活动平板运动试验阳性与冠状动脉造影的对比研究
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摘要
目的 患者进行运动平板试验，检测病人的代谢当量、运动时间及最大心率，通过12导联连续心电检测，观察ST段变化及有无胸痛等且在适当时间接受冠状动脉造影及左室造影，了解冠状动脉病变范围及左室射血分数。探讨心电图活动平板试验阳性结果的患者对冠心病的诊断价值及对病变狭窄程度的估计价值。
方法 选取平板运动试验阳性者，且于试验前或后一周内行冠状动脉造影术患者94例，检测病人的代谢当量、运动时间及最大心率，通过12导联连续心电检测，观察ST段变化及有无胸痛的发生。病人在适当时间接受冠状动脉造影及左室造影，了解冠状动脉病变范围及左室射血分数。将其结果进行对比分析。
结果 冠状动脉狭窄程度越重，运动试验中ST段压低出现时间越早、幅度越大、持续时间越长。合并高血压和／或糖尿病的冠状动脉病变者比单纯性冠状动脉病变者程度重，表现在运动试验中ST段压低出现时间早、持续时间较长。冠脉狭窄程度与运动功量等级呈负相关。运动平板试验对冠状动脉多支病变具有重要的诊断参考价值，若以ST段下移大于0.1mV为阳性判断标准，运动试验诊断冠脉多支病变的敏感性、特异性、阳性预测值、阴性预测值分别是：76％、36％、81％、71％。若以ST段下移大于0.2mV为阳性标准，则诊断的敏感性明显降低至16％，而特异性最高为85％，同时其阳性预测值也升高至80％。若以代谢当量(METS)≤6.0为阳性标准，对多支冠脉病变诊断的敏感性较低，为44％，但特异性较高为85％，同时发现：ST段下移结合低代谢当量(METS≤6.0)对冠脉多支病变诊断的敏感性最高达到64％。本研究也显示，冠状动脉病变部位与ST段阳性改变的导联之间有一定的对应关系，分布频率较高的导联是：Ⅱ、Ⅲ、aVF、V_2、V_3、V_4、V_5、V_6导联，而avR导联的分布频率为零。冠脉病变部位与ST段阳性改变的导联之间有一定的对应关系，但并不总是恒定和唯一的。
结论 ①运动平板试验对诊断冠心病简单易行，准确度较高，是目前较理想
中文摘要
的非创伤性检查方法。通过多项指标如运动时间长短、最大METs、ST短压低持续
时间长短等综合判断结果可以初步推测病变程度。②冠脉病变部位与ST段阳性改
变的导联之间有一定的对应关系，但并不总是恒定和唯一的。③冠状动脉的狭窄程
度与运动功量等级呈负相关。④运动平板试验对冠状动脉多支病变具有明确的诊
断价值，可以初步判断冠状动脉病变部位，为冠状动脉造影提供有价值的参考资
料。⑤运动中有无胸痛的发生有助于判断单支或多支病变。⑥选择的指标不同，
则运动平板试验对冠状动脉多支病变诊断的敏感性、特异性、阳性预测值及阴性
预测值也发生相应改变。
Objective to detect metabolic equivalents (METS), exercise timing and maximum heart rate of the patients. Meanwhile, ST segment fluctuations and whether pectoris angina is accured were monitored by 12 leads electrocardiogram. The patients underwent coronary angiography and left ventriculography at appropriate time to investigate the extent of coronary artery disease and left ventricular ejection fraction(LVEF). The study is to elucidate the diagnositic value and stenosis degree of treadmill exercise testing in coronary artery disease (CAD).
Methods ninty-four patients were examined by coronary angiography (CAG) and treadmill exercise testing. To detect metabolic equivalents (METs), exercise timing and maximum heart rate of the patients. Meanwhile, ST segment fluctuations and whether pectoris angina is accured were monitored by 12 leads electrocardiogram. The patients underwent coronary angiography and left ventriculography at appropriate time to investigate the extent of coronary artery disease and left ventricular ejection fraction(LVEF). Analyze the results and process it with SPSS.
Results The more heavier coronary artery obstacled,the more earlier will it be when ST segment depression occurred. So as the ST amplitude and the time it lasted. The sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by exercise -induced ST segment depression >0.1mV was 76% , 36% , 81%, 71% respectively. The sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by METS<6.0 was 44% 85% 92% 70%. However, the sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by exercise -induced ST segment depression >0.2mV was 16% 85% 80% 78% respectively .By combining low workload and ST segment depression was 64%
93% 97% 58% respectively. METs maximum heart rate and exercise timing were not statistically significant between the single vessel disease and two vessel disease.(p>0.05) . Whereas, the three parameters mentioned above were statistically significant between single vessel disease and three vessel disease as well as two vessel disease and three vessel disease (P<0.05). No significantly comparable relations between the location of coronary artery disease and leads with positive ST segment changes were found out simultaneously. The leads with higher distributing frequencies
were II, III, aVF/V2 V3 V, V5 V6.
Conclusions (1) Exercise ECG test is an effective non-invasive method in the diagnosis of CAD . Some parameters in ECG test are helpful to predict the severity of CAD. (2)No significantly comparable relations between the location of coronary artery disease and leads with positive ST segment changes were found out simultaneously.(3) (4)There is an negtive correlation between the degree of coronary artery stenosis and metabolic equivalents (5)Whether there was pectoris angina contributed to determine single-vessel disease or multi-vessel disease.
方法 选取平板运动试验阳性者，且于试验前或后一周内行冠状动脉造影术患者94例，检测病人的代谢当量、运动时间及最大心率，通过12导联连续心电检测，观察ST段变化及有无胸痛的发生。病人在适当时间接受冠状动脉造影及左室造影，了解冠状动脉病变范围及左室射血分数。将其结果进行对比分析。
结果 冠状动脉狭窄程度越重，运动试验中ST段压低出现时间越早、幅度越大、持续时间越长。合并高血压和／或糖尿病的冠状动脉病变者比单纯性冠状动脉病变者程度重，表现在运动试验中ST段压低出现时间早、持续时间较长。冠脉狭窄程度与运动功量等级呈负相关。运动平板试验对冠状动脉多支病变具有重要的诊断参考价值，若以ST段下移大于0.1mV为阳性判断标准，运动试验诊断冠脉多支病变的敏感性、特异性、阳性预测值、阴性预测值分别是：76％、36％、81％、71％。若以ST段下移大于0.2mV为阳性标准，则诊断的敏感性明显降低至16％，而特异性最高为85％，同时其阳性预测值也升高至80％。若以代谢当量(METS)≤6.0为阳性标准，对多支冠脉病变诊断的敏感性较低，为44％，但特异性较高为85％，同时发现：ST段下移结合低代谢当量(METS≤6.0)对冠脉多支病变诊断的敏感性最高达到64％。本研究也显示，冠状动脉病变部位与ST段阳性改变的导联之间有一定的对应关系，分布频率较高的导联是：Ⅱ、Ⅲ、aVF、V_2、V_3、V_4、V_5、V_6导联，而avR导联的分布频率为零。冠脉病变部位与ST段阳性改变的导联之间有一定的对应关系，但并不总是恒定和唯一的。
结论 ①运动平板试验对诊断冠心病简单易行，准确度较高，是目前较理想
中文摘要
的非创伤性检查方法。通过多项指标如运动时间长短、最大METs、ST短压低持续
时间长短等综合判断结果可以初步推测病变程度。②冠脉病变部位与ST段阳性改
变的导联之间有一定的对应关系，但并不总是恒定和唯一的。③冠状动脉的狭窄程
度与运动功量等级呈负相关。④运动平板试验对冠状动脉多支病变具有明确的诊
断价值，可以初步判断冠状动脉病变部位，为冠状动脉造影提供有价值的参考资
料。⑤运动中有无胸痛的发生有助于判断单支或多支病变。⑥选择的指标不同，
则运动平板试验对冠状动脉多支病变诊断的敏感性、特异性、阳性预测值及阴性
预测值也发生相应改变。
Objective to detect metabolic equivalents (METS), exercise timing and maximum heart rate of the patients. Meanwhile, ST segment fluctuations and whether pectoris angina is accured were monitored by 12 leads electrocardiogram. The patients underwent coronary angiography and left ventriculography at appropriate time to investigate the extent of coronary artery disease and left ventricular ejection fraction(LVEF). The study is to elucidate the diagnositic value and stenosis degree of treadmill exercise testing in coronary artery disease (CAD).
Methods ninty-four patients were examined by coronary angiography (CAG) and treadmill exercise testing. To detect metabolic equivalents (METs), exercise timing and maximum heart rate of the patients. Meanwhile, ST segment fluctuations and whether pectoris angina is accured were monitored by 12 leads electrocardiogram. The patients underwent coronary angiography and left ventriculography at appropriate time to investigate the extent of coronary artery disease and left ventricular ejection fraction(LVEF). Analyze the results and process it with SPSS.
Results The more heavier coronary artery obstacled,the more earlier will it be when ST segment depression occurred. So as the ST amplitude and the time it lasted. The sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by exercise -induced ST segment depression >0.1mV was 76% , 36% , 81%, 71% respectively. The sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by METS<6.0 was 44% 85% 92% 70%. However, the sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by exercise -induced ST segment depression >0.2mV was 16% 85% 80% 78% respectively .By combining low workload and ST segment depression was 64%
93% 97% 58% respectively. METs maximum heart rate and exercise timing were not statistically significant between the single vessel disease and two vessel disease.(p>0.05) . Whereas, the three parameters mentioned above were statistically significant between single vessel disease and three vessel disease as well as two vessel disease and three vessel disease (P<0.05). No significantly comparable relations between the location of coronary artery disease and leads with positive ST segment changes were found out simultaneously. The leads with higher distributing frequencies
were II, III, aVF/V2 V3 V, V5 V6.
Conclusions (1) Exercise ECG test is an effective non-invasive method in the diagnosis of CAD . Some parameters in ECG test are helpful to predict the severity of CAD. (2)No significantly comparable relations between the location of coronary artery disease and leads with positive ST segment changes were found out simultaneously.(3) (4)There is an negtive correlation between the degree of coronary artery stenosis and metabolic equivalents (5)Whether there was pectoris angina contributed to determine single-vessel disease or multi-vessel disease.
引文
1 赵学。现代介入心脏病学实用技术。重庆：重庆出版社，1997，10～15．
2 陈湛。现代心脏病治疗指南。北京：科学技术出版社，1996，402～412。
3 Detrano R, Gianrossi R, Froelicher V. The diagnostic accuracy of the exercise electrocardiogram: a meta-analysis of 22 years of research. Prog Cardiovasc Dis ,1989, 32:173.
4 Philbrick JT, Horwitz RI, Feinstein AR. Methodologic problems of exercise testing for coronary artery disease: groups ,analysis and bias,Am J Cardiol, 1980,46:807.
5 李大元，汪丽蕙，朱国英，等。心电图负荷试验对判断经皮腔内冠状动脉成形术后再狭窄得意义。中华心血管病杂志，1995，14(4)：217。
6 Gibson RS ,Beller GA ,Should exercise electrocardiography be replaced by radionuclide methods? In: Rahimtoola SH, Brest AH, eds. Controversies in coronary artery disease .Philadelphia: FA Davis Co, 1981,1.
7 Hlatky MA, Pryor DB, Harrell FE, et al. Factors affecting sensitivity and specificity of exercise electrocardiography: multivariable analysis. Am J Med. 1984,77:64.
8 吴林，张均华，邵耕，等。心电图运动试验与冠状动脉造影得对照研究。中华内科杂志，1996，35：107～109。
9 Visser FC, van Leeuwen FT, Cemohorsky B ,et al. Slient versus symptomatic myocardial ischemia during exercise testing: a comparison with coronary angiography findings. Inter J Cardiol,1990,27:71.
10 Falcone C, de Servi S, Poma E, et al. Clinical significance of exercise induced silent myocardial ischemia in patients with coronaryartery disease.J Am Coll Cardiol, 1987,9:295.
11 Steven ER, Sidney O.Gottlieb prognostic implication of transient asymptomatic myocardial ischemia as detected by ambulatory electrocardiographic monitoring. Prog Cardiol Dis, 1992,35:77.
12 Starling MR. Predictive value of early post—myocardial infarction modified treadmill exercise testing in multi—vessel coronary artery disease detection.
Am Heart J 1981; 102:169
13 刘霞，张娟赢，沈卫峰等．急性心肌梗死恢复期运动试验的价值．临床心电学杂志，1992：1(1)：8
14 胡大一，王吉云．如何规范心电图运动负荷试验．中国医刊，2000：35(3)：18
15 陈在嘉，徐义枢，孔华宇主编 临床冠心病学，北京：人民军医出版社，1994：105-109
16 颜红兵．运动平板试验与冠状动脉造影的对应关系 中国心脏起搏与心电生理杂志，2002：16：150
17 路方红，等。前壁心肌梗塞波变化的临床意义。临床心血管病杂志，1993，9(6)：352。
18 Morris JJ, et al. P-Wave Analysis in Valvular Heart Disease. Circulation, 1964,29:242.
19 顾勇，等。运动试验Ptfv_1异常与超声心动图A/E的关系及临床意义。心电学杂志。1995，14(1)：6
20 刘鸿闽，等。Ptfv_1诊断冠心病的价值与左心功能的关系。心电学杂志，1993，12(4)：293。
2 陈湛。现代心脏病治疗指南。北京：科学技术出版社，1996，402～412。
3 Detrano R, Gianrossi R, Froelicher V. The diagnostic accuracy of the exercise electrocardiogram: a meta-analysis of 22 years of research. Prog Cardiovasc Dis ,1989, 32:173.
4 Philbrick JT, Horwitz RI, Feinstein AR. Methodologic problems of exercise testing for coronary artery disease: groups ,analysis and bias,Am J Cardiol, 1980,46:807.
5 李大元，汪丽蕙，朱国英，等。心电图负荷试验对判断经皮腔内冠状动脉成形术后再狭窄得意义。中华心血管病杂志，1995，14(4)：217。
6 Gibson RS ,Beller GA ,Should exercise electrocardiography be replaced by radionuclide methods? In: Rahimtoola SH, Brest AH, eds. Controversies in coronary artery disease .Philadelphia: FA Davis Co, 1981,1.
7 Hlatky MA, Pryor DB, Harrell FE, et al. Factors affecting sensitivity and specificity of exercise electrocardiography: multivariable analysis. Am J Med. 1984,77:64.
8 吴林，张均华，邵耕，等。心电图运动试验与冠状动脉造影得对照研究。中华内科杂志，1996，35：107～109。
9 Visser FC, van Leeuwen FT, Cemohorsky B ,et al. Slient versus symptomatic myocardial ischemia during exercise testing: a comparison with coronary angiography findings. Inter J Cardiol,1990,27:71.
10 Falcone C, de Servi S, Poma E, et al. Clinical significance of exercise induced silent myocardial ischemia in patients with coronaryartery disease.J Am Coll Cardiol, 1987,9:295.
11 Steven ER, Sidney O.Gottlieb prognostic implication of transient asymptomatic myocardial ischemia as detected by ambulatory electrocardiographic monitoring. Prog Cardiol Dis, 1992,35:77.
12 Starling MR. Predictive value of early post—myocardial infarction modified treadmill exercise testing in multi—vessel coronary artery disease detection.
Am Heart J 1981; 102:169
13 刘霞，张娟赢，沈卫峰等．急性心肌梗死恢复期运动试验的价值．临床心电学杂志，1992：1(1)：8
14 胡大一，王吉云．如何规范心电图运动负荷试验．中国医刊，2000：35(3)：18
15 陈在嘉，徐义枢，孔华宇主编 临床冠心病学，北京：人民军医出版社，1994：105-109
16 颜红兵．运动平板试验与冠状动脉造影的对应关系 中国心脏起搏与心电生理杂志，2002：16：150
17 路方红，等。前壁心肌梗塞波变化的临床意义。临床心血管病杂志，1993，9(6)：352。
18 Morris JJ, et al. P-Wave Analysis in Valvular Heart Disease. Circulation, 1964,29:242.
19 顾勇，等。运动试验Ptfv_1异常与超声心动图A/E的关系及临床意义。心电学杂志。1995，14(1)：6
20 刘鸿闽，等。Ptfv_1诊断冠心病的价值与左心功能的关系。心电学杂志，1993，12(4)：293。