急性心肌梗死后运动平板试验与冠状动脉造影的对比研究
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摘要
目的 对急性心肌梗死恢复期病人进行症状限制性运动平板试验，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段变化及各种心律失常的发生。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，评价急性心肌梗死恢复期进行运动平板试验的价值。
方法 对60例急性心肌梗死恢复期病人(10-53天)在冠状动脉造影之前，进行症状限制性运动平板试验，通过冠状动脉造影及左室造影，明确冠状动脉病变范围(单支、双支、三支病变)，对相关指标进行评价。
结果 运动试验中，ST段压低大于0.1mv诊断冠状动脉多支病变的敏感性、特异性、阳性预测值及阴性预测值分别为：62％、67％、76％、50％。代谢当量(METS)小于或等于6.0诊断多支病变的敏感性、特异性、阳性预测值及阴性预测值分别是：46％、86％、85％、52％。若以运动试验中ST段压低大于0.2mv为判断标准，则诊断多支病变的敏感性、特异性、阳性预测值及阴性预测值分别是：35％、91％、86％、55％。而ST段下移与代谢当量两个指标相结合，则诊断多支病变的敏感性、特异性、阳性预测值及阴性预测值又分别为：76％、62％、77％、40％。运动试验中的代谢当量、最大心率、运动时间在单支和双支冠状动脉病变中无统计学差异(P＞0.05)而以上3个指标在单支和三支病变、双支和三支病变中比较有统计学意义(P＜0.05)。同时发现：冠状动脉病变部位与ST段阳性改变的导联之间无明显的对应关系．分布频率较高的导联是：Ⅱ、Ⅲ、aVF、V2、V3、V4、V5、V6导联。运动试验诱发的ST段抬高与心肌梗死部位及室壁瘤也有一定的相关性，ST段抬高主要发生于前间壁或前壁心肌梗死，与其他梗死部位相比有统计学意义(P＜0.05)．在运动试验中ST段抬高的12例病人中，室壁瘤的发生率为66％。另外，60例病人运动试验中室性心律失常的发生率为31％，房性心律失常的发生率为3.3％，代谢当量与左室射血分数之间无相关性。
结论 ①急性心肌梗死后恢复期病人进行运动平板试验是安全的、可靠的。本试验中未有心脏意外事件发生。②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。
中文摘要
另外，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。③运动试验诱发的ST段抬高对心肌
梗死后病人室壁瘤及心肌梗死部位的判断有重要的提示意义。④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。⑤代谢当量与左室射血分数之间无
相关。
Objective The symptom-limited treadmill exercise test was performed in patients at recovery phase of acute myocardial infarction to detect metabolic equivalents (METS), exercise timing and maximum heart rate of the patients.meanwhile. ST segment fluctuations and various arrhythmias 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. We can evaluate the significance of performing treadmill exercise test at early stage of acute myocardial infarction.
Methods The symptom-limited treadmill exercise test was carried out in 60 patients with acute myocardial infarction before coronary angiography . The average timing of the treadmill exercise test was 32 days (10-53days). The coronary angiography and left ventriculography were performed to determine the extent of coronary artery disease (single vessel disease, two vessel disease, three vessel disease) and left ventricular ejection fraction. Some related parameters were evaluated.
Results The sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by exercise -induced ST segment depression >0.1 mv was 62% , 67% , 76%. 50% respectively. The sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by METS<6.0 was 46% 86% 85% 52%. However, the sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by exercise -induced ST segment depression >0.2mv was 35% 91% 86% 55% respectively .By combining low workload and ST segment depression was 76% 62% 77% 40% 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 V4 V5 V6 . ST segment elevation correlates with the location of myocardial infarction and aneurysm. The incidence of the aneurysm in 12 patients with
exercise-induced ST segment elevation was 66%. ST segment elevation induced by exercise test was more prevalent in patients with anterior myocardial infarction than in patients with other infarct locations (P<0.05). In addition, the incidence of ventricular arrhythmias in 60 patients undergoing exercise test was 31 %. The incidence of atrial arrhythmias was 3.3%. No correlation between METS and left ventricular ejection fraction was found.
Conclusions (1)Treadmill exercise test is both safe and reliable in patients at early phase of acute myocardial infarction . No cardiac event occurs in our study. (2)Treadmill exercise test has definite value in predicting coronary multivessel disease . The location of coronary artery disease can be primarily determined so as to provide valuable reference for coronary angiography. The sensitivity, specificity , positive predictive value and negative predictive value in predicting multivessel disease varies respectively with the selective parameters .(3) ST segment elevation induced by exercise test is significantly indicative of the location of myocardial infarction and aneurysm.
方法 对60例急性心肌梗死恢复期病人(10-53天)在冠状动脉造影之前，进行症状限制性运动平板试验，通过冠状动脉造影及左室造影，明确冠状动脉病变范围(单支、双支、三支病变)，对相关指标进行评价。
结果 运动试验中，ST段压低大于0.1mv诊断冠状动脉多支病变的敏感性、特异性、阳性预测值及阴性预测值分别为：62％、67％、76％、50％。代谢当量(METS)小于或等于6.0诊断多支病变的敏感性、特异性、阳性预测值及阴性预测值分别是：46％、86％、85％、52％。若以运动试验中ST段压低大于0.2mv为判断标准，则诊断多支病变的敏感性、特异性、阳性预测值及阴性预测值分别是：35％、91％、86％、55％。而ST段下移与代谢当量两个指标相结合，则诊断多支病变的敏感性、特异性、阳性预测值及阴性预测值又分别为：76％、62％、77％、40％。运动试验中的代谢当量、最大心率、运动时间在单支和双支冠状动脉病变中无统计学差异(P＞0.05)而以上3个指标在单支和三支病变、双支和三支病变中比较有统计学意义(P＜0.05)。同时发现：冠状动脉病变部位与ST段阳性改变的导联之间无明显的对应关系．分布频率较高的导联是：Ⅱ、Ⅲ、aVF、V2、V3、V4、V5、V6导联。运动试验诱发的ST段抬高与心肌梗死部位及室壁瘤也有一定的相关性，ST段抬高主要发生于前间壁或前壁心肌梗死，与其他梗死部位相比有统计学意义(P＜0.05)．在运动试验中ST段抬高的12例病人中，室壁瘤的发生率为66％。另外，60例病人运动试验中室性心律失常的发生率为31％，房性心律失常的发生率为3.3％，代谢当量与左室射血分数之间无相关性。
结论 ①急性心肌梗死后恢复期病人进行运动平板试验是安全的、可靠的。本试验中未有心脏意外事件发生。②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。
中文摘要
另外，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。③运动试验诱发的ST段抬高对心肌
梗死后病人室壁瘤及心肌梗死部位的判断有重要的提示意义。④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。⑤代谢当量与左室射血分数之间无
相关。
Objective The symptom-limited treadmill exercise test was performed in patients at recovery phase of acute myocardial infarction to detect metabolic equivalents (METS), exercise timing and maximum heart rate of the patients.meanwhile. ST segment fluctuations and various arrhythmias 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. We can evaluate the significance of performing treadmill exercise test at early stage of acute myocardial infarction.
Methods The symptom-limited treadmill exercise test was carried out in 60 patients with acute myocardial infarction before coronary angiography . The average timing of the treadmill exercise test was 32 days (10-53days). The coronary angiography and left ventriculography were performed to determine the extent of coronary artery disease (single vessel disease, two vessel disease, three vessel disease) and left ventricular ejection fraction. Some related parameters were evaluated.
Results The sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by exercise -induced ST segment depression >0.1 mv was 62% , 67% , 76%. 50% respectively. The sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by METS<6.0 was 46% 86% 85% 52%. However, the sensitivity specificity positive predictive value and negative predictive value in predicting multivessel disease by exercise -induced ST segment depression >0.2mv was 35% 91% 86% 55% respectively .By combining low workload and ST segment depression was 76% 62% 77% 40% 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 V4 V5 V6 . ST segment elevation correlates with the location of myocardial infarction and aneurysm. The incidence of the aneurysm in 12 patients with
exercise-induced ST segment elevation was 66%. ST segment elevation induced by exercise test was more prevalent in patients with anterior myocardial infarction than in patients with other infarct locations (P<0.05). In addition, the incidence of ventricular arrhythmias in 60 patients undergoing exercise test was 31 %. The incidence of atrial arrhythmias was 3.3%. No correlation between METS and left ventricular ejection fraction was found.
Conclusions (1)Treadmill exercise test is both safe and reliable in patients at early phase of acute myocardial infarction . No cardiac event occurs in our study. (2)Treadmill exercise test has definite value in predicting coronary multivessel disease . The location of coronary artery disease can be primarily determined so as to provide valuable reference for coronary angiography. The sensitivity, specificity , positive predictive value and negative predictive value in predicting multivessel disease varies respectively with the selective parameters .(3) ST segment elevation induced by exercise test is significantly indicative of the location of myocardial infarction and aneurysm.
引文
1. Weiner DA, Ryan TJ, McCabe CH , etal. Significance of silent myocardial ischemia during exercise testing in patients with coronary artery disease. Am J Cardiol, 1987; 59:725
2. Hamm LF, Sfull A, Crow RS. Exercise testing early alter myocardial infarction historic perspective and current uses. Prog Cardiovasc Dis, 1986;28:463
3. Atterhog JH, Ekeland LG, kaijser L. Electrocardiographic abnormalities during exercise 3 weeks to 18 months after anterior myocardial infarction. Br Heart J, 1971; 33:871
4. Ericsson M, Grahath A, Ohlsen P , etal. Arrhythmias and symptoms during treadmill testing 3 weeks after myocardial infarction in 100 patients. Br Heart J, 1973; 35:787
5. Fein SA, Klein NA, Frishman WH. Exercise testing soon after uncomplicated myocardial infarction prognostic value and safety. JAMA, 1981; 245:1836
6. Fuller CM, Raizner AE, Verani MS, etal. Early post-myocardial infarction treadmill testing —An accurate predict of multi-vessel coronary disease and subsequent cardiac events. Ann Intern Med, 1981; 94:734
7. O'Rourke RA. Clinical decisions in post infarction patients. Mod Cone Cardiovasc Dis, 1986;55:55
8. 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
9．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
10．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
11．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
12．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
13. Sullivan ID, Davies DW, Sowton E. Submaximal exercise testing early after myocardial infarction . Prognostic importance of exercise induced ST segment elevation. Br Heart J 1984; 52:147—53
14. Weiner DA. ST segment changes of post -infarction: predictive value for multi-vessel coronary disease and left ventricular aneurysm. Circulation 1978; 58:
887
15. Lahiri A. Exercise -induced ST segment elevation : Electrocardiographic, angiographic and scintigraphic evaluation. Br Heart J 1980; 43:582
16. Specchia G, Deservi S, Falcone C, etal. Significance of exercise induced ST segment elevation in patients without myocardial infarction. Circulation 1981; 63:46-53
17. Hossack KF, Sivarajan ES, Almes MJ, etal. Prognostic value of ST elevation during low level treadmill testing early after myocardial infarction. Am J Cardiol 1982; 49:932
18. Hosoya Y. The clinical significance of exercise induced ST segment changes in patients with previous inferior myocardial infarction. Am Heart J 1990; 120:554
19．帅莉，卢喜烈，冯志勇等．活动平板运动试验诱发急性心肌梗死1例．中华心血管病杂志，2001，12，28；(12)：764
20．李建军，陈芳，江洪等．活动平板运动试验诱发冠心病心律失常．临床心电学杂志．1999，11，26；8(4)：199-201
2. Hamm LF, Sfull A, Crow RS. Exercise testing early alter myocardial infarction historic perspective and current uses. Prog Cardiovasc Dis, 1986;28:463
3. Atterhog JH, Ekeland LG, kaijser L. Electrocardiographic abnormalities during exercise 3 weeks to 18 months after anterior myocardial infarction. Br Heart J, 1971; 33:871
4. Ericsson M, Grahath A, Ohlsen P , etal. Arrhythmias and symptoms during treadmill testing 3 weeks after myocardial infarction in 100 patients. Br Heart J, 1973; 35:787
5. Fein SA, Klein NA, Frishman WH. Exercise testing soon after uncomplicated myocardial infarction prognostic value and safety. JAMA, 1981; 245:1836
6. Fuller CM, Raizner AE, Verani MS, etal. Early post-myocardial infarction treadmill testing —An accurate predict of multi-vessel coronary disease and subsequent cardiac events. Ann Intern Med, 1981; 94:734
7. O'Rourke RA. Clinical decisions in post infarction patients. Mod Cone Cardiovasc Dis, 1986;55:55
8. 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
9．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
10．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
11．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
12．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
13. Sullivan ID, Davies DW, Sowton E. Submaximal exercise testing early after myocardial infarction . Prognostic importance of exercise induced ST segment elevation. Br Heart J 1984; 52:147—53
14. Weiner DA. ST segment changes of post -infarction: predictive value for multi-vessel coronary disease and left ventricular aneurysm. Circulation 1978; 58:
887
15. Lahiri A. Exercise -induced ST segment elevation : Electrocardiographic, angiographic and scintigraphic evaluation. Br Heart J 1980; 43:582
16. Specchia G, Deservi S, Falcone C, etal. Significance of exercise induced ST segment elevation in patients without myocardial infarction. Circulation 1981; 63:46-53
17. Hossack KF, Sivarajan ES, Almes MJ, etal. Prognostic value of ST elevation during low level treadmill testing early after myocardial infarction. Am J Cardiol 1982; 49:932
18. Hosoya Y. The clinical significance of exercise induced ST segment changes in patients with previous inferior myocardial infarction. Am Heart J 1990; 120:554
19．帅莉，卢喜烈，冯志勇等．活动平板运动试验诱发急性心肌梗死1例．中华心血管病杂志，2001，12，28；(12)：764
20．李建军，陈芳，江洪等．活动平板运动试验诱发冠心病心律失常．临床心电学杂志．1999，11，26；8(4)：199-201