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病例分享：宽QRS波心动过速的鉴别诊断

2018-05-20 江苏省人民医院 卢妙 许迪 黄元铸 中国医学论坛报今日循环

宽QRS波心动过速鉴别诊断
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1例76岁男性患者，因胸痛、心悸20分钟至急诊室就诊。

1例76岁男性患者，因胸痛、心悸20分钟至急诊室就诊。



心电图诊断：1. 室性心动过速；2. 心率170次/分。

评述

1. 本心电图表现为宽QRS波心动过速。Brugada四步法是从体表鉴别诊断宽QRS波心动过速最常用的方法，具体步骤见下表。 




表中第四步V1、V2和V6导联符合室性心动过速（室速）图形是指：① QRS波呈右束支传导阻滞图形时，V1和（或）V2导联呈R、qR或Rs形，而V6呈QS形或R/S＜1.0；② QRS波呈左束支传导阻滞图形时，V1和（或）V2导联 r波宽度＞30 ms，或R-S间期＞60 ms，而V6导联呈QR或QS形波。

2. 本心电图QRS波呈完全性右束支传导阻滞图形，V1导联呈R形波，V6导联呈rS形，R/S＜1.0，故符合室速图形。

3. 室速定位：首先，本例室速呈完全性右束支传导阻滞波形提示异位激动为左室来源；其次，下壁导联呈rS形，侧壁导联呈R形波，提示室速来源于左后间隔。

4. 该患者虽接受了药物治疗，但仍反复发作室速，遂行射频消融治疗，术中电生理检查证实为后乳头肌来源室速，消融手术后室速未再复发。

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    2018-06-14 121757d6m64(暂无昵称)

    学习下

    0

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    2018-05-25 yfjms

    学习

    0

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    2018-05-22 fengyi814

    #心动过速#

    0

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    2018-05-22 Homburg

    #鉴别诊断#

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=324127, encodeId=c2dd32412ef3, content=学习下, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/05/21/3ca7e45a5a3a70cdf0a44fb6301db4ff.jpg, createdBy=aa512256377, createdName=121757d6m64(暂无昵称), createdTime=Thu Jun 14 13:39:53 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=318401, encodeId=ae92318401fd, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Fri May 25 09:14:42 CST 2018, time=2018-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1471117, encodeId=d12714e111784, content=<a href='/topic/show?id=f06c5090466' target=_blank style='color:#2F92EE;'>#心动过速#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=50904, encryptionId=f06c5090466, topicName=心动过速)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=35817104001, createdName=fengyi814, createdTime=Tue May 22 08:55:00 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1506930, encodeId=4417150693028, content=<a href='/topic/show?id=a66b9624e0c' target=_blank style='color:#2F92EE;'>#鉴别诊断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96247, encryptionId=a66b9624e0c, topicName=鉴别诊断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=77179846395, createdName=Homburg, createdTime=Tue May 22 08:55:00 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317389, encodeId=628431e38964, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Tue May 22 06:39:23 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317238, encodeId=6a4431e23856, content=值得学习.好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKibA62IFMeUJEmSyIe8DvYFeERuOsfrRd8iano7nENqQU1dRR3tqeQOUL3eqgYgEZRT2t2iaEsib0JEw/132, createdBy=66771693911, createdName=易水河, createdTime=Mon May 21 14:48:05 CST 2018, time=2018-05-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=316977, encodeId=0a543169e7fe, content=好知识.值得借鉴!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=59321624668, createdName=zb1235672, createdTime=Sun May 20 18:51:59 CST 2018, time=2018-05-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=316971, encodeId=43983169e1f2, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Sun May 20 18:45:01 CST 2018, time=2018-05-20, status=1, ipAttribution=)]
    2018-05-22 yfjms

    学习

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=324127, encodeId=c2dd32412ef3, content=学习下, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/05/21/3ca7e45a5a3a70cdf0a44fb6301db4ff.jpg, createdBy=aa512256377, createdName=121757d6m64(暂无昵称), createdTime=Thu Jun 14 13:39:53 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=318401, encodeId=ae92318401fd, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Fri May 25 09:14:42 CST 2018, time=2018-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1471117, encodeId=d12714e111784, content=<a href='/topic/show?id=f06c5090466' target=_blank style='color:#2F92EE;'>#心动过速#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=50904, encryptionId=f06c5090466, topicName=心动过速)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=35817104001, createdName=fengyi814, createdTime=Tue May 22 08:55:00 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1506930, encodeId=4417150693028, content=<a href='/topic/show?id=a66b9624e0c' target=_blank style='color:#2F92EE;'>#鉴别诊断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96247, encryptionId=a66b9624e0c, topicName=鉴别诊断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=77179846395, createdName=Homburg, createdTime=Tue May 22 08:55:00 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317389, encodeId=628431e38964, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Tue May 22 06:39:23 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317238, encodeId=6a4431e23856, content=值得学习.好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKibA62IFMeUJEmSyIe8DvYFeERuOsfrRd8iano7nENqQU1dRR3tqeQOUL3eqgYgEZRT2t2iaEsib0JEw/132, createdBy=66771693911, createdName=易水河, createdTime=Mon May 21 14:48:05 CST 2018, time=2018-05-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=316977, encodeId=0a543169e7fe, content=好知识.值得借鉴!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=59321624668, createdName=zb1235672, createdTime=Sun May 20 18:51:59 CST 2018, time=2018-05-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=316971, encodeId=43983169e1f2, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Sun May 20 18:45:01 CST 2018, time=2018-05-20, status=1, ipAttribution=)]
    2018-05-21 易水河

    值得学习.好好学习

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=324127, encodeId=c2dd32412ef3, content=学习下, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/05/21/3ca7e45a5a3a70cdf0a44fb6301db4ff.jpg, createdBy=aa512256377, createdName=121757d6m64(暂无昵称), createdTime=Thu Jun 14 13:39:53 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=318401, encodeId=ae92318401fd, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Fri May 25 09:14:42 CST 2018, time=2018-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1471117, encodeId=d12714e111784, content=<a href='/topic/show?id=f06c5090466' target=_blank style='color:#2F92EE;'>#心动过速#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=50904, encryptionId=f06c5090466, topicName=心动过速)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=35817104001, createdName=fengyi814, createdTime=Tue May 22 08:55:00 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1506930, encodeId=4417150693028, content=<a href='/topic/show?id=a66b9624e0c' target=_blank style='color:#2F92EE;'>#鉴别诊断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96247, encryptionId=a66b9624e0c, topicName=鉴别诊断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=77179846395, createdName=Homburg, createdTime=Tue May 22 08:55:00 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317389, encodeId=628431e38964, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Tue May 22 06:39:23 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317238, encodeId=6a4431e23856, content=值得学习.好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKibA62IFMeUJEmSyIe8DvYFeERuOsfrRd8iano7nENqQU1dRR3tqeQOUL3eqgYgEZRT2t2iaEsib0JEw/132, createdBy=66771693911, createdName=易水河, createdTime=Mon May 21 14:48:05 CST 2018, time=2018-05-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=316977, encodeId=0a543169e7fe, content=好知识.值得借鉴!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=59321624668, createdName=zb1235672, createdTime=Sun May 20 18:51:59 CST 2018, time=2018-05-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=316971, encodeId=43983169e1f2, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Sun May 20 18:45:01 CST 2018, time=2018-05-20, status=1, ipAttribution=)]
    2018-05-20 zb1235672

    好知识.值得借鉴!

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=324127, encodeId=c2dd32412ef3, content=学习下, beContent=null, objectType=article, channel=null, level=null, likeNumber=51, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/05/21/3ca7e45a5a3a70cdf0a44fb6301db4ff.jpg, createdBy=aa512256377, createdName=121757d6m64(暂无昵称), createdTime=Thu Jun 14 13:39:53 CST 2018, time=2018-06-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=318401, encodeId=ae92318401fd, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Fri May 25 09:14:42 CST 2018, time=2018-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1471117, encodeId=d12714e111784, content=<a href='/topic/show?id=f06c5090466' target=_blank style='color:#2F92EE;'>#心动过速#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=50904, encryptionId=f06c5090466, topicName=心动过速)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=35817104001, createdName=fengyi814, createdTime=Tue May 22 08:55:00 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1506930, encodeId=4417150693028, content=<a href='/topic/show?id=a66b9624e0c' target=_blank style='color:#2F92EE;'>#鉴别诊断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=96247, encryptionId=a66b9624e0c, topicName=鉴别诊断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=77179846395, createdName=Homburg, createdTime=Tue May 22 08:55:00 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317389, encodeId=628431e38964, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3da1990174, createdName=yfjms, createdTime=Tue May 22 06:39:23 CST 2018, time=2018-05-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=317238, encodeId=6a4431e23856, content=值得学习.好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKibA62IFMeUJEmSyIe8DvYFeERuOsfrRd8iano7nENqQU1dRR3tqeQOUL3eqgYgEZRT2t2iaEsib0JEw/132, createdBy=66771693911, createdName=易水河, createdTime=Mon May 21 14:48:05 CST 2018, time=2018-05-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=316977, encodeId=0a543169e7fe, content=好知识.值得借鉴!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=59321624668, createdName=zb1235672, createdTime=Sun May 20 18:51:59 CST 2018, time=2018-05-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=316971, encodeId=43983169e1f2, content=一起学习学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/TDiaAWyicHgedzX3wKo3qcxudVJib7AfibfvNeufHRF2jG3Bw8MmZyWjIhtBV1mpJI7Sy9n7RcBKK5t3CuOKuOFxkg/0, createdBy=dd702206933, createdName=wzb521zf, createdTime=Sun May 20 18:45:01 CST 2018, time=2018-05-20, status=1, ipAttribution=)]
    2018-05-20 wzb521zf

    一起学习学习

    0