动态心电图及心率变异性对冠心病及其严重程度的诊断价值的探讨
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摘要
目的 探讨动态心电图(AECG)及心率变异性(HRV)对判断冠状动脉病变及其严重程度的预测价值。方法 选择126例同期行冠状动脉造影(CAG)和24h动态心电图(AECG)监测的病人，按CAG结果分组，对AECG所获得的心率、心律失常、ST-T变化及HRV各项指标进行统计学分析和比较。结果 (1) ST指标(ST、ST／HR)及HRV部分指标(SDNN、RMSSD、TRI、VLI、Poincare Plot散点图)在CAG阳性与CAG阴性两组间以及单支、双支、三支病变三组间比较差异有统计学意义，且随冠脉病变范围的增大，上述指标的变化值加大；而心律失常指标(包括心律失常类型、数量)及HRV中的LF／HF、VAI在上述组间比较差异均无统计学意义。(2) ST、ST／HR与冠脉病变范围及程度呈下相关，SDNN、TRI、VLI与冠脉病变范围及程度呈负相关。(3) ST、ST／HR、SDNN对冠脉病变诊断的真实性较好，且随冠脉病变范围增大其诊断的敏感性递增，其中单一指标诊断以ST／HR价值最大，联合运用时可使对冠心病的诊断价值增高，其中以ST／HR与SDNN并联效果最佳。(4) 单一指标的筛检试验及联合筛检试验均显示对冠心病的诊断价值男性优于女性。结论 (1) ST、ST／HR指标是反映冠心病心肌缺血及冠脉病变严重程度的可靠指标。(2) SDNN、TRI、VLI指标是预测冠心病自主神经功能损害及其严重程度的敏感指标。(3) ST／HR与SDNN联合运用(并联)可提高AECG对冠心病的诊断价值。(4) AECG对冠心病的诊断价值存在性别差异，对男性优于对女性。
Objective: To study the predictable value of the diagnosis of coronary heart disease (CHD) and its extend by ambulatory electrocardiograph (AECG) and heart rate variability (HRV).Methods: we selected 126 patients who had undergone 24h AECG and selective coronary angiography (CAG) in the same period. The groups were divided according to the results of CAG. Then we analyzed and compared with all of the data which had accepted by AECG. Results: (1) Significant difference were found in the variables of ST, ST/HR, SDNN, RMSSD, TRI, VLI and Poincare Plot between the groupes of CHD [CAG(+)] and non-CHD [CAG(-)], and the same results were found in the three groups of single, double and triplet coronary pathology. The changes of the variables above were increasing by the extend of coronary pathology. No significant difference were found in the variables of arrhythmia, LH/HF and VAI. (2) Positive correlation was found between the variables of ST, ST/HR and the extend of coronary pathology. While negative correlation w
as found between the variables of SDNN, TRI, VLI and the extend of coronary pathology. (3) The variables of ST, ST/HR, SDNN had better truthfulness than those of the others in the diagnosis of CHD. The sensitivity to the diagnosis of CHD was increasing by the extend of coronary pathology. The variable of ST/HR had the best diagnostic value in the three variables when we used any single variable. The diagnostic value to CHD would be improved when we combined these variables for use. Compared with all sorts of patterns of connection, parallel connection of ST/HR and SDNN was the best way of connection. (4) Whatever we used single or
combined variables to diagnosis CHD, male was prior to female. Conclusions: (1)ST and ST/HR were the reliable variables of reflecting myocardial ischemia and the extend of coronary pathology. (2) SDNN, TRI and VLI were the sensitive variables of predicting autonomic neuropathy and its extend. (3) Using the method of parralled connection by ST/HR and SDNN could improve the diagnostic value to CHD. (4) Male is prior to female when we used AECG to diagnosis CHD.
Objective: To study the predictable value of the diagnosis of coronary heart disease (CHD) and its extend by ambulatory electrocardiograph (AECG) and heart rate variability (HRV).Methods: we selected 126 patients who had undergone 24h AECG and selective coronary angiography (CAG) in the same period. The groups were divided according to the results of CAG. Then we analyzed and compared with all of the data which had accepted by AECG. Results: (1) Significant difference were found in the variables of ST, ST/HR, SDNN, RMSSD, TRI, VLI and Poincare Plot between the groupes of CHD [CAG(+)] and non-CHD [CAG(-)], and the same results were found in the three groups of single, double and triplet coronary pathology. The changes of the variables above were increasing by the extend of coronary pathology. No significant difference were found in the variables of arrhythmia, LH/HF and VAI. (2) Positive correlation was found between the variables of ST, ST/HR and the extend of coronary pathology. While negative correlation w
as found between the variables of SDNN, TRI, VLI and the extend of coronary pathology. (3) The variables of ST, ST/HR, SDNN had better truthfulness than those of the others in the diagnosis of CHD. The sensitivity to the diagnosis of CHD was increasing by the extend of coronary pathology. The variable of ST/HR had the best diagnostic value in the three variables when we used any single variable. The diagnostic value to CHD would be improved when we combined these variables for use. Compared with all sorts of patterns of connection, parallel connection of ST/HR and SDNN was the best way of connection. (4) Whatever we used single or
combined variables to diagnosis CHD, male was prior to female. Conclusions: (1)ST and ST/HR were the reliable variables of reflecting myocardial ischemia and the extend of coronary pathology. (2) SDNN, TRI and VLI were the sensitive variables of predicting autonomic neuropathy and its extend. (3) Using the method of parralled connection by ST/HR and SDNN could improve the diagnostic value to CHD. (4) Male is prior to female when we used AECG to diagnosis CHD.
引文
1 Pashkow, FJ(美)，Dafoe，WA(加)著，李振有，王惠中译。Clinical Cardiac Rehabilitation．A Cardiologist's guide，临床心脏康复指导，天津：天津科技翻译出版公司。2000，5 1
2 王茂斌，曲镭等。心脏疾病的康复医疗学，北京：人民卫生出版社。2000，1 1
3 张开滋，郭继鸿，刘海祥等。临床心电信息学，长沙，湖南科学技术出版社。2002．10 744-745
4 Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation, 1995,91:2335-44
5 罗义，郭南山等。冠状动脉病变程度于胰岛素敏感性的关系。中华心血管病杂志。2001，28(3)：273-276
6 Ootto AM. The Forgotten Risk Factor. Circulation, 1998,97:1027
7 陈清启，杨庭树，卢喜烈等。心电图学。山东：山东科学技术出版社。2002，1769-771
8 陈新主编。临床心律失常学。北京：人民卫生出版社。2000，11 1011
9 Rich MW, Saini JS, Kleiger RE, et al. Correlation of Heart Rate Variability with Clinical and Angiographic Variables and Late Mortality After Coronary Angiography. Am J Cardiol, 1988,62:714-717
10 Hayano J, YamadaA, Mukai S, et al. Severity of coronary atherosclerosis correlates with the respiratory component of heart rate variability. Am Heart J,1991,121:1070-1079
11 胡静泠，秦勉等。心率变异性与冠状动脉病变范围及严重度关系初探。西北国防医学杂志，2000，12，30：21(4)269-271
12 李上共，黄之伟等。冠心病心率变异特征及其影响因素。温州医学院学报，1999 29(3)：196-198
13 邵海峰．刘惠明等。冠心病发作性心肌缺血患者心率变异性与室性心律失常及其相关性。临床荟萃，1998．13(17)：780-781
14 章黎苹，朱建华等。不同程度冠状动脉狭窄患者的心率变异性分析。心电学杂志，1999，11(1)：15-17
15 Huikuri HV, Linnaluoto MK, Seppanen T, et al. HRV and its circadian rhythm in survivors of cardiac arrest [J]. Am J Cardiol, 1992,70:610-615
16 Algra A, Tijssem J GP, Reolandt JRTC, et al. HRV from 24 hours electrocardiography and the 2 years risk for sudden death [J]. Circulation, 1993,88:180-185
17 Ilia R, Carmel S, Gueron M. Patients with coronary collaterals and normal left ventricular systolic function: clinical, hemodynamic, and angiographic characteristics [J]. Angiology, 1998,49(8):631
18 Melidonis A, Tournis S, Kouvaras G, et al. Comparison of coronary collateral circulation in diabetic and nondiabetic patients suffering from coronary artery disease [J].Clin Cardiol, 1999,22(7):465
19 Harold LK, Nobel EG, Wolf E, et al. Ambulatory electrocardiograph and myocardial ischemia. Am Heart J 1989; 117:164
20 Steven HK, Patmei ST, Armstrong WF, et al. Use of the ambulatory ECG to diagnose coronary artery disease. J Electrocardiol 1980; 13:341
21 Dimarco JP, Philbrick JT, Use of ambulatory electrocardiographyic monitoring[J]. Ann Intern Med, 1990,113(1): 77-79.
22 吴林，张钧华，邵耕，等。三种无创性检查方法诊断冠心病无症状心肌缺血的价值[J]。中国循环杂志，1992，7(2)：137-140。
23 Tzivoni D, Bertram P, Donnelly RF, et al. Day-to-Day variability of myocardial ischemic episodes in coronary artery disease. Am J Cardiol 1987:60:1003
24 卢军，覃绍明，王风。心电图、动态心电图、心脏超声心动图及冠脉造影在冠
心病诊断的价值。广西医学1999，21(5)：880-882
25 Kingwell BA, Thompson JM, Kaye DM, et al. Heart rate spectral analysis, cardiac norepinephrine spillover, and myscle sympathetic nerve activity during human sympathetic nervous activation and failure. Circulation, 1994, 90 (1) 234
26 Moser M, Lehofer M, Sedminek A, et al. Heart rate variability as a prognostic tool in cardiology: a contribution to the problem from a theoretical point of view. Circulation, 1994, 90(2):1078
27 陈柯萍，王崇慧等。心率变异性与冠状动脉病变关系。临床心电学杂志，1996，5(4)：153-155
28 刘双凤，李建美等。不同冠状动脉病变支数患者经皮腔内冠脉成形术前术后心率变异性对比分析。山西医药杂志，1996，25(6)：413-414
29 homobardi f, Verrier RL, Lown B. Relationship between Sympathetic neural activity, coronary dynamics and vulnerability to ventricular fibrillation during myocardial ischemia and reperfusion, AM Heart J, 1983,105:958
30 Collins MN, Biltman GE. iutonomic response to coronary occlusion in animals susceptible to ventricular fibrillation. AM J Physiol, 1989,26:H 1886
2 王茂斌，曲镭等。心脏疾病的康复医疗学，北京：人民卫生出版社。2000，1 1
3 张开滋，郭继鸿，刘海祥等。临床心电信息学，长沙，湖南科学技术出版社。2002．10 744-745
4 Caracciolo EA, Davis KB, Sopko G, et al. Comparison of surgical and medical group survival in patients with left main equivalent coronary artery disease. Long-term CASS experience. Circulation, 1995,91:2335-44
5 罗义，郭南山等。冠状动脉病变程度于胰岛素敏感性的关系。中华心血管病杂志。2001，28(3)：273-276
6 Ootto AM. The Forgotten Risk Factor. Circulation, 1998,97:1027
7 陈清启，杨庭树，卢喜烈等。心电图学。山东：山东科学技术出版社。2002，1769-771
8 陈新主编。临床心律失常学。北京：人民卫生出版社。2000，11 1011
9 Rich MW, Saini JS, Kleiger RE, et al. Correlation of Heart Rate Variability with Clinical and Angiographic Variables and Late Mortality After Coronary Angiography. Am J Cardiol, 1988,62:714-717
10 Hayano J, YamadaA, Mukai S, et al. Severity of coronary atherosclerosis correlates with the respiratory component of heart rate variability. Am Heart J,1991,121:1070-1079
11 胡静泠，秦勉等。心率变异性与冠状动脉病变范围及严重度关系初探。西北国防医学杂志，2000，12，30：21(4)269-271
12 李上共，黄之伟等。冠心病心率变异特征及其影响因素。温州医学院学报，1999 29(3)：196-198
13 邵海峰．刘惠明等。冠心病发作性心肌缺血患者心率变异性与室性心律失常及其相关性。临床荟萃，1998．13(17)：780-781
14 章黎苹，朱建华等。不同程度冠状动脉狭窄患者的心率变异性分析。心电学杂志，1999，11(1)：15-17
15 Huikuri HV, Linnaluoto MK, Seppanen T, et al. HRV and its circadian rhythm in survivors of cardiac arrest [J]. Am J Cardiol, 1992,70:610-615
16 Algra A, Tijssem J GP, Reolandt JRTC, et al. HRV from 24 hours electrocardiography and the 2 years risk for sudden death [J]. Circulation, 1993,88:180-185
17 Ilia R, Carmel S, Gueron M. Patients with coronary collaterals and normal left ventricular systolic function: clinical, hemodynamic, and angiographic characteristics [J]. Angiology, 1998,49(8):631
18 Melidonis A, Tournis S, Kouvaras G, et al. Comparison of coronary collateral circulation in diabetic and nondiabetic patients suffering from coronary artery disease [J].Clin Cardiol, 1999,22(7):465
19 Harold LK, Nobel EG, Wolf E, et al. Ambulatory electrocardiograph and myocardial ischemia. Am Heart J 1989; 117:164
20 Steven HK, Patmei ST, Armstrong WF, et al. Use of the ambulatory ECG to diagnose coronary artery disease. J Electrocardiol 1980; 13:341
21 Dimarco JP, Philbrick JT, Use of ambulatory electrocardiographyic monitoring[J]. Ann Intern Med, 1990,113(1): 77-79.
22 吴林，张钧华，邵耕，等。三种无创性检查方法诊断冠心病无症状心肌缺血的价值[J]。中国循环杂志，1992，7(2)：137-140。
23 Tzivoni D, Bertram P, Donnelly RF, et al. Day-to-Day variability of myocardial ischemic episodes in coronary artery disease. Am J Cardiol 1987:60:1003
24 卢军，覃绍明，王风。心电图、动态心电图、心脏超声心动图及冠脉造影在冠
心病诊断的价值。广西医学1999，21(5)：880-882
25 Kingwell BA, Thompson JM, Kaye DM, et al. Heart rate spectral analysis, cardiac norepinephrine spillover, and myscle sympathetic nerve activity during human sympathetic nervous activation and failure. Circulation, 1994, 90 (1) 234
26 Moser M, Lehofer M, Sedminek A, et al. Heart rate variability as a prognostic tool in cardiology: a contribution to the problem from a theoretical point of view. Circulation, 1994, 90(2):1078
27 陈柯萍，王崇慧等。心率变异性与冠状动脉病变关系。临床心电学杂志，1996，5(4)：153-155
28 刘双凤，李建美等。不同冠状动脉病变支数患者经皮腔内冠脉成形术前术后心率变异性对比分析。山西医药杂志，1996，25(6)：413-414
29 homobardi f, Verrier RL, Lown B. Relationship between Sympathetic neural activity, coronary dynamics and vulnerability to ventricular fibrillation during myocardial ischemia and reperfusion, AM Heart J, 1983,105:958
30 Collins MN, Biltman GE. iutonomic response to coronary occlusion in animals susceptible to ventricular fibrillation. AM J Physiol, 1989,26:H 1886