發(fā)布時(shí)間：2018-05-21 16:26

  本文選題：心力衰竭 + QRS波��； 參考：《西安醫(yī)學(xué)院》2017年碩士論文

【摘要】：背景及目的:心力衰竭發(fā)生進(jìn)展的主要病理生理機(jī)制為心臟重構(gòu)。心臟重構(gòu)包括心臟結(jié)構(gòu)重構(gòu)及電重構(gòu),前者如心肌肥厚、心腔增大等,后者如心室復(fù)極時(shí)間延長(zhǎng)、復(fù)極離散度增加等。心臟的電重構(gòu)與心力衰竭患者心律失常的發(fā)生及心源性猝死密切相關(guān);心電圖簡(jiǎn)單易得,代表整個(gè)心臟除極及復(fù)極過程,可以間接反映心臟的電重構(gòu)特點(diǎn),心力衰竭患者常發(fā)生不同程度的改變。本研究通過分析心力衰竭患者常規(guī)12導(dǎo)聯(lián)心電圖特點(diǎn),研究QRS波寬度、振幅、Tp-Te間期與心力衰竭患者預(yù)后的相關(guān)性。方法:此研究經(jīng)過陜西省人民醫(yī)院倫理委員會(huì)審查通過,選取2014年1月-2016年4月,在陜西省人民醫(yī)院住院的200例心力衰竭患者。所有患者均滿足Framingham心力衰竭診斷標(biāo)準(zhǔn),且以心臟B超射血分值(EF)小于50%,或者血BNP100pg/ml作為參考;排除標(biāo)準(zhǔn):明顯的電解質(zhì)異常,包括高鉀血癥或低鉀血癥,高鈣血癥或低鈣血癥;甲狀腺功能亢進(jìn)癥;起搏器植入術(shù)后;預(yù)激綜合征等;心房撲動(dòng);交界性心律失�；蚴倚孕穆墒С�;嚴(yán)重的腎功能不全(血肌酐265umol/L);正在使用抗心律失常藥物(普羅帕酮,胺碘酮)等。所有受檢者都于清醒安靜休息10分鐘后,由經(jīng)過培訓(xùn)的醫(yī)師或者護(hù)士,記錄12導(dǎo)聯(lián)心電圖,心電圖走紙速度為25mm/s,電壓為全電壓1mv,如為半電壓則在測(cè)量絕對(duì)振幅時(shí)進(jìn)行轉(zhuǎn)換。所有結(jié)果皆拍成照片,在電腦上放大后進(jìn)行測(cè)量;測(cè)量?jī)?nèi)容包括,AVR導(dǎo)聯(lián)的QRS波絕對(duì)振幅;V1-V6導(dǎo)聯(lián)的Tp-Te間期平均值;選擇II、V1及V6導(dǎo)聯(lián)上最清晰的QRS波測(cè)量它的寬度并記錄,然后在每一導(dǎo)聯(lián)測(cè)量3個(gè)心動(dòng)周期,計(jì)算不同心動(dòng)周期和不同導(dǎo)聯(lián)軸上的平均值作為實(shí)測(cè)的QRS波寬度。將病人的QRS波寬度由小到大排列,按人數(shù)進(jìn)行四分位分組,分別為組1(85ms)、組2(85-100ms)、組3(100-120ms)、組4(120ms)。將1年全因死亡率及再次住院率定義為復(fù)合終點(diǎn)事件。首先是比較不同組間的1年復(fù)合終點(diǎn)事件發(fā)生率以及全因死亡率的差異,同時(shí)觀察不同組間,Tp-Te間期,QRS波振幅的差異。結(jié)果:1.樣本QRS波寬度不滿足正態(tài)分布(P=0.000),因此使用四分位數(shù)法,對(duì)QRS波時(shí)限進(jìn)行分組比較。2.基線資料:從第一組到第四組年齡增加8歲,差異有顯著性(p=0.001);心功能iii-iv級(jí)所占比顯著增加(p=0.011);bnp絕對(duì)值顯著增加(p=0.000)。四個(gè)象限之間女性所占的性別比,糖尿病病史陽性率等沒有統(tǒng)計(jì)學(xué)差異(分別為p=0.659,p=0.266)。3.實(shí)驗(yàn)室檢查資料:四個(gè)組之間的實(shí)驗(yàn)室檢查資料不完全相同(p0.05);繼續(xù)兩兩比較組間的差異,總膽固醇的比較顯示第一組和其余組之間有統(tǒng)計(jì)學(xué)差異,而第二第三第四組各自之間無明顯統(tǒng)計(jì)學(xué)差異(p=0.855)。甘油三脂量的比較顯示四個(gè)組之間均有顯著性差異,各自為各自的同類子集;且排序?yàn)榈谝唤M第四組第三組第二組。尿素氮的比較顯示,第一組第二組之間沒有統(tǒng)計(jì)學(xué)差異(p=0.743),但它們與第三組、第四組之間均有統(tǒng)計(jì)學(xué)差異;第三組與第四組之間也有顯著性差異。血肌酐濃度的比較顯示第一組與第二組為同類子集(p=0.698),并且它們和第三組及第四組比較后均有統(tǒng)計(jì)學(xué)意義;而第三組與第四組之間亦存在統(tǒng)計(jì)學(xué)差異。4.出院時(shí)的治療方案:出院時(shí)四個(gè)組之間的β受體阻滯劑,血管緊張素受體拮抗劑或血管緊張素轉(zhuǎn)換酶抑制劑,螺內(nèi)酯的使用率上沒有顯著性差別(分別為p=0.944,p=0.838,p=0.333)。5.其他心電圖指標(biāo):四個(gè)組之間相比,tp-te間期呈增加趨勢(shì),且差異有顯著性(p=0.00)。四個(gè)組之間avr導(dǎo)聯(lián)qrs波絕對(duì)振幅呈遞減趨勢(shì),差異有顯著性(p=0.001)。6.kaplanmeier生存分析:將再次住院率及死亡率作為復(fù)合終點(diǎn)事件來看,四個(gè)組之間呈逐層惡化的趨勢(shì);單獨(dú)分析全因死亡率時(shí),除第一組和第二組以外,其余各組之間均呈升高的趨勢(shì)。7.log-rank檢驗(yàn):復(fù)合終點(diǎn)事件無顯著性差異的有:第一組和第二組(p=0.565);第二組和第三組(p=0.155);第三組和第四組(p=0.178)。有統(tǒng)計(jì)學(xué)意義的有:第一組和第三組(p=0.045);第一組和第四組(p=0.001);第二組和第四組(p=0.007);全因死亡率無顯著性差異的有:第一組和第二組(p=1);第一組和第三組(p=0.163);第二組和第三組(p=0.163);第三組和第四組(p=0.513)。有統(tǒng)計(jì)學(xué)意義的有:第一組和第四組(p=0.048);第二組和第四組(p=0.048)。8.cox風(fēng)險(xiǎn)比例回歸模型:以第一組為參照的復(fù)合終點(diǎn)事件相對(duì)危險(xiǎn)度,其中第二組和第一組之間無統(tǒng)計(jì)學(xué)意義(p=0.5700.05);第三組相對(duì)第一組的相對(duì)危險(xiǎn)度為1.982(p=0.047,rr95%cl1.010-3.887);第四組相對(duì)第一組的危險(xiǎn)度為3.048(P=0.000,RR 95%CL 1.632-5.691);全因死亡率:組二、組三、組一之間均無統(tǒng)計(jì)學(xué)意義(P值分別為0.373和0.071);組四與組一間的相對(duì)危險(xiǎn)度為3.129(P=0.048,RR 95%CL 1.109-9.704)。結(jié)論:隨著QRS波寬度的增加,復(fù)合終點(diǎn)事件的發(fā)生率呈梯度增加,從100ms時(shí)開始顯著;在QRS波120ms時(shí),將顯著的增加患者的全因死亡風(fēng)險(xiǎn);QRS波寬度和BNP以及心功能III-IV級(jí)的發(fā)生率具有良好的相關(guān)性,間接的反映了QRS波寬度的增加是心功能惡化的有效指標(biāo);同時(shí)年齡和QRS波的寬度有一定的相關(guān)性;QRS波大于100ms時(shí)腎功能開始有顯著性差異;膽固醇四組之間有統(tǒng)計(jì)學(xué)差異,但是考慮意義不大;對(duì)于甘油三脂后兩組的降低,考慮由于心力衰竭的營(yíng)養(yǎng)不良狀況所致;QRS波寬度在一定范圍內(nèi)與Tp-Te間期,QRS波振幅具有相關(guān)性,充分說明了心力衰竭時(shí)心臟的電重構(gòu)具有一定的整體性,是一個(gè)除級(jí),復(fù)級(jí),傳導(dǎo)特性綜合性改變的過程。
[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.
【學(xué)位授予單位】：西安醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.6

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