电张调整性T波改变患者误诊为急性心肌梗塞7例分析

Analysis of misdiagnosis on 7 patients with electrotonic modulation of T wave as acute myocardial infarction

目的:探讨电张调整性T波改变患者被误诊为急性心肌梗塞的原因。方法:对7例显性预激综合征患者成功射频消融术后出现电张调整性T波改变,而被误诊为急性心肌梗塞的患者进行镇静、止痛治疗,而不进行溶栓治疗。并观察其临床表现、心电图、肌钙蛋白T、肌酸磷酸激酶的同工酶(CK-MB)。结果:7例患者均为显性预激综合征,其中右后间隔旁道3例、左侧游离壁旁道4例,所有患者术后心电图T波的方向与术前心脏激动顺序改变时QRS波群方向一致。3例右后间隔旁道患者下壁导联T波倒置深度Ⅲ>aVF>Ⅱ,出现ST压低;4例左侧游离壁旁道患者高侧壁导联T波倒置深度aVL>Ⅰ,V1～V6导联出现不同程度J点抬高、J波和ST段水平抬高;镇定和止痛等对症治疗2～3 d,心前区疼痛消失,肌钙蛋白T阴性(射频消融术后4～6 d),CK-MB均正常,随访8～10 w后心电图恢复正常。结论:急诊专业的医师对电张调整性T波改变缺乏认识;医生没有仔细询问病史,对射频消融术治疗预激综合征认识不足;对急性心肌梗塞的诊断认识不全面。以上是导致错误诊断的重要的原因。

Objective： To discuss the reason of misdiagnosis of acute myocardial infarction in electrotonic modulation T-wave change. Methods： Electrotonic modulation T-wave change in 7 patients with preexcitation syndrome after radiofrequency catheter ablation, were misdiagnosed as acute myocardial infarction （AMI）. To analyze their clinical manifestation, electrocardiogram, troponin T and creatine phosphokinase isoenzyme（CK-MB）,treated with sedative and pain relieving,other than thrombolysis. Results： Seven patients with manifest preexcitation （3 with right posterior septal accessory pathway, 4 with free wall accessory pathway）, in their electrocardiogram after operation, the direction of T-wave was the same as the QRS-wave when the heart excitive sequence changed preoperatively, inverted T-wave amplitude was Ⅲ aVF〉Ⅱ in 3 right posterior septal accessory pathway; while aVL〉Ⅰ in 4 left free wall accessory pathway; ＂J＂ point with different degrees, J-wave and ST-segment horizontally elevated in V1 -V6. Chest pain disappeared after sedated and pain management, troponin T negative, and CK-MB normal （4-6 dayes after radiofrequency catheter ablation）. Its electrocardiogram recovered normally after 8-10 week as followed-up. Conclusion： It is the major reasons of misdiagnosis that history inquiry carelessful, recognition deficiency of electrotonic modulation T-wave change, radiofrequency ablation of preexcitation syndrome and AMI distinction in emergency physicians.