T波形态学参数对心力衰竭患者的预后价值研究

发布时间：2018-07-29 14:48

【摘要】：目的:心力衰竭是各种心血管疾病严重和终末阶段,心脏结构和(或)功能发生改变,伴心室复极异常,可发生恶性心律失常甚至猝死。心室复极异常的主要心电图表现为QT间期延长及T波形态改变。研究表明心电图T波形态学参数是预后不良的预测指标。方法:收集单中心资料,按一定的纳入及排除标准选定心衰组及非心衰组患者。收集临床资料,T波形态学参数由计算机软件自动计算,为12导联参数的平均值,包括QRS-T夹角、QT间期离散度和QTp间期离散度、T波峰末间期、T波主要成分比值、扁平性评分、不对称性评分、切迹性评分、形态综合评分。对心衰组采取电话随访,终点事件为死亡,其中心因死亡包括泵衰竭、急性心肌梗死、恶性心律失常。非心衰组未实行随访。先进行心衰组与非心衰组基线资料及T波形态学参数比较;后对心衰患者的心因死亡组与存活组基线资料、T波形态学参数进行比较;心因性死亡的生存时间分析及其影响因素COX回归分析;最后对独立危险因素作为判断标准的价值分析。结果:纳入心衰患者219人,对照组210人,两组年龄、性别无差异(P0.05),除QTp间期离散度外,其他T波形态学参数均有差异;心衰组QRS-T夹角、T波峰末间期、QT间期离散度、T波主要成分比值、形态综合评分、扁平性评分高于对照组,心衰组T波不对称性评分低于对照组。心衰组患者平均随访17.50±7.40个月,全因死亡16人,其中心因性死亡11人,生存203人,心因死亡率5.02%。对比心因死亡及存活组的基线资料(除高血压外)均无差异(P0.05),对比T波形态学参数,QRS-T夹角死亡组高于存活组(142(126-161)vs 87(47-120),P=0.002),T波形态综合评分死亡组低于存活组(76(71-88)vs 84(72-101),P=0.047),T波不对称性评分死亡组低于存活组(7(3-10)vs 8(4-16),P=0.048),其它无差异。随访期内平均生存时间为33.35个月,95%置信区间为(32.06-33.72)个月,累计生存率1年为99.5%,2年为97.7%,QRS-T夹角≥90°者1年后生存率较90°者明显下降(P=0.002)。采用乘积极限法行COX回归分析,单因素分析提示合并房颤、房扑的患者平均生存时间短于不合并者(31.112±0.546 VS 33.937±0.370,P=0.039),QRS夹角≥90°者平均生存时间短于90°者(33.18±0.14 VS 32.35±0.68,P=0.002),其它基线资料以及其它T波形态学参数无差异(P均0.05),其中QTp间期离散度的P=0.083,为临界值。将P0.05或为临界值的参数及性别、年龄、左室射血分数纳入多因素分析,提示QRS-T夹角仍是影响预后的因素,P=0.020,QRS夹角增大(≥90°)的相对危险度RR为12.113。若将QRS-T夹角作为判断心衰患者发生心因死亡的预测标准,ROC曲线下面积分别为0.733(0.50),P值为0.002(0.05)、95%可信区间为0.619-0.926,说明QRS-T夹角作为判断心衰预后的指标是有意义的。结论:心衰患者T波形态学参数较非心衰者存在显著改变。QRS-T夹角是心衰患者发生心因性死亡的独立危险因素,QRS-T夹角≥90°作为判断预后的标准是有效的。
[Abstract]:Objective: heart failure is a serious and terminal stage of various cardiovascular diseases, cardiac structure and / or function changes, accompanied by abnormal ventricular repolarization, malignant arrhythmia or even sudden death. The main electrocardiographic manifestations of ventricular repolarization abnormalities were the prolongation of QT interval and the changes of T wave morphology. The study showed that T wave morphological parameters were predictors of poor prognosis. Methods: single-center data were collected to select patients with heart failure and non-heart failure according to certain inclusion and exclusion criteria. The morphological parameters of T wave were calculated automatically by computer software, which was the average value of 12 lead parameters, including QRS-T angle, QT interval dispersion and QTp interval dispersion, the ratio of main components of T wave at the end of T wave peak and the flat score. Asymmetry score, notch score, morphological comprehensive score. The heart failure group was followed up by telephone. The terminal event was death. The central death included pump failure, acute myocardial infarction, and malignant arrhythmia. No follow-up was performed in the non-heart failure group. Baseline data and T wave morphological parameters of heart failure group and non-heart failure group were compared firstly, and then T wave morphological parameters of heart failure group and survival group were compared. The survival time of psychogenic death and its influencing factors were analyzed by COX regression analysis. Finally, the value analysis of independent risk factors as the criterion was analyzed. Results: there was no difference in age and sex between the two groups (P 0.05). The morphological parameters of T wave were all different except QTp interval dispersion. In the heart failure group, the ratio of the main components, the morphological comprehensive score and the flat score were higher than those in the control group, and the T wave asymmetry score in the heart failure group was lower than that in the control group. The patients in the heart failure group were followed up for an average of 17.50 卤7.40 months. All the 16 patients died because of heart failure, of which 11 died because of the heart, 203 survived, and 5.02 died of the heart failure. There was no difference in baseline data (except hypertension) in cardiac death and survival group (P0.05). The morphological parameters of T wave and QRS-T angle in death group were higher than those in survival group (142 (126-161) vs 87 (47-120) P0. 002). The comprehensive score of T wave morphology in death group was lower than that in survival group (76 (71-88) vs 84 (72-101) P0. 047). The sex score in the death group was lower than that in the survival group (7 (3-10) vs 8 (4-16) P 0. 048). The mean survival time was 33.35 months, 95% confidence interval was (32.06-33.72) months, the cumulative survival rate was 99.5 months, and the survival rate was significantly lower in those with 97.7 QRS-T angle 鈮，

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