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ST上昇(心電図)

著者: 三宅誠1) 天理よろづ相談所病院 循環器内科/先天性心疾患センター

著者: 中川義久2) 滋賀医科大学 循環器内科

監修: 代田浩之 順天堂大学大学院医学研究科循環器内科学

著者校正/監修レビュー済:2021/02/24
患者向け説明資料

概要・推奨   

  1. ST上昇を示す病態は多岐にわたるが、最も重要なものが急性心筋梗塞である。
  1. 胸部症状を伴うST上昇は、緊急の対応を要することが多い。
  1. 健診などで指摘された無症候性ST上昇は、待機的な精査で対応可能である。特に、若年男性においては病的意義がないことがほとんどである。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
三宅誠 : 特に申告事項無し[2021年]
中川義久 : 特に申告事項無し[2021年]
監修:代田浩之 : 未申告[2021年]

改訂のポイント:
  1. 新しいガイドラインに基づき、定義や分類などの改定を行った。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. ガイドラインでは、急性心筋虚血の心電図所見として、ST上昇は次のように定義されている[1]
  1. V2-3 誘導では、40 歳以上の男性の場合は2.0 mm 以上のST 上昇、40 歳未満の男性の場合は2.5 mm 以上のST上昇、女性の場合は年齢を問わず1.5 mm 以上のST 上昇
  1. V2-3 誘導以外では1.0mm 以上のST 上昇(この定義は左室肥大や左脚ブロックのない場合に適用され、ST レベルはJ 点で計測、10 mmは1.0 mV として記録)
  1. ST上昇を示す病態は多岐にわたるが、最も重要なものが急性心筋梗塞である。急性心筋梗塞以外にST上昇を示す虚血性心疾患としては、冠攣縮性狭心症、心筋梗塞後心室瘤がある。
  1. 虚血性心疾患以外では、急性心膜炎、左室肥大、左脚ブロック、心筋炎、たこつぼ心筋症などでST上昇がみられる。
  1. Brugadaパターンと呼ばれる、右側前胸部誘導での特徴的な(saddle backあるいはcovedと呼ばれる)ST上昇を伴う右脚ブロック様の心電図を健診で指摘され、受診する患者がしばしばみられる( Brugada症候群 については他稿を参照されたい)。
  1. まれではあるが、左室への腫瘍浸潤、心室外傷、低体温、高カリウム血症によりST上昇を来すことがある。
  1. 病的意義のないST上昇としては、早期再分極、若年男性での生理的ST上昇がある。
問診・診察のポイント  
  1. 胸部症状を伴うST上昇は、重篤な心疾患による可能性がある。問診はきわめて重要である。

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文献 

著者: R G HISS, L E LAMB, M F ALLEN
雑誌名: Am J Cardiol. 1960 Jul;6:200-31.
Abstract/Text
PMID 13855921  Am J Cardiol. 1960 Jul;6:200-31.
著者: Borys Surawicz, Sanjay R Parikh
雑誌名: J Am Coll Cardiol. 2002 Nov 20;40(10):1870-6.
Abstract/Text OBJECTIVES: This study was designed to establish the cause of electrocardiographic (ECG) pattern differences between genders.
BACKGROUND: The male and female patterns of early ventricular repolarization in normal ECGs differ from each other. The male pattern displays a higher J-point amplitude and increased ST angle. The distribution of these patterns between genders has not been studied.
METHODS: Normal ECGs of 529 males and 544 females, age 5 to 96 years, were subdivided into nine age groups in each gender. We designated the pattern as female if the J point was <0.1 mV in each of the leads V(1) to V(4), and as male if the J point was > or =0.1 mV and the ST angle > or =20 degrees in at least one of the V(1) to V(4) leads; the pattern was indeterminate if the J point was > or =0.1 mV and the ST angle was <20 degrees.
RESULTS: Distribution of patterns was significantly different between genders (p < 0.001). In females, the patterns were distributed similarly from puberty to advanced age with about 80% prevalence of the female pattern. In males, the male pattern prevalence increased at puberty, reached 91% in the age group of 17 to 24 years and declined gradually with advancing age to 14% in the oldest males. The prevalence of indeterminate pattern was about 10% in both genders. Patterns were unchanged in 95% of 493 subjects who had ECGs recorded at separate times or at different heart rates.
CONCLUSIONS: Gender differences in early ventricular repolarization were caused by age-dependent changes in prevalence of the male pattern.

PMID 12446073  J Am Coll Cardiol. 2002 Nov 20;40(10):1870-6.
著者: Sally J Aldous, Mark Richards, Louise Cullen, Richard Troughton, Martin Than
雑誌名: CMAJ. 2012 Mar 20;184(5):E260-8. doi: 10.1503/cmaj.110773. Epub 2012 Jan 30.
Abstract/Text BACKGROUND: High-sensitivity troponin assays are now available for clinical use. We investigated whether early measurement with such an assay is superior to a conventional assay in the evaluation of acute coronary syndromes.
METHODS: Patients presenting to an emergency department with chest pain who did not have ST-segment elevation were prospectively recruited from November 2007 to December 2010. Patients underwent serial testing with a conventional cardiac troponin I assay. Samples were also obtained at presentation and two hours later for measurement of troponin T levels using a high-sensitivity assay. The primary outcome was diagnosis of myocardial infarction on admission; secondary outcomes were death, myocardial infarction and heart failure at one year.
RESULTS: Of the 939 patients enrolled in the study, 205 (21.8%) had myocardial infarction. By two hours after presentation, the high-sensitivity troponin T assay at the cut-off point of the 99th percentile of the general population (14 ng/L) had a sensitivity of 92.2% (95% confidence interval [CI] 88.1%-95.0%) and a specificity of 79.7% (95% CI 78.6%-80.5%) for the diagnosis of non-ST-segment myocardial infarction. The sensitivity of the assay at presentation was 100% among patients who presented four to six hours after symptom onset. By one year, the high-sensitivity troponin T assay was found to be superior than the conventional assay in predicting death (hazard ratio [HR] 5.4, 95% CI 2.7-10.7) and heart failure (HR 27.8, 95% CI 6.6-116.4), whereas the conventional assay was superior in predicting nonfatal myocardial infarction (HR 4.0, 95% CI 2.4-6.7).
INTERPRETATION: The high-sensitivity troponin T assay at the cut-off point of the 99th percentile was highly sensitive for the diagnosis of myocardial infarction by two hours after presentation and had prognostic utility beyond that of the conventional assay. To rule out myocardial infarction, the optimal time to test a second sample using the high-sensitivity troponin T level may be four to six hours after symptom onset, but this finding needs verification in future studies before it can become routine practice.

PMID 22291171  CMAJ. 2012 Mar 20;184(5):E260-8. doi: 10.1503/cmaj.1107・・・
著者: Martin Than, Sally Aldous, Sarah Jane Lord, Stephen Goodacre, Christopher M A Frampton, Richard Troughton, Peter George, Christopher Michael Florkowski, Michael Ardagh, David Smyth, David Lewis Jardine, William Frank Peacock, Joanna Young, Gregory Hamilton, Joanne M Deely, Louise Cullen, A Mark Richards
雑誌名: JAMA Intern Med. 2014 Jan;174(1):51-8. doi: 10.1001/jamainternmed.2013.11362.
Abstract/Text IMPORTANCE: Patients with chest pain represent a high health care burden, but it may be possible to identify a patient group with a low short-term risk of adverse cardiac events who are suitable for early discharge.
OBJECTIVE: To compare the effectiveness of a rapid diagnostic pathway with a standard-care diagnostic pathway for the assessment of patients with possible cardiac chest pain in a usual clinical practice setting.
DESIGN, SETTING, AND PARTICIPANTS: A single-center, randomized parallel-group trial with blinded outcome assessments was conducted in an academic general and tertiary hospital. Participants included adults with acute chest pain consistent with acute coronary syndrome for whom the attending physician planned further observation and troponin testing. Patient recruitment occurred from October 11, 2010, to July 4, 2012, with a 30-day follow-up.
INTERVENTIONS: An experimental pathway using an accelerated diagnostic protocol (Thrombolysis in Myocardial Infarction score, 0; electrocardiography; and 0- and 2-hour troponin tests) or a standard-care pathway (troponin test on arrival at hospital, prolonged observation, and a second troponin test 6-12 hours after onset of pain) serving as the control.
MAIN OUTCOMES AND MEASURES: Discharge from the hospital within 6 hours without a major adverse cardiac event occurring within 30 days.
RESULTS: Fifty-two of 270 patients in the experimental group were successfully discharged within 6 hours compared with 30 of 272 patients in the control group (19.3% vs 11.0%; odds ratio, 1.92; 95% CI, 1.18-3.13; P = .008). It required 20 hours to discharge the same proportion of patients from the control group as achieved in the experimental group within 6 hours. In the experimental group, 35 additional patients (12.9%) were classified as low risk but admitted to an inpatient ward for cardiac investigation. None of the 35 patients received a diagnosis of acute coronary syndrome after inpatient evaluation.
CONCLUSIONS AND RELEVANCE: Using the accelerated diagnostic protocol in the experimental pathway almost doubled the proportion of patients with chest pain discharged early. Clinicians could discharge approximately 1 of 5 patients with chest pain to outpatient follow-up monitoring in less than 6 hours. This diagnostic strategy could be easily replicated in other centers because no extra resources are required.
TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12610000766011.

PMID 24100783  JAMA Intern Med. 2014 Jan;174(1):51-8. doi: 10.1001/jam・・・
著者: W J Brady, S A Syverud, C Beagle, A D Perron, E A Ullman, C Holstege, R J Riviello, A Ripley, C A Ghaemmaghami
雑誌名: Acad Emerg Med. 2001 Oct;8(10):961-7.
Abstract/Text UNLABELLED: Acute myocardial infarction (AMI) is one of many causes of ST-segment elevation (STE) in emergency department (ED) chest pain (CP) patients. The morphology of STE may assist in the correct determination of its cause, with concave patterns in non-AMI syndromes and non-concave waveforms in AMI.
OBJECTIVES: To determine the impact of STE morphologic analysis on AMI diagnosis and the ability of this technique to separate AMI from non-infarction causes of STE.
METHODS: The electrocardiograms (ECGs) of consecutive ED adult CP patients (with three serial troponin I determinations) were interpreted in two-step fashion by six attending emergency physicians (EPs): 1) the determination of STE by three EPs followed by 2) STE morphologic analysis (either concave or non-concave) in those patients with STE. The impact of STE morphology analysis was investigated in the identification of AMI and non-AMI causes of STE. Acute myocardial infarction was diagnosed by abnormal serum troponin I values (>0.1 mg/dL) followed by a rise and fall of the serum marker; STE diagnoses of non-AMI causes were determined by medical record review. Interobserver reliability concerning STE morphology was determined. Study inclusion criteria included at least three troponin values performed in serial fashion no more frequently than every three hours, initial ED ECG, ED diagnosis, and final hospital diagnosis.
RESULTS: Five hundred ninety-nine CP patients were entered in the study, with 171 (29%) individuals having STE on their ECGs. Of the 171 patients who had STE, 56 had AMI, 50 had unstable angina pectoris (USAP), and 65 had non-coronary final diagnoses. Forty-nine patients had non-concave STE, 46 with AMI and three with USAP; no patient with a non-coronary diagnosis had a non-concave STE morphology. The sensitivity and specificity of the non-concave STE morphology for AMI diagnoses were 77% and 97%, respectively; the positive and negative predictive values for non-concave morphology in AMI diagnoses were 94% and 88%, respectively. Interobserver reliability in the STE morphology determination revealed a kappa coefficient of 0.87.
CONCLUSIONS: A non-concave STE morphology is frequently encountered in AMI patients. While the sensitivity of this pattern for AMI diagnosis is not particularly helpful, the presence of this finding in adult ED chest pain patients with STE strongly suggests AMI. This technique produces consistent results among these EPs.

PMID 11581081  Acad Emerg Med. 2001 Oct;8(10):961-7.
著者: W J Brady, A D Perron, M L Martin, C Beagle, T P Aufderheide
雑誌名: Am J Emerg Med. 2001 Jan;19(1):25-8. doi: 10.1053/ajem.2001.18029.
Abstract/Text The objective of this study was to determine the electrocardiographic diagnoses of chest pain patients with ST segment elevation (STE) on the 12-lead electrocardiogram (ECG). This study was a retrospective ECG review of adult chest pain patients in a university hospital emergency department (ED) over a 3-month period (January 1, 1996 to March 31, 1996). STE was determined if the ST segment was elevated >/=1 mm in the limb leads and >/=2 mm in the precordial leads in at least two anatomically contiguous leads. Results showed 902 patients who met entry criteria and of whom 202 (22.4%) had STE. Thirty-one (15%) patients had STE acute myocardial infarction (AMI) as the final hospital diagnosis which caused the STE; 171 (85%) patients with STE had non-AMI diagnosis responsible for the ST segment elevation, including left ventricular hypertrophy (LVH) 51 (25%), left bundle branch block (LBBB) 31 (15%), benign early repolarization (BER) 25 (12%), right bundle branch block 10 (5%), nonspecific bundle branch block 10 (5%), left ventricular aneurysm 5 (3%), acute pericarditis 2 (1%), ventricular paced rhythm 2 (1%), and undefined ST segment elevation 35 (17%). Forty-four patients had AMI as the final diagnosis of whom 31 showed STE on presentation to the ED. In 2 of 31 (6%) cases of STE AMI, the ST segment waveform was atypical for acute infarction. We concluded that AMI is not the most common cause of STE in ED chest pain patients. LVH is most often responsible for electrocardiographic STE followed by AMI and LBBB which occur at equal frequencies.

PMID 11146012  Am J Emerg Med. 2001 Jan;19(1):25-8. doi: 10.1053/ajem.・・・
著者: L A Otto, T P Aufderheide
雑誌名: Ann Emerg Med. 1994 Jan;23(1):17-24.
Abstract/Text STUDY OBJECTIVE: To determine retrospectively the diagnostic accuracy of various ECG ST segment elevation criteria for the prehospital ECG diagnosis of acute myocardial infarction.
DESIGN AND SETTING: During a six-month period, paramedics acquired prehospital 12-lead ECGs on adult chest pain patients. Investigators interpreted ECGs independently, retrospectively, and blinded to patient outcome. ECGs were classified as meeting or not meeting the six ST segment elevation criteria regardless of ECG morphology if the criteria were present in two or more anatomically contiguous leads: 1 mm or more ST segment elevation; 2 mm or more ST segment elevation; 1 mm or more ST segment elevation in the limb leads or 2 mm or more ST segment elevation in the precordial leads; and the first three criteria with the simultaneous presence of reciprocal changes. ECGs that did not meet any ST segment elevation criteria were classified as normal, nonspecific ST/T wave changes, abnormal but not ischemic, and ischemic. Hospital charts were reviewed for final cardiac diagnosis.
TYPE OF PARTICIPANT: Four hundred twenty-eight stable adult prehospital chest pain patients in whom paramedics acquired prehospital 12-lead ECGs.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Of the 428 cases, 123 (29%) met 1 mm or more ST segment elevation criteria. Sixty-three (51%) of these 123 patients did not have myocardial infarctions. ECG characteristics most frequently associated with these non-myocardial infarction ECGs were left bundle branch block (21%) and left ventricular hypertrophy (33%). The three criteria that required the presence of reciprocal changes had the highest positive predictive values (93% to 95%), with sensitivities ranging from 20% to 33%. The criteria of 1 mm or more ST segment elevation with the simultaneous presence of reciprocal changes had a positive predictive value of 94% and included 18 of the 21 (86%) myocardial infarction patients who had ST segment elevation and received thrombolytic therapy within five hours after hospital arrival. Of the 428 cases, 305 (71%) did not meet any ST segment elevation criteria and had a sensitivity of 81% and a negative predictive value of 49% for the absence of acute myocardial infarction.
CONCLUSION: Fifty-one percent of patients whose prehospital 12-lead ECG met 1 mm or more ST segment elevation criteria had non-myocardial infarction diagnoses. ST segment elevation alone lacks the positive predictive value necessary for reliable prehospital myocardial infarction diagnosis. Inclusion of reciprocal changes in prehospital ECG myocardial infarction criteria improved the positive predictive value to more than 90% and included a significant majority (62% to 86%) of acute myocardial infarction patients with ST segment elevation who received thrombolytic therapy within five hours after hospital arrival. ST segment elevation criteria that include reciprocal changes identify patients who stand to benefit most from early interventional strategies.

PMID 8273952  Ann Emerg Med. 1994 Jan;23(1):17-24.
著者: William J Brady, Andrew D Perron, Scott A Syverud, Charlotte Beagle, Ralph J Riviello, Chris A Ghaemmaghami, Edward A Ullman, Brian Erling, Anne Ripley, Christopher Holstege
雑誌名: Am J Emerg Med. 2002 Jan;20(1):35-8.
Abstract/Text Acute myocardial infarction (AMI) is one of many causes of electrocardiographic ST segment elevation (STE) in ED chest pain (CP) patients; at times, the electrocardiographic diagnosis may be difficult. Coexistent ST segment depression has been reported to assist in the differentiation of non-infarction causes of STE from AMI-related ST segment elevation. The objective was to determine the effect of AMI diagnosis on the presence of STD among ED CP patients with electrocardiographic STE. Adult CP patients with electrocardiographic STE in at least 2 anatomically distributed leads were reviewed for the presence or absence of ST segment depression in at least 1 lead and separated into 2 groups, both with and without ST segment depression. A comparison of the 2 groups was performed in 2 approaches: all STE patients and then only with STE patients who lacked confounding electrocardiographic pattern (bundle branch block [BBB], left ventricular hypertrophy [LVH], or right ventricular paced rhythm [VPR]). All patients in the study underwent prolonged observation in the ED (at least 8 hours) with 3 serial troponin T determinations and 3 electrocardiograms (ECG). AMI was diagnosed by abnormal serum troponin T values (>0.1 mg/dL); electrocardiographic STE diagnoses of non-AMI causes were determined by medical record review. There were 171 CP patients with STE were entered in the study with 112 (65.5%) individuals show ST segment depression. When considering all study patients, ST segment depression was present at statistically equal rates in AMI and non-AMI situations (P = NS). The sensitivity, specificity, positive predictive value, and negative predictive value for the electrocardiographic diagnosis of AMI were 63%, 34%, 30%, and 67%, respectively. Patients with confounding patterns (LVH 46, BBB 19, and VPR 6) were removed from the analysis group, leaving 100 patients for analysis; 38 of these patients had ST segment depression. When considering this group of study patients, ST segment depression was present significantly more often in AMI patients (P <.0001). The sensitivity, specificity, positive predictive value, and negative predictive value for the electrocardiographic diagnosis of AMI were 69%, 93%, 93%, and 71%, respectively. Clinical diagnoses were as follows: 56 AMI, 50 USAP, and 65 noncoronary syndrome. When all CP patients with electrocardiographic STE are considered, the presence of ST segment depression is not helpful in distinguishing AMI from non-AMI. If one considers only patterns which lack electrocardiographic ST segment depression caused by altered intraventricular conduction, the presence of ST segment depression strongly suggests the diagnosis of AMI. In these cases, reciprocal ST segment depression is of considerable value in establishing the electrocardiographic diagnosis of STE AMI.

PMID 11781911  Am J Emerg Med. 2002 Jan;20(1):35-8.
著者: Joseph Rhinehardt, William J Brady, Andrew D Perron, Amal Mattu
雑誌名: Am J Emerg Med. 2002 Nov;20(7):638-43. doi: 10.1053/ajem.2002.34800.
Abstract/Text Wellens' syndrome is a pattern of electrocardiographic T-wave changes associated with critical, proximal left anterior descending (LAD) artery stenosis. The syndrome is also referred to as LAD coronary T-wave syndrome. Syndrome criteria include T-wave changes plus a history of anginal chest pain without serum marker abnormalities; patients lack Q waves and significant ST-segment elevation; such patients show normal precordial R-wave progression. The natural history of Wellens' syndrome is anterior wall acute myocardial infarction. The T-wave abnormalities are persistent and may remain in place for hours to weeks; the clinician likely will encounter these changes in the sensation-free patient. With definitive management of the stenosis, the changes resolve with normalization of the electrocardiogram. It is vital that the physician recognize these changes and the association with critical LAD obstruction and significant risk for anterior wall myocardial infarction.

Copyright 2002, Elsevier Science (USA). All rights reserved.)
PMID 12442245  Am J Emerg Med. 2002 Nov;20(7):638-43. doi: 10.1053/aje・・・
著者: Jeffrey A Tabas, Robert M Rodriguez, Hilary K Seligman, Nora F Goldschlager
雑誌名: Ann Emerg Med. 2008 Oct;52(4):329-336.e1. doi: 10.1016/j.annemergmed.2007.12.006. Epub 2008 Mar 17.
Abstract/Text STUDY OBJECTIVE: Numerous investigators have evaluated the ECG algorithm described by Sgarbossa et al to predict acute myocardial infarction in the presence of left bundle branch block and have arrived at divergent conclusions. To clarify the utility of the Sgarbossa ECG algorithm, we perform a systematic review and meta-analysis of these trials.
METHODS: A structured search was applied to MEDLINE and Scopus databases, beginning with the year that the algorithm was derived (1996). Two reviewers independently screened citations, assessed for method quality, and extracted data (individual study characteristics, screening performance, and interobserver agreement) with a standardized extraction tool. We assessed qualifying studies for heterogeneity and generated summary estimates for the sensitivity, specificity, and positive and negative likelihood ratios with fixed-effect models.
RESULTS: We identified 11 studies with 2,100 patients that met criteria for at least 1 component of the analysis. Ten studies with 1,614 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 3. These yielded a summary sensitivity of 20% (95% confidence interval [CI] 18% to 23%), specificity of 98% (95% CI 97% to 99%), a positive likelihood ratio of 7.9 (95% CI 4.5 to 13.8), and a negative likelihood ratio of 0.8 (95% CI 0.8 to 0.9). The summary diagnostic odds ratio revealed homogeneity. Seven studies with 1,213 patients reported a Sgarbossa ECG algorithm score of greater than or equal to 2. These yielded sensitivities ranging from 20% to 79% and specificities ranging from 61% to 100%. Positive likelihood ratios ranged from 0.7 to 6.6 and negative likelihood ratios ranged from 0.2 to 1.1. The summary diagnostic odds ratio revealed heterogeneity. Intra- and interobserver agreement was substantial. Sensitivity analysis using the highest-quality studies yielded similar results.
CONCLUSION: A Sgarbossa ECG algorithm score of greater than or equal to 3, representing greater than or equal to 1 mm of concordant ST elevation or greater than or equal to 1 mm ST depression in leads V1 to V3, is useful for diagnosing acute myocardial infarction in patients who present with left bundle branch block on ECG. The scoring system demonstrates good to excellent overall interobserver variability. A score of 2, representing 5 mm or more of discordant ST deviation, demonstrated ineffective positive likelihood ratios. A Sgarbossa ECG algorithm score of 0 is not useful in excluding acute myocardial infarction.

PMID 18342992  Ann Emerg Med. 2008 Oct;52(4):329-336.e1. doi: 10.1016/・・・
著者: M E Hands, E F Cook, P H Stone, J E Muller, T Hartwell, B E Sobel, R Roberts, E Braunwald, J D Rutherford
雑誌名: Am Heart J. 1988 Jul;116(1 Pt 1):23-31.
Abstract/Text Whether myocardial infarction (MI) can be diagnosed electrocardiographically in the presence of left bundle branch block (LBBB) is controversial. Our study sought to test the reliability of ECG criteria for diagnosing MI in patients with LBBB. Among 985 patients presenting within 18 hours of the onset of ischemic chest pain, 35 had complete LBBB. Acute MI was identified by serial MB-creatine kinase (CK) elevations and prior MI was determined by previously documented ECG and/or enzyme changes. Among those with LBBB, 24 patients had acute and/or prior MI, while 11 had neither. Eleven ECG criteria previously proposed for detecting MI in the presence of LBBB were evaluated. In patients presenting with ischemic chest pain and complete LBBB, presence of any one of the following ECG criteria was highly specific (90% to 100%) and predictive (85% to 100%) for acute or prior MI: Q waves in at least two of leads I, aVL, V5, or V6; R wave regression from V1 to V4; notching of the upstroke of the S wave in at least two of leads V3, V4, or V5, and primary ST-T wave changes in two or more adjacent leads.

PMID 3394629  Am Heart J. 1988 Jul;116(1 Pt 1):23-31.
著者: E B Sgarbossa, S L Pinski, A Barbagelata, D A Underwood, K B Gates, E J Topol, R M Califf, G S Wagner
雑誌名: N Engl J Med. 1996 Feb 22;334(8):481-7. doi: 10.1056/NEJM199602223340801.
Abstract/Text BACKGROUND: The presence of left bundle-branch block on the electrocardiogram may conceal the changes of acute myocardial infarction, which can delay both its recognition and treatment. We tested electrocardiographic criteria for the diagnosis of acute infarction in the presence of left bundle-branch block.
METHODS: The base-line electrocardiograms of patients enrolled in the GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) trial who had left bundle-branch block and acute myocardial infarction confirmed by enzyme studies were blindly compared with the electrocardiograms of control patients who had chronic coronary artery disease and left bundle-branch block. The electrocardiographic criteria for the diagnosis of infarction were then tested in an independent sample of patients presenting with acute chest pain and left bundle-branch block.
RESULTS: Of 26,003 North American patients, 131 (0.5 percent) with acute myocardial infarction had left bundle-branch block. The three electrocardiographic criteria with independent value in the diagnosis of acute infarction in these patients were an ST-segment elevation of 1 mm or more that was concordant with (in the same direction as) the QRS complex; ST-segment depression of 1 mm or more in lead V1, V2, or V3; and ST-segment elevation of 5 mm or more that was disconcordant with (in the opposite direction from) the QRS complex. We used these three criteria in a multivariate model to develop a scoring system (0 to 10), which allowed a highly specific diagnosis of acute myocardial infarction to be made.
CONCLUSIONS: We developed and validated a clinical prediction rule based on a set of electrocardiographic criteria for the diagnosis of acute myocardial infarction in patients with chest pain and left bundle-branch block. The use of these criteria, which are based on simple ST-segment changes, may help identify patients with acute myocardial infarction, who can then receive appropriate treatment.

PMID 8559200  N Engl J Med. 1996 Feb 22;334(8):481-7. doi: 10.1056/NE・・・
著者: J E Madias, A Sinha, H Agarwal, R Ashtiani
雑誌名: J Electrocardiol. 2001 Jan;34(1):87-8.
Abstract/Text
PMID 11327045  J Electrocardiol. 2001 Jan;34(1):87-8.
著者: M Kosuge, K Kimura, T Ishikawa, T Shimizu, K Hibi, N Nozawa, S Umemura
雑誌名: Heart. 2005 Jan;91(1):95-6. doi: 10.1136/hrt.2003.030973.
Abstract/Text
PMID 15604347  Heart. 2005 Jan;91(1):95-6. doi: 10.1136/hrt.2003.03097・・・

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