心房颤动的动态心电图研究
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摘要
目的：探讨持续性心房颤动(AF)心室率(HR)的波动情况，阵发性AF(PAF)发作、持续、终止的节律变化，诱发PAF的可能因素，及P波离散度(Pd)的动态变化。方法：3导、12导同步动态心电图(DCG)检测，采用心室率各参数和24h每小时平均心室率的频率趋势图分析持续性AF的HR波动情况；分析PAF各时段发作、终止的次数和持续时间的节律变化；研究PAF发作与窦性心室率、前5min窦性心律的心率变异、房早及其配对间期的关系；实时12导联同步DCG测量PAF发作前即刻、前1h的Pd。结果：(1)持续性AF最快、最慢、和平均HR两两比较P＜0.001，HR存在昼快夜慢的节律变化；(2)PAF发作于3：00增多，凌晨4：00～6：00达高峰，终止与发作的节律变化基本一致，持续高峰在11：00～16：00；(3)PAF发作前HR＜60bpm者78次(32.09％)，伴LF／HF＜1.5者68次(87.18％)；HR＞90bpm者52次(21.3％)，伴LF／HF＞2.0者43次(82.69％)；(4)诱发PAF的房早配对间期(453.21
士57.32ms)及配对间期<500ms者与对照组比较P<0.05，0.01。
(5)PAF发作前即刻、发作前lh的Pd为46.8士9.45ms，43.20
士7，83ms，P<0.05。结论:DcG对评价持续性AF心室率的
控制，分析PAF发作、持续、终止的节律变化，PAF发作与窦
性心率、自主神经介导、房早及配对间期的关系，是一项十分
有用的检查方法，能为临床预防PAF的发生及复律等治疗提供
依据;实时12导同步DCG能直接反映PAF发作前即刻Pd的
动态变化，较12导同步体表ECG更为客观准确。
Objective To investigate ventricular heart rate (HR) changes of persistent atrial fibrillation (AF) and circadian variation of the onset, maintenance and termination of paroxysmal atrial fibrillation (PAF), possible factors of eliciting PAF, dynamic changes of P wave dispersion. Methods Monitored by 3-lead and 12 -lead dynamic Electrocardiograms (DCG). Analyzed the changes of heart rate with parameters of ventricular rate and hourly frequency gram. Observed circadian variation of onset and termination incidence and time lasting changes. Studied HR variation of sinus rhythm before 5 minutes attacking, relationship between premature atrial contraction, coupling interval and PAF episodes. Calculated P wave dispersion before PAF attacking and 1 hour before. Results (1) In persistent AF group most fast, most slowly and average HR, compared within two groups, P<0.001. It showed the regulative rhythm of fast in daytime and slow in the night. (2) PAF episodes began to increase from 3Am, became peak from 4Am to 6Am.
Circadian variation of onset and termination kept same. Persistent peak was between 11Am to 4Pm. (3) Before PAF attacking, there were 78 episodes, which HR was lower than 60bpm (32.09%), companied by 68 episodes, which LF/HF
<1.5(87.18%). There were 52 episodes which HR was faster than 90bpm (21.3%), companied by 43 episodes which LF/HF
> 2.0 (82.69%) . (4) The coupling interval of premature atrial contractions eliciting PAF (453. 21±57.32ms) compared with coupling interval of less than 500ms, P<0.05, 0.01; (5)P wave dispersions of immediately before and 1 hour before onset were 46.8±9.45ms and 43.20± 7.83ms, P<0.05. Conclusions DCG was very important and valuable, in which evaluated HR control of persistent AF, analyzed circadian variation of the onset, maintenance and termination of PAF, studied the relationship among sinus rhythm of PAF attacking and before attacking, autonomic nervous system, premature atrial contractions and coupling interval. It can provide evidence for clinical treatment, such as prediction the incidence of PAF and conversion et al.12-lead DCG can directly show ambulatory changes of P wave dispersion before PAF onset. It was more correctly than routine 12-lead ECG in diagnos ing.
士57.32ms)及配对间期<500ms者与对照组比较P<0.05，0.01。
(5)PAF发作前即刻、发作前lh的Pd为46.8士9.45ms，43.20
士7，83ms，P<0.05。结论:DcG对评价持续性AF心室率的
控制，分析PAF发作、持续、终止的节律变化，PAF发作与窦
性心率、自主神经介导、房早及配对间期的关系，是一项十分
有用的检查方法，能为临床预防PAF的发生及复律等治疗提供
依据;实时12导同步DCG能直接反映PAF发作前即刻Pd的
动态变化，较12导同步体表ECG更为客观准确。
Objective To investigate ventricular heart rate (HR) changes of persistent atrial fibrillation (AF) and circadian variation of the onset, maintenance and termination of paroxysmal atrial fibrillation (PAF), possible factors of eliciting PAF, dynamic changes of P wave dispersion. Methods Monitored by 3-lead and 12 -lead dynamic Electrocardiograms (DCG). Analyzed the changes of heart rate with parameters of ventricular rate and hourly frequency gram. Observed circadian variation of onset and termination incidence and time lasting changes. Studied HR variation of sinus rhythm before 5 minutes attacking, relationship between premature atrial contraction, coupling interval and PAF episodes. Calculated P wave dispersion before PAF attacking and 1 hour before. Results (1) In persistent AF group most fast, most slowly and average HR, compared within two groups, P<0.001. It showed the regulative rhythm of fast in daytime and slow in the night. (2) PAF episodes began to increase from 3Am, became peak from 4Am to 6Am.
Circadian variation of onset and termination kept same. Persistent peak was between 11Am to 4Pm. (3) Before PAF attacking, there were 78 episodes, which HR was lower than 60bpm (32.09%), companied by 68 episodes, which LF/HF
<1.5(87.18%). There were 52 episodes which HR was faster than 90bpm (21.3%), companied by 43 episodes which LF/HF
> 2.0 (82.69%) . (4) The coupling interval of premature atrial contractions eliciting PAF (453. 21±57.32ms) compared with coupling interval of less than 500ms, P<0.05, 0.01; (5)P wave dispersions of immediately before and 1 hour before onset were 46.8±9.45ms and 43.20± 7.83ms, P<0.05. Conclusions DCG was very important and valuable, in which evaluated HR control of persistent AF, analyzed circadian variation of the onset, maintenance and termination of PAF, studied the relationship among sinus rhythm of PAF attacking and before attacking, autonomic nervous system, premature atrial contractions and coupling interval. It can provide evidence for clinical treatment, such as prediction the incidence of PAF and conversion et al.12-lead DCG can directly show ambulatory changes of P wave dispersion before PAF onset. It was more correctly than routine 12-lead ECG in diagnos ing.
引文
1. Kannel WB, Abbot RD, Savage DD,et al.Coronary heart disease andatrial fibrillation: the Framinghm study . Am Heart J, 1983,106:389.
2．陈新．关于心房颤动的治疗．中华心律失常杂，2000，4(1)5．
3. Kawano S, Hiroka M, Sawanobori T. Electro cartographic features of P wave from patients with transient atrial fibrillation. Jpn Heart J,1988,29(1):57.
4. Levy S, Breithardt G, Campbell RWF, et al.On behalf of the Working Group on Arrthymial of the European Society of Cardiology. Atrial fibrillation; current knowledge and recommendations for management. Eur Heart J, 1998,19:1294.
5. Rawles JM, Woodrow B, Valentin F. What is meant by a "controlled" ventricularrate in atrial firiliiation? Br. Heart J, 1990, 63:157.
6. Lemery R, Brugada P, Cheriex E, et al. Reversibility of tachycardia-induced dysfunction after closed chest ablation of the atrioventricular junction for itract-able atrial fibrillation. Am J Cardiol, 1987, 60: 1406.
7．钱秉源，马临安，王建平，等．心房纤颤时心电图诊断二度房窒传达室导阻滞的价值．中华心血管病杂志，1993，21：36．
8. Lundstrow T, Moor E, Ryden L. Differential effects of xamoterol and verpapamil on ventricular rate regulation in patients with chronic atrial fibrillation. Am Heart J, 1992, 124:917.
9. Prystowsky EN, Benson JD, Woodrow MD, et al. Management of patients witatrial fibrillation:a statement for healthcare professionals from the subcommittee on electrocardiogrphy and electrophysiology, American Heart Association. Circulation, 1996,93:1262-1277.
10. Prystowsky EN. Management of atrial fibrillation: therapeutic options and clinical decision. Am J Cardiol,2000.85:3D.
11 张或，黄立萍，张树龙，等．持续性心房颤动心室率昼夜节律变化的特点．医师进修杂志，2000，23：27．
12．梁柱．综，心力衰竭时神经体源作用及其临床意义．心血管病学进展 1995，16：207．
13. Krum H, Bigger T, Goldsmith RL, et al. Effect of long-term digoxin therapy on auonomic funcation in patients with chronic heart failure .JACC, 1995,25:289.
14. Muller JE, Tofler GH, Stone PH. Circadian variation and triggers of onset of acute cardiovascular disease. Circulation. 1989, 79:733.
15. Parker JD, Teata MA, Jimenez AH, et al. Morning increasing ambulatory ischemia in patients with stable coronaryartery diseases. Circulation, 1994,89:604.
16. Yamashita T, Murakawa Y, Sezakimk , et al. Circadian variation of. paroxysmal atrial fibrillation. Circulation, 1997, 96(5):1537.
17. Kupari M, Koskinen P, Lenonen H. Double-peaking circadian variation in the occurrence of sustaind supraventricular tachyarrhthmias.
Am Heart J, 1990, 120 (6):1364.
18．叶玲娣，陈宝仙，赵力，等．阵发性心房颤动24h动态心电图分析．心电学杂志，2000，19(1)：24．
19．仟施政，房振英，韩献华．阵发性心房颤的昼夜分布节律．中华心律失常学杂志，1999，3(3)：175-176．
20. Coumel P. Neurogenic and humoral influences of the autonomic nervous system in the determination of paroxysmal atrial fibrillation. In:Atteul P, Coumel P, Janse MJ, eds. The atrium in health and disease. Mount Kisco, NY: Futura Publishing Co, 1989.213-232.
21．郭继鸿主编．新概念心电图．北京：北京医科大学出版社，第二版，2002，318-322．
22．林治湖，杨延忠，杨东辉．自主神经系统与心律失常．中华心律失常学杂志，2002，6(2)：120．
23. Capucci A, Santarelli A, Boriani G, et al. Atrial premature beats coupling interval determines lone paroxysmal atrial fibrillation onset. Int J Cardiol, 1992, 36: 87.
24．吴瑛，牛过栋，李宏才，等．阵发性心房颤动发作特点的研究．中华心律失常杂志，2000，5(3)：142．
25．郭继鸿主编．新概念心电图。北京：北京医科大学出版社，第二版，2002，309-317．
26．黄立萍，杨东辉，张树龙，等．动态心电图在评价灶性房颤中的意义．临床心电学杂志，2002，11(1)7．
27. Josephsin ME, Kastor JA, Morganroth J. Electrcardiographic leftatrial enlargement: electrophydiologic, electrcardiographic and
hemodynamic correlates. Am J Cardiol, 1977,39:967.
28. Dilaveris PE, Gialafos EJ, Siderris SK, et al. Simple electrocardiogggraphic marker for the prediction of paroxysmal idiopathic atrial fibrillation. Am Heart J, 1998,135:733.
29．郭继鸿．P波离散度．临床心电学杂志，1999，8(3)：189．
30. Aytemir K, Ozer N, Atalar E, et al. P wave dispersion on 12-lead electrocardiography in patients with paroxysmal atrial fibrillation. Pacing Clin Electrophysiol,2000,23(7):1109.
2．陈新．关于心房颤动的治疗．中华心律失常杂，2000，4(1)5．
3. Kawano S, Hiroka M, Sawanobori T. Electro cartographic features of P wave from patients with transient atrial fibrillation. Jpn Heart J,1988,29(1):57.
4. Levy S, Breithardt G, Campbell RWF, et al.On behalf of the Working Group on Arrthymial of the European Society of Cardiology. Atrial fibrillation; current knowledge and recommendations for management. Eur Heart J, 1998,19:1294.
5. Rawles JM, Woodrow B, Valentin F. What is meant by a "controlled" ventricularrate in atrial firiliiation? Br. Heart J, 1990, 63:157.
6. Lemery R, Brugada P, Cheriex E, et al. Reversibility of tachycardia-induced dysfunction after closed chest ablation of the atrioventricular junction for itract-able atrial fibrillation. Am J Cardiol, 1987, 60: 1406.
7．钱秉源，马临安，王建平，等．心房纤颤时心电图诊断二度房窒传达室导阻滞的价值．中华心血管病杂志，1993，21：36．
8. Lundstrow T, Moor E, Ryden L. Differential effects of xamoterol and verpapamil on ventricular rate regulation in patients with chronic atrial fibrillation. Am Heart J, 1992, 124:917.
9. Prystowsky EN, Benson JD, Woodrow MD, et al. Management of patients witatrial fibrillation:a statement for healthcare professionals from the subcommittee on electrocardiogrphy and electrophysiology, American Heart Association. Circulation, 1996,93:1262-1277.
10. Prystowsky EN. Management of atrial fibrillation: therapeutic options and clinical decision. Am J Cardiol,2000.85:3D.
11 张或，黄立萍，张树龙，等．持续性心房颤动心室率昼夜节律变化的特点．医师进修杂志，2000，23：27．
12．梁柱．综，心力衰竭时神经体源作用及其临床意义．心血管病学进展 1995，16：207．
13. Krum H, Bigger T, Goldsmith RL, et al. Effect of long-term digoxin therapy on auonomic funcation in patients with chronic heart failure .JACC, 1995,25:289.
14. Muller JE, Tofler GH, Stone PH. Circadian variation and triggers of onset of acute cardiovascular disease. Circulation. 1989, 79:733.
15. Parker JD, Teata MA, Jimenez AH, et al. Morning increasing ambulatory ischemia in patients with stable coronaryartery diseases. Circulation, 1994,89:604.
16. Yamashita T, Murakawa Y, Sezakimk , et al. Circadian variation of. paroxysmal atrial fibrillation. Circulation, 1997, 96(5):1537.
17. Kupari M, Koskinen P, Lenonen H. Double-peaking circadian variation in the occurrence of sustaind supraventricular tachyarrhthmias.
Am Heart J, 1990, 120 (6):1364.
18．叶玲娣，陈宝仙，赵力，等．阵发性心房颤动24h动态心电图分析．心电学杂志，2000，19(1)：24．
19．仟施政，房振英，韩献华．阵发性心房颤的昼夜分布节律．中华心律失常学杂志，1999，3(3)：175-176．
20. Coumel P. Neurogenic and humoral influences of the autonomic nervous system in the determination of paroxysmal atrial fibrillation. In:Atteul P, Coumel P, Janse MJ, eds. The atrium in health and disease. Mount Kisco, NY: Futura Publishing Co, 1989.213-232.
21．郭继鸿主编．新概念心电图．北京：北京医科大学出版社，第二版，2002，318-322．
22．林治湖，杨延忠，杨东辉．自主神经系统与心律失常．中华心律失常学杂志，2002，6(2)：120．
23. Capucci A, Santarelli A, Boriani G, et al. Atrial premature beats coupling interval determines lone paroxysmal atrial fibrillation onset. Int J Cardiol, 1992, 36: 87.
24．吴瑛，牛过栋，李宏才，等．阵发性心房颤动发作特点的研究．中华心律失常杂志，2000，5(3)：142．
25．郭继鸿主编．新概念心电图。北京：北京医科大学出版社，第二版，2002，309-317．
26．黄立萍，杨东辉，张树龙，等．动态心电图在评价灶性房颤中的意义．临床心电学杂志，2002，11(1)7．
27. Josephsin ME, Kastor JA, Morganroth J. Electrcardiographic leftatrial enlargement: electrophydiologic, electrcardiographic and
hemodynamic correlates. Am J Cardiol, 1977,39:967.
28. Dilaveris PE, Gialafos EJ, Siderris SK, et al. Simple electrocardiogggraphic marker for the prediction of paroxysmal idiopathic atrial fibrillation. Am Heart J, 1998,135:733.
29．郭继鸿．P波离散度．临床心电学杂志，1999，8(3)：189．
30. Aytemir K, Ozer N, Atalar E, et al. P wave dispersion on 12-lead electrocardiography in patients with paroxysmal atrial fibrillation. Pacing Clin Electrophysiol,2000,23(7):1109.
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