心脏性猝死预测和治疗相关问题的临床研究
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摘要
第一部分碎裂QRS波对特发性扩张型心肌病患者全因死亡率和室性心律失常的预测作用
[背景]特发性扩张型心肌病是一种严重危害人类健康的心脏疾病,患者大多死于心力衰竭或恶性室性心律失常,如何选用简单、方便的无创性检测方法预测这些患者的预后,并给予积极治疗有着重要的临床意义。研究表明12导联心电图上存在的各种RSR'形式的碎裂QRS波与冠心病患者死亡率及室性心律失常发生率增加显著相关。但是,目前却少有文献报道碎裂QRS波在特发性扩张型心肌病患者中的预测价值。
[目的]本研究旨在评估碎裂QRS波对伴有左室功能障碍的特发性扩张型心肌病患者全因死亡和室性心律失常的预测作用。
[方法]回顾性分析2009年1月至2009年12月在阜外心血管病医院住院的特发性扩张型心肌病(伴左室功能障碍,左室射血分数≤40%)的患者病历资料。根据12导联心电图上的QRS时限和是否存在碎裂QRS波,将入选患者分为三组：1)碎裂QRS波组(f-QRS组,QRS时限<120ms和存在碎裂QRS波,51例)；2)宽QRS波组(wQRS组,QRS时限≥120ms,48例)；3)非碎裂QRS波组(non-fQRS组,QRS时限<120ms,且不存在碎裂QRS波,29例)。本研究采用联合终点,即全因死亡和室性心律失常事件(包括ICD记录并给予适当治疗的室性心动过速或心室颤动)。
[结果]共入选128例患者,平均年龄54±14(19-83)岁,68%为男性。碎裂QRS波分布在下壁、侧壁和前壁的患者分别为28例(21.9%)、17例(13.3%)和20例(15.6%),其中14例(10.9%)患者至少在两个冠脉供血区域出现碎裂QRS波。碎裂QRS波组左室射血分数显著低于非碎裂QRS波组(29%±6%Vs33%±7%,P=0.013)。碎裂QRS波组和宽QRS波组患者的左室舒张末期内径较非碎裂QRS组患者显著增大(分别为68.8±7.9mm,69.4±9.Omm和65.2±6.5mm,P值均<0.05)。所有入选患者平均随访14±5个月,25例(19.5%)患者出现联合终点事件(全因死亡或室性心律失常事件)。碎裂QRS波组和宽QRS波组患者的联合终点事件发生率明显高于非碎裂QRS波组患者(分别为23.5%,25%和3.4%,P值均<0.05)。Kaplan-Meier生存分析提示,与非碎裂QRS波组患者比较,碎裂QRS波组患者生存率显著降低(P=0.02)。单因素Cox回归分析提示,碎裂QRS波(OR值7.90,P=0.015)是伴有左室功能障碍的特发性扩张型心肌病患者发生死亡和室性心律失常事件的独立预测因素。
[结论]在伴有左室功能障碍的特发性扩张型心肌病患者中,常规12导联心电图上存在碎裂QRS波是预测全因死亡和室性心律失常事件的强有力指标。
第二部分植入式心律转复除颤器患者的临床随访研究
[背景]恶性室性心律失常(室速和室颤)是心脏性猝死的主要原因。植入式心律转复除颤器(ICD)是治疗室性心律失常,防治心脏性猝死的最有效方法,可以显著提高患者生存率。但ICD不适当识别和治疗是植入心律转复除颤器后的-个主要并发症,严重影响患者生活质量,尤其是不适当电击治疗,可导致患者心功能恶化,增加死亡风险。然而,目前关于不适当电击治疗的预测指标,尚无一致的结论。
[目的]本研究通过随访观察植入ICD的心脏性猝死高危患者,分析患者心律失常发作情况,评价抗心动过速起搏(ATP)终止室速的疗效；分析不适当识别和治疗事件,以期得出不适当电击治疗的预测因素。
[方法]选择2007年3月至2010年8月在阜外心血管病医院植入ICD,并能完成定期随访的患者。随访时,了解患者生存状况,并应用体外程控仪调出ICD储存信息,回顾ICD中记录的室性心律失常事件,通过分析腔内电图评价ICD对事件的诊断和治疗情况。
[结果]共入选115例植入心律转复除颤器的患者,平均年龄51±17(8-80)岁,男性78例(67.8%),其中108例(93.9%)患者为心脏性猝死二级预防,83例(72.2%)患者植入单腔ICD。平均随访14±11(2-48)个月,8例(7.0%)患者死亡,其中5例(62.5%)死于心力衰竭。随访期间,58例(50.4%)患者发生过持续性室性心律失常事件(室速/室颤),ICD发放了适当治疗(ATP和/或电击)。46例(40%)患者共发生783次持续性室速,652次(83.3%)经ATP治疗成功转复,仅6次(0.8%)室速事件经ATP治疗后恶化为室颤,经ICD电击治疗后均成功复律。22例(19.1%)患者发生ICD不适当识别和治疗,最主要的原因是由于不适当识别室上性心动过速(81.8%),其中不适当电击治疗17例(14.8%)。植入ICD后发生首次不适当放电的中位数时间为114天。单因素Cox风险比例回归模型分析显示,心房颤动病史是植入ICD患者发生不适当电击治疗的一个预测指标(OR值5.3,95%可信区间1.88-14.92,P=0.002)。
[结论]ICD分层治疗方案中,ATP能成功转复绝大多数室速事件；心房颤动病史是植入ICD患者发生不适当放电的一个独立预测指标。
Part I
Fragmented QRS is associated with all-cause mortality and ventricular arrhythmias in patient with idiopathic dilated cardiomyopathty
[Background] Idiopathic dilated cardiomyopathy is a serious heart disease damaging human being's health, and most patients die of heart failure or malignant ventricular arrhythmias. So it has important clinical significance to estimate prognosis of these patients using simple and convenient noninvasive techniques. Several studies have showed that fragmented QRS complexes on a routine 12-lead electrocardiogram were associated with increased mortality and arrhythmic events in patients with coronary artery disease, but relatively little data were available regarding idiopathic dilated cardiomyopathy.
[Objective] The purpose of this study was to evaluate the relationship between fragmentation of QRS and the combined endpoint of all-cause mortality and ventricular arrhythmias in patients with idiopathic dilated cardiomyopathy.
[Methods] Patients who were diagnosed as idiopathic dilated cardiomyopathy with left ventricular dysfunction (ejection fraction, EF< or=40%) at our hospital from January 1,2009 to December 31,2009 were analyzed respectively. According to QRS duration and the existence of f-QRS on 12-lead ECG, the study populations were divided into three groups:1) the f-QRS group (QRS< 120ms and with fragmented QRS, n=51),2) the wQRS group (QRS> or= 120ms, n=48), and 3) the non-fQRS group (QRS< 120ms and without fragmented QRS, n=29).
[Results] A total of 128 patients (mean age 54±14 years, male 68 %) were control into this study. f-QRS was present in 28 patients (21.9 %),17 patients (13.3%), and 20 patients (15.6%) of inferior, lateral, and anterior leads, respectively, and was present in more than one lead set in 14 cases (10.9%). LVEF was significantly lower in the f-QRS group than the non-fQRS group (29%±6%vs 33%±7%, P=0.013). Left ventricular end-diastolic dimension in the f-QRS and the wQRS groups were 68.8±7.9mm and 69.4±9.0mm, respectively, which was significantly larger than in the non-fQRS group (65.2±6.5mm, P<0.05 for both). During a mean follow-up of 14±5 months,25 (19.5%) patients had deaths or ventricular arrhythmic events. The combined endpoint of all-cause mortality and ventricular tachyarrhythmias was significantly higher in the f-QRS and wQRS groups than the non-fQRS group (23.5%,25%, and 3.4%, respectively; P<0.05 for both). Event-free was significantly decreased in the f-QRS group versus the non-fQRS group (P=0.02). Univaritae Cox regression analysis revealed that f-QRS (odds ratio [OR] 7.90, P=0.015) was a stronger predictor of mortality and arrhythmic events in idiopathic dilated cardiomyopathy patients.
[Conclusion] f-QRS on 12-lead ECG has a high predictive value for the combined endpoint of all-cause mortality and ventricular tachyarrhythmias in idiopathic dilated cardiomyopathy patients with left ventricular dysfunction.
Part II Clinical application and follow up of implantable cardioverter-defibrillator
[Background] Malignant ventricular arrhythmias, ventricular tachycardia (VT) or ventricular fibrillation (VF), are the main reason of sudden cardiac death. The implantable cardioverter-defibrillator (ICD) provides a significant reduction in mortality in survivors of sudden cardiac arrest and high-risk patients with cardiovascular disease. Inappropriate detection and therapy of ICD are the most common side effects and impact the quality-of-life in ICD patients. Inappropriate shocks will reduce cardiac function and increase mortality risk. Several studies identify some predictors for inappropriate shocks, but they show less consistency.
[Objective] The purpose of this study was to assess the incidence of tachycardia, the capability of ATP therapy for termination of ventricular tachycardia, and the incidence and predictors of inappropriate shocks in ICD patients.
[Methods] From March 2007 to August 2010, patients who receive ICD implantation for preventing the sudden cardiac death in Fu Wai Cardiovascular Hospital were enrolled in this study. Patients were followed up by regular intervals after implantation. During follow-up, the occurrence of arrhythmia, all-cause mortality, the rate of successful termination ventricular tachycardia by ATP and inappropriate shocks were noted.
[Results] A total of 115 ICD patients (mean age 51±17 years, male 67.8%) were include in the analysis.93.9% reveived an ICD for sudden cardiac death second prevention, and 72.7% received single-chamber ICDs. During the follow-up period of 14±11 months,8 patients died and the major cause of death was heart failure (5 cases,62.5%).58 patients (50.4%) experienced appropriate therapy (ATP and/or shock) due to sustained ventricular arrhythmia. ATP was attempted for 783 sustained VT episodes in 46 patients (40%), and 652 (83.3%) of the VT episodes were successfully terminated by ATP. Six VT events were accelerated by ATP and required termination by ICD shock.22 patients (19.1%) experienced inappropriate detections and therapies and 17 patients (14.8%) had inappropriate shocks. The median time from ICD implantation to first inappropriate shock was 114 (1～1006) days. Univaritae Cox regression analysis revealed that a history of atrial fibrillation (odds ratio [OR] 5.3,95% CI 1.88～14.92, P=0.002) was a stronger predictor of the occurrence of inappropriate shocks.
[Conclusion] Sustained VT terminated by ATP therapy was efficiency and safe; ICD inappropriate shocks were a common complication after implantation and a history of atrial fibrillation can increase inappropriate shocks risk.
[背景]特发性扩张型心肌病是一种严重危害人类健康的心脏疾病,患者大多死于心力衰竭或恶性室性心律失常,如何选用简单、方便的无创性检测方法预测这些患者的预后,并给予积极治疗有着重要的临床意义。研究表明12导联心电图上存在的各种RSR'形式的碎裂QRS波与冠心病患者死亡率及室性心律失常发生率增加显著相关。但是,目前却少有文献报道碎裂QRS波在特发性扩张型心肌病患者中的预测价值。
[目的]本研究旨在评估碎裂QRS波对伴有左室功能障碍的特发性扩张型心肌病患者全因死亡和室性心律失常的预测作用。
[方法]回顾性分析2009年1月至2009年12月在阜外心血管病医院住院的特发性扩张型心肌病(伴左室功能障碍,左室射血分数≤40%)的患者病历资料。根据12导联心电图上的QRS时限和是否存在碎裂QRS波,将入选患者分为三组：1)碎裂QRS波组(f-QRS组,QRS时限<120ms和存在碎裂QRS波,51例)；2)宽QRS波组(wQRS组,QRS时限≥120ms,48例)；3)非碎裂QRS波组(non-fQRS组,QRS时限<120ms,且不存在碎裂QRS波,29例)。本研究采用联合终点,即全因死亡和室性心律失常事件(包括ICD记录并给予适当治疗的室性心动过速或心室颤动)。
[结果]共入选128例患者,平均年龄54±14(19-83)岁,68%为男性。碎裂QRS波分布在下壁、侧壁和前壁的患者分别为28例(21.9%)、17例(13.3%)和20例(15.6%),其中14例(10.9%)患者至少在两个冠脉供血区域出现碎裂QRS波。碎裂QRS波组左室射血分数显著低于非碎裂QRS波组(29%±6%Vs33%±7%,P=0.013)。碎裂QRS波组和宽QRS波组患者的左室舒张末期内径较非碎裂QRS组患者显著增大(分别为68.8±7.9mm,69.4±9.Omm和65.2±6.5mm,P值均<0.05)。所有入选患者平均随访14±5个月,25例(19.5%)患者出现联合终点事件(全因死亡或室性心律失常事件)。碎裂QRS波组和宽QRS波组患者的联合终点事件发生率明显高于非碎裂QRS波组患者(分别为23.5%,25%和3.4%,P值均<0.05)。Kaplan-Meier生存分析提示,与非碎裂QRS波组患者比较,碎裂QRS波组患者生存率显著降低(P=0.02)。单因素Cox回归分析提示,碎裂QRS波(OR值7.90,P=0.015)是伴有左室功能障碍的特发性扩张型心肌病患者发生死亡和室性心律失常事件的独立预测因素。
[结论]在伴有左室功能障碍的特发性扩张型心肌病患者中,常规12导联心电图上存在碎裂QRS波是预测全因死亡和室性心律失常事件的强有力指标。
第二部分植入式心律转复除颤器患者的临床随访研究
[背景]恶性室性心律失常(室速和室颤)是心脏性猝死的主要原因。植入式心律转复除颤器(ICD)是治疗室性心律失常,防治心脏性猝死的最有效方法,可以显著提高患者生存率。但ICD不适当识别和治疗是植入心律转复除颤器后的-个主要并发症,严重影响患者生活质量,尤其是不适当电击治疗,可导致患者心功能恶化,增加死亡风险。然而,目前关于不适当电击治疗的预测指标,尚无一致的结论。
[目的]本研究通过随访观察植入ICD的心脏性猝死高危患者,分析患者心律失常发作情况,评价抗心动过速起搏(ATP)终止室速的疗效；分析不适当识别和治疗事件,以期得出不适当电击治疗的预测因素。
[方法]选择2007年3月至2010年8月在阜外心血管病医院植入ICD,并能完成定期随访的患者。随访时,了解患者生存状况,并应用体外程控仪调出ICD储存信息,回顾ICD中记录的室性心律失常事件,通过分析腔内电图评价ICD对事件的诊断和治疗情况。
[结果]共入选115例植入心律转复除颤器的患者,平均年龄51±17(8-80)岁,男性78例(67.8%),其中108例(93.9%)患者为心脏性猝死二级预防,83例(72.2%)患者植入单腔ICD。平均随访14±11(2-48)个月,8例(7.0%)患者死亡,其中5例(62.5%)死于心力衰竭。随访期间,58例(50.4%)患者发生过持续性室性心律失常事件(室速/室颤),ICD发放了适当治疗(ATP和/或电击)。46例(40%)患者共发生783次持续性室速,652次(83.3%)经ATP治疗成功转复,仅6次(0.8%)室速事件经ATP治疗后恶化为室颤,经ICD电击治疗后均成功复律。22例(19.1%)患者发生ICD不适当识别和治疗,最主要的原因是由于不适当识别室上性心动过速(81.8%),其中不适当电击治疗17例(14.8%)。植入ICD后发生首次不适当放电的中位数时间为114天。单因素Cox风险比例回归模型分析显示,心房颤动病史是植入ICD患者发生不适当电击治疗的一个预测指标(OR值5.3,95%可信区间1.88-14.92,P=0.002)。
[结论]ICD分层治疗方案中,ATP能成功转复绝大多数室速事件；心房颤动病史是植入ICD患者发生不适当放电的一个独立预测指标。
Part I
Fragmented QRS is associated with all-cause mortality and ventricular arrhythmias in patient with idiopathic dilated cardiomyopathty
[Background] Idiopathic dilated cardiomyopathy is a serious heart disease damaging human being's health, and most patients die of heart failure or malignant ventricular arrhythmias. So it has important clinical significance to estimate prognosis of these patients using simple and convenient noninvasive techniques. Several studies have showed that fragmented QRS complexes on a routine 12-lead electrocardiogram were associated with increased mortality and arrhythmic events in patients with coronary artery disease, but relatively little data were available regarding idiopathic dilated cardiomyopathy.
[Objective] The purpose of this study was to evaluate the relationship between fragmentation of QRS and the combined endpoint of all-cause mortality and ventricular arrhythmias in patients with idiopathic dilated cardiomyopathy.
[Methods] Patients who were diagnosed as idiopathic dilated cardiomyopathy with left ventricular dysfunction (ejection fraction, EF< or=40%) at our hospital from January 1,2009 to December 31,2009 were analyzed respectively. According to QRS duration and the existence of f-QRS on 12-lead ECG, the study populations were divided into three groups:1) the f-QRS group (QRS< 120ms and with fragmented QRS, n=51),2) the wQRS group (QRS> or= 120ms, n=48), and 3) the non-fQRS group (QRS< 120ms and without fragmented QRS, n=29).
[Results] A total of 128 patients (mean age 54±14 years, male 68 %) were control into this study. f-QRS was present in 28 patients (21.9 %),17 patients (13.3%), and 20 patients (15.6%) of inferior, lateral, and anterior leads, respectively, and was present in more than one lead set in 14 cases (10.9%). LVEF was significantly lower in the f-QRS group than the non-fQRS group (29%±6%vs 33%±7%, P=0.013). Left ventricular end-diastolic dimension in the f-QRS and the wQRS groups were 68.8±7.9mm and 69.4±9.0mm, respectively, which was significantly larger than in the non-fQRS group (65.2±6.5mm, P<0.05 for both). During a mean follow-up of 14±5 months,25 (19.5%) patients had deaths or ventricular arrhythmic events. The combined endpoint of all-cause mortality and ventricular tachyarrhythmias was significantly higher in the f-QRS and wQRS groups than the non-fQRS group (23.5%,25%, and 3.4%, respectively; P<0.05 for both). Event-free was significantly decreased in the f-QRS group versus the non-fQRS group (P=0.02). Univaritae Cox regression analysis revealed that f-QRS (odds ratio [OR] 7.90, P=0.015) was a stronger predictor of mortality and arrhythmic events in idiopathic dilated cardiomyopathy patients.
[Conclusion] f-QRS on 12-lead ECG has a high predictive value for the combined endpoint of all-cause mortality and ventricular tachyarrhythmias in idiopathic dilated cardiomyopathy patients with left ventricular dysfunction.
Part II Clinical application and follow up of implantable cardioverter-defibrillator
[Background] Malignant ventricular arrhythmias, ventricular tachycardia (VT) or ventricular fibrillation (VF), are the main reason of sudden cardiac death. The implantable cardioverter-defibrillator (ICD) provides a significant reduction in mortality in survivors of sudden cardiac arrest and high-risk patients with cardiovascular disease. Inappropriate detection and therapy of ICD are the most common side effects and impact the quality-of-life in ICD patients. Inappropriate shocks will reduce cardiac function and increase mortality risk. Several studies identify some predictors for inappropriate shocks, but they show less consistency.
[Objective] The purpose of this study was to assess the incidence of tachycardia, the capability of ATP therapy for termination of ventricular tachycardia, and the incidence and predictors of inappropriate shocks in ICD patients.
[Methods] From March 2007 to August 2010, patients who receive ICD implantation for preventing the sudden cardiac death in Fu Wai Cardiovascular Hospital were enrolled in this study. Patients were followed up by regular intervals after implantation. During follow-up, the occurrence of arrhythmia, all-cause mortality, the rate of successful termination ventricular tachycardia by ATP and inappropriate shocks were noted.
[Results] A total of 115 ICD patients (mean age 51±17 years, male 67.8%) were include in the analysis.93.9% reveived an ICD for sudden cardiac death second prevention, and 72.7% received single-chamber ICDs. During the follow-up period of 14±11 months,8 patients died and the major cause of death was heart failure (5 cases,62.5%).58 patients (50.4%) experienced appropriate therapy (ATP and/or shock) due to sustained ventricular arrhythmia. ATP was attempted for 783 sustained VT episodes in 46 patients (40%), and 652 (83.3%) of the VT episodes were successfully terminated by ATP. Six VT events were accelerated by ATP and required termination by ICD shock.22 patients (19.1%) experienced inappropriate detections and therapies and 17 patients (14.8%) had inappropriate shocks. The median time from ICD implantation to first inappropriate shock was 114 (1～1006) days. Univaritae Cox regression analysis revealed that a history of atrial fibrillation (odds ratio [OR] 5.3,95% CI 1.88～14.92, P=0.002) was a stronger predictor of the occurrence of inappropriate shocks.
[Conclusion] Sustained VT terminated by ATP therapy was efficiency and safe; ICD inappropriate shocks were a common complication after implantation and a history of atrial fibrillation can increase inappropriate shocks risk.
引文
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