心电图QRS波向量与心力衰竭患者预后的相关性研究

发布时间：2018-05-21 16:26

本文选题：心力衰竭 + QRS波　；参考：《西安医学院》2017年硕士论文

【摘要】：背景及目的:心力衰竭发生进展的主要病理生理机制为心脏重构。心脏重构包括心脏结构重构及电重构,前者如心肌肥厚、心腔增大等,后者如心室复极时间延长、复极离散度增加等。心脏的电重构与心力衰竭患者心律失常的发生及心源性猝死密切相关;心电图简单易得,代表整个心脏除极及复极过程,可以间接反映心脏的电重构特点,心力衰竭患者常发生不同程度的改变。本研究通过分析心力衰竭患者常规12导联心电图特点,研究QRS波宽度、振幅、Tp-Te间期与心力衰竭患者预后的相关性。方法:此研究经过陕西省人民医院伦理委员会审查通过,选取2014年1月-2016年4月,在陕西省人民医院住院的200例心力衰竭患者。所有患者均满足Framingham心力衰竭诊断标准,且以心脏B超射血分值(EF)小于50%,或者血BNP100pg/ml作为参考;排除标准:明显的电解质异常,包括高钾血症或低钾血症,高钙血症或低钙血症;甲状腺功能亢进症;起搏器植入术后;预激综合征等;心房扑动;交界性心律失常或室性心律失常;严重的肾功能不全(血肌酐265umol/L);正在使用抗心律失常药物(普罗帕酮,胺碘酮)等。所有受检者都于清醒安静休息10分钟后,由经过培训的医师或者护士,记录12导联心电图,心电图走纸速度为25mm/s,电压为全电压1mv,如为半电压则在测量绝对振幅时进行转换。所有结果皆拍成照片,在电脑上放大后进行测量;测量内容包括,AVR导联的QRS波绝对振幅;V1-V6导联的Tp-Te间期平均值;选择II、V1及V6导联上最清晰的QRS波测量它的宽度并记录,然后在每一导联测量3个心动周期,计算不同心动周期和不同导联轴上的平均值作为实测的QRS波宽度。将病人的QRS波宽度由小到大排列,按人数进行四分位分组,分别为组1(85ms)、组2(85-100ms)、组3(100-120ms)、组4(120ms)。将1年全因死亡率及再次住院率定义为复合终点事件。首先是比较不同组间的1年复合终点事件发生率以及全因死亡率的差异,同时观察不同组间,Tp-Te间期,QRS波振幅的差异。结果:1.样本QRS波宽度不满足正态分布(P=0.000),因此使用四分位数法,对QRS波时限进行分组比较。2.基线资料:从第一组到第四组年龄增加8岁,差异有显著性(p=0.001);心功能iii-iv级所占比显著增加(p=0.011);bnp绝对值显著增加(p=0.000)。四个象限之间女性所占的性别比,糖尿病病史阳性率等没有统计学差异(分别为p=0.659,p=0.266)。3.实验室检查资料:四个组之间的实验室检查资料不完全相同(p0.05);继续两两比较组间的差异,总胆固醇的比较显示第一组和其余组之间有统计学差异,而第二第三第四组各自之间无明显统计学差异(p=0.855)。甘油三脂量的比较显示四个组之间均有显著性差异,各自为各自的同类子集;且排序为第一组第四组第三组第二组。尿素氮的比较显示,第一组第二组之间没有统计学差异(p=0.743),但它们与第三组、第四组之间均有统计学差异;第三组与第四组之间也有显著性差异。血肌酐浓度的比较显示第一组与第二组为同类子集(p=0.698),并且它们和第三组及第四组比较后均有统计学意义;而第三组与第四组之间亦存在统计学差异。4.出院时的治疗方案:出院时四个组之间的β受体阻滞剂,血管紧张素受体拮抗剂或血管紧张素转换酶抑制剂,螺内酯的使用率上没有显著性差别(分别为p=0.944,p=0.838,p=0.333)。5.其他心电图指标:四个组之间相比,tp-te间期呈增加趋势,且差异有显著性(p=0.00)。四个组之间avr导联qrs波绝对振幅呈递减趋势,差异有显著性(p=0.001)。6.kaplanmeier生存分析:将再次住院率及死亡率作为复合终点事件来看,四个组之间呈逐层恶化的趋势;单独分析全因死亡率时,除第一组和第二组以外,其余各组之间均呈升高的趋势。7.log-rank检验:复合终点事件无显著性差异的有:第一组和第二组(p=0.565);第二组和第三组(p=0.155);第三组和第四组(p=0.178)。有统计学意义的有:第一组和第三组(p=0.045);第一组和第四组(p=0.001);第二组和第四组(p=0.007);全因死亡率无显著性差异的有:第一组和第二组(p=1);第一组和第三组(p=0.163);第二组和第三组(p=0.163);第三组和第四组(p=0.513)。有统计学意义的有:第一组和第四组(p=0.048);第二组和第四组(p=0.048)。8.cox风险比例回归模型:以第一组为参照的复合终点事件相对危险度,其中第二组和第一组之间无统计学意义(p=0.5700.05);第三组相对第一组的相对危险度为1.982(p=0.047,rr95%cl1.010-3.887);第四组相对第一组的危险度为3.048(P=0.000,RR 95%CL 1.632-5.691);全因死亡率:组二、组三、组一之间均无统计学意义(P值分别为0.373和0.071);组四与组一间的相对危险度为3.129(P=0.048,RR 95%CL 1.109-9.704)。结论:随着QRS波宽度的增加,复合终点事件的发生率呈梯度增加,从100ms时开始显著;在QRS波120ms时,将显著的增加患者的全因死亡风险;QRS波宽度和BNP以及心功能III-IV级的发生率具有良好的相关性,间接的反映了QRS波宽度的增加是心功能恶化的有效指标;同时年龄和QRS波的宽度有一定的相关性;QRS波大于100ms时肾功能开始有显著性差异;胆固醇四组之间有统计学差异,但是考虑意义不大;对于甘油三脂后两组的降低,考虑由于心力衰竭的营养不良状况所致;QRS波宽度在一定范围内与Tp-Te间期,QRS波振幅具有相关性,充分说明了心力衰竭时心脏的电重构具有一定的整体性,是一个除级,复级,传导特性综合性改变的过程。
[Abstract]:Background and purpose: the main pathophysiological mechanism of the progression of heart failure is cardiac remodeling. Cardiac remodeling includes cardiac structural remodeling and electrical remodeling. The former is such as cardiac hypertrophy, heart cavity enlargement, the latter, such as the prolongation of ventricular repolarization time, the increase of repolarization dispersion, and the occurrence of cardiac arrhythmias and cardiac origin in heart failure patients. It is closely related to sudden sexual death; the electrocardiogram is simple and easy to obtain, representing the whole cardiac depolarization and repolarization process, which can indirectly reflect the characteristics of electrical reconfiguration of the heart. The patients with heart failure often have varying degrees of change. This study analyzed the characteristics of the conventional 12 lead electrocardiogram in patients with heart failure, and studied the width, amplitude, Tp-Te interval and heart failure of the QRS wave. The correlation of patient prognosis. Methods: This study was passed through the Shaanxi People's Hospital ethics committee and selected 200 patients with heart failure hospitalized in April -2016 January 2014. All patients met the diagnostic criteria of Framingham heart failure, and the EF was less than 50%, or blood BNP100pg. /ml as reference; exclusion criteria: obvious electrolyte abnormalities, including hyperkalemia or hypokalemia, hypercalcemia or hypocalcemia; hyperthyroidism; pacemaker implantation; preexcitation syndrome; atrial flutter; borderline arrhythmias or ventricular arrhythmias; severe renal insufficiency (265umol/L); resistance to use. Cardiac arrhythmia drugs (propafenone, amiodarone). All subjects were given 10 minutes after sober and quiet rest. The 12 lead electrocardiogram was recorded by a trained physician or nurse. The electrocardiogram was 25mm/s, the voltage was 1mV, and the absolute amplitude was measured when the half voltage was measured. All the results were photographed. The measurements were made on the computer, and the measurements included the absolute amplitude of the QRS wave in the AVR lead, the Tp-Te interval average of the V1-V6 lead, the width and record of the most clear QRS waves on the II, V1, and V6 leads, and then measured in each of the 3 cardiac cycles in each lead, calculating the average value on the different cardiac cycle and the different lead axis as real. The width of the QRS wave was measured. The patient's QRS wave width was arranged from small to large and divided into four sub groups according to the number of people, group 1 (85ms), group 2 (85-100ms), group 3 (100-120ms), and group 4 (120ms). The 1 year total cause of mortality and rehospitalization rate were defined as compound endpoint events. The first first was to compare the incidence of 1 year endpoint events and all causes among different groups. The difference in mortality rate and the difference of amplitude between different groups, Tp-Te interval and QRS wave. Results: 1. sample QRS wave width was not satisfied with normal distribution (P=0.000), so using the four quantile method, the QRS wave time limit was grouped to compare the.2. baseline data: the age of 8 years from the first group to the fourth group was 8 years, the difference was significant (p=0.001); cardiac function III-IV BNP absolute value increased significantly (p=0.011), and the absolute value of BNP increased significantly (p=0.000). There was no statistical difference between the sex ratio of the four quadrants and the positive rate of diabetes history (p=0.659, p=0.266): the laboratory examination data between the groups were not exactly the same (P0.05); and the 22 comparison groups continued. The difference, the comparison of total cholesterol showed that there were statistical differences between the first group and the other groups, but there was no significant difference between the second groups and the third groups (p=0.855). The comparison of glycerol and three fat showed that there were significant differences between the four groups, and they were their respective subsets in the first group and the first group fourth groups, third groups and second groups. The comparison of urea nitrogen showed that there was no statistical difference between the first second groups (p=0.743), but there were statistical differences between the third groups and the fourth groups, and there was a significant difference between the third and the fourth groups. The comparison of the serum creatinine concentration showed that the first group and the second group were similar subsets (p=0.698), and they were in the third and four groups. There were statistical significance in the group comparison, but there was also a statistically significant difference between the third and fourth groups at discharge of.4.: beta blocker, angiotensin receptor antagonist or angiotensin converting enzyme inhibitor, and no significant difference in the use rate of spironolactone between four groups (p=0.944, p=0.838, respectively). P=0.333).5. other electrocardiogram indicators: the Tp-Te interval increased, and the difference was significant (p=0.00). The absolute amplitude of the AVR lead QRS wave between the four groups was reduced, and the difference was significant (p=0.001).6.kaplanmeier survival analysis: the recurrence rate and death rate were considered as the compound endpoint event, and four groups were found. There was a trend of layer by layer deterioration; in the individual analysis of total cause mortality, except for the first and second groups, the other groups were increased by.7.log-rank test: the first and second groups (p=0.565), the second group and the third group (p=0.155), the third group and the fourth group (p=0.178). The first and third groups (p=0.045); the first and fourth groups (p=0.001); the second and the fourth (p=0.007); the first and second groups (p=1); the first and third groups (p=0.163); the second and third groups (p=0.163); the third and fourth (p=0.513). The first group was statistically significant: the first group And fourth groups (p=0.048); second and fourth groups (p=0.048).8.cox risk proportional regression model: the relative risk degree of the composite terminal event with the first group as reference, of which there was no statistical significance between the second and the first groups (p=0.5700.05); the relative risk degree of the third group was 1.982 (p=0.047, rr95%cl1.010-3.887), and the fourth groups were in the fourth group. The risk degree of the first group was 3.048 (P=0.000, RR 95%CL 1.632-5.691); the total cause of mortality was two and three. There was no statistical significance between the group (P value 0.373 and 0.071), and the relative risk of group four and group one was 3.129 (P=0.048, RR 95%CL 1.109-9.704). Conclusion: the incidence of the compound terminal event is with the increase of QRS wave width. The gradient increased significantly from 100ms; at the time of QRS wave 120ms, the risk of all causes of death was significantly increased; the QRS wave width and BNP, as well as the incidence of III-IV at the heart function, were well correlated. The increase in the width of the QRS wave was an indirect indicator of the deterioration of cardiac function; at the same time, the width of age and QRS waves had a certain phase. There was a significant difference in renal function when the QRS wave was greater than 100ms; there was a statistical difference between four groups of cholesterol, but the significance was not significant; the decrease in the two groups after three glycerin was considered due to the malnutrition of the heart failure; the width of the QRS wave was related to the amplitude of the Tp-Te interval and the amplitude of the QRS wave, fully said It is clear that the electrical remodeling of heart has a certain integrity in heart failure. It is a process of comprehensive removal of grade, complex and conduction characteristics.
【学位授予单位】：西安医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.6

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