本文關鍵詞： 變異型心絞痛 Tp-e 離散度 惡性室性心律失常　出處：《鄭州大學》2017年碩士論文　論文類型：學位論文

【摘要】：背景及目的:惡性心律失常,作為冠心病導致猝死的重要因素一直備受廣大臨床醫(yī)生和研究者所關注,特別是在急性心肌梗死、變異型心絞痛(variant angina pectoris,VAP)的患者中,惡性心律失常的發(fā)生率尤為突出。既往研究資料顯示:冠脈痙攣病人室性惡性心律失常的發(fā)生率為5%-15%,而嚴重心律失�？芍骡�。研究發(fā)現(xiàn)VAP病人中與沒有發(fā)生心跳驟停、暈厥等惡性事件的人群相比,發(fā)生發(fā)生心跳驟�；驎炟实腝T離散度明顯增大,這表明VAP患者可能存在異常的心室復極離散度,導致發(fā)生惡性心律失常事件(malignant ventricular arrhythmia events,MVAE)風險增加。但有研究表明QT離散度并不能直接反映心室復極離散度,并不是一個可靠的反映心室復極離散度的指標。越來越多的基礎和臨床研究表明,增大的Tp-e間期(心電圖上T波的頂點到終點的距離,Tpeak-Tend interval)與惡性室性心律失常的發(fā)生有關。Tp-e和Tp-e/QT這些指標近年一直在進行臨床研究并用于預測惡性心律失常的發(fā)生,而對Tp-e離散度(Tp-ed)研究較少。上述這些指標在VAP患者發(fā)作時的變化及其對MVAE的預測價值報道尚無。本研究通過對變異型心絞痛患者發(fā)作時QT間期、校正QT間期(corrected Tp-e interval,c QT)、Tp-e間期,校正Tp-e間期(corrected Tp-e interval,c Tp-e)、Tp-e/QT比值、Tp-e離散度(Tp-e interval dispersion,Tp-ed)、校正Tp-e離散度(corrected Tp-e interval dispersion,c Tp-ed)和Tp-ed/QT比值的測算,評價其對惡性心律失常事件的預測價值。方法:選取鄭州大學人民醫(yī)院住院或門診就診的變異型心絞痛患者,50例單純VAP患者和23例VAP合并MVAE的患者入選本研究。VAP發(fā)作時并發(fā)MVAE為觀察組;VAP發(fā)作時未并發(fā)MVAE為對照組。使用t檢驗、logistic回歸分析和受試者工作曲線(receiver operating characteristic curve,ROC)分析ST段抬高時期心電圖參數(shù)和MVAE(室性心動過速/心室顫動、暈厥和成功復蘇的心源性猝死)發(fā)生的關系。結(jié)果:1.觀察組(VAP發(fā)作時并發(fā)MVAE)與對照組(VAP發(fā)作時未并發(fā)MVAE)之間年齡、性別等一般資料差異無明顯統(tǒng)計學意義。2.VAP發(fā)作時并發(fā)MVAE組比VAP發(fā)作時未并發(fā)MVAE組有更長的QT間期(424.26±72.55vs385.62±38.97;P=0.04)、Tp-e間期(141.48±45.15 vs 104.00±14.80;P0.001)、c Tp-e(142.22±41.74 vs 112.75±20.44;P=0.001)、Tp-ed(66.04±38.46 vs 27.30±14.11;P0.001)、c Tp-ed(65.90±36.86vs29.49±15.13;P0.001)和更大的Tp-e/QT比值(0.334±0.087 vs 0.271±0.042;P=0.001)、Tp-ed/QT比值(0.153±0.071 vs 0.071±0.035;P0.001)。3.單因素回歸分析顯示QT比值比(odds ratio,OR)=1.014;95%可信區(qū)間(confidence intervals,CI)1.003-1.025;P=0.011)、Tp-e間期(OR=1.083;95%CI 1.037-1.131;P0.001)、c Tp-e(OR=1.040;95%CI 1.014-1.066;P0.001)、Tp-e/QT比值(OR=1.018;95%CI1.007-1.030;P=0.002)、Tp-ed(OR=1.114;95%CI 1.058-1.173;P0.001)、c Tp-ed(OR=1.108;95%CI 1.054-1.164;P0.001)和Tp-ed/QT(OR=1.045;95%CI 1.023-1.068;P0.001)均顯示與MVAE的發(fā)作有關。多因素逐步回歸分析顯示,只有Tp-ed/QT可以進入回歸方程作為預測因子。4.ROC曲線下面積(area under curve,AUC)QT為0.653、Tp-e間期為0.847、c Tp-e為0.752、Tp-e/QT為0.736、Tp-ed為0.893、c Tp-ed為0.886、Tp-ed/QT為0.883(均P0.05)。Z檢驗顯示Tp-ed、c Tp-ed的AUC與QT、Tp-e間期、c Tp-e、Tp-e/QT比值的AUC相比均有顯著差異(均P0.05),Tp-ed/QT比值的AUC與QT、c Tp-e、Tp-e/QT比值的AUC相比均有顯著差異(均P0.05),Tp-e比值的AUC與Tp-e/QT、QT的AUC相比均有顯著差異(均P0.05)。結(jié)論:QT在合并MVAE的VAP患者中明顯增高,但其預測MVAE的發(fā)生的價值有限;Tp-e、c Tp-e、Tp-e/QT、Tp-ed、c Tp-ed和Tp-ed/QT在合并MVAE的VAP患者中明顯增高,均可預測MVAE的發(fā)生。Tp-ed是最敏感的預測因子。Tp-ed可能是反映整體復極離散度的更有價值的心電圖參數(shù)。
[Abstract]:Background and objective: malignant arrhythmia, coronary heart disease is an important factor leading to sudden death has always been the majority of clinicians and researchers concerned, especially in patients with acute myocardial infarction, angina pectoris (variant angina, pectoris, VAP) in patients with malignant arrhythmia is particularly prominent. The previous research data showed that patients with coronary spasm ventricular arrhythmia incidence rate was 5%-15%, which can cause severe arrhythmia and sudden cardiac death. VAP was found in patients with and without cardiac arrest, compared with syncope and malignant events crowd, occurrence of syncope or cardiac arrest have QT dispersion significantly increased, suggesting that VAP patients may have abnormal ventricular repolarization. Lead to the occurrence of malignant arrhythmia events (malignant ventricular arrhythmia events, MVAE) increased risk. But studies have shown that the QT dispersion does not directly reflect the ventricle Dispersion of repolarization, and not a reliable reflection of ventricular repolarization dispersion index. More and more basic and clinical research shows that the increase of the Tp-e interval (range, T wave peak to the end point of electrocardiographic Tpeak-Tend interval and Tp-e/QT.Tp-e) with these indicators in recent years has been engaged in clinical research and for predicting malignant arrhythmia the occurrence of arrhythmia and malignant ventricular arrhythmias, and the dispersion of Tp-e (Tp-ed) research. These changes in indicators in VAP patients during the attack and prediction of the value of the MVAE have not been reported. This study based on the onset of patients with variant angina QT interval, corrected QT interval (corrected Tp-e interval. C QT), Tp-e interval, corrected Tp-e interval (corrected Tp-e interval, C Tp-e), Tp-e/QT ratio, Tp-e dispersion (Tp-e interval dispersion, Tp-ed), corrected Tp-e (corrected Tp-e dispersion interval dis Persion, C Tp-ed) and Tp-ed/QT ratio calculation, the evaluation of the predictive value of malignant arrhythmia. Methods: select Zhengzhou University people's hospital inpatient or outpatient treatment in patients with variant angina, 50 cases of VAP patients and 23 VAP patients with MVAE were enrolled in this study of.VAP attack with MVAE as the observation group VAP attack; not with MVAE as the control group. Using t test, logistic regression analysis and receiver operating curve (receiver operating characteristic curve, ROC) of ST elevation and MVAE period of ECG parameters (ventricular tachycardia and ventricular fibrillation, cardiac syncope and successful resuscitation of sudden death) occurred. Results: the observation group (1. VAP attack with MVAE) and control group (VAP attack without concurrent MVAE) between age, gender and other demographic data showed no statistically significant differences between the onset of.2.VAP complicated with MVAE group than in the VAP attack is not Concurrent MVAE group had a longer QT interval (424.26 + 72.55vs385.62 + 38.97; P=0.04), Tp-e interval (141.48 + 45.15 vs 104 + 14.80; P0.001), C Tp-e (142.22 + 41.74 vs 112.75 + 20.44; P=0.001), Tp-ed (66.04 + 38.46 vs 27.30 + 14.11; P0.001), C Tp-ed (65.90. 36.86vs29.49 + 15.13; P0.001) and Tp-e/QT ratio were greater (0.334 + 0.087 vs 0.271 + 0.042; P=0.001), the ratio of Tp-ed/QT (0.153 + 0.071 vs 0.071 + 0.035; P0.001).3. single factor regression analysis showed that the ratio of QT (odds ratio, OR =1.014); 95% confidence interval (confidence intervals, CI 1.003-1.025); P=0.011), Tp-e interval (OR=1.083; 95%CI 1.037-1.131; P0.001), C Tp-e (OR=1.040; 95%CI 1.014-1.066; P0.001), the ratio of Tp-e/QT (OR=1.018; 95%CI1.007-1.030; P=0.002), Tp-ed (OR=1.114; 95%CI 1.058-1.173; P0.001), C Tp-ed (OR=1.108; 95%CI 1.054-1.164; P0.001) and Tp-ed/QT (OR=1.045; 95%CI 1.023-1.06 8; P0.001) were associated with the onset of MVAE. Multiple stepwise regression analysis showed that only Tp-ed/QT can enter the regression equation as the predictive factor of area under the curve of.4.ROC (area under curve, AUC) QT 0.653, Tp-e interval was 0.847, C Tp-e 0.752, Tp-e/QT 0.736, Tp-ed 0.893, C Tp-ed 0.886, Tp-ed/QT was 0.883 (P0.05).Z test showed that Tp-ed, AUC and QT, C Tp-ed, C Tp-e, Tp-e interval, significant differences between the Tp-e/QT ratio AUC were compared (P0.05), AUC and QT, the ratio of Tp-ed/QT C Tp-e, the ratio of Tp-e/QT compared to AUC were significant difference (P0.05). AUC and Tp-e/QT Tp-e ratio, QT AUC showed a significant difference (P0.05). Conclusion: QT and MVAE increased significantly in VAP patients, but its limited value in predicting the occurrence of MVAE C Tp-e, Tp-e/QT; Tp-e, Tp-ed, C Tp-ed and Tp-ed/ QT increased significantly in patients with MVAE VAP that can predict MV The occurrence of.Tp-ed in AE is the most sensitive predictor of.Tp-ed, which may be a more valuable electrocardiogram parameter reflecting the overall repolarization dispersion.

【學位授予單位】：鄭州大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R541

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