Fernandez A R, Sequeira R F, Chakko S, Correa L F, de Marchena E J, Chahine R A, Franceour D A, Myerburg R J
Department of Medicine, University of Miami School of Medicine, Florida, USA.
J Am Coll Cardiol. 1995 Sep;26(3):675-83. doi: 10.1016/0735-1097(95)00208-L.
This study was designed to test the hypothesis that monitoring the ST segment on a single electrocardiographic (ECG) lead reflecting activity in the infarct zone provides sensitive and specific recognition of reperfusion within 60 min of initiation of therapy in acute myocardial infarction.
Infarct-related arteries that fail to recanalize early may benefit from immediate rescue angioplasty. Hence, detection of reperfusion has important practical clinical implications.
Of 41 patients with acute myocardial infarction who had ambulatory ECG (Holter) monitors placed, 38 had adequate ST segment monitoring for 3 h; 35 of the 38 were treated with thrombolytic agents and 3 with primary angioplasty. All patients underwent early coronary angiography and were classified into two groups: Group P (22 patients) had angiographic patency (Thrombolysis in Myocardial Infarction [TIMI] grade 2 or 3 flow), the Group O (16 patients) had persistent occlusion (TIMI grade 0 or 1 flow) of the infarct-related vessel at 60 min from initiation of therapy. The initial ST segment level was defined as the first ST segment level recorded; the peak ST segment level was defined as the highest ST segment level measured during the 1st 60 min. To assess the optimal ST segment recovery criteria for reperfusion, the presence or absence of a > or = 75%, > or = 50% and > or = 25% decrement from initial and peak ST segment levels, sampled and analyzed at 2.5-, 5-, 10-, 15-and 20-min intervals, was correlated with patency of the infarct-related artery at 60 min.
ST segment recovery of > or = 50% reduction from peak ST segment levels with sampling rates at < or = 10-min intervals provided the optimal criterion for recognizing coronary artery patency at 60 min (sensitivity 96%, 95% confidence interval [CI] 77% to 99%; specificity 94%, 95% CI 69% to 99%, p < 0.0001). The subgroup of 13 patients in Group P with TIMI grade 3 reperfusion flow all met this criterion (sensitivity 100%, 95% CI 75% to 100%). The use of the initial ST segment level as the baseline for determining the presence of a > or = 50% reduction in ST segment levels within 60 min was less sensitive. Prediction of coronary reperfusion within 60 min of therapy on the basis of a > or = 75% decrement from peak ST segment levels was less sensitive, and the use of a > or = 25% decrement was less specific.
ST segment monitoring of a single lead reflecting the infarct zone provides a reliable method for assessing reperfusion within 60 min of acute myocardial infarction. Optimal criteria for ECG reperfusion include a > or = 50% decrease from peak ST segment levels, with ST segment measurements recorded continuously or at least every 10 min.
本研究旨在验证以下假设：监测反映梗死区域活动的单导联心电图（ECG）上的ST段，能够在急性心肌梗死治疗开始后60分钟内对再灌注进行敏感且特异的识别。
未能早期再通的梗死相关动脉可能从即刻补救性血管成形术中获益。因此，再灌注的检测具有重要的临床实际意义。
41例急性心肌梗死患者接受了动态心电图（Holter）监测，其中38例有足够的ST段监测3小时；38例中的35例接受了溶栓治疗，3例接受了直接血管成形术。所有患者均接受早期冠状动脉造影，并分为两组：P组（22例患者）梗死相关血管造影显示通畅（心肌梗死溶栓治疗[TIMI]2级或3级血流），O组（16例患者）在治疗开始60分钟时梗死相关血管持续闭塞（TIMI 0级或1级血流）。初始ST段水平定义为记录的首个ST段水平；峰值ST段水平定义为第1个60分钟内测量到的最高ST段水平。为评估再灌注的最佳ST段恢复标准，以2.5、5、10、15和20分钟的间隔采样并分析，将初始和峰值ST段水平下降≥75%、≥50%和≥25%的情况与治疗开始60分钟时梗死相关动脉的通畅情况进行关联。
以≤10分钟的间隔采样，ST段从峰值水平下降≥50%可作为识别60分钟时冠状动脉通畅的最佳标准（敏感性96%，95%置信区间[CI]77%至99%；特异性94%，95%CI 69%至99%，p<0.0001）。P组中13例TIMI 3级再灌注血流的患者亚组均符合该标准（敏感性100%，95%CI 75%至100%）。将初始ST段水平作为确定60分钟内ST段水平下降≥50%的基线，敏感性较低。基于峰值ST段水平下降≥75%预测治疗开始60分钟内冠状动脉再灌注，敏感性较低，而使用下降≥25%则特异性较低。
监测反映梗死区域的单导联ST段可为评估急性心肌梗死60分钟内的再灌注提供可靠方法。心电图再灌注的最佳标准包括ST段从峰值水平下降≥50%，且ST段测量应连续记录或至少每10分钟记录一次。
