2014.04.12 2014.12.12 1 3 2 4 2.1............................................ 4 2.2 Einthoven triangle........................................ 4 2.3............................................ 4 2.4............................................. 5 2.5....................................... 6 3 7 3.1.......................................... 7 3.2............................................ 7 3.3......................................... 7 3.4......................................... 8 3.5............................................. 8 3.6......................................... 9 3.7....................................... 9 3.8....................................... 9 3.9....................................... 10 3.10....................................... 10 3.11............................................ 10 3.12............................................ 10 3.13............................................ 11 3.14............................................... 11 4 12 4.1 P............................................. 12 4.2 P............................................. 12 4.3 His......................................... 13 1
4.4 R............................................. 13 4.5 q.............................................. 13 4.6 s.............................................. 14 4.7 J................................................ 14 4.8 T............................................. 14 4.9 avr VR............................................ 15 4.10 avr............................................ 15 4.11 avr, avl, avf P.................................. 15 4.12............................................ 16 4.13 QRS.................................. 16 4.14 ST segment............................................ 16 5 17 5.1............................................. 17 5.2.............................................. 17 5.3.......................................... 18 5.4................................... 19 5.5.......................................... 19 5.6....................................... 20 5.7 ()............................. 20 5.8 ( )........................................ 21 5.9............................................... 21 5.10.............................................. 21 5.11............................................... 21 5.12.......................................... 21 5.13 K +............................................ 21 5.14 K +............................................ 23 5.15 Ca 2+........................................... 23 5.16 Ca 2+........................................... 23 2
1 Einthoven 20 21 Einthoven Einthoven Q Q Einthoven 24 3
2 2.1 19 A. D. Waller Wallerian degeneration A. V. Waller 1887 [1] [2, 3] Waller Willem Einthoven [4] Einthoven [5] I, II, III Einthoven Einthoven 2.2 Einthoven triangle Einthoven 1913 Einthoven triangle [6] potential difference Einthoven Einthoven triangle 2.3 Einthoven Frank N. Wilson Wilson Wilson V R, V L, V F Einthoven Wilson 1913 4
[7] D. B. Geselowitz [8] (source) (sink) sink source Einthoven Wilson [7] 2.4 19 [9, 10] 20 [11, 12, 13] [11] source sink 5
2.5 Einthoven 19 [14] 6
3 3.1 Einthoven I Einthoven I II III 3.2 Ringer I 0 3.3 3.2 I Ringer Ringer I Ringer Ringer 7
3.4 I 1: S 1, S 2, S 3 R L V ( ) 3.5 3.4 () Na + Ca 2+ K + K + 8
3.3 3.6 ( ) 1 R L 3.7 3.6 I 1 3.8 3.2 I Ringer 9
3.9 3.8 I 3.8 I 3.10 3.8 I Ringer 3.11 I 1 L 3.12 3.11 I 10
2: 3.13 I 3.8, 3.9 I 3.14 I 3.10 11
4 4.1 P I II P Einthoven triangle V 1 P P *1 I II III V 1 P 4.2 P I P ( ) I 1, I 2, I 3 I 1, I 2, I 3 I 1, I 2, I 3 P I 1 P I 3 *2 P I 1 I 3 I 2 *1 *2 His 12
4.3 His P QRS plateau, His His plateau His His 4.4 R I II R R His I II Purkinje Purkinje I II 4.5 q I q q I Einthoven 13
I 4.6 s II s s s Purkinje 4.7 J II QRS ST junction J 4.14 0 4.8 T II T Purkinje Purkinje T Purkinje Purkinje 14
T 4.9 avr VR avr VR avr VR 1.5 ϕ l, ϕ r, ϕ f av R = ϕ r ϕ l + ϕ f 2 (1) V R = ϕ r ϕ l + ϕ r + ϕ f 3 = 2 3 ϕ r ϕ l + ϕ f 3 3 V R = av R (3) 2 (2) 4.10 avr avr avr VR VR VR 4.11 avr, avl, avf P avr, avl, avf P avl avf avl avr avf P 15
avr P avl, avf P 4.12 V 1 V 6 avr, avl, avf 4.13 QRS V 1 QRS V 5 QRS 4.12 V 1 V 5 QRS V 1 V 1 V 5 QRS V 1 V 6 4.14 ST segment S T ST segment T T J Purkinje Purkinje 16
5 ABC 2 10 ( ) 5.1 P V 1 P P V 1 P P P 5.2 QRS qrs I V 5, V 6 R S I V 5, V 6 R T QRS Purkinje plateau Purkinje Purkinje T QRS Purkinje 17
5.3 5.3.1 Purkinje his Purkinje QRS I V 6 R qrs QRS 60 ms I V 6 R QRS 100 ms I V 6 S V 1 R R S 5.3.2 Purkinje QRS 60 ms I V 6 Q R 100 ms I V 6 R V 1 S QRS I q V 1 R Purkinje 5.3.3 Purkinje QRS Purkinje 18
QRS S I I R I R S 5.4 QRS QRS Purkinje QRS Purkinje Purkinje 5.5 ST Q ST (ST-Elevated Myocardial Infarction; STEMI) 5.5.1 R, ST, T 0 R ST segment T ST 19
5.5.2 12 Q R 1/4 Q 0 Q Q ST Q 5.5.3 2 1 T T ST ST T ST 5.5.4 1 1 T 5.6 ST T P T P 0 ST segment ST 5.7 () ST ATP K + β ATP 20
ST 5.8 ( ) ST Na + -K + ATPase ST 5.9 5.10 ST PQ T ST Q PQ T 5.11 5.12 ABC 5.13 K + K + Na + -K + -ATPase K + K + K + K + K + Na + K + 21
K + Na + * 3 ABC ST QT T * 4 PQ 3 QT Purkinje ( p.38) Purkinje T T T *3 K + K + *4 20mM 22
5.14 K + Purkinje Purkinje T 2 plateau Na + /Ca 2+ 3 1 Na + /Ca 2+ Na + /Ca 2+ Purkinje T U T U 5.15 Ca 2+ Ca 2+ Na + /Ca 2+ Na + Ca 2+ Ca 2+ 2 Ca 2+ 2 ST segment QT 5.16 Ca 2+ Ca 2+ 23
[1] Waller, A. D., Reid., E. W., On the Action of the Excited Mammalian Heart, Philosophical Transactions of the Royal Society of London. B, 178, 215-256 (1887). [2] Waller, A. D., A Demonstration on Man of Electromotive Changes Accompanying the Heart s Beat, Journal of Physiology, 8, 229-234 (1887). [3] Waller, A. D., On the Electromotive Changes Connected with the Beat of the Mammalian Heart, and of the Human Heart in Particular, Philosophical Transactions of the Royal Society of London. B, 180, 169-194 (1889). [4] Kligfield, P., Derivation of the Correct Waveform of the Human Electrocardiogram by Willem Einthoven, 1890-1895, Cardiology Journal, 17, 109-113 (2010). [5],,, 1, 148-151 (1935). [6] Einthoven, W., Fahr, G., de Waart, A., On the Direction and Manifest size of the Variations of Potential in the Human Heart and on the Influence of the Position of the heart on the form of the electrocardiogram, American Heart Journal, 40, 163-194 (1950). (Translated into English) [7] Wilson, F. N., Johnston, F. D., Rosenbaum, F. F., et al., On Einthoven s Triangle, the Theory of Unipolar Electrocardiographic Leads, and the Interpretation of the Precordial Electrocardiogram, American Heart Journal, 32, 277-310 (1946). [8] Geselowitz, D. B., Dipole Theory in Electrocardiography, The American Journal of Cardiology, 14, 301-306 (1964). [9],,, 10, 43-44 (1944). [10],,, 10, 44-45 (1944). [11], ( ),, 2, 552-561 (1945). [12], ( ),, 2, 625-636 (1945). [13], ( ),, 2, 735-744 (1945). [14], Einthoven,, 10, 51-53 (1944). [15] ABC 2 ( ) 2005. [16] 10 ( ) 2009. [17] ( ) 2012. 24