本文選題：兒童　切入點(diǎn)：頻發(fā)室性早搏　出處：《重慶醫(yī)科大學(xué)》2014年碩士論文

【摘要】：目的： 利用倍他樂克對(duì)不同類型兒童頻發(fā)室性早搏的作用，探討倍他樂克干預(yù)兒童頻發(fā)室性早搏的臨床價(jià)值。 方法： 收集2012年1月-2014年3月重慶醫(yī)科大學(xué)附屬兒童醫(yī)院就診的頻發(fā)室性早搏（Premature Ventricular Contractions，PVCs）患兒21例,分組方法有兩種,一是依據(jù)體表心電圖上QRS的形態(tài)確定PVCs的起源位置并分為左室型及右室型兩組;二是依據(jù)PVCs出現(xiàn)的時(shí)間規(guī)律，將所有患兒分為混合型、夜間型及日間型。所有病例給予倍他樂克1-2mg/（kg·d），2次/天，連續(xù)口服2周，無效病例停藥，有效病例繼續(xù)使用3個(gè)月，并逐漸減量至停藥。治療前后隨訪動(dòng)態(tài)心電圖、心臟彩超，比較各組之間治療效果差異及治療前后心率變異性（Heart RateVariability，HRV）時(shí)域指標(biāo)的差別。 結(jié)果： 1．PVCs與心率(Heart Rate，HR)之間的關(guān)系：正相關(guān)組（PVCs hadPositive Correlation with HR，P-PVCs）：PVCs隨HR的增加而增加，減少而減少，呈現(xiàn)同增共減的關(guān)系；共11例，其中男7例，女4例，年齡7.72±2.17歲。負(fù)相關(guān)組（PVCs had Negative Correlation with HR，N-PVCs）：PVCs隨HR的增加而減少，減少而增加；共5例，其中男3例，女2例，年齡6.48±3.63歲。獨(dú)立組（PVCs were Independentwith HR，I-PVCs）：PVCs與HR的增加或減少無明顯線性相關(guān)性；共5例，其中男4例，女1例，年齡4.48±1.38歲。 2. PVCs與自主神經(jīng)系統(tǒng)（Autonomic Nervous System，ANS）的關(guān)系：經(jīng)Pearson相關(guān)性檢驗(yàn)，15例（71.4%）患兒與SDNN相關(guān)。其中12例與RMSSD成正相關(guān)，3例與RMSSD成負(fù)相關(guān)。有11例與PNN50成正相關(guān)，7例與PNN50成負(fù)相關(guān)。在N-PVCs中5例（100%）全部與PNN50成正相關(guān)，在P-PVCs中3例（27.3%）與PNN50成正相關(guān)，有6例（54.5%）與PNN50成負(fù)相關(guān)。P-PVCs、N-PVCs和I-PVCs3組之間在性別、年齡、是否合并心肌炎、PVCs起源位置、平均HR及24小時(shí)PVCs次數(shù)占總心搏的百分比分布均無顯著差異，，在晝夜規(guī)律上有顯著差異。其中8例日間型病例全部分布在P-PVCs，在P-PVCs組中占72.7%，而N-PVCs組中有1例夜間型，其余均為混合型，在I-PVCs組中則5例均為混合型。HRV各時(shí)域指標(biāo)SDNN、SDNNI、SDANN、PNN50、RMSSD在3組之間無顯著差異；在P-PVCs組與交感神經(jīng)活性有關(guān)HRV時(shí)域指標(biāo)SDANN(124.36±55.08ms)大于N-PVCs組的(123.00±44.72ms)，而在N-PVCs組與迷走神經(jīng)活動(dòng)有關(guān)的HRV時(shí)域作指標(biāo)RMSSD（166.20±42.65ms）大于P-VPCs組的（113.73±51.03ms）。 3.倍他樂克對(duì)與HR呈不同關(guān)系的PVCs的作用：根據(jù)PVCs與HR關(guān)系的分組的分析，11例患兒的P-PVCs組有9例為有效，2例無效，有效率81.8%；5例患兒的N-PVCs組和I-PVCs組，均為2例有效，3例無效，有效率40.0%。P-PVCs組的有效率高于N-PVCs組和I-PVCs組。 4.倍他樂克對(duì)不同起源位置PVCs的作用：根據(jù)PVCs的起源位置分析，21例病例中起源于左室者13例，起源于右室者8例，兩組間在年齡、性別、是否合并器質(zhì)性心臟病、平均HR、PVCs占總心搏的百分比、及PVCs晝夜規(guī)律均無顯著差異。使用倍他樂克后，右室起源的PVCs患兒中6例有效（75.0%）高于左室起源的PVCs（7例有效，53.8%）。 5.倍他樂克對(duì)不同晝夜規(guī)律PVCs的作用：根據(jù)PVCs出現(xiàn)的晝夜時(shí)間規(guī)律分析，21例病例中有8例日間型，12例混合型和1例夜間型。混合型與日間型在年齡、性別、病因、24小時(shí)平均HR、PVCs占總心搏的百分比及PVCs起源部位，兩組間分布均無顯著差異。日間型中有7例有效（87.5%），對(duì)倍他樂克的敏感性高于混合型（5例有效，41.7%）。 6.治療前后心率變異性（Heat Rate Variability, HRV）各時(shí)域參數(shù)的變化情況：使用倍他樂克治療后隨訪動(dòng)態(tài)心電圖HRV時(shí)域參數(shù)的變化情況，SDNN較治療前稍有升高，SDANN較用藥前降低，RMSSD較用藥前有升高，但3者在治療前后均無顯著差異。 7．PVCs在隨訪時(shí)間內(nèi)的變化情況：本組21例患兒中，有13例對(duì)倍他樂克的治療有效，在用藥第2或第4周室24小時(shí)動(dòng)態(tài)心電圖提示室早次數(shù)較用藥前減少"g50%，但是隨著倍他樂克的減量及停藥，除外確診為心肌炎的2例病例外，其余患兒在隨訪至3月或更長(zhǎng)時(shí)間后，PVCs呈現(xiàn)逐漸增加趨勢(shì)，部分恢復(fù)到用藥前水平甚至超過了用藥前的水平。 結(jié)論： 1.對(duì)于體表心電圖上不同起源位置的頻發(fā)PVCs，倍他樂克對(duì)右室型的抑制作用優(yōu)于左室型。 2.對(duì)不同晝夜規(guī)律的PVCs，倍他樂克對(duì)日間型療效優(yōu)于混合型。 3.倍他樂克對(duì)不同的兒童頻發(fā)PVCs作用不同。對(duì)無明顯器質(zhì)性病變與自主神經(jīng)功能相關(guān)的PVCs停藥后易復(fù)發(fā)，可能需隨訪較長(zhǎng)時(shí)間至自主神經(jīng)功能發(fā)育的完善才可能消失；對(duì)于與心肌炎有關(guān)的自主神經(jīng)功能損傷或失衡所致的PVCs療效較好，停藥后不易復(fù)發(fā)。
[Abstract]:Purpose :

To investigate the effect of betaloc on the ventricular premature beat of children with different types of children , and to discuss the clinical value of betaxlek ' s intervention in children ' s frequent ventricular premature beats .

Method :

Methods Twenty - one cases of premature ventricular premature beat ( PVCs ) were collected from January 2012 to March 2014 in Chongqing Medical University Affiliated to Chongqing Medical University . One was divided into two groups : left ventricular type and right ventricular type according to QRS morphology on body surface electrocardiogram . All cases were divided into mixed type , night type and daytime type . All cases were given betaxle1 - 2mg / ( kg 路 d ) , 2 times / day , continuous oral 2 weeks , ineffective case discontinuation , effective cases continued to be used for 3 months , and gradually decreased to discontinuation . After treatment , the dynamic electrocardiogram and heart color Doppler ultrasound were used to compare the difference of treatment effect between groups and the difference of time domain indexes of heart rate variability ( HRV ) before and after treatment .

Results :

1 . The relationship between PVCs and heart rate ( HR ) : PVCs hadpositive correlation with HR , P - PVCs : PVCs increased with the increase of HR , decreased and decreased with increasing HR .
There were 11 cases , including 7 males and 4 females , age 7.72 鹵 2.17 years . The negative correlation group ( PVCs had Negative Correlation with HR , N - PVCs ) : PVCs decreased with the increase of HR , decreased and increased ;
There were 5 males and 2 females , age 6.48 鹵 3.63 years old . PVCs were independent with HR , I - PVCs : PVCs had no obvious linear correlation with the increase or decrease of HR ;
There were 5 males , 4 females , 1 female , 4.48 鹵 1.38 years old .

2 . The relationship between PVCs and autonomic nervous system ( ANS ) was studied by Pearson correlation . Among them , 15 cases ( 71.4 % ) had positive correlation with PNN50 . Among them , 12 cases were positively correlated with PNN50 . There were 11 cases of P - PVCs positive correlation with PNN50 . There were 6 cases ( 54.5 % ) in the P - PVCs group .
In the P - PVCs group , the HRV time - domain indexes SDANN ( 124.36 鹵 55.08 ms ) were greater than that of the N - PVCs group ( 123.00 鹵 44.72ms ) , while the HRV time - domain index RMSSD ( 166.20 鹵 42.65ms ) in the N - PVCs group and the vagus nerve activity was larger than that in the P - VPCs group ( 11.73 鹵 51.03ms ) .

3 . The effect of betaloc on PVCs with HR was : According to the analysis of the relationship between PVCs and HR , 9 out of 11 children with P - PVCs were effective , 2 were ineffective and the effective rate was 81.8 % ;
The efficiency of the P - PVCs group was higher than that of the group I - PVCs and the group I - PVCs .

4 . The effect of betaxlek on PVCs in different origins : According to the origin position analysis of PVCs , 13 cases originated from the left ventricle in 21 cases , 8 cases originated from right ventricle , 8 cases were originated from right ventricle , 6 of PVCs in right ventricular origin were more effective ( 75.0 % ) than PVCs in the left ventricle ( 7 cases were effective , 53.8 % ) .

5 . The effect of betaloc on PVCs of different day and night was analyzed . According to the day and night time rule of PVCs , 8 of 21 cases were daytime type , 12 mixed type and 1 night type . The average HR , PVCs and PVCs were not significantly different between the two groups . There were 7 cases ( 87.5 % ) in daytime type , and the sensitivity to betaxlek was higher than that of mixed type ( 5 cases , 41.7 % ) .

6 . Changes of time domain parameters of heart rate variability ( HRV ) before and after treatment : The changes of HRV time domain parameters were observed after treatment with betaloc , SDNN was slightly increased before treatment , SDANN was lower before treatment , and the RMSSD increased before the treatment , but no significant difference was found between the 3 patients before and after treatment .

7 . The changes of PVCs during follow - up time : 13 of the 21 children in this group were effective in the treatment of betaloc , and the dynamic electrocardiogram suggested that the number of premature beats decreased " g50 % before administration , but with the dose reduction and withdrawal of betaloc , except for 2 cases diagnosed as myocarditis , the rest of the children showed a progressive increase in PVCs after the follow - up to March or longer , and the level of partial recovery to the pre - medication level was even more than the pre - medication level .

Conclusion :

1 . The inhibitory effect of betaxlek on the right ventricular type was superior to that of the left ventricular type for the frequency of PVCs with different origins in the body surface electrocardiogram .

2 . PVCs with different day and night laws and betaloc were superior to those of mixed type .

3 . The effect of Betaloc on different children ' s frequency of PVCs was different . There were no obvious organic lesions after withdrawal of PVCs related to autonomic nervous function . It may be necessary to follow up for a long time until the development of autonomic nervous function is complete .
The effect of PVCs due to the injury or imbalance of the autonomic nervous function associated with myocarditis is good , and it is not easy to recur after discontinuation .

【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R725.4

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