慢性心力衰竭患者心脏失同步化与QRS时限及氨基末端前脑钠肽的相关性研究

Relation of QRS duration and N-terminal-proBNP in patients with cardiac desynchronization in chronic heart failure

目的探讨QRS时限、氨基末端前脑钠肽（NT—proBNP）和心功能参数在判断心脏失同步的敏感性。方法入选慢性心力衰竭（CHF）患者122例，经标准化药物治疗，NYHA心功能Ⅲ～Ⅳ级，左心室射血分数（LVEF）≤35％。所有入选患者均行下列检查：①心电图检查；②检测NT—proBNP；③M型超声心动图测量左心室舒张末内径（left ventricular end—diastolic diameter，LVEDD）；④二维超声心动图测量LVEF；⑤彩色多普勒超声心动图测量QRS波起始至肺动脉血流开始的时间（T1），QRS波起始至主动脉血流开始的时间T2，T2-T1〉40ms表示左、右心室问收缩失同步；⑥组织多普勒测量QRS波起始至左心室每一节段收缩期峰值速度时限即Ts，计算左心室12个节段达峰时间标准差（Ts—SD），Ts～sD〉33ms表示左心室内收缩不同步。心室失同步（ventricular desynchronization，VD）指T2-T1〉40ms和（或）Ts—SD〉33ms。根据QRS波时限将入选患者分为QRS≥120ms组（A组）和QRS〈120ms组（B组）；根据是否存在VD，将A组分为A1亚组（VD组）和A2亚组（非VD组），B组分为B1亚组（VD组）和B2亚组（非VD组）。结果①A组VD百分比率为75．0％，B组VD百分比率为35．4％，两者差异有统计学意义（P〈0．05）；②A、B两组血浆NT-proBNP水平差异有统计学意义（P〈0．01），而两组LVEDD和LVEF差异均无统计学意义（P〉0．05）；③QRS时限与NT-proBNP、LVEDD呈正相关（r=0．720、0．360，P〈0．01或〈0．05），与LVEF呈负相关（r=0．320，P〈0．01）；④A1亚组和A2亚组、B1亚组和B2亚组、A1亚组和B1亚组血浆NT-proBNP水平比较差异均有统计学意义（P〈0．01），A2和B2两亚组血浆NT-proBNP比较差异无统计学意义（P〉0．05）。用LVEDD和LVEF做上述相同比较，差异均无统计学意义（P〉0．05）。结论①QRs波时限不是反映心室失同步的唯一指标，窄QRS波慢性心衰患者也存在心室失同步；②QRS波时限与NT—proBNP水平有良好的相关性，二者结合可提高检测心室失同步的敏感性。

Objective To investigate the sensitivity of N-terminal probrain natriuretic peptide（NT-proBNP）, QRS duration and the parameter of cardiac function in evaluating cardiac desynehronization. Methods A total of 122 patients with chronic heart failure （CHF） were enrolled. Selection criteria included patients with optimal pharmacological treatments, New York Heart Association （NYHA） Ⅲ - Ⅳ, left ventricular ejection fraction （LVEF） 35 %. All enrolled patients underwent the following checks： ① electrocardiography （ECG） ; ② NT-proBNP;③ M- echocardiography：left ventricular end-diastolic diameter（LVEDD） ;④two-dimensional eehocardiography：left ventricular ejection fraction（LVEF） ;O color Doppler echocardiography：T2--T1,T1 is time interval from the start of QRS wave to the beginning of pulmary blood flow,T2 is time interval from the start of QRS wave to the beginning of aortic blood flow,T2--T1〉40 ms is defined interventricular desychronization;⑤tissue Dopple imaging（TDI） ：Ts is time interval from the start of QRS wave to peak systolic speed of each segment of left ventrivular,Ts--SD is standard deviation of Ts of 12 segments of left ventricular, Ts- SD〉 33 ms is defined intraventricular desychronization. Ventricular desychronization（VD） includes T2--T1〉40 ms and（or） Ts--SD〉33 ms. Patients with QRS≥120 ms are A group, including A1 （VD） subgroup and A2 （non VD） subgroup. Patients with QRS〈120 ms are B group,including A1 （VD） subgroup and A2 （non VD） subgroup. Results ①The rate of VD was 75.0% in A group and 34.5% in B group,which was significantly different between two groups （ P 〈 0.05）. ①The level of NT-proBNP was significantly different between A and B group（ P 〈0.01）, but LVEDD and LVEF had no significant difference between two groups（ P 〈0.05）. ②There were positive correlations between QRS duration and NT-proBNP, LVEDD（ r = 0. 720,0. 360, P〈 0.01 or 〈0.05） ,and negative correlation between QRS duration and LVEF（ r = -0. 320, P 〈0.01）. QThe level of NT-proBNP was significantly different between A1 subgroup and A2 subgroup, B1 subgroup and B2 subgroup, A1 subgroup and B1 subgroup（all P 〈0.01 ） ,but not between A2 subgroup and B2 subgroup （ P 〉0.05）. The comparison with LVEDD and LVEF between A1 subgroup and A2 subgroup, B1 subgroup and B2 subgroup, A1 subgroup and Blsubgroup,A2 subgroup and B2 subgroup showed no significant difference （all P 〈0.05）. Conclusion ① QRS duration is not a only marker to evaluate VD, and the patients with narrow QRS in heart failure also present VD. ② There is a good correlation between QRS duration and NT-proBNP, and the combination of QRS duration and NT-proBNP can increase the sensitivy to detect VD.