心肌梗死急性期QRS波增宽预测远期心脏性猝死发生的价值

QRS duration during the acute phase can predict the sudden cardiac death in long-term follow-up for patients with acute myocardial infarction

目的探讨急性心肌梗死后早期无创性指标左心室射血分数(LVEF)、QRS波时限和QTc间期预测远期心脏性猝死(SCD)发生的价值。方法采集289例急性心肌梗死后存活患者在急性期(<30 d)超声测定LVEF、体表心电图测定QRS波时限和QTc间期的数据,临床随访观察远期(>1年)发生的SCD事件。LVEF降低的界值为35%,QRS波增宽的界值为110 ms,QTc间期延长的界值为450 ms(男)/460 ms(女)。根据随访结果将患者分为SCD组和幸存组。结果在心肌梗死后平均(15±3)个月内,15例(5.2%)患者发生SCD。与幸存组患者相比,SCD组患者的LVEF明显降低[35%(28%～52%)比50%(33%～60%),P<0.0001],QRS波时限明显延长[115(88～152)ms比105(91～126)ms,P=0.0222],而两组患者QTc间期差异无统计学意义[458(416～513)ms比450(394～493)ms,P=0.1836]。SCD组患者中LVEF降低、QRS波增宽和QTc间期延长的比率依次为40%、67%和60%。生存分析提示,LVEF降低(26.1%比3.4%,P<0.0001)和QRS波增宽(9.7%比2.7%,P=0.0098)患者远期SCD发生率增加。多元Logistic回归分析显示,LVEF降低[RR:6.0(2.0～17.8),P=0.0011]和QRS波增宽[RR:3.1(1.0～9.0),P=0.0345]均为SCD发生的独立危险因素。结论急性心肌梗死后早期QRS波增宽能独立预测远期SCD的发生。

Objective To investigate the predictive value of left ventricular ejection fraction （LVEF）, QRS duration and QTc interval during the acute phase on the sudden cardiac death （SCD） events in long-term follow-up for Chinese patients with acute myocardial infarction （AMI）. Methods A total of 289 survived patients with AMI during the early phase （≤ 30 days） were enrolled. The LVEF were measured by echocardiography. The QRS duration and the QTc interval were measured automatically by electrocardiography and were checked manually. The left ventricular dysfunction （LVD） were defined as LVEF 〈35%. The wide QRS wave was defined as its duration 〉 110 ms. The extended QTc interval was defined as its value 〉 450 ms for male or 〉 460 ms for female. Regular follow-ups were carried out to detect the SCD event which was defined as the death due to any cardiac disease that occurs out of hospital, in an emergency department, or in an individual reported dead on arrival at a hospital. The patients were divided into two groups according to the follow-up outcome, the SCD group and the survived group. Results During the mean follow-up of （15 ＋3） months, 15 patients （5.2%） were died due to SCD. Compared to the survived group, patients in SCD group were related with lower LVEF [35% （28% -52% ） vs. 50% （33% -60% ）, P 〈 0. 0001 ] and longer QRS duration [115（88-152） ms vs. 105（91-136） ms, P =0. 0222], but not related with QTc interval [458（416-513） ms vs. 450（394493） ms, P =0. 1836]. In SCD group, the percentage of patients with LVD, QRS prolongation and QTc prolongation was 40%, 67% and 60%, respectively. As for the incidence of SCD, patients with LVD was 8 times higher than those with preserved LVEF [26. 1% vs. 3.4%, P 〈 0. 0001 ], patients with QRS prolongation was 4 times higher than those with normal QRS duration [9. 7% vs. 2. 7%, P =0. 0098] and patients with QTc prolongation was 2 times higher than those with normal QTcinterval [6.7% vs. 3.9%, P=0.2671]. LVD [RR： 6.0（2.0, 17.8）, P=O. O011] and QRS prolongation [ RR： 3. 1 （ 1.0, 9.0 ）, P = 0. 0435 ] were independent SCD risk factors after multivariate analysis. Conclusions QRS duration is an independent risk factor for SCD in patients with AMI.