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心电学习笔记(217)房速?房颤?房扑?

  • 2026-01-11 10:25:07
心电学习笔记(217)房速?房颤?房扑?
今天来看一份困扰到的图：
87岁女性，既往有高血压、脑梗、冠心病等病史。此次因头晕、头疼加重1天门诊就诊。
图1.心电图如上，该图该如何下诊断？
当时系统自动诊断为窦性心律，短PR间期，房性早搏等，我一看就觉得不对。
图1-a.如图中箭头所示，均为P波，P波形态不符合窦性P波特点，所以一开始要把系统自动诊断的窦性心律伴短PR间期去掉；PP间期相等，P波频率约187次/分，也不符合房颤f波的特点，故也不考虑为房颤。
剩下的就是房扑与房速之间考虑。心房率为187次/分，PP之间存在等电位线，所以就写了房性心动过速伴不等比下传，这种比较感觉又定性但是有比较模糊的诊断，建议其进一步完善holter检查，但是没有做。
等空下来的时候再细细回顾这个图，如图1-a，我只是测量前半部分的PP，后半部分我没有标记，为什么呢？因为一开始我觉得是干扰（老人家很瘦+冬天皮肤干燥，容易引起基线不稳），但是其实心里也不能排除房颤，所以拿着图去请教了上级。
图1-b.如图所示，经上级指导，可以测量我认为是干扰的后半部分，其实不是干扰，仔细测量心房波，如绿色箭头所示，以F1F2为测量间距，发现心房波间期是相等的，心房率约333次/分，符合房扑的特点。
所以上级医师说可能是心房扑动，伴传出阻滞（房扑波的传出阻滞）。
我说我考虑得比较简单直接，前半段是房速不等比下传，后半段是心动扑动。
上级说也不排除这种可能性，因为仔细观察，两者心房波形态是不一样的，心房频率也不一致，代表起源不同。
房性心律失常的特点之一就是多变性，如果P波形态多变，或同时存在房早、房速甚至房扑的人，后续进展为心房颤动的风险会更高。
图2.按照这个思路去分析她的18导联心电图，与前面不同步，相当于加多了10s的图。
发现，红色箭头所示的心房波间期相等，频率为187次/分，与图1-a前半部分对应；而绿色箭头所示的心房波间期也基本相等，频率为333次/分，与图1-b后半部分相等；而黑色箭头所示的心房波形态，与其他均不一样，我个人考虑可能为窦性心律。
至此，这份图我就分析完毕了，为：房性心动过速不等比下传，心房扑动，可见短暂窦性心律。
追溯患者既往在我院就诊或体检做的图，基本上都是上面的这种，窦性心律伴一度房室传导阻滞（PR间期358ms）。
对于以上分析，仅代表个人目前的想法。欢迎各位老师留言纠错、讨论、分享。
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  1. CONNECT:[ UseTime:0.000682s ] mysql:host=127.0.0.1;port=3306;dbname=no_67808;charset=utf8mb4
  2. SHOW FULL COLUMNS FROM `fenlei` [ RunTime:0.000856s ]
  3. SELECT * FROM `fenlei` WHERE `fid` = 0 [ RunTime:0.015455s ]
  4. SELECT * FROM `fenlei` WHERE `fid` = 63 [ RunTime:0.018061s ]
  5. SHOW FULL COLUMNS FROM `set` [ RunTime:0.000880s ]
  6. SELECT * FROM `set` [ RunTime:0.013228s ]
  7. SHOW FULL COLUMNS FROM `article` [ RunTime:0.000881s ]
  8. SELECT * FROM `article` WHERE `id` = 458641 LIMIT 1 [ RunTime:0.037833s ]
  9. UPDATE `article` SET `lasttime` = 1768163608 WHERE `id` = 458641 [ RunTime:0.046666s ]
  10. SELECT * FROM `fenlei` WHERE `id` = 65 LIMIT 1 [ RunTime:0.004223s ]
  11. SELECT * FROM `article` WHERE `id` < 458641 ORDER BY `id` DESC LIMIT 1 [ RunTime:0.005551s ]
  12. SELECT * FROM `article` WHERE `id` > 458641 ORDER BY `id` ASC LIMIT 1 [ RunTime:0.003783s ]
  13. SELECT * FROM `article` WHERE `id` < 458641 ORDER BY `id` DESC LIMIT 10 [ RunTime:0.049145s ]
  14. SELECT * FROM `article` WHERE `id` < 458641 ORDER BY `id` DESC LIMIT 10,10 [ RunTime:0.145841s ]
  15. SELECT * FROM `article` WHERE `id` < 458641 ORDER BY `id` DESC LIMIT 20,10 [ RunTime:0.001670s ]
0.430934s