?９６４?
ＴｄＰ发作的心电图预警参数
某腾心电图改变可以作为预警信号提示ＴｄＰ的发生。应注意这些典型的心电图预警表现往往呈动态变化。同一患者不同时间的心电图变化不同，尤其是Ｔ－ｕ波的畸形，往往随着心动周期的变化而变化，需要动态监测才能发现。
Ｉ．ＱＴｃ间期延长：在先天性ＬＱｌｓ患者中，ＱＴｃ每增加１０咖使ＴｄＰ的发生危险呈５％一７％指数性的增加旧彤１。啦＞５００Ｉｌｌｓ者ＴｄＰ的发生危险增加２～３倍。药物诱发帆＞５００ｒｎ￥时，ＴｄＰ的危险也同样增加¨…。但目前没有一个明确的可诱发ＴｄＰ的ＱＴｃ阈值。尽管对于先天性ＬＱＴｓ的研究显示，发生晕厥和猝死的危险与ＱＴ间期长短有直接的关系惮Ｊ，但只靠监测ＱＴ／ＱＴｃ间期来预测ＴｄＰ是不够的惭Ｊ，还需注意下述其他心电图改变。
２．Ｔ－Ｕ波畸形和间歇依赖现象：Ｔ?ｕ波形态异常通常包括Ｔ波低平、双向、ｕ波加大并与Ｔ波融合、Ｔ波降支逐渐下降并时限延长，使Ｔ波的末端难以辨认。一些报道指出，Ｔ波波峰至Ｔ波终末（Ｔｐ—Ｔｅ）时程代表着整个心脏最早和最迟复极完毕的时间问期。Ｔｐ－Ｔｅ延长是心肌复极离散度增加的表现，容易发生ＴｄＰ惭。Ｊ。
药物诱发的ＬＱ，ｒｓ患者，在正常窦性心律时可能没有不良效应。但在ＴｃｌＰ开始前可出现典型的短一长－短ＲＲ问期（间歇依赖现象），即长间歇后心搏的ＱＴ间期明显延长，Ｔ．ｕ波形态也明显异常。电生理研究表明，间歇后心搏的异常Ｔ—Ｕ波的振幅与间歇的长度和间歇前的心率有关嘲Ｊ。出现长间歇的原因最可能是早搏的代偿问期，暂时性的窦性停搏或房室传导阻滞，但也可能是变化十分微小的窦性心律不齐。这种不同心搏之间的ＱＴ间期不稳定性与心律失常发生的机制有关旧Ｊ。由此而产生的显著ＱＴ问期延长和Ｔ．ｕ波形态异常可以触发窜早，从而再次产生长间歇，直至ＴｄＰ的发生。因此心脏间歇后出现显著的ＱＴ间期延长和Ｔ．Ｕ波形态异常应当认为是发生ＴｄＰ的强预警信号。这种间歇依赖现象虽可在１２导联心电图中记录到，但更常见于监测心电图（图Ｉ）。应注意在监测心电图中寻找这种现象，特别要注意寻找早搏前是否有异常的Ｔ－Ｕ波，往往很有帮助。
３．Ｔ波电交替：除了凹间期的延长和Ｔ．Ｕ波形态异常，ＴｄＰ发生的另外一个少见但不良的前兆心电图表现是宏观Ｔ波电交替ｍ１（图２）。
ＴｄＰ的心电图特征
ＴｄＰ．的心电图特征见图３。
１．ＱＲＳ波群：Ｔｒｉｐ的典型特征是ＱＲｓ波群的形态及极
向围绕一假想基线或等电位线呈周期性变化，ＱＲｓ波的主波可以从正向波为主逐渐转变为以负向波为主，中间还可以有过渡ＱＲＳ波，呈一种周期性的波形和振幅变化。在典型者，其振幅可类似正弦曲线。这种周期性变化常发生在５一１５个心动周期中。但这种特征性的图形并不是在所有导联中均可见到。ＴｃｌＰ的心率一般为１６０—２４０次／ｍｉｎ，慢于心室颤动（室颤）的心率。
２．短－长－短周期：药物引发的ＴｄＰ，通常先出现短一长一短ＲＲ间期变化，即在前述的间歇依赖现象的基础上，反复出现室早和新的间歇，最终诱发ＴｄＰ【７１Ｊ。造成１．甘Ｊ歇的早搏一般落在前一个窦性心搏的Ｔ波顶峰附近，其联律问期并不很短。但是由于存在基础ＱＴ间期显著延长，使得触发ＴｄＰ的早搏事实上表现为Ｒ—∞－Ｔ。这与触发特发性室颤的更短的Ｒ．ｏｎ－Ｔ的窜早不同。
３．温醒现象：ＴｄＰ发作时会表现出一种温醒现象，即室速发作初始的几个心搏频率较其后的心搏稍慢。
４．冷却现象：与室颧不同，ＴｄＰ的发作即使不进行除颤通常也会自行终止，具有自限性。室速终止前的２—３个心动周期的窜速频率常有先减慢后终止的规律，呈现冷却现象。但有时ＴｄＰ也会进展为室颤导致猝死，也有诱发持续单形性室速的病例报道。
ＴｄＰ和多形性室速的鉴别
不伴ＱＴ间期延长的多形性室速与ＴｄＰ的鉴别十分重要。二者的发生机制、临床表现和处理完全不同。如果误诊，患者无法得到ｊＦ确的治疗，将造成严重后果。
不伴ＱＴ延长的多形性事速的ＱＲｓ形态有时与ＴｄＰ难以区别，也可能具备上述发作的所谓“尖端扭转”特征。因此仅注意室速发作时的图形特点会出现误诊。重要的是，在心电图中没有ＱＴ间期延长，发作一般不具有短一长－短的间歇依赖现象，往往是一个早搏直接诱发室速（图４）。多形性室速大多有疾病诱因，如急性心肌缺血，心衰，缺氧等。患者可有交感神经兴奋的征象如窦性心动过速。在纠正病因并适当给予抗心律失常药后，这种室速可以消失。
在二者的鉴别中要强调ＱＴ间期延长的重要性，重视间歇依赖现象的识别，注意识别ＱＴ间期延长的相关因素。
ＱＴ／ＱＴｃ问期的监测方法
一、Ｑ乳的计算方法
通常用Ｂａｚｅｔｔ’ｓ公式（帆＝叫，／－ｆｆｆｆ）计算校正的ＱＴ间期，即测得的未校正的ＱＴ间期除以ＲＲ间期的平方根（以ｓ为单位）。
圈ｌ监测导联心电图显示短．长－短的ＲＲ问期（间歇依赖现象）及Ｔ波异常（箭头所指）继而出现尖端扭转型室性心动过速
生堡：垒查置瘟盘壶垫！Ｑ生！！旦箜！！鲞筮！！麴垦！垫！ｇ！堕ｉ！！：塑型！坐！垫！Ｑ：！尘：！！№：！！
图２体表１２导联心电图显示ＱＴ间期延长伴宏观Ｔ波电交替尖端扭转型室性心动过速的心电图特征
圉３体表肢导联心电图显示继发于三度房室传导阻滞的尖端扭转型室性心动过速
现在越来越认识到，心率较快尤其是在８５次／ｒａｉｎ以上时，Ｂａｚｅｔｔ校ｉＥ会得出过长的ＱＴｃ值，这在住院患者中很常见。
现已有其他替代的帆计算方法，包括线性和非线性的校
正，可在心率较快时得到更准确的结果。比如Ｆｒｉｄｅｒｉｃｉａ公式（将测得的ＱＴ间期除以ＲＲ长度的立方根），将来可能会
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在评价住院患者的心电监测结果时发挥更霞要的作用。
二、叽的监测方法
临床上多年来一直通过定期记录标准１２导联心电图来测量ＱＴ间期并计算ＱＴｃ。在使用床旁心脏监护仪的患者中，可以描记心电条囹，使用分规手工测ｆｉｌ：ＱＴ问期。一些监测仪提供了电脑辅助的电子分规，用于测量ＱＴ和ＲＲ间期。近期，已有完伞自动化的监测系统进行实时ＱＴ／ＱＴｃ监测¨２１。目前还没有研究证实哪一种是对住院患者ＱＴ／Ｑ＇ｒｃ监测的最好方法。
１．手工测量法：ＱＴ间期的测量是从ＱＲＳ波的起始处到Ｔ波的终末。如果患者新出现ｒ宽ＱＲＳ波（如新出现束支传导阿Ｉ滞），总ＱＴ问期会延长。但这种ＱＴ问期延长不庇被
认为是获得性ＬＱ＇ｒＳ和ＴｄＰ的预兆¨“。如果出现了束支传导艮ｉ滞，可用减去阻滞前后ＱＲＳ宽度差的方法来对ＱＴ间期进行调整。还可以改为测量Ｊ１＇间期，即从ＱＲＳ波的末端到
Ｔ波的末端，从而在测量中去除了ＱＲＳ波变化的因素。要注意对间一例患者在监测期间应始终使用相同的方法。
ＱＲＳ波的起始通常很明显，但Ｔ波的末端却不容易辨认，尤其是在Ｔ波的幅度较低或存在药物诱导的Ｔ．ｕ变形等情况。手工测量ＱＴ间期应在１２导联心电图中选择．Ｉ＇波波
圈４监测导联心电图显示多形性室性心动过速，其发作时心电图图形变化与尖端扭转型室性心动过速无明显差别，但不伴
ｑｒ间期延长，早搏直接诱发
获得性长QT间期综合征的防治建议
作者：中华医学会心血管病学分会心律失常学组， 中华心血管病杂志编辑委员会， 中国心脏起搏与心电生理杂志编辑委员会， Arrhythmic Working Group of Chinese Society of Car，
Editorial Board of Chinese Journal of Cardiology， Editorial Board of Chinese
Journal of Cardiac Paci
作者单位：
刊名：
中华心血管病杂志
英文刊名：CHINESE JOURNAL OF CARDIOLOGY
年，卷(期)：2010，38(11)
被引用次数：0次
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