入院时QRS波群时限与急性心肌梗死近期预后的关系
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摘要
急性心肌梗死作为临床上常见的急重症,其死亡率高,预后不佳,早期识别高危的急性心肌梗死患者,对高危患者实施针对性治疗,可显著降低急性心肌梗死的病死率及改善患者预后;因此对急性心肌梗死预后的研究历来是研究的热点,新近发现,除传统的年龄、性别、高血压、2型糖尿病、心肌梗死部位、发病时患者的心功能等因素外,入院时患者心电图QRS波群时限也是影响急性心肌梗死预后的因素之一,本文就旨在研究因急性心肌梗死住院的患者其入院时心电图QRS波群时限与患者住院期间心血管事件发生率之间的关系,对于符合条件的患者,根据其入院时QRS波群时限进行分组,结果发作,不同分组之间的患者其住院期间心血管事件的发生率具有显著性差异,其预后显著不同,经统计学分析差异具有显著性P<0.05,这就提示QRS波群时限是影响急性心肌梗死近期预后的因素之一,借助入院时QRS波群时限可以评估急性心肌梗死患者的近期预后。
Object: To investigate the relation between the QRS wave duration on admission (QRS d) and the prognosis in the near future in people who suffered acute myocardial infarction;to ascertain whether we can use QRS wave duration on admission-a simple、easy-accessed clinical definition to evaluating the prognosis in the near future in people who suffered acute myocardial infarction, through this, we can distinguish high-risk patients、perform some treatment in time、reduce mortality of acute myocardial infarction in the near future and improve the recent prognosis of patients who suffered acute myocardial infarction.
Methods:Randomly selected 88 patients suffered acute myocardial infarction who were hospitalized in cardiovascular department of the first hospital affiliated to Jilin University from January 1, 2002 to January 1, 2008; 55 of them were male, All the patients conform to WHO diagnostic criteria about acute myocardial infarction (1979 year): meet the following three criteria at least two ; 1) typical ischemic chest pain lasts more than 30 minutes; 2) ECG ST-T dynamic evolution; 3) enzyme markers of myocardial injury and their dynamic evolution. Exclusion criteria: 1) established cerebral infarction in past history, or cerebral hemorrhage in history; 2) complete atrioventricular block; 3) different intraventricular conduction or other clinical conditions that could interfere with the accurate measurement of QRS wave duration, such as early repolarization syndrome; 4) implanting permanent pacemaker in history; 5) patients who do not agree with coronary angiography; In order to facilitate the analysis, all the patients are acute ST-segment elevation myocardial infarction and all the patients accept coronary angiography. Divide enrolled patients into three different groups according to their QRS duration on admission: group A: QRS wave duration on admission lies between 0.06s to 0.08s; group B: QRS wave duration on admission lies between 0.08s to 0.10s; group C: QRS wave duration on admission was longer than 0.10s; Observe and record cardiovascular events in each groups respectively when patients are in hospital; Cardiovascular events are defined as sudden cardiac death, cardiac shocks, Adam-Strokes syndrome, cardiac insufficiency or cardiac Doppler ultrasound examination confirmed that LVEF≤40%, low blood pressure that must use vasoactive drugs such as dopamine or hydroxylamineto to maintain blood pressure, serious arrhythmias, such as worse than degree II atrioventricular block, paroxysmal or sustained ventricular tachycardia, ventricular fibrillation, and atrial fibrillation that can influence hemodynamics.
Data process: Data use the mean plus or minus the standard deviation, enumeration data use chi square check; measurement data use analysis of variance (ANOVA), After statistical process, we define P<0.05 as statistically significant.
Results: Common clinical informations such as age, sex ratio, hypertension, type 2 diabetes, previous history of angina and other related histories has no significant differences among each groups; the type of myocardial infarction, cardiac function on admission (assessed by Killip classification) also have no significant difference among each groups; When the patients were in hospital, compared patients in A group and in C group, we found that the patients in C group received lessβ-blocker therapy, the reasons may lies in thatβ-blockers have negative inotropic, negative role of conductivity; Compare with patients in A group, patients in C group with longer QRS duration had worse cardiac function, so patients in C group received lessβ-blocker treatment; Using chi-square check among the three groups, we find that: B group and A group, C group and A group have statistically significant differences in the incidence of cardiovascular events when in hospital(chi-square check P value<0.05),but B group and C group do not have statistically significant differences, (chi-square check P value>0.05); There is no significant difference in the incidence of cardiovascular events between B group and C group,which suggests that turnover point of QRS wave duration associated with cardiovascular events lies in 0.08-0.10s;All patients enrolled in the study accept coronary angiography; Through analyzing coronary angiography ,we find that: comparing with A group, patients in B group and C group have more coronary artery lesions, meanwhile, coronary artery lesions are more severe in B group and C group than A group, the differences have statistically meaning (by chi-square check P value<0.05), while comparing B group with C group, the differences have no statistically meaning, (by chi-square check P value>0.05).
Conclusion: The study confirmed that there is relation between QRS wave duration on admission and the prognosis in the near future in people who suffered acute myocardial infarction, after adjusting other factors such as age, sex, history of hypertension, mellitus diabetes, history of angina pectoris, and cardiac function on admission (assessed by Killip classification), those factors are thought to have influences on prognosis in patients who suffered acute myocardial infarction. Patients with QRS duration on admission lies in 0.06-0.08s have less cardiovascular events when they are in-patient, thus have a better prognosis in the near future, while those patients with QRS duration on admission lies in 0.08-0.10s or longer than 0.10s have more cardiovascular events when they are in-patient, which lead to a worse prognosis in the near future, After statistical process, the difference in incidence of cardiovascular events has statistically meanings, (by chi-square check P value<0.05);When comparing patients with QRS duration on admission lies in 0.08-0.10s with those QRS duration on admission longer than 0.10s,the cardiovascular events incidence difference have no statistically meaning,(by chi-square check P value>0.05), It suggests that turn-over point of QRS wave duration associated with cardiovascular events lies in 0.08-0.10s. So we can draw a conclusion that QRS wave duration on admission is a useful indicator that help to evaluate prognosis of acute myocardial infarction in the near future,and patients with QRS duration on admission lies in 0.06-0.08s have a better prognosis.
Object: To investigate the relation between the QRS wave duration on admission (QRS d) and the prognosis in the near future in people who suffered acute myocardial infarction;to ascertain whether we can use QRS wave duration on admission-a simple、easy-accessed clinical definition to evaluating the prognosis in the near future in people who suffered acute myocardial infarction, through this, we can distinguish high-risk patients、perform some treatment in time、reduce mortality of acute myocardial infarction in the near future and improve the recent prognosis of patients who suffered acute myocardial infarction.
Methods:Randomly selected 88 patients suffered acute myocardial infarction who were hospitalized in cardiovascular department of the first hospital affiliated to Jilin University from January 1, 2002 to January 1, 2008; 55 of them were male, All the patients conform to WHO diagnostic criteria about acute myocardial infarction (1979 year): meet the following three criteria at least two ; 1) typical ischemic chest pain lasts more than 30 minutes; 2) ECG ST-T dynamic evolution; 3) enzyme markers of myocardial injury and their dynamic evolution. Exclusion criteria: 1) established cerebral infarction in past history, or cerebral hemorrhage in history; 2) complete atrioventricular block; 3) different intraventricular conduction or other clinical conditions that could interfere with the accurate measurement of QRS wave duration, such as early repolarization syndrome; 4) implanting permanent pacemaker in history; 5) patients who do not agree with coronary angiography; In order to facilitate the analysis, all the patients are acute ST-segment elevation myocardial infarction and all the patients accept coronary angiography. Divide enrolled patients into three different groups according to their QRS duration on admission: group A: QRS wave duration on admission lies between 0.06s to 0.08s; group B: QRS wave duration on admission lies between 0.08s to 0.10s; group C: QRS wave duration on admission was longer than 0.10s; Observe and record cardiovascular events in each groups respectively when patients are in hospital; Cardiovascular events are defined as sudden cardiac death, cardiac shocks, Adam-Strokes syndrome, cardiac insufficiency or cardiac Doppler ultrasound examination confirmed that LVEF≤40%, low blood pressure that must use vasoactive drugs such as dopamine or hydroxylamineto to maintain blood pressure, serious arrhythmias, such as worse than degree II atrioventricular block, paroxysmal or sustained ventricular tachycardia, ventricular fibrillation, and atrial fibrillation that can influence hemodynamics.
Data process: Data use the mean plus or minus the standard deviation, enumeration data use chi square check; measurement data use analysis of variance (ANOVA), After statistical process, we define P<0.05 as statistically significant.
Results: Common clinical informations such as age, sex ratio, hypertension, type 2 diabetes, previous history of angina and other related histories has no significant differences among each groups; the type of myocardial infarction, cardiac function on admission (assessed by Killip classification) also have no significant difference among each groups; When the patients were in hospital, compared patients in A group and in C group, we found that the patients in C group received lessβ-blocker therapy, the reasons may lies in thatβ-blockers have negative inotropic, negative role of conductivity; Compare with patients in A group, patients in C group with longer QRS duration had worse cardiac function, so patients in C group received lessβ-blocker treatment; Using chi-square check among the three groups, we find that: B group and A group, C group and A group have statistically significant differences in the incidence of cardiovascular events when in hospital(chi-square check P value<0.05),but B group and C group do not have statistically significant differences, (chi-square check P value>0.05); There is no significant difference in the incidence of cardiovascular events between B group and C group,which suggests that turnover point of QRS wave duration associated with cardiovascular events lies in 0.08-0.10s;All patients enrolled in the study accept coronary angiography; Through analyzing coronary angiography ,we find that: comparing with A group, patients in B group and C group have more coronary artery lesions, meanwhile, coronary artery lesions are more severe in B group and C group than A group, the differences have statistically meaning (by chi-square check P value<0.05), while comparing B group with C group, the differences have no statistically meaning, (by chi-square check P value>0.05).
Conclusion: The study confirmed that there is relation between QRS wave duration on admission and the prognosis in the near future in people who suffered acute myocardial infarction, after adjusting other factors such as age, sex, history of hypertension, mellitus diabetes, history of angina pectoris, and cardiac function on admission (assessed by Killip classification), those factors are thought to have influences on prognosis in patients who suffered acute myocardial infarction. Patients with QRS duration on admission lies in 0.06-0.08s have less cardiovascular events when they are in-patient, thus have a better prognosis in the near future, while those patients with QRS duration on admission lies in 0.08-0.10s or longer than 0.10s have more cardiovascular events when they are in-patient, which lead to a worse prognosis in the near future, After statistical process, the difference in incidence of cardiovascular events has statistically meanings, (by chi-square check P value<0.05);When comparing patients with QRS duration on admission lies in 0.08-0.10s with those QRS duration on admission longer than 0.10s,the cardiovascular events incidence difference have no statistically meaning,(by chi-square check P value>0.05), It suggests that turn-over point of QRS wave duration associated with cardiovascular events lies in 0.08-0.10s. So we can draw a conclusion that QRS wave duration on admission is a useful indicator that help to evaluate prognosis of acute myocardial infarction in the near future,and patients with QRS duration on admission lies in 0.06-0.08s have a better prognosis.
引文
[1]黄宛等.临床心电图学(第5版).北京:人民卫生出版社, 2005.
[2] Radek Pudil, Micha S.Feinberg et al. The prognosis significant of interm- ediate QRS prolongation in acute myocardial infarction. International Journal of Cardiology, 78(2001),233-239.
[3] J. Jimenez-Candil et al, Relationship between QRS duration and prognosis in non ST-segment elevation acute coronary syndrome.International Journal of Cardiology, 126(2008),196-203.
[4] W Shamim, M Yousufuddin, M Cicorin et al, Incremental changes in the QRS duration in serial ECGs over time identified high risk elderly patients with heart failure. Heart 2002;88:47-52.
[5] Murkofsky RL, Dangas G, Diamond JA et al, A prolonged QRS duration on surface electrocadiagram is a spectific indictor of left ventricular dysfunction. J Am Coll Cardial 1998;32:476-82.
[6] C-M Yu, H lin, Q zhang, JE Sanderson, High prevalence of left ventricular systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration.Heart 2003;89:54-60.
[7] Stefano Ghio, Cristina Constantin, Catherine Klersy et al, Interventricular and intraventricular dyssynchrony are common in heart failure patients, regardless of QRS duration. European Heart Journal (2004)25,571-578.
[8] Turner MS, Bleasdale RA, Vinereanu D, et al, Electrical and mechanical components of dyssynchrony in heart failure patients with normal QRSduration and left bundle-branch block:impact of left and biventricular pacing. Circulation, 2004,196:2544-2549 .
[9] Turner MS, Bleasdale RA, et al, Left ventricular pacing improves haemod- ynamics variables in patients with heart failure with a normal QRS duration. Heart 2004,90:502-505.
[10] NG, Kenneth; Kdedia, Navin; Martin, David, Tchou, Patrick. Natale, Andrea, Wilkoff, Bruce; Starling, Randall, Grimm, Richard, The Benefits of Biventricular Pacing in Heart Failure Patients with Narrow QRS, NYHA Class II and Right Ventricular Pacing. Pacing & Clinical Electrophysiology. 30(2): 193-198, February 2007.
[11] Michael O. Sweeney, Anne S. Hellkamp, Kerry L. Lee et al, Associaton of prolonged QRS duration with death in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation 2005;111:2418-2325.
[12]杨跃进,华伟等.阜外心血管内科手册.北京:人民卫生出版社, 2006.
[13] Ashwath, Mahi Lakshmi MD; Sogade, Felix O. MD, FACC. Ejection Fraction and QRS Width as Predictors of Event Rates in Patients with Impla- ntable Cardioverter Defibrillators. Southern Medical Journal. 98(5): 513-517, May 2005.
[14] Stecker, Eric C.; Zargarian, Mehdi; Dogra, Vivek; John, Benjamin T. Kron, Jack; McAnulty, John H.; Chugh, Sumeet S. * Native QRS duration predicts the occurrence of arrhythmic events in ICD recipients. Europace. 8(10): 859-862, October 2006.
[15] van Huysduynen, Bart Hooft; van Straten, Alexander; Swenne, Cees A. Maan, Arie C. Ritsema van Eck, Henk J. Schalij, Martin J. van der Wall Ernst E; de Roos, Albert; Hazekamp, Mark G; Vliegen, Hubert W. Reduction of QRS duration after pulmonary valve replacement in adult Fallot patients is related to reduction of right ventricular volume. European Heart Journal. 26(9):928-932, May 2005.
[16] Oosterhof, Thomas; Vliegen, Hubert W; Meijboom, Folkert J; Zwinde- rman, Aeilko H; Bouma, Berto 1; Mulder, Barbara J M Long-term effect of pulmonary valve replacement on QRS duration in patients with corrected tetralogy of Fallot. Heart. 93(4):506-509, April 2007.
[17]王吉云,马志敏,陈喆等译.心脏电生理检查(第4版).北京:人民卫生出版社, 2007.
[18]谭真,刘兴斌.心脏再同步治疗的研究现状.心血管病学进展2008;29:2. .
[1]胡大一:为什么经皮冠脉介入不能改善美国老年急性心肌梗死的远期预后?中国循证医学杂志, 2005,Vol5(7),509-510.
[2] Radek Pudil, Micha S. Feinberg et al. The prognosis significant of interm- ediate QRS prolongation in acute myocardial infarction. International Journal of Cardiology, 78(2001),233-239.
[3] J. Jimenez-Candil et al, Relationship between QRS duration and prognosis in non ST-segment elevation acute coronary syndrome. International Journal of Cardiology, 126(2008),196-203
[4] Murkofsky RL, Dangas G, Diamond JA et al, A prolonged QRS duration on surface electrocadiagram is a spectific indictor of left ventricular dysfun- ction. J Am Coll Cardial 1998;32:476-82
[5]王吉耀,廖二元,胡品津,等.内科学.北京:人民卫生出版社
[6] Beatricle Brembilla-Perrit, Pierre Houriez, et al: Evolution of QRS duration after my- ocardial infarction: clinical consequence. PACE 1999; 22: 1466-1475.
[7] C-M Yu, H lin, Q zhang, JE Sanderson, High prevalence of left ventricular systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration. Heart 2003;89:54-60
[8] Stefano Ghio, Cristina Constantin, Catherine Klersy et al, Interventricular and intraventricular dyssynchrony are common in heart failure patients,regardless of QRS duration. European Heart Journal (2004)25,571-578.
[9] Angel A Cantor, Benjamin Goldfarb, Reabra Ilia: QRS duration: a sensitive marker of ischemia during percutaneous transluminal coronary angio- plasty. Catherization and Cardiovascular intervention. 2000;27:177-183.
[10] Aexl Bauer et al, QRS duration and late mortality in unselected post- infarction patients of the revascularization era. Euopean Heart Journal 2006;27:427-433.
[11] W Shamim, M Yousufuddin, M Cicorin et al, Incremental changes in the QRS duration in serial ECGs over time identified high risk elderly patients with heart failure. Heart 2002;88:47-52.
[12]黄宛等.临床心电图学(第5版).北京:人民卫生出版社, 2005.
[2] Radek Pudil, Micha S.Feinberg et al. The prognosis significant of interm- ediate QRS prolongation in acute myocardial infarction. International Journal of Cardiology, 78(2001),233-239.
[3] J. Jimenez-Candil et al, Relationship between QRS duration and prognosis in non ST-segment elevation acute coronary syndrome.International Journal of Cardiology, 126(2008),196-203.
[4] W Shamim, M Yousufuddin, M Cicorin et al, Incremental changes in the QRS duration in serial ECGs over time identified high risk elderly patients with heart failure. Heart 2002;88:47-52.
[5] Murkofsky RL, Dangas G, Diamond JA et al, A prolonged QRS duration on surface electrocadiagram is a spectific indictor of left ventricular dysfunction. J Am Coll Cardial 1998;32:476-82.
[6] C-M Yu, H lin, Q zhang, JE Sanderson, High prevalence of left ventricular systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration.Heart 2003;89:54-60.
[7] Stefano Ghio, Cristina Constantin, Catherine Klersy et al, Interventricular and intraventricular dyssynchrony are common in heart failure patients, regardless of QRS duration. European Heart Journal (2004)25,571-578.
[8] Turner MS, Bleasdale RA, Vinereanu D, et al, Electrical and mechanical components of dyssynchrony in heart failure patients with normal QRSduration and left bundle-branch block:impact of left and biventricular pacing. Circulation, 2004,196:2544-2549 .
[9] Turner MS, Bleasdale RA, et al, Left ventricular pacing improves haemod- ynamics variables in patients with heart failure with a normal QRS duration. Heart 2004,90:502-505.
[10] NG, Kenneth; Kdedia, Navin; Martin, David, Tchou, Patrick. Natale, Andrea, Wilkoff, Bruce; Starling, Randall, Grimm, Richard, The Benefits of Biventricular Pacing in Heart Failure Patients with Narrow QRS, NYHA Class II and Right Ventricular Pacing. Pacing & Clinical Electrophysiology. 30(2): 193-198, February 2007.
[11] Michael O. Sweeney, Anne S. Hellkamp, Kerry L. Lee et al, Associaton of prolonged QRS duration with death in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation 2005;111:2418-2325.
[12]杨跃进,华伟等.阜外心血管内科手册.北京:人民卫生出版社, 2006.
[13] Ashwath, Mahi Lakshmi MD; Sogade, Felix O. MD, FACC. Ejection Fraction and QRS Width as Predictors of Event Rates in Patients with Impla- ntable Cardioverter Defibrillators. Southern Medical Journal. 98(5): 513-517, May 2005.
[14] Stecker, Eric C.; Zargarian, Mehdi; Dogra, Vivek; John, Benjamin T. Kron, Jack; McAnulty, John H.; Chugh, Sumeet S. * Native QRS duration predicts the occurrence of arrhythmic events in ICD recipients. Europace. 8(10): 859-862, October 2006.
[15] van Huysduynen, Bart Hooft; van Straten, Alexander; Swenne, Cees A. Maan, Arie C. Ritsema van Eck, Henk J. Schalij, Martin J. van der Wall Ernst E; de Roos, Albert; Hazekamp, Mark G; Vliegen, Hubert W. Reduction of QRS duration after pulmonary valve replacement in adult Fallot patients is related to reduction of right ventricular volume. European Heart Journal. 26(9):928-932, May 2005.
[16] Oosterhof, Thomas; Vliegen, Hubert W; Meijboom, Folkert J; Zwinde- rman, Aeilko H; Bouma, Berto 1; Mulder, Barbara J M Long-term effect of pulmonary valve replacement on QRS duration in patients with corrected tetralogy of Fallot. Heart. 93(4):506-509, April 2007.
[17]王吉云,马志敏,陈喆等译.心脏电生理检查(第4版).北京:人民卫生出版社, 2007.
[18]谭真,刘兴斌.心脏再同步治疗的研究现状.心血管病学进展2008;29:2. .
[1]胡大一:为什么经皮冠脉介入不能改善美国老年急性心肌梗死的远期预后?中国循证医学杂志, 2005,Vol5(7),509-510.
[2] Radek Pudil, Micha S. Feinberg et al. The prognosis significant of interm- ediate QRS prolongation in acute myocardial infarction. International Journal of Cardiology, 78(2001),233-239.
[3] J. Jimenez-Candil et al, Relationship between QRS duration and prognosis in non ST-segment elevation acute coronary syndrome. International Journal of Cardiology, 126(2008),196-203
[4] Murkofsky RL, Dangas G, Diamond JA et al, A prolonged QRS duration on surface electrocadiagram is a spectific indictor of left ventricular dysfun- ction. J Am Coll Cardial 1998;32:476-82
[5]王吉耀,廖二元,胡品津,等.内科学.北京:人民卫生出版社
[6] Beatricle Brembilla-Perrit, Pierre Houriez, et al: Evolution of QRS duration after my- ocardial infarction: clinical consequence. PACE 1999; 22: 1466-1475.
[7] C-M Yu, H lin, Q zhang, JE Sanderson, High prevalence of left ventricular systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration. Heart 2003;89:54-60
[8] Stefano Ghio, Cristina Constantin, Catherine Klersy et al, Interventricular and intraventricular dyssynchrony are common in heart failure patients,regardless of QRS duration. European Heart Journal (2004)25,571-578.
[9] Angel A Cantor, Benjamin Goldfarb, Reabra Ilia: QRS duration: a sensitive marker of ischemia during percutaneous transluminal coronary angio- plasty. Catherization and Cardiovascular intervention. 2000;27:177-183.
[10] Aexl Bauer et al, QRS duration and late mortality in unselected post- infarction patients of the revascularization era. Euopean Heart Journal 2006;27:427-433.
[11] W Shamim, M Yousufuddin, M Cicorin et al, Incremental changes in the QRS duration in serial ECGs over time identified high risk elderly patients with heart failure. Heart 2002;88:47-52.
[12]黄宛等.临床心电图学(第5版).北京:人民卫生出版社, 2005.