心肌透壁缺血时心脏表面心电图ST段位移的仿真研究

利用心肌的双域模型计算机模拟了不同区域心肌透壁缺血时ＳＴ 段位移在心脏表面的分布,发现心脏表面ＳＴ 段位移的分布式样和缺血区域大小有关,一个小面积的透壁缺血在缺血区上出现均匀分布的ＳＴ 段上升, 而在心脏表面的其他部位上几乎没有出现ＳＴ 段下降; 一个大面积的缺血像左降支或左旋支区域的缺血, ＳＴ 段位移在心脏表面的左侧区出现了一个偶极子式的分布,在缺血区为ＳＴ 段上升, 在正常区为ＳＴ 段下降, 并且其幅度随远离缺血边界而减小; 同时发现透壁缺血时的ＳＴ 段下降是缺血电流源的不可分割的一部分。 比较了这些模拟结果和在动物实验中所观察到的ＳＴ 段位移的变化,从而分析了本文得到的结论在临床上定位心肌缺血的指导意义。     

Electromechanical coupling in cardiomyocytes from transmural layers of guinea pig left ventricle

The electrical and mechanical activity of heart ventricle cardiomyocytes is known to vary depending on the spatial location of cells in the wall, in particular, transmurally from the sub-endocardial layer to the sub-epicardial one. To investigate intracellular mechanisms of the functional heterogeneity of cardiomyocytes we developed mathematical models of the electromechanical coupling in cardiomyocytes from different transmural layers across the left ventricle (LV) wall of guinea pig. It is shown that the mechanisms of both direct linkages and feedback in the electromechanical coupling contribute to differences in both the shape and duration of action potential, and speed characteristics of contraction between isolated cardiac myocytes from the sub-endocardial and sub-epicardial layers.     

How ischaemic region shape affects ST potentials in models of cardiac tissue

This numerical study uses a simple bidomain model of cardiac tissue to compare the effect of three different ischaemic region geometries (rectangular, cylindrical and semi-ellipsoidal) on the extracellular epicardial potentials during the ST segment. Results are obtained using anisotropic conductivities based on experimentally derived data. The model is then altered, to include heterogeneous conductivities in the ischaemic region and larger border zone widths, in order to better reproduce realistic scenarios. Initial results for the rectangular and cylindrical ischaemic shapes show a central depression over the ischaemic region, for low ischaemic thicknesses, which separates into three depressions as the ischaemic thickness increases. For ischaemic thicknesses above 70% an elevation appears over the ischaemic region and this increases in magnitude as the ischaemia becomes transmural. Results for the semi-ellipsoidal shape, however, differ, with the central depression separating into only two depressions as the thickness increases. Changing the conductivity inside the ischaemic region significantly affects results for each geometry, with depression staying over the ischaemic region for much higher levels of ischaemia (up to 90% thickness). Increasing the intramural border zone thickness did not significantly affect the epicardial potential distributions.     

Effects of simulated ischaemia on the electrical activity of ventricular myocardium in the presence of antiarrhythmic drugs.

The effects of a nutrient solution simulating the 'ischaemic milieu' (combined hyperkalaemia, hypoxia and acidosis) on the electrical activity of rabbit isolated ventricular myocardium were examined in the absence and presence of antiarrhythmic drugs. In such a simulated ischaemia the resting membrane potential, the rate of depolarization (Vmax) and the action potential duration (APD) were all diminished with a resultant decrease in conduction and a shortening of the effective refractory period (ERP). Sotalol, a Class 3 antiarrhythmic drug (5 x 10(-6)-10(-5) M/l) afforded a marked protection against the "ischaemic" abbreviation of the ERP and APD. To a much lesser extent, the same applied to propafenone, a predominantly Class 1C antidysrhythmic agent (1.65-3.3 x 10(-6) M/l). The 'ischaemia'-induced depression of Vmax was increased considerably by propafenone and diminished slightly by sotalol. The results are in keeping with the efficacy of propafenone and sotalol in ventricular arrhythmias of ischaemic origin and also with the proposal that the major mechanism by which propafenone inhibits postinfarction ventricular arrhythmias is a further depression of ischaemic myocardial cells resulting in conduction block of the reentrant wave front.     

L-type Ca2+ channel mutations and T-wave alternans: a model study

A number of mutations have been linked to diseases for which the underlying mechanisms are poorly understood. An example is Timothy Syndrome (TS), a multisystem disorder that includes severe cardiac arrhythmias. Here we employ theoretical simulations to examine the effects of a TS mutation in the L-type Ca(2+) channel on cardiac dynamics over multiple scales, from a gene mutation to protein, cell, tissue, and finally the ECG, to connect a defective Ca(2+) channel to arrhythmia susceptibility. Our results indicate that 1) the TS mutation disrupts the rate-dependent dynamics in a single cardiac cell and promotes the development of alternans; 2) in coupled tissue, concordant alternans is observed at slower heart rates in mutant tissue than in normal tissue and, once initiated, rapidly degenerates into discordant alternans and conduction block; and 3) the ECG computed from mutant-simulated tissue exhibits prolonged QT intervals at physiological rates and with small increases in pacing rate, T-wave alternans, and alternating T-wave inversion. At the cellular level, enhanced Ca(2+) influx due to the TS mutation causes electrical instabilities. In tissue, the interplay between faulty Ca(2+) influx and steep action potential duration restitution causes arrhythmogenic discordant alternans. The prolongation of action potentials causes spatial dispersion of the Na(+) channel excitability, leading to inhomogeneous conduction velocity and large action potential spatial gradients. Our model simulations are consistent with the ECG patterns from TS patients, which suggest that the TS mutation is sufficient to cause the clinical phenotype and allows for the revelation of the complex interactions of currents underlying it.     

Role of the ECG in initial acute coronary syndrome triage: primary PCI regardless presence of ST elevation or of non-ST elevation

The major initial triaging decision in acute coronary syndrome (ACS) is whether or not percutaneous coronary intervention (PCI) is the primary treatment. Current guidelines recommend primary PCI in ST-elevation ACS (STEACS) and initial antithrombotic therapy in non-ST-elevation ACS (NSTEACS). This review probes the question whether this decision can indeed be based on the ECG. Genesis of STE/NSTE ECGs depends on the coronary anatomy, collateral circulation and site of the culprit lesion. Other causes than ischaemia may also result in ST-segment changes. It has been demonstrated that the area at risk cannot reliably be estimated by the magnitude of the ST change, that complete as well as incomplete occlusions can cause STE as well as NSTE ECGs, and that STE and NSTE patterns cannot differentiate between transmural and non-transmural ischaemia. Furthermore, unstable angina can occur with STE and NSTE ECGs. We conclude that the ECG can be used to assist in detecting ischaemia, but that electrocardiographic STE and NSTE patterns are not uniquely related to distinctly different pathophysiological mechanisms. Hence, in ACS, primary PCI might be considered regardless of the nature of the ST deviation, and it should be done with the shortest possible delay, because ‘time is muscle’.     

基于单个细胞动作电位计算心电:若干异常仿真心电图

根据构造的心脏电生理模型及提出的基于单细胞动作电位计算心电图的算法,介绍异常心电活动的描述方式及对若干异常心电图的仿真结果,包括心肌缺血、心肌梗死、房室传导阻滞、束支传导阻滞、以及房室旁路,并对这些心电图的 产生机制进行说明,算法及仿真结果表明,细胞间的跨缝隙连结电位差是产生场点电热进而产生各种心电图波形的原因。     

Protective effect of cerebrocrast on rat brain ischaemia induced by occlusion of both common carotid arteries

Diabetes mellitus is accompanied by several cardiovascular complications including atherosclerosis, cerebral ischaemia and stroke. We examined the neuroprotective effect of a 1,4-dihydropyridine derivative cerebrocrast (C, a new antidiabetic agent, synthesized in the Latvian Institute of Organic Synthesis) on the level of ATP in the brain, and on changes of the EEG and ECG, as well as blood pressure parameters in anaesthetized Wistar male rats before and during 10-min occlusion of both common carotid arteries. Cerebrocrast was administered i.v. at doses of 1.0 and 10 microg/kg in the v. femoralis 20 min prior to ischaemia. After 10-min ischaemia animals were decapitated and the brain was immediately frozen in liquid nitrogen and subsequently used for analysis of changes of ATP contention. Cerebrocrast, administered at doses of 1.0 and 10 microg/kg 20 min prior to occlusion of both common carotid arteries, completely prevented a fall in the ATP content of brain compared with the control rats. In control rats the content of ATP in brain during ischaemia decreased from 2.77 +/- 0.22 (basal level) to 1.74 +/- 0.20 micromol/g as a result of ischaemia. By administration of cerebrocrast 20 min before occlusion of the arteries, the content of ATP in the brain remained at the level of preischaemia (1.0 microg/kg C + ischaemia 2.82 +/- 0.36; 10 microg/kg C + ischaemia 2.42 +/- 0.22 micromol/g). Analysis of EEG parameters both before and during 10 min of occlusion showed that at a C dose of 1.0 microg/kg before occlusion produced a regular alpha rhythm during ischaemia and prevented cerebral bioelectric activity from significant changes. The depression of basal rhythm was observed at a C dose of 10 microg/kg during ischaemia in two rats out of six as well as an increase in the ECG ST segment above the isoelectric line. Blood pressure was decreased by about 10-20 mm Hg. We propose that pretreatment of rats with cerebrocrast at doses of 1.0 or 10 microg/kg 20 min prior to ischaemia can prevent ischaemic damage of rat brain, maintain necessary energy consumption, promote ATP production in brain cells, and prevent significant changes in EEG and ECG parameters. These properties are important in diabetes mellitus and its evoked cardiovascular complications as stroke, ischaemia, etc.     

Myocardial ischaemia in patients with frequent angina pectoris.

One hundred patients with angina pectoris underwent 16-point electrocardiographic (ECG) mapping of the left hemithorax during a standardised exercise test. Forty-five patients had maximum ST-segment depression at position V5, while 35 had no ECG signs of ischaemia at this position. In 20 V5 was on the edge of the precordial area, which showed less severe ST-depression than the central positions. An Oxford ECG recorder and highspeed analyser were modified and used in 50 of the patients with daily angina for recording ST-segment changes over 24 hours. Serial 24-hour ambulatory recordings from the edge of the precordial area of ischaemia identified during exercise detected a mean of only 14 +/- SD 3% of the episodes of ST-segment changes recorded from the centre of the same area. Only 16 +/- 2% of the episodes detected by ECG were accompanied by chest pain. More episodes occurred between 4 am and 6 am than at any other time during the night. This study shows the importance of recording ECG evidence of ischaemia from the precordial position showing maximum changes during exercise. ECG evidence of ischaemia occurs more frequently than anginal pain. These objective measurements add important information to the frequency of chest pain reported by patients with ischaemic heart disease.     

The exercise ECG: still a useful exercise?

What is wrong with traditional ST-segment criteria during the exercise ECG? As we all know from daily practice, poor sensitivity of the exercise ECG for the detection of myocardial ischaemia is a major diagnostic weakness and a critical limitation of the exercise procedure. In standard meta-analyses, 1.0 mm (0.1 mV) of horizontal or downward-sloping ST depression has a sensitivity of only 68% for the detection of coronary artery disease (CAD), and this figure is even lower for women. This might explain our increasing reliance on noninvasive imaging modalities such as nuclear imaging (SPECT), magnetic resonance imaging (MRI), and computed tomography angiography (CTA), all of which show sensitivities between 80 and 90% for detecting CAD. As a result, there is a tendency to consider the exercise ECG as a poor man’s procedure to demonstrate myocardial ischaemia due to CAD. Is this the right consideration?     

Cardiac mechano-electric feedback in man: clinical relevance

Clinical conditions associated with sudden cardiac death due to arrhythmia are frequently accompanied by abnormalities of mechanical loading and wall stretch. These arrhythmias may result from several mechanisms including secondary depolarisations during or following the action potential or from a combination of conduction slowing and action potential shortening. Mechanical perturbations have been shown to reproduce these electrophysiological effects experimentally. However the effect of mechanical intervention is complex depending on the timing and intensity of the stimulus and the interplay between effects mediated via stretch activated channels and calcium cycling. Studies in patients during cardiac catheterisation or cardiac surgery using monophasic action potentials have shown alteration in the time course and shape of action potential repolarisation in response to changes in ventricular loading. Although stretch in experimental preparations has been shown to be arrhythmogenic, particularly in pathological conditions, the role of mechanically induced electrophysiological changes in important clinical ventricular arrhythmias remains to be established.     

Electrocardiogram ST-Segment Morphology Delineation Method Using Orthogonal Transformations

Differentiation between ischaemic and non-ischaemic transient ST segment events of long term ambulatory electrocardiograms is a persisting weakness in present ischaemia detection systems. Traditional ST segment level measuring is not a sufficiently precise technique due to the single point of measurement and severe noise which is often present. We developed a robust noise resistant orthogonal-transformation based delineation method, which allows tracing the shape of transient ST segment morphology changes from the entire ST segment in terms of diagnostic and morphologic feature-vector time series, and also allows further analysis. For these purposes, we developed a new Legendre Polynomials based Transformation (LPT) of ST segment. Its basis functions have similar shapes to typical transient changes of ST segment morphology categories during myocardial ischaemia (level, slope and scooping), thus providing direct insight into the types of time domain morphology changes through the LPT feature-vector space. We also generated new Karhunen and Lo ève Transformation (KLT) ST segment basis functions using a robust covariance matrix constructed from the ST segment pattern vectors derived from the Long Term ST Database (LTST DB). As for the delineation of significant transient ischaemic and non-ischaemic ST segment episodes, we present a study on the representation of transient ST segment morphology categories, and an evaluation study on the classification power of the KLT- and LPT-based feature vectors to classify between ischaemic and non-ischaemic ST segment episodes of the LTST DB. Classification accuracy using the KLT and LPT feature vectors was 90% and 82%, respectively, when using the k-Nearest Neighbors (k = 3) classifier and 10-fold cross-validation. New sets of feature-vector time series for both transformations were derived for the records of the LTST DB which is freely available on the PhysioNet website and were contributed to the LTST DB. The KLT and LPT present new possibilities for human-expert diagnostics, and for automated ischaemia detection.     

The electrophysiological effects of disopyramide phosphate on canine ventricular muscle and Purkinje fibers in normal and low potassium

We studied the effect of lowering the extracellular potassium concentration ([K+]o) on the electrophysiological actions of disopyramide phosphate, a new antiarrhythmic drug. At low [K+]o, therapeutic concentrations of disopyramide phosphate caused significantly less depression of action potential amplitude and maximum upstroke velocity of both Purkinje fiber and ventricular muscle action potentials. The drug shifted the membrane responsiveness curve along the voltage axis to more negative membrane potentials regardless of [K+]o. However, a greater shift occurred when [K+]o was normal. Disopyramide phosphate prolonged both action potential duration and effective refractory period in all fibers but there was consistently greater prolongation of these parameters at low [K+]o. More importantly, disopyramide phosphate altered repolarization time course of action potentials in such a way that action potentials with dissimilar durations throughout the ventricular conducting system became more equal. The drug was less effective in decreasing this disparity in action potential durations throughout the ventricles in the presence of low [K+]o. These modifications of the electrophysiological actions of disopyramide by low [K+]o suggest that a therapeutic concentration of disopyramide might have less of an antiarrhythmic effect in the presence of hypokalemia.     

Ischaemic preconditioning in the pig assessed by myocardial perfusion imaging and histochemistry

Ischaemic preconditioning (IP) is a strong endogenous infarct reducing stimulus which has not previously been evaluated with myocardial perfusion imaging using 99mTc-MIBI. Factors responsible for cellular MIBI uptake are affected by both IP and acute ischaemia (plasma membrane and mitochondrial membrane potential and oxidative metabolism). IP seems to involve mitochondrial K-ATP channels affecting mitochondrial membrane potential and thereby potentially MIBI uptake. The study evaluated the performance of MPI with MIBI as a tracer to characterise the extent that severely ischaemic compromised myocardium was salvaged by IP. In a closed chest model, an ischaemic preconditioned group (8 pigs) subjected to IP before introducing a 45 min period of catheter based coronary occlusion was compared with a control group (9 pigs). Area at risk'(AAR), infarct size (IS) and IS relative to AAR was determined by MIBI SPECT and by a standard histochemical method. The results demonstrated that infarct size was significantly smaller in the IP group both relative to left ventricle (IS/LV) and to area at risk (IS/AAR). Both AAR/LV and IS/LV, however, were greater when measured by MPI than with histochemistry. There was no difference in the ratio between infarct size and area at risk (IS/AAR). In conclusion, MPI with MIBI is a reliable measurement of infarct reduction by ischaemic preconditioning. Myocardium affected by recent ischaemia is correctly distinguished as viable by MPI in early reperfusion, when compared to a standard histochemical technique.     

Ischaemia-induced cellular electrical uncoupling and ventricular fibrillation

Sudden death resulting from ventricular fibrillation (VF) during acute myocardial ischaemia forms an important contribution to mortality associated with infarction. Its temporal distribution is not known, but 30% of mortality occurs within the first 60 minutes. Two distinct phases of arrhythmias have been demonstrated in laboratory animals subjected to coronary occlusion. The mechanism of the second, 1B phase (which is associated with more lethal events than the first, 1A phase) is largely unknown but appears to be related to cellular uncoupling, i.e. the closure of gap junctions.Gap junctions are intercellular communication channels that are permeable for ions and metabolites and are necessary for normal propagation of electrical activation. It has been suggested that closure of gap junctions results in a largely inhomogeneous substrate in which microreentry forms the electrophysiological mechanism for VF. However, there is growing support for the hypothesis that arrhythmias relate to the persistence of residual coupling rather than to the occurrence of uncoupling. With this, the ischaemic midmyocardium can depress the intrinsically viable tissue of the ischaemic subepicardium and subendocardium and cause conduction slowing and block leading to arrhythmias. Progression of uncoupling terminates this interaction and allows the subepicardium and subendocardium to recover. Indeed, electrophysiological properties recover subepicardially whereas the midmyocardial tissue becomes inexcitable. In addition, activation patterns during VF become restricted to the two-dimensional plane of the subepicardium. These observations support the hypothesis of residual coupling as an arrhythmogenic mechanism during the delayed phase of acute ischaemia. Whether this mechanism is equally important in patients with remodelled and failing hearts can at this time only be speculated upon. However, modifying intercellular coupling might turn out a new antiarrhythmic therapy.     

Mimicry of a host anion channel by a Helicobacter pylori pore-forming toxin

Bacterial pore-forming toxins have traditionally been thought to function either by causing an essentially unrestricted flux of ions and molecules across a membrane or by effecting the transmembrane transport of an enzymatically active bacterial peptide. However, the Helicobacter pylori pore-forming toxin, VacA, does not appear to function by either of these mechanisms, even though at least some of its effects in cells are dependent on its pore-forming ability. Here we show that the VacA channel exhibits two of the most characteristic electrophysiological properties of a specific family of cellular channels, the ClC channels: an open probability dependent on the molar ratio of permeable ions and single channel events resolvable as two independent, voltage-dependent transitions. The sharing of such peculiar properties by VacA and host ClC channels, together with their similar magnitudes of conductance, ion selectivities, and localization within eukaryotic cells, suggests a novel mechanism of toxin action in which the VacA pore largely mimics the electrophysiological behavior of a host channel, differing only in the membrane potential at which it closes. As a result, VacA can perturb, but not necessarily abolish, the homeostatic ionic imbalance across a membrane and so change cellular physiology without necessarily jeopardizing vitality.     

Cytochemical evidence of NADH-oxidase activity in the isolated working rabbit heart subjected to normothermic global ischaemia

Summary The cytochemical localization of NADH-oxidase, a possible source of oxygen derived toxic species was studied in the isolated working rabbit heart subjected to normothermic global ischaemia. The activity of this oxidase could be important for the damage observed during ischaemia, when cellular defence mechanisms against free radicals are depleted. In non-ischaemic myocardium only small amounts of the NADH-oxidase reaction product were present in the mitochondria. Although the reaction product could already be observed after 45 min of incubation, prolonged incubation times up to 2 h were necessary to clearly define these reactive sites. The reaction product is substrate dependent and is not affected by cyanide. Exposure of the hearts to ischaemia resulted in an alteration of the enzyme activity depending on the degree of ischaemic damage. In ultrastructurally slightly altered areas a high degree of cytochemical study supports the hypothesis that hydrogen peroxide and oxygen radicals produced in the mitochondria by NADH-oxidase activity may contribute to the mitochondrial damage observed during ischaemia when NADH is no longer oxidized by the respiratory chain and cellular defence mechanisms are impaired.     

Effects of Weak Environmental Magnetic Fields on the Spontaneous Bioelectrical Activity of Snail Neurons

We examined the effects of 50-Hz magnetic fields in the range of flux densities relevant to our current environmental exposures on action potential (AP), after-hyperpolarization potential (AHP) and neuronal excitability in neurons of land snails, Helix aspersa. It was shown that when the neurons were exposed to magnetic field at the various flux densities, marked changes in neuronal excitability, AP firing frequency and AHP amplitude were seen. These effects seemed to be related to the intensity, type (single and continuous or repeated and cumulative) and length of exposure (18 or 20 min). The extremely low-frequency (ELF) magnetic field exposures affect the excitability of F1 neuronal cells in a nonmonotonic manner, disrupting their normal characteristic and synchronized firing patterns by interfering with the cell membrane electrophysiological properties. Our results could explain one of the mechanisms and sites of action of ELF magnetic fields. A possible explanation of the inhibitory effects of magnetic fields could be a decrease in Ca²⁺ influx through inhibition of voltage-gated Ca²⁺ channels. The detailed mechanism of effect, however, needs to be further studied under voltage-clamp conditions.     

Early exercise testing after treatment with thrombolytic drugs for acute myocardial infarction: importance of reciprocal ST segment depression.

OBJECTIVE--To investigate the clinical importance of reciprocal ST depression induced by exercise testing early after acute myocardial infarction in patients treated with thrombolysis. DESIGN--Prospective observational study. SETTING--District general hospital in London. SUBJECTS--202 patients (170 men) aged 33-69 with acute myocardial infarction treated with thrombolysis. MAIN OUTCOME MEASURES--All patients underwent exercise testing and coronary arteriography. ST depression induced by exercise was classified as either reciprocal (associated with ST elevation) or isolated (occurring on its own). The relation between reciprocal ST depression and the following end points was studied: characteristics of the infarct, left ventricular ejection fraction, extent of coronary artery disease on arteriography, and presence of angina induced by exercise. RESULTS--Reciprocal ST depression occurred almost exclusively in Q wave infarctions and was associated with a lower overall ejection fraction than isolated ST depression. It tended to be associated with persistent occlusion of the coronary artery related to the infarct and did not indicate remote ischaemia due to multivessel coronary disease. Unlike isolated ST depression, reciprocal ST depression was not associated with angina induced by exercise. CONCLUSIONS--Reciprocal ST depression induced by exercise is usually associated with extensive Q wave infarctions and persistent occlusion of the artery related to the infarct. It does not seem to indicate reversible ischaemia and should not be used as a non-invasive marker of multivessel disease in the assessment of requirements for further investigation soon after acute myocardial infarction.