心电图讲座(下)

异常心电图心律失常心肌梗死室上性心律失常1.房性早搏2.交界性早搏3.房颤4.房扑5.异位房速和节律6.多源性房速7.阵发性室上速8.交界区节律和心动过速1、房早不下传差异传导正常传导左束支不应期右束支不应期2、交界性早搏AV交界性早搏P波在QRS波前P波在QRS波中P波在QRS波后Atrialfibrillationistheresultofmultiplewaveletsofdepolarisation(shownbyarrows)movingaroundtheatriachaotically,rarelycompletingare-entrantcircuit3、房颤(Af)Af，LBBBAf并III度AVBAtrialflutterisusuallytheresultofasinglere-entrantcircuitintherightatrium(top);atrialfluttershowingobviousflutterwaves(bottom)4、房扑(AF):5、房性心动过速Atrialtachycardiawith2:1blockinpatientwithdigoxintoxicity6、多源性房速(MAT)Multifocalatrialtachycardia7、阵发性室上速(PSVT)Anatrioventricularnodalre-entranttachycardiaTerminationofatrioventricularnodalreentranttachycardiaMechanismsfororthodromic(left)andantidromic(right)atrioventricularre-entranttachycardia8、交界区心律和心动多速交界区逸搏交界区逸搏心律加速性交界区心律非阵发性交界性心动过速室性心律失常1.室早2.差传与室早3.室速4.加速性室性自主心律5.室性逸搏心律6.室性并行心律1、室性早搏1、室性早搏宽大畸形的原因–QRS宽心肌组织传导慢于正常传导系统–QRS波很高很深室早起源于一侧心室，因此该心室除极先于另一侧心室，没有来自于对侧的相反的除极2.差传与室早的鉴别•有无P波；•代偿间歇是否完全；•Long-ShortRule(AshmanPhenomenon)•QRS形态分析•提早出现的时间IntheaboveECGthewideprematureQRSisaPVCbecauseofthe0.06sdelayfromonsetoftheQRStothenadiroftheSwave(approximately0.08s).3、室速4、加速性室性自主心律5、室性逸搏心律6、室性并行心律心肌梗死R波Q波梗死定位•前间壁V1,V2,(V3)•前壁(V2),V3,V4,(V5)•广泛前壁V1~V6,(I,aVL)–侧壁V5,V6,I,aVL–前侧壁V4,V5,V6–高侧壁I,aVL•下壁II,III,aVF•后壁V7,V8,V9•右室V3R,V4R,V5R•下壁心梗•陈旧下壁心梗•急性下后壁心梗右室心梗.右胸导联尤其是V4RST抬高1mm前间壁心梗•高侧壁心梗Non-QWaveMI•心梗时ST-T动态变化，而未形成病理性Q波(患者有典型胸痛症状和/或心肌特异性酶学升高)•虽然临床希望通过出现特异ST-T改变的导联来定位NQMI的部位,但实际上这仅适用于ST段抬高型者Non-QWaveMI•动态ST-T改变可能包括以下形态:–只有ST段下移(常见)–只有ST段弓背向上或平直抬高(不常见)–仅有对称性T波倒置(常见)–以上变化兼而有之Non-QWaveMI•Example:AnterolateralST-Twavechanges实战演习II度I型AVBRAHAFwithslowedventricularresponse2nddegreeAVblocktypeII(Mobitz)LVHwithstrainBigeminyofVPVTExtensiveanteriormyocardialinfarctionWPW并AfLVH，LAH，IAVB，RBBBAF,RBBB预激综合征非阵发性交界性心动过速，RBBB,VPIII-AVB,ventricularescaperhythmAcceleratedventricularrhythmJunctionalrhythmAcuteanteroseptalQwaveinfarctionSB,AP,RBBBSinusarrest,junctionalescapeSinusarrhythmia,AP,LAHB,AMI(anterolateral)OMI(inferior),LAH,RBBBIIIAVB,JunctionalEscapeRhythm,VPIAVB,OMI(inferior),LBBB,LAHSinusrhythmwith1stdegreeAVblock;occasionalPVCAT(2:1)IAVB,RBBB,Sinuspause,LAHB(rate-dependent)SB,VP,RBBB,LAHB,OMI(anterior)IAVB,LVHwithstrain,OMI(inferior)Af，LBBBIntermittentWPWAMI(inferior),RBBB