胸前导联ST段抬高的伪装——一个“错解”的心电图向量警示与解析及临床启示

张斌

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胸前导联ST段抬高的伪装——一个“错解”的心电图向量警示与解析及临床启示

特约专稿 | 更新时间：2026-03-30

- 胸前导联ST段抬高的伪装——一个“错解”的心电图向量警示与解析及临床启示
- ST-Segment Elevation in the Precordial Leads: A Vector Masquerade — Analysis and Clinical Implications of Electrocardiographic Misinterpretation
- 临床心电学杂志 2026年35卷第1期页码：12-18
- 作者机构：
  
  529030 广东江门，江门市中心医院心血管内科
- 作者简介：
  
  [ "张斌，江门市中心医院心血管内科副主任医师、博士。长期致力于心血管内科的临床诊疗与科研工作，临床与科研工作主要聚焦于冠状动脉疾病、心力衰竭的治疗与管理，以及心血管危重症心电图的临床解读。在学术研究方面，以第一作者或通讯作者发表SCI论文多篇，形成了以血管内皮功能、心肌损伤与修复为主要方向的研究特色并对临床大数据（数据库）有深入研究。在心电图临床诊断领域，对应激性心肌病、急性心肌梗死、肺栓塞、心脏性猝死等相关心电现象进行了探索与总结，相关系列病例报告发表于《BMJ》（Case review）、《Circulation》（ECG challenge）等国际知名临床期刊。现担任广东省医学会心血管病分会动脉粥样硬化与冠心病学组委员、广东省医疗行业协会心源性卒中管理分会委员、世界中医药学会联合会高血压专业委员会常务理事、广东省医师协会心脏重症医师分会委员、广东省医疗行业协会高血压病管理分会委员、广东省转化医学心血管分会委员、广东省生物医学工程学会生物3D打印与再生医学分会委员、广东省中西医结合学会心血管病专业委员会委员等学术职务。" ]
- 基金信息：
- DOI：
  中图分类号： R540.4+1;R540.4+2
- 收稿：2026-01-19，
  
  录用：2026-01-29，
  
  纸质出版：2026-02-28
- 稿件说明：
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张斌. 胸前导联ST段抬高的伪装——一个“错解”的心电图向量警示与解析及临床启示[J]. 临床心电学杂志, 2026, 35(1): 12-18.

ZHANG Bin.ST-Segment Elevation in the Precordial Leads: A Vector Masquerade — Analysis and Clinical Implications of Electrocardiographic Misinterpretation[J].J Clin Electrocardiol,2026,35(01):12-18.
张斌. 胸前导联ST段抬高的伪装——一个“错解”的心电图向量警示与解析及临床启示[J]. 临床心电学杂志, 2026, 35(1): 12-18. DOI：

ZHANG Bin.ST-Segment Elevation in the Precordial Leads: A Vector Masquerade — Analysis and Clinical Implications of Electrocardiographic Misinterpretation[J].J Clin Electrocardiol,2026,35(01):12-18. DOI：

摘要

65岁男性患者，既往高血压病史，平素血压控制良好，因突发心前区压榨样疼痛4小时就诊。发病首份心电图示下壁（Ⅱ，Ⅲ，aVF）及广泛前壁（V

）导联ST段抬高，且胸前以V

导联抬高更显著，间隔初始向量正常。急诊冠脉造影证实为右冠状动脉（RCA）近段闭塞，左前降支（LAD）及左回旋支（LCX）存在非罪犯病变，介入开通RCA后患者症状缓解。术后心电图示前壁导联ST段迅速回落，R波递增良好；术后一周随访心电图显示下壁导联出现病理性Q波及T波倒置，前壁导联恢复正常。该病例挑战了“V

抬高即代表前（间）壁心肌梗死（LAD病变）”的传统认知，凸显了准确理解胸前导联对应心脏解剖部位（特别是右心室）及心电图向量变化在急性心肌梗死定位诊断中的重要性。通过心脏磁共振成像（CMR）的心脏解剖位置有助于明确导联定位与心肌损伤区域的对应关系。临床需警惕此类心电图表现，避免误判罪犯血管。

Abstract

A 65-year-old male patient with a history of well-controlled hypertension presented with acute oppressive precordial pain lasting 4 hours. The initial electrocardiogram (ECG) showed ST-segment elevation in the inferior (Ⅱ

Ⅲ

aVF) and anterior (V

) leads

with more pronounced elevation in the precordial leads V

. The initial septal vector remained normal. Emergency coronary angiography confirmed a proximal occlusion of the right coronary artery (RCA)

with non-culprit lesions present in the left anterior descending (LAD) and left circumflex (LCX) arteries. Percutaneous coronary intervention successfully revascularized the RCA

leading to symptom resolution. Post-procedural ECG demonstrated rapid resolution of ST-segment elevation in the anterior leads with preserved R-wave progression. A follow-up ECG one week later revealed pathological Q waves and T-wave inversion in the inferior leads

while the anterior leads returned to normal. This case challenges the traditional paradigm that "ST-segment elevation in V

-V

indicates anterior (septal

) myocardial infarction due to LAD occlusion

" highlighting the critical importance of accurately understanding the cardiac anatomical regions corresponding to precordial leads (particularly the right ventricle) and interpreting ECG vector changes for precise infarct localization in acute myocardial infarction. Correlation with cardiac magnetic resonance (CMR) imaging can aid in clarifying the relationship between lead positioning and the area of myocardial injury. Clinicians must remain vigilant regarding such ECG patterns to avoid misidentification of the culprit vessel.

关键词

Keywords

references

SIDHU M S , AGGARWAL K , FAY W P . Acute isolated right ventricular myocardial infarction masquerading as acute anterior myocardial infarction [J ] . BMJ Case Rep , 2014 , 2014 : bcr2012008087 .

COOSEMANS M , KOEVOETS R , VYDT T . A right ventricular infarction disguised as an anterior infarction due to an occluded isolated right ventricular branch [J ] . Acta Cardiol , 2008 , 63 ( 5 ): 641 - 645 .

ARROYO RIVERA B , ACEÑA Á , SÁNCHEZ-BORQUE P , et al . Cardiac arrest with ST-segment-elevation in V 1 and V 2 : differential diagnosis [J ] . Circulation , 2018 , 137 ( 16 ): 1742 - 1744 .

ALZAND B S , GORGELS A P . Combined anterior and inferior ST-segment elevation Electrocardiographic differentiation between right coronary artery occlusion with predominant right ventricular infarction and distal left anterior descending branch occlusion . J Electrocardiol , 2011 , 44 ( 3 ): 383 - 388 .

BIRNBAUM Y . Combined anterior and inferior ST-segment elevation. Electrocardiographic differentiation between right coronary artery occlusion with predominant right ventricular infarction and distal left anterior descending branch occlusion [J ] . J Electrocardiol , 2011 , 44 ( 4 ): 487 - 489 .

WU H Y , CHENG G , CAO Y W . Chest pain showing precordial ST-segment elevation in a 96-year-old woman with right coronary artery occlusion: A case report [J ] . World J Clin Cases , 2021 , 9 ( 8 ): 1877 - 1884 .

SUKMAWATI I , GOH F Q , YIP A , et al . A case report: anteroseptal ST elevation due to acute isolated right ventricular infarction [J ] . Int J Emerg Med , 2023 , 16 ( 1 ): 46 .

FRANCO J J , BROWN M , BASHIR R , et al . Acute anterior ST-elevation myocardial infarction and electrical storm secondary to nondominant right coronary artery occlusion [J ] . Tex Heart Inst J , 2014 , 41 ( 3 ): 335 - 337 .

LIN Y N , LIANG H Y , LO P H , et al . Precordial ST-segment elevation caused by proximal occlusion of a non-dominant right coronary artery [J ] . Acta Cardiol Sin , 2014 , 30 ( 5 ): 497 - 500

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