Original Articles Korean Circulation J 1998;28 10 : 급성심근경색증에서경색심근의관류정도와 12 유도 심전도상 R 파, ST 절, QRS 평점과의관계 안정천 김수미 황교승 이은미 송우혁 임도선박창규 김영훈 서홍석 심
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1 Original Articles Korean Circulation J 1998;2810: 급성심근경색증에서경색심근의관류정도와 12 유도 심전도상 R 파, ST 절, QRS 평점과의관계 안정천 김수미 황교승 이은미 송우혁 임도선박창규 김영훈 서홍석 심완주 오동주 노영무 Significance of ST Segment, R Wave, Q Wave and QRS Score for Assessing Myocardial Perfusion in Acute Myocardial Infarction Jeong Cheon Ahn, MD, Soo Mi Kim, MD, Kyo Seung Hwang, MD, Eun Mi Lee, MD, Woo Hyuk Song, MD, Chang Gyu Park, MD, Young Hoonm Kim, MD, Hong Seog Seo, MD, Wan Joo Shim, MD, Dong Joo Oh, MD and Young Moo Ro, M.D. Department of Internal Medicine, College of Medicine, Korea University, Seoul, Korea ABSTRACT Background and ObjectivesThe restoration of infarct-related coronary artery IRA patency in acute myocardial infarction AMI linked to a significant improvement in survival. Because of microvascular and cellular injury, patent IRA does not always represent successful reperfusion. With progress of myocardial ischemia, standard 12 lead ECG shows evolutional changes of ST-segment, R wave and Q wave. But their relations to myocardial perfusion were uncertain. MethodsTotal 41 patients of the first anterior wall AMI were enrolled and serial ECGs were taken to measure sum of ST-segment elevation ST, sum of Q wave Q, sum of R wave R, and QRS score QRSs proposed by Selvester in each patients before thrombolytic therapy i, after coronary angiography at 90 minutes of thrombolytic therapy a, and before discharge d. Myocardial contrast echocardiography was performed within 10 days of AMI to estimate opacification score OS and opacification index OI in segments of LAD territory. We investigate the relation between evolution of ECG changes and perfusion status of infarcted myocardium. Results1 There was no relation between OI and ST, but R and QRSs showed significant relation with OI before discharge r0.59, 0.33, p0.05, respectively, post thrombolytic therapy r0.51, 0.61, p0.05, and baseline ECG r0.53, 0.51, p The number of segments with OS 0.5 showed no singificant relation to the degree of ST and Q, but number of segments with OS 0 showed singinficant relation to that of R and QRSs r of Ri, Ra, Rd vs number of segments with OS 00.59, 0.66, 0.43, p0.05, QRSi, QRSa, QRSd vs number of segments with OS 00.58, 0.58, 0.57, p0.05. ConclusionThese findings suggest that the ECG changes of R wave and QRS scores could be useful markers of perfusion state in thrombolytic era. Korean Circulation J 1998;2810: KEY WORDSAcute myocardial infarction Myocardial perfusion ECG Myocardial contrast-echocardiography. 1707
2 서론 1708 대상및방법 연구대상 관동맥조영술및심근조영심초음파도검사의시행 Korean Circulation J 1998;2810:
3 심전도검사 통계처리 Fig. 1. Observed segments in LAD territory. Table 1. QRS scoring system in Anterior wall acute myocardial infarction V12 Any Q **1 V43 Q20ms 1 R/S0.5 2 Q or S1.8mV 1 R/Q0.5 2 R/S1 1 V21 Any Q 1 R/Q1 1 R0.7mV 1 R10ms 1 Notched R 1 R0.1mV 1 V53 Q30ms 1 R/S1 2 RRV1mV 1 R/Q1 2 R/S2 1 V31 Any Q 1 R/Q2 1 R0.7mV 1 R20ms 1 Notched R 1 R0.2mV 1 V63 Q30ms1 R/S1 2 R/Q1 2 R/S3 1 R/Q3 1 R0.6mV 1 Notched R 1 *score limit for each lead, **score for each criteria Total 13 points 1709
4 결과 대상환자의특성 ST절의상승및 Q파크기의합계와경색심근의관류정도의관계 1710 Fig. 2. Changes of ST and Q. Fig. 3. Change of R and QRSs. R파고의감소및 QRS 평점과조영지수의관계 Korean Circulation J 1998;2810:
5 Table 2. Correlation between R, QRSs and perfusion status R Ra Rd QRSi QRSa QRSd OI r No of OS No of OS0.5 NS NS NS NS NS NS OIopacification index iinitial study OSopacification score apost-angiography 90 minutes study QRSQRS score dpre-discharge study Fig. 4. Regression analysis between OI and R. 조영점수에따른 R파고의총합과 QRS평점의변화 1711
6 Fig. 5. Comparision of R between groups. Fig. 7. Comparision of QRSs between groups. Fig. 6. Sequential changes of R within a specific group Fig. 8. Sequential changes of QRSs within a specific group. ST절의하강정도에따른심근관류정도의비교 Korean Circulation J 1998;2810:
7 고찰 ST절및 Q파의변화와관류지수와의관계 1713
8 R 파고및 QRS 평점과관류정도의상관관계 1714 결론 Korean Circulation J 1998;2810:
9 연구배경 : 요약 방법 : 결과 : 결론 : 중심단어 REFERENCES 1) The I.S.A.M Study group. A prospective trial of intravenous streptokinase in acute myocardial infarction I.S.A.M. 1715
10 N Engl J Med ) Simons ML, Serruys PW, van der Brand M. Early thyrombolysis in acute myocardial infarction Limitation of infarct size and improved survival. J Am Coll Cardiol ) Kennedy JW, Ritche JL, Davis KB, Fritz JK. Western Washington randomized trial of intracoronary streptokinase in acute myocardial infarction. N Engl J Med ) Gruppo Italiano per lo Studio della Streptokinasi nell Infarto miocardico GISSI. Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet ) ISIS-2 Second International Study of Infarct Survival Collaborative Group. Randomized trial of intravenous streptokinase, oral aspirin, both or neither among 17,877 cases of suspected acute myocardial infarction ISIS-2. Lancet ) Res JCJ, Simmons ML, van der Wall EE. Long term improvement in global left ventricular function after early thrombolytic treatment in acute myocardial infarction. Br Heart J ) Stacks RS, Philips HR III, Gierson DS. Functional improvement of jeopardized myocardium following intracoronary streptokinase infusion in acute myocardial infarction. J Clin Invest ) Erlebacher JA, Weiss JL, Weisfeldt ML, Bulkley MB. Early dilatation of the infarcted segments in acute transmural myocardial infarction Role of infarct expansion in acute ventricular enlargement. J Am Coll Cardiol ) Hochman JS, Choo H. Limitation of myocardial infarct expansion by reperfusion independent of myocardial salvage. Circulation ) Ito H, Yu H, Tomook T, Masyuama T, Aburaua M, Sakai N, et al. Incidence and time course of left ventricular dilatation in the early convalescent stage of reperfused anterior wall acute myocardial infarction. Am J Cardiol ) Roval D, DeMaria AN, Batte LA. Myocardial contrastecho effect The dilemma of coronary blood flow and volume. J Am Coll Cardiol ) Peter C, Peer G, Kari S, Flemming P, Jesper HS, Nancy BW, et al. Effect of intravenous streptokinase on the relation between initial ST-predicted size and final QRS-estimated size of acute myocardial infarcts. J Am Coll Cardiol ) Rolf S, Rudget D, Thomas B, Karl W, Ulrich T. Extent of early ST segment elevation resolution A simple but predictor of outcome in patients with acute myocardial infarction. J Am Coll Cardiol ) Dissman R, Goerke M, von Amelen H. Prediction of early reperfusion and left ventricular damage by ST segment analysis during thrombolysis in acute myocardial infarction. Z Kardiol ) Hills LD, Former S, Braunwald E. Risk stratification before thrombolytic therapy in patients with acute myocardial infarction. J Am Coll Cardiol ) Selvester R, Wagner G, Hindman N. The Selvester QRS scoring system for estimating myocardial infarct size. The development of and application of the system. Arch Intern Med ) Michael HP, Gerard TW, Patricia AR, Arthur EW. Natural history of left ventricular size and function after acute myocardial infarction. Circulation ) Hindman NB, Schoken DD, Widman M. Evalution of a QRS scoring system for estimating myocardial infarct size. Specificity and method of application of the complete system. Am J Cardiol ) Scoroder R, Linderer T, Bruggman T. Controversial indications, rationale for thrombolysis Later than 46 hr from chest pain onset and in patients with smaller myocardial infarction. Eur Heart J Suppl F ) Frits WB. Paul GA, Volders MS, Frank V, Hei JW. Development of ST segment elevation and Q and R wave changes in acute myocardial infarction and influence of thrombolytic therapy. Am J Cardiol ) Chares F. Electrocardiography. In Braunwald E, editors. Heart Disease. 5th ed. Saunders1997. p ) Kawasaki K, Kusachi S, Hina K, Yamasaki S, Kita T, Endo C, et al. Q wave regression unrelated to patency of infarct related artery or left ventricular ejection fraction or volume after anterior wall acute myocardial infarction treated with or without reperfusion therapy. Am J Cardiol ) Depasque NP, Burch GE, Phillips JH. Electrocardiographic alterations associated with electrically silent areas of myocardium. Heart J ) Haia R, Chiche P. Transient abnormal Q waves in the course of ischemic heart disease. Chest ) Bruken R, Tillisch J, Schweiger M, Child JS, Marshal R, Mandelkerm M, et al. Regional perfusion, glucose metabolism, and wall motion in patients with chronic electrocardiographic Q wave infarctions Evidence for persistence of viable tissue in some infarct region by positron emission tomography. Circulation ) Aland RF, Rafael FS, Simmon C, Lusin C, Eduardo de M, Robert, et al. ST segment tracking for rapid determination of patency of the infarct-related artery in acute myocardial infarction. J Am Coll Cardiol Korean Circulation J 1998;2810:
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