冠心病患者心脏变时功能不全的临床意义

Chronotropic incompetence predicts angiographic severity in patients with coronary artery disease

目的探讨冠心病患者心脏变时功能不全与冠心病严重度的关系,以及运动试验中心脏变时功能不全的临床应用价值。方法选择130例完成冠状动脉造影(CAG)的病例,对冠状动脉病变进行 Duke 评分和 Gensini 评分,并分为对照组(39例)、冠状动脉单支病变组(30例)、双支病变组(31例)和三支病变组(30例);CAG 前1个月内完成症状限制性踏车运动试验并测定心脏变时功能指标最高心率与预测最大心率值之比(rHR)和心率储备率(HRR)。结果冠心病双支病变组[rHR(0.79±0.08),HRR(0.63±0.11)]和三支病变组[rHR(0.78±0.07),HRR(0.59±0.12)]的心脏变时功能指标明显低于对照组[rHR(0.89±0.06),HRR(0.80±0.10)]和单支病变组[rHR(0.86±0.08),HRR(0.74±0.15)](均 P<0.01);rHR 在双支病变组和三支病变组之间及对照组和单支病变组之间差异无统计学意义(P>0.05);HRR 在双支病变组和三支病变组之间差异无统计学意义(P>0.05),而对照组和单支病变组比较差异有统计学意义(P<0.05)。rHR 和 HRR 与 Duke 评分(r 分别为-0.554、-0.578,均 P<0.01)和 Gennisi 评分(r 分别为-0.453、-0.467,均 P<0.01)呈明显的负相关。运动试验无 ST 段下移但 rHR<85%或 HRR<72%的患者中冠心病发生率达75%。以 rHR<85%或 HRR<72%作为 ST 标准阴性患者的附加阳性判定标准对冠心病的诊断价值[敏感性86.8%(P<0.01)、84.6%(P<0.01),特异性46.2%、46.2%,准确性74.6%(P<0.05)、73.1%,阳性预测值79.0%、78.6%,阴性预测值60.0%、56.3%]略高于传统的 ST 标准(敏感性63.7%,特异性64.1%,准确性63.8%,阳性预测值80.6%,阴性预测值43.1%)。结论心脏变时功能与冠心病的严重度呈负相关,心脏变时功能不全可以预测冠心病的严重度。运动试验中无 ST 段下移的变时功能不全患者有较高的冠心病发生率,rHR<85%或 HRR<72%可以作为运动试验阳性的附加判定标准。

Objective To investigate the relationship between the chronotropic incompetence and angiographic severity in patients with coronary artery disease （CAD）. Methods Coronary angiography was performed in 130 patients suspected for CAD and angiographic severity of coronaryartery was quantitated by Duke score and Gensini score. Patients were divided to 4 groups： non-CAD group （39 patients）, CAD group with one coronary artery involved （CHD1 group, 30 patients）, CHD group with two coronary arteries involved （CHD2 group, 31 patients） and CAD group with three coronary arteries involved （CHD3 group,30 patients）. One month before coronary angiography, symptom-limited exercise treadmill tests were made and the ratio of heart rate reserve （HRR） and the percent maximal agepredicted heart rate achieved （rHR） were measured. Results rHR and HRR were significantly lower in CHD2 group （ rHR 0. 79 ± 0. 08 , HRR 0. 63 ± 0. 11 ） and CHD3 （ rHR 0. 78 ± 0. 07, HRR 0. 59 ± 0. 12） than that in non-CHD group （ rHR 0. 89 ± 0.06, HRR0.80±0. 10）and CHD1 group（ rHR 0. 86 ±0.08 ,HRR0.74±0. 15, all P〈0.05）, rHR and HRR also significantly correlated with Duke score（r = -0. 554, -0. 578 ,all P 〈0. 01 ） and Gennisi score （r = -0. 453, -0. 467 ,all P 〈 0. 01 ）. CHD incidence rate was 75% in patients with positive rHR （ or HRR） but without ST lowering during exercise. Conclusion Chronotropic incompetence are negatively related to angiographic coronary severities and thus predict angiographic coronary severities. There is a high CAD incidence in patients with positive rHR （ or HRR） but no ST lowering during symptom-limited exercise treadmill tests.