硝酸甘油激发直立倾斜试验心率预警指标的探讨

Early warning heart rate indicators in positive vasovagal response to upright tilt table testing provoked by nitroglycerin

目的探讨提示舌下含服硝酸甘油激发直立倾斜试验阳性的心率预警指标。方法回顾2019年5月至11月在北京大学人民医院进行舌下含服硝酸甘油激发直立倾斜试验的连续411例中408例患者检查结果的血压心率趋势报告,分析比较血管迷走性反应阳性及阴性患者的心率变化特点。计算0.5分钟内的心率下降幅度最大值(MHRD)及MHRD与峰值心率的比值(M/P),并绘制受试者工作特征曲线(ROC曲线),比较不同指标界值的敏感度、特异度、约登指数(J=灵敏度+特异度-1)、加权约登指数(Jω=2×[ω×灵敏度+(1-ω)×特异度]-1,ω=0.6)、诊断准确性、阳性似然比及阴性似然比。结果(1)408例患者中,硝酸甘油激发直立倾斜试验血管迷走性反应阳性者205例,阴性者203例。(2)阳性组与阴性组相比,平卧时的基础心率68.4±11.3 vs.68.2±10.9次/分(p>0.05);含服硝酸甘油前心率87.4±14.3 vs.82.5±13.9次/分(p<0.001);含药后心率达峰时间3.6±1.5 vs.4.9±1.6次/分(p<0.001);峰值心率114.6±19.8 vs.108.2±18.8次/分(p=0.001);MHRD为18(11)vs.13(7)次/分(p<0.001);M/P为0.160(0.08)vs.0.114(0.05)(p<0.001)。(3)用于预测血管迷走性反应阳性时,MHD的ROC曲线下面积为0.751,M/P的ROC曲线下面积为0.747。(4)在心率指标中,MHRD≥15次/分预测血管迷走性反应阳性的加权约登指数最大,为0.398,敏感度73.2%,特异度65.0%,诊断准确性0.691,阳性似然比2.09,阴性似然比0.412。结论在舌下含服硝酸甘油激发直立倾斜试验中,血管迷走性反应阳性者心率达峰时间短于阴性者,峰值心率高于阴性者,且心率下降速度快于阴性者,0.5分钟内的心率下降最大值≥15次/分可作为血管迷走性反应阳性的心率预警指标。

Objective To explore the early warning indicators of heart rate suggesting positive vasovagal response to upright tilt table testing provoked by nitroglycerin.Methods Review the heart rate trend reports of 408 out of 411 consecutive patients who performed upright tilt table testing provoked by sublingual nitroglycerin in People’s Hospital of Peking University from May to November 2019 and analyze and compare the characteristics of heart rate changes in positive vasovagal responses patients and negative patients.The area under the ROC curves(AUC)of the maximum value of the heart rate dropping in 0.5 min(MHRD)and the ratio of MHRD to the peak heart rate(M/P)as the early warning indicators of the positive vasovagal response were calculated.The sensitivity(Se),specificity(Sp),Youden index(J=Se+Sp-1),weighed Youden index(Jω=2*[ω*Se+(1-ω)*Sp]-1,ω=0.6),positive likelihood ratio(+Lr)and negative likelihood ratio(-Lr)of different indicators were calculated.Results(1)Among the 408 patients,205 patients had positive vasovagal response in upright tilt table testing provoked by nitroglycerin,203 patients had negative response.(2)In the positive group and the negative group,the basic heart rate is 68.4±11.3 vs.68.2±10.9 bpm(p>0.05),the heart rate before taking nitroglycerin is 87.4±14.3 vs.82.5±13.9 bpm(p<0.01),the time it takes to reach the peak heart rate after taking nitroglycerin is 3.6±1.5 vs.4.9±1.6 min(p<0.01),the peak heart rate after sublingual nitroglycerin is 114.6±19.8 vs.108.2±18.8 bpm(p<0.01),MHRD is 18(11)vs.13(7)bpm(p<0.01),P/M is 0.160(0.08)vs.0.114(0.05)(p<0.01).(3)When using MHRD as the early warning indicator for positive vasovagal response in the upright tilt table testing provoked by nitroglycerin,AUC ROC is 0.751,while the AUC of M/P is 0.747.When using MHRD≥15 bpm as the early warning indicator for positive vasovagal response in the upright tilt table testing provoked by nitroglycerin,Se is 73.2%,Sp is 65.0%,Jωis 0.398,+Lr is 2.09,-Lr is 0.412.Conclusions In the upright tilt table testing provoked by sublingual nitroglycerin,in the patients with positive vasovagal response it takes shorter time to reach the peak heart rate than the negative ones,the peak heart rate is higher than that of the negative ones,and the heart rate drops faster than that of the negative ones.The maximum heart rate dropping within 0.5 min greater than or equal to 15 bpm can be used as an early warning heart rate indicator for positive vasovagal response.