Birnbaum Itamar, Birnbaum Yochai
The Department of Medicine, Baylor College of Medicine and St Luke Episcopal Hospital, Houston, TX, USA.
J Electrocardiol. 2013 Nov-Dec;46(6):535-9. doi: 10.1016/j.jelectrocard.2013.06.008. Epub 2013 Jul 15.
The current guidelines advocate distinct approaches (urgent reperfusion therapy) to patients with suspected acute coronary syndromes (ACS) presenting with ST elevation (STE) versus patients without STE on their electrocardiogram (ECG). This is based on the paradigm that STE represents ongoing transmural ischemia due to an acute occlusion of an epicardial coronary artery whereas the significance of other ECG findings is more contentious. The role of urgent coronary angiography in patients without STE is less clear and initial stabilization with conservative treatment is recommended. However, in some cases the distinction between STEMI and non-STE-ACS is difficult. Acute occlusion of a coronary artery may cause less than the current recommended threshold STE. On the other hand, many patients may have STE secondary to nonischemic etiology. In many patients with non-STE-ACS the coronary artery is not completely occluded at the time of presentation and there are rapid fluctuations in the severity of ischemia and hence, dynamic changes are observed in the ECG. Several ECG patterns associated with particular coronary anatomy and high-risk prognosis have been identified. Patients with ACS presenting with these high-risk patterns should probably be referred for coronary angiography with the possibility of urgent intervention with the goal of prevention of ischemic complications, rather than for immediate myocardial salvage, as in classic STEMI.
当前指南提倡对心电图（ECG）表现为ST段抬高（STE）的疑似急性冠状动脉综合征（ACS）患者与无STE的患者采用不同的方法（紧急再灌注治疗）。这是基于这样一种范式，即STE代表由于心外膜冠状动脉急性闭塞导致的持续性透壁缺血，而其他ECG表现的意义更具争议性。紧急冠状动脉造影在无STE患者中的作用尚不清楚，建议采用保守治疗进行初始稳定。然而，在某些情况下，ST段抬高型心肌梗死（STEMI）和非ST段抬高型急性冠状动脉综合征（non-STE-ACS）之间的区分很困难。冠状动脉急性闭塞可能导致低于当前推荐阈值的STE。另一方面，许多患者可能因非缺血性病因继发STE。在许多非ST段抬高型急性冠状动脉综合征患者中，冠状动脉在就诊时并未完全闭塞，缺血严重程度存在快速波动，因此在ECG上可观察到动态变化。已经确定了几种与特定冠状动脉解剖结构和高危预后相关的ECG模式。表现出这些高危模式的急性冠状动脉综合征患者可能应接受冠状动脉造影，并有可能进行紧急干预，目的是预防缺血性并发症，而不是像经典STEMI那样立即进行心肌挽救。
