围术期临床心脏疾病中危因素患者动态心电图监测及临床意义

The dynamic electrocardiogram monitoring and its clinical significance in the intraoperative patients with clinical risk factors

目的探讨围术期临床心脏疾病中危因素患者心血管事件（PCE）中心律失常和心肌缺血的发生及其与心率变异性（HRV）的关系。方法随机选择非心脏择期手术围术期临床心脏疾病中危因素患者171例，根据年龄将其分为3组：①组，〈65岁共54例；②组，65-75岁共72例；③组，〉75岁共45例。所有患者行术前与术后连续48h动态心电图（DCG）监测，对Ⅱ级以上室性期前收缩、阵发性室上性心动过速（PSVT）、阵发性心房颤动（PM）及传导阻滞等心律失常，阵发性sT段缺血性改变等作出分析、诊断；删除影响HRV及sT段分析的病例，选择113例患者的DCG分析研究HRV的变化及其与心律失常、心肌缺血发生的关系。结果心律失常及心肌缺血发生情况：术前各组相比差异无统计学意义（P〉0．05）；术后①组ⅣA级室性期前收缩、PAf及心肌缺血的发生增多（P〈0．05）；②组与③组中，除③组Ⅱ级室性期前收缩无明显增加外，其余术后均明显增多，差异有统计学意义（P〈O．05）。术后组间比较：随年龄增大，心律失常及心肌缺血发生增加且类别增多。术前发生心肌缺血15例（13．27％），术后发生40例（35．40％）。术后发生PAf23例（13．45％），组间比较，随年龄增大PAf的发生增加（P〈0．05），其发生与左房增大无明显关系。HRV比较：术前组间比较，随年龄增大HRV呈下降趋势（P〈0．05），术后HRV各参数较术前显著降低（P〈0．05），术后第2个24h较第1个24hHRV指标进一步降低（除外②组的TI）（P〈O．05）；术后组间比较，随年龄增长HRV均有不同程度的减低，③组高龄患者降低尤为显著（P〈O．05）。结论术后随患者年龄增大，复杂性及恶性心律失常、心肌缺血等PCE的发生增加，其自主神经功能降低更明显，HRV指标尤其是SDAA、TI等指标显著降低，迷走及交感神经张力的失衡相对更为严重且持续时间长。提示心律失常及心肌缺血的发生可能与自主神经系统活性HRV降低有关。

Objective To investigate the relationship between intraoperative arrhythmia and myocardial ischemia and Heart rate variability （HRV） in the patients with clinical risk factors undergoing noncardiac surgery. Methods According to age, 171 patients with clinical risk factors undergoing noncardiac surgery were divided in- to three groups. Group（1） （〈65y,n=54）, group（2） （65-75y,n=72） and gToup（3） （〉75y,n=45）. All patients were monitored with dynamic electrocardiogram （DCG） for 24 h before surgery and from the begining of operation to continuously 48 h. Ventricular premature beat, PAf and conduction block and other arrhythmias, paroxysmal is- chemic ST segment changes were analysed. In all patients, the patients whose results of the HRV and ST segment analysis were affected were excluded. Finally, 113 cases of patients,were analysed the changes of HRV and its relationship with cardiac arrhythmia, myocardial ischemia by DCG. Results The occurrence of arrhythmia and myocardial ischemia was no significant difference preoperative in each group （P〉0.05）,the incidence of IVA-level ventricular premature beat, PAf and myocardial ischemia increased postoperative in the group（1） （P〈0.05）. In the group（2） and （3）,except the Ⅱ Class ventricular premature beat was no significant increase in Group（3）,the rest were significantly increased after the operation（P〈0.05 ）. Comparison among the three groups postoperative： the in- cidence of arrhythmia and myocardial ischemia in a corresponding increase with increasing age and the species of arrhythmia and myocardial ischemia also increased at the same time. The incidence of myocardial ischemia in pre- operative was 15 cases（ 13.27% ）, postoperative 40 cases（35.40% ）. There were 23 patients who found PAf postop- erative （13.45%）. Comparison among the three groups,the incidence of PAf in a corresponding increase with in- creasing age （P〈0.05）. And indicates that the occurrence of perioperative PM was no significant relationship with the left atrial enlargement. Comparison of HRV in the three groups： Preoperative, HRV declined （P〈0.05） with the increasing age. Postoperation： postoperative HRV parameters significantly lower than preoperative （P〈0.05）, and HRV of second 24 h further decreased than the first 24 h HRV, P〈0.05（In addition to the TI in the second group patients）. Postoperative comparison among the three groups： increased with age, HRV were decreased in varying degrees （the elderly patients in group（3） was particularly significant decreased in HRV）, P〈0.05. Conclusion With the increasing age of the patient, the incidence of PCE such as complex and malignant arrhythmias and my- ocardial ischemia increased corresponding postoperation. Autonomic nervous functions in patients with more pro- nounced reduction, HRV indicators, particularly SDAA and TI indicators significantly reduce. Vagal and sympa- thetic tone unbalance in a relatively more serious and laste longer, which suggest that the occurrence of arrhythmia and myocardial ischemia may be related to the reduction of the autonomic nervous functions activity and the HRV.