При тромбоэмболии легочной артерии (ТЭЛА) ЭКГ отображает резко изменившиеся условия внутрисердечной гемодинамики, конкретно – перегрузку правых отделов сердца, которая проявляется несколькими электрокардиографическими вариантами:
Первый ЭКГ вариант – синдром SI — QIII -Т III .
При первом ЭКГ варианте ТЭЛА на электрокардиограмме появляются глубокие зубец S в I стандартном и зубец Q в III стандартном отведениях, а зубец T в III стандартном отведении становится отрицательным.
Особо значимыми становятся указанные изменения ЭКГ при определении их в динамике, T. е. при сопоставлении исследуемой электрокардиограммы с предыдущими, зарегистрированными ранее, до возникновения ТЭЛА.
Появление (или углубление) зубца Q в III стандартном отведении в сочетании с развивающейся негативностью зубца T здесь же весьма напоминает ЭКГ картину при заднем (нижнем) инфаркте миокарда, что следует иметь в виду при дифференциальной диагностике ТЭЛА.
Второй ЭКГ вариант – остро возникшая гипертрофия правых отделов сердца.
Резкое переполнение объемом крови правых отделов сердца, наблюдаемое при ТЭЛА, проявляется на электрокардиограмме признаками остро возникший гипертрофии этих отделов: правого предсердия и правого желудочка (второй ЭКГ вариант).
Гипертрофия правого предсердия проявляется на ЭКГ феноменом P — pulmonale – высокий заостренный зубец P во II стандартном отведении (см. гл. IV .4).
Гипертрофия правого желудочка с перегрузкой описывалась подробно в гл. IV .3, напомним лишь, что остро возникшая полная или неполная блокада правой ножки пучка Гиса также свидетельствует о перегрузке правого желудочка.
Третий ЭКГ вариант – остро возникшие наджелудочковые тахиаритмии.
Переполнение объемом крови правого предсердия, его перерастяжение существенно затрудняет работу синусового узла, снижает порог возбудимости миокарда предсердия, что приводит к появлению различных видов остро возникших наджелудочковых аритмий: частая наджелудочковая экстрасистолия, наджелудочковая пароксизмальная тахикардия, пароксизм мерцания, мерцательная тахиаритмия, о которых подробно говорилось в соответствующих разделах. Это и есть третий ЭКГ вариант.
Естественно, выделенные нами три различных ЭКГ варианта ТЭЛА не охватывают все многообразие изменений кардиограммы при этой патологии. Могут быть сочетания вариантов, возможно, есть и иные проявления (подъем сегмента S -T в V 1, V 2, V 3, появление глубокого зубца S во всех грудных отведениях), однако рассмотренная нами ЭКГ картина при ТЭЛА встречается наиболее часто.
• ТЭЛА вызывает острую перегрузку правого сердца, которая, однако, не обусловлена первичной патологией сердца.
• Для острой ТЭЛА характерен синдром МакГинна-Уайта, при котором отмечается сочетание SI-QIII и депрессия сегмента ST в отведении V1 с подъемом сегмента ST и отрицательной терминальной частью зубца Т в отведении III, причем в отведении III регистрируется большой зубец Q.
• К другим изменениям, выявляемым на ЭКГ при ТЭЛА, относятся неполная или полная блокада ПНПГ, высокий зубец R в отведении V1 и глубокий отрицательный зубец Т в грудных отведениях.
• Серьезные нарушения ритма, например, групповые желудочковые экстрасистолы или желудочковая тахикардия, регистрируются в тяжелых случаях, обычно в терминальной стадии.
При ТЭЛА возникает внезапная перегрузка правых отделов сердца (острое легочное сердце), которая, однако, не связана с первичным заболеванием сердца, например поражением клапанов. Наиболее частой причиной ТЭЛА бывает тромбоз глубоких вен, например в послеоперационном периоде, после тяжелых родов, а также передозировка диуретиков.
ЭКГ-изменения характерны для ТЭЛА и имеют диагностическое значение при своевременной регистрации ЭКГ. Поскольку ТЭЛА при фульминантной форме представляет непосредственную угрозу жизни больного и без лечения обычно приводит к смерти, к изменениям ЭКГ следует отнестись очень внимательно.
На ЭКГ, регистрируемой сразу после появления клинической картины острой ТЭЛА, отмечается так называемой синдром МакГинна-Уайта. Это важный признак острой ТЭЛА. Для него характерно сочетание SI-QIII, которое соответствует повороту электрической оси сердца кзади. В отведении I при этом регистрируется глубокий зубец S, а в отведении III — большой (т.е. глубокий и уширенный) зубец Q.
Кроме того, для ТЭЛА характерны также следующие важные изменения. В отведении I, помимо глубокого зубца S, регистрируется депрессия сегмента ST. При блокаде ПНПГ, когда в отведении I также регистрируется глубокий зубец S, такая депрессия ST не наблюдается. В то же время в отведении III, наряду с большим зубцом Q, регистрируются подъем сегмента ST, отрицательная терминальная часть зубца Т.
Большой зубец Q может стать причиной ошибочной диагностики ИМ задней стенки. В отведении aVL изменения ЭКГ часто бывают такими же, как в отведении I. Описанные изменения известны как синдром МакГинна-Уайта. Cиндром МакГинна-Уайта является характерной особенностью острой ТЭЛА. Однако его выявляют не всегда, так как он обычно бывает преходящим и уже через несколько часов может исчезнуть.
При острой ТЭЛА возможны также другие изолированные изменения: неполная или полная блокада ПНПГ, признаки гипертрофии правого желудочка (ПЖ) (например, высокий зубец R или R’ в отведении V1), позднее появляются также остроконечный отрицательный зубец Т с депрессией сегмента ST в отведениях V1-V4, иногда даже в отведении V6.
Известны также случаи, когда, несмотря на то, что диагноз ТЭЛА не вызывал сомнений, на ЭКГ внезапно появлялись признаки, соответствующие правому типу, правопредсердный зубец Р, иногда синусовая тахикардия без соответствующих изменений. Эти изменения быстро исчезают при улучшении клинического состояния больного.
Серьезные нарушения ритма сердца, такие как групповые желудочковые экстрасистолы и желудочковая тахикардия или фибрилляция желудочков, часто появляются в терминальной стадии фульминантной ТЭЛА.
Особенности ЭКГ при ТЭЛА:
• Сочетание SI-QIII, подъем сегмента ST и большой зубец Q в отведении I
• Блокада правой ножки пучка Гиса (ПНПГ)
• Признаки гипертрофии ПЖ
• Отрицательный зубец Т в отведениях V1-V4
• Нарушения ритма сердца (синусовая тахикардия)
Острая ТЭЛА.
Синусовая тахикардия с частотой сокращений желудочков 150 ударов в минуту.
Сочетание SI-QIII, депрессия сегмента ST в отведении I, большой зубец Q и подъем сегмента ST и отрицательная терминальная часть зубца Т в отведении III представляют собой синдром МакГинна-Уайта.
Инфаркта миокарда (ИМ) задней стенки нет.
Клиническая симптоматика ТЭЛА неспецифична, так как сходные симптомы могут наблюдаться при целом ряде различных заболеваний. В то же время, правильная интерпретация клинических данных позволяет обоснованно заподозрить эмболию и наметить адекватный план обследования. Клиническая картина ТЭЛА определяется объемом поражения легочных артерий и преэмболическим кардиопульмональным статусом пациента (ХСН, ХНЗЛ).
Внезапно возникшая одышка — самая частая жалоба при ТЭЛА, усиливающаяся при переходе пациента в положение сидя или стоя, когда уменьшается приток крови к правым отделам сердца. При наличии блока кровотока в легком уменьшается наполнение левого желудочка, что способствует снижению МО и падению АД. При СН одышка уменьшается при ортопозиции пациента, а при пневмонии и ХНЗЛ она не меняется при изменении положения больного.
Периферическая боль в грудной клетке при ТЭЛА, наиболее характерная для поражения мелких ветвей легочной артерии, обусловлена вовлечением в воспалительный процесс висцеральных листков плевры. Боль в правом подреберье свидетельствует об остром увеличении печени и растяжении Глиссоновой капсулы.
Загрудинная стенокардитическая боль характерна для эмболии крупных ветвей легочной артерии. Она возникает в результате расширения правых отделов сердца, приводящего к сдавлению коронарных артерий между перикардом и расширенными правыми отделами сердца. Чаще всего загрудинная боль имеет место у пациентов с ИБС, переносящих ТЭЛА.
Кровохарканье при инфаркт-пневмонии в результате ТЭЛА в виде кровяных полосок в мокроте отличаются от кровохарканья при стенозе митрального клапана — кровяная мокрота.
Парадоксальные эмболии представляют собой внезапно развивающиеся симптомы массивной ТЭЛА в сочетании с острым нарушением мозгового кровообращения.
В основе развития данной формы ТЭЛА лежит наличие внутрисердечного шунта со сбросом крови справа налево, самая частая причина которого — открытое foramen ovale.
Возникновение указанных выше симптомов у пациентов с признаками тромбоза в системе нижней полой вены любой врач не замедлит связать с возможностью ТЭЛА. Трудность заключается в том, что в половине случаев в момент развития эмболии (даже массивной) венозный тромбоз протекает бессимптомно, то есть легочная эмболия является первым симптомом наличия тромбоза глубоких вен нижних конечностей или таза.
Физикальные признаки ТЭЛА также многообразны и требуют особого внимания со стороны практикующих врачей.
Шум трения плевры диагностируется, в среднем, у 53% пациентов.
Усиление II тона над легочной артерией и появление систолического ритма галопа при ТЭЛА свидетельствует о повышении давления в системе легочной артерии и гиперфункции правого желудочка и встречаются, в среднем, у 53% пациентов.
Тахипноэ при ТЭЛА чаще всего превышает 20 дыхательных движений в 1 минуту и характеризуется стойкостью и поверхностным характером дыхания. Данный симптом вместе с выраженной одышкой, в среднем, проявляется у 60-82% пациентов.
Уровень тахикардии при ТЭЛА находится в прямой зависимости от размеров поражения сосудов, выраженности нарушений центральной гемодинамики, дыхательной и циркуляторной гипоксемии.
Повышенная потливость имеет место в 34% случаев среди пациентов преимущественно с массивной ТЭЛА и является следствием повышенной симпатической активности, сопровождающейся чувством тревоги и кардиопульмональным дистрессом.
Боль за грудиной проявляется у 49% пациентов, кашель — у 20%, обморок — у 14%, кровохарканье — у 7% пациентов. Периферический флебит проявляется у 33% больных, цианоз — у 18%. Лихорадка (>37°) наблюдается при массивной ТЭЛА — у 42% больных.
При подозрении ТЭЛА на основе жалоб больного и оценки факторов риска венозного тромбоза, необходимо провести рутинные методы инструментального обследования: ЭКГ, рентгенографию, ЭхоКГ, клинический и биохимический анализ крови.
M.Rodger и P.S.Wells (2001) предложили предварительную балльную оценку вероятности ТЭЛА:
наличие клинических симптомов тромбоза глубоких вен конечностей — 3 балла;
при проведении дифференциальной диагностики ТЭЛА наиболее вероятна — 3 балла;
вынужденный постельный режим на протяжении последних 3-5 дней -1,5 балла;
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