“死人征”心电图
急性冠脉综合征的独特预测信号
震锋晨读
本病例代表下壁 MI，具有独特的死人征，可预测罪魁祸首动脉和阻滞水平。该体征通常与缓慢性心律失常和快速性心律失常的病程有关。大约 70% 的人从右冠状动脉的后降支获得心脏下壁的血液供应，在 10% 的人中，它是左回旋支的分支，在休息时，20% 的人从 RCA 和 LCX 获得双重血液供应 。下壁心肌梗死占所有急性心肌梗死的 40%，通常由右冠状动脉急性阻塞引起，死亡率低于 10%。下壁心肌梗死的诊断依据是 12 导联心电图显示 II、aVF、III 导联 ST 段抬高，伴或不伴 I 导联和 VL 的相互变化 。RV 梗死与 10-50% 的下壁梗死共存，通常通过右侧胸部导联存在 ST 段抬高来诊断 RV4-V6.In 右侧导联的诊断是通过 V1 导联 ST 段抬高和 V2 导联段压低来诊断的 。ST 段抬高型心肌梗死通过直接冠状动脉介入治疗或溶栓治疗，具体取决于症状出现的持续时间。如果门到球囊的时间少于 90 分钟，则首选经皮介入治疗，其余病例先用溶栓治疗，然后择期经皮介入治疗。This case represents inferior wall MI with unique dead man sign which predict the culprit artery and level of the block. This sign is commonly associated with the course of bradyarrhythmias and tachyarrhythmias.Inferior wall of heart receives it blood supply from posterior descending artery branch of right coronary artery in about 70% people and in 10% it is the branch of left circumflex artery in rest 20% it receives dual blood supply form both RCA and LCX .Inferior wall MI consists of 40% of all acute myocardial infarction and occurs commonly due to acute obstruction of right coronary artery with mortality rate less than 10%. Diagnosis of inferior wall infarction is made by 12 lead ECG showing ST segments elevation in leads II, aVF, III with or without reciprocal changes in lead I and a VL . RV infarction is coexisted with 10-50% of inferior wall infarction and is usually diagnosed by presence of ST segment elevation in right sided chest leads from RV4-V6.In the absence of right sided leads diagnosis of right ventricular infarction is made by ST segment elevation in lead V1 with segment depression in lead V2 。 ST elevation myocardial infarction is treated with primary coronary intervention or thrombolytics depending upon the time duration from symptoms onset. If door to balloon time is less than 90 mins primary percutaneous intervention is the treatment of choice and rest cases are treated with thrombolytics followed by elective percutaneous intervention.我们收治了一名 52 岁的男性，主诉胸痛，并进行了心电图检查（图 1）心电图显示窦性心律，心室率为 60 分钟，下导联 ST 段升高（II、aVF、III）和 ST 段抬高 V1 导联，V2 导联 ST 段压低，导联 I 和 aVL 倒数 ST 段压低。因此，诊断为下壁心肌梗死伴右室梗死，因为 III 导联 ST 段抬高高于导联 II （III>II），并且 V1 段抬高伴 V2 段压低是 RV 梗死的高度特异性当右侧胸导联不可用时。We admitted a 52 years old man with the complain of chest pain and ECG was done (Figure 1) ECG is showing sinus rhythm with ventricular rate of 60 min with ST segment elevation in inferior leads (II, aVF, III) and ST segment elevation in lead V1 with ST segment depression in V2 and reciprocal ST segment depression in leads I and aVL. So, diagnosis of inferior wall myocardial infarction with Right ventricular infarction was made as there was ST segments elevation in lead III was more than lead II (III>II) and ST segment elevation in V1 with segment depression in V2 is highly specific of RV infarction when right sided chest leads are not available.患者在进行另一次心电图时出现类似癫痫发作的活动（图 2），心电图中捕获到多形性广泛复杂室性心律失常，以 150 J 的直流电击结束。由于胸痛持续时间超过 2 小时，因此给予溶栓治疗并重复溶栓后心电图（图3）。Patient developed seizure like activity while taking another ECG (Figure 2) and polymorphic broad complex ventricular arrhythmia was captured in ECG which was terminated with DC shock of 150 J. As chest pain was of more than 2 hours duration so thrombolytics were administered and Post thrombolysis ECG was repeated (Figure 3).溶栓后，胸痛完全消退，下导联和导联 V1 导联 ST 段抬高消退超过 50%，提示溶栓成功。患者接受了冠状动脉造影，显示右冠状动脉、LAD 和 LCX 动脉正常 （图 4-6）。Following thrombolysis there was complete resolution of chest pain with more than 50% resolution ST segment elevation in inferior leads and in lead V1 suggestive of successful thrombolysis. Patient underwent coronary angiography which was showing normal Right coronary artery, LAD and LCX artery (Figure 4-6).![]()
该心电图中有趣的发现是，aVF 的 ST 段抬高和 aVL 的 ST 段压低共同呈现“死人征”（躺在地上的死人）的外观。该心电图与右冠状动脉完全或接近完全闭塞有关。The interesting finding present here in this ECG is that ST segment elevation in aVF and ST segment depression in aVL combinedly giving appearance of a “DEAD MAN SIGN” (dead man lying on ground). This ECG sign is associated with total or near total occlusion of right coronary artery.心电图死人征提示右冠状动脉近端完全或接近完全闭塞，伴有缓慢性心律失常和快速性心律失常（室上性或室性快速性心律失常）。在这种情况下，患者表现为心率为 55/min 的心动过缓，但后来他发展为广泛的复杂室性心律失常，当看到下壁心肌梗死时，这通常与死人征有关 [4]。患者接受溶栓治疗，就诊时间超过 2 小时。溶栓后 ST 段抬高消退超过 50%。然而，冠状动脉造影显示右冠状动脉近端阻塞正常，因为患者已经接受了溶栓治疗，溶栓后 ST 段抬高消退提示溶栓成功。Dead man sign of ECG is suggestive of total or near total occlusion of proximal right coronary artery with course of bradyarrhythmia and tachyarrhythmia (supraventricular or ventricular tachyarrhythmias). In this case patient presented with bradycardia with the heart rate of 55/min but later he developed broad complex ventricular arrhythmia which is typically associated with dead man sign when seen with inferior wall myocardial infarction [4]. Patient received thrombolytics as presentation was more than 2 hours. following thrombolysis ST segment elevation subsided more than 50%. However proximal right coronary artery obstruction was normal on coronary angiography as patient already received thrombolytics with resolution of ST segment elevation following thrombolysis is suggestive of successful thrombolysis.总之，该病例显示下壁心肌梗死伴 RV 心肌梗死，心率为 55 min，患者出现多形性宽复杂室性快速性心律失常，表现为心电图中死者征的常见表现，伴有下壁心肌梗死。In conclusion this case demonstrates inferior wall myocardial infarction with RV myocardial infarction with the heart rate of 55 min later on patient developed polymorphic broad complex Ventricular tachyarrhythmia demonstrating the usual presentation seen with the dead man sign in ECG with inferior wall myocardial infarction.
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