心电图以及心肌梗死的问题

心电图显示心肌梗死可能,要怎么才能确认是不是~

做心脏超声和查心肌酶可以确定

中医超级宝典11内科学02循环系统疾病13心肌梗死：诊断方法，临床表现，实验室检查及心电图的特征

下壁心肌梗死是毫无疑问的，
但是，感觉后壁也可能有问题，
不知道医院为什么没有加做后壁导联的心电图（V7， V8，V9）。
如果医院没有做，
说明当时接诊的医生似乎并非专业。

为什么说是下壁心肌梗死呢？
因为
Ⅱ Ⅲ AVF导联ST段明显太高（就是高尖的尖尖后面的部分）
他表示的就是心脏的下壁，
所以说下壁梗死是确定的，

为什么说后壁也有问题呢？
因为V2导联R波稍高，ST段压低，
正常情况下是不应该出现的，
这种情况高度提示后壁梗死，
并且，下壁梗死很容易合并后壁梗死，
这在心内科医生是个常识性的问题。

治疗？
不知道楼主是要知道什么？
如果不是学医的，
那么，可能我说得清楚，您不一定看得懂，
就如上面的那些，
您看懂了吗？
我已经尽量最大的努力试图使您看懂。

如果心肌梗死6小时内，
静脉溶栓是必要的，
尿激酶150万单位半小时内静脉滴完，
并且，
越早越好，
在有条件的医院，
可以考虑介入治疗，（俗称支架）
但是，必须在有条件的实力较强的医院。

还有，
肠溶阿司匹林，波利维，－－抗血小板聚集，
他汀类调脂药物－－稳定斑块，降脂
硝酸甘油类药物－－扩张冠状动脉，
低分子肝素－－抗凝，
这些都是必要的。

其余的要根据情况来看。
譬如，血压高，要降压药。

护理，
近几日绝对卧床，
大小便要在床上，
低盐低脂饮食，
密切监护心脏，血压，

祝早日康复，
期待您的高分，呵呵。

再有疑问可以留言。

General Treatment

Monitoring, O2
Bed rest initially, with early ambulation
Low-salt, low-fat diet
Stool softeners, anxiolytics as needed
Drugs

Aspirin Some Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
, clopidogrel Some Trade Names
PLAVIX
Click for Drug Monograph
, or both
β-Blocker
Glycoprotein IIb/IIIa inhibitor for patients undergoing PCI and for those at high risk (eg, with markedly elevated cardiac markers, TIMI risk score ≥ 4, persistent symptoms)
A heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
(unfractionated or low mol wt heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
)
IV nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
(unless low-risk, uncomplicated MI)
Fibrinolytics for select patients with STEMI when timely PCI unavailable
ACE inhibitor (as early as possible) and statin

Antiplatelet and antithrombotic drugs, which stop clots from forming, are used routinely. Anti-ischemic drugs (eg, β-blockers, IV nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
) are frequently added, particularly when chest pain or hypertension is present (see Table 3: Coronary Artery Disease: Drugs for Coronary Artery Disease ). Fibrinolytics should be used if not contraindicated for STEMI if primary PCI is not immediately available but worsen outcome for unstable angina and NSTEMI.

Chest pain can be treated with morphine Some Trade Names
DURAMORPH
MS CONTIN
MSIR
ROXANOL
Click for Drug Monograph
or nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
. Morphine Some Trade Names
DURAMORPH
MS CONTIN
MSIR
ROXANOL
Click for Drug Monograph
2 to 4 mg IV, repeated q 15 min as needed, is highly effective but can depress respiration, can reduce myocardial contractility, and is a potent venous vasodilator. Hypotension and bradycardia secondary to morphine Some Trade Names
DURAMORPH
MS CONTIN
MSIR
ROXANOL
Click for Drug Monograph
can usually be overcome by prompt elevation of the lower extremities. Nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
is initially given sublingually, followed by continuous IV drip if needed.

BP is normal or slightly elevated in most patients on arrival at the emergency department; BP gradually falls over the next several hours. Continued hypertension requires treatment with antihypertensives, preferably IV nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
, to lower BP and reduce cardiac workload. Severe hypotension or other signs of shock are ominous and must be treated aggressively with IV fluids and sometimes vasopressors (see Shock and Fluid Resuscitation: Prognosis and Treatment).

Antiplatelet drugs: Aspirin Some Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
, clopidogrel Some Trade Names
PLAVIX
Click for Drug Monograph
, ticlopidine Some Trade Names
TICLID
Click for Drug Monograph
, and glycoprotein (GP) IIb/IIIa inhibitors are examples. All patients are given aspirin Some Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
160 to 325 mg (not enteric-coated), if not contraindicated, at presentation and 81 mg once/day indefinitely thereafter. Chewing the first dose before swallowing quickens absorption. Aspirin Some Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
reduces short- and long-term mortality risk. If aspirin Some Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
cannot be taken, clopidogrel Some Trade Names
PLAVIX
Click for Drug Monograph
75 mg once/day or ticlopidine Some Trade Names
TICLID
Click for Drug Monograph
250 mg bid may be used. Clopidogrel Some Trade Names
PLAVIX
Click for Drug Monograph
has largely replaced ticlopidine Some Trade Names
TICLID
Click for Drug Monograph
for routine use because neutropenia is a risk with ticlopidine Some Trade Names
TICLID
Click for Drug Monograph
and WBC must be monitored regularly. Patients with unstable angina or NSTEMI in whom intervention is not possible or recommended are given both aspirin Some Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
and clopidogrel Some Trade Names
PLAVIX
Click for Drug Monograph
for at least 1 mo. The optimal duration of double antiplatelet therapy for these patients is the subject of ongoing investigation.

In patients undergoing PCI, a clopidogrel Some Trade Names
PLAVIX
Click for Drug Monograph
loading dose (300 to 600 mg po once) improves outcomes, particularly when administered 24 h in advance. However, delaying PCI for 24 h is not appropriate for many patients. Further, such a loading dose increases risk of perioperative bleeding in patients who require coronary artery bypass grafting (CABG) because their coronary anatomy proves unfavorable for PCI. Thus, many clinicians administer a clopidogrel Some Trade Names
PLAVIX
Click for Drug Monograph
loading dose only in the catheterization laboratory once coronary anatomy and lesions have been proven to be amenable to PCI.

For patients receiving a stent for revascularization, aspirin Some Trade Names
BUFFERIN
ECOTRIN
GENACOTE
Click for Drug Monograph
is continued indefinitely, and clopidogrel Some Trade Names
PLAVIX
Click for Drug Monograph
should be used for at least 1 mo in patients with a bare-metal stent. Patients with a drug-eluting stent have a prolonged risk of thrombosis and may benefit from 12 mo of clopidogrel Some Trade Names
PLAVIX
Click for Drug Monograph
treatment, although the recommended duration is still unclear.

GP IIb/IIIa inhibitors ( abciximab Some Trade Names
REOPRO
Click for Drug Monograph
, tirofiban Some Trade Names
AGGRASTAT
Click for Drug Monograph
, eptifibatide Some Trade Names
INTEGRILIN
Click for Drug Monograph
) are potent antiplatelet drugs that must be given IV. Patients undergoing PCI should receive a GP IIb/IIIa inhibitor; results appear to be better if the drug is initiated at least 6 h before PCI and continued for 18 to 24 h thereafter. If PCI is not being done, a GP IIb/IIIa inhibitor is given to all high-risk patients (eg, those with markedly elevated cardiac markers, a TIMI risk score ≥ 4, or persistent symptoms despite adequate drug therapy). The GP IIb/IIIa inhibitor is continued for 24 to 36 h, and angiography is done before the infusion period is over. Routine use of GP IIb/IIIa inhibitors with fibrinolytics is not recommended at this time. Although abciximab Some Trade Names
REOPRO
Click for Drug Monograph
is the drug recommended in most published guidelines, eptifibatide Some Trade Names
INTEGRILIN
Click for Drug Monograph
is cheaper and is thought to have comparable efficacy and is thus often used. Studies continue to investigate the comparative efficacy of the different GP IIb/IIIa inhibitors.

Anticoagulant drugs: Either a low mol wt heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
(LMWH) or unfractionated heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
is given routinely to patients with ACS unless contraindicated (eg, by active bleeding or planned use of streptokinase Some Trade Names
STREPTASE

or anistreplase). Choice of agent is somewhat involved.

Unfractionated heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
is more complicated to use because it requires frequent (q 6 h) dosing adjustments to achieve an activated PTT (aPTT) 1.5 to 2 times the control value. In those undergoing angiography, further dosing adjustment is performed to achieve an activated clotting time (ACT) of 200 to 250 sec if the patient is treated with a GP IIb/IIIa inhibitor and 250 to 300 sec if a GP IIb/IIIa inhibitor is not being given. However, the effects of unfractionated heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
are shorter and can be reversed (with prompt discontinuation of heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
infusion and with administration of protamine sulfate Some Trade Names
No US trade name
Click for Drug Monograph
) if bleeding develops following catheterization.

The LMWHs have better bioavailability, are given by simple weight-based dose without monitoring aPTT and dose titration, and have lower risk of heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
-induced thrombocytopenia. They also may produce an incremental benefit in outcomes relative to unfractionated in patients with ACS. Of the LMWHs, enoxaparin Some Trade Names
LOVENOX
Click for Drug Monograph
appears to be superior to dalteparin Some Trade Names
FRAGMIN
Click for Drug Monograph
or nadroparin Some Trade Names
No US trade name
Click for Drug Monograph
. However, enoxaparin Some Trade Names
LOVENOX
Click for Drug Monograph
may pose a higher bleeding risk in patients with STEMI who are > 75, and its effects are not completely reversible with protamine.

Thus, taking all into account, many published guidelines recommend LMWH (eg, enoxaparin Some Trade Names
LOVENOX
Click for Drug Monograph
) over unfractionated heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
in patients with unstable angina or NSTEMI and in patients < 75 with STEMI who are not undergoing PCI. By contrast, unfractionated heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
is recommended when emergency PCI is performed (eg, patients with acute STEMI who proceed to the catheterization laboratory), when CABG is indicated within the next 24 h, and in patients at high risk for bleeding complications (eg, history of GI bleeding within the last 6 mo) or with creatinine clearance < 30 mL/min. Ongoing studies should help clarify the choice between LMWH and unfractionated heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
.

For those undergoing PCI, post-procedure heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
is no longer recommended unless patients are at high risk of thromboembolic events (eg, those with large anterior MI, known LV thrombus, atrial fibrillation), as post-procedure ischemic events have decreased with the use of stents and antiplatelet drugs. For those not undergoing PCI, heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
is continued for 48 h (or longer if symptoms persist).

The difficulties with the heparins (including bleeding complications, the possibility of heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
-induced thrombocytopenia, and, with unfractionated heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
, the need for dosing adjustments) have led to the search for better anticoagulants. The direct thrombin inhibitors, bivalirudin Some Trade Names
ANGIOMAX
Click for Drug Monograph
and argatroban Some Trade Names
No US trade name
Click for Drug Monograph
, may have a lower incidence of major bleeding and improved outcomes, particularly in patients with renal insufficiency (hirudin, another direct thrombin inhibitor, appears to cause more bleeding than the other drugs). The factor Xa inhibitor, fondaparinux Some Trade Names
ARIXTRA
Click for Drug Monograph
, reduces mortality and reinfarction in patients with NSTEMI who undergo PCI without increasing bleeding but may result in worse outcomes than unfractionated heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
in patients with STEMI. Although routine use of these alternative anticoagulants is thus not currently recommended, they should be used in place of unfractionated heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
or LMWH in patients with a known or suspected history of heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
-induced thrombocytopenia.

Patients at high risk of systemic emboli also require long-term therapy with oral warfarin Some Trade Names
COUMADIN
Click for Drug Monograph
. Conversion to warfarin Some Trade Names
COUMADIN
Click for Drug Monograph
should begin 48 h after symptom resolution or PCI.

β-Blockers: These drugs are recommended unless contraindicated (eg, by bradycardia, heart block, hypotension, or asthma), especially for high-risk patients. β-Blockers reduce heart rate, arterial pressure, and contractility, thereby reducing cardiac workload and O2 demand. IV β-blockers given within the first few hours improve prognosis by reducing infarct size, recurrence rate, incidence of ventricular fibrillation, and mortality risk. Infarct size largely determines cardiac performance after recovery.

Heart rate and BP must be carefully monitored during treatment with β-blockers. Dosage is reduced if bradycardia or hypotension develops. Excessive adverse effects may be reversed by infusion of the β-adrenergic agonist isoproterenol Some Trade Names
ISUPREL
Click for Drug Monograph
1 to 5 μg/min.

Nitrates: A short-acting nitrate, nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
, is used to reduce cardiac workload in selected patients. Nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
dilates veins, arteries, and arterioles, reducing LV preload and afterload. As a result, myocardial O2 demand is reduced, lessening ischemia. IV nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
is recommended during the first 24 to 48 h for patients with heart failure, large anterior MI, persistent chest discomfort, or hypertension. BP can be reduced by 10 to 20 mm Hg but not to < 80 to 90 mm Hg systolic. Longer use may benefit patients with recurrent chest pain or persistent pulmonary congestion. In high-risk patients, nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
given in the first few hours reduces infarct size and short-term and possibly long-term mortality risk. Nitroglycerin Some Trade Names
NITRO-BID
NITRO-DUR
NITROL
NITROQUICK
Click for Drug Monograph
is not routinely given to low-risk patients with uncomplicated MI.

Fibrinolytics: Tenecteplase Some Trade Names
TNKASE
Click for Drug Monograph
(TNK), alteplase Some Trade Names
ACTIVASE
Click for Drug Monograph
(rTPA), reteplase Some Trade Names
RETAVASE
Click for Drug Monograph
(rPA), streptokinase Some Trade Names
STREPTASE

, and anistreplase (anisoylated plasminogen activator complex—APSAC), all given IV, are plasminogen activators. They convert single chain plasminogen to double chain plasminogen, which has fibrinolytic activity. They have different characteristics and dosing regimens (see Table 7: Coronary Artery Disease: IV Fibrinolytic Drugs Available in the US) and are appropriate only for selected patients with STEMI (see below).

Tenecteplase Some Trade Names
TNKASE
Click for Drug Monograph
and reteplase Some Trade Names
RETAVASE
Click for Drug Monograph
are recommended most often because of their simplicity of administration; tenecteplase Some Trade Names
TNKASE
Click for Drug Monograph
is given as a single bolus over 5 sec and reteplase Some Trade Names
RETAVASE
Click for Drug Monograph
as a double bolus 30 min apart. Administration time and drug errors are reduced compared with other fibrinolytics. Tenecteplase Some Trade Names
TNKASE
Click for Drug Monograph
, like alteplase Some Trade Names
ACTIVASE
Click for Drug Monograph
, has an intermediate risk of intracranial hemorrhage, has a higher rate of recanalization than other fibrinolytics, and is expensive. Reteplase Some Trade Names
RETAVASE
Click for Drug Monograph
has the highest risk of intracranial hemorrhage and a recanalization rate similar to that of tenecteplase Some Trade Names
TNKASE
Click for Drug Monograph
, and it is expensive.

Streptokinase Some Trade Names
STREPTASE

may induce allergic reactions, especially if it has been used previously, and must be given by infusion over 30 to 60 min; however, it has a low incidence of intracerebral hemorrhage and is relatively inexpensive. Anistreplase, related to streptokinase Some Trade Names
STREPTASE

, is similarly allergenic and slightly more expensive but can be given as a single bolus. Neither requires concomitant heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
. For both, recanalization rate is lower than that with other plasminogen activators. Because of the possibility of allergic reaction, patients who previously received streptokinase Some Trade Names
STREPTASE

or anistreplase are not given that drug.

Alteplase Some Trade Names
ACTIVASE
Click for Drug Monograph
is given in an accelerated or front-loaded dosage over 90 min. Alteplase Some Trade Names
ACTIVASE
Click for Drug Monograph
with concomitant IV heparin Some Trade Names
HEPFLUSH-10
Click for Drug Monograph
improves patency, is nonallergenic, has a higher recanalization rate than other fibrinolytics, and is expensive.

Table 7

IV Fibrinolytic Drugs Available in the US

This table is presented as a PDF and requires the free Adobe PDF reader. Get Adobe Reader

Other drugs: ACE inhibitors appear to reduce mortality risk in MI patients, especially in those with anterior infarction, heart failure, or tachycardia. The greatest benefit occurs in the highest-risk patients early during convalescence. ACE inhibitors are given > 24 h after thrombolysis stabilization and, because of continued beneficial effect, may be prescribed long-term.

Angiotensin II receptor blockers may be an effective alternative for patients who cannot tolerate ACE inhibitors (eg, because of cough). Currently, they are not first-line treatment after MI. Contraindications include hypotension, renal failure, bilateral renal artery stenosis, and known allergy.

HMG-CoA reductase inhibitors (statins) have long been used for prevention of CAD and ACS, but there is now increasing evidence that they also have short-term benefits, such as stabilizing plaque, reversing endothelial dysfunction, decreasing thrombogenicity, and reducing inflammation. Thus, all patients without contraindications to therapy should receive a statin as early as possible following ACS. LDL levels of 70 to 80 mg/dL (1.81 to 2.07 mmol/L) are the recommended ultimate target.

诊断心肌梗死，心电图一定要有梗死图形，T波倒置，S--T段抬高，Q波加深加宽。心肌梗死临床可分
早期，数分钟至数小时出现巨大高耸T波，S--T段称谢上型抬高，不出现异常Q波。
急性期，6---12小时出现，常需48---72小时才出现急性期心电图，ST段抬高工背向上，T波倒置，病理性Q波。
亚急性期，梗死后数周至数月，图形逐渐恢复。但Q波不改变。
陈旧期，大部分图形回复，只剩病理性Q波。
这种病早发现早治疗预后良好，提供给的心电图有S--T 段抬高但不太清楚不太典型可能和时间有关系。治疗应在医师指导下用药。祝早日康复。

According to the case, the nursing goals for Johnson is to decrease chest pain, limit infarct size and relieve myocardial ischemia. The goals achievement indicators are chest pain reduce to 2/10 or lower, return of the ST segment to baseline and early peaking of CK levels. The measures of those goal achievements and rationales will be discussed following.

Currently, Mr. Johnson’s V-signs are Temp: 37.1(N: 36.5-37.5), HR: 90(N:80-100), RR: 20(N:14-20), SaO2: 96% in RA (N:95-100%), all of above still within the normal ranges. His BP at 160/100 mmHg, above the 90-120/60-90mmHg normal range. Assess and document Vital Signs (RR,HR,SaO2, T) on the Obs chart every 15mins continuously. Because decreased cardiac output activates compensatory mechanisms that may cause tachycardia and vasoconstriction. SaO2 indicates the gas exchange and the effectiveness of O2 administration.

Mr. Johnson’s left sided chest pain at 9/10, and has been constant for 1hr. Monitor the pain, including the duration, level and site every 15min continuously, because chest pain occurs when O2 supply to the heart muscle does not meet the demand and it indicates the degree of myocardial ischemia. Attend Morphine 2.5 mg IVI as order for pain, because Morphine decreases the pain and anxiety effective. And it also reduces the cardiac work & O2 demand. IV is the most rapid route, the recommended dose for IV is 2-4mg. Nurses should monitor the RR Pre/Post morphine attended, because it side effect is depressing the respiration. Pain level also needs to be assessed to evaluate the effect of morphine.

Apply O2*6L via Hudson mask as order to supply O2 for the heart muscle cells, decreasing ischemia and pain. As a kind of simple face-masks, Hudson mask can provide 30-60% O2. Nurses need to alter to the risk of retention when flow rate < 6L for adults using H-mask.

Give other two medications as order. Aspirin 300mg should be given IMMEDIATELY. As antiplatelet agent, its side effect is bleeding, recommended dose at 160-325mg. Atenolol 50mg as B-blocker are used to decrease myocardial O2 demand by reducing HR, BP and contractility. HR needs to be check before and after this meds, to prevent bradycardia.

Apply other medical tests as the order: FBC, EUC, LFT and BSL are the routine tests for the admission to ensure Mr. Johnson does not have other problems. Cardiac markers including CK and CTn1. Mr. Johnson’s CK at 240u/L (N: 12-80u/L for Male), CTn1 at 0.9ng/L(N: <0.3g/L). Both two should exist in the myocardial cell, the elevations of contents in blood relate with the extent of myocardial damage. ECG needs to be monitored continuously. Mr. Johnson’s ECG is regular, currently show ST-segments elevation and T-wave inversion. They are the indicators of myocardial injury. Chest X-ray used to showed pulmonary conditions and the shape of the heart. Congestion/oedema of pulmonary or enlargement of the heart indicates heart failure.

急性下壁心肌梗死，最好的方法是做急诊冠状动脉介入手术。如果医院没有条件，90分钟内不能开通血管，那么发病才1个小时的急性心肌梗死溶栓也是可行的。如果都做不了，就用阿司匹林、氯吡格雷、低分子肝素，加对症处理，待病情稳定后转院做介入手术。

---

曲阜市13080631678： 心电图可以查出心梗吗 - 全科 - 复禾健康？
别德云南： 根据你的描述一般需要上医院正规治疗积极治疗,需要营养支持治疗,增加营养补充维生素微量元素,避免不良刺激. 身体是个整体系统,虽然这只是个小毛病,但是也需要综合的调理,均衡饮食,建议您日常生活中多多锻炼,提高身体素质,增强身体对疾病的抵抗力,这样不仅能够尽快的帮助身体恢复,也能从根源上减少患病概率,祝您健康.

曲阜市13080631678： 心肌梗死典型心电图表现? - ？
别德云南： 您好,心肌梗死典型心电图表现:1、深而宽的Q波;2、抬高的ST段;3、T波倒置.希望我的回答给您带来帮助,祝您健康快乐.