Optimal electrocardiographic leads for detecting acute myocardial ischemia
Optimal electrocardiographic leads for detecting acute myocardial ischemia
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DOI：
10.1054/jelc.2001.28844
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发表时间：
2001-01-01
影响因子：
1.3
通讯作者：
Feldman, CL
中科院分区：
文献类型：
--
作者：
Horácek, BM;Warren, JW;Feldman, CL
本研究确定了监测急性冠状动脉缺血引起的ST段变化最敏感的心电图导联。数据集包括3组单支血管疾病患者（左前降支[LAD]，32例;右冠状动脉[RCA]，36例;左回旋支[LCx]，23例）在球囊扩张血管成形术期间数字记录的120导联心电图（ECG）。在基线和缺血状态下测量所有记录的导联的ST段偏移，并在352个部位计算这2种状态之间的差异（DeltaST），并绘制为DeltaST图。根据DeltaST标准将每组患者分为“应答者”和“无应答者”亚组。计算每组/亚组的平均Δ ST，并通过相应的标准差（SD）进行标准化;将这些值绘制为平均Δ ST和t图。在每组/亚组中进行的bootstrap试验中寻找DeltaST极值最常发生的部位。结果表明，缺血敏感电极导线的最佳部位是：对于LAD相关缺血，V-3（+）和略低于V-8（-）;对于RCA相关缺血，左髂嵴（+）和第三肋间隙V-2以上（-）;对于LCx相关的缺血，仅低于V-8（+）和高于V-2（-）。在LAD、RCA和LCx组的应答者中，使用这些部位记录的三种“最佳”双极导联的平均DeltaST（+/- SD）分别为232 59、245 96和158 +/- 91 μ V;相应的t值为15、14、9.90和6.75。在12导联ECG中，只有V-3导联接近LAD应答者的最佳DeltaST和t值（187 +/- 61 μ V; t = 11.75），而III导联接近RCA应答者的最佳DeltaST和t值（191 +/- 76 μ V; t = 9.73），但即使这些值也明显为次优值（分别为P = 0.0011和P = 0.0120）。我们发现，通过使用预先计算的回归系数，可以从12个标准电极导线或3个EASI电极导线（3个电极位于Frank的横向水平，1个电极位于手动水平）中获得“最佳”双极电极导线，达到极好的近似值。通过bootstrap试验，我们估计了3种“最佳”血管特异性电极导线在测试集中可识别与LAD、RCA和LCx动脉相关的缺血的平均灵敏度（SE）和平均阳性预测值（PPV），分别为（SE/PPV）94.7/92.8%、78.7/80.9%和81.5/80.9%。通过12导联ECG（93.0/93.4%、76.6/82.0%和82.7/77.1%）和EASI导联系统（97.8/88.4%、78.0/80.2%和76.8/83.2%）得出的血管特异性导联可实现相似的诊断性能。因此，尽管发现用于检测与3个冠状动脉中的每一个相关的缺血的最佳”双极“导联需要在12导联ECG之外进行采样，但是这些导联可以从12个标准导联的全套中导出，或者对于临床监测应用，通过在方便的位置使用较少的电极从EASI导联系统导出。
This study identifies the most sensitive electrocardiographic leads for monitoring ST-segment changes caused by acute coronary ischemia. The data set consisted of 120-lead electrocardiograms (ECGs) digitally recorded during balloon-inflation angioplasty in 3 groups of patients with single-vessel disease (left anterior descending [LAD], 32; right coronary artery [RCA], 36; left circumflex [LCx], 23). The ST deviation was measured in all recorded leads during baseline and ischemic states, and its difference between these 2 states (DeltaST) was calculated at 352 sites and plotted as DeltaST maps. The patients in each group were divided, by means of DeltaST criteria, into subgroups of "responders" and "nonresponders." Mean DeltaSTs for each group/subgroup were calculated and standardized by the corresponding standard deviation (SD); these values were plotted as mean DeltaST and t maps. Sites where extrema of DeltaST occurred most frequently were sought in bootstrap trials, performed in each group/subgroup, The results suggest that the optimal sites for the ischemia-sensitive leads are; V-3 (+) and just below V-8 (-) for LAD-related ischemia; the left iliac crest (+) and above V-2 at the third intercostal space (-) for RCA-related ischemia; and just below V-8 (+) and above V-2 at the third intercostal space (-) for LCx-related ischemia, Three "optimal" bipolar leads using these sites registered, in the responders from the LAD, RCA, and LCx groups, mean DeltaST (+/- SD) of 232 59, 245 96 and 158 +/- 91 muV, respectively; the corresponding t values were 15,14, 9.90, and 6.75. In the 12-lead ECG, only lead V-3 approached optimal DeltaST and t values for the LAD responders (187 +/- 61 muV; t = 11.75) and lead III for the RCA responders (191 +/- 76 muV; t = 9.73), but even these values were significantly Suboptimal (P = 0.0011 and P = 0.0120, respectively). We found that the "optimal" bipolar leads can be derived, to an excellent approximation, from the 12 standard leads or from 3 EASI leads (with 3 electrodes at Frank's transverse level and I on the manubrium), by using precalculated regression coefficients. By means of bootstrap trials, we estimated the mean sensitivity (SE) and the mean positive predictive value (PPV) with which 3"optimal" vessel-specific leads Could identify ischemia related to the LAD, RCA, and LCx arteries, in the test set, as (SE/PPV) 94.7/92.8%, 78.7/80.9 %, and 81.5/80.9%. A similar diagnostic performance can be achieved by vessel-specific leads derived from the 12-lead ECG (93.0/93.4%, 76.6/82.0%, and 82.7/77.1 %) and, interestingly, from the EASI lead system (97.8/88.4%, 78.0/80.2%, and 76.8/83.2%). Thus, although the,optimal" bipolar leads for detecting ischemia related to each of the 3 coronary arteries were found to require sampling outside the 12-lead ECG, these leads can be derived from the full set of 12 standard leads or-for clinical monitoring applications-from the EASI lead system by using fewer electrodes at convenient locations.