Microsoft PowerPoint - 2- 남기병

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1 쉽게풀어보는심전도 울산대서울아산병원남기병

2 심전도진단 Chamber enlargement (hypertrophy) Bundle branch block Myocardial infarction WPW ST-T change: Nonsp ST-T change, Early repolarization Arrhythmia: tachycardia, PVC, AF

3 남자 63 세. 20 년전고혈압진단. 최근 1 년전부터혈압약복용. 심전도진단은?

4 Echocardiographic and Electrocardiographic Diagnoses of Left Ventricular Hypertrophy Predict Mortality Independently of Each Other Circulation. 2001;103:

5 Electrocardiographic Strain Pattern and Prediction of New-Onset Congestive Heart Failure in Hypertensive Patients Circulation. 2006;113:67-73

7 남자 53세. 20년전고혈압진단받고최근 5년간혈압약복용. 심전도상정상범위 (nonspecific ST-T change) 심장상태는? 1. 심전도상정상이므로심비대의가능성은없다. 2. 심비대가있어도심전도의전압증가가나타나지않을가능성이있다.

8 Criteria of LVH Sokolow-Lyon voltage SV1+RV5 or RV6 3.5 mv * SN 20-45%, SP 95% Romhilt-Estes point score system (4 points-probable, 5 points-definite) 1. Voltage (3) Any R or S (limb lead) 2.0 mv or SV1 or SV2 3.0 mv or RV5 or RV6 3.0 mv 2. ST-T change: typical strain (3) 3. LA involvement PTF 4 mv*ms (3) 4. Left axis deviation (2) 5. QRS duration > 90 msec * SN 60%, SP 90% Specificity Sensitivity

9 심비대의심전도진단 심비대 - 심비대 + 심전도 - 심전도 - 심비대를놓칠수있다 심비대가없는데심비대로진단되어불필요한추가검사를시행한다. ( 젊은남자 ) 심전도 + 심전도 +

10 심전도진단 Chamber enlargement (hypertrophy) Bundle branch block Myocardial infarction WPW ST-T change: Nonsp ST-T change, Early repolarization Arrhythmia: tachycardia, PVC, AF

11 V6 V1 V6 V1 V6 V1

12 V6 V6 V6 V1 V1 V1

13 심전도상각차단이있는무증상환자의예후는? 모든환자에서심장검사가필요한가? 1. 안심시킨다. 2. 종합병원에의뢰하여정밀검사를받도록한다. 3. 완전방실차단및급사의위험이높으므로자주 홀터검사를시행하여위험도를예측한다.

15 1. Sweden, Goteborg, 30 년 f/u 2. 빈도 : 50 대남자 1%, 80 대 17% 3. RBBB: 심질환 / 사망률차이없음방실차단 3 배 / 심박동기 5 배증가 4. LBBB: 심질환 2-5 배 / 사망률 2 배증가방실차단 16 배 / 심박동기 11 배증가 European Heart Journal (2005) 26,

$patients with reduced left ventricular ejection fraction,$

17 심부전환자에서심전도상각차단이있을경우 : 양심실을동시에조율 (resynchronization) Cardiac resynchronization therapy is beneficial for patients with reduced left ventricular ejection fraction, symptoms of heart failure, and prolonged QRS, regardless of NYHA class.

18 심전도상각차단이있는무증상환자는어떻게하는가? 1. BBB는나이와관련되어나타나는일종의퇴행성현상. 2. BBB와사망률과의연관 일반인 : 좌각차단이심질환 / 사망률증가-관련정도미약심질환 : 일반인에비하여심질환, 사망률이현저히증가 3. 일반인에서 BBB가있다고하여어떤특정심장질환과연관시키거나, 사망률이현저히달라지는것은아니므로불필요하게걱정을안겨줄필요는없다. * 우각차단 : Hx, PE, Chest PA, ECG * 좌각차단 : + 협심증검사 / 심초음파 * 좌심부전이있고증상이있을경우에는양심실조율이도움이된다.

19 심전도진단 Chamber enlargement (hypertrophy) Bundle branch block Myocardial infarction WPW ST-T change: Nonsp ST-T change, Early repolarization Arrhythmia: tachycardia, PVC, AF

20 54 세남자환자가운동시발생하는흉통과호흡곤란을주소로내원. 심전도진단은? 1. Myocardial infarction 2. LVH 3. WPW 4. Nonspecific ST-T change

21 Q wave Myocardial infarction Q > 40 msec Q > 1/4 R

22 Patient A : limb leads Patient B : limb leads Normal Septal q Pathologic Q

23 23 세무증상여자환자. 심전도진단은? 1. Normal 2. Myocardial infarction (inferior) 3. Hypertrophic cardiomyopathy 4. WPW

24 WPW syndrome: risk stratification Low risk feature 가없는무증상의환자들은어떻게할것인 가?

25 WPW syndrome: Risk stratification 1. Conservative approach: observation if asymptomatic 2. Aggressive approach: routine EPS if inducible, RFCA J Am Coll Cardiol Jan 15;41(2): N Engl J Med Nov 6;349(19):

26 WPW syndrome: Risk stratification Low risk feature: intermittent preexcitation High risk feature: Symptom or spontaneous tachycardia (esp. shortest RR <250ms) Asymptomatic: Observation EP study, if inducible - RFCA Trans-esophageal pacing Long ERP-reassurance Short ERP or inducible tachycardia - RFCA * 직업 ( 파일롯, 운전사 ), 활동정도 ( 운동선수 ) 등고려

27 심전도진단 Chamber enlargement (hypertrophy) Bundle branch block Myocardial infarction WPW ST-T change: Nonsp ST-T change, Early repolarization Arrhythmia: tachycardia, PVC, AF

28 NSSTT

29 Criteria for minor ST-segment depression (1) ST-J depression < 0.5 mm, ST segment downward sloping or (2) ST-J depression > 1.0 mm, ST segment upward sloping Criteria for minor T-wave abnormality (1)T-wave amplitude zero (flat), negative, or diphasic (-/+ type only) (2) T-wave amplitude positive and T/R-wave < 1:20 in any of leads I, II, avl, or V3 to V6

30 Minor NSSTTA: have been considered benign, indicative of transient alterations of physiologic states related to ingestion of food, change in posture, or emotional distress. hyperventilation, hyperkinetic heart syndrome, lesions of the CNS, abnormalities in LV wall motion wo coronary artery disease, persistent juvenile pattern, electrolyte disturbance, athletic ability. use of drugs (ie, digitalis, antiarrhythmic, and psychotrophic drugs) Minor NSSTTA may represent subclinical coronary artery disease, early LVH, or increased LV mass, or autonomic imbalance.

32 Early repolarization Early repolarization, by Wasserburger 1) ST segment elevation (>0.1mV) in 2 precordial or limb leads in the absence of acute ischemia, pericarditis or other QRS abnormality that could cause secondary ST segment elevation, 2) upward concavity 3) notch and/or slur on QRS, and 4) symmetrical T waves of large amplitudes 젊은남자, 운동, 부교감 Wasserburger RH, Alt WJ. The normal RS-T segment elevation variant. Am J Cardiol :8:

33 Pericarditis Early repolarization Acute MI Serial change! Enzyme follow up! The Journal of Emergency Medicine, Vol. 17, No. 3, pp , 1999 N Engl J Med 2003;349: Circulation 1982;65:

34 Long-term Outcome in Patients with Early repolarization Heikki V. Huikuri, et. al. N Engl J Med 2009;361-1

35 Haissaguerre et al. NEJM 358;19, 2008

36 조기재분극의임상적의의 1. 대부분 benign 2. 젊은남자, 운동선수 3. 하벽유도 (inferior wall) 의 J파는장기예후와관련 4. 극히일부에서는심실세동, 급사 : 미리알수있는방법은없다

37 심전도진단 Chamber enlargement (hypertrophy) Bundle branch block Myocardial infarction WPW ST-T change: Nonsp ST-T change, Early repolarization Arrhythmia: tachycardia, PVC, AF

38 24 세여자. 가슴이덜컹거리고답답한증상이있어서내원. 급사의위험성은? 치료는?

39 PVC 는위험한가?

42 심장질환이있는환자에서는? NEJM 1989;321:406

43 (J Am Coll Cardiol 2005;45: )

44 PVC, 임상적의의 In asymptomatic patients, frequent PVC during exercise : associated with increased risk of CV/all cause death. In patients post-mi, CHF, frequent VPCs (>10/h) : associated with increased mortality (prethrombolytic era) * association is weak in pts receiving thrombolysis : pharmacologic suppression, ass with unexpected and deleterious outcomes. Frequent VPCs, (esp. bigemini) : can precipitate tachycardia-induced cardiomyopathy : may decrease cardiac systolic function - may be reversed by elimination of the PVCs (RFCA)

45 요약 흔한심전도이상 : 심질환 / 사망률증가와관련 LVH : anti-ht Tx BBB : 일부심부전환자에서양심실조율 MI : ASA/BB/ACEI WPW : 증상있거나고위험직업인 - 고주파절제술 Nonspecific ST-T change, Early repolarization PVC : 일부심부전환자에서전극도자절제술

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ºÎÁ¤¸ÆV10N³»Áö case of brugada syndrome presented as chest pain STRCT rugada syndrome was described in 1992 as a new clinical entity characterized by electrocardiographic STsegment elevation in the right precordial leads