【作者】 戴朝晖；

【导师】 刘启明；

【作者基本信息】 中南大学 ， 心内科学， 2008， 硕士

【摘要】 目的:对冠心病患者窦性心率震荡（heart rate turbuience,HRT）及心率变异性（heart rate variability,HRV）指标进行分析,评价冠心病、冠脉病变与HRT、HRV的关系,以及两种指标的相关性,并探讨急性心肌梗死（acute myocardial infarction,AMI）后直接经皮冠状动脉介入（percutaneous coronary intervention,PCI）治疗前、后患者HRT指标的变化。方法:选择经冠状动脉造影证实的冠心病患者103例（A组）,其中稳定性心绞痛（stable angina pectoris,SAP）患者35例（A₁组）、不稳定性心绞痛（unstable angina pectoris,UAP）患者28例（A₂组）、AMI患者40例（A₃组）与有室性期前收缩但无器质性心脏病患者30例为健康对照组（B组）,行常规24h动态心电图检查,测定HRT指标（震荡起始TO及震荡斜率TS）及HRV各时域指标（SDNN、PNN50、HF）并做以下分析:①A组各亚组与B组HRT和HRV各项指标变化情况;②对A₁组患者根据冠脉造形结果,按照Gensini评分法进行冠脉评分,并分析HRT及HRV指标与冠脉评分（Gensini score）的相关性;③对A、B组HRT、HRV进行线性回归分析,探讨两指标相关性;④对A₃组患者于PCI前及PCI后2h、12-24h及术后1周进行24h动态心电图检查,分析HRT变化情况。结果:①A组各亚组TO值明显高于B组,TS值明显低于B组（P＜0.05）;A₃组与A₁、A₂组之间TO、TS值均差异有显著性（P＜0.01）,而A₁、A₂组之间TO、TS值差异无显著性（P＞0.05）;②A组各亚组HRV各时域指标（SDNN、PNN50、HF）值均明显低于B组（P＜0.05）;除PNN50值在A₁与A₂组之间差异无显著性（P＞0.05）外,HF、SDNN在A₁、A₂、A₃组两两相比中均有显著性差异（P＜0.01）;③在A₁组中,对HRT及HRV各项指标与冠脉评分（Gensini score）进行线性回归分析提示,TO与Gensini score正相关;TS、SDNN、PNN50、HF与Gensini score负相关,其中与TS相关性最强（r=-0.45）;④TO与SDNN、PNN50、HF均呈中等程度负相关;TS与SDNN、PNN50、HF均呈正相关,其中与HF的相关性相对较强（r=0.47）;⑤A₃组AMI患者成功直接PCI（TIMI-Ⅲ级）术后2h内TS值即明显改善:TS明显升高（P＜0.01）,而TO无明显改善（P＞0.05）;术后12-24h及一周后TO及TS较术前、术后2h均有明显改善（P＜0.01）,但术后12-24h及一周后HRT差异无统计学意义（P＞0.05）;AMI后行PCI（TIMI-Ⅱ级）患者术前、术后HRT差异无统计学意义（P＞0.05）。结论:①冠心病患者HRT现象变钝（TO值升高,TS值降低）,HRV各时域指标降低;②在预测冠脉病变严重程度上,HRT参数特别是TS相对HRV指标能更敏感地反映冠脉严重程度;③HRT与HRV参数间有相关性,其中TS与HF相关性较强;④AMI患者成功直接PCI再灌注（TIMI-Ⅲ级）治疗后可明显改善HRT,提示成功直接PCI可改善和恢复AMI患者心脏自主神经系统,尤其是迷走神经的抗心律失常保护作用机制。更多还原

【Abstract】 Objective: To analyze the changes of heart rate turbulence （HRT） and heart rate variability （HRV） in the coronary heart disease （CHD）, to evaluate the relationship between CHD, coronary artery disease （CAD）, and the 2 parameters of HRT and HRV, and to investigate the correlation of the 2 parameters and the changes of HRT in patients undergoing direct percutaneous coronary intervention after acute myocardial infarction （AMI）.Methods: We performed coronary angiography in all 103 patients with CHD （group A）, who were classified into 3 subgroups: 35 patients of stable angina pectoris （group A₁）, 28 patients of unstable angina pectoris （group A） and 40 patients of AMI （group A3）, and 30 structurally normal patients with ventricular premature contraction were included in healthy control group （group B）. The 24-hour ambulatory electrocardiogram was performed in all the patients and the parameters of HRT and HRV were obtained, including the parameters for HRT （TO and TS） and those for HRV （SDNN, PNN50, and HF）. The investigation included: （1）analyzing the changes of HRT and HRV in group A and group B; （2）analyzing the correlation between Gensini score and HRT,as well as HRV in patients of group A₁; （3）analyzing the correlation between HRT and HRV; and （4） monitoring the dynamic electrocardiogram before percutaneous coronary intervention （PCI） and within 2h, 12～24h, and 1 week after PCI in patients with AMI, and analyzing the changes of HRT.Results: （1）The value of the TO onset of group A was significantly higher than that of group B, the value of TS of group A was lower than that of group B （P<0.05 or P<0.01）. The value of TO/TS onset of group A3 had significant difference with group A₁ and group A₂, while the value of TO/TS onset had no significant difference between group A₁ and group A₂. （2）The values of SDNN, PNN50, and HF of group A were significantly lower than those of group B （P<0.05）. The values of SDNN and HF were also statistically different among the 3 subgroups of A₁, A₂, A₃ （P<0.01）, while the value of PNN50 onset was not statistically different between group A₁ and group A₂（P>0.05）; （3）TO was positively correlated with Gensinies score while TS, SDNN, PNN50. and HF were negatively correlated with Gensinies score, and TS showed the strongest negative correlation with Gensini score （r=-0.45）; （4）TO was negatively correlated with SDNN, PNN50, and HF; while TS was positively correlated with SDNN, PNN50 and HF, and TS showed much stronger correlation with HF （r=0.47）; and （5）The value of TS onset was significantly higher within 2h after successful PCI （TIMI-III） in patients with AMI （P<0.01）. Compared with 2h after PCI and before PCI ,the value of TO and TS onset were all improved significantly in 12-24h and 1 week after PCI （TIMI-III） （P<0.01）. There was no significant difference in TO and TS between 12²4h and 1 week after PCI（TIMI-III） （P>0.05）; HRT （TO and TS） values after PCI （TIMI-II） were not improved significantly （P>0.05）.Conclusions: （1） HRT is dramatically blunted and HRV is significantly lower in patients with CHD; （2）HRT and HRV of group A₁ were significantly correlated with Gensini score, and TS had the strongest correlation with Gensini score; （3）TO and TS were correlated with SDNN, PNN50, and HF, and TS had much stronger correlation with HF; and （4）Successful direct PCI （TIMI-III） could improve HRT significantly after AMI （P<0.01）. PCI could improve and revive heart autonomic nerve system, especially vagal antiarrhythmia protection integrity.更多还原