[雙語翻譯]醫(yī)學(xué)外文翻譯--急性肺栓塞與t波倒置的急性冠脈綜合征的心電圖鑒別診斷（原文）

1、Electrocardiographic Differentiation Between Acute Pulmonary Embolism and Acute Coronary Syndromes on the Basis of Negative T WavesMasami Kosuge, MD, Kazuo Kimura, MD*, Toshiyuki Ishikawa, MD, Toshiaki Ebina, MD, Kiyoshi

2、 Hibi, MD, Ikuyoshi Kusama, MD, Tatuya Nakachi, MD, Mitsuaki Endo, MD, Naohiro Komura, MD, and Satoshi Umemura, MDNegative T waves in precordial leads are often seen in patients with acute coronary syndrome (ACS), but al

3、so occur in those with acute pulmonary embolism (APE). However, little attention has been given to differences in negative T waves between patients with these 2 diseases. The present study examines the value of electroca

4、rdiograms for discrim- inating between 40 patients with APE and 87 patients with ACS who had negative T waves in the precordial leads (V1 to V4) on the admission electrocardiogram. In 77 patients (89%) with ACS, the culp

5、rit lesion was confirmed angiographically to be located in the left anterior descending coronary artery. Pulmonary P waves, S1S2S3 pattern, S1Q3T3 pattern, low voltage, and clockwise rotation were specific for APE, but s

6、ensitivities of these findings were very low. In patients with APE, negative T waves were commonly present in leads II, III, aVF, V1, and V2, but were less frequent in leads I, aVL, and V3 to V6 (p <0.05). Negative T

7、waves in leads III and V1 were observed in only 1% of patients with ACS compared with 88% of patients with APE (p <0.001). The sensitivity, specificity, positive predictive value, and negative predictive value of this

8、 finding for the diagnosis of APE were 88%, 99%, 97%, and 95%, respectively. In conclusion, the presence of negative T waves in both leads III and V1 allows APE to be differentiated simply but accurately from ACS in pati

9、ents with negative T waves in the precordial leads. © 2007 Elsevier Inc. All rights reserved. (Am J Cardiol 2007;99:817–821)Negative T waves in the precordial leads are often seen in patients with acute coronary syn

10、dromes (ACSs). This elec- trocardiographic (ECG) finding suggests severe ischemia of the anterior wall.1,2 However, negative T waves also appear frequently in patients with acute pulmonary embolism (APE).3–5 Symptoms of

11、APE, such as chest pain or dyspnea, are nonspecific and are often difficult to differentiate from symptoms of ACS.6,7 An isolated case report documented a patient initially given a diagnosis of ACS because of chest pain

12、and dyspnea, deep negative T waves in leads V1 to V5, and increased troponin I levels at admission. This patient subsequently was found to have massive APE and died because of delayed diagnosis and treatment.8 Most preve

13、nt- able deaths associated with APE have been ascribed to missed diagnoses rather than failure to respond to available therapies.7 Increased levels of cardiac troponin, a highly sensitive and specific marker of myocardia

14、l cell injury, have been found in high-risk patients with APE as well as those with ACS,9–11 indicating limited value for differential diag- nosis. Echocardiography is useful for discriminating be- tween those with high-

15、risk APE and ACS.2,12 However, echocardiography has several technical limitations and fully assessable echocardiographic (ECG) images are frequently not obtained. The 12-lead electrocardiogram is simple, ubiquitously ava

16、ilable, and inexpensive. In the presentstudy, we compare ECG findings between APE and ACS in patients with negative T waves in precordial leads.Methods and ResultsClinical features and ECG findings obtained from 40 con-

17、secutive patients with APE were compared with those from 87 consecutive patients with ACS at our hospital. Patients fulfilled the criteria of (1) no conditions precluding the evaluation of ST-segment changes on the elect

18、rocardiogram (i.e., complete left or right branch bundle block, left ven- tricular hypertrophy, ventricular pacing, electrolyte abnor- malities, metabolic disease, or administered drugs with po- tential effects on the el

19、ectrocardiogram); (2) no obvious history of cardiopulmonary disease; and (3) fully assessable electrocardiogram on admission with negative T waves of ?1.0 mm in ?2 contiguous precordial leads (V1 to V4). Patients with ne

20、w ST-segment elevation of ?2.0 mm in 2 contiguous precordial leads on the admission electrocardio- gram or a Q-wave myocardial infarction on presentation were excluded. All patients gave informed consent. The study proto

21、col was approved by our internal review boards. Patients who had clinical signs and symptoms suggesting APE, such as acute onset of dyspnea, tachypnea, chest pain, palpitations, syncope, hypotension, or shock, were studi

22、ed. The diagnosis of APE was confirmed using pulmonary angiography in 31 patients (78%), lung perfusion scintigra- phy in 27 patients (68%), or spiral computed tomography in 26 patients (65%). Twelve patients had results

23、 positive for APE on all 3 examinations, and 20 had positive results on 2 examinations. Patients who had chest discomfort suggested to be cardiac ischemia lasting ?5 minutes and involving anDivision of Cardiology, Yokoha

24、ma City University Medical Center, Yokohama, Japan. Manuscript received September 17, 2006; revised manuscript received and accepted October 30, 2006. *Corresponding author: Tel.: 81-45-261-5656; fax: 81-45-261-9162. E-m

25、ail address: c-kimura@urahp.yokohama-cu.ac.jp (K. Kimura).0002-9149/07/$ – see front matter © 2007 Elsevier Inc. All rights reserved. www.AJConline.org doi:10.1016/j.amjcard.2006.10.043negative T waves in leads I, a

26、VL, and V3 to V6. Negative T waves in both leads III and V1 were present in only 1% of patients with ACS compared with 88% of those with APE (p ?0.001). Representative electrocardiograms obtained on admission in patients

27、 with APE and ACS are shown in Figure 2. Table 3 lists the sensitivity, specificity, and pre- dictive accuracy of ECG findings for the diagnosis of APE. Pulmonary P waves, S1S2S3 pattern, S1Q3T3 pattern, low voltage, and

28、 clockwise rotation were specific for APE, but sensitivities of these findings were low. The absence of negative T waves in leads I and aVL and the presence of negative T waves in leads V1 or V2 were very sensitive for A

29、PE, and the absence of negative T waves in leads V3 and V4 and the presence of negative T waves in lead aVF were very specific for APE. The presence of negative T waves in lead III was highly predictive of APE. Furthermo

30、re, the diagnostic accuracy of the presence of negative T waves in both leads III and V1 was very high, but this did not reach statistical difference in comparison with that in only lead III.DiscussionOur study includes

31、only patients with a clinical diagnosis of APE or ACS who had negative T waves in ?2 contiguous precordial leads (V1 to V4). The presence of negative T waves in both leads III and V1 strongly suggests APE, thereby allowi

32、ng APE to be simply but accurately differen- tiated from ACS. Negative T waves in precordial leads in patients with ACS are considered to indicate severe ischemia of the left ventricular anterior wall.1,2 Severe ischemia

33、 may alter and reverse the pathway of electrical repolarization, resulting in negative T waves.13 In the present study, the culprit lesion was located in the left anterior descending coronary artery in most patients with

34、 ACS. Most patients had negative T waves in leads V2 to V4, indicating ischemia of the antero- septal region. If ischemia extends to the anterolateral region, negative T waves are likely to be observed in leads I and aVL

35、. Similarly, if ischemia extends to the inferolateral re- gion, negative T waves are likely to appear in leads V5 and V6. Negative T waves in lead V1 were observed in half the patients with ACS. Lead V1 is considered to

36、reflect the right paraseptal region, supplied by the septal branches of the left anterior descending coronary artery alone or together with the conal branch.14 The presence of negative T waves in lead V1 may suggest seve

37、re ischemia of the interventricular septum caused by proximal left anterior descending coro- nary artery disease in the absence of a large conal branch. Conversely, frequencies of negative T waves in inferior leads were

38、very low. We speculate that the relations between culprit lesion sites and leads with negative T waves in patients with ACS are similar to those between culprit lesion sites and leads with ST-segment elevation in patient

39、s with acute myocar- dial infarction. The incidence of inferior ST-segment eleva- tion in patients with anterior acute myocardial infarction was reported to range from only 5% to 16%.15–17 These reports concluded that ST

40、-segment elevation in inferior leads occurs when the left anterior descending coronary artery that wraps around the apex and supplies the inferior wall (so-called “wrapped left anterior descending coronaryFigure 2. Repre

41、sentative electrocardiograms on admission of patients with APE and ACS. (A) APE in a 61-year-old man. Negative T waves are seen in leads III, aVF, and V1 to V4. A computed tomographic scan of the chest showed multiple fi

42、lling defects in the main right and left pulmonary arteries. Lung perfusion scintigraphy showed filling defects in the right upper, right middle, and left upper lung fields. (B) ACS in a 54-year-old woman. Negative T wav

43、es are seen in leads I, aVL, and V1 to V6. Coronary angiography performed 3 days after admission showed 90% stenosis of the proximal lesion of left anterior descending artery.819 Coronary Artery Disease/Precordial Negati