慢性心衰患者QRS时程和新发房颤的相关性研究

目的 探讨慢性心衰患者QRS时程（QRSd）增宽对新发房颤的预测价值.方法 选择患有心衰但无房颤病史的患者1098例,将其分为三组：QRSd≤120 ms、120 ms〈QRSd〈150 ms及QRSd≥150 ms组,随访跟踪各组新发房颤的概率.通过二元分析和多元logistic回归分析探讨QRS时程和房颤新发概率之间的相关性.结果 对患者群体的统计表明,房颤的新发概率为35.7%.通过二元分析发现,房颤的新发概率存在组间差别（21.7%、35.9%、42.5%,P〈0.01）;进一步通过多元回归发现,QRS时程是独立的影响因素.结论 QRS是慢性心衰患者新发房颤的独立预测因素.     

QRS波时限对起搏器依赖患者心脏功能的影响

目的:观察右心室起搏QRS波时限对起搏器依赖患者心脏功能的影响。方法:选取在我院诊断为Ⅲ度房室传导阻滞并行永久性右心室起搏的患者112例,以起搏QRS波时限将患者分为A组(起搏QRS波时限<190ms)和B组(起搏QRS波时限≥190ms),并对每例患者进行临床评估和心脏彩色多普勒超声检查,动态随访心脏功能,以随访期间出现明显心功能下降为终点,观察起搏QRS波时限与心脏功能的关系。同时根据随访期间是否出现心功能下降将患者分为心功能下降组(Y组)和心功能无下降组(N组),并进行各因素与心功能下降之间的单因素分析,取P<0.1的因素纳入Logistic回归模型,寻找影响起搏器依赖患者心功能的因素。结果:平均随访(45.46±23.00)个月,40例(28.57%)出现明显心功能下降,其中,A组24例(27.27%),B组16例(66.67%),2组间差异有统计学意义(P=0.0004),Y组的起搏QRS波时限较N组明显延长[(176.58±22.71)∶(159.74±20.23)ms,P<0.0001]。多元Logistic逐步回归分析结果显示,左心室舒张末期内径增大、射血分数下降、左束支传导阻滞、起搏QRS波时限≥190ms、年龄及起搏时间是起搏器依赖患者心功能下降的危险因素。结论:起搏QRS波时限延长是心脏功能下降和心力衰竭发生的危险因素,可以作为起搏器依赖患者起搏后心脏功能下降的预测指标。除此之外,左心室增大、左束支传导阻滞、射血分数降低、年龄及起搏时间也是起搏器依赖患者心脏功能下降的危险因素。     

QRS Fragmentation and the Risk of Sudden Cardiac Death in MADIT II

QRS Fragmentation and the Risk of Sudden Cardiac Death in MADIT II. Background: QRS fragmentation (fQRS) has been reported as a useful ECG parameter in predicting mortality in high‐risk postinfarction patients. Its prognostic value for sudden cardiac death (SCD) and ventricular arrhythmias in ischemic cardiomyopathy (ICM) remains unknown. Methods: MADIT II enrollment 12‐lead ECGs were analyzed for fQRS defined as RSR’ patterns (≥1 R’ or notching of S or R wave) in patients with a normal QRS duration and >2 notches on the R or S wave in patients with abnormal QRS duration, present in 2 contiguous leads. Exclusion criteria included a paced rhythm and an uninterpretable or incomplete ECG. Study endpoints included SCD, SCD or appropriate implantable cardioverter defibrillator (ICD) shock, and total mortality (TM). Results: Of the 1,232 ECGs reviewed, 1,040 were of suitable quality for fQRS analysis. QRS fragmentation was found in 33% of patients in any leads, in 10% of patients in anterior leads, in 8% of patients in lateral leads and in 21% of patients in inferior leads. Anterior and lateral location of QRS fragmentation was not associated with follow‐up events. Inferior location of fQRS was found to be predictive of SCD/ICD shock (hazard ratio [HR] 1.46, P = 0.032), SCD (HR 2.05, P = 0.007), and TM (HR 1.44, P = 0.036). This association was driven primarily by the increase in events found in LBBB patients: SCD/ICD shock (HR 2.05, P = 0.046), SCD (HR 4.24, P = 0.002), and TM (HR 2.82, P = 0.001). Conclusions: Fragmented QRS, especially identified in inferior leads, is predictive of SCD, SCD or appropriate ICD shock, and all‐cause mortality in patients with ICM. Identifying inferior fQRS in patients with LBBB is of particular prognostic significance and should reinforce the use of ICD therapy in this high‐risk group. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1343‐1348, December 2012)     

ECG changes in patients with acute ethanol intoxication

Objectives. To assess how ethanol in potential lethal serum concentrations affects features of the ECG that may be associated with cardiac arrhythmias. Design. We included 84 patients, who were hospitalised with assumed acute ethanol intoxication. In the emergency room resting ECG was recorded and blood was collected for serum osmolality measurement used as a proxy for ethanol level. Thirty-two also had ECG recorded at discharge. Twenty-seven hospitalised patients without known alcohol ingestion served as controls. ECG segment durations were compared with controls and related to intoxication level. Results. In subjects with moderately elevated to high serum osmolality, the P wave and QTc intervals were prolonged compared with sober subjects. P wave, PR, QRS and QTc intervals were longer when the subjects had high blood ethanol levels (at admission) than at discharge (p-values: 0.0001, 0.0002, 0.010 and < 0.0001 for P wave, PR, QRS and QTc intervals. n = 32). Conclusions. Ethanol at high to very high blood concentration causes several changes in the ECG that might be associated with increased risk of arrhythmias.     

High triglyceride level is associated with severe coronary artery disease in hypertensive subjects

Background. The contribution of triglycerides (TG) to the extent of coronary artery disease (CAD) in hypertensive patients remained unclear. Methods. Consecutive 821 (aged 64.5±11.5 years, 482 males) hypertensive patients undergoing coronary angiography were included. The relationship of TG levels (<150 vs. ≥150 mg/dl) to the extent of CAD in all patients was examined by multiple logistic regression, adjusting for other CAD risk factors. In the lipid group, low levels of HDL were also adjusted. Results. Higher levels of TG were found in subjects with severe CAD compared to those with no or minimal CAD. The adjusted odds ratios for high levels of TG in the severe CAD subgroup versus the no or minimal CAD subgroup were 5.20 (95% CI, 3.13 to 8.63) in all patients and 7.51 (95% CI, 3.19 to 17.65) in the lipid group. Conclusions. High levels of TG are strong clinical markers of greater extent of CAD in hypertensive subjects undergoing coronary angiography. The results may have clinical relevance for physicians in therapeutic decision making.     

Optimal sensed atrio-ventricular interval determined by paced QRS morphology

BACKGROUND: In cardiac resynchronization therapy (CRT), the atrio-ventricular (AV) and interventricular (VV) intervals have to be optimized. For maximal optimization, the paced and sensed AV intervals have to be determined. We hypothesized that the morphology of the paced QRS complex at the optimal paced AV interval (PAV) can be used to determine the optimal sensed AV (SAV) interval in patients with normal AV conduction. PATIENTS AND METHODS: In 16 patients with implanted CRT devices, the optimal PAV and V-V interval were determined by invasive measurement of left ventricle (LV) dP/dt(max). A 12-lead electrocardiogram (ECG) was recorded at the optimum setting. Subsequently, during atrial sensing ventricular pacing, the SAV interval was changed until the QRS morphology was identical to the morphology at the optimal PAV interval. The optimal SAV interval was verified by repeated measurement of LV dP/dt(max). RESULTS: By optimization of the PAV and VV interval, the LV dP/dt(max) increased from 639 +/- 204 to 789 +/- 223 mmHg/s (+23%; P = 0.0000002). The optimized PAV was 149 +/- 19 ms; the optimized SAV was 100 +/- 20 ms and the corresponding LV dP/dt(max) at this interval was 774 +/- 204 ms (+21%; P = 0.000004). LV dP/dt(max) at optimized SAV - 20 ms and optimized SAV + 20 ms was 747 +/- 213 mmHg/s (P = 0.00004) and 751 +/- 203 mmHg/s (P = 0.0000003), respectively. The mean difference in optimized PAV and optimized SAV was 49 +/- 17 ms, ranging from 20 to 80 ms. CONCLUSIONS: The QRS morphology at optimized PAV can be used as a template to determine the optimal SAV, provided that the patient has normal AV conduction.     

通心络胶囊联合氯吡格雷治疗急性心肌梗死的临床研究

目的探讨通心络胶囊联合硫酸氢氯吡格雷片治疗急性心肌梗死的临床疗效。方法选取2015年1月—2017年7月抚顺市中心医院收治的急性心肌梗死患者92例为对象研究,所有患者随机分为对照组和治疗组,每组各46例。对照组口服硫酸氢氯吡格雷片,首次剂量300 mg/次,之后75 mg/次,1次/d;治疗组在对照组的基础上口服通心络胶囊4粒/次,3次/d。两组患者均连续治疗3个月。观察两组的临床疗效,比较两组的心功能指标、炎性因子、心肌酶学指标、QRS积分和心肌梗死面积。结果治疗后,对照组和治疗组的总有效率分别为78.3%、91.3%,两组比较差异具有统计学意义(P0.05)。治疗后,两组左室收缩期末内径(LVESD)、左室舒张期末内径(LVEDD)、左室收缩末期容积(LVESV)和左室舒张末期容积(LVEDV)均明显降低,左室射血分数(LVEF)明显升高,同组治疗前后比较差异具有统计学意义(P0.05);且治疗组这些观察指标的改善程度明显优于对照组,两组比较差异具有统计学意义(P0.05)。治疗后,两组高敏C反应蛋白(hs-CRP)、白细胞介素-6(IL-6)和白细胞介素-18(IL-18)水平均显著降低,同组治疗前后比较差异有统计学意义(P0.05);且治疗组这些观察指标明显低于对照组,两组比较差异具有统计学意义(P0.05)。治疗后,两组血清脑钠肽(BNP)、心肌肌钙蛋白T(c Tn T)、乳酸脱氢酶(LDH)和肌酸激酶同工酶(CK-MB)水平均显著降低,同组治疗前后比较差异有统计学意义(P0.05);且治疗组这些观察指标明显低于对照组,两组比较差异具有统计学意义(P0.05)。治疗后,两组QRS积分、心肌梗死面积均显著降低,同组治疗前后比较差异有统计学意义(P0.05);且治疗组这些观察指标明显低于对照组,两组比较差异具有统计学意义(P0.05)。结论通心络胶囊联合硫酸氢氯吡格雷片治疗急性心肌梗死具有较好的临床疗效,可改善心功能,降低炎性反应,具有一定的临床推广应用价值。     

Exercise‐induced ventricular tachycardia in a case with hypertrophic cardiomyopathy taking cibenzoline

We report a 17‐year‐old woman with hypertrophic cardiomyopathy (HCM) successfully resuscitated from ventricular fibrillation while taking cibenzoline. During exercise–stress testing before implanting an implantable cardioverter–defibrillator, ventricular tachycardia was induced and thought to be a proarrhythmia due to the use‐dependent effect of the Na channel blockade with cibenzoline. In patients with arrhythmogenic substrates such as HCM, it is critical to pay attention to the proarrhythmic effects of class I antiarrhythmic drugs while increasing heart rate.