运动疗法在心脏术后康复中的作用

目的：探讨运动疗法在心脏术后康复中的作用。方法：21例心脏手术后患者均接受功率自行车或／和跑台训练为主的康复训练，并采用常规心电运动试验对康复训练前后的各项指标进行比较。结果：运动训练后，运动时间和最大运动负荷显著增加，安静时，心率、血压（包括收缩压和舒张压）、心率－血压乘积均显著下降（P＜0．05，P＜0．01），安静时心电图最大ST段压低明显改善（P＜0．01）；同等负荷量运动时，心率、血压、心率－血压乘积及运动诱发的最ST段压低与安静状态时有相似的改变(P＜0．05，P＜0．01）。结论：心脏术后的康复训练有助于增加体能，减轻心肌缺血，增加心肌储备功能，从而改善了患者的生活质量。     

平板运动试验心电图阳性各时段QTd和QTcd观察

目的观察平板运动心脏负荷试验诱发患者心电图ST段缺血型改变时QT离散度（QTd）和校正QT离散度（QTcd）。方法选择临床疑诊为冠心患者进行平板运动负荷心电图试验，诱发心电图ST段呈缺血型下移者35例（缺血组），测量运动前、运动后缺血型ST段下移达最大值时及运动后ST段恢复正常时QTd及QTcd，与平板运动负荷心电图ST段无缺血型改变者35例（正常组）进行对比研究。结果缺血组在运动后ST段下移达最大值时QTd、QTcd分别为（57．60±11．74）及（76．62±9．35）ms，与运动前及运动后ST段恢复正常时的QTd、QTcd之间存在显著差异（P〈0．01），与正常组运动后即刻QTd、QTcd对比同样存在显著差异（P〈0．01），而正常组在运动前、运动后即刻及运动后6min时QTd、QTcd无显著性差异（P〉0．05）。结论平板运动负荷试验诱发冠心病患者心电图ST段呈缺血型改变时QTd、QTcd明显增大。冠心病患者心肌缺血时存在心肌复极的不均一性和电的不稳定性，是导致严重室性心律失常和心脏猝死的独立危险因素。     

12周运动康复程序对急性期后心肌梗死患者身体机能的影响

目的:探讨康复运动对急性期后心肌梗死患者(PMIP)身体机能的影响。方法:101例男性PMIP参加了12周有氧多样化运动康复程序,程序前后通过递增负荷运动实验对其身体机能、运动能力等指标进行了测定分析。结果:受试者在康复训练后血胆固醇由5.9mmol/L降低到5.4mmol/L(P<0.01);对应跑台各级负荷时的摄氧量(VO2)、心率(HR)、心率-血压乘积(RPP)和主观用力感觉(RPE)在康复程序后有显著的下降(P<0.01或P<0.05);峰值HR、峰值%HRmax和峰值RPP分别增长了7.5%、8.5%和11.7%。结论:PMIP参加12周运动康复程序后,有氧工作能力有所增强、心血管机能有所改善。     

运动试验诱发心肌缺血和心绞痛的性别特点研究

目的：观察运动试验诱发男女心肌缺血和心绞痛的特点和差异。方法：将运动试验阳性中出现终止指征没完成次极量的94例患者分为男、女两组，分析其心电图、运动能力、临床症状等，并和部分患者的冠状动脉造影结果对照。结果：男性代谢当量、运动时间明显大于女性（P〈0．05），男性终止症状多见于Bruce2级，女性多见于Bruce1级结束时。ST段下移程度男性高于女性（P〈0．05），下移形态女性水平型多（P〈0．05）、男性近似水平型多（P〈0．05），男性T波倒置多（P〈0．05）。冠状动脉造影结果男性异常率高（78％），女性低（50％）。结论：运动试验对男性心肌缺血和心绞痛的诊断价值较女性大。男性运动试验诱发心肌缺血和心绞痛多发生于Bruce2级。     

稳定型心绞痛不同冠脉狭窄与心肌缺血程度的平板运动试验特征分析

目的：分析稳定型心绞痛患者不同冠脉狭窄与心肌缺血程度的平板运动试验特征。方法：选取2019年5月~2020年5月收治的稳定型心绞痛患者107例为研究对象，所有患者均进行平板运动试验，以冠脉造影为参照标准，分析不同冠脉狭窄与心肌缺血程度的平板运动试验特征，为临床治疗提供一定的指导依据。结果：随着冠脉狭窄程度不断加深，运动诱发ST段下降0.1 mV所需时间、达目标心率时间逐渐缩短，诱发ST段下降0.1 mV所需运动量逐渐减少，最大负荷量逐渐减少，最大ST段下降逐渐延长，耗氧量逐渐减少，达最大负荷量时心率逐渐升高，心率恢复时间、ST段下移持续时间逐渐延长，三组间各指标比较差异显著（P＜0.05）；轻度狭窄组平板运动试验阳性率为23.08%（3/13），中度狭窄组平板运动试验阳性率为58.06%（18/31），重度狭窄组平板运动试验阳性率为92.06%（58/63），三组间比较差异显著（P＜0.05）。结论：稳定型心绞痛患者不同冠脉狭窄与心肌缺血程度的平板运动试验具有明显特征性，可对稳定型心绞痛病情进行评估。     

高血压合并无症状心肌缺血的冠心病患者动态血压与动态心电图监测结果分析

目的探讨无症状心肌缺血患者的动态血压及室性心律失常特点。方法回顾性分析74例高血压合并无症状心肌缺血的冠心病患者同时行动态血压及动态心电图监测的临床资料，其中缺血型ST段下移组23例（A组），无ST段偏移组51例（B组），研究2组间的血压及室性心律失常变化。结果A组的24h收缩压、白天收缩压及夜间收缩压显著高于B组，差异有统计学意义（均P〈0．01）；24h舒张压、白天舒张压及夜间舒张压显著高于B组，差异有统计学意义（均P〈0．01）。B组的室性期前收缩数目比A组显著增加．差异有统计学意义（P〈0．01）；Lown分级Ⅲ级以上的室性心律失常在A组的发生率为39．1％，B组发生率为9．8％，2组比较差异有统计学意义（P〈0．05）。结论无症状心肌缺血患者的动态血压指标升高，室性期前收缩数目虽然不增加，但Lown分级Ⅲ级以上的室性心律失常发生率上升。     

急性STEMI患者急诊PCI监测ST段的意义

目的监测ST段回落程度评价急性STEMI急诊PCI疗效及预测患者近期预后。方法对急性STEMI并急诊行PCI患者在手术前和手术后半小时内记录18导联心电图。根据ST段回落幅度分三组分析左心室舒张末内径、左室射血分数、左心室室壁收缩运动得分指数及IRA开通时间。结果（1）ST段完全回落组LVEDD为45±9mm，EF为51％±7，MF为2．1±0．5。（2）ST段明显回落组LVEDD为52±10mm，EF为47％±8，MF为2．3±0．6。（3）ST段无回落组LVEDD为56±11mm，EF为42％±8，MF为2．6±0．9。（4）ST段无回落组IRA开通时间较其他两组明显延长（P〈0．05）。结论比较PCI患者术后ST段回落程度，可反映急性STEMI进行PCI治疗的效果，并与患者近期预后密切相关。     

平板运动试验中出现心房间传导阻滞的临床意义及机制探讨

目的探讨平板运动试验中出现房间传导阻滞（IAB）的临床意义及机制。方法选择因胸闷、胸痛怀疑冠心病的患者69例，行平板运动试验及冠状动脉造影检查，按照运动试验中心电图P波时限的变化分为IAB组和无IAB组，比较两组患者的临床特征、平板试验中ST段最大下降程度和冠状动脉造影中冠状动脉狭窄程度和病变支数。结果①IAB组患者年龄高于无IAB组，（61．6±10．3）岁VS（56．8±8．9）岁（P=0．043）；②IAB组ST段最大下降≥1mm患者的比例高于无IAB组（80．5％VS48．5％，P=0．005）；ST段最大下降程度IAB组高于无IAB组，（1．78±1．45）mm VS（1．15±1．11）mm（P=0．047）；③冠状动脉造影中至少1支冠状动脉狭窄≥50％患者的比例，IAB组高于无IAB组（80．6％VS21．2％，P=0．001）；不同病变血管数患者的比例，两组间差异有统计学意义（P=0．006）。结论平板运动试验中出现IAB可能作为评价冠心病的辅助指标之一。     

术前口服心得安预防颈丛神经阻滞下甲状腺手术患者循环反应的观察

目的：通过对非甲亢甲状腺手术患者术前口服心得安后,血压和心率变化的观察,评价心得安预防颈丛阻滞麻醉甲状腺手术心动过速和血压升高的意义。方法：60例甲状腺手术患者,随机分为对照组（n=30）和用药组（n=30）,均采用患侧颈深丛＋双侧颈浅丛神经阻滞,局麻药为0．25％布比卡因（不含肾上腺素）,用药组于术前晚和术前1h分别口服心得安10mg,对照组除不用心得安外,其余处理两组相同。结果：组间比较：对照组和用药组各时点BP无显著差异（P＞0．05）;组内比较：各时点BP与基础值比均显著增高（P＜0．01或P＜0．05）。用药组心率显著低于对照组（P＜0．01或P＜0．05）,RPP（收缩压与心率乘积）用药组显著低于对照组（P＜0．01或P＜0．05）。结论：在本组条件下,非甲亢患者在颈丛阻滞下行甲状腺手术者,术前晚及术晨分别口服心得安10mg后,可预防颈丛阻滞下手术期心动过速反应,并降低RPP值,但对血压升高无明显预防作用。     

运动负荷诱发冠心病患者心律失常相关因素分析

目的：探讨活动平板运动试验中室性心律失常的发生与冠心病严重程度和运动时生理指标变化的关系。方法：选取1998-07／2003-06在中山大学附属第一医院心内科进行活动平板运动试验并经冠状动脉造影确诊为冠心病患者211例，男132例，女79例。所选患者运动前均无室性心律失常，也不伴有心瓣膜病，传导阻滞等。运动中，根据室性心律失常的发生程度分为3级，并以此作为分组依据：心律失常Ⅰ级组(n=145)：运动中无室性心律失常发生；心律失常Ⅱ级组(n=38)：运动中偶发室性期前收缩；心律失常Ⅲ级组(n=28)：运动中出现严重室性心律失常。分析运动时室性心律失常的发生与冠状动脉病变程度，心肌缺血范围的大小以及运动中各生理指标变化的关系。结果：心律失常Ⅲ级组3支病变发生率(28．57％)高于心律失常Ⅰ级组(12．59％)(X^2=4．56，P&;lt;0．05)。核素运动心肌显像显示运动中心律失常Ⅲ级组患者多发性缺损的出现率(81．25％)明显高于心律失常Ⅰ级组(43．10％)(X^2=7．30，P&;lt;0．01)。运动试验阳性患者ST段压低开始的时间和压低的程度，各组间比较差异均有显著性意义(F=5．69．P&;lt;0．01；F=4．08，P&;lt;0．05)；其中心律失常Ⅲ级组患者的ST段压低最大值分别明显大于心律失常Ⅰ，Ⅱ级组(F=4．08，P&;lt;0．05)；心律失常Ⅱ，Ⅲ级组患者的ST段压低1mm开始时间(185．26，146．42s)明显短于心律失常Ⅰ级组(258．36s)(F=5．69，P&;lt;0．01)。心律失常Ⅱ，Ⅲ级组患者运动后1min心率恢复值低于正常。结论：严重冠状动脉病变及显著心肌缺血与运动导致严重室性心律失常有关。同时运动中室性心律失常的发生与神经内分泌系统调节失衡有关。     

Significance of ST depression during exercise treadmill stress and adenosine infusion myocardial perfusion imaging

Background: ST segment depression on the electrocardiogram during the exercise treadmill test (ETT) is used as a predictor of coronary artery disease (CAD), although it is recognised that both false-positive and false-negative results limit the value of this procedure. Although adenosine does not produce an inotropic or chronotropic effect upon the myocardium it may cause ST depression during infusion. Methods: The 12-lead ECG recordings obtained during 825 adenosine stress and 425 ETT procedures, performed as part of a 2-day Tc-MIBI protocol, were retained for examination and comparison with the appearances at subsequent myocardial perfusion imaging (MPI). Results: ST depression was associated with 44 (4.9%) of the adenosine stress and 44 (10.4%) of the ETT procedures. Both 1 and 2 mm ST depression during adenosine stress were significant predictors of reversible ischaemia (p < 0.01; p < 0.01). However, even though 2 mm ST depression on ETT was significant as a predictor of reversible ischaemia (p < 0.01), 1 mm ST depression on ETT was not (p = 0.4). There were more female cases with false positive ECG changes in both the adenosine stress (63.6%) group and the ETT (66.7%) group. There was no significant correlation between the territory of the ischaemic changes seen on the ECG with the location of defects developing on MPI in both the adenosine stress and ETT groups.Conclusions: ST depression of 1 mm occurring with adenosine stress, unlike with the ETT, is a significant predictor of ischaemia.     

冠心病患者运动中心率-收缩压双乘积与血乳酸浓度和ST段水平的关系

目的:使冠心病患者能够利用心率-收缩压双乘积(RPP)这一简便指标推测其乳酸无氧阈和心肌缺血阈,以便确定适宜的有氧运动强度.方法:44例女性冠心病患者(66.0±6.0岁)在活动跑台上进行了递增负荷运动实验,其间连续监测心电图中ST段的变化,并每3min测定1次血乳酸浓度(BL)和RPP.然后建立用RPP推测BL和ST的公式.结果:RPP推测BL的数学公式为,Y=2.6723-0.0071X+ 0.00000027 X3(P＜0.05),其中y为BL,X为RPP.乳酸阈强度约为RPP 180搏动次数·mmHg· 100-1.RPP推测ST的数学公式为,Y=0.5652-0.00005 X2+0.000000072 X3(P＜0.05),其中y为ST,X为RPP.缺血阈强度约为RPP 210搏动次数·mmHg·100-1.结论:冠心病患者的康复运动不但要考虑到心肌的缺血、缺氧,而且骨骼肌在这方面的变化也不容忽视.利用RPP可对这些指标进行推测.     

Symptomless myocardial ischemia: feasibility of diagnostic mistakes

AIM: To examine feasibility of ST segment depression on ECG in treadmill exercise test and 24-h ECG monitoring in subjects with coronarographically intact coronary arteries. MATERIALS AND METHODS: 9 males aged 41 to 52 years with chest pains unrelated to muscular load. They had neither stenosis of coronary arteries, nor arterial hypertension, valvular defects, disturbance of electrolyte metabolism. All of them have undergone treadmill exercise test and 24-h ECG monitoring. RESULTS: The exercise test provoked chest pain in none of the examinees. ST segment was depressed in one patient. 24-h monitoring registered depression of ST segment in one more patient. The rest 7 patients showed no changes in ST segment either in exercise test or 24-h ECG monitoring. CONCLUSION: It is confirmed that typical ischemic ECG changes (horizontal depression of ST segment) in healthy persons can occur and may be mistaken for silent myocardial ischemia.     

A randomized, double-blind comparison of lercanidipine 10 and 20 mg in patients with stable effort angina: clinical evaluation of cardiac function by ambulatory ventricular scintigraphic monitoring

We evaluated the antiischemic action and the effects on left ventricular response to exercise of lercanidipine, a long-acting dihydropyridine calcium antagonist, in 23 patients with stable effort angina in a randomized, double-blind, parallel trial. Left ventricular function was assessed during upright bicycle exercise using an ambulatory radionuclide detector for continuous noninvasive monitoring of cardiac function. Exercise was performed under control conditions before (run-in placebo period) and after 2-week treatment with lercanidipine 10 or 20 mg once daily. During the placebo run-in period and at the study end, patients underwent clinical examination, ECG, exercise tests, ambulatory ventricular scintigraphic monitoring (VEST). Results showed that both drug doses increased time to onset of ST segment depression >/=1 mm and peak ST segment depression, with improvement of total exercise duration. Heart rate, blood pressure, and the rate-pressure product did not significantly change with respect to pretreatment value. The left ventricular ejection fraction, indicating contractility state of myocardium, was unchanged at rest and during exercise after both lercanidipine doses. In conclusion, lercanidipine is safe and effective in reducing ischemia in patients with stable effort angina without any deterioration of cardiac function.     

ST/HR指数联合常规ST段标准提高心电图运动试验对冠状动脉介入术后再狭窄诊断的研究

目的探讨通过心电图运动试验测定ST/HR指数联合常规ST段标准诊断冠状动脉介入术后再狭窄的敏感性和特异性.方法对成功行冠状动脉介入治疗的129例患者,在术后3～6个月进行随访,心电图运动试验测量ST/HR指数及常规ST段阳性标准二者联合诊断再狭窄,通过冠状动脉造影确定有无再狭窄,评价其诊断再狭窄的价值.结果二者联合应用诊断再狭窄的敏感性和特异性分别为75.0%和83.3%,高于传统ST段标准（53.3%和66.7%）（均P＜0.05）.结论联合应用ST/HR指数及常规ST段标准可作为诊断再狭窄的无创手段.     

Value of leads V4R and CM5 in the detection of coronary artery disease during exercise electrocardiographic test

The usefulness of the right precordial unipolar leads and the value of the bipolar lead CM5 in the detection of coronary artery disease (CAD) with exercise electrocardiographic (ECG) test are not well documented. The objective of this study was to evaluate the diagnostic performance of leads V4R and CM5. The study population comprised 579 patients referred for a bicycle exercise ECG test in the Finnish Cardiovascular Study. Patients were divided into three groups: angiographically proven CAD (CAD, n = 255), no CAD by angiography (NoCAD, n = 126), and low likelihood of CAD (LLC, n = 198). The maximum ST‐segment depression at peak exercise was used as a parameter, and the diagnostic accuracy of different leads was assessed by receiver operating characteristic (ROC) analysis. Sensitivity and specificity values at a cut‐off criterion of ?0·10 mV ST‐segment, 1‐mm ST depression, were determined. According to the results, incorporating lead V4R with the standard leads decreased the ROC area from 0·71 to 0·69 (comparison CAD versus LLC) and from 0·55 to 0·53 (comparison CAD versus NoCAD) and had no effect on sensitivity or specificity. Adding lead CM5 to the standard leads did not affect the ROC area but increased the sensitivity and decreased the specificity. In conclusion, the use of right precordial lead V4R along with the standard 12‐lead system does not improve the performance of the exercise ECG in diagnosing CAD. Adding lead CM5 to the standard leads increases the sensitivity but does not change the overall diagnostic performance.     

急性下壁心肌梗塞时心前导联心电图ST段压低的临床意义

为评价急性下壁心肌梗塞(AIMI)时心前导联ST段压低的意义,对43例心电图示透壁急性心肌梗塞患者进行了研究。其中,31例有心前导联ST段压低(甲组),12例无心前导联ST段压低(乙组),两组临床表现无差异。研究结果表明,甲组患者血清酶平均峰值显著升高且左室衰竭的发生率升高;甲组室性心律紊乱、心肌再梗塞、心源性休克和房室传导阻滞的发生率亦显著高于乙组(P>0.01～0.05)。本研究资料提示,AIMI时心前导联ST段压低可能与广泛性心肌缺血和危重并发症的发生率高有关,从而认为,可将之用来预测AIMI的临床严重程度,治疗效果和预后。     

急性下壁心肌梗死患者的临床特点分析

目的 分析研究急性下壁心肌梗死患者的临床特点. 方法 将急性下壁心肌梗死患者100例根据冠状动脉造影结果分为两组:76例为右冠状动脉(RCA)闭塞(A组),24例为左回旋支冠状动脉(LCX)闭塞(B组). 结果 心电图ST段抬高STⅢ>STⅡ及ST段压低STAVL>ST I A组显著高于B组(均P<0.05);ST段抬高STⅢ0.1 mV A组显著高于B组(P<0.05);胸前导联V1～6ST段压低患者中,合并左前降支冠状动脉(LAD)病变的患者显著高于胸前导联V1～6ST段无压低者(P<0.05);左心室射血分数(LVEF)A组[(51±14)%]显著低于B组[(57±10)%](P<0.05);合并右心室心肌梗死A组显著高于B组(P<0.05);急性下壁心肌梗死患者总的住院病死率6%,均为A组,但心源性休克、心力衰竭、Ⅱ、Ⅲ度房室传导阻滞,室性心动过速/心室颤动及住院病死率,两组差异均无统计学意义(均P>0.05);死亡者中心源性休克占83.3%. 结论 心电图Ⅲ、Ⅱ、I、AVL、及V4R导联ST段变化能预测急性下壁心肌梗死相关血管,急性下壁心肌梗死患者伴胸前导联ST段压低提示LAD病变,RCA闭塞所致下壁心肌梗死LVEF低于LCX闭塞者,心源性休克为死亡主要原因.     

Reciprocal ST segment depression: impact on the electrocardiographic diagnosis of ST segment elevation acute myocardial infarction.

Acute myocardial infarction (AMI) is one of many causes of electrocardiographic ST segment elevation (STE) in ED chest pain (CP) patients; at times, the electrocardiographic diagnosis may be difficult. Coexistent ST segment depression has been reported to assist in the differentiation of non-infarction causes of STE from AMI-related ST segment elevation. The objective was to determine the effect of AMI diagnosis on the presence of STD among ED CP patients with electrocardiographic STE. Adult CP patients with electrocardiographic STE in at least 2 anatomically distributed leads were reviewed for the presence or absence of ST segment depression in at least 1 lead and separated into 2 groups, both with and without ST segment depression. A comparison of the 2 groups was performed in 2 approaches: all STE patients and then only with STE patients who lacked confounding electrocardiographic pattern (bundle branch block [BBB], left ventricular hypertrophy [LVH], or right ventricular paced rhythm [VPR]). All patients in the study underwent prolonged observation in the ED (at least 8 hours) with 3 serial troponin T determinations and 3 electrocardiograms (ECG). AMI was diagnosed by abnormal serum troponin T values (>0.1 mg/dL); electrocardiographic STE diagnoses of non-AMI causes were determined by medical record review. There were 171 CP patients with STE were entered in the study with 112 (65.5%) individuals show ST segment depression. When considering all study patients, ST segment depression was present at statistically equal rates in AMI and non-AMI situations (P = NS). The sensitivity, specificity, positive predictive value, and negative predictive value for the electrocardiographic diagnosis of AMI were 63%, 34%, 30%, and 67%, respectively. Patients with confounding patterns (LVH 46, BBB 19, and VPR 6) were removed from the analysis group, leaving 100 patients for analysis; 38 of these patients had ST segment depression. When considering this group of study patients, ST segment depression was present significantly more often in AMI patients (P <.0001). The sensitivity, specificity, positive predictive value, and negative predictive value for the electrocardiographic diagnosis of AMI were 69%, 93%, 93%, and 71%, respectively. Clinical diagnoses were as follows: 56 AMI, 50 USAP, and 65 noncoronary syndrome. When all CP patients with electrocardiographic STE are considered, the presence of ST segment depression is not helpful in distinguishing AMI from non-AMI. If one considers only patterns which lack electrocardiographic ST segment depression caused by altered intraventricular conduction, the presence of ST segment depression strongly suggests the diagnosis of AMI. In these cases, reciprocal ST segment depression is of considerable value in establishing the electrocardiographic diagnosis of STE AMI.