心电图aVR导联ST段抬高和严重左主干狭窄的关系研究

Relationship study between aVR ST elevation and severe left main stenosis

目的 我们假定慢性左主干严重狭窄患者心绞痛发作时,只有aVR导联抬高≥1 mm,伴或不伴其他导联压低,前瞻性分析了急性冠脉综合征（ACS）患者冠状动脉左主干慢性严重狭窄病变的心电图特点.方法 单中心前瞻性连续选取典型心绞痛发作时12导联心电图aVR导联ST段抬高≥1 mm,其他导联ST段压低或不抬高者作为研究对象,心绞痛缓解后aVR导联ST段抬高≥1 mm恢复到等电位线.符合这一标准者共计76例住院急性冠脉综合征患者.依冠状动脉造影结果,分析左主干病变特点和其他冠状动脉病变特征.目测狭窄程度≥70％,为严重左主干狭窄病变.结果 单纯左主干严重狭窄54例（54/76,71.1％）,左主干病变＋前降支近端近开口病变6例（6/76,7.9％）,单纯左回旋支狭窄3例（3/76,3.9％）,其他复杂三支血管病变13例（13/76,17.1％）.冠状动脉正常者为零.左主干严重狭窄患者,aVR导联ST段抬高比非左主干患者更明显[（0.25±0.10）mV比（0.20±0.11）mV,P＜0.01];ST段压低导联多见于Ⅱ、Ⅲ、aVF和V3～V6导联,左主干严重狭窄患者,ST压低导联ST段压低程度比非左主干患者更明显（P＜0.001）.这一特点诊断左主干严重狭窄的特异性78.9％,假阳性21.1％.结论 冠心病患者心绞痛发作时体表心电图aVR导联ST段抬高≥1 mm,其他导联ST段压低或不抬高者预测左主干病变有更高的敏感性及符合率.

Objective We made a hypothesis that when left main coronary has a severe stenosis and angina pectoris happens, a special change is only ST elevation ≥ 1 mm on aVR and no ST changes or ST depression on other ECG leads. We further prospectively investigated the feature of electrocardiogram in the diagnosis of the severe left main coronary artery （LM） of patients with acute coronary syndrome （ACS）. Methods Totally 76 patients with ACS were of transit ST segment elevation when angina pectoris emerged who underwent coronary angiography due to suspending left main disease （LM group, n=60, including only LM 54 cases, LM＋ LAD 6 cases. Non-LM group, n=16, including multi-vessel disease 6 cases, left circumflex-OM 3 cases）. 12- lead ECGs were recorded and measured when typical chest pain appeared and compared with rest ECG and analyzed prospectively between the two groups. The relationship was analyzed between the corresponding ST segment variation of 12-lead ECG and coronary artery lesion. Results 54 patients （54/76,71.1%） of 76 had only LM severe stenosis, 6 patients （6/76,7.9%） had severe LM and proximal or close orifice stenosis of LAD （left anterior descending coronary artery）, other patients（n=16） included 3 cases of left circumflex severe stenosis and 13 cases of multi-vessel disease. ST elevation degree on aVR was more significant at severe LM stenosis patients than non-LM severe patients [（0.25±0.10）mV vs （0.20±0.11）mV, P〈0.01 ]. ST depression leads weremore frequendy seen on Ⅱ ,Ⅲ, aVF and V3-V6. ST depression degree on predominant leads was more significantly seen on 11 111 aVF and V3-V6 at severe LM stenosis patients than non-LM severe patients. The specificity was 78.9% and the false positive rate was 21.1%. Conclusion Only ST elevation≥ 1 mm on aVR and ST depression on other ECG leads when angina pectoris happens strongly indicates that left main coronary has a severe stenosis and can accurately predict LM as culprit vessel.