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1、心电图阅读的基础与方法,心率 节律 间期 电轴 肥大 梗死 临床相关性,1912年,Cambridge Instrument,心电图的地位与作用,心电图阅读的基本问题,正常心电图 ？ 异常心电图？,正常心电图,异常心电图,Basic Competency in Electrocardiography,(Modified from: ACC/AHA Clinical Competence Statement, JACC 2001;38:2091),NORMAL TRACING Normal ECG TECHNICAL PROBLEM Lead misplaced Artifact SINUS R
2、HYTHMS/ARRHYTHMIAS Sinus rhythm (50-90 bpm) Sinus tachycardia (90 bpm) Sinus bradycardia (50 bpm) Sinus Arrhythmia Sinus arrest or pause Sino-atrial exit block,OTHER SV ARRHYTHMIAS PACs (nonconducted) PACs (conducted normally) PACs (conducted with aberration) Ectopic atrial rhythm or tachycardia (un
3、ifocal) Multifocal atrial rhythm or tachycardia Atrial fibrillation Atrial flutter Junctional prematures Junctional escapes or rhythms Accelerated Junctional rhythms Junctional tachycardia Paroxysmal supraventricular tachycardia,VENTRICULAR ARRHYTHMIAS PVCs Ventricular escapes or rhythm Accelerated
4、ventricular rhythm Ventricular tachycardia (uniform) Ventricular tachycardia (polymorphous or torsades) Ventricular fibrillation,AV CONDUCTION 1st degree AV block Type I 2nd degree AV block (Wenckebach) Type II 2nd degree AV block (Mobitz) AV block, advanced (high grade) 3rd degree AV block (junctio
5、nal escape rhythm) 3rd degree AV block (ventricular escape rhythm) AV dissociation (default) AV dissociation (usurpation) AV dissociation (AV block),INTRAVENTRICULAR CONDUCTION Complete LBBB, fixed or intermittent Incomplete LBBB Complete RBBB, fixed or intermittent Incomplete RBBB Left anterior fas
6、cicular block (LAFB) Left posterior fascicular block (LPFB) Nonspecific IVCD WPW preexcitation pattern,QRS AXIS AND VOLTAGE Right axis deviation (+90 to +180) Left axis deviation (-30 to -90) Bizarre axis (-90 to -180) Indeterminate axis Low voltage frontal plane (0.5 mV) Low voltage precordial (1.0
7、 mV),HYPERTROPHY/ENLARGEMENTS Left atrial enlargement Right atrial enlargement Left ventricular hypertrophy Right ventricular hypertrophy,ST-T, AND U ABNORMALITIES Early repolarization (normal variant) Nonspecific ST-T abnormalities ST elevation (transmural injury) ST elevation (pericarditis pattern
8、) Symmetrical T wave inversion Hyperacute T waves Prominent upright U waves U wave inversion Prolonged QT interval,MI PATTERNS (acute, recent, old) Interior MI Inferoposterior MI Inferoposterolateral MI True posterior MI Anteroseptal MI Anterior MI Anterolateral MI High lateral MI Non Q-wave MI Righ
9、t ventricular MI,CLINICAL DISORDERS Chronic pulmonary disease pattern Suggests hypokalemia Suggests hyperkalemia Suggests hypocalcemia Suggests hypercalcemia Suggests digoxin effect Suggests digoxin toxicity Suggests CNS disease,PACEMAKER ECG Atrial-paced rhythm Ventricular paced rhythm AV sequentia
10、l paced rhythm Failure to capture (atrial or ventricular) Failure to inhibit (atrial or ventricular) Failure to pace (atrial or ventricular),The 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 s
11、o 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.,心率 节律 间期 电轴 肥大 梗死 临床相关性,心率 节律 间期 电轴 肥大 梗死 临床相关性,心率 节律 间期 电轴 肥大 梗死 临床相关性,心电图讨论,记住,心率 节律 间期 电轴 肥大 梗死 临床相关性,心率 节律 间期 电轴 肥大 梗死 临床相关性,心率 节律 间期 电轴 肥大 梗死 临床相关性,心率 节
12、律 间期 电轴 肥大 梗死 临床相关性,心率 节律 间期 电轴 肥大 梗死 临床相关性,图中箭头所指的是什么？,这是什么图型？,心率 节律 间期 电轴 肥大 梗死 临床相关性,这是什么图型？,心率 节律 间期 电轴 肥大 梗死 临床相关性,问题在哪里？,问题在哪里？,请给出诊断,心率 节律 间期 电轴 肥大 梗死 临床相关性,请给出诊断,心率 节律 间期 电轴 肥大 梗死 临床相关性,这是什么图形？,心率 节律 间期 电轴 肥大 梗死 临床相关性,这是什么图形？,心电图诊断?,心电图诊断?,心率 节律 间期 电轴 肥大 梗死 临床相关性,心电图诊断?,心率 节律 间期 电轴 肥大 梗死 临床相
13、关性,Match the tracings with the correct interpretation,A. Second Degree Block Type 1 B. PAC C. Second Degree Block Type 2 D. Paroxysmal Supraventricular Tachycardia,Match the tracings with the correct interpretation:,A. Ventricular Tachycardia B. Second Degree Block Type 1 (Wenckebach) C. Junctional
14、Rhythm D. Wandering Atrial Pacemaker,The correct matches？,Clinical Cases,Case 1：A 60-year-old “walk-in” patient without a primary care physician arrives at your 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 pa
15、tient 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 vital signs were remarkable only for some bradycardia, the medical assistant is concerned that the patient appears ill. A stat ecg was don
16、e 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 节律 间期 电轴 肥大 梗死 临床相关性,Case 1 Answer,心率 - 50 节律- 窦性心动过缓 间期 - PR
17、、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 get your advice on starting a new exercise program to get back into shape. The program involves heavy aerobic workouts and he needs
18、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 history, high cholesterol and hypertension. He has a sedentary lifestyle and has not participated in any strenuous physical acti
19、vity 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 part 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，
20、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
21、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 beats“. She has felt slightly dizzy lately but does not have any other symptoms. Overall she has been feeling w
22、ell, 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 range but the rest of the exam is unremarkable. You obtain the following electrocardiogram,Case 3 Ans
23、wer,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 a new patient. He is concerned about his elevated blood pressure. A year ago, in a physicia
24、ns 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 and currently takes no medications. His cardiac exam is remarkable for a laterally d
25、isplaced 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！,心率 节律 间期 电轴 肥大 梗死 临床相关性,