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3 Poor 4, L5, M5の5誘 R Wave Progression例 に お け る 陳 旧性 前 壁 梗 塞 の 鑑 別 点 に お け る電 位 時 間積 分 値 の 平 均 値 を梗 塞 群, 導 点 を 用 い た 判 別 式Z=- 非 梗 塞 群 の 各 々 で 求 め 平 均 電 位 図 を作 成 した G5-9.0 G2+6.0 H L M5+0.4 (単 位:mV)で, ま た, QRS開 Z 0な 始 よ り20msecの ら ば 梗 塞 群, Z<0な ら ば 非 梗 塞 群 と診 断 す る と, 均 値 よ りIsopotential sensitivity specificity 図 を作 成 し た.梗 塞 群,非 racy 93.9%, 93.3%で,い 92.6%, accu ず れ の 判 別 式 も極 め て 高 い分 別 能 を 示 し た(表2).前 壁 梗 塞 の 心 電 図 変 化 は, 主 と して 左 前 胸 部 の 誘 導 を 中 心 に 現 わ れ る こ と は よ く知 ら れ て い る.そ 点(E I列)の し た.左 用 い て,同 こ で,左 前 胸 部32誘 導 み を用 い た 場 合 の 診 断 能 を検 討 前 胸 部32誘 447 導 点 のQRST 様 の 方 法 でG4, area F1の2誘 を 比 較 す る と, QRST 時点 の電位 の平 (Q 20) mapの 梗 塞 群 の平 均 電 位 図 area mapで 導 点 を選 は,梗 塞 群 は 非 梗 塞 群 に 比 べ て 左 前 胸 部 に 陰 性 域 が 張 り出 し,極 大,極 小 の 位 置 が 左 下 方 に 偏 位 し た.し か し, QRS area map, で は 梗 塞 群,非 Isopotential (Q 20) map 梗 塞 群 の2群 間 に 大 き なパ ター ン の 差 は 見 られ な か っ た(図2).そ mapを 平均 電位 パ ター ン に 差 の 見 られ たQRST こで両群 に area mapを 用 択 し,こ れ か ら 導 か れ た 判 別 式Z=-4.2 G4+ い て,左 前 胸 部 に-20μVS以 2.4 F1+0.2を め るか 否 か で 前 壁 梗 塞 の有 無 を診 断 す る と,sensi sensitivity 用 い て2群 87.9%, 間 の 判 別 を 行 う と, specificity 85.2%と87誘 導 点 か ら求 め た も の に 比 べ て 診 断 率 は や や 劣 っ て い た.尚,こ こ で い うsensitivityは(true tive)/(true positive+false negative)/(true false し て 算 出 し た. 4. 平 均 電 位 図 の2群 QRST 図1 area map, negative+ area 87.9%, 誘導 85.2%, area mapの accuracy パ ター ンか らで もあ る程 度 鑑 別 が 可 能 で あ っ た. 標 準12誘 導 心 電 図 を用 い た 診 断 基 準 次 にmapか ら得 ら れ た こ れ らの 情 報 を参 考 準12誘 導 心 電 図 を用 い て両 群 の判 別 を試 み た. QRST mapで,各 specificity あ り, QRST に し て,標 間 の比較 QRS 86.7%で 5. negative), specificityは(true positive)と posi tivity 上 の 陰 性 部 分 を認 mapに area mapお よびQRS area お い て,判 別 関 数 を作 成 す る際 にG4の PRWP例 の梗 塞 群 と非 梗 塞群 で有 意差 の あっ た誘 導部 位 いず れ のmapで も左 前 胸部 誘 導 で梗 塞群 の 値 が有 意 に低 か った. A線 は右 中腋 窩線, I線 は左 中 腋窩 線, E線 は胸部 正 中線 を示 す.黒 丸は 標 準12 誘 導心 電 図 の胸 部 誘 導 点 を示 す.
4 448 井 点 が 最 も判 別 に 寄 与 す る と考 え られ た.そ 標 準12誘 導 心 電 図 の 胸 部 誘 導 の う ち,最 に近 いV4誘 の 異 常Q波(幅 比>15%)6)が 表2 図2 導 を用 い て 検 討 し た.即 0.04sec,深 存 在 す るか,ま 判 別 関数 を用 い たPRWP例 PRWP例 こで もG4 ちV4で さ 2mm, た はT波 原 Q/R 敬 子 つ ま り 陰 性T波 ま た は 二 相 性T波 場 合 を 前 壁 梗 塞 とす る と,診 90.9%, specificity 66.7%, が 存在 す る 断 率 はsensitivity accuracy 80.0%で あ っ た. の 変 化, の診 断率Z 0な らば梗 塞群, Z<0な の梗 塞 群(左 側)と 非梗塞 群(右 側)の 平均 値 の電 位 図QRST らば 非梗 塞群 と診 断 した. area map(上 段)で は,梗 塞 群 で左 前 胸 部 に陰 性域 が張 り出 し,極 大,極 小 の位 置 が左 下 方 に偏位 してい る.陰 影 の部 分 は 陽性 電位 領 域,+は 極 大,-は 極小.
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8 2) Yamada K, Toyama J, Wada M, Sugiyama S, Sugenoya J, Toyoshima H, Mizuno Y, Kobayashi T, Okajima M: Body surfase isopotential mapping in Wolff-Parkinson-White syndrome: noninvasive method to determine the localization of the accessory atrioventricular pathway. Am Heart J (1975) 90, ) Toyama S, Suzuki K, Koyama M, Yosino K, Fujimoto K: The body surface isopotential mapping of the QRS wave in myocardial infarction. A comparative Electrocardiol (1982) 15, study of scintigram with Tallium 201. J 7) Young E, Cohr PF, Gorlin R, Levine HD, Herman MV: Vectorcardiographic diagnosis and electrocardiographic correlation in left ventricular asynergy due to coronary artery disease I: Severe asynergy of the anterior and apical segments. Circulation (1975) 51, ) Zema MJ, Klibfdeld P: Electrocardiographic poor R wave progression I: Correlation with the Frank vectorcardiogram. J Electrocardiol (1979) 12, ) DePace NL, Colby J, Hakki A, Manno B, Horowitz LN, Iskandrian AS: Poor R wave progression in the precordial leads: Clinical implications for the diagnosis of myocaridal infarction. JACC (1983) 2,
9 New York. 13) Grant RP: The relationship of unipolar chest leads to the electrical field of the heart. Circulation (1950) 1, ) Zema MJ, Kligfield P: Electrocardiographdic poor R wave progression III: The Normal Variant. J Electrocardiol (1980) 13, ) Zema MJ. Collins M, Alonso DR, Kligfield P: Electrocardiographic poor R wave progression: Correlation with post mortem findings. Chest (1981) 79, ) Wilson FN: The determination and significance of the areas of the ventricular deflections of the electrocardiogram. Am Heart J (1934) 10, ) Zema MJ, Kligfield P: Electrocardiographic poor R wave progression II: Correlation with angio graphy. J Electrocardiol (1979) 12, ) Zema MJ, Kligfield P: ECG Poor R wave progression: Review and synthesis. Arch Intern Med (1982) 142,
10 Usefulness of body surface maps for discriminating old myocardial infarction in cases with ECG findings of poor R wave progression Keiko IHARA First Department of Internal Medicine, Okayama University Medical School, Okayama 700, Japan (Director: Prof. T. Tsuji) The clinical usefulness of the body surface maps (maps) to discriminate old anterior myocardial infarction (OAMI) in patients whose ECG showed poor R wave progression (PRWP) was examined. The maps of 60 patients with PRWP, including 33 cases of OAMI and 27 without myocardial infarction (non-mi) were recorded. The multivariate stepwise discriminant analysis elucidated that 5 leads (G4, C3, J5, B3, A5) of the QRST area map would contribute to the discrimination of OAMI from non-mi, and the the formula z=-6.0 ~G ~C3+9.1 ~J ~B3-9.0 ~A5-1.1 (unit: 0.1mVS), using these parameters two groups were separated with a sensitivity of 90.9% and a specificity of 96.3%. The discriminating performance using 5 leads (G4, H2, H4, L6, M5) of the QRS area map and 5 leads (G5, G2, H4, L5, M5) of the Q20 map gave a sensitivity of 90.9%, and 93.9%, and specificity of 96.3%, and 92.6%, respectively. Furthermore, the formula was applied to 26 new consecutive patients with PRWP for evaluating this formula. The indicies obtained from the QRST area map gave the best results, and provided a sensitivity of 85.7% and a specificity of 100%. In the pattern of the QRST area map, the existence of the regions less than -20ƒÊVS can fairly identify the OAMI (sensitivity 87.9%, specificity 85.2%). These findings suggest that the mathematical models obtained from the result of map analysis, especially QRST area maps, are useful to discriminate OAMI among the cases with PRWP.
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