Zehender M, Kasper W, Kauder E, Schönthaler M, Geibel A, Olschewski M, Just H
Abteilung für Kardiologie, Innere Medizin III, Universitätsklinik Freiburg, Germany.
N Engl J Med. 1993 Apr 8;328(14):981-8. doi: 10.1056/NEJM199304083281401.
Acute inferior myocardial infarction frequently involves the right ventricle. We hypothesized that right ventricular involvement, as diagnosed by ST-segment elevation in the right precordial lead V4R, may affect the prognosis of patients with inferior myocardial infarctions.
In 200 consecutive patients admitted to the hospital with acute inferior myocardial infarctions, we assessed the prevalence and diagnostic accuracy of ST-segment elevation in lead V4R (as compared with four other diagnostic procedures) to identify right ventricular involvement and its prognostic implications for in-hospital and long-term outcomes.
The in-hospital mortality after inferior myocardial infarction was 19 percent, and major complications occurred in 47 percent of the patients. The presence of ST-segment elevation in lead V4R in 107 patients (54 percent) was highly predictive of right ventricular infarction (sensitivity, 88 percent; specificity, 78 percent; diagnostic accuracy, 83 percent), as compared with the other diagnostic procedures. The patients with ST-segment elevation in lead V4R had a higher in-hospital mortality rate (31 percent vs. 6 percent, P < 0.001) and a higher incidence of major in-hospital complications (64 percent vs. 28 percent, P < 0.001) than did those without ST-elevation in V4R. Multiple logistic-regression analysis showed ST elevation in V4R to be independent of and superior to all other clinical variables available on admission for the prediction of in-hospital mortality (relative risk, 7.7; 95 percent confidence interval, 2.6 to 23) and major complications (relative risk, 4.7; 95 percent confidence interval, 2.4 to 9). The post-hospital course (follow-up, at least 1 year; mean follow-up, 37 months) was similar in patients with and in those without electrocardiographic evidence of right ventricular infarction.
Right ventricular involvement during acute inferior myocardial infarction can be accurately diagnosed by the presence of ST-segment elevation in lead V4R, a finding that is a strong, independent predictor of major complications and in-hospital mortality. Electrocardiographic assessment of right ventricular infarction should be routinely performed in all patients with acute inferior myocardial infarctions.
急性下壁心肌梗死常累及右心室。我们推测，根据右胸前导联V4R的ST段抬高所诊断的右心室受累，可能会影响下壁心肌梗死患者的预后。
在200例因急性下壁心肌梗死入院的连续患者中，我们评估了V4R导联ST段抬高的发生率和诊断准确性（与其他四种诊断方法相比），以确定右心室受累情况及其对住院期间和长期预后的影响。
下壁心肌梗死后的住院死亡率为19%，47%的患者发生了主要并发症。与其他诊断方法相比，107例患者（54%）V4R导联ST段抬高高度提示右心室梗死（敏感性88%；特异性78%；诊断准确性83%）。V4R导联ST段抬高的患者住院死亡率较高（31%对6%，P<0.001），住院主要并发症发生率也较高（64%对28%，P<0.001）。多因素logistic回归分析显示，V4R导联ST段抬高独立于入院时所有其他临床变量，且在预测住院死亡率（相对风险7.7；95%置信区间2.6至23）和主要并发症（相对风险4.7；95%置信区间2.4至9）方面优于其他变量。有和没有右心室梗死心电图证据的患者出院后的病程（随访至少1年；平均随访37个月）相似。
急性下壁心肌梗死期间右心室受累可通过V4R导联ST段抬高准确诊断，这一发现是主要并发症和住院死亡率的有力独立预测指标。所有急性下壁心肌梗死患者均应常规进行右心室梗死的心电图评估。
