老年心力衰竭患者自主神经功能与心功能的相关性研究

目的 探讨老年心力衰竭(CHF)患者自主神经功能活动与心功能受损严重程度的相关性。方法 分析61例老年CHF患者和30例对照者的心率变异性时域指标及心功能指标。结果 CHF组与对照组比较，HRV各测值均非常显著降低(均P＜0．001)；HRV各测值均随心功能的下降而呈递减性下降，在心功能各级别间具有显著差异(P＜0．05或P＜0．001)，SDNN和TI下降与心功能NYHA分级呈负相关(P＜0．01)。结论 老年CHF患者存在着严重的自主神经功能受损和失衡，且与心功能损害程度密切相关。     

QT离散度对慢性充血性心力衰竭的临床意义

本文分析６６例ＮＹＨＡ分级法心功能Ⅲ－Ⅳ级的慢性充血性心力衰竭患者治疗前后ＱＴ离散度，并与正常组对照，结果表明：１．ＣＨＦ组较正常对照组ＱＴｄ显著延长，不同病因组间无差异；２．住院观察期间，ＱＴｄ在非持续性室速组及死于慢性心衰的病人组无显著延长，１例心性猝死者ＱＴｄ显著处长；３．治疗好转后ＱＴｄ呈下降趋势，治疗无效，恶化者ＱＴｄ进一步延长。     

The effects of chronic carvedilol therapy on QT dispersion in patients with congestive heart failure.

BACKGROUND: Carvedilol therapy reduces mortality from sudden cardiac death and progressive pump failure in congestive heart failure (CHF). However, the effect(s) of carvedilol on ventricular repolarization characteristics is unclear. AIM: The aim of the study was to investigate the effects of chronic carvedilol therapy on ventricular repolarization characteristics as assessed by QT dispersion (QTd) in patients with CHF. METHOD: Nineteen patients (age 53+/-12 years; 16 male, three female) with CHF (eight ischemic, 11 non-ischemic dilated cardiomyopathy) were prospectively included in the study. Carvedilol was administered in addition to standard therapy for CHF at a dose of 3.125 mg bid and uptitrated biweekly to the maximum tolerated dose. From standard 12-lead electrocardiograms the maximum and minimum QT intervals (QTmax, QTmin), QTd, corrected QT intervals (QTcmax, QTcmin) and corrected QTd (QTcd) values were calculated at baseline, after the 2nd and the 16th month of carvedilol therapy. RESULTS: A significant reduction was noted in the QTd and QTcd values with carvedilol therapy after the 16th month (QTd: 81+/-22 ms vs. 40+/-4.3 ms P<0.001; QTcd: 91+/-25 ms vs. 51+/-7 ms P<0.001), but not after the 2nd month (P>0.05). The resting heart rate was also significantly reduced after a 16-month course of carvedilol therapy (78+/-13 bpm vs. 66+/-15 bpm, P<0.05). Carvedilol therapy did not alter QTmax and QTcmax intervals (P>0.05), however, QT min and QTcmin significantly increased with carvedilol at the 16th month (P<0.001 and P<0.01, respectively). CONCLUSION: Long-term carvedilol therapy was associated with a reduction in QTd, an effect that might contribute to the favorable effects of carvedilol in reducing sudden cardiac death in CHF.     

葡甲酸环腺苷酸对老年冠心病充血性心力衰竭患者校正QT离散度的影响

目的：探讨葡甲酸环腺苷酸治疗对冠心病充血性心力衰竭患者QTcd的影响。方法：将80例冠心病充血性心力衰竭患者随机分为葡甲酸环腺苷酸治疗组和非葡甲酸环腺苷酸治疗组。观察分析了80例冠心病充血性心力衰竭患者葡甲酸环腺苷酸治疗前后QTc max、QTc min、QTcd的变化。结果：与治疗前比较，两组心衰患者治疗后QTc max、QTcd均有减少，差异有显著性（P＜0.01)，以葡甲酸环腺苷酸治疗组减少更明显。治疗后两组间QTc max、QTcd差异有显著性（P＜0.01)。结论：葡甲酸环腺苷酸可通过缩短QTc max而减少冠心病心衰患者的QTcd。     

卡维地洛治疗扩张型心肌病心力衰竭疗效观察

目的　评价第三代 β受体阻滞剂卡维地洛治疗扩张型心肌病 (DCM)心力衰竭的临床疗效。方法　 6 2例 DCM心力衰竭患者在接受常规治疗 (洋地黄、利尿剂、血管紧张素转换酶抑制剂 )病情稳定后 ,随机分为卡维地洛组和美多心安组。均从小剂量 (卡维地洛组 ,2 .5 m g bid;美多心安组 ,6 .2 5 m g bid)缓慢递增。检测治疗前后 DCM患者左心室功能和结构的变化以及血液中内皮素 - 1(ET- 1)、心钠素 (ANP)和血管紧张素 (Ang )的改变。结果　治疗 6个月后 ,两组心脏功能分级均明显改善 ,左心室射血分数 (L VEF)、短轴缩短率 (FS)、左心室射血前期与射血时间比(PEP/ L VET)、舒张早期峰值血流速度 (PFVE)、舒张早期峰值血流速度与舒张晚期峰值血流速度比 (PFVE/ PF-VA)均明显增加 ,卡维地洛组较美多心安组 L VEF增加更为明显。两组左心房内径 (L AD)、左心室收缩末期内径(L VSD)、左心室舒张末期内径 (L VDD)明显减小 ,卡维地洛组 L VSD减小较美多心安组更明显。治疗后血浆中ET- 1、ANP和 Ang 均明显降低。结论　卡维地洛和美多心安都能够改善 DCM心力衰竭患者左心室收缩和舒张功能 ,逆转左心室重构 ,卡维地洛较美多心安疗效更佳。     

Effect of dofetilide on QT dispersion and the prognostic implications of changes in QT dispersion for patients with congestive heart failure

AIMS: Drug-induced changes in QT dispersion may be a way of detecting harmful repolarisation abnormalities for patients receiving antiarrhythmic drugs affecting ventricular repolarisation. METHODS AND RESULTS: In 463 congestive heart failure (CHF) patients enrolled in the Danish Investigations Of Arrhythmia and Mortality On Dofetilide-CHF (DIAMOND-CHF) study, both pre-treatment and on-treatment day 2-6 QT dispersion was available from standard 12-lead ECGs. Patients were randomised in a double-blind manner to receive either placebo or dofetilide, a new class III antiarrhythmic drug. During a median follow-up of 19 months (minimum 1 year), 179 patients (39%) died (135 patients from cardiac causes). Changes in QT dispersion did not predict all-cause or cardiac mortality for patients treated with dofetilide in multivariate survival analysis (Risk ratio: 1.02, 95% confidence interval: 0.97-1.08, P>0.4). This finding was independent of pre-treatment QT dispersion. Dofetilide caused a small QT dispersion increment of 8 ms, not different from the changes seen in the placebo group (3 ms). CONCLUSION: For patients with CHF and reduced left ventricular systolic function, changes in QT dispersion following treatment with dofetilide do not predict all-cause or cardiac mortality. The dofetilide-induced QT dispersion changes are small and comparable to those seen in placebo treated patients.     

充血性心力衰竭QT离散度变化及美托洛尔对其影响

目的 :测定充血性心力衰竭 （CHF）患者的 QT离散度 （QTd）及美托洛尔对 QTd的影响。方法 :110例 CHF患者和 5 0例健康人同时作 QTd测量 ,CHF患者中 38例进行美托洛尔治疗 ,与未使用美托洛尔的 78例作比较。结果 :CHF患者的 QTd明显高于健康人 （P<0 .0 1） ;QTd与心功能受损的程度呈正相关 ;CHF伴室性心律失常者QTd大于不伴室性心律失常者 （P<0 .0 5 ） ;予美托洛尔治疗后 CHF患者 QTd明显缩短 （P<0 .0 5 ）。结论 :CHF患者 QTd明显增大。美托洛尔可使 QTd缩小 ,对防治严重心律失常和猝死有重要意义     

Prognostic value of QT/RR slope in predicting mortality in patients with congestive heart failure

Introduction: Repolarization dynamics, reflecting adaptation of QT to changing heart rate, is considered a marker of unfavorable prognosis in patients with heart diseases. We aimed to evaluate the prognostic value of QT/RR slope in predicting total mortality (TM) and sudden death (SD) in patients with congestive heart failure (CHF). Methods and Results: In 651 sinus rhythm patients with CHF in NYHA class II–III enrolled in the MUSIC study, 24‐hour Holter monitoring was performed at enrollment to assess slope of the QTa/RR (QT apex) and QTe/RR (QTend) during the entire 24‐hour Holter recording and separately during day and night periods. Patients were followed for a median of 44 months, with the primary endpoint defined as TM and the secondary as SD. Analysis of repolarization dynamics was feasible in 542 patients (407M), mean age 63 years, 83% in NYHA class II, 49% with ischemic cardiomyopathy, with mean LVEF 37%. Mean value of QTa/RR slope was 0.172 and QTe/RR was 0.193. During the 44‐month follow‐up there were 119 deaths including 47 SD. Nonsurvivors were characterized by steeper QT/RR slopes. Increased QT/RR slopes during the daytime (>0.20 for QTa and >0.22 for QTe) were independently associated with increased TM in multivariate analysis after adjustment for clinical covariates with respective hazard ratios 1.57 and 1.58, P = 0.002. None of the dynamic repolarization parameters was associated with increased risk of SD in the entire population. Conclusions: Abnormal repolarization dynamics reflected as increased daytime QT/RR slopes is an independent risk stratifier of all‐cause mortality in patients with chronic heart failure     

Relationship of QT interval variability to heart rate and RR interval variability

The study investigated whether the beat-to-beat QT interval variability relationship to the mean heart rate and the RR interval variability depended on the cardiovascular autonomic status changed by postural positioning. Repeated long-term 12-lead Holter recordings were obtained from 352 healthy subjects (mean age 32.7 ± 9.1 years, 176 females) while they underwent postural provocative tests involving supine, unsupported sitting and unsupported standing positions. Each recording was processed as a sequence of overlapping 10-second segments. In each segment, the mean RR interval, the coefficients of variance of the RR intervals (RRCV) and the QT intervals (QTCV) were obtained. In each subject, these characteristics, corresponding to different postural positions, were firstly averaged and secondly used to obtain within-subject correlation coefficients between the different characteristics at different postural positions. While the within-subject means of RRCV generally decreased when changing the position from supine to sitting and to standing (4.53 ± 1.95%, 4.12 ± 1.51% and 3.26 ± 1.56% in females and 3.99 ± 1.44%, 4.00 ± 1.24% and 3.53 ± 1.32% in males respectively), the means of QTCV systematically increased during these position changes (0.96 ± 0.40%, 1.30 ± 0.56% and 1.88 ± 1.46% in females and 0.85 ± 0.30%, 1.13 ± 0.41% and 1.41 ± 0.59% in males, respectively). The intra-subject relationship between QTCV, RRCV and mean RR intervals was highly dependent on postural positions. The study concludes that no universally applicable normalization of the QT interval variability for the heart rate and/or the RR interval variability should be assumed. In future studies of the QT variability, it seems preferable to report on the absolute values of QT variability, RR variability and mean heart rate separately.     

扩张型心肌病伴心衰患者肝细胞生长因子浓度与心功能的关系

目的探讨扩张型心肌病伴心衰患者血清肝细胞生长因子（HGF）浓度与心功能的关系。方法检测试验组扩张型心肌病伴心功能不全患者（NYHA心功能Ⅰ级15例、Ⅱ级16例、Ⅲ级15例、Ⅳ级17例）和26名健康对照者血清HGF浓度、NT—proBNP浓度、LVEDD值和LVEF值,比较各组各项指标的差异;同时探讨血清HGF浓度和上述指标的相关性。结果HGF浓度、NT—proBNP浓度、LVEDD值和LVEF值对照组分别为（323±29）pg／ml、（251±102）pg／ml、（42±7）mm和（57±11）％;NYHA心功能Ⅰ级组分别为（492±47）pg／ml、（973±112）pg／ml、（50±6）mm和（50±7）％;NYHA心功能Ⅱ级组分别为（607±68）pg／ml、（1229±214）pg／ml、（54±9）mm和（48±9）％;NYHA心功能Ⅲ级组分别为（662±94）pg／ml、（4208±1562）pg／ml、（59±16）mm和（42±7）％;NYHA心功能Ⅳ级组分别为（1028±135）pg／ml、（6963±2129）pg／ml、（66±19）mm和（38±6）％,各组间比较差异均有统计学意义（P〈0．05）.血清HGF浓度和NT—proBNP浓度呈正相关,相关系数为0．79;血清HGF浓度和LVEDD值呈正相关,相关系数为0．73;血清HGF浓度和LVEF值呈负相关,相关系数为-0．69。结论扩张型心肌病伴心功能不全患者血清HGF浓度和心功能不全的严重程度有关,可以作为心功能不全严重程度的预测因子。     

培哚普利对心力衰竭患者心率变异性的影响及意义

将５９例充血性心力衰竭患者随机分两组。对照组仅给常规治疗,治疗组在常规治疗基础上加服培哚普利。前后行２４小时动态心电图监测,进行心率变异性（ＨＲＶ）时域分析。结果表明,治疗组治疗前后及与对照组比较,其ＨＲＶ均有显著性差异（分别为Ｐ〈０．０１,〈０．０５）,提示培哚普利能显著提高心力衰竭患者的ＨＲＶ。     

长期美托洛尔治疗充血性心力衰竭减少P波离散度

目的观察长期美托洛尔(metoprolol)治疗充血性心力衰竭患者的P波离散度改变,探讨其临床意义。方法充血性心力衰竭患者68例,均接受基础抗心力衰竭治疗,其中美托洛尔组41例,对照组27例。治疗前和治疗6个月后检测同步12导联心电图。测量P波最大时限(Pmax)、P波最小时限(Pmin)、P波离散度(P-wavedispersion,PD)。结果Pmax美托洛尔组(102±12)ms,对照组(113±13)ms,差异有统计学意义(P<0.01)。PD美托洛尔组(28±10)ms,对照组(39±10)ms,差异有统计学意义(P<0.01)。结论长期美托洛尔治疗使充血性心力衰竭患者PD减少,表明美托洛尔可减少充血性心力衰竭患者发生心房颤动的可能性。     

Acute hemodynamic and neurohumoral effects of moxonidine in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.

Elevated plasma norepinephrine (PNE) has been shown to be an important predictor of morbidity and mortality in patients with congestive heart failure (CHF). Moxonidine selectively stimulates imidazoline receptors located in the medulla, which centrally inhibit sympathetic outflow. PNE is suppressed and peripheral vasodilation reduces systemic blood pressure. This study evaluated the acute neurohumoral and hemodynamic effects of a single dose of oral moxonidine in 32 patients (22 men, mean ± SD age 66 ± 10 years) with CHF. All patients were in New York Heart Association functional class III and stabilized on chronic therapy with diuretics, digitalis, and angiotensin-converting enzyme inhibitors. The mean PNE concentration was 509 ± 304 pg/ml at baseline. Patients underwent invasive hemodynamic monitoring after double-blind randomization to either placebo (n = 12), moxonidine 0.4 mg (n = 9), or moxonidine 0.6 mg (n = 11). Moxonidine produced a dose-dependent, vasodilator response compared with placebo. Analysis of the time-averaged change from baseline over 6 hours demonstrated that moxonidine 0.6 mg caused significant reductions in mean systemic arterial pressure (p <0.0001), mean pulmonary arterial pressure (p <0.005), systemic vascular resistance (p <0.05), pulmonary vascular resistance (p <0.01), and heart rate (p <0.05). Stroke volume was unchanged. PNE was reduced substantially (−180 pg/ml at 4 hours, p <0.005) and the reduction was highly correlated with the baseline level (r = −0.968). Moxonidine was well tolerated in this single-dose study and resulted in a modest, dose-dependent, vasodilator response, with substantial reductions in systemic and pulmonary arterial blood pressure. Trials designed to evaluate the clinical efficacy of chronic moxonidine therapy in CHF added to conventional therapy would be appropriate.     

卡维地洛对慢性心力衰竭患者室性心律失常和心率变异性影响

目的 探讨卡维地洛对慢性心力衰竭患者室性心律失常和心率变异性的影响。方法 97例慢性心力衰竭患者按随机分配原则，分为治疗组49例和对照组48例，治疗组在常规治疗的基础上加用卡维地洛，初始剂量2．5mg，每Et两次，每2周增加一次剂量，直至20mg一次或最大耐受量为止。用动态心电图分析治疗前后心率、室性心律失常和心率变异性变化，并用超声心动图测定患者治疗前后的心功能。结果 治疗组用卡维地洛治疗6个月后，心率下降、室性心律失常减少、心率变异性参数改善（P〈0．01）；心功能改善亦非常显著（P〈0．01）。结论 卡维地洛治疗慢性心力衰竭患者，可降低室性心律失常的发生，改善心率变异性和心功能。     

Acute hemodynamic and neurohumoral effects of moxonidine in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy

Elevated plasma norepinephrine (PNE) has been shown to be an important predictor of morbidity and mortality in patients with congestive heart failure (CHF). Moxonidine selectively stimulates imidazoline receptors located in the medulla, which centrally inhibit sympathetic outflow. PNE is suppressed and peripheral vasodilation reduces systemic blood pressure. This study evaluated the acute neurohumoral and hemodynamic effects of a single dose of oral moxonidine in 32 patients (22 men, mean ± SD age 66 ± 10 years) with CHF. All patients were in New York Heart Association functional class III and stabilized on chronic therapy with diuretics, digitalis, and angiotensin-converting enzyme inhibitors. The mean PNE concentration was 509 ± 304 pg/ml at baseline. Patients underwent invasive hemodynamic monitoring after double-blind randomization to either placebo (n = 12), moxonidine 0.4 mg (n = 9), or moxonidine 0.6 mg (n = 11). Moxonidine produced a dose-dependent, vasodilator response compared with placebo. Analysis of the time-averaged change from baseline over 6 hours demonstrated that moxonidine 0.6 mg caused significant reductions in mean systemic arterial pressure (p <0.0001), mean pulmonary arterial pressure (p <0.005), systemic vascular resistance (p <0.05), pulmonary vascular resistance (p <0.01), and heart rate (p <0.05). Stroke volume was unchanged. PNE was reduced substantially (−180 pg/ml at 4 hours, p <0.005) and the reduction was highly correlated with the baseline level (r = −0.968). Moxonidine was well tolerated in this single-dose study and resulted in a modest, dose-dependent, vasodilator response, with substantial reductions in systemic and pulmonary arterial blood pressure. Trials designed to evaluate the clinical efficacy of chronic moxonidine therapy in CHF added to conventional therapy would be appropriate.     

盐酸依托必利对老年冠心病患者QT间期和QT离散度的影响

目的探讨盐酸依托必利对老年冠心病患者QT间期和QT离散度（Qtdispersion,QTd）的影响,评估其心血管安全性。方法58例老年冠心病患者,合并功能性消化不良或功能性便秘,服用盐酸依托必利片50mg／次,3次,d,连续服用7～56d,平均（28．7±12．8）d,服药前后记录12导联心电图,计算QT和QTd值,比较服药前、后二者变化。其中28例患者服药14d时加量至100mg／次,3次／d,记录服药前、后和14d的QT和QTd值,然后进行比较。结果治疗前、后患者QT和QTd值均无明显变化,药物加量至300mg／d对QT和QTd值无影响。结论盐酸依托必利对于老年冠心病患者QT间期和QT离散度无影响,且药物加量至300mg／d也未见有潜在的心血管危险性。     

Recovery and recurrence of left ventricular systolic dysfunction in patients with idiopathic dilated cardiomyopathy

BACKGROUND:

Some patients with nonischemic left ventricular (LV) systolic failure recover to have normal LV systolic function. However, few studies on the rates of recovery and recurrence have been reported, and no definitive indicators that can predict the recurrence of LV dysfunction in recovered idiopathic dilated cardiomyopathy (IDCMP) patients have been determined. It was hypothesized that patients who recovered from nonischemic LV dysfunction have a substantial risk for recurrent heart failure.

METHODS:

Forty-two patients (32 men) with IDCMP (mean [± SD] age 56.9±8.7 years) who recovered from systolic heart failure (LV ejection fraction [LVEF] of 26.5±6.9% at initial presentation) to a near-normal state (LVEF of 40% or greater, and a 10% increase or greater in absolute value) were monitored for recurrence of LV systolic dysfunction. Patients with significant coronary artery disease were excluded. Patients were monitored for 41.0±26.3 months after recovery (LVEF 53.4±7.6%) from LV dysfunction.

RESULTS:

LV systolic dysfunction reappeared (LVEF 27.5±8.1%) during the follow-up period in eight of 42 patients (19.0%). No significant difference between the groups with or without recurrent heart failure was observed in the baseline clinical and echocardiographic characteristics. However, more patients in the recurred IDCMP group than those in the group that maintained the recovery state had discontinued antiheart failure medication (62.5% versus 5.9%, P<0.05).

CONCLUSIONS:

LV dysfunction recurs in some patients with reversible IDCMP. The recurrence was significantly correlated with the discontinuation of antiheart failure drugs. The results suggest that continuous medical therapy may be mandatory in patients who recover from LV systolic dysfunction.     

老年慢性心力衰竭患者心室结构-心电重构与心律失常的关系

目的探讨老年心肌梗死后慢性心力衰竭（CHF）患者心室结构-心电重构与心律失常的关系。方法收集老年心肌梗死后CHF患者55例[心功能（NYHA分级）:II级23例,III级15例,Ⅳ级17例]及心肌梗死后心功能（NYHA）I级患者30例,采用超声心动图,标准12导联心电图及24小时动态心电图检测其心室腔大小,QT间期,校正QT间期（QTc）及心律失常。结果与心功能I级组比较,CHF组心室腔显著扩大[CHF组:左室舒张末直径（LVEDD）（57±8）mm,左室收缩末直径（LVESD）（45±8）mm;心功能I级组:LVEDD（45±5）mm,LVESD（31±5）mm,P<0.05]。两组间心室复极指标无显著差异[CHF组:QT（0.41±0.07）s,QTc（0.44±0.06）s;心功能I级组:QT（0.41±0.04）s,QTc（0.44±0.04）s]。两组间室性心律失常亦无显著差异[CHF组:室性早搏（VPB）（219±598）次/24h;心功能I级组:VPB（345±504）次/24h]。结论老年心肌梗死后CHF时,心室结构重构显著,心室腔显著扩大,但在本研究中心室结构重构未见引起显著心电重构,心室复极延长及室性心律失常未见显著增加。     

慢性心衰猝死患者QT离散度的变化

本文观察研究慢性心衰(观察组),和无心脏病病人(对照组)各60例的QT离散度。发现观察组的QT离散度较对照组大。而观察组中心衰猝死者(11例)的QT离散度明显大于观察组心衰存活组(30例)、心衰进展死亡组(19例)的QT离散度(P<0.001)。并发现心衰猝死组QT离散度的增大与心功能分级、电解质的血清浓度无相关性。慢性心衰猝死组QTd均值为96.81ms.提示QT离散度的明显增大,是慢性心衰发生猝死的一项具有警告性的重要标志。     

不同程度冠心病患者QT变异和QT变异指数的观察

目的探讨冠心病患者的QT变异(QTV)和病变程度的相关性。方法122例冠心病患者(75例劳累性心绞痛患者,47例非ST段抬高性心肌梗死患者)和55例正常对照组,在保持日常生活起居的情况下佩戴12导联动态心电图监测仪,计算机辅助下自动测量QT间期,计算相应时间段的QT间期均值(QTm)、QTV、HR间期均值(HRm)、HR间期变异(HRV)和QT变异指数(QTVI)。同时采用时域法(SDNN)和频域法(LF、HF)分析心率变异性。结果①正常对照组24hLF/HF、HF、QTV均呈昼夜节律性变化。②非ST段抬高性心肌梗死组、劳累性心绞痛组和正常对照组之间的QTV差异显著(29.2±13.6ms、26.8±13.1ms、21.7±12.4ms,P<0.05)。③正常对照组QTV与SDNN存在负相关,相关系数为-0.40,P<0.05。而劳累性心绞痛组和非ST段抬高性心肌梗死组的QTV与SDNN无相关性,P>0.05。④QTV、QTVI随着冠状动脉病变程度的加重而变大,且各组比较有显著性差异,P<0.05。结论QTV与冠状动脉病变程度有关,QTV的变化不仅依赖于自主神经,而且是许多不同病理生理因素作用的结果,在心肌缺血的情况下,能更直接地反映心肌的代谢和病变状态。