrosis. NSTE-ACS patients are classified as having either unstable angina or NSTE-MI, based also on the absence or presence of biomarkers of mycardial necrosis. The information obtained from the 12-lead ECG at presentation should be complemented by repeated ECGs especially during symptoms indicative of ischemia and, if applicable, by comparing the findings with reference ECGs. Also, continuous ECG recording in a coronary care setting, including the comparison of ECGs with and without pain, adds to the information gained at patient presentation. In this article, mechanisms of ischemic ECG changes and the ECG patterns recorded in both STE-ACS and NSTE-ACS are described. ECG patterns of NSTE-ACS, which include ST depression, negative T wave, and even normal ECG, need to be better defined in future studies to correlate them with the severity and extent of ischemia and to explore to what extent they are explained by acute active ischemia or represent consequences of ischemia. One of the aims of this article is to propose a classification of the ECG patterns encountered in different clinical scenarios of ACS. How these patterns will aid in guiding the diagnostic and therapeutic process is discussed.
心电图（ECG）仍然是指导急诊治疗策略时最直接可用且应用广泛的诊断工具。急性心肌缺血期间记录的心电图具有诊断、治疗及预后意义。在因供血减少导致心肌缺血的患者中，初始12导联心电图通常显示：（1）作为ST段抬高型急性冠状动脉综合征（STE-ACS）一部分的显著ST段抬高（STE），或（2）无显著STE，即非ST段抬高型ACS（NSTE-ACS）。根据是否存在心肌坏死生物标志物，显著STE患者被分类为有非持续性心肌梗死（MI）或ST段抬高型MI（STEMI）。MI可能因缺血心肌在心肌细胞坏死发生前自发或经治疗再灌注而终止。NSTE-ACS患者也根据是否存在心肌坏死生物标志物被分类为不稳定型心绞痛或NSTE-MI。就诊时从12导联心电图获得的信息应通过重复心电图进行补充，尤其是在出现缺血症状时，并且如果适用，通过与参考心电图比较结果来补充。此外，在冠心病监护环境中进行连续心电图记录，包括比较有痛和无痛时的心电图，可增加就诊时获得的信息。在本文中，描述了缺血性心电图改变的机制以及STE-ACS和NSTE-ACS中记录的心电图模式。NSTE-ACS的心电图模式，包括ST段压低、T波倒置，甚至正常心电图，在未来研究中需要更好地界定，以便将它们与缺血的严重程度和范围相关联，并探讨它们在多大程度上由急性活动性缺血所解释或代表缺血的后果。本文的目的之一是提出ACS不同临床场景中遇到的心电图模式的分类。还讨论了这些模式将如何有助于指导诊断和治疗过程。
