Selvester QRS心电图评分与肥厚型心肌病心肌纤维化及左心结构与功能的关系探讨

发布时间：2018-01-02 01:08

本文关键词：Selvester QRS心电图评分与肥厚型心肌病心肌纤维化及左心结构与功能的关系探讨　出处：《北京协和医学院》2017年博士论文　论文类型：学位论文

【摘要】：第一部分:SelvesterQRS心电图评分与肥厚型心肌病心肌纤维化的关系探讨目的:SelvesterQRS心电图评分系统是一种利用心电图指标来评估心肌梗死后心肌瘢痕量的有效方法,其在评价肥厚型心肌病(hypertrophic cardiomyopaphy,HCM)心肌纤维化方面的应用价值尚不明确。本研究旨在探讨Selvester QRS心电图评分系统在评价HCM心肌纤维化的意义。方法:本研究纳入149名HCM患者,行钆对比剂延迟增强(late gadolinium enhanced,LGE)对心肌纤维化进行定性及定量分析,行标准12导联心电图检查计算Selvester QRS评分,对Selvester QRS评分和LGE积分进行相关性分析,探讨Selvester QRS评分对HCM心肌纤维化的评估价值。结果:在149名受试者中,Selvester QRS评分与LGE积分成显著相关,利用Selvester QRS评分测算的左心室纤维化瘢痕量为13.4±11.4%,利用LGE%测算的左心室纤维化程度为22.1±19.6%,差值为8.7%(95%CI:5.1-12.4%),利用Bland-Altman法评估Selvester QRS评分与LGE这两种方法评估HCM心肌纤维化的差别和一致性,可以发现当心肌纤维化或瘢痕面积增大时,这两种方法所测数值间的差值也随之增大。多因素回归分析校正其他变量的影响因素后发现,Selvester QRS 评分和最大左室壁厚度(maximum left ventricular wall thickness,MWT)是预测LGE阳性的独立预测因子。ROC曲线分析Selvester QRS评分和最大左室壁厚度是预测LGE阳性的最佳界值,发现当Selvester QRS评分≥3.5时或MWT21mm时,对LGE阳性有良好的预测价值。结论:在HCM患者中,SelvesterQRS心电图评分与心肌纤维化水平(通过MRI-LGE测得)显著相关,其总分≥3.5对LGE阳性有较好的预测作用。第二部分:Selvester QRS心电图评分与肥厚型心肌病左心结构与功能的关系探讨目的:研究表明,舒张功能障碍在肥厚型心肌病(hypertrophic cardiomyopaphy,HCM)中十分常见,且与心肌纤维化关系密切。而SelvesterQRS心电图评分对HCM心肌纤维化及瘢痕有一定的预测意义。该研究旨在探讨Selvester QRS心电图评分对HCM舒张功能障碍的评估意义。方法:60名HCM患者行超声心动图及组织多普勒超声检查,测量舒张早期二尖瓣环血流速度峰值(early diastolic peak inflow velocity,E)、舒张晚期二尖瓣环血流速度峰值(late diastolic peak inflow velocity,A)等速度峰值、E峰减速时间(deceleration time,DT)、E/A比值、舒张早期二尖瓣环运动峰速(early diastolic peak velocity of mitral annular,Ea)、舒张晚期二尖瓣环运动锋速(late diastolic peak velocityofmitralannular,Aa)等速度峰值、E/Ea比值、等容舒张期时间(isovolumic relaxation time,IVRT)等指标。行标准12导联心电图检查计算Selvester QRS评分,并抽取外周静脉血检测纤维化标志物,探讨SelvesterQRS评分与反映HCM舒张功能障碍的超声学指标及外周血纤维化标志物之间的关系。结果:与Selvester QRS评分阴性组的患者相比,Selvester QRS阳性组的患者其室间隔厚度(22.3±5.10mmvs 19.11±4.18mm,P=0.043)及最大室壁厚度更大(26.67±4.80mmvs22.2±4.32mm,P=0.004)(图 1),Ea 侧壁(6.22±2.47cm/svs 10.5±5.0cm/s,P=0.009)及 Ea 间隔(5.63±2.38cm/svs8.03±2.91cm/s,P=0.003)值更小,而 E/Ea 侧壁(15.5±5.70vs9.38±3.16,P0.001)及 E/Ea 间隔(17.2±5.45 vs12.0±3.43,P=0.002)值更大(图 3),且Ⅰ型前胶原羧基端肽(procollagentypeⅠN-terminal propeptide,PICP)的浓度值(170.8±55.5ng/ml vs 128.1 ±53.6ng/ml,P=0.019)更高。相关性分析发现,SelveseterQRS评分与cTnI浓度(r=0.388,P=0.002)、室间隔厚度(r=0.463,P0.001)、最大室壁厚度(r=0.255,P=0.001)、静息左室流出道压差(r=0.319,P=0.013)、E/Ea 侧壁(r=0.310,P=0.016)、E/Ea 间隔(r=0.429,P=0.001)成显著正相关。多因素回归分析结果提示,Selvester QRS评分是影响HCM患者E/Ea间隔的独立预测因素(beta=0.482,P=0.045),而非影响E/Ea侧壁的独立预测因素(beta=0.139,P0.05)的独立预测因素,PICP(beta=0.032,P=0.034)及 NYHA 心功能分级(beta=3.334,P=0.014)是影响E/Ea侧壁的独立预测因素。结论:在HCM患者中Selvester QRS评分与E/Ea侧壁、E/Ea间隔成显著相关,是影响HCM患者E/Ea间隔的独立因素,提示Selvester QRS评分对HCM的舒张功能障碍有一定的指示意义。
[Abstract]:The first part: the relationship between myocardial fibrosis score and SelvesterQRS ECG in patients with hypertrophic cardiomyopathy Objective: SelvesterQRS ECG scoring system is an effective method to evaluate myocardial scar volume by using electrocardiogram, the evaluation of hypertrophic cardiomyopathy (hypertrophic cardiomyopaphy HCM) application value of myocardial fibrosis is still unclear. The purpose of this study is to to investigate the Selvester QRS ECG scoring system in evaluating HCM myocardial fibrosis. Methods: the study included 149 patients with HCM, underwent gadolinium contrast delayed enhancement (late gadolinium enhanced, LGE) qualitative and quantitative analysis of myocardial fibrosis, for standard 12 lead electrocardiogram Selvester QRS score calculation, analyze the correlation between the Selvester score of QRS to investigate the Selvester and LGE score, QRS score to assess the value of myocardial fibrosis of HCM. Results: 14 9 subjects, Selvester QRS score and LGE score was significantly correlated with left ventricular fibrosis, scar Selvester QRS score calculation is 13.4 + 11.4%, the left ventricular fibrosis LGE% measure was 22.1 + 19.6%, the difference was 8.7% (95%CI:5.1-12.4%), Selvester QRS score and LGE assessment of these two kinds of evaluation methods HCM myocardial fibrosis difference and consistency by using the Bland-Altman method, can be found when myocardial fibrosis or scar area increases, the two methods of measuring the difference between numerical increases. Multiple regression analysis of factors affecting the correction of other variables after the discovery, Selvester QRS score and the maximum left ventricular wall thickness (maximum left ventricular wall thickness, MWT Selvester) is the analysis of the QRS score and the maximum left ventricular wall thickness is best predicted LGE positive predictive value of LGE positive field independent predictors of.ROC curve, when Sel Vester QRS score more than 3.5 or MWT21mm, the LGE positive predictive value. Conclusion: in HCM patients, SelvesterQRS ECG score and the level of myocardial fibrosis (measured by MRI-LGE) was significantly related to the total score of more than 3.5 of LGE positive prediction function. The second part: the relationship between Selvester score and QRS ECG hypertrophy cardiomyopathy with left ventricular structure and function of the objective: studies show that diastolic dysfunction in patients with hypertrophic cardiomyopathy (hypertrophic cardiomyopaphy, HCM) is very common, and is closely related with myocardial fibrosis. SelvesterQRS ECG score can predict the HCM of myocardial fibrosis and scar. This study aimed to investigate the significance of evaluation of Selvester QRS ECG score HCM diastolic dysfunction. Methods: 60 HCM patients underwent echocardiography and tissue Doppler ultrasound measurement of early diastolic mitral valve Ring peak velocity (early diastolic peak inflow velocity, E), late diastolic peak velocity of mitral annulus (late diastolic peak inflow velocity, A), peak velocity, E peak deceleration time (deceleration time, DT E/A), the ratio of early diastolic peak velocity of mitral annulus (early diastolic peak velocity of mitral annular. Ea), late diastolic mitral annulus velocity (late diastolic peak velocityofmitralannular front, Aa), peak velocity, E/Ea ratio, isovolumic relaxation time (isovolumic relaxation, time, IVRT). The indexes for standard 12 lead electrocardiogram calculation of Selvester QRS score, and peripheral blood was taken for the detection of fibrosis markers, SelvesterQRS score with the reflection of ultrasonic HCM diastolic dysfunction index and peripheral blood fibrosis markers between the patients with Selvester. Results: the QRS score in the negative group Selvester, QRS positive patients with the ventricular septal thickness (22.3 + 5.10mmvs 19.11 + 4.18mm, P=0.043) and the maximum wall thickness was greater (26.67 + 4.80mmvs22.2 + 4.32mm, P=0.004) (Figure 1), the Ea side wall (6.22 + 2.47cm/svs 10.5 + 5.0cm/s, P=0.009) and Ea interval (5.63 + 2.38cm/svs8.03 + 2.91cm/s, P=0.003 and E/Ea) is small, the side wall (15.5 + 5.70vs9.38 + 3.16, P0.001) and E/Ea interval (17.2 + 5.45 vs12.0 + 3.43, P=0.002) values (Figure 3), and procollagen I carboxy terminal peptide (procollagentype I N-terminal propeptide, PICP) concentration (170.8 + 55.5ng/ml vs 128.1 + 53.6ng/ml, P=0.019) higher. Correlation analysis showed that SelveseterQRS score and the concentration of cTnI (r=0.388, P=0.002), interventricular septal thickness (r=0.463, P0.001), the maximum wall thickness (r=0.255, P=0.001), resting left ventricular outflow pressure (r=0.319, P=0.013), E/Ea (r=0.310, P=0.016) side wall E/Ea. The interval (r=0.429, P=0.001) a significant positive correlation. Regression analysis showed that Selvester QRS score were independent predictive factors of HCM patients with E/Ea interval (beta=0.482, P=0.045), and the effect of non independent prediction of E/Ea side wall factors (beta=0.139, P0.05) of the independent predictor of PICP (beta=0.032, P=0.034) NYHA and heart function classification (beta=3.334, P=0.014) were independent prognostic factors for E/Ea side wall. Conclusion: in patients with HCM Selvester QRS score and the E/Ea side wall, E/Ea interval was significantly correlated with HCM, were independent factors affecting the E/Ea interval, Selvester QRS score of HCM diastolic dysfunction has certain instruction significance.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R542.2

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