提高胸痛伴严重左主干冠状动脉狭窄患者急性心肌梗死的检出率。

Improved detection of acute myocardial infarction in patients with chest pain and significant left main stem coronary stenosis.

机构信息

The Heart Centre, Royal Victoria Hospital, Grosvenor Road, Belfast, Northern Ireland BT12 6BA, UK.

出版信息

QJM. 2012 Feb;105(2):127-35. doi: 10.1093/qjmed/hcr134. Epub 2011 Sep 3.

DOI:10.1093/qjmed/hcr134

PMID:21890878

Abstract

BACKGROUND

Non-invasive diagnosis of acute myocardial infarction (AMI) associated with significant left main stem (LMS) stenosis remains challenging.

METHODS

Consecutive patients presenting with acute ischaemic-type chest pain from 2000 to 2010 were analysed. Entry criteria: 12-lead ECG and Body Surface Potential Map (BSPM) at presentation, cardiac troponin T (cTnT) ≥12 h and coronary angiography during admission. cTnT ≥0.03 µg/l defined AMI. ECG abnormalities assessed: STEMI by Minnesota criteria; ST elevation (STE) aVR ≥0.5 mm; ST depression (STD) ≥0.5 mm in ≥2 contiguous leads (CL); T-wave inversion (TWI) ≥1 mm in ≥2 CL. BSPM STE was ≥2 mm in anterior, ≥1 mm in lateral, inferior, right ventricular or high right anterior and ≥0.5 mm in posterior territories. Significant LMS stenosis was ≥70%.

RESULTS

Enrolled were 2810 patients (aged 60 ± 12 years; 71% male). Of these, 116 (4.1%) had significant LMS stenosis with AMI occurring in 92 (79%). STEMI by Minnesota criteria occurred in 13 (11%) (sensitivity 12%, specificity 92%), STE in lead aVR in 23 (20%) (sensitivity 23%, specificity 92%), TWI in 38 (33%) (sensitivity 34%, specificity 71%) and STD in 51 (44%) (sensitivity 49%, specificity 75%). BSPM STE occurred in 85 (73%): sensitivity 88%, specificity 83%, positive predictive value 95% and negative predictive value 65%. Of those with AMI, 74% had STE in either the high right anterior or right ventricular territories not identified by the 12-lead ECG. C-Statistic for AMI diagnosis using BSPM STE was 0.800 (P < 0.001).

CONCLUSION

In patients with significant LMS stenosis presenting with chest pain, BSPM STE has improved sensitivity (88%), with specificity 83%, over 12-lead ECG in the diagnosis of AMI.

摘要

背景

对于伴严重左主干（LMS）狭窄的急性心肌梗死（AMI）的非侵入性诊断仍然具有挑战性。

方法

对 2000 年至 2010 年期间因急性缺血性胸痛就诊的连续患者进行了分析。入选标准：入院时进行 12 导联心电图和体表电位图（BSPM）检查，心肌肌钙蛋白 T（cTnT）>12 小时，且入院期间行冠状动脉造影。cTnT≥0.03μg/l 定义为 AMI。评估心电图异常：Minnesota 标准的 ST 段抬高型心肌梗死（STEMI）；ST 段抬高（STE）aVR≥0.5mm；至少 2 个连续导联（CL）的 ST 段压低（STD）≥0.5mm；至少 2 个 CL 的 T 波倒置（TWI）≥1mm。BSPM STE 在前壁≥2mm，侧壁、下壁、右心室或高位前侧壁≥1mm，后壁≥0.5mm。严重的 LMS 狭窄定义为≥70%。

结果

共纳入 2810 例患者（年龄 60±12 岁；71%为男性）。其中，116 例（4.1%）有严重的 LMS 狭窄，92 例（79%）伴 AMI。Minnesota 标准的 STEMI 发生率为 13 例（11%）（敏感性 12%，特异性 92%），aVR 导联的 STE 发生率为 23 例（20%）（敏感性 23%，特异性 92%），TWI 的发生率为 38 例（33%）（敏感性 34%，特异性 71%），51 例（44%）有 STD（敏感性 49%，特异性 75%）。BSPM STE 阳性 85 例（73%）：敏感性 88%，特异性 83%，阳性预测值 95%，阴性预测值 65%。AMI 患者中，74%的患者存在高右前壁或右心室区域的 STE，12 导联心电图无法识别。BSPM STE 用于诊断 AMI 的 C 统计量为 0.800（P<0.001）。