IBHRE国际心律失常考官委员会英文资料：V.Assessment and SAECG

1、Clinical Assessment (8%) Clinical Assessment (16 Questions) A. History 1. No structural heart disease 2. Acquired structural heart disease 3. Congenital heart disease B. Cardiac Physical Examination C. Non-invasive Diagnostic Tests and Evaluation 1. Signal average ECG 2. Tilt table testing 3. Ambula

2、tory ECG monitoring, Event monitoring 4. Stress testing 5. Echocardiography: TEE, ICE 6. Novel non-invasive diagnostic test technologies D. Inherited Arrhythmia syndromes, Channelopathies ECG Indications & Significance Indications Myocardial Infarction Myocardial Ischemia Cardiac Arrhythmias Conduct

3、ion defects Electrolyte imbalance Drug toxicity Chamber enlargement, dilatation & hypertropy Significance Recognitioin of cardiac disease or abnormalities ECG changes correlated with clinical findings Significant when combined with total cardiac assessment (history & physical examination) Chest X-Ra

4、y Cardiac size and position Pulmonary abnormalities effusion/ edema Ventricular aneurysm Lead and PG placement Lead integrity ICD patches Echocardiography Valvular function Regional wall abnormalities Chamber size Ventricular systolic & diastolic function Intra or peri-cardiac tumor and thrombi Peri

5、cardial effusion/ tamponade Location of pacemaker leads Lead perforation Hemodynamic evaluation of dual chamber pacemaker Congenital anomalies TEE Congenital Heart disease ASD, VSD, PDA, TOF, Transposition of the great vessels Valvular & Chamber assessment Biscupid AV, stenosis, regurgitation, Mitra

6、l subvular appratus assessment Pericardial disease Constrictive / Restrictive Pericarditis, Pericardial tumors Endocarditis Prosthetic valve dysfunction in AV, MV & TV Cardiac Tumors or thrombi in A or V Aortic dissection Intraoperative monitoring of cardiac function Assessment of valvular repair &

7、replacement Radionuclide Imaging (e.g. MUGA) Evaluation of the extent & location of myocardial ischemia during stress testing and rest comparison Myocardial viability/ diagnosis of acute MI Risk / therapy / prognosis assessment after AMI EF and Ventricular wall motion assessment Shunt analysis Exerc

8、ise ECG (Stress ECG) Suspected CAD Cardiovascular functional capacity Arrhythmia evaluation Evaluate patient responses to medical or surgical therapy Effect of pacemaker therapy Response to antiarrhythmic therapy Stress Echo Risk stratification before nonsurgical procedures Risk stratification post

9、MI Identification of viable myocardium Evaluation of suspected CAD Prognostic evaluation post MI Heart Rate Variability Quantitative recording and expression of sinus arrhythmia Reduced HRV is a reflection of the reduction, relative or absolute in autonomic activity Types Time domain analysis (a) R-

10、R interval analysis (b) R R interval difference analysis Frequency domain (HR power spectrum) analysis (a) Fast fourier transform (FFT) (b) Auto- regressive model (linear model) Indications & Diagnositc significance Risk stratification for sudden cardiac death or sustained VT Decreased HRV predictor

11、 of arrhythmic events post MI HRV with SA ECG strong predictor Ambulatory ECG (Holter) & Transtelephonic ECG Ambulatory ECG monitoring of patient for 12, 24 or 48 hours Indications Arrhythmia/ Drug efficacy/ Pacemaker function Use of a device capable of recording ECG strip which is transmitted via t

12、he telephone to a receiving center Indications Arrhythmia/ Symptom correlation/ Drug efficacy/ Pacemaker and ICD surveillance MRI (Magnetic Resonance Imaging) Anatomy and morphology of the great vessels and myocardium are depicted in 3D images without X-ray exposure Indications Cardiomyopathies Valv

13、ular heart disease Transplant rejection Pericardial disease Cardiac and related mediastinal masses Congenital heart disease Disease of Aorta and great vessels Ischemic heart disease Diagnostic Significance Evaluation of intracardiac thrombi Intra and Extra Cardiac tumor IHD cardiac function & other

14、therapeutic effectiveness Thoracic Aorta disease coarctation of Aorta, Marfan Syndrome/ Intimal tears of Aorta Valvular heart disease AS/ AR/ MS/ MR CT (Computed Tomography) Scan CAD Pericardial disease (PE) Primary myocardial disease Congenital heart disease Valvular disease Disease of the great ve

15、ssels Cardiac tumor Others Cardiac catheterization EPS Endomyocardial Biopsy Signal Average ECG Signal Average ECG Computerized method of analyzing highly amplified ECG signals which identifies particular microvolt level abnormal signals Recorded with 3 bipolar orthogonal leads Types Time domain ana

16、lysis (Vector magnitude analysis) - for Ventricular late potentials, Bundle of His activity, Notches & slurs in QRS Frequency domain analysis fast fourier transform (FFT) ratios of peaks and areas of selected segments of the average cardiac cycle Bipolar Electrodes X Leads 4th ICS in both midaxillar

17、y lines Y Leads Superior aspect of manubrium & upper Lt leg or iliac crest Z Leads 4th ICS (V2) & opposite posteriorly on the Lt side of vertebra (+) ive Leads Lt (X), Inferior (Y), Anterior (Z) Indications Risk stratification for clinical VT Screening patients for VT study Unexplained syncope Wide

18、complex tachycardia Asymptomatic complex VE in patients with structural heart disease Ventricular arrhythmia risk stratification following MI Indications Sustained VT risk stratification of sustained VT or sudden cardiac death VF more (-)ive test in pts with VF than in VT pt Non-sustained VT risk st

19、ratification Syncope pt with syncope with (+)ive test prone to VT, (+) ive pt with syncope no need EP study Asymptomatic complex ectopy used for risk stratification together with other investigations (Holter) Dilated non-ischemic cardiomyopathy risk stratification for VT Determination of success of

20、arrhythmia surgery (remove myocardium) Significance of SA ECG (+) of Late potentials correlate with clinical VT events or (+) ive test for VT study Predictive of arrhythmic events post MI SA ECG Post MI patients with history of sustained VT have abnormal & fragmented EGM than who dont have VT Late p

21、otential originated from delayed conduction, microvolt level, high-frequency waveforms continuous with QRS complex until 10 ms into the ST segment Maximum prognostic info is obtained when the SAECG is performed 8-10 days post infarct Incidence of having abnormal SAECG is higher in inf or inferoposte

22、rior MI than ant or antseptal MI Ventricular Late Potential Abnormal late potential arising from areas of slow conducting myocardium Result of delayed and fractionated electrical waveform reflect depolarization activity More reflective of endocardial activity rather than epicardial activity SAECG Co

23、mputer based technique used to reduce the random noise such as skeletal muscle activity, respiration & environmental noise Enhance the detection of low-amplitude signals, late potentials Process the multiple samples of a repetitive waveform, then high-pass filters them to reduce or cancel noise Desi

24、red signal of late potential will be accumulated by averaging successive cycles of 100 -400 after clearing those noises No ectopic beats are counted in Data Analysis Time-domain analysis Criteria for standard (normal) are High pas filter of 25 Hz or 40 Hz Butterworth filter, a noise cutoff of 1 v us

25、ing 25 Hz or 0.7 v at 40 Hz Criteria for positive are A filtered QRS (HFQD) 114 ms A D-40 38 ms A root mean square amplitude (RMSA) 20 v Data Analysis Sample takes about 100- 400 cycles Recommended residual noise level 0.2 0.3 v RMS for maximizing sensitivity for VT Factors affect the quality of tra

26、cing Frequent ectopy Environmental noise Lead placement and skin contact Presence of BBB RBBB or paced rhythms obscures the late potentials Fully paced rhythms require to lower the HR Time domain analysis for LBBB But Frequency domain analysis improves for conduction system abnormalities Time Domain

27、 & Frequency Domain Time Domain - Analysis of a vector magnitude of the filtered QRS complex, most used method Time Domain analysis identified patients with VT with significantly fewer false (+)ive result than Frequency Domain (Superior than Frequency) Frequency Domain Using the fast fourier transfo

28、rm, the ECG can be represented in the frequency domain, more accurate Suggested Normal SAECG Criteria EquipmentGenderfQRS (ms)LAS (ms)RMS (v) Marquette (GE) M F = 124 =116 = 42 = 16 =15 ART (Corozonix) M F = 115 = 107 = 47 = 1 = 13 Abnormal SAECG found in Non-ischemic Dilated HOCM Family h/o sudden

29、cardiac death H/O syncope Maximal LV wall thickness MVP Duchennes muscular dystrophy TOF Procainamide can convert to N SAECG Tilt Table Testing Tilt Test Recurrent syncope or a single syncopal episode in high risk patients Part of evaluation for exercise associated or induced syncope Evaluation of p

30、atient with unexplained falls Tilt Test For identifying of syncopal episode as a result of neurally mediated hypotension and/ or bradycardia (Vasovagal Syndrome) 60 80 mins of procedure tilt at 70 for 30- 45 mins if (- )ive same procedure with isoproteonol infuses at titrated rates 1 g/min for 5-10

31、mins - dose up to 5 g/min for another10 mins Positive test pre-syncope (warmth, dizziness, nausea) or syncope in conjunction with significant hypotension and/or bradycardia without isuprel) Negative test tilt for 10 mins with isuprel infusion at 5 g/min without significant hypotension or bradycardia Contraindications Recent MI Unstable angina Critical AS/MS Critical Cerebrovascular stenosis Congestive HF Hemo