aVR导联四步流程在宽QRS波心动过速鉴别诊断中的应用

Value of aVR lead four steps algorithm on differential diagnosis of wide QRS complex tachycardia

目的 验证分析aVR导联四步流程对宽QRS波心动过速（WCT）进行鉴别诊断的应用价值.方法 回顾性分析113例患者发生WCT时12导联体表心电图的形态学特征.按aVR导联四步流程分步骤地对113例WCT患者的心电图进行室性心动过速（室速）和室上性心动过速（室上速）的鉴别,将分析的结果与电生理检查结果进行比较,计算每一步鉴别诊断室速的准确度、特异度和敏感度.第一步根据aVR导联QRS波起始为R波诊断室速;第二步根据QRS波起始r或q波宽度＞40ms诊断室速;第三步以负相QRS波为主导的负相起始波降支上出现切迹诊断室速;第四步根据心室激动速率比值Vi/Vt≤1诊断为室速.计算aVR导联四步流程鉴别诊断窒速的准确度、特异度和敏感度并与Brugada四步流程和Vereckei四步流程检测结果进行比较.结果 入选113例WCT患者,室上速31例,室速82例,通过aVR导联四步流程鉴别诊断窒速的准确度为91.2%,敏感度为90.2%,特异度为77.4%;aVR导联四步流程的准确度和敏感度优于Brugada四步流程和Vereckei四步流程（P＜0.05）;特异度与Brugada四步流程相似（P＞0.05）,低于Vereckei四步流程（P＜0.05）,aVR导联四步流程更利于临床医师掌握和应用.结论 aVR导联四步流程对WCT中室速的诊断具有较好的灵敏度和准确度,对WCT鉴别的准确度较高,具有简便易行的特点和较好的临床应用价值.

Objective The aVR lead four steps is a new algorithm for differential diagnosis of wide QRS complex tachycardia（WCT）. The study explores the clinical value of this new algorithm on differential diagnosis of WCT. Methods Application of aVR lead four steps to analysis the electrocardiogram of patients with WCT proved by electrophysiological study. Every step＇s accuracy rate, sensitivity and specificity to differential diagnosis of ventricular tachycardia（VT）were calculated. The first step diagnosed VT according to presence of an initial R wave in the aVR lead. The second step diagnosed VT according to width of an initial r or q wave 〉40 ms in the aVR lead. The third step diagnosed VT according to notching on the initial downstroke of a predominantly negative QRS complex in the aVR lead. The fourth step diagnosised VT according to ventricular activation-velocity ratio（Vi/Vt）in the aVR lead, Vi/Vt ≤ 1 suggested VT. Results derived from aVR lead four steps algorithm were compared with results derived from Brugada and Vereckei four steps algorithm. Results A total of 113 patients with WCT were analyzed（31 supraventricular tachycardia, SVT and 82 ventricular tachycardia, VT）. The accuracy rate of differential diagnosis VT is 91.2%, sensitivity is 90. 2% and specificity is 77.4%. The accuracy and sensitivity of the aVR lead four steps algorithm for differential diagnosis of WCT were superior to the Brugada Vereckei four steps algorithm （P 〈 0. 05）. The specificity of the Vereckei four steps algorithm was superior to aVR lead and Brugada four steps algorithm（P 〈0. 05）,while the specificity of the aVR lead four steps algorithm was similar as Brugada four steps algorithm（P 〉 0. 05）. Conclusions The aVR lead four steps algorithm is associated with excellent accuracy rate, sensitivity for differential diagnosis of WCT. This algorithm is simple and could be easily learned and applied by physician.