1、心电图阅读的基础与方法心电图阅读的基础与方法心率心率 节律节律 间期间期 电轴电轴肥大肥大 梗死梗死临床相关性临床相关性1912年,Cambridge Instrument心电图的地位与作用心电图的地位与作用 病史体检辅助检查三大常规、肝肾功能、X线、超声、心电图心电图1 1、识别各种心律失常（最有价值）、识别各种心律失常（最有价值）2 2、辅助诊断心房、心室肥大、辅助诊断心房、心室肥大 3 3、反映心肌缺血、反映心肌缺血、心肌梗死心肌梗死4 4、心电监护、心电监护 5 5、了解药物的疗效及对心肌的影响、了解药物的疗效及对心肌的影响6 6、辅助诊断电解质代谢紊乱、辅助诊断电解质代谢紊乱 心电图
2、阅读的基本问题正常心电图正常心电图？异常心电图？异常心电图？正常心电图正常心电图异常心电图异常心电图Basic Competency in Electrocardiography(Modified from:ACC/AHA Clinical Competence Statement,JACC 2019;38:2091)NORMAL TRACINGNormal ECGTECHNICAL PROBLEM Lead misplaced ArtifactSINUS RHYTHMS/ARRHYTHMIAS Sinus rhythm(50-90 bpm)Sinus tachycardia(90 bpm)S
3、inus bradycardia(50 bpm)Sinus ArrhythmiaSinus arrest or pauseSino-atrial exit blockOTHER SV ARRHYTHMIASPACs(nonconducted)PACs(conducted normally)PACs(conducted with aberration)Ectopic atrial rhythm or tachycardia(unifocal)Multifocal atrial rhythm or tachycardiaAtrial fibrillationAtrial flutterJuncti
4、onal prematuresJunctional escapes or rhythmsAccelerated Junctional rhythmsJunctional tachycardiaParoxysmal supraventricular tachycardiaVENTRICULAR ARRHYTHMIASPVCsVentricular escapes or rhythmAccelerated ventricular rhythmVentricular tachycardia(uniform)Ventricular tachycardia(polymorphous or torsade
5、s)Ventricular fibrillationAV CONDUCTION1st degree AV blockType I 2nd degree AV block(Wenckebach)Type II 2nd degree AV block(Mobitz)AV block,advanced(high grade)3rd degree AV block(junctional escape rhythm)3rd degree AV block(ventricular escape rhythm)AV dissociation(default)AV dissociation(usurpatio
6、n)AV dissociation(AV block)INTRAVENTRICULAR CONDUCTIONComplete LBBB,fixed or intermittentIncomplete LBBBComplete RBBB,fixed or intermittentIncomplete RBBBLeft anterior fascicular block(LAFB)Left posterior fascicular block(LPFB)Nonspecific IVCDWPW preexcitation patternQRS AXIS AND VOLTAGERight axis d
7、eviation(+90 to+180)Left axis deviation(-30 to-90)Bizarre axis(-90 to-180)Indeterminate axisLow voltage frontal plane(0.5 mV)Low voltage precordial(1.0 mV)HYPERTROPHY/ENLARGEMENTSLeft atrial enlargementRight atrial enlargementLeft ventricular hypertrophy Right ventricular hypertrophyST-T,AND U ABNOR
8、MALITIESEarly repolarization(normal variant)Nonspecific ST-T abnormalitiesST elevation(transmural injury)ST elevation(pericarditis pattern)Symmetrical T wave inversionHyperacute T wavesProminent upright U wavesU wave inversionProlonged QT intervalMI PATTERNS(acute,recent,old)Interior MIInferoposteri
9、or MIInferoposterolateral MITrue posterior MIAnteroseptal MIAnterior MIAnterolateral MIHigh lateral MINon Q-wave MIRight ventricular MICLINICAL DISORDERSChronic pulmonary disease patternSuggests hypokalemiaSuggests hyperkalemiaSuggests hypocalcemiaSuggests hypercalcemiaSuggests digoxin effectSuggest
10、s digoxin toxicitySuggests CNS diseasePACEMAKER ECGAtrial-paced rhythmVentricular paced rhythmAV sequential paced rhythmFailure to capture(atrial or ventricular)Failure to inhibit(atrial or ventricular)Failure to pace(atrial or ventricular)心肌梗死的定位诊断前间壁V1-V3前壁V2、V3(V4)侧壁、aVL、V5、V6下壁、aVF后壁V7、V8、V9广泛前壁
11、V1V6The ectopic atrial rate is 150 bpm.Some of the ectopic P waves are easily seen and indicated by the arrows.Other P waves are burried in the T waves and not so easily identified.Atrial tachycardia with AV block is often a sign of digitalis intoxication.3:2 and 2:1 AV block is seen in this example
12、.心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性心电图讨论记住记住心率 节律 间期 电轴肥大 梗死临床相关性心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死
13、 临床相关性临床相关性图中箭头所指的是什么？这是什么图型？心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性这是什么图型？心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性问题在哪里？问题在哪里？请给出诊断心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性请给出诊断心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性这是什么图形？心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性这是什么图形？心电图诊断?心电图诊断?心率心率 节律节律 间期间期 电
14、轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性心电图诊断?心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性Match the tracings with the correct interpretation A.Second Degree Block Type 1B.PACC.Second Degree Block Type 2D.Paroxysmal Supraventricular TachycardiaMatch the tracings with the correct interpretation:A.Ventricular TachycardiaB
15、.Second Degree Block Type 1(Wenckebach)C.Junctional RhythmD.Wandering Atrial PacemakerThe correct matches？1、Wandering Atrial Pacemaker2、Ventricular Tachycardia3、Second Degree Block Type 1(Wenckebach)Clinical Cases Case 1：A 60-year-old“walk-in”patient without a primary care physician arrives at your
16、clinic near the end of a busy afternoon clinic session.The patient is not on any medications and has not seen a physician in years.The patient complains of several hours of severe chest pressure and as he lives nearby he thought he would come to your clinic and try to see a physician.Although the vi
17、tal signs were remarkable only for some bradycardia,the medical assistant is concerned that the patient appears ill.A stat ecg was done and you are asked to see this patient immediately.The following ecg is handed to you as you are on your way to see this patient.一位既往无特殊病史的60岁的患者傍晚走进了你的诊所就诊.该患者未曾服用任
18、何药物，数年来也未曾就诊过.这次来主要是因为胸部压迫感持续了数小时不缓解.表情痛苦，脉搏较缓慢，入院后随即做了心电图，如下图所见：心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性Case 1 Answer 心率-50节律-窦性心动过缓间期-PR、QRS 间期正常电轴-正常 肥大-无 梗死-V1-V4导联ST段抬高，提示急性心肌损伤 临床相关性-急性心梗是临床特别是急诊科常见的急危症之一.结合其剧烈胸痛及急性前壁损伤的心电图表现，该患者的情况不容乐观.于是立即拨打120启动急救系统Case 2 A 55-year-old patient comes in to g
19、et your advice on starting a new exercise program to get back into shape.The program involves heavy aerobic workouts and he needs a form filled out that he is medically cleared to participate in this workout program.In talking to him you learn he has cardiac risk factors for smoking,positive family
20、history,high cholesterol and hypertension.He has a sedentary lifestyle and has not participated in any strenuous physical activity for years.Although his cardiorespiratory review of systems is negative,you are concerned that his activity level is very limited and he has significant risk factors.As p
21、art of the workup you obtain the following ecg to interpret:一位55岁的患者想通过参加一种新的锻炼保持体形，该锻炼方式对体力要求很大.你对该患者详细评估后发现他虽然无心肺疾患的体征，但是存在诸多危险因素：吸烟，阳性家族史，高胆固醇血症，经常坐着，很少运动.故告知该患者他的运动量是受限的，下图是他的心电图:Case 2 Answer 心率 约70节律 窦性心率并1度房室传导阻滞间期-PR间期延长至.2 S,QRS时限正常 电轴 正常 肥大 左室肥大伴劳损图形 梗死 V2、V3导联可见Q波，可能为前间壁陈旧性心梗 临床相关性 此类病人临床
22、上不能轻易放走.他有众多的危险因素，且心电图有陈旧性心梗改变，故需进一步检查评估心脏情况.Case 3 一位70岁的女性高血压患者来访.一直在服用利尿剂，近几天自觉心率较乱，且轻微眩晕.既往心电图提示正常.体检脉搏为130，其余体检阳性体征未及.如下图是她的心电图：A 76-year-old patient,with a history of hypertension,comes to see you.She is currently on a diuretic prescription and is complaining of a few days of skipped heart bea
23、ts.She has felt slightly dizzy lately but does not have any other symptoms.Overall she has been feeling well,her only medical issue has been hypertension.Previous electrocardiograms in her chart show normal sinus rhythm and are otherwise unremarkable.Her exam shows an irregular pulse in the 130 rate
24、 range but the rest of the exam is unremarkable.You obtain the following electrocardiogram Case 3 Answer 心率 在 130-150之间节律 房颤 间期-PR 无法测量,QRS 时限正常电轴 正常(aVF向下，II 向上)肥大-无梗死 无 临床相关性-房颤是最常见的心律失常之一，常见于老年患者，是血栓事件发生的主要原因.对于该患者应积极寻找病因，并给予常规治疗：如控制心室率，抗凝，抗心律失常等.Case 4 A 35-year-old man comes into your office as
25、 a new patient.He is concerned about his elevated blood pressure.A year ago,in a physicians office,he had a reading of 150/100.A month ago,while being evaluated for bronchitis at a walk-in clinic,his blood pressure was 150/105.At todays office visit his blood pressure is 155/105.He is asymptomatic a
26、nd currently takes no medications.His cardiac exam is remarkable for a laterally displaced PMI and an S4.As part of the workup,you obtain the following electrocardiogram 一位35岁的男性患者因血压升高就诊.1年前测得血压为150/100，1月前因支气管炎就诊时测得血压为155/105，无自觉症状，最近未服药.心脏最强搏动点左移，且可闻及S4.下面是此次就诊的心电图：Case 4 Answer 心率 约 100 节律-窦性心率 间期 PR、QRS时限均正常 电轴 正常 肥大 左室和左房肥大 梗死 无 临床相关性-该患者三个时间点测得的血压值均升高，心脏听诊可闻及S4，心电图提示左室及左房肥大，故需积极降压治疗.谢谢各位！谢谢各位！心率心率 节律节律 间期间期 电轴电轴 肥大肥大 梗死梗死 临床相关性临床相关性谢谢
