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慢性心力衰竭患者常会发生左心室机械同步性失调,机械同步性失调是慢性心力衰竭患者预后不良的重要因素[1]。左心室机械同步性失调是指左心室各室壁节段心肌的舒张和(或)收缩时间不一致,进而导致心脏整体的运动不协调。左心室机械同步性的评估可通过多种检查方式实现,主要包括心脏MRI、斑点追踪超声心动图、核素显像等。心脏MRI因检查费用高、检查时间长且无法应用于心脏起搏器植入术后的患者等,故其临床应用受到限制;超声检查易受人为因素的影响,导致结果可重复性较差,同时变异程度较大;核素显像主要包括门控心血池显像和门控心肌灌注显像(gated myocardial perfusion imaging,GMPI),其中GMPI的相位分析技术因具有简便易开展、重复性极佳、可量化评估左心室机械同步性的严重程度等优点而被认为是评估左心室机械同步性的标准检查方式[2]。纽约心功能分级是当前评估慢性心力衰竭患者心功能受损严重程度最常用的方法,但该方法主要依靠患者的症状进行评估,是一种非量化的标准,因此存在较强的主观因素,对于症状不够典型或耐受性较好的患者,其评估结果可能存在一定误差。
GMPI除了可以评估左心室机械同步性,还可同时获得一系列反映心脏功能的参数指标,在反映慢性心力衰竭患者心功能发展的严重程度方面提供客观的定量依据。同时,核素显像作为功能影像方法,或可早期诊断心力衰竭。明确导致心肌发生收缩和(或)舒张不同步的原因和潜在机制能够为慢性心力衰竭患者的治疗提供新的途径和思路。因此本研究拟探讨GMPI与慢性心力衰竭患者心功能受损严重程度的关系,并基于GMPI评估慢性心力衰竭患者的左心室机械同步性,探讨慢性心力衰竭患者发生左心室机械同步性失调的影响因素。
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81例慢性心力衰竭患者中,17例患者的纽约心功能分级评估结果为心功能Ⅰ级、22例为心功能Ⅱ级、37例为心功能Ⅲ级、5例为心功能Ⅳ级。慢性心力衰竭患者的典型静息GMPI显像图、靶心图和相位直方图见图1、2。
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健康对照组与纽约心功能Ⅰ级的慢性心力衰竭患者组在年龄、性别、BMI上的差异均无统计学意义(t=1.431、1.693,χ²= 1.710,P=0.160、0.071、0.191)。由表1可见,在心功能Ⅰ级组的慢性心力衰竭患者与健康对照组的比较中,LVEF、LVEDV、LVESV、PFR、PSD、NTpro-BNP间的差异均有统计学意义(均P<0.05)。NTpro-BNP、Hs-CRP以及GMPI的各项指标在心功能Ⅰ级组、心功能Ⅱ级组、心功能Ⅲ~Ⅵ级组患者间的差异均有统计学意义(均P<0.05),且随着心功能受损严重程度的进展,LVEDV、LVESV、PHB、PSD、Hs-CRP、NTpro-BNP水平呈上升趋势,LVEF、PFR水平呈下降趋势。
组别 LVEF(%) LVEDV(ml) LVESV(ml) PFR(EDV/s) PHB(°) PSD(°) Hs-CRP(mg/L) NTpro-BNP(ng/L) 健康对照组(n=23) 71(70,75) 62(54,82) 18(14,26) 4.80±1.38 36.70±10.57 12.57±4.72 0.5(0.5,1.1) 52(34,94) 心功能Ⅰ级组(n=17) 68(61,70)a 94(77,115)a 32(23,43)a 3.29±0.73a 41(36,54) 16(11,20)a 0.5(0.5,1.5) 145(85,184)a 心功能Ⅱ级组(n=22) 54(46,62) 127(96,151) 55(43,78) 3.00±1.06 101(64,189) 42(23,52) 0.8(0.5,1.9) 399(186,546) 心功能Ⅲ~Ⅳ级组(n=42) 40(23,51)b 168(109,220)b 106(59,167)b 2.62±1.13b 139(75,205)b 47(29,59)b 3.3(1.5,16.3)b 1730(479,4105)b 注:a表示心功能Ⅰ级组慢性心力衰竭患者与健康对照组相比,差异有统计学意义(t=4.084、Z=3.462、3.038、3.519、3.489、2.203,P<0.001、P<0.001、P=0.002、P<0.001、P<0.001、P=0.028);b表示心功能Ⅰ级、Ⅱ级、Ⅲ~Ⅳ级慢性心力衰竭患者多组间的比较,差异有统计学意义(H=23.846、14.791、21.089、6.251、18.892、20.347、19.171、35.654,P<0.001、P=0.001、P<0.001、P=0.044、P<0.001、P<0.001、P<0.001、P<0.001)。LVEF为左心室射血分数;LVESV为左心室收缩末期容积;LVEDV为左心室舒张末期容积;PFR为高峰充盈率;EDV为舒张末期容积;PHB为相位直方图带宽;PSD为相位分布标准差;Hs-CRP为超敏C反应蛋白;NTpro-BNP为N末端B型利钠肽原 表 1 健康对照组与不同纽约心功能分级的慢性心力衰竭患者门控心肌灌注显像和实验室检查结果的比较[
、M(Q1,Q3)]$ \bar {x} \pm s$ Table 1. Comparison of gated myocardial perfusion imaging and laboratory test results between healthy control group and chronic heart failure patients with different concentric functional class [
, M(Q1, Q3)]$ \bar {x} \pm s$ -
慢性心力衰竭患者的SRS、LVESV、LVEDV、PHB、PSD、NTpro-BNP、Hs-CRP水平与纽约心功能分级呈正相关(r=0.235、0.547、0.474、0.481、0.458、0.671、0.439,P=0.035、P<0.001、<0.001、<0.001、<0.001、<0.001、P=0.001);LVEF、PFR水平与纽约心功能分级呈负相关(r=−0.563、−0.304,P<0.001、P=0.006)。
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慢性心力衰竭患者发生左心室机械同步性失调的比例为74.1%(60/81),其中心功能Ⅰ级患者发生左心室机械同步性失调的比例为23.5%(4/17)、心功能Ⅱ级为90.5%(19/21)、心功能Ⅲ级为84.2%(32/38)、心功能Ⅳ级为100%(5/5)。
由表2可见,左心室机械同步的慢性心力衰竭患者的年龄、LVEF、PFR水平均高于不同步患者,且差异均有统计学意义(均P<0.05);左心室机械不同步患者的心率、LVEDV、LVESV、SRS、Hs-CRP、NTpro-BNP水平均高于同步患者,且差异均有统计学意义(均P<0.05)。左心室机械同步与不同步患者间的性别、BMI、合并症(高血压、糖尿病、高脂血症、心律失常、肺炎、冠心病、肺动脉高压、心肌病)发病率、搏出量、高峰充盈时间的比较,差异均无统计学意义(均P>0.05)。
项目 左心室机械同步(n=21) 左心室机械不同步(n=60) 检验值 P值 一般资料 性别(男/女) 12/9 44/16 χ2=1.911 0.167 年龄(岁) 63.4±14.7 53.6±15.3 t=2.550 0.013 BMI(kg/m2) 23.05(21.48,27.25) 24.52(22.27,27.26) Z=1.110 0.267 心率(次/分) 65(61,72) 73(66,82) Z=3.149 0.002 合并症发病率[例(%)] 高血压 15(71.4) 28(46.7) χ2=3.830 0.050 糖尿病 7(33.3) 17(28.3) χ2=0.187 0.666 高脂血症 8(38.1) 11(18.3) χ2=3.384 0.066 心律失常 4(19.0) 16(26.7) χ2=0.486 0.486 肺炎 0(0) 3(5.0) − 0.564 冠心病 14(66.7) 43(71.7) χ2=0.187 0.666 肺动脉高压 1(4.8) 9(15.0) χ2=0.709 0.400 心肌病 1(4.8) 9(15.0) χ2=0.709 0.400 GMPI指标 LVEF(%) 69.0(65.5,71.0) 42.0(23.8,54.0) χ2=6.146 <0.001 LVEDV(ml) 79.0(62.5,104.5) 149.5(115,210.8) χ2=5.335 <0.001 LVESV(ml) 26.0(18.5,34.0) 91.5(54.5,159.5) χ2=5.993 <0.001 SV(ml) 57.0±17.0 61.8±23.9 t=0.850 0.398 PFR(EDV/s) 3.61±0.73 2.60±0.14 t=4.042 <0.001 TPFR(ms) 218.56±59.26 189.93±86.61 t=1.402 0.100 SRS(分) 3.0(2.0,5.0) 13.0(6.3,19.8) Z=4.978 <0.001 实验室检查指标 Hs-CRP阳性例数[例(%)] 6(28.6) 36(60.0) χ2=6.154 0.013 NTpro-BNP(ng/L) 156(123.5,231.5) 806.5(319.8,2275.0) Z=4.381 <0.001 注:−表示检验方法为Fisher确切概率法,无检验值;BMI为体质指数;GMPI为门控心肌灌注显像;LVEF为左心室射血分数;LVEDV为左心室舒张末期容积;LVESV为左心室收缩末期容积;SV为博出量;PFR为高峰充盈率;EDV为舒张末期容积;TPFR为高峰充盈时间;SRS为静息总积分;Hs-CRP为超敏C反应蛋白;NTpro-BNP为N末端B型利钠肽原 表 2 左心室机械同步与不同步慢性心力衰竭患者的单因素分析[
、M(Q1,Q3)、例(%)]$ \bar {x} \pm s$ Table 2. Univariate analysis of mechanical synchronous and asynchronous of the left ventricle chronic heart failure patients[
, M(Q1, Q3), case(%)]$ \bar {x} \pm s$ -
多因素Logistic回归分析结果显示,LVEF、SRS是慢性心力衰竭患者发生左心室机械同步性失调的独立影响因素(B=−0.166、0.278,B值标准误为0.068、0.130,Wald χ2=5.927、4.584,P=0.015、0.032,OR=0.847、1.320,95%CI:0.741~0.968、1.024~1.702)。
门控心肌灌注显像评估慢性心力衰竭患者左心室机械同步性的应用及其与纽约心功能分级的关系
Use of gated myocardial perfusion imaging to assess left ventricular mechanical synchrony in patients with chronic heart failure and its relationship to New York heart functional class
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摘要:
目的 探讨门控心肌灌注显像(GMPI)在评估慢性心力衰竭患者左心室机械同步性中的应用价值及其与纽约心功能分级的关系,分析慢性心力衰竭患者发生左心室机械同步性失调的影响因素。 方法 回顾性分析2020年1月至2021年12月在昆明医科大学附属延安医院行GMPI检查的81例慢性心力衰竭患者的临床资料,其中男性56例、女性25例,年龄(56.1±15.6)岁,同时纳入同期就诊的23名健康受检者为健康对照组,采集所有研究对象的GMPI指标[包括左心室射血分数(LVEF)、高峰充盈率(PFR)、左心室收缩末期容积(LVESV)、左心室舒张末期容积(LVEDV)、相位分布标准差(PSD)、相位直方图带宽(PHB)、静息总积分(SRS)]和实验室检查结果[包括超敏C反应蛋白(Hs-CRP)、N末端B型利钠肽原(NTpro-BNP)],GMPI检查和实验室检查的时间间隔不超过7 d。通过Kruskal Wallis检验与Spearman相关性分析法分析GMPI各指标、Hs-CRP、NTpro-BNP与慢性心力衰竭患者纽约心功能分级的关系。2组间独立样本的比较采用 t 检验或Mann-Whitney U 检验,计数资料的组间比较采用卡方检验或Fisher确切概率法。通过Logistic回归分析探讨不同因素对慢性心力衰竭患者左心室机械同步性的影响。 结果 LVEF、LVEDV、LVESV、PFR、PHB、PSD、Hs-CRP、NTpro-BNP在心功能Ⅰ级组、心功能Ⅱ级组、心功能Ⅲ~Ⅳ级组间的差异均有统计学意义(H=23.846、14.791、21.089、6.251、18.892、20.347、19.171、35.654,均P<0.05);心功能Ⅰ级组慢性心力衰竭患者与健康对照组相比,LVEF、LVEDV、LVESV、PFR、PSD、NTpro-BNP间的差异均有统计学意义(t=4.084,Z=3.462、3.038、3.519、3.489、2.203,均P<0.05)。SRS、LVESV、LVEDV、PHB、PSD、NTpro-BNP、Hs-CRP水平与纽约心功能分级呈正相关(r=0.235、0.547、0.474、0.481、0.458、0.671、0.439,均P<0.05);LVEF、PFR与纽约心功能分级呈负相关(r=−0.563、−0.304,均P<0.05)。单因素分析结果显示,左心室机械同步与不同步的慢性心力衰竭患者的年龄、LVEF、PFR、心率、LVEDV、LVESV、SRS、Hs-CRP、NTpro-BNP比较,差异均有统计学差异(t=2.550、χ2=6.146、t=4.042、Z=3.149、χ2=5.335、χ2=5.993、Z=4.978、χ2=6.154、Z=4.381,均P<0.05);多因素Logistic回归分析结果显示,LVEF、SRS是慢性心力衰竭患者发生左心室机械同步性失调的独立影响因素(B=−0.166、0.278,B值标准误为0.068、0.130,Wald χ2=5.927、4.584,P=0.015、0.032,OR=0.847、1.320,95%CI:0.741~0.968、1.024~1.702)。 结论 LVEF、LVEDV、LVESV、PFR、PSD、NTpro-BNP可能具有早期诊断慢性心力衰竭的潜在价值;LVEF、LVESV、PFR、LVEDV、PHB、PSD、NTpro-BNP、Hs-CRP对慢性心力衰竭患者的心功能受损严重程度有提示作用,以NTpro-BNP、LVEF、LVESV的提示作用较优;SRS水平升高、LVEF水平降低是慢性心力衰竭患者发生左心室机械同步性失调的独立预测因子。 -
关键词:
- 心脏门控单光子发射计算机辅助体层摄影术 /
- 心力衰竭 /
- 左心室机械同步性 /
- 纽约心功能分级
Abstract:Objectives To investigate the application value of gated myocardial perfusion imaging (GMPI) in the evaluation of left ventricular mechanical synchrony in patients with chronic heart failure and its relationship with the New York cardiac functional class, and to analyze the influencing factors of left ventricular mechanical synchrony disorder in patients with chronic heart failure. Methods The clinical data of 81 patients with chronic heart failure admitted to Yan'an Hospital Affiliated to Kunming Medical University from January 2020 to December 2021 were selected, including 56 males and 25 females, aged (56.1±15.6) years, and 23 healthy subjects admitted during the same period were included as healthy control group. GMPI indicators (including left ventricular ejection fraction (LVEF), peak filling rate (PFR), left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), phase standard deviation (PSD), phase histogram bandwidth (PHB), and summed rest score (SRS)) and laboratory tests (including hypersensitivity C-reactive protein (Hs-CRP) and N-terminal pro-B-type natriuretic peptide (NTpro-BNP)) of all subjects were collected, and the interval between GMPI examination and laboratory examination was no more than 7 days. Kruskal Wallis test and Spearman correlation analysis were used to analyze the relationship between GMPI, Hs-CRP, NTpro-BNP and classification of nyha heart function in patients with chronic heart failure. The independent samples between two groups were compared by t test or Mann-Whitney U test, and the inter-group comparison of counting data was performed by Chi-square test or Fisher exact probability method. Logistic regression analysis was conducted to explore the effects of different factors on left ventricular mechanical synchrony in patients with chronic heart failure. Results There were significant differences of LVEF, LVEDV, LVESV, PFR, PHB, PSD, Hs-CRP and NTpro-BNP in the cardiac function grade Ⅰ group, the cardiac function grade Ⅱ group and the cardiac function grade Ⅲ-Ⅳ groups (H=23.846, 14.791, 21.089, 6.251, 18.892, 20.347, 19.171, 35.654, all P<0.05). There were significant differences in LVEF, LVEDV, LVESV, PFR, PSD and NTpro-BNP between the patients with chronic heart failure in the cardiac function grade Ⅰ group and the healthy control group (t=4.084, Z=3.462, 3.038, 3.519, 3.489, 2.203; all P<0.05). The levels of SRS, LVESV, LVEDV, PHB, PSD, NTpro-BNP, Hs-CRP were positively correlated with the New York cardiac functional class (r=0.235, 0.547, 0.474, 0.481, 0.458, 0.671, 0.439; all P<0.05). Univariate analysis showed that there were statistically significant differences in age, LVEF, PFR, heart rate, LVEDV, LVESV, SRS, Hs-CRP and NTpro-BNP between patients with left ventricular mechanical synchrony and those with non-synchronous chronic heart failure (t=2.550, χ2=6.146, t=4.042, Z=3.149, χ2=5.335, χ2=5.993, Z=4.978, χ2=6.154, Z=4.381; all P<0.05); The results of multivariate regression analysis showed that LVEF and SRS were independent influencing factors for the occurrence of left ventricular mechanical synchronization dysregulation in patients with chronic heart failure (B=−0.166, 0.278; B standard error=0.068, 0.130; Wald χ2=5.927, 4.584; P=0.015, 0.032; OR=0.847, 1.320; 95%CI=0.741-0.968, 1.024-1.702). Conclusion LVEF, LVEDV, LVESV, PFR, PSD, NTpro-BNP may have potential value in early diagnosis of chronic heart failure. LVEF, LVESV, PFR, LVEDV, PHB, PSD, NTpro-BNP and Hs-CRP have suggestive effects on the severity of cardiac function impairment in patients with chronic heart failure, and NTpro-BNP, LVEF and LVESV have better suggestive effects. Increased SRS and decreased LVEF were independent predictors of left ventricular mechanical synchrony in patients with chronic heart failure. -
表 1 健康对照组与不同纽约心功能分级的慢性心力衰竭患者门控心肌灌注显像和实验室检查结果的比较[
、M(Q1,Q3)]$ \bar {x} \pm s$ Table 1. Comparison of gated myocardial perfusion imaging and laboratory test results between healthy control group and chronic heart failure patients with different concentric functional class [
, M(Q1, Q3)]$ \bar {x} \pm s$ 组别 LVEF(%) LVEDV(ml) LVESV(ml) PFR(EDV/s) PHB(°) PSD(°) Hs-CRP(mg/L) NTpro-BNP(ng/L) 健康对照组(n=23) 71(70,75) 62(54,82) 18(14,26) 4.80±1.38 36.70±10.57 12.57±4.72 0.5(0.5,1.1) 52(34,94) 心功能Ⅰ级组(n=17) 68(61,70)a 94(77,115)a 32(23,43)a 3.29±0.73a 41(36,54) 16(11,20)a 0.5(0.5,1.5) 145(85,184)a 心功能Ⅱ级组(n=22) 54(46,62) 127(96,151) 55(43,78) 3.00±1.06 101(64,189) 42(23,52) 0.8(0.5,1.9) 399(186,546) 心功能Ⅲ~Ⅳ级组(n=42) 40(23,51)b 168(109,220)b 106(59,167)b 2.62±1.13b 139(75,205)b 47(29,59)b 3.3(1.5,16.3)b 1730(479,4105)b 注:a表示心功能Ⅰ级组慢性心力衰竭患者与健康对照组相比,差异有统计学意义(t=4.084、Z=3.462、3.038、3.519、3.489、2.203,P<0.001、P<0.001、P=0.002、P<0.001、P<0.001、P=0.028);b表示心功能Ⅰ级、Ⅱ级、Ⅲ~Ⅳ级慢性心力衰竭患者多组间的比较,差异有统计学意义(H=23.846、14.791、21.089、6.251、18.892、20.347、19.171、35.654,P<0.001、P=0.001、P<0.001、P=0.044、P<0.001、P<0.001、P<0.001、P<0.001)。LVEF为左心室射血分数;LVESV为左心室收缩末期容积;LVEDV为左心室舒张末期容积;PFR为高峰充盈率;EDV为舒张末期容积;PHB为相位直方图带宽;PSD为相位分布标准差;Hs-CRP为超敏C反应蛋白;NTpro-BNP为N末端B型利钠肽原 表 2 左心室机械同步与不同步慢性心力衰竭患者的单因素分析[
、M(Q1,Q3)、例(%)]$ \bar {x} \pm s$ Table 2. Univariate analysis of mechanical synchronous and asynchronous of the left ventricle chronic heart failure patients[
, M(Q1, Q3), case(%)]$ \bar {x} \pm s$ 项目 左心室机械同步(n=21) 左心室机械不同步(n=60) 检验值 P值 一般资料 性别(男/女) 12/9 44/16 χ2=1.911 0.167 年龄(岁) 63.4±14.7 53.6±15.3 t=2.550 0.013 BMI(kg/m2) 23.05(21.48,27.25) 24.52(22.27,27.26) Z=1.110 0.267 心率(次/分) 65(61,72) 73(66,82) Z=3.149 0.002 合并症发病率[例(%)] 高血压 15(71.4) 28(46.7) χ2=3.830 0.050 糖尿病 7(33.3) 17(28.3) χ2=0.187 0.666 高脂血症 8(38.1) 11(18.3) χ2=3.384 0.066 心律失常 4(19.0) 16(26.7) χ2=0.486 0.486 肺炎 0(0) 3(5.0) − 0.564 冠心病 14(66.7) 43(71.7) χ2=0.187 0.666 肺动脉高压 1(4.8) 9(15.0) χ2=0.709 0.400 心肌病 1(4.8) 9(15.0) χ2=0.709 0.400 GMPI指标 LVEF(%) 69.0(65.5,71.0) 42.0(23.8,54.0) χ2=6.146 <0.001 LVEDV(ml) 79.0(62.5,104.5) 149.5(115,210.8) χ2=5.335 <0.001 LVESV(ml) 26.0(18.5,34.0) 91.5(54.5,159.5) χ2=5.993 <0.001 SV(ml) 57.0±17.0 61.8±23.9 t=0.850 0.398 PFR(EDV/s) 3.61±0.73 2.60±0.14 t=4.042 <0.001 TPFR(ms) 218.56±59.26 189.93±86.61 t=1.402 0.100 SRS(分) 3.0(2.0,5.0) 13.0(6.3,19.8) Z=4.978 <0.001 实验室检查指标 Hs-CRP阳性例数[例(%)] 6(28.6) 36(60.0) χ2=6.154 0.013 NTpro-BNP(ng/L) 156(123.5,231.5) 806.5(319.8,2275.0) Z=4.381 <0.001 注:−表示检验方法为Fisher确切概率法,无检验值;BMI为体质指数;GMPI为门控心肌灌注显像;LVEF为左心室射血分数;LVEDV为左心室舒张末期容积;LVESV为左心室收缩末期容积;SV为博出量;PFR为高峰充盈率;EDV为舒张末期容积;TPFR为高峰充盈时间;SRS为静息总积分;Hs-CRP为超敏C反应蛋白;NTpro-BNP为N末端B型利钠肽原 -
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