‫ﻣﻘﺎﻟﻪ ﭘﮋوﻫﺸﻲ‬ ‫ﻣﺠﻠﻪ ﻋﻠﻤﻲ ﭘﮋوﻫﺸﻲ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ اراك‬ ‫ﺳﺎل ‪ ،12‬ﺷﻤﺎره ‪) 3‬ﺷﻤﺎره ﭘﻴﺎﭘﻲ ‪ ،(48‬ﭘﺎﻳﻴﺰ ‪23-28 ،1388‬‬ ‫ﺷﻴﻮع و اﻫﻤﻴﺖ ﺑﺎﻟﻴﻨﻲ ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ ‪ ST‬در ﻟﻴﺪﻫﺎي اﻟﻜﺘﺮوﻛﺎردﻳﻮﮔﺮاﻓﻲ ﺧﻠﻔﻲ‬ ‫در اﻧﻔﺎرﻛﺘﻮس ﺣﺎد ﻣﻴﻮﻛﺎرد‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻬﻴﺪ رﺟﺎﻳﻲ ﺗﻬﺮان ‪1381‬‬ ‫دﻛﺘﺮ وﻟﻲ اﻟﻪ ﺧﺪﻳﺮ‪ ،*1‬دﻛﺘﺮﺳﻌﻴﺪ اورﻋﻲ‬ ‫‪2‬‬ ‫‪ -1‬اﺳﺘﺎدﻳﺎر‪ ،‬ﻣﺘﺨﺼﺺ ﻗﻠﺐ و ﻋﺮوق‪ ،‬ﮔﺮوه ﻗﻠﺐ و ﻋﺮوق‪ ،‬داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ اراك‪ ،‬اراك‪ ،‬اﻳﺮان‬ ‫‪D‬‬ ‫‪ -2‬ﻓﻮق ﺗﺨﺼﺺ اﻟﻜﺘﺮوﻓﻴﺰﻳﻮﻟﻮژي‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن دي‪ ،‬ﺗﻬﺮان‪ ،‬اﻳﺮان‬ ‫‪SI‬‬ ‫ﭼﻜﻴﺪه‬ ‫ﺗﺎرﻳﺦ درﻳﺎﻓﺖ ‪ ، 88/2/6‬ﺗﺎرﻳﺦ ﭘﺬﻳﺮش ‪88/6/11‬‬ ‫‪of‬‬ ‫ﻣﻘﺪﻣﻪ‪ :‬ﻣﻌﻴﺎرﻫﺎي ﻓﻌﻠﻲ اﻟﻜﺘﺮوﻛﺎردﻳﻮﮔﺮاﻓﻲ ﺑﺮاي ﺗﺸﺨﻴﺺ اﻧﻔﺎرﻛﺘﻮس ﺧﻠﻔﻲ ﻗﻠﺐ ﻏﻴـﺮ ﺣـﺴﺎس ﻣـﻲﺑﺎﺷـﺪ و اﻛﺜﺮﻳـﺖ اﻳـﻦ‬ ‫ﺑﻴﻤﺎران ﺗﺸﺨﻴﺺ داده ﻧﻤﻲﺷﻮﻧﺪ‪ .‬ﻫﺪف از اﻳﻦ ﻣﻄﺎﻟﻌﻪ ارزﻳﺎﺑﻲ ﺷﻴﻮع و اﻫﻤﻴﺖ ﺑﺎﻟﻴﻨﻲ ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ ‪ ST‬در ﻟﻴـﺪﻫﺎي ﺧﻠﻔـﻲ‬ ‫ﻗﻠﺐ در ﺑﻴﻦ ﺑﻴﻤﺎران ﺑﺎ ﺗﺸﺨﻴﺺ اﻧﻔﺎرﻛﺘﻮس ﺣﺎد ﻣﻴﻮﻛﺎرد ﻣﻲ ﺑﺎﺷﺪ‪.‬‬ ‫روش ﻛﺎر‪ :‬در ﻃﻲ ﻳﻚ ﻣﻄﺎﻟﻌﻪ ﻣﻘﻄﻌﻲ – ﺗﺤﻠﻴﻠﻲ در ‪ 210‬ﺑﻴﻤﺎر ﻣﺘﻮاﻟﻲ ﭘﺬﻳﺮش ﺷﺪه ﺑﺎ ﺗﺸﺨﻴﺺ اﻧﻔﺎرﻛﺘﻮس ﺣـﺎد ﻣﻴﻮﻛـﺎرد‬ ‫در ﺑﺨﺶ ﻣﺮاﻗﺒﺖﻫﺎي وﻳﮋه ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻬﻴﺪ رﺟﺎﺋﻲ‪ ،‬ﺑﻼﻓﺎﺻﻠﻪ ﻟﻴﺪﻫﺎي اﻟﻜﺘﺮوي ﺧﻠﻔﻲ)‪ (V7,V8 and V9‬ﺑﻪ ﻣـﻮازات ‪12‬‬ ‫ﻟﻴﺪ اﺳﺘﺎﻧﺪارد ﺛﺒﺖ ﺷﺪ‪ .‬اﻧﻔﺎرﻛﺘﻮس ﻣﺠﺪد‪ ،‬آرﻳﺘﻤﻲﻫﺎي ﻣﺪاوم‪ ،‬اﻓﺖ ﻓﺸﺎر ﺧﻮن‪ ،‬ﺷﻮك ﻛﺎردﻳﻮژﻧﻴﻚ‪ ،‬ﻧﺎرﺳﺎﻳﻲ ﻗﻠﺒﻲ ﻋﻼﻣـﺖ دار‬ ‫و ﻳﺎ ادم ﺣﺎد رﻳﻪ ﺑﻪ ﻋﻨﻮان ﻋﻮارض داﺧﻞ ﺑﻴﻤﺎرﺳﺘﺎﻧﻲ در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪﻧﺪ‪ .‬ﭘﺎراﻣﺘﺮﻫﺎي ﻣﺮﺗﺒﻂ ﺑﺎ ﻣﺸﺨـﺼﺎت زﻣﻴﻨـﻪاي و ﺳـﻴﺮ‬ ‫ﺑﻌﺪي ﺑﻴﻤﺎران در دو ﮔﺮوه ﺑﻴﻤﺎران ﺑﺎ و ﺑﺪون ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ ‪ ST‬در ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ ﻣﻘﺎﻳﺴﻪ ﺷﺪﻧﺪ‪.‬‬ ‫ﻧﺘﺎﻳﺞ‪ 153 :‬ﺑﻴﻤﺎر ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ ‪ ST≥1‬ﻣﻴﻠﻲ ﻟﻴﺘﺮ را در دو ﻟﻴﺪ ﻣﺠـﺎور ﻳـﺎ ﺑﻴـﺸﺘﺮ داﺷـﺘﻨﺪ‪12/4 .‬درﺻـﺪ ﺑﻴﻤـﺎران ‪ST≥1‬‬ ‫ﻣﻴﻠﻲ ﻣﺘﺮ در ‪ 2‬ﻟﻴﺪ ﺧﻠﻔﻲ داﺷﺘﻨﺪ ﻛﻪ ﻳﺎ ﺑﻪ ﺗﻨﻬﺎﻳﻲ )‪ 4/6‬درﺻﺪ( و ﻳﺎ ﻫﻤﺮاه ﺑﺎ ﺗﻐﻴﻴﺮات در ﻟﻴﺪﻫﺎي ﺗﺤﺘﺎﻧﻲ ﻳﺎ ﺧﺎرﺟﻲ ﻗﻠـﺐ )‪7/8‬‬ ‫درﺻﺪ( ﺑﻮد‪ .‬اﻟﻜﺘﺮوي ‪ 12‬ﻟﻴﺪ اﺳﺘﺎﻧﺪارد در ‪ 2‬ﺑﻴﻤﺎر ﻧﺮﻣﺎل ﺑﻮد و ‪ 5‬ﺑﻴﻤﺎر دﻳﮕﺮ ﺑﺎ ﺗﺸﺨﻴﺺ اﻧﻔﺎرﻛﺘﻮس ﺑـﺪون ﻣـﻮج ‪ Q‬ﺑـﺴﺘﺮي‬ ‫ﺷﺪﻧﺪ‪ .‬ﻣﻮج ‪ R‬ﺑﻠﻨﺪ در ‪ V1/V2‬در ‪ 26/3‬درﺻﺪ ﺑﻴﻤﺎران اﻳﺠﺎد ﺷﺪ‪ .‬ﻋﻮارض داﺧـﻞ ﺑﻴﻤﺎرﺳـﺘﺎﻧﻲ در ﺑﻴﻤـﺎران ﺑـﺎ ﺗﻐﻴﻴـﺮات در‬ ‫ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ ﺷﺎﻳﻊﺗﺮ ﺑﻮد )‪ 47/3‬درﺻﺪ در ﻣﻘﺎﺑﻞ ‪ 20/9‬درﺻﺪ‪.(p=0/01 ،‬‬ ‫ﻧﺘﻴﺠﻪ ﮔﻴﺮي‪ :‬ﺗﻐﻴﻴﺮات در ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ در اﻧﻔﺎرﻛﺘﻮس ﺣﺎد ﻗﻠﺒﻲ ﻧﺎﺷﺎﻳﻊ ﻧﻴﺴﺖ و ﻣﻤﻜﻦ اﺳﺖ ﻧـﺸﺎﻧﻪ ﺳـﻴﺮ ﺑـﺪ ﺑﻴﻤﺎرﺳـﺘﺎﻧﻲ‬ ‫ﺑﺎﺷﺪ‪.‬‬ ‫واژﮔﺎن ﻛﻠﻴﺪي‪ :‬اﻟﻜﺘﺮوﻛﺎردﻳﻮﮔﺮاﻓﻲ‪ ،‬اﻧﻔﺎرﻛﺘﻮس ﻣﻴﻮﻛﺎرد‪ ،‬ﭘﻴﺶ آﮔﻬﻲ‬ ‫‪ive‬‬ ‫‪ch‬‬ ‫‪Ar‬‬ ‫* ﻧﻮﻳﺴﻨﺪه ﻣﺴﺌﻮل‪ :‬اراك‪ ،‬ﺑﻴﻤﺎرﺳﺘﺎن اﻣﻴﺮﻛﺒﻴﺮ‬ ‫‪Email: [email protected]‬‬ ‫‪23‬‬ ‫‪www.SID.ir‬‬ ‫ﺷﻴﻮع و اﻫﻤﻴﺖ ﺑﺎﻟﻴﻨﻲ ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ ‪ ST‬در ﻟﻴﺪﻫﺎي ‪...‬‬ ‫دﻛﺘﺮ وﻟﻲ اﻟﻪ ﺧﺪﻳﺮ و ﻫﻤﻜﺎران‬ ‫آﻧــﺰﻳﻢﻫــﺎي ﻗﻠﺒــﻲ ﺑــﺪون ‪ STE‬ﻳــﺎ ﻣــﻮج ‪ Q‬در ﻫــﺮ ﻛــﺪام از‬ ‫ﻣﻘﺪﻣﻪ‬ ‫در ﻃﻲ دﻫﻪ ﻫﺎي اﺧﻴﺮ درﻣﺎن ﺗﺮوﻣﺒﻮﻟﻴﺘﻴـﻚ‪ ،‬ﻣﻴـﺰان‬ ‫ﻟﻴﺪﻫﺎي ﻗﻠﺒﻲ ﺑﻮد‪ .‬ﺗﻤﺎم ﺑﻴﻤﺎران ﺑﺪون دﺧﺎﻟﺖ ﻣﻄﺎﻟﻌﻪ ﻛﻨﻨﺪﮔﺎن‬ ‫ﻣﺮگ ﻧﺎﺷﻲ از اﻧﻔﺎرﻛﺘﻮس ﺣﺎد ﻗﻠﺒﻲ ‪(Acute Myocardial‬‬ ‫ﺗﻮﺳﻂ ﻣﺘﺨﺼﺼﺎن ﻣﺴﻮول درﻣـﺎن ﺷـﺪﻧﺪ و در ﺧـﻼل ﺑـﺴﺘﺮي‬ ‫)‪ Infarction- AMI‬را ﺑﻪ ﻃـﻮر ﻗﺎﺑـﻞ ﺗـﻮﺟﻬﻲ ﻛـﺎﻫﺶ داده‬ ‫ﭘﻲﮔﻴﺮي ﺷﺪﻧﺪ‪.‬‬ ‫روش درﻣﺎن ﻣﻲﺑﺎﺷﻨﺪ)‪ .(4‬در ﺣﺎل ﺣﺎﺿـﺮ ﺑـﺮاي ﺑﻴﻤـﺎراﻧﻲ ﻛـﻪ‬ ‫ﺳﻦ )‪ ≥ 45‬ﺳـﺎل در ﻣـﺮدان و ‪ ≥55‬ﺳـﺎل در زﻧـﺎن(‪ ،‬ﻣـﺼﺮف‬ ‫اﻓﺰاﻳﺶ ﻗﻄﻌﻪ ‪ (ST Elevation )ST‬در ﻟﻴﺪﻫﺎي اﺳﺘﺎﻧﺪارد را‬ ‫ﻓﻌﻠـﻲ ﺳـﻴﮕﺎر‪ ،‬ﻫﻴﭙﺮﻛﻠـﺴﺘﺮوﻣﻲ)‪serum LDL level ≥130‬‬ ‫ﻧﺪارﻧﺪ اﻳﻦ روش درﻣﺎﻧﻲ ﺗﻮﺻـﻴﻪ ﻧﻤـﻲﺷـﻮد)‪ ،(5‬درﺣـﺎﻟﻲ ﻛـﻪ‬ ‫ﻣﻴﻠﻲ ﮔﺮم در دﺳـﻲ ﻟﻴﺘـﺮ(‪ ،‬ﺳـﻄﺢ ﺳـﺮﻣﻲ ﭘـﺎﻳﻴﻦ ‪<35) HDL‬‬ ‫ﺑﻌﻀﻲ از اﻳﻦ ﺑﻴﻤﺎران ﻣﻤﻜﻦ اﺳﺖ دﭼـﺎر اﻧﻔـﺎرﻛﺘﻮس ﺗـﺮاﻧﺲ‬ ‫ﻣﻴﻠﻲ ﮔﺮم در دﺳﻲ ﻟﻴﺘﺮ(‪ ،‬ﻫﻴﭙﺮﺗﺎﻧﺴﻴﻮن‪ ،‬دﻳﺎﺑﺖ ﺷﻴﺮﻳﻦ و ﺳـﺎﺑﻘﻪ‬ ‫ﻣــــــﻮرال )ﻫﻤــــــﺮاه ﻣــــــﻮج‪ (Q‬در ﻧــــــﻮاﺣﻲ ﺧــــــﺎﻣﻮش‬ ‫ﺧﺎﻧﻮادﮔﻲ از ﺑﻴﻤﺎري ﻋﺮوق ﻛﺮوﻧﺮ زودرس ﺑﻮد‪.‬‬ ‫‪D‬‬ ‫اﺳﺖ)‪ .(1-3‬ﺑﺎ اﻳﻦ ﺣﺎل ﺗﻌﺪاد ﻣﻮارد ﻛﻤـﻲ ﻣﻨﺎﺳـﺐ ﺑـﺮاي اﻳـﻦ‬ ‫ﻓﺎﻛﺘﻮرﻫﺎي ﺧﻄﺮ ﻗﻠﺒﻲ و ﻋﺮوﻗـﻲ ﺛﺒـﺖ ﺷـﺪه ﺷـﺎﻣﻞ‬ ‫‪SI‬‬ ‫اﻟﻜﺘﺮوﻛﺎردﻳﻮﮔﺮاﻓﻴـــﻚ ﺷـــﻮﻧﺪ ﻛـــﻪ ﺑـــﺎ ﻟﻴـــﺪﻫﺎي اﻟﻜﺘـــﺮوي‬ ‫اﺳﺘﺎﻧﺪارد ﺗﺸﺨﻴﺺ داده ﻧﺸﻮﻧﺪ)‪ .(6‬اﻧﻔﺎرﻛﺘﻮس ﻧﺎﺣﻴﻪ ﺧﻠﻔﻲ از‬ ‫ﻧﻮاﺣﻲ اﺳﺖ ﻛﻪ ﺑﺎ ﻣﺮگ و ﻣﻴـﺮ ﺑـﺎﻻ ﻫﻤـﺮاه اﺳـﺖ)‪ .(7‬ﺑـﺎ ﺑﻬـﺮه‬ ‫اﻧﻔﺎرﻛﺘﻮس ﻣﺠﺪد‪،‬آرﻳﺘﻤﻲ ﻫﺎي ﻣﺪاوم‪ ،‬اﻓـﺖ ﻓـﺸﺎر‬ ‫ﺧﻮن‪ ،‬ﺷﻮك ﻛﺎردﻳﻮژﻧﻴﻚ‪ ،‬ﻧﺎرﺳﺎﻳﻲ ﻗﻠﺒـﻲ ﻋﻼﻣـﺖ دار و ﻳـﺎ‬ ‫ادم ﺣـﺎد رﻳــﻪ ﺑـﻪ ﻋﻨــﻮان ﻋــﻮارض داﺧـﻞ ﺑﻴﻤﺎرﺳــﺘﺎﻧﻲ در ﻧﻈــﺮ‬ ‫ﻧــﻮع از اﻧﻔــﺎرﻛﺘﻮس را اﻓــﺰاﻳﺶ داد)‪ .(8‬اﻳــﻦ ﻣﻄﺎﻟﻌــﻪ اوﻟﻴــﻪ در‬ ‫ﺑﻌــﺪي ﺑﻴﻤــﺎران در دو ﮔــﺮوه ﺑﻴﻤــﺎران ﺑــﺎ و ﺑــﺪون ‪ STE‬در‬ ‫ﺟﻬﺖ ارزﻳﺎﺑﻲ ﺷﻴﻮع و اﻫﻤﻴﺖ ﺑﺎﻟﻴﻨﻲ ‪ STE‬در ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ‬ ‫ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ ﻣﻘﺎﻳﺴﻪ ﺷﺪﻧﺪ‪.‬‬ ‫‪of‬‬ ‫ﺟﻮﻳﻲ از ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ ﻗﻠﺐ ﻣـﻲﺗـﻮان ﻗـﺪرت ﺗـﺸﺨﻴﺺ اﻳـﻦ‬ ‫ﮔﺮﻓﺘﻪ ﺷﺪﻧﺪ‪ .‬ﭘﺎراﻣﺘﺮﻫﺎي ﻣﺮﺗﺒﻂ ﺑﺎ ﻣﺸﺨﺼﺎت زﻣﻴﻨـﻪاي و ﺳـﻴﺮ‬ ‫ﻗﻠﺐ در ﺑﻴﻦ ﺑﻴﻤﺎران ﭘـﺬﻳﺮش ﺷـﺪه ﺑﺎﺗـﺸﺨﻴﺺ‪ AMI‬ﺻـﻮرت‬ ‫‪ive‬‬ ‫ﮔﺮﻓﺖ‪.‬‬ ‫ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ اﻳﻦ ﻛﻪ در ﺑﺮرﺳـﻲ ﺑﻴﻤـﺎران اﺳـﺎﻣﻲ آﻧﻬـﺎ‬ ‫ﻓــﺎش ﻧــﺸﺪه و ﻫــﻢﭼﻨــﻴﻦ ﺗــﺪاﺧﻞ درﻣــﺎﻧﻲ ﺻــﻮرت ﻧﮕﺮﻓﺘــﻪ و‬ ‫روش ﻛﺎر‬ ‫ﻛﻪ ﺑﺎ ﺗﺸﺨﻴﺺ‪ AMI‬از اردﻳﺒﻬـﺸﺖ ﺗـﺎ ﺷﻬﺮﻳﻮرﺳـﺎل ‪ 1381‬در‬ ‫ﺑﺨﺶ ﻣﺮاﻗﺒﺖﻫﺎي وﻳﮋه ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻬﻴﺪ رﺟﺎﻳﻲ ﺑﺴﺘﺮي ﺷﺪﻧﺪ‬ ‫ﻫﺰﻳﻨﻪاي از اﻳﻦ ﺑﺎﺑﺖ ﺑﺮ ﺑﻴﻤﺎر ﺗﺤﻤﻴﻞ ﻧﺸﺪه اﺳﺖ‪ .‬ﻛﻠﻴﻪ ﻣﻮازﻳﻦ‬ ‫اﺧﻼق در ﭘﮋوﻫﺶ رﻋﺎﻳﺖ ﮔﺮدﻳﺪ‪.‬‬ ‫ﻧﺘﺎﻳﺞ‬ ‫‪ch‬‬ ‫در ﻳﻚ ﻣﻄﺎﻟﻌﻪ ﻣﻘﻌﻄﻲ‪ -‬ﺗﺤﻠﻴﻠﻲ‪ 210‬ﺑﻴﻤـﺎر ﻣﺘـﻮاﻟﻲ‬ ‫ﺻﺮﻓﺎ در ﻧﺤﻮه اﺧﺬ ﻧـﻮار ﻗﻠـﺐ اوﻟﻴـﻪ ﺗﻔـﺎوت وﺟـﻮد داﺷـﺘﻪ و‬ ‫راه ﻓﺮﻋــﻲ و اﺧــﺘﻼل ﻫﻤﻮدﻳﻨﺎﻣﻴــﻚ ﺑﻮدﻧــﺪ از ﻣﻄﺎﻟﻌــﻪ ﺣــﺬف‬ ‫ﻛﺪام از ﻟﻴﺪﻫﺎ ‪ STE‬ﻧﺪاﺷﺘﻨﺪ‪ .‬ﻣﺤﻞﻫﺎي اﻧﻔﺎرﻛﺘﻮس ‪ STE‬در‬ ‫ﺷﺪﻧﺪ‪ 12.‬ﻟﻴﺪ اﺳﺘﺎﻧﺪارد اﻟﻜﺘﺮو ﻫﻤﺮاه ﺑﺎ ﻟﻴﺪﻫﺎي ﺳﻄﺢ ﺧﻠﻔﻲ و‬ ‫‪ 153‬ﺑﻴﻤﺎر)‪ 72/8‬درﺻﺪ( دﻳﮕﺮ در ﺟﺪول ‪ 1‬ﻟﻴﺴﺖ ﺷﺪه اﺳﺖ‪.‬‬ ‫‪Ar‬‬ ‫ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﻗﺮار ﮔﺮﻓﺘﻨﺪ‪ .‬اﻓﺮادي ﻛﻪ دﭼﺎر ﺑﻠـﻮك ﺷـﺎﺧﻪاي‪،‬‬ ‫در ‪ 57‬ﺑﻴﻤـﺎر)‪ 27/1‬درﺻــﺪ از ‪ 210‬ﻣـﻮرد( در ﻫــﻴﭻ‬ ‫ﺳﻤﺖ راﺳـﺖ ﻗﻠـﺐ ﺑﻼﻓﺎﺻـﻠﻪ ﭘـﺲ از ﭘـﺬﻳﺮش ﺗﻤـﺎم ﺑﻴﻤـﺎران‬ ‫ﺟﺪول ‪ .1‬ﻣﺤﻠﻬﺎي اﻧﻔﺎرﻛﺘﻮس ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ ‪ ST‬ﺑﺮاﺳﺎس ﺗﻐﻴﻴﺮات‬ ‫ﮔﺮﻓﺘﻪ ﺷﺪ‪ .‬ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ ﻗﻠﺐ ﺑﺎ ﮔﺬاﺷﺘﻦ ﻟﻴـﺪﻫﺎي اﻟﻜﺘـﺮو در‬ ‫اﻟﻜﺘﺮوﻛﺎردﻳﻮﮔﺮاﻓﻴﻚ در ‪ 153‬ﺑﻴﻤﺎر ﺑﺴﺘﺮي در ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻬﻴﺪ رﺟﺎﺋﻲ‬ ‫ﻓﻀﺎﻫﺎي ﺑﻴﻦ دﻧﺪهاي ﭘﻨﺠﻢ در ﺧﻂ ﺧﻠﻔﻲ آﮔﺰﻳﻼري )‪ (V7‬و‬ ‫ﺗﻬﺮان ‪1381‬‬ ‫در ﺧــﻂ وﺳــﻂ ﻛﺘــﻒ )‪ (V8‬و ﻣﺠــﺎور ﺳــﺘﻮن ﻓﻘــﺮات )‪(V9‬‬ ‫ﮔﺮﻓﺘــﻪ ﺷــﺪ‪ .‬ﺗــﺸﺨﻴﺺ ‪ AMI‬ﺑﺮاﺳــﺎس ﻣﻌﻴﺎرﻫــﺎي ﺳــﺎزﻣﺎن‬ ‫ﺑﻬﺪاﺷﺖ ﺟﻬﺎﻧﻲ داده ﺷﺪ‪ .‬اﻧﻔﺎرﻛﺘﻮس ﻣﻴﻮﻛﺎرد ﺑﺪون ﻣﻮج ‪Q‬‬ ‫زﻣﺎﻧﻲ در ﻧﻈـﺮ ﮔﺮﻓﺘـﻪ ﺷـﺪ ﻛـﻪ درد ﺳـﻴﻨﻪ ﻃـﻮﻻﻧﻲ و اﻓـﺰاﻳﺶ‬ ‫ﻣﺠﻠﻪ ﻋﻠﻤﻲ ﭘﮋوﻫﺸﻲ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ اراك‪ ،‬ﺳﺎل دوازدﻫﻢ‪ ،‬ﺷﻤﺎره ‪ ،3‬ﭘﺎﻳﻴﺰ ‪1388‬‬ ‫‪www.SID.ir‬‬ ‫ﺗﻌﺪاد )درﺻﺪ(‬ ‫ﻣﺤﻞ‬ ‫‪(41/2)63‬‬ ‫‪(43/1)66‬‬ ‫‪(12/4)19‬‬ ‫‪(20/9)32‬‬ ‫‪(14/4)22‬‬ ‫ﻗﺪاﻣﻲ‬ ‫ﺗﺤﺘﺎﻧﻲ‬ ‫ﺧﻠﻔﻲ‬ ‫ﺧﺎرﺟﻲ‬ ‫ﭘﺮه ﻛﻮردﻳﺎل راﺳﺖ‬ ‫‪24‬‬ ‫ﺷﻴﻮع و اﻫﻤﻴﺖ ﺑﺎﻟﻴﻨﻲ ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ ‪ ST‬در ﻟﻴﺪﻫﺎي ‪...‬‬ ‫‪ STE‬در ‪ 19‬ﺑﻴﻤﺎر )‪ 12/4‬درﺻﺪ( از ‪ 153‬ﻣـﻮرد ﻳـﺎ‬ ‫دﻛﺘﺮ وﻟﻲ اﻟﻪ ﺧﺪﻳﺮ و ﻫﻤﻜﺎران‬ ‫ﺑﺤﺚ‬ ‫ﺳﻄﻮح ﺗﺤﺘﺎﻧﻲ ﻳـﺎ ﺧـﺎرﺟﻲ در ‪ 12‬ﻣـﻮرد )‪ 7/8‬درﺻـﺪ( دﻳـﺪه‬ ‫ﺧﺎﻣﻮش اﻟﻜﺘﺮوﻛﺎردﻳﻮﮔﺮاﻓﻴﮓ ﻗﻠﺐ ﻣﻲﺑﺎﺷﺪ‪ .‬ﻣﻌﻴﺎرﻫﺎي ﻓﻌﻠﻲ‬ ‫ﺷﺪ‪ .‬اﻟﻜﺘﺮوي اﺳﺘﺎﻧﺪارد ‪ 12‬ﻟﻴﺪ در دو ﺑﻴﻤﺎر ﻛﺎﻣﻼ ﻧﺮﻣﺎل ﺑﻮد و‬ ‫اﻟﻜﺘﺮوﻛﺎردﻳﻮﮔﺮاﻓﻲ ﺑﺮاي ﺗﺸﺨﻴﺺ اﻧﻔـﺎرﻛﺘﻮس ﺧﻠﻔـﻲ ﻗﻠـﺐ‬ ‫‪ 5‬ﺑﻴﻤﺎر دﻳﮕﺮ ﺑﺎ ﺗﺸﺨﻴﺺ اﻧﻔـﺎرﻛﺘﻮس ﺑـﺪون ﻣـﻮج ‪ Q‬ﺑـﺴﺘﺮي‬ ‫ﻏﻴﺮ ﺣﺴﺎس ﻣﻲﺑﺎﺷـﺪ و اﻛﺜﺮﻳـﺖ اﻳـﻦ ﺑﻴﻤـﺎران ﺗـﺸﺨﻴﺺ داده‬ ‫ﺷﺪﻧﺪ‪ .‬ﻣﻮج ‪ R‬ﺑﻠﻨﺪ در ﻟﻴﺪ ‪ V1‬و ﻳﺎ ‪ V2‬در ‪ 5‬ﺑﻴﻤﺎر اﻳﺠﺎد ﺷـﺪ‬ ‫ﻧﻤﻲ ﺷـﻮﻧﺪ)‪ .(11 ،10‬ﺷـﺎه و ﻫﻤﻜـﺎران ﮔـﺰارش ﻛﺮدﻧـﺪ ﻛـﻪ ﺑـﺎ‬ ‫)‪ 26/3‬درﺻــﺪ از ‪ 19‬ﺑﻴﻤــﺎر(‪ .‬اﺧــﺘﻼل ﺣﺮﻛــﺎت دﻳــﻮارهاي در‬ ‫اﻧــﺴﺪاد ﻛﺎﻣــﻞ ﺳــﺮﺧﺮگ ﭼﺮﺧــﺸﻲ ﭼــﭗ ﻗﻠــﺐ در ﺧــﻼل‬ ‫ﻧﺎﺣﻴﻪ ﺧﻠﻔﻲ در ﺗﻤﺎﻣﻲ اﻳﻦ ﺑﻴﻤﺎران ﺑﻪ روش اﻛﻮﻛﺎردﻳﻮﮔﺮاﻓﻲ‬ ‫آﻧﮋﻳﻮﭘﻼﺳﺘﻲ‪ STE ≥1 ،‬ﻣﻴﻠﻲ ﻣﺘـﺮ در ﻟﻴـﺪﻫﺎي اﺳـﺘﺎﻧﺪارد در‬ ‫ﺛﺒﺖ ﺷﺪ‪ .‬اﺳﻜﻦ ﺗﻜﻨﺴﻴﻮم ﭘﻴﺮوﻓـﺴﻔﺎت ﺑـﻪ روش اﺳـﭙﻜﺖ ‪-48‬‬ ‫‪ 35‬درﺻــــﺪ ﺑﻴﻤــــﺎران و ﭘــــﺎﻳﻴﻦ رﻓــــﺘﻦ ﻗﻄﻌــــﻪ‪ST‬‬ ‫‪ 24‬ﺳﺎﻋﺖ ﺑﻌﺪ از ﭘﺬﻳﺮش ﻣﻄﺮح ﻛﻨﻨﺪه اﻧﻔﺎرﻛﺘﻮس ﺧﻠﻔـﻲ در‬ ‫)‪ Depression‬در ‪ 35‬درﺻﺪ دﻳﮕﺮ رخ داد‪ ،‬در ﺣﺎﻟﻲ ﻛـﻪ در‬ ‫ﺗﻤﺎﻣﻲ ﺑﻴﻤﺎران ﺑﺎ ‪ STE‬در ﻟﻴـﺪﻫﺎي ﺧﻠﻔـﻲ ﺑـﻪ ﻏﻴـﺮ از ‪ 2‬ﺑﻴﻤـﺎر‬ ‫‪ 30‬درﺻﺪ ﺑﻴﻤﺎران ﺗﻐﻴﻴـﺮات‪ ST‬دﻳـﺪه ﻧـﺸﺪ)‪ .(12‬اﻛﺜـﺮ ﻣـﻮارد‬ ‫‪D‬‬ ‫ﺑﻪ ﻃﻮر اﻳﺰوﻟﻪ در ‪ 7‬ﻣﻮرد )‪ 4/6‬درﺻﺪ( ﻳـﺎ ﻫﻤـﺮاه ﺑـﺎ ‪ STE‬در‬ ‫ﻣﻴﻮﻛﺎرد ﺳﻄﺢ ﺧﻠﻔـﻲ ﺑﻄـﻦ ﭼـﭗ ﻳﻜـﻲ از ﻧـﻮاﺣﻲ‬ ‫‪SI‬‬ ‫ﺑﻮد‪.‬‬ ‫ﺟﺪول ‪ 2‬ﻣﺸﺨﺼﺎت ﺑﺎﻟﻴﻨﻲ و دﻣﻮﮔﺮاﻓﻴﻚ ﺑﻴﻤـﺎران‬ ‫‪(ST‬‬ ‫اﻧﻔﺎرﻛﺘﻮس ﺧﻠﻔﻲ آﺷﻜﺎرا ﻫﻤـﺮاه ﺑـﺎ اﻧﻔـﺎرﻛﺘﻮسﻫـﺎي ﺳـﻄﺢ‬ ‫ﺗﺤﺘﺎﻧﻲ ﻳﺎ ﺧﺎرﺟﻲ ﻣﻲﺑﺎﺷﺪ)‪.(13‬‬ ‫اﮔــﺮ ﭼــﻪ ﻫﻨــﻮز ﻣــﻮرد ﺑﺤــﺚ اﺳــﺖ‪ ،‬ﺷــﻮاﻫﺪ ﻗﺎﺑــﻞ‬ ‫‪of‬‬ ‫را ﺑﺮاﺳـﺎس وﺟـﻮد ﻳـﺎ ﻋـﺪم وﺟـﻮد ‪ STE‬در ﻟﻴـﺪﻫﺎي ﺧﻠﻔـﻲ‬ ‫ﺗــﻮﺟﻬﻲ وﺟــﻮد دارد ﻛــﻪ ‪ ST DEP‬در ﺧــﻼل اﻧﻔــﺎرﻛﺘﻮس‬ ‫ﺧﻼﺻﻪ ﻛﺮده اﺳﺖ‪.‬‬ ‫ﺗﺤﺘـﺎﻧﻲ ﻣﻮﻳــﺪ ﮔﺮﻓﺘـﺎري ﺳــﻄﺢ ﺧﻠﻔـﻲ‪ -‬ﺧــﺎرﺟﻲ ﺑﻄـﻦ ﭼــﭗ‬ ‫ﺟﺪول ‪ . 2‬ﻣﺸﺨﺼﺎت ﺑﻴﻤﺎران ﺑﺎ ﻳﺎ ﺑﺪون ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ ‪ (STE) ST‬در‬ ‫‪1381‬‬ ‫ﺑﺰرﮔــﻲ از ﺑﻴﻤــﺎران ﺑــﺎ اﻧﻔــﺎرﻛﺘﻮس ﺗﺤﺘــﺎﻧﻲ‪ STDEP ،‬ﺑــﺎ‬ ‫‪p‬‬ ‫ﮔﺮﻓﺘﺎري ﭼﻨﺪ رگ ﻳﺎ ﮔﺮﻓﺘﺎري ﻫﻤﺰﻣﺎن ﺷﺎﺧﻪ ﻛﺮوﻧﺮي ﭼـﭗ‬ ‫ﻫﻤﺮاه ﻧﺒﻮد)‪ ،(18‬اﻣﺎ ارﺗﺒﺎط آن ﺑﺎ ﮔﺮﻓﺘـﺎري ﺷـﺎﺧﻪﻫـﺎي ﺗﻐﺬﻳـﻪ‬ ‫ﺑﺎ ‪ STE‬در‬ ‫ﺑﺪون ‪ STE‬در‬ ‫ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ‬ ‫ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ‬ ‫‪68/4‬‬ ‫‪67/9‬‬ ‫‪96/0‬‬ ‫‪(7/3)64/4‬‬ ‫‪(9/0)57/2‬‬ ‫‪0/001‬‬ ‫‪(1/1)3/4‬‬ ‫‪(1/1)2/5‬‬ ‫‪0/002‬‬ ‫‪(10/5) 2‬‬ ‫‪(38/1) 51‬‬ ‫‪0/01‬‬ ‫‪(47/4) 9‬‬ ‫‪(38/1)51‬‬ ‫‪0/43‬‬ ‫ﻣﻲﺑﺎﺷﺪ‪ .‬اﻳﻦ ﺑﻴﻤﺎران ﻣﻤﻜﻦ اﺳﺖ اﻟﻜﺘـﺮوي اﺳـﺘﺎﻧﺪارد ﻧﺮﻣـﺎل‬ ‫‪(47/3)9‬‬ ‫‪(20/9)28‬‬ ‫‪0/01‬‬ ‫داﺷﺘﻪ ﻳﺎ ﺑﻪ ﺻﻮرت اﻧﻔﺎرﻛﺘﻮس ﺑﺪون ﻣﻮج ‪ Q‬ﺗﻈﺎﻫﺮ ﻛﻨﻨﺪ)‪،10‬‬ ‫‪(26/3)5‬‬ ‫‪(11/2)15‬‬ ‫‪0/07‬‬ ‫‪ch‬‬ ‫ﻛﻨﻨﺪه ﺳﻄﺢ ﺧﻠﻔﻲ‪ -‬ﺧﺎرﺟﻲ ﺑﻄﻦ ﭼـﭗ ﻛﺮوﻧـﺮ راﺳـﺖ ﻧـﺸﺎن‬ ‫داده ﺷــﺪ)‪ .(19‬در ﺣــﺎل ﺣﺎﺿــﺮ ﺣﺘــﻲ ﺑــﺎ ﺑﻬﺘــﺮﻳﻦ روشﻫــﺎي‬ ‫درﻣﺎﻧﻲ‪ ،‬ﻣﻴﺰان ﻣﺮگ اﻳﻦ ﺑﻴﻤﺎران ﺑﻪ ﻣﻴﺰان آن در اﻧﻔـﺎرﻛﺘﻮس‬ ‫ﻗﺪاﻣﻲ ﻣﻲرﺳﺪ)‪ .(20‬ﻓﺮض ﺷﺪه ﻛﻪ ﻣﻴﺰان ﻣﺮگ ﺑﻪ ﻃﻮر ﺧﻄﻲ‬ ‫‪Ar‬‬ ‫ﺟﻨﺲ ﻣﺬﻛﺮ‬ ‫)درﺻﺪ(‬ ‫ﺳﻦ‬ ‫ﻣﻴﺎﻧﮕﻴﻦ )اﻧﺤﺮاف‬ ‫ﻣﻌﻴﺎر(‬ ‫ﻓﺎﻛﺘﻮرﻫﺎي ﺧﻄﺮ‬ ‫ﻣﻴﺎﻧﮕﻴﻦ )اﻧﺤﺮاف‬ ‫ﻣﻌﻴﺎر(‬ ‫درﻣﺎن ﺑﺎ‬ ‫ﺗﺮوﻣﺒﻮﻟﻴﺘﻴﻚ‬ ‫ﺗﻌﺪاد )درﺻﺪ(‬ ‫ﻧﺎرﺳﺎﻳﻲ ﺑﻄﻦ ﭼﭗ‬ ‫ﺗﻌﺪاد )درﺻﺪ(‬ ‫ﻋﻮارض داﺧﻞ‬ ‫ﺑﻴﻤﺎرﺳﺘﺎﻧﻲ‬ ‫ﺗﻌﺪاد )درﺻﺪ(‬ ‫ﻣﺮگ‬ ‫ﺗﻌﺪاد )درﺻﺪ(‬ ‫‪ive‬‬ ‫ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ اﻟﻜﺘﺮوﻛﺎردﻳﻮﮔﺮاﻓﻲ در ﺑﻴﻤﺎرﺳﺘﺎن ﺷﻬﻴﺪ رﺟﺎﺋﻲ ﺗﻬﺮان‬ ‫ﻣﻲﺑﺎﺷﺪ)‪ .(14-17‬در ﮔﺰارﺷﻲ از ﻣﺤﻘﻘﺎن ﮔﻮﺳـﺘﻮ در ﺟﻤﻌﻴـﺖ‬ ‫ﺑﺎ اﻓﺰاﻳﺶ ﻣﻴﺰان ‪ ST DEP‬اﻓﺰاﻳﺶ ﻣﻲﻳﺎﺑﺪ)‪ (21‬و ﻣﻲﺗـﻮان ﺑـﺎ‬ ‫ﺗﺠﻮﻳﺰ ﺑﻪ ﻣﻮﻗﻊ ﺗﺮوﻣﺒﻮﻟﻴﺘﻴﻚ آن را ﻛﺎﻫﺶ داد)‪.(22‬‬ ‫ﺗــﺸﺨﻴﺺ اﻧﻔــﺎرﻛﺘﻮس ﺧﻠﻔــﻲ اﻳﺰوﻟــﻪ ﻣــﺸﻜﻞﺗــﺮ‬ ‫‪ .(11‬ﻣﻤﻜﻦ اﺳﺖ ﺛﺎﺑﺖ ﺷﻮد ﻛﻪ اﻓﺰودن ﻟﻴـﺪﻫﺎي ﺧﻠﻔـﻲ روش‬ ‫ﺑﺎ ارزﺷﻲ در ﺗﺸﺨﻴﺺ اﻳﻦ ﻣﻮارد ﺑﺎﺷﺪ‪ .‬ﻧﺸﺎن داده ﺷﺪه ﻛﻪ اﻳﻦ‬ ‫روش ﺣﺴﺎﺳﻴﺖ ﺗﺸﺨﻴﺺ اﻧﻔﺎرﻛﺘﻮس را اﻓﺰاﻳﺶ ﻣﻲدﻫﺪ)‪.(23‬‬ ‫در ﮔﺮوه ﻣﻮرد ﻣﻄﺎﻟﻌﻪ ﻣﺎ‪ 19 ،‬ﺑﻴﻤﺎر‪ STE‬در ﻟﻴـﺪﻫﺎي ﺧﻠﻔـﻲ و‬ ‫ﻣﺠﻠﻪ ﻋﻠﻤﻲ ﭘﮋوﻫﺸﻲ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ اراك‪ ،‬ﺳﺎل دوازدﻫﻢ‪ ،‬ﺷﻤﺎره ‪ ،3‬ﭘﺎﻳﻴﺰ ‪1388‬‬ ‫‪www.SID.ir‬‬ ‫‪25‬‬ ... ‫ در ﻟﻴﺪﻫﺎي‬ST ‫ﺷﻴﻮع و اﻫﻤﻴﺖ ﺑﺎﻟﻴﻨﻲ ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ‬ ‫ﻳﺎ ﺷﻮاﻫﺪ دﻳﮕـﺮ اﻧﻔـﺎرﻛﺘﻮس ﺧﻠﻔـﻲ را داﺷـﺘﻨﺪ در ﺣـﺎﻟﻲ ﻛـﻪ‬ ‫ ﻣــﻮرد از آﻧﻬــﺎ‬5 ‫ ﺗﻨﻬــﺎ در‬V1-V2 ‫ ﺑﻠﻨــﺪ در ﻟﻴــﺪﻫﺎي‬R ‫ﻣــﻮج‬ ‫ ﭘـﻨﺞ ﻣـﻮرد از اﻳـﻦ‬،‫ اﮔﺮ ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ اﺧﺬ ﻧﻤﻲﺷﺪ‬.‫دﻳﺪه ﺷﺪ‬ (Non Q Wave)‫ﺑﻴﻤﺎران ﺑﺎ ﺗﺸﺨﻴﺺ اﻧﻔﺎرﻛﺘﻮس ﺑﺪون ﻣﻮج‬ .‫از اﺛﺮات ﻣﻔﻴﺪ ﺗﺮوﻣﺒﻮﻟﻴﺘﻴﻚ ﻣﺤﺮوم ﻣﻲﺷﺪﻧﺪ‬ ‫در ﺣﺎل ﺣﺎﺿﺮ ﻣـﺎ ﺷـﺎﻫﺪ اﻓـﺰاﻳﺶ ﻋـﻮارض داﺧـﻞ‬ (Ejection ‫ﺑﻴﻤﺎرﺳﺘﺎﻧﻲ و ﻛﺎﻫﺶ ﺑﻴـﺸﺘﺮ ﻗـﺪرت ﻋـﻀﻠﻪ ﻗﻠـﺐ‬ ‫ و اﻓﺰاﻳﺶ ﻣﺮگ در ﺑﻴﻤﺎران ﺑﺎ اﻧﻔـﺎرﻛﺘﻮس‬Fraction- EF) D ‫ﺧﻠﻔﻲ در ﻣﻘﺎﻳـﺴﻪ ﺑـﺎ دﻳﮕـﺮ اﻧـﻮاع اﻧﻔـﺎرﻛﺘﻮس ﻣـﻲﺑﺎﺷـﻴﻢ ﻛـﻪ‬ ‫ﻣﻲﺗﻮاﻧﺪ ﻧﺎﺷﻲ از ﻛﺎﻫﺶ ﻗﺎﺑﻞ ﺗﻮﺟﻪ در ﺗﺠـﻮﻳﺰ ﺗﺮوﻣﺒﻮﻟﻴﺘﻴـﻚ‬ ‫ ﺷﺎﻣﻞ ﺳﻦ ﺑﺎﻻﺗﺮ و وﺟـﻮد ﻋﻮاﻣـﻞ‬،‫ﻳﺎ وﺟﻮد ﺧﻄﺮ زﻣﻴﻨﻪاي ﺑﺎﻻ‬ .‫ﺧﻄﺮ ﻣﺘﻌﺪد ﺑﺎﺷﺪ‬ ‫ﻧﺘﻴﺠﻪ ﮔﻴﺮي‬ Ar ch ive of myocardial infarction in United States (19901993). Observations from the national registry of myocardial infarction. Circulation 1994; 90: 2103-14. 4.Anenymous. The TIMI IIIB investigators. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q wave myocardial infarction. Results of the TIMI IIIB trial. Thrombolysis in myocardial ischemia. Circulation 1994; 89:1545-56. 5. Guadagnoli E, Hauptman PJ, Ayanian JZ, Pashos CL, McNeil BJ, Cleary PD. Variation in the use of cardiac procedures after myocardial infarction. N Engl J Med 1995; 333:573-8. 6. Agarwal JB, Khaw K, Aurignac F, Locuto A. Importance of posterior chest leads in patients with suspected myocardial infarction, but nondiagnostic, routine 12-lead electrocardiogram. Am J Cardiol 1999; 83(3): 323-6. 7. Wung SF, Drew BJ. New electrocardiographic criteria for posterior wall acute myocardial ischemia validated by a percutaneous transluminal coronary angioplasty model of acute myocardial infarction. Am J Cardiol 2001; 87(8):970-4. 8. Menown IB, Allen J, Anderson JM, Adgey AAY. Early diagnosis of right ventricular or posterior infarction associated with inferior wall left ventricular acute myocardial infarction. Am J Cardiol 2000; 85(8):934-8. 9. Sclarovsky S, Topaz O, Rechavia E, Strasberg B, Agmon J. Ischemic ST depression in leads V2-V3 as the presenting electrocardiographic feature of posterolateral wall myocardial infarction. Am Heart J 1987; 113: 1085-9. 10. Schamroth L. The 12-lead electrocardiogram. Boston: Blackwell; 1989. vol 1. p. 825-7. 11. Libby P, Bonow R, Mann DL, Zipes DP, Braunwald E. Braunwald’s Heart Disease, A Textbook of Cardiovascular Medicine. 5th ed. Philadelphia: Sounders; 1997.p.134-5. 12. Shah A, Wagner GS, Green CL, Crater SW, Sawchak ST, Wildermam NM, et al. Electrocardiographic differentiation of the STsegment depression of acute myocardial injury SI ‫دﻛﺘﺮ وﻟﻲ اﻟﻪ ﺧﺪﻳﺮ و ﻫﻤﻜﺎران‬ 26 ‫ ﻧﺎﺷﺎﻳﻊ‬AMI ‫ در ﻟﻴﺪﻫﺎي ﺧﻠﻔﻲ در ﺑﻴﻤﺎران ﺑﺎ‬STE ‫ﻧﻤﻲ ﺑﺎﺷﺪ و ﻣﻤﻜﻦ اﺳـﺖ ﻧـﺸﺎﻧﻪ ﭘـﻴﺶ آﮔﻬـﻲ ﺑـﺪ ﺑﻴﻤﺎرﺳـﺘﺎﻧﻲ‬ ‫ ﺛﺒـﺖ ﻟﻴـﺪﻫﺎي ﺧﻠﻔـﻲ ﻣﻤﻜـﻦ اﺳـﺖ در‬AMI ‫ در ﺧﻼل‬.‫ﺑﺎﺷﺪ‬ ‫ در ﻟﻴـﺪﻫﺎي اﺳـﺘﺎﻧﺪارد‬STE ‫ﻳﺎﻓﺘﻦ ﮔﺮوﻫﻲ از ﺑﻴﻤـﺎران ﺑـﺪون‬ .‫ ﻛﻤﻚ ﻛﻨﻨﺪه ﺑﺎﺷﺪ‬،‫ﻛﻪ از درﻣﺎن ﺗﺮوﻣﺒﻮﻟﻴﺘﻴﻚ ﺳﻮد ﻣﻲﺑﺮﻧﺪ‬ ‫ﺗﺸﻜﺮ و ﻗﺪرداﻧﻲ‬ ‫ﺑﺪﻳﻨﻮﺳﻴﻠﻪ از زﺣﻤﺎت و ﻣﺴﺎﻋﺪت ﻫﻤﻜﺎران ﮔﺮاﻣﻲ‬ ‫در ﺑﺨﺶ ﻣﺮاﻗﺒﺖﻫﺎي وﻳﮋه و اورژاﻧﺲ ﺑﻴﻤﺎرﺳﺘﺎن ﻗﻠـﺐ ﺷـﻬﻴﺪ‬ ‫ ﺗـﺸﻜﺮ و‬،‫رﺟﺎﻳﻲ ﻛﻪ ﻣﺎ را در اﻧﺠﺎم اﻳﻦ ﻣﻄﺎﻟﻌﻪ ﻳـﺎري ﻧﻤﻮدﻧـﺪ‬ .‫ﻗﺪرداﻧﻲ ﻣﻲﻧﻤﺎﻳﻴﻢ‬ ‫ﻣﻨﺎﺑﻊ‬ 1. Hennekens CH. Thrombolytic therapy: preand post-GISSI-2, ISIS-3, and GUSTO-1. Clin Cardiol 1994; 17(suppl):115-17. 2. The GUSTO investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993; 329 (10):673-82. 3. Rogers WJ, Bowlby LJ, Chandra MC, French WJ, Gore JM, Lambrew CT, et al. Treatment of 1388 ‫ ﭘﺎﻳﻴﺰ‬،3 ‫ ﺷﻤﺎره‬،‫ ﺳﺎل دوازدﻫﻢ‬،‫ﻣﺠﻠﻪ ﻋﻠﻤﻲ ﭘﮋوﻫﺸﻲ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ اراك‬ www.SID.ir ... ‫ در ﻟﻴﺪﻫﺎي‬ST ‫ﺷﻴﻮع و اﻫﻤﻴﺖ ﺑﺎﻟﻴﻨﻲ ﺑﺎﻻ رﻓﺘﻦ ﻗﻄﻌﻪ‬ D infarctions: results in 16185 patients. J Am Coll Cardiol 1995; special issue: 342A. 19. Shah PK, Pichler M, Berman DS, Maddahi J, Peter T, Singh BN, et al. Non-invasive identification of a high risk subset of patients with acute inferior myocardial infarction. Am J Cardiol 1980; 46:915-21. 20. Hlatky MA, Califf RM, Lee KL, Pryor DB, Wagner GS, Rosati RA. Prognostic significance of precordial ST-segment depression during inferior acute myocardial infarction. Am J Cardiol 1985; 55(4): 325-9. 21. Willems JL, Willems RJ, Willems RM, Arnold AER, Van de Werf F, Verstraete M. Significance of initial ST segment elevation and depression for the management of thrombolytic therapy in acute myocardial infarction. Circulation 1990; 82:1147-58. 22. Peterson ED, Hathaway WR, Zabel KM, Pieper KS, Granger CB, Wagner GS, et al. Prognostic significance of precordial STsegment depression during inferior myocardial infarction in the thrombolytic era: results in 16521 patients. J Am Coll Cardiol 1996; 28:305-12. 23. Zalenski RJ, Rydman RJ, Sloan EP, Hahm K, Cook D, Tacker J, et al. Value of posterior and right ventricular leads in comparison to the standard 12-lead electrocardiogram in evaluation of ST-segment elevation in suspected acute myocardial infarction. Am J Cardiol 1997; 79:1579-85. Ar ch ive of due to the left circumflex artery occlusion from that of myocardial ischemia of nonocclusive etiologies. Am J Cardiol 1997; 80:512-3. 13. Perloff JK. The recognition of strictly posterior myocardial infarction by conventional scalar electrocardiography. Circulation 1964; 30:706-18. 14. Shah PK, Pichler M, Berman DS, Madashi J, Peter T, Singh BN, et al. Noninvasive identification of a high risk subset of patients with acute inferior myocardial infarction. Am J Cardiol 1980; 46:915- 21. 15. Goldberg HL, Borer JC, Kluger J, Scheidt SS, Alonso DR. Anterior ST-segment depression in acute inferior myocardial infarction: indicator of posterolateral infarction. Am J Cardiol 1981; 48:1009-15. 16. Gibson JS, Crampton RS, Watson DD, Taylor GJ, Carabello BA, Holt ND, Beller GA. Precordial ST-segment depression during acute inferior myocardial infarction: clinical, scintigraphic and angiographic correlations. Circulation 1982; 66: 732-41. 17. Ong L, Valdellon B, Coromilas J, Brody R, Reiser P, Morrison J. Precordial ST-segment depression in inferior myocardial infarction: evaluation by quantitative thallium-201 scintigraphy and technetium99m ventriculography. Am J Cardiol 1983; 51:734-9. 18. Peterson ED, Hathaway WR, Zabel KM, Woodlief LH, Granger CB, Wagner GS, et al. The prognostic importance of anterior STsegment depression in inferior myocardial SI ‫دﻛﺘﺮ وﻟﻲ اﻟﻪ ﺧﺪﻳﺮ و ﻫﻤﻜﺎران‬ 27 1388 ‫ ﭘﺎﻳﻴﺰ‬،3 ‫ ﺷﻤﺎره‬،‫ ﺳﺎل دوازدﻫﻢ‬،‫ﻣﺠﻠﻪ ﻋﻠﻤﻲ ﭘﮋوﻫﺸﻲ داﻧﺸﮕﺎه ﻋﻠﻮم ﭘﺰﺷﻜﻲ اراك‬ www.SID.ir Arak Medical University Journal (AMUJ) Autumn 2009; 12(3): 23-28 Original Article Prevalence and clinical value of ST-segment elevation in posterior electrocardiography leads during acute myocardial infarction, Shahid Rajaei hospital, Tehran, 2003 Khadir V¹*, Oraii S² 1-Assistant Professor, Cardiologist, Department of Cardiology, Arak University of Medical Science, Arak, Iran 2- Cardiologist, Interventional Electro physiologist, Day Hospital, Tehran, Iran D Received 26 Apr, 2009 Accepted 2 Sep, 2009 Abstract Ar ch ive of SI Background: Current electrocardiography (ECG) criteria are insensitive for the detection of posterior acute myocardial infarction (AMI) and most of these cases remain undiagnosed. The purpose of this study has been evaluated of prevalence and clinical value of ST-segment in posterior electrocardiography leads during acute myocardial infarction. Materials and Methods: In cross- sectional analytic study, posterior ECG leads (V7, V8 and V9) as well as standard 12 leads in 210 consecutive patients with acute myocardial infarction admitted to CCU wards of Shahid Rijaie hospital. Reinforcing, continuous arrhythmia, hypotension, cardiologic shock, marked heart failure and/or acute pulmonary edema were considered. Related parameters to basic characteristics and next process of patients in two groups with/ without ST- segment elevation in posterior ECG lead were compared. Results: There were 153 patients with ST-segment elevation ≥1 mm in ≥2 contiguous leads. 12.4% patients had STE≥1 mm in ≥2 posterior leads, either as an isolated finding (4.6%) or in association with STE at inferior or lateral sites (7.8%). The standard 12-lead electrocardiogram was normal in two patients and 5 other patients were admitted with the diagnosis of non-Q infarctions. Tall R waves in V1/V2 developed in 5 cases. In-hospital complications were significantly more frequent among patients with STE in posterior leads (47.4% vs. 20.9% respectively, P=0.01). Conclusion: STE in posterior electrocardiography leads is not uncommon during acute myocardial infarction and may portend a worse in-hospital course. Keywords: Electrocardiography, Myocardial infarction, Prognosis *Corresponding author; Email: [email protected] Address: Amir Kabir hospital, Arak, Iran. 28 www.SID.ir