跳到主要內容

臺灣博碩士論文加值系統

(44.211.117.197) 您好!臺灣時間:2024/05/21 03:47
字體大小: 字級放大   字級縮小   預設字形  
回查詢結果 :::

詳目顯示

我願授權國圖
: 
twitterline
研究生:周立平
研究生(外文):Li-Ping Chou
論文名稱:以新的心電圖診斷要點來判定急性下壁心肌梗塞的病灶部位
論文名稱(外文):New Electrocardiographic Criteria for Identification the Culprit Site of Coronary Artery in Inferior Wall Acute Myocardial Infarction
指導教授:譚秀芬譚秀芬引用關係
指導教授(外文):Hsiu-Fen Tan
學位類別:碩士
校院名稱:長榮大學
系所名稱:醫務管理學系碩士班
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2007
畢業學年度:95
語文別:中文
論文頁數:59
中文關鍵詞:心電圖急性心肌梗塞冠狀動脈攝影
外文關鍵詞:ElectrocardiogramAcute myocardial infarctionCoronary angiographyReceiver operating characteristic
相關次數:
  • 被引用被引用:0
  • 點閱點閱:445
  • 評分評分:
  • 下載下載:0
  • 收藏至我的研究室書目清單書目收藏:0
背景:急性下壁心肌梗塞的病灶血管會影響臨床癒後,包括右冠狀動脈近端及遠端和左迴旋動脈三處。數篇發表的文章以不同的心電圖診斷要點來區分右冠狀動脈或左迴旋動脈,但是只有一篇文章是以心電圖的V3/Ⅲ比值來預估三處可能引發心肌梗塞的血管,更具有廣泛的臨床運用價值,可惜病人有選擇性。本研究是利用新的心電圖診斷要點來判定可能引發急性下壁心肌梗塞的可能三處冠狀動脈。
方法及結果:71位急性下壁心肌梗塞的病人,沒有心肌梗塞病史,心電圖沒有束枝傳導阻塞,且第一張心電圖是在胸痛發病的12小時內取得的病人,被選入在本研究。這些病人病灶根據冠狀動脈攝影被分為三群,右冠狀動脈的右心室枝之前(近端)、後(遠端)及左迴旋動脈。第一張心電圖上的導程Ⅲ除以Ⅱ的值當作預測指標。近側右冠狀動脈,遠側右冠狀動脈及迴旋動脈之Ⅲ/Ⅱ比值分別為2.1 ± 0.7,1.6 ± 0.6,1.0 ± 0.2(P < 0.0001)。依據receiver operating characteristic座標值選定Ⅲ/Ⅱ比值大於等於1.8判定為近側右冠狀動脈病灶;小於1.8且大於等於1.2判定為遠側冠狀動脈;小於1.2判定為左迴旋動脈。如此預測之敏感性分別為73%,76%,75%,專一性為88%,79%,92%。
結論:導程Ⅲ/Ⅱ比值的心電圖診斷要點,可以提供簡單、又有用的方法,來判定急性下壁心肌梗塞的病灶血管部位。
Background: The culprit coronary artery in inferior wall acute myocardial infarction (AMI) is one of the major factors of determining the clinical outcome. Several electrocardiographic criteria have been proposed to differentiate between the right coronary artery (RCA) and the left circumflex coronary artery (LCX) as culprit artery in inferior wall AMI. Only one previous study had ever used V3/III ratio as a criteria to predict infarct-related artery at three possible sites which had provided more extensively clinical use. This study was designed to identify the three possible sites of coronary artery in inferior AMI by new electrocardiographic criteria.
Methods and Results: Seventy-one patients who have no previous myocardial infarction or bundle branch block and whose first electrocardiogram was obtained less than 12 hours after the onset of chest pain were enrolled in this study. These patients were divided into three groups by confirmed coronary angiography, including culprit lesion before (proximal) and after (distal) the right ventricular branch of RCA and LCX. The ratio of ST elevation in lead III to lead II obtained from first surface electrocardiogram was used to determine the criteria. For culprit artery of proximal RCA, distal RCA, and LCX, III/II ratio was 2.1 ± 0.7, 1.6 ± 0.6, 1.0 ± 0.2 (P < 0.0001 ), respectively. According to the data of the receiver operating characteristic plot, III/II ratio > 1.8 was chosen to predict lesion at proximal RCA, III/II ratio was between 1.2 and 1.8 to predict distal RCA, and III/II ratio < 1.2 to predict LCX with sensitivity of 73%, 76%, 75%, and specificity of 88%, 79%, 92%, respectively.
Conclusion: The new electrocardiographic criteria with III/II ratio provided a simple, and useful method for early identification the culprit site of coronary artery in inferior wall AMI.
目 錄
中文摘要................................................... Ⅰ
英文摘要................................................... Ⅱ
目 錄................................................... Ⅲ
表 目 錄................................................... V
圖 目 錄................................................... Ⅵ
第一章 緒論................................................ 1
1.1 研究動機............................................ 1
1.2 研究目的............................................ 2
1.3 名詞解釋............................................ 3
第二章 文獻探討............................................ 11
2.1 下壁心肌梗塞癒後之研究.............................. 11
2.2 心電圖預測急性下壁心肌梗塞病灶血管的研究............ 13
第三章 研究方法............................................ 27
3.1 研究設計與步驟...................................... 27
3.2 研究架構............................................ 28
3.3 研究樣本............................................ 29
3.4 研究工具............................................ 31
3.5 統計分析............................................ 32
第四章 結果................................................ 33
4.1 病人的特徵.......................................... 33
4.2 心電圖表徵.......................................... 36
4.3 新的心電圖診斷要點.................................. 36
4.4 診斷要點之價值...................................... 41
第五章 討論................................................ 45
第六章 結論與建議.......................................... 50
6.1 結論................................................ 50
6.2 建議................................................ 51
參考文獻................................................... 52
附錄一..................................................... 58

表 目 錄
表2.1 以心電圖診斷要點預估右冠狀動脈為病灶血管............. 14
表2.2 以心電圖診斷要點預估左迴旋動脈為病灶血管............. 18
表2.3 以V3/III比值預估冠狀動脈阻塞位置之準確性............. 34
表4.1 病人之臨床特徵....................................... 35
表4.2 病灶血管與心電圖研究結果的相關....................... 37
表4.3 以ROC曲線座標值選擇III/II的比值判別近端右冠狀動脈... 39
表4.4 以ROC曲線座標值選擇III/II的比值判別左迴旋動脈....... 40
表4.5 III/II比值與冠狀動脈阻塞的位置之關連性............... 41
表4.6 由III/II比值來預測冠狀動脈阻塞的位置之敏感性、專一性、
陽性預測值以及陰性預測值............................. 41

圖 目 錄
圖1.1 六個肢體導程......................................... 4
圖1.2 六個胸前導程及其他胸前導程........................... 4
圖1.3 肢體導程在額面形成環狀位置........................... 5
圖1.4 胸前導程在額面形成環狀位置........................... 5
圖1.5 每一心動週期包含P-QRS-T波之圖形...................... 6
圖1.6 心肌梗塞後心電圖的變化............................... 7
圖1.7 三條主要冠狀動脈..................................... 8
圖1.8 ROC曲線圖........................................... 10
圖2.1 以心電圖預測下壁心肌梗塞的病灶血管流程(Fiol)........... 25
圖2.1 以心電圖預測下壁心肌梗塞的病灶血管流程(Zimetbaum)..... 26
圖3.1 本研究流程圖......................................... 28
圖3.2 研究架構............................................. 29
圖3.3 收集樣本數與病灶分佈情形............................. 30
圖4.1 以Ⅲ/Ⅱ比值判別近端右冠狀動脈為病灶血管之價值......... 39
圖4.2 以Ⅲ/Ⅱ比值判別左迴旋動脈為病灶血管之價值............. 40
圖4.3 心電圖診斷要點對應冠狀動脈攝影的結果(近端右冠狀動脈). 42
圖4.4 心電圖診斷要點對應冠狀動脈攝影的結果(遠端右冠狀動脈). 43
圖4.5 心電圖診斷要點對應冠狀動脈攝影的結果(左迴旋動脈) ..... 44
圖5.1 左迴旋動脈下壁心肌梗塞其心電圖向量............... .... 46
圖5.2 右冠狀動脈引發之下壁心肌梗塞其心電圖向量... .......... 47
1.Hasdai, D., Birnbaum, Y., Herz, I., Sclarovsky, S., Mazur, A. & Solodky, A. (1995), ST-segment depression in lateral limb leads in inferior wall acute myocardial infarction: implications regarding the culprit artery and the site of obstruction, Eur Heart J, 16:1549-53.
2.Braat, S.H., Brugada, P., den Dulk, K., van Ommen, V. & Wellens, H.J.J.(1984), Value of lead V4R for recognition of the infarct coronary artery in acute inferior myocardial infarction, Am J Cardiol, 53:1538-41.
3.Herz, I., Assali, A.R., Alder, Y. & Solodky, A. & Sclarosky, S. (1997), New electrocardiographic criteria for predicting either the right or left circumflex artery as the culprit coronary artery in inferior wall acute myocardial infarction, Am J Cardiol, 80:1343-45.
4.Bairey, C.N., Shah, P.K., Lew, A.S. & Hulse, S. (1987), Electrocardiographic differientiation of occlusion of the left circumflex versus the right coronary artery as a cause of inferior acute myocardial infarction, Am J Cardiol, 60:456-9.
5.Kontos, M.C., Desai, P.V., Jesse, R.L. & Ornato, J.P. (1997), Usefulness of the admission electrocardiogram for identifying the infarct-related artery in inferior wall acute myocardial infarction, Am J Cardiol, 79:182-4.
6.Nair, R. & Glancy, D.L.(2002), ECG discrimination between right and left circumflex coronary arterial occlusion in patients with acute inferior myocardial infarction: value of old criteria and use of lead aVR, Chest , 122:134-9.
7.Zimetbaum, P.J. & Josephson, M.E. (2003)Use of the electrocardiogram in acute myocardial infarction, N Engl J Med , 348:933-40.
8.Chiang, C.Y., Ku, P.M., Huang, T.Y., Cheng, C.C., Wu, W.S., Chen, Z.C. & Chou, M.T.(2006), EKG criteria predict infarct-related artery of inferior wall acute myocardial infarction, Acta Cardiol Sin, 22:67-74.
9.Kosuge, M., Kimura, K., Ishikawa, T., Hongo, Y., Mochida, Y., Sugiyama, M. & Tochikubo, O.(1998), New electrocardiographic criteria for predicting the site of coronary artery occlusion in inferior wall acute myocardial infarction, Am J Cardio, 82:1318-1322.
10.Huey, B.L., Beller, G.A., Kaiser, D.L. & Gibson, R.S.(1998), A comprehensive analysis of myocardial infarction due to left circumflex artery occlusion: comparison with infarction due to right coronary artery and left anterior descending artery occlusion, J Am Coll Cardiol, 12:1156-66.
11.Birnbaum, Y., Sclarovasky, S., Mager, A., Sirasberg, B. & Rechavia.(1993), ST segment depression in aVL: a sensitive marker for acute inferior myocardial infarction, Eur Heart J, 14:4-7.
12.Blanke, H., Cohen, M., Schlueter, G.U., Karsch, K.R. & Rentrop, K.P.(1984), Electrocardiographic and coronary arteriographic correlations during acute myocardial infarction, Am J Cardiol, 54:249-255.
13.Sclarovsky, S., Topaz, O., Rechavia, E., Strasberg, B. & Agmon, J.(1987), Ischemic ST segment depression in leads V2-V3 as the presenting electrocardiographic feather of posterolateral wall myocardial infarction, Am Heart J, 113:1085-1090.
14.Wong, T.W., Huang, X.H., Liu, W., Ng, K. & Ng, K.S.(2004), New electrocardiographic criteria for identifying the culprit artery in inferior wall acute myocardial infaction—usefulness of T-wave amplitude ration in Leads II/III and T-wave polarity in the right V5 lead, Am J Cardiol, 94:1168-1171.
15.Fiol, M., Cygankiewicz, I., Carrillo, A., Bayes-Genis, A., Santoyo, O., Gomez, A., Bethencourt, A. & de Lung, A.B.(2004), Value of electrocardiographic algorithm based on “ups and downs” of ST in assessment of a culprit artery in evolving inferior wall acute myocardial infarction, Am J Cardiol, 94:709-714.
16.Kabakci, G., Yildirir, A., Yildiran, L., Batur, M.K., Cagrikul, R., Onalan, O., Tokgozoglu, L., Oto, A., Ozmen, F. & Kes, S.(2001), The diagnostic value of 12-lead electrocardiogram in predicting infarct-related artery and right ventricular involvement in acute inferior myocardial infarction, A.N.E., 6(3):229-235.
17.Bayram, E. & Atalay, C.(2004), Identification of the culprit artery involved in inferior wall acute myocardial infarction using electrocardiographic criteria, J Inter Med Resea, 32:39-44.
18.Assali, A.R., Herz, I., Vaturi, M., Adler, Y., Solodky, A., Birnbaum, Y. & Sclarovsky, S. (1999), Electrocardiographic criteria for predicting the culprit artery in inferior wall acute myocardial infarction, Am J Cardiol, 84:87-89.
19.Chia, B.L., Yip, J.W.L., Tan, H.C. & Lim, Y.T. (2000), Usefulness of ST elevation II/III ratio and ST deviation in lead I for identifying the culprit artery in inferior wall acute myocardial infarction, Am J Cardiol, 86:341-343.
20.Robalino, B.D., Whitlow, P.L., Underwood, D.A., Salcedo, E.E.(1989), Electrocardiographic manifestations of right ventricular infarction, Am J Cardiol, 118(1):138-144.
21.Lew, A.S., Laramee, P., Shah, P.K., Maddahi, T., Peter, T. & Ganz, W.(1986), Ratio of ST segment depression in lead V2 to ST segment elevation in lead aVF in evolving inferior acute myocardial infarction: an aid to the early recognition of right ventricular ischemic, Am J Cardiol, 57:1047-1051.
22.Barnhill, J.E. III., Tendera, M., Cade, H., Campbell, W.B. & Smith RE.(1989), Depolarization changes early in the course of myocardial infarction: significance of changes in the terminal portion of the QRS complex, J Am Coll Cardiol, 14:143-149.
23.Berger, P.B. & Ryan, T.J.(1990), Inferior myocardial infarction: high risk subgroups, Circulation , 81:401-411.
24.Berry, C., Zalewski, A., Kovach, R., Savage, M. & Goldberg, S.(1989), Surface electrocardiogram ischemic during coronary artery occlusion, Am J Cardiol, 63:21-26.
25.Newman, N.H., Dunn, R.F., Harris, P.J., Bantovich, G.J., McLanghlin, A.F. & Kelly DT.(1983), Differentiation between right and circumflex coronary artery disease in thallium myocardial scanning, Am J Cardiol , 1052-1056.
26.Chockalingam, A. & Balaguer-Vintro, I.(1999), Impending global pandemic of cardiovascular disease. Barcelona: Prous Science.
27.Tunstall-Pedoe, H., Kuulasmaa, K., Mahonen, M., Tolonen, H., Ruokokoski, E. & Amouuyel P.(1999), Contribution of trends in survival and coronary-event rates to changes in coronary heart disease mortality: 10-year results from 37 WHO MONICA projects populations. Monitoring trends and determinants in cardiovascular disease, Lancet , 353:1547-57.
28.Thom, T., Haase, N., Rosamond, W., et al.(2006), American Heart Association statistical update: heart disease and stroke statistics—2006 update. January 1, 2006. Available from: http:// circ.ahajournals.org/cgi/content/short/113/6/e85.
29.Liu, H., Li, G., Cumberland, W.G. & Wu, T.(2005), Testing statistically significance of the area under receiving operating characteristic curve for repeated measure design with bootstrapping, J. Data Science , 257-278.
30.Tape, T.G. Interpreting diagnostic test. http://gim.unmc.edu/dxtests/Basintro.htm
31.Bueno, H., Lopez-Palop, R., Bermejo, J., Lopez-Sendon, J.L. & Delcan, J.L.(1997), In-hospital outcome of elderly patients with acute inferior myocardial infarction and right ventricular involvement, Circulation, 96:436-441.
32.Bueno, H., Lopez-Palop, R., Perez-David, E., Garcia-Garcia, J., Lopez-Sendon, J.L. & Delcan, J.L.(1998), Combined effect of age and right ventricular involvement on acute inferior myocardial infarction prognosis, Circulation, 98:1714-1720.
33.Tans, A.C., Lie, K.I. & Durrer, D.(1980), Clinical setting and prognostic significance of high degree atrioventriclar block in acute inferior myocardial infarction: a study of 144 patients, Am Heart J, 99:4-8.
34.Braat, S.H., Brugada, P., den Dulk, K., van Ommen, V. & Vellens, H.J.J. Value of lead V4R for recognition of the infarct coronary artery in acute inferior myocardial infarction, Am J Cardiol, 53:1538-1541.
35.Topol, E.J. Textbook of cardiovascular medicine 3th ed, Phelidelphia: Lippincott Eilliums & Wilkins.
36.Sheehan, F.H. Braunwald, E., Canner, P., Dodge, H.T., Gore, J., Van Natta, P., Passamani, E.R., Williams, D.O. & Zaret, B.(1987), The effect of intravenous thrombolytic therapy on left ventricular function: a report on tissue-type plasminogen activator and streptokinase from the Thrombolysis in Myocardial Infarction (TIMI Phase I) trial, Circulation, 75(4):817-29.
37.Cooksey, J.D., Dunn, M. & Massie, E.(1997), Inferoposterior myocardial infarction. In: Cooksey JD, Dunn M, Massie E, Eds. Clinical Vectrocardiography and Electrocardiography. Chicago: Year Book Medical Publishers, 391-427.
38.Berger, P.B. & Ryan, T.J.(1990), Inferior myocardial infarction: high risk subgroups, Circulation, 81:401-411.
39.Gacioch, G.M. & Topol, E.J.(1989), Sudden paradoxical clinical deterioration during angioplasty of the occluded right coronary artery in acute myocardial infarction, J Am Coll Cardiol, 14:1202-1209.
40.Berry, C., Zalewski, A., Kovach, R., Savage, M. & Goldberg, S.(1989), Surface electrocardiogram ischemia during the coronary artery occlusion, Am J Cardiol, 63:21-26.
QRCODE
 
 
 
 
 
                                                                                                                                                                                                                                                                                                                                                                                                               
第一頁 上一頁 下一頁 最後一頁 top