心电图中无“小”波，细微之处见真章！

2018-01-18 金迪、王玉伟医学界心血管频道

xujie.L

医生/

今天，我们如同“格列佛”，游历到心电图的“小人国”，一起领略那些“小”波背后的故事。

今天，我们如同“格列佛”，游历到心电图的“小人国”，一起领略那些“小”波背后的故事。

壹

★ 故事梗概：老年男性，长期嗜酒，近期出现意识不清。患者心电图为窦性心律，J波（Osborne波）提示低体温，经保暖复苏治疗后，J波逐渐缩小。

★ 故事起源：多数学者认为J波是心室提前发生的复极波。

★ 心得体会：那么，问题来了，心电图为何与体温有瓜葛？

其实，不难理解，我们知道强烈的全身性低温时新陈代谢会变慢，同样也会使心室肌的除极和复极减慢。“前一道程序”——除极正缓缓的进行着，除极尚未全部完成，此时部分心室肌已提早迈入了“下一道程序”——复极，导致QRS波群终末部结束之前出现了J波。低体温心电图还可表现为间期延长、心动过缓、房室传导阻滞等。

Tips

最早于1938年，Tomashewski发现意外冻伤的病人心电图上ST段初始部位出现这样缓慢的“驼峰状”波。1992年，Brugada兄弟描述了致命性快速心律失常发作导致晕厥及猝死的患者，心电图表现V1～V3导联出现J波、ST段抬高、T波倒置酷似右束支阻滞的图形（被认为是无器质性心脏病患者猝死的标志）。

因此，J波不断被赋予更多内涵，J波不仅出现在低体温，还可见于高钙血症、早期复极综合征、Brugada综合征、特发性心室颤动等。

此外，J波的鉴别也很重要，J波容易与致心律失常性右室心肌病的特征性心电图异常“小”波——Epsilon波相混淆。

Epsilon波为右胸导联QRS波终末部或ST段起始部出现向上的小棘波，如下图示，其发生机制与致心律失常性右室心肌病患者右室病变心肌细胞的延迟缓慢除极有关，此类患者主要表现为室性心律失常、心力衰竭和猝死，Epsilon波也是预测猝死风险的心电图标志波之一。

贰

★ 故事梗概：患者中年女性，偶有心悸不适。心电图表现为PR间期缩短，QRS波时限延长，可见δ波，符合WPW综合征心电图。

★ 故事起源：WPW综合征发生原因是存在正常房室传导系统以外的先天性房室附加通道（kent旁路）。脱离了正常的房室传导通道，而是经附加通道下传，使部分或者全部心室肌提前激动，常合并阵发性室上性心动过速发作。

★ 心得体会：δ波是WPW综合征的典型心电图表现之一，所有的预激综合征都有δ波吗？答案是否定的。

LGL综合征，又称为短PR间期综合征，存在房室结旁路（James束），然而由于James束止于房室结末端，而非直接止于心室，因此心室肌不被提前激动，也就不会出现δ波。

Tips

WPW综合征是典型预激综合征，是各型预激综合征中最多见的一种，大多无器质性心脏病。不伴有心律失常的预激综合征，无任何临床症状，但是旁路本身已经为折返性心律失常的发生提供了解剖学基础。

预激综合征患者有40%-80%伴发快速性心律失常，最常见的是阵发性室上性心动过速，其次为心房颤动、心房扑动，也有报告发生室速、室颤者，少数可发生猝死。

叁

★ 故事梗概：患者近1周来出现多次腹泻，伴有纳差。心电图为窦性心律，QT间期延长，出现T-U融合波，提示低钾血症。

★ 故事起源：U波的发生机制存在多种假说：浦肯野纤维的复极波、部分心肌延迟发生的复极波、机械电耦联引起的后电位等。

★ 心得体会：临床工作中，心电图U波增高最常见于低钾血症，当血钾浓度低于3.0 mmol/l，就可出现U波增高、T波低平和ST段下移，应警惕低血钾诱发的各种室性心律失常。此外，U波增高还会受某些药物的影响，如儿茶酚胺类药物、奎尼丁、洋地黄、钙剂等。

Tips

1903年Einthoven在心电图T波后发现一个独立的低振幅波，按英文字母排序将其命名为“U波”。

目前普遍认为U波改变可由许多因素引起，甚至是严重器质性心脏病患者心电图的唯一表现，诊断价值并不低于T波。U波的异常包括U波增高、降低、倒置等，可发生于心血管疾病、药物影响以及电解质紊乱等。

原始出处：1. J波综合征.心血管病学进展. 2011年7月第32卷第4期.

2.郭继鸿.新概念心电图[M].3版，北京：北京大学医学出版社，2007年.

3.Epsilon波的心电图特征与研究进展，心电与循环，2015年第34卷第6期

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2018-01-24 topnew

厉害厉害

0 0
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2018-01-20 能力无止境

很好

143 0
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2018-01-20 能力无止境

好

107 0
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2018-01-20 一个字-牛

学习了谢谢分享

105 0
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2018-01-19 天涯183

非常好的文章.学习了

0 0
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2018-01-19 1dd8c52fm63(暂无匿称)

了解了解.学习学习

68 0
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createdTime=Fri Jan 19 08:51:52 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279970, encodeId=05f82e99701a, content=学习了新知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201006/4db877c2887649beb09cb5effd0b38c7/916f66edd48a4e77b20ebc3e14b6e45c.jpg, createdBy=141e1980133, createdName=Y—xianghai, createdTime=Fri Jan 19 08:08:17 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279961, encodeId=9c052e9961f2, content=长见识了.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, 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2018-01-19 明月清辉

谢谢分享.学习了

55 0
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createdBy=a22097948, createdName=天地飞扬, createdTime=Fri Jan 19 07:42:35 CST 2018, time=2018-01-19, status=1, ipAttribution=)]
2018-01-19 龙胆草

学习谢谢分享

72 0
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createdTime=Fri Jan 19 08:51:52 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279970, encodeId=05f82e99701a, content=学习了新知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201006/4db877c2887649beb09cb5effd0b38c7/916f66edd48a4e77b20ebc3e14b6e45c.jpg, createdBy=141e1980133, createdName=Y—xianghai, createdTime=Fri Jan 19 08:08:17 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279961, encodeId=9c052e9961f2, content=长见识了.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Fri Jan 19 07:42:35 CST 2018, time=2018-01-19, status=1, ipAttribution=)]
2018-01-19 Y—xianghai

学习了新知识

70 0
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createdTime=Fri Jan 19 08:51:52 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279970, encodeId=05f82e99701a, content=学习了新知识, beContent=null, objectType=article, channel=null, level=null, likeNumber=70, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201006/4db877c2887649beb09cb5effd0b38c7/916f66edd48a4e77b20ebc3e14b6e45c.jpg, createdBy=141e1980133, createdName=Y—xianghai, createdTime=Fri Jan 19 08:08:17 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279961, encodeId=9c052e9961f2, content=长见识了.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Fri Jan 19 07:42:35 CST 2018, time=2018-01-19, status=1, ipAttribution=)]
2018-01-19 天地飞扬

长见识了.谢谢分享!

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