大剂量多巴酚丁胺负荷试验结合二维应变成像早期诊断冠心病的价值
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摘要
目的：探讨大剂量多巴酚丁胺负荷试验结合二维应变成像技术早期诊断冠心病的价值。
方法：对临床可疑的冠心病患者28例,进行大剂量多巴酚丁胺负荷试验,分别在静息状态及各级负荷状态下观察室壁运动情况、测定左室各心肌节段心内膜下心肌的纵向收缩期峰值应变,比较大剂量多巴酚丁胺负荷试验目测法及大剂量多巴酚丁胺负荷试验结合二维应变成像技术诊断缺血心肌的敏感性和特异性；计算正常组、冠心病组缺血节段和非缺血节段的纵向收缩期峰值应变平均值并进行组内及组间比较,利用受试者操作特征曲线下面积评价纵向收缩期峰值应变预测缺血心肌的敏感性和特异性。
结果：冠心病组多巴酚丁胺剂量为40μg·Kg-1·min-1时目测法检出室壁运动异常6例(共20个节段),计算纵向收缩期峰值应变以后,检测缺血心肌15例(共148节段)；冠心病组大多数缺血节段纵向收缩期峰值应变较正常组及非缺血节段相同负荷状态明显减低(P<0.05),大剂量多巴酚丁胺负荷试验目测法和大剂量多巴酚丁胺负荷试验结合二维应变成像技术诊断缺血心肌的敏感性分别为35.3%和88.2%(P<0.01)、特异性分别为100%和100%(P>0.05)和准确度分别为60.7%和92.8%(P<0.01)。多巴酚丁胺剂量为40μg·Kg-1·min-1时纵向收缩期峰值应变绝对值<14.97为截断值,预测缺血心肌节段的敏感性和特异性分别为83.3%和91.7%。
结论：大剂量多巴酚丁胺负荷试验结合二维应变成像技术可以提高检出缺血心肌的敏感性,在大剂量多巴酚丁胺负荷试验状态下,二维应变成像技术能通过测定纵向收缩期峰值应变的变化,定量评价心肌收缩功能的微小改变,发现心肌隐匿性缺血,为临床诊断早期冠心病患者提供了无创性新方法。
目的探讨应变率成像结合大剂量多巴酚丁胺负荷试验评价早期冠心病左室心肌舒张功能变化。方法对28例可疑冠心病患者进行大剂量多巴酚丁胺负荷试验,测量舒张早期峰值应变率(SRe)和舒张晚期峰值应变率(SRa),并进行冠心病组和正常对照组的比较。结果冠心病组缺血节段SRe在多巴酚丁胺剂量20μg/(kg.min)时达到最大,与静息状态比较差异有统计学意义；在多巴酚丁胺剂量30和40μg/(kg.min)时降低,与正常对照组、非缺血节段同一负荷状态比较差异有统计学意义。以多巴酚丁胺剂量40μg/ (kg.min)时SRe<1.70为截断值,预测缺血心肌舒张功能异常的敏感性和特异性分别为88.9%和83.3%。结论SRe是反映心肌局部舒张功能变化敏感而特异的指标。
Objective To investigate the value of high-dose dobutamine stress echocardiography combined with two-dimensional strain imaging in early diagnosis of coronary artery disease.
Methods High-dose dobutamine stress echocardiography was performed in 28 patients with suspected coronary artery disease and all wall motion movement was observed respectively in baseline and at all stress levels; the peak systolic longitudinal strain in subendomyocardial segments of left ventricular were measured to compare the sensitivity and specificity of high-dose dobutamine stress echocardiography visual method and high-dose dobutamine stress echocardiography combined with two-dimensional strain imaging in diagnosis of myocardial ischemia; the peak systolic longitudinal strain average were calculated in all groups and were compared inside and between different groups. Receiver operating characteristic analysis was used to evaluate the peak systolic longitudinal strain predicting the sensitivity and the specificity of myocardial ischemia.
Results With 40μg·-Kg-1·min-1 of dobutamine dose, wall motion abnormalities occurred in 6 patients(20 segments) of coronary artery disease group; after calculating the peak systolic longitudinal strain, myocardial ischemia was found in 15 patients (148 segments); the majority of coronary artery disease ischemic segments of peak systolic longitudinal strain were significantly reduced(P<0.05) compared with the non-ischemic segments and control group. High-dose dobutamine stress echocardiography visual method and high-dose dobutamine stress echocardiography combined with two-dimensional strain imaging in diagnostic sensitivity of myocardial ischemia were respectively 35.3 % and 88.2 % (P< 0.01), the specificity were respectively 100 % and 100 % (P>0.05), and the accuracy were respectively 60.7 % and 92.8 % (P< 0.01). When the cutoff absolute value of the peak systolic longitudinal strain was less than 14.97, the sensitivity and specificity in diagnosing of myocardial ischemia were respectively 83.3 % and 91.7 % .
Conclusions High-dose dobutamine stress echocardiography combined with two-dimensional strain imaging can increase the sensitivity of myocardial ischemia detection. During high-dose dobutamine stress echocardiography, measuring the peak systolic longitudinal strain by two-dimensional strain imaging could quantitatively evaluate the subendomyocardial systolic function and detect concealed myocardial ischemia by analyzing longitudinal strain. As a new non-invasive method, high-dose dobutamine stress echocardiography combined with two-dimensional strain imaging could be used in early diagnosis of coronary artery disease.
Objective To assess the left ventricular diastolic function in early myocardial ischemia by strain rate imaging combined with high-dose dobutamine stress echocardiography.
Methods High-dose dobutamine stress echocardiography was performed in 28 patients with suspected coronary artery disease. Early diastolic peak strain rate (SRe) and late diastolic peak strain rate (SRa) were measured. According to the results of coronary angiography myocardial segments were divided in control group and coronary artery disease group.The SRe and SRa average were calculated in all groups and were compared inside and between different groups.
Results The maximum SRe in coronary artery disease ischemic group was obtained with dose of 20μg/(kg.min) and SRe decreased significantly with dose of 30 and 40μg/(kg.min), compared with the control group. When the cutoff value of SRe was less than 1.70s-1, the sensitivity and specificity of diastolic function of myocardial ischemia were respectively 88.9 % and 83.3 % .
Conclusions SRe is a sensitive and specific indicator in reflecting the reduction of diastolic function in regional myocardial ischemia.
方法：对临床可疑的冠心病患者28例,进行大剂量多巴酚丁胺负荷试验,分别在静息状态及各级负荷状态下观察室壁运动情况、测定左室各心肌节段心内膜下心肌的纵向收缩期峰值应变,比较大剂量多巴酚丁胺负荷试验目测法及大剂量多巴酚丁胺负荷试验结合二维应变成像技术诊断缺血心肌的敏感性和特异性；计算正常组、冠心病组缺血节段和非缺血节段的纵向收缩期峰值应变平均值并进行组内及组间比较,利用受试者操作特征曲线下面积评价纵向收缩期峰值应变预测缺血心肌的敏感性和特异性。
结果：冠心病组多巴酚丁胺剂量为40μg·Kg-1·min-1时目测法检出室壁运动异常6例(共20个节段),计算纵向收缩期峰值应变以后,检测缺血心肌15例(共148节段)；冠心病组大多数缺血节段纵向收缩期峰值应变较正常组及非缺血节段相同负荷状态明显减低(P<0.05),大剂量多巴酚丁胺负荷试验目测法和大剂量多巴酚丁胺负荷试验结合二维应变成像技术诊断缺血心肌的敏感性分别为35.3%和88.2%(P<0.01)、特异性分别为100%和100%(P>0.05)和准确度分别为60.7%和92.8%(P<0.01)。多巴酚丁胺剂量为40μg·Kg-1·min-1时纵向收缩期峰值应变绝对值<14.97为截断值,预测缺血心肌节段的敏感性和特异性分别为83.3%和91.7%。
结论：大剂量多巴酚丁胺负荷试验结合二维应变成像技术可以提高检出缺血心肌的敏感性,在大剂量多巴酚丁胺负荷试验状态下,二维应变成像技术能通过测定纵向收缩期峰值应变的变化,定量评价心肌收缩功能的微小改变,发现心肌隐匿性缺血,为临床诊断早期冠心病患者提供了无创性新方法。
目的探讨应变率成像结合大剂量多巴酚丁胺负荷试验评价早期冠心病左室心肌舒张功能变化。方法对28例可疑冠心病患者进行大剂量多巴酚丁胺负荷试验,测量舒张早期峰值应变率(SRe)和舒张晚期峰值应变率(SRa),并进行冠心病组和正常对照组的比较。结果冠心病组缺血节段SRe在多巴酚丁胺剂量20μg/(kg.min)时达到最大,与静息状态比较差异有统计学意义；在多巴酚丁胺剂量30和40μg/(kg.min)时降低,与正常对照组、非缺血节段同一负荷状态比较差异有统计学意义。以多巴酚丁胺剂量40μg/ (kg.min)时SRe<1.70为截断值,预测缺血心肌舒张功能异常的敏感性和特异性分别为88.9%和83.3%。结论SRe是反映心肌局部舒张功能变化敏感而特异的指标。
Objective To investigate the value of high-dose dobutamine stress echocardiography combined with two-dimensional strain imaging in early diagnosis of coronary artery disease.
Methods High-dose dobutamine stress echocardiography was performed in 28 patients with suspected coronary artery disease and all wall motion movement was observed respectively in baseline and at all stress levels; the peak systolic longitudinal strain in subendomyocardial segments of left ventricular were measured to compare the sensitivity and specificity of high-dose dobutamine stress echocardiography visual method and high-dose dobutamine stress echocardiography combined with two-dimensional strain imaging in diagnosis of myocardial ischemia; the peak systolic longitudinal strain average were calculated in all groups and were compared inside and between different groups. Receiver operating characteristic analysis was used to evaluate the peak systolic longitudinal strain predicting the sensitivity and the specificity of myocardial ischemia.
Results With 40μg·-Kg-1·min-1 of dobutamine dose, wall motion abnormalities occurred in 6 patients(20 segments) of coronary artery disease group; after calculating the peak systolic longitudinal strain, myocardial ischemia was found in 15 patients (148 segments); the majority of coronary artery disease ischemic segments of peak systolic longitudinal strain were significantly reduced(P<0.05) compared with the non-ischemic segments and control group. High-dose dobutamine stress echocardiography visual method and high-dose dobutamine stress echocardiography combined with two-dimensional strain imaging in diagnostic sensitivity of myocardial ischemia were respectively 35.3 % and 88.2 % (P< 0.01), the specificity were respectively 100 % and 100 % (P>0.05), and the accuracy were respectively 60.7 % and 92.8 % (P< 0.01). When the cutoff absolute value of the peak systolic longitudinal strain was less than 14.97, the sensitivity and specificity in diagnosing of myocardial ischemia were respectively 83.3 % and 91.7 % .
Conclusions High-dose dobutamine stress echocardiography combined with two-dimensional strain imaging can increase the sensitivity of myocardial ischemia detection. During high-dose dobutamine stress echocardiography, measuring the peak systolic longitudinal strain by two-dimensional strain imaging could quantitatively evaluate the subendomyocardial systolic function and detect concealed myocardial ischemia by analyzing longitudinal strain. As a new non-invasive method, high-dose dobutamine stress echocardiography combined with two-dimensional strain imaging could be used in early diagnosis of coronary artery disease.
Objective To assess the left ventricular diastolic function in early myocardial ischemia by strain rate imaging combined with high-dose dobutamine stress echocardiography.
Methods High-dose dobutamine stress echocardiography was performed in 28 patients with suspected coronary artery disease. Early diastolic peak strain rate (SRe) and late diastolic peak strain rate (SRa) were measured. According to the results of coronary angiography myocardial segments were divided in control group and coronary artery disease group.The SRe and SRa average were calculated in all groups and were compared inside and between different groups.
Results The maximum SRe in coronary artery disease ischemic group was obtained with dose of 20μg/(kg.min) and SRe decreased significantly with dose of 30 and 40μg/(kg.min), compared with the control group. When the cutoff value of SRe was less than 1.70s-1, the sensitivity and specificity of diastolic function of myocardial ischemia were respectively 88.9 % and 83.3 % .
Conclusions SRe is a sensitive and specific indicator in reflecting the reduction of diastolic function in regional myocardial ischemia.
引文
1. 王新房,谢明星,邓又斌,等.超声心动图学,北京：人民卫生出版社,第4版,2009：470.
2. 吴锡桂.我国人群冠心病流行现况与趋势.中国慢性病预防与控制,2003,11(4)：190-191.
3. 胡盛寿.未来10年我国心血管疾病将大流行.医学研究杂志,2008,37(2)：55.
4. Ruffolo RR.The pharmacology of dobutamine. Am J Med. Sci,1987,294(2):244-248.
5. Canna CLA, Alfieri O, Ciubbini R,et al. Echocardiography during infusion of dobutamine for identification of reversible dysfunction in patients with chronic coronary artery disease. J AM Coll Cardiol,1994,23:617-626.
6. 朱天刚,阎小娣,杨松娜,等.多巴酚丁胺负荷试验对心肌纵向收缩功能的影响.放射学实践,2004,19(3)：159-162.
7. Heimdal A, Stoylen A, Torp H, et al. Real-time strain rate imaging of the left ventricle by ultrasound. J Am Soc Echocardiogr,1998,11:1013-1019.
8. Castro PL,Greenberg NL,Drinko J,et al. Potential pitfalls of strain rate imaging:angle dependency.Biomed Sci Instrum,2000,36:97-202.
9. Amundsen BH, Helle-Valle T, Edvardsen T, et al. Noninvasive myocardial strain measurement by speckle tracking echocardiography validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol,2006,47(4):789-793.
10. Gracia FM, Azevedo J, Moreno M, et al. Regional diastolic function in ischemic heart disease using pulsed wave Doppler tissue imaging.Eur Heart J,1999,20:496-498.
11. Pellikka PA, Roger VL, Oh JK, et al. Stress echocardiography, Ⅱ:dobutamine stress echocardiography:techniques, implementation, clinical applications, and correlations. Mayo Clin Proc.1995,70:16-27.
12. Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. J Am Soc Echocardiogr, 1989,2:358-367.
13. Segar DS, Brow SE, Sawasa SG, et al. Dobutamine stress echocardiography:correlation with coronary lesion severity as determined by quantitative angiography. J Am Coll Cardiol,1992,19:1197-1202.
14. Hashimoto Ⅰ, Li X, Hejmadi BA, et al. Myocardial strain rate is a superior method for evaluation of left ventricular subendocardial function compared with tissue Doppler imaging. J Am Coll Cardiol,2003,42(9):1574-1583.
15.籍振国,刘坤申,张源祥,等.多巴酚丁胺二维超声心动图负荷试验在冠心病中的临床应用.河北医药,2004,26(5)：383-384.
16.杜国庆.薛竟宜主编的实用临床超声心动图学(精).辽宁科学技术出版社,2003,P66
17. Jamal F, Strotmann J, Weidemann F, et al. Noninvasive quantification of the contractile reserve of stunned myocardium by ultrasonic strain rate and strain. Circulation.2001,104: 1059-1065.
18. Weidemann F, Jamal F, Sutherland G, et al. Myocardial function defined by strain rate and strain during alterations in inotropic states and heart rate. Am J Physiol.2002,283: 792-799.
19. Kukulski T, Jamal F, D'Hooge J, et al. Acute changes in systolic and diastolic events during clinical coronary angioplasty:a comparison of regional velocity, strain rate and strain measurement. J Am Soc Echocardiogr.2002,15:1-12.
20. Urheim S, Edvardsen T, Torp H, et al. Myocardial strain by Doppler echocardiography: validation of a new method to quantify regional myocardial function. Circulation. 2000,102:1158-1164.
21. Moore CC,Lugo Olivieri CH,Mc Veigh ER,et al. Three-dimension systolic strain patterns in the normal human left ventricle:characterization with tagged MR imaging. Radiology,2000,214(2):453-466.
22. Voigt JU, Exner B, Schmiedehausen K, et al. Strain rate imaging during dobutamine stress echocardiography provides objectives evidence of inducible ischemia. Circulation, 2003,107:2120-2126.
23.郭瑞强,胡佳琪,周青等.多巴酚丁胺负荷超声心动图结合应变率评价冠心病的临床研究.中华超声影像学杂志,2006,15：262-265.
24.王寒梅,田家玮,杜国庆,等.应变率成像结合多巴酚丁胺负荷试验检测早期心肌缺血的临床研究.中华超声影像学杂志,2007,16：568-572.
25.胡佳琪,石华,郭瑞强,等.多巴酚丁胺负荷试验时应变率检测冠心病的价值.中国医学影像技术,2007,23：1317-1319.
1. Sebastian C, Patel JJ, Sadaniantz A, et al. Stress echocardiography:A review of the Principles and Practice. Echocardiography,1998,15(7):669-692.
2. Voigt JU, Flachskampf FA. Strain and Strain rate. New and clinically relevant echo parameters of regional myocardial function. Z kardiol,2004,93(4):249-258.
3. Ruffolo RR.The pharmacology of dobutamine.Am J Med.Sci,1987,294(2):244-248.
4. Urheim S, Edvardsen T, Torp H, et al. Myocardial strain by Doppler echocardiography: validation of a new method to quantify regional myocardial function. Circulation,2000; 102(10):1158-1164.
5. Gracia FM, Azevedo J, Moreno M, et al. Regional diastolic function in ischemic heart disease using pulsed wave Doppler tissue imaging. Eur Heart J,1999; 20:496-505.
6. Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. J Am Soc Echocardiogr,1989; 2: 358-367.
7. Segar DS, Brow SE, Sawasa SG,et al. Dobutamine stress echocardiography:correlation with coronary lesion severity as determined by quantitative angiography. J Am Coll Cardiol,1992; 19:1197-1202.
8. Hashimoto Ⅰ, Li X, Hejmadi BA, et al. Myocardial strain rate is a superior method for evaluation of left ventricular subendocardial function compared with tissue Doppler imaging. J Am Coll Cardiol,2003; 42(9):1574-1583.
9.王新房,谢明星,邓又斌,等.超声心动图学,4版.北京：人民卫生出版社,2009：238.
10. Jamal F.Kukulski T,Sutherland GR,et al. Can changes in systolic longitudinal deformation quantify regional myocardial function after an acute infarction:An Ultrasonic strain rate study. J Am Soc Echocardiogr,2002,15(7):723-730.
11. Urheim S, Edvardsen T, Torp H,et al. Myocardial strain by Doppler echocardiography: validation of a new method to quantify regional myocardial function. Circulation,2000, 102 (10):1158-1164.
12.胡佳琪,石华,郭瑞强,等.多巴酚丁胺负荷试验时应变率检测冠心病的价值.中国医学影像技术,2007,23(9)：1317-1319.
2. 吴锡桂.我国人群冠心病流行现况与趋势.中国慢性病预防与控制,2003,11(4)：190-191.
3. 胡盛寿.未来10年我国心血管疾病将大流行.医学研究杂志,2008,37(2)：55.
4. Ruffolo RR.The pharmacology of dobutamine. Am J Med. Sci,1987,294(2):244-248.
5. Canna CLA, Alfieri O, Ciubbini R,et al. Echocardiography during infusion of dobutamine for identification of reversible dysfunction in patients with chronic coronary artery disease. J AM Coll Cardiol,1994,23:617-626.
6. 朱天刚,阎小娣,杨松娜,等.多巴酚丁胺负荷试验对心肌纵向收缩功能的影响.放射学实践,2004,19(3)：159-162.
7. Heimdal A, Stoylen A, Torp H, et al. Real-time strain rate imaging of the left ventricle by ultrasound. J Am Soc Echocardiogr,1998,11:1013-1019.
8. Castro PL,Greenberg NL,Drinko J,et al. Potential pitfalls of strain rate imaging:angle dependency.Biomed Sci Instrum,2000,36:97-202.
9. Amundsen BH, Helle-Valle T, Edvardsen T, et al. Noninvasive myocardial strain measurement by speckle tracking echocardiography validation against sonomicrometry and tagged magnetic resonance imaging. J Am Coll Cardiol,2006,47(4):789-793.
10. Gracia FM, Azevedo J, Moreno M, et al. Regional diastolic function in ischemic heart disease using pulsed wave Doppler tissue imaging.Eur Heart J,1999,20:496-498.
11. Pellikka PA, Roger VL, Oh JK, et al. Stress echocardiography, Ⅱ:dobutamine stress echocardiography:techniques, implementation, clinical applications, and correlations. Mayo Clin Proc.1995,70:16-27.
12. Schiller NB, Shah PM, Crawford M, et al. Recommendations for quantitation of the left ventricle by two-dimensional echocardiography. J Am Soc Echocardiogr, 1989,2:358-367.
13. Segar DS, Brow SE, Sawasa SG, et al. Dobutamine stress echocardiography:correlation with coronary lesion severity as determined by quantitative angiography. J Am Coll Cardiol,1992,19:1197-1202.
14. Hashimoto Ⅰ, Li X, Hejmadi BA, et al. Myocardial strain rate is a superior method for evaluation of left ventricular subendocardial function compared with tissue Doppler imaging. J Am Coll Cardiol,2003,42(9):1574-1583.
15.籍振国,刘坤申,张源祥,等.多巴酚丁胺二维超声心动图负荷试验在冠心病中的临床应用.河北医药,2004,26(5)：383-384.
16.杜国庆.薛竟宜主编的实用临床超声心动图学(精).辽宁科学技术出版社,2003,P66
17. Jamal F, Strotmann J, Weidemann F, et al. Noninvasive quantification of the contractile reserve of stunned myocardium by ultrasonic strain rate and strain. Circulation.2001,104: 1059-1065.
18. Weidemann F, Jamal F, Sutherland G, et al. Myocardial function defined by strain rate and strain during alterations in inotropic states and heart rate. Am J Physiol.2002,283: 792-799.
19. Kukulski T, Jamal F, D'Hooge J, et al. Acute changes in systolic and diastolic events during clinical coronary angioplasty:a comparison of regional velocity, strain rate and strain measurement. J Am Soc Echocardiogr.2002,15:1-12.
20. Urheim S, Edvardsen T, Torp H, et al. Myocardial strain by Doppler echocardiography: validation of a new method to quantify regional myocardial function. Circulation. 2000,102:1158-1164.
21. Moore CC,Lugo Olivieri CH,Mc Veigh ER,et al. Three-dimension systolic strain patterns in the normal human left ventricle:characterization with tagged MR imaging. Radiology,2000,214(2):453-466.
22. Voigt JU, Exner B, Schmiedehausen K, et al. Strain rate imaging during dobutamine stress echocardiography provides objectives evidence of inducible ischemia. Circulation, 2003,107:2120-2126.
23.郭瑞强,胡佳琪,周青等.多巴酚丁胺负荷超声心动图结合应变率评价冠心病的临床研究.中华超声影像学杂志,2006,15：262-265.
24.王寒梅,田家玮,杜国庆,等.应变率成像结合多巴酚丁胺负荷试验检测早期心肌缺血的临床研究.中华超声影像学杂志,2007,16：568-572.
25.胡佳琪,石华,郭瑞强,等.多巴酚丁胺负荷试验时应变率检测冠心病的价值.中国医学影像技术,2007,23：1317-1319.
1. Sebastian C, Patel JJ, Sadaniantz A, et al. Stress echocardiography:A review of the Principles and Practice. Echocardiography,1998,15(7):669-692.
2. Voigt JU, Flachskampf FA. Strain and Strain rate. New and clinically relevant echo parameters of regional myocardial function. Z kardiol,2004,93(4):249-258.
3. Ruffolo RR.The pharmacology of dobutamine.Am J Med.Sci,1987,294(2):244-248.
4. Urheim S, Edvardsen T, Torp H, et al. Myocardial strain by Doppler echocardiography: validation of a new method to quantify regional myocardial function. Circulation,2000; 102(10):1158-1164.
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