作者：饶太萍，李春梅，李俊，叶芳媛

单位：

641000 四川省内江市第一人民医院特检科

Units：

Special Examination Department，the First People's Hospital of Neijiang，Neijiang 641000，China

关键词：

心肌梗死；ST 段抬高；心律失常；心电描计术；缺血分级；靶血管

Keywords：

Myocardial infarction；ST-segment elevation；Arrhythmia；Electrocardiography；Ischemic grading；Target vessel

CLC：

DOI：

10.12114/j.issn.1008-5971.2021.00.015

Funds：

四川省科学技术厅科技计划项目（2018SZ13725）

摘要：

背景　目前，心电图 QRS 波群形态缺血分级与 ST 段抬高型心肌梗死（STEMI）患者严重心律失常发生风险及靶血管的关系尚未完全明确。目的　探讨心电图 QRS 波群形态缺血分级与 STEMI 患者严重心律失常及靶血管的关系。方法　选取 2016 年 7 月—2019 年 11 月内江市第一人民医院收治的 126 例 STEMI 患者作为研究对象，按照入院时心电图 QRS 波群形态进行心肌缺血分级，其中Ⅱ级缺血组（n=75）、Ⅲ级缺血组（n=51）。两组患者均于发病 12 h 内实施溶栓治疗。比较两组患者一般资料，入院时及溶栓 2 h 后心电图 ST 段情况，入院 24 h 内 N 末端脑钠肽前体（NT-proBNP）峰值、心肌肌钙蛋白 I（cTnI）峰值、肌酸激酶同工酶（CK-MB）峰值，住院期间严重心律失常发生情况及靶血管。STEMI 患者发生严重心律失常的影响因素分析采用多因素 Logistic 回归分析。结果　Ⅲ级缺血组患者入院时、溶栓 2 h 后∑ ST 大于Ⅱ级缺血组，溶栓 2 h 后 ST 段回降≥ 50% 者所占比例低于Ⅱ级缺血组（P＜ 0.05）。Ⅲ级缺血组患者入院 24 h 内 NT-proBNP 峰值、cTnI 峰值、CK-MB 峰值均高于Ⅱ级缺血组（P ＜ 0.05）。Ⅲ级缺血组患者住院期间严重心律失常发生率为 27.4%（14/51），高于Ⅱ级缺血组的 12.0%（9/75）（P ＜ 0.05）。Ⅲ级缺血组患者右冠状动脉主干、回旋支病变发生率低于Ⅱ级缺血组，左主干、左前降支病变发生率高于Ⅱ级缺血组（P ＜ 0.05）。多因素 Logistic 回归分析结果显示，发病至溶栓时间〔OR=4.092，95%CI（1.575，10.628）〕、入院时∑ ST〔OR=5.563，95%CI（1.972，15.687）〕、溶栓 2 h 后∑ ST〔OR=4.081，95%CI（1.934，9.032）〕、溶栓2 h 后 ST 段回降≥ 50%〔OR=0.411，95%CI（0.265，0.666）〕、入院 24 h 内 NT-proBNP 峰值〔OR=5.293，95%CI（1.718，16.298）〕、入院 24 h 内 cTnI 峰值〔OR=4.890，95%CI（2.028，11.788）〕、入院 24 h 内 CK-MB 峰值〔OR=5.882，95%CI（2.029，17.052）〕和心电图 QRS 波群形态缺血分级〔OR=2.560，95%CI（1.307，5.014）〕是STEMI 患者发生严重心律失常的独立影响因素（P ＜ 0.05）。结论　心电图 QRS 波群形态缺血分级为Ⅲ级的 STEMI患者严重心律失常发生风险较高，且该类患者多为左主干、左前降支病变。

Abstract：

Background　At present，the relationship of ischemic grading of QRS complex morphology of ECG with severe arrhythmia and target vessel in patients with ST-segment elevation myocardial infarction（STEMI） has not been fully defined.Objective　To investigate the relationship of ischemic grading of QRS complex morphology of eletrocadiogram（ECG）with severe arrhythmia and target vessel in patients with STEMI.Methods　From July 2016 to November 2019，a total of 126 patients with STEMI in the First People's Hospital of Neijiang were selected as the research objects.The myocardial ischemiaclassification was adopted according to the QRS complex morphology of the ECG at admission，and they were divided into grade Ⅱ ischemia group（n=75） and grade Ⅲ ischemia group（n=51）.Both groups received thrombolytic therapy within 12 hours of onset.The general information，ST segment of ECG at admission and 2 hours after thrombolysis，peak values of N-terminal pro-brain natriuretic peptide precursor（NT-proBNP），cardiac troponin I（cTnI） and creatine kinase isoenzyme（CK-MB） within 24 hours after admission，occurrence of severe arrhythmia during hospitalization and target vessel were compared between the two groups.Multivariate Logistic regression analysis was used to explore the influencing factors of severe arrhythmiain STEMI patients.Results　The ∑ ST at admission and 2 hours after thrombolysis in the grade Ⅲ ischemia group were higher than those in the grade Ⅱ ischemia group，while the proportion of patients with ST segment depression ≥ 50% at 2 hours after thrombolysis was lower than that in grade Ⅱ ischemia group （P ＜ 0.05）.The peak values of NT-proBNP，cTnI and CK-MB within 24 hours after admission in the grade Ⅲ ischemia group were higher than those in the grade Ⅱ ischemia group（P＜0.05）.The incidence of severe arrhythmia in grade Ⅲ ischemia group was 27.4%（14/51），which was higher than 12.0%（9/75）in grade Ⅱ ischemia group（P ＜ 0.05）.The incidence of lesions in right main coronary artery and circumflex branch in gradeⅢ ischemia group were lower than those in grade Ⅱ ischemia group，and the incidence of lesions in left main coronary artery and left anterior descending branch were higher than those in grade Ⅱ ischemia group（P ＜ 0.05）.The results of multivariate Logistic regression analysis showed that the time from onset to thrombolysis〔OR=4.092，95%CI（1.575，10.628）〕，∑ STat admission〔OR=5.563，95%CI（1.972，15.687）〕，∑ ST at 2 hours after thrombolysis〔OR=4.081，95%CI（1.934，9.032）〕，ST segment depression ≥ 50% at 2 hours after thrombolysis〔OR=0.411，95%CI（0.265，0.666）〕，peak value of NT-proBNP within 24 hours after admission〔OR=5.293，95%CI（1.718，16.298）〕，peak value of cTnI within24 hours after admission〔OR=4.890，95%CI（2.028，11.788）〕，peak value of CK-MB within 24 hours after admission〔OR=5.882，95%CI（2.029，17.052〕 and ischemic grading of QRS complex morphology of ECG 〔OR=2.560，95%CI （1.307，5.014）〕 were independent influencing factors for severe arrhythmia in STEMI patients（P＜0.05）.Conclusion　The risk of severe arrhythmia is higher in STEMI patients with ischemic grading Ⅲ of QRS complex morphology of ECG，and most of them are right main coronary artery and circumflex artery lesions.

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