基于平板运动试验指标建立冠心病诊断模型

目的利用平板运动试验（TET）指标建立冠心病（CHD）预测模型,提高CHD无创诊断的可靠性。方法以3个研究中心经冠脉造影（CAG）证实的CHD患者156例和非CHD者76例为研究对象,分析TET中相关指标的变化。结果 （1）CHD组最大心率（HRmax）、变时指数（CRI）低于非CHD组,而典型胸痛构成比、QRS时限、ST段压低和上抬高于非CHD组,差异有统计学意义（P〈0.05或P〈0.01）。（2）多因素Logistic回归分析显示：ST段压低（OR=6.885）,QRS时限（OR=1.090）,典型胸痛（OR=6.356）是预测CHD的独立指标,（P=0.000）。（3）CHD预测模型：Logit（P）=1.929ST段压低（mm）＋0.086QRS时限（ms）＋1.849典型胸痛-7.891。其预测CHD的受试者工作特征曲线（ROC）下面积是0.880（95%CI：0.833～0.928）,大于ST段压低〔0.751（95%CI：0.686～0.816）〕、QRS时限〔0.744（95%CI：0.677～0.811）〕和典型胸痛〔0.709（95%CI：0.639～0.779）〕3个独立指标的任何一个。预测模型、ST段压低、QRS时限和典型胸痛诊断CHD的敏感度分别是0.788、0.673、0.654和0.615,特异度分别是0.855、0.816、0.750和0.803。结论 TET中ST段压低、QRS时限延长和典型胸痛均可作为预测CHD的重要指标,以此3个指标构建的联合预测模型诊断CHD的可靠性优于单一指标。     

男性冠心病患者平板运动试验的意义

目的 探讨平板运动试验诊断男性冠心病的价值.方法 选择拟诊冠心病的男性患者224例,入选病例全部行冠状动脉造影检查,且造影前或造影后1个月行平板运动试验,对比观察以冠状动脉造影直径法确定的冠状动脉狭窄程度和范围与平板运动试验的结果.结果 在224例冠状动脉造影中,阳性171例,阴性53例.其中单支病变87例,双支病变55例,三支病变29例.在平板运动试验中,阳性143例,阴性81例;以冠状动脉造影结果为标准,平板运动试验诊断冠心病的灵敏度为81.3％,阳性预测值为97.2％.同时发现合并高血压或糖尿病患者比单纯冠状动脉病变患者在平板运动试验中ST段下降时间早、持续时间也长,多支病变在平板运动试验中出现ST段下降时间长于单支病变,出现的导联数也多于单支病变.结论 平板运动试验是诊断冠心病的重要手段,并可初步估测冠状动脉狭窄程度.     

Angina pectoris, provocable by exercise, and silent myocardial ischemia in the light of results of coronary angiography]

Correlation between coronary anatomy and the presence or absence of chest pain was studied during bicycle exercise testing in 101 patients. All of them had significant ST segment depression during the stress test. ECG changes were accompanied by chest pain in 66 patients (group A). 35 patients were free of symptoms (group B). Coronary arteriography showed significant stenosis of one or more coronary artery branch in 50 patients of group A, and in 24 patients of group B, the difference was not significant statistically. The presence or absence of chest pain weren't valuable markers in the differential diagnosis of true and false positive ST segment depression. Frequency of three-vessel disease was significantly higher in group A (14 cases), than in the other group (1 case). In conclusion, if a significant ST segment depression occurs during exercise stress either with or without anginal pain coronary arteriography is recommended to perform.     

平板运动试验和动态心电图联合检查对评估冠状动脉狭窄程度的预测价值

目的：为了明确活动平板运动试验和动态心电图联合检测对冠状动脉病变的预测价值。方法：选取冠状动脉造影阳性且造影前3个月内做平板运动试验和动态心电图的患者165例,冠状动脉造影用通用直径法确定冠状动脉狭窄程度,并与平板运动试验和动态心电图的结果进行对比观察。结果：平板运动试验中ST段下移出现越早,ST段下移程度越大,持续时间越长,冠状动脉狭窄程度越重。冠状动脉造影阳性而平板运动试验阴性者,多为单支病变或者病变程度较轻;平板运动试验的敏感性为71．8％,特异性为80．5％,动态心电图的敏感性为63．7％,特异性为78．1％。结论：活动平板运动试验和动态心电图联合检测可提高冠心病诊断的准确性。     

冠状动脉内心电图ST段改变对冠心病患者PCI相关心肌损伤判断价值

目的:研究冠状动脉内心电图ST段改变对冠心病患者PCI相关心肌损伤的判断价值。方法:纳入80例患者作为此次研究的对象,纳入时间段为2018年2月~2019年2月,所有患者均在本院确诊为冠心病并接受PCI治疗,在术前及术后分别测定患者cTnT(血清心肌钙)的水平,同时记录患者手术过程中心电图ST段的改变情况,术后,c TnT平均水平≥0.1ng/mL的患者判断为心肌损伤,纳为损伤组,而cTnT<0.1ng/mL的患者判断为无心肌损伤情况,纳为无损伤组。通过多因素回归分析判断ST段改变对冠心病患者PCI相关心肌损伤的影响情况。结果:患者术前的cTnT水平均正常,30例(37.5%)患者在术中表现为ST段改变阳性(有意义的ST段改变),50例(62.5%)患者表现为ST段改变阴性(无意义的ST段改变);术后,损伤组37例(46.25%),其中27例(72.91%)为ST段改变阳性,无损伤组43例(53.75%),其中3例(6.98%)为ST段改变阳性,组间差异显著(P<0.05);多因素回归分析结果显示,ST段改变阳性是心肌损伤的独立预测因素(P<0.05)。结论:冠心病PCI患者术中心电图ST段的改变对其相关心肌损伤有着准确、敏感的监测价值,可作为判断PCI患者心肌损伤的经济、有效的方法。     

Cost-effectiveness of screening strategies for left main coronary artery disease in patients with stable angina

To define optimal strategies for screening for left main coronary artery disease (LMCAD), the authors evaluated the cost-effectiveness of exercise tolerance testing and cardiac catheterization in patients with mild stable chest pain, such as patients with definite or probable angina in the Coronary Artery Surgery Study registry (prevalence of LMCAD = 9%). Performance characteristics of the exercise test, operative mortality, long-term survival rates, and rates of crossing over to surgical therapy for patients initially managed with medical therapy were derived from pooled literature data; cost estimates were based on local charge data. Strategies using the exercise test to identify candidates for catheterization were associated with longer life expectancies than either the conservative strategy in which patients would be observed or the more aggressive strategy in which all patients would undergo coronary angiography. The most cost-effective option was to screen patients with an exercise test and to perform catheterization in patients with greater than or equal to 2 mm of ST-segment change. Compared with a strategy of catheterization for greater than or equal to 3 mm of ST-segment change only, this strategy increased life expectancy at marginal costs per year of life saved ranging from $11,263 to $18,100 for 40- to 70-year-old patients, respectively, while, compared with a strategy of observation unless symptoms worsened, its incremental cost-effectiveness was $6,510 to $12,428 per year of life saved. Thus, screening patients with stable chest pain syndromes with exercise tests and performing catheterization for patients with greater than or equal to 2 mm of ST-segment change has cost-effectiveness comparable to that of the treatment of moderate diastolic hypertension.     

计算机化运动心电自动分析系统

本文介绍一种计算机化运动心电分析系统，该系统设计专用ＣＭ５、ＡＶＦ和Ｖ５导联组合，采用最新ＳＴ／ＨＲ、ＳＴ段压低和ＱＴｃ三参数综合判别和微机自动识别技术，完成了从运动前到运动后，特别是运动中的心电信号放大，采集、存储、分析、打印和修正的硬软件设计，为冠心病的检查与诊断提供了有效的手段。     

心电图对急性前壁心肌梗死罪犯血管病变部位的预测价值

目的探讨急性前壁心肌梗死时体表心电图改变与冠状动脉病变部位的关系。方法回顾性分析80例急性前壁心肌梗死患者心电图改变与冠状动脉造影结果。结果80例患者中,前降支(LAD)近端病变(PD)组40例,远端病变(DD)组40例,两组间结果比较:(1)III、II、aVF导联ST段压低在PD组为45.0%,DD组为22.5%(P<0.05),预测LAD近端病变的灵敏度为45.0%,特异度为77.5%;III、II、aVF导联ST段抬高在PD组为2.5%,DD组为15.0%(P<0.05),预测LAD远端病变的灵敏度为15.0%,特异度为97.5%。(2)I、aVL导联ST段抬高在PD组为40.0%,DD组为15.0%(P<0.05),预测LAD近端病变的灵敏度为40.0%,特异度为85.0%(。3)STI/aVL<1在PD组为32.5%,DD组为5.0%(P<0.01),预测LAD近端病变的灵敏度和特异度分别为32.5%和95.0%。(4)ST V2/V3>1在PD组为60.0%,DD组为27.5%(P<0.01),预测LAD近端病变的灵敏度为60.0%,特异度为72.5%。结论III、II、aVF导联ST段压低与罪犯血管外合并其他血管病变无关,为LAD近端病变的有意义的判断指标;I、aVL导联ST段抬高,III、II、aVF导联ST段压低,STI/aVL<1以及STV2/V3>1有利于诊断LAD近端病变,而III、II、aVF导联ST段抬高为LAD远端病变的特异度指标。     

Septal Q wave responses to exertion in the diagnosis of proximal stenosis of the anterior descending coronary artery

In 29 patients with coronary artery disease (CAD) involving the proximal segment of left anterior descending coronary artery (LAD) and in 25 patients with normal coronary anatomy (control group) Q wave amplitude changes were studied in response to exercise with bicycle and treadmill. Decrease of the Q wave amplitude was observed only in the patient group. Increase in amplitude was found only in the control group. The sensitivity of bicycle test for a significant ST segment depression was 51.7%. The same value, obtained by treadmill exercise was 50%. When either a significant ST depression or decrease of Q wave amplitude was evaluated as an abnormal response to exercise, the sensitivity was 62% (bicycle) and 65% (treadmill). Taking both ST segment depression and reduction of Q wave amplitude, an increased sensitivity of exercise ECG examination can ben attained.     

平板运动试验参数对冠状动脉病变的评价

目的：评价平板运动试验参数对冠状动脉病变判定的意义。方法：确诊的冠心病91例：根据冠状动脉脉造影结果分为单支病变组40例，双支病变组35例，三支病变组16例，对3组患者平板运动试验参数：平均运动时间，运动贮量和ST段压低最大值，ST段压低开始时间，ST段压低持续时间进行比较。结果：单支病变、双支病变和三支病变组平均运动时间、运动贮量、ST段压低最大值、ST段压低开始时间，ST段压低持续时间差异有显著性（P〈0．05）。结论：平板运动试验参数可作为评估冠状动脉病变的指标。     

False positive stress tests due to undetected left ventricular hypertrophy

Without large vessel coronary artery disease, clinically evident left ventricular hypertrophy (LVH) is an identified cause of ischemic ST segment changes during exercise. The contribution of subclinical LVH to false positive exercise stress test was evaluated from data of 31 patients without electrocardiographic evidence of LVH who underwent concurrent exercise stress testing, M-mode echocardiography and coronary arteriography at Temple University Hospital, Philadelphia, PA, between January, 1976, and December, 1979, and who met echocardiographic criteria for LVH. Using Bayes theorem, the authors found the probability was 0.59 that a patient with electrocardiogram-undetected LVH does not have significant coronary disease with a positive stress test. The probability of normal coronary arteries with a positive stress test in patients without LVH on echocardiogram was 0.24. Inapparent LVH detected by echocardiography increases the likelihood that a patient with a positive stress test does not have coronary disease. Thus, the positive exercise electrocardiogram should be cautiously interpreted in apparently normal patients who have LVH detectable only by echocardiography.     

The study of a case of single coronary artery using stress 201thalium single photon emission computed tomogram

A 48-year-old female, who had been having episodes of chest discomfort and oppression lasting for several minutes for 15 years was diagnosed as having a single left coronary artery by coronary angiography. The electrocardiogram taken during a chest pain attack demonstrated the depression of the ST-segment in leads II, III, aVF, and V4-6. The chest pain was relieved, and the ischemic change in ECG was improved by sublingual nitroglycerine. 201Thalium single photon emission computed tomography under stress indicated poor uptake in both the anterior and infero-posterior myocardium, which was compatible with the change in ECG either during the attack or during exercise. The anterior myocardial ischemia was reduced by propranolol and the chest pain was successfully relieved by propranolol. The chest pain in this case might have partly been due to the myocardial ischemia in the anterior and infero-posterior myocardium, under stress, which could have been the steal phenomenon to lateral myocardium due to the anatomical anomaly, besides other possible mechanisms for chest pain proposed in the case of single coronary artery. Our findings suggested that 201Thalium stress single photon emission computed tomography is a useful method for detecting the myocardial ischemia in patients with single coronary artery and those suffering from chest pain without any coronary stenosis.     

Coronary arteriovenous fistula with vasospastic angina

A 50-year-old man was admitted to our hospital because of chest pain. Twenty-four-hour ECG recording demonstrated ST-segment depression and elevation at the time of spontaneous angina. During treadmill exercise test, the patient developed chest pain with ST-segment depression in leads V4 to V6. After the administration of nifedipine (10 mg), the patient was able to reach up to the maximum predicted heart rate without anginal symptoms and ST-T changes. Coronary arteriogram demonstrated 50% stenosis at the proximal portion of the left anterior descending artery (LAD) and two small fistulas originated from LAD to pulmonary artery. Spasm was induced at the proximal portion of LAD by the hyperventilation. If patients with coronary arteriovenous fistula (CAVF) have symptoms, elective CAVF ligation has been recommended. However, this case suggests that coronary spasm could be one of the cause of angina pectoris in patients with CAVF. Elective CAVF ligation must be carefully indicated in CAVF patients with angina pectoris.     

Angiographic characteristics of coronary artery disease in diabetic patients compared with matched non-diabetic subjects

The aim of this study was to assess the extent and the severity of coronary artery disease (CAD) in diabetic patients. Angiographic findings were retrospectively analysed in 50 diabetic and in 50 non-diabetic patients, matched for age and sex, undergoing coronary angiography for evaluation of clinically CAD or silent ischaemia. Baseline characteristics did not show any increase of cardiovascular risk in diabetics compared to the non-diabetic group. Diabetic patients present less chest pain and more electric abnormalities, reflecting CAD specificity for diabetic patients. Angiograms of the coronary tree were divided into 13 segments and two experienced angiographers have developed a methodic analysis of selected coronary segment stenosis. The number of significant coronary artery stenosis (> or = 50%) per patient was higher in diabetic than in non-diabetic subjects (5.06+/-2.16 vs 2.40+/-1.97, p < 0.05). Diabetics had also more left main CAD (7/50 vs 1/50,p < 0.05). Though we did not find at any time statistical difference for multivessel, distal or diffuse CAD between the two groups, nevertheless there are more diffuse and distal lesions of the diabetic coronary artery trees. This debate is not closed, there is always controversy concerning whether the angiographic findings in diabetic or non-diabetic patients are different. But these results corroborate the hypothesis of a greater severity of angiographic proven CAD in diabetic than in non-diabetic patients, especially in the left main coronary artery.     

Docosahexaenoic acid-rich fish oil improves heart rate variability and heart rate responses to exercise in overweight adults

Dietary fish oil supplementation and regular physical activity can improve outcomes in patients with established CVD. Exercise has been shown to improve heart rate variability (HRV), a predictor of cardiac death, but whether fish oil benefits HRV is controversial. Obese adults at risk of future coronary disease have impaired HRV and may benefit from these interventions. We evaluated the effect of DHA-rich tuna fish oil supplementation with and without regular exercise on HRV in sedentary, overweight adults with risk factors for coronary disease. In a randomised, double-blind, parallel comparison, sixty-five volunteers consumed 6 g fish oil/d (DHA 1.56 g/d, EPA 0.36 g/d) or sunflower-seed oil (placebo) for 12 weeks. Half of each oil group also undertook regular moderate physical activity (3 d/week for 45 min, at 75 % of age-predicted maximal heart rate (HR)). Resting HR and the HR response to submaximal exercise were measured at weeks 0, 6 and 12. In forty-six subjects, HRV was also assessed by power spectrum analysis of 20 min electrocardiogram recordings taken supine at baseline and 12 weeks. Fish oil supplementation improved HRV by increasing high-frequency power, representing parasympathetic activity, compared with placebo (P = 0.01; oil x time interaction). It also reduced HR at rest and during submaximal exercise (P = 0.008; oil x time interaction). There were no significant fish oil x exercise interactions. Dietary supplementation with DHA-rich fish oil reduced HR and modulated HRV in keeping with an improved parasympathetic-sympathetic balance in overweight adults with risk factors for future coronary disease.     

Application of Holter electrocardiography to exercise testing for the group examination of school children: comparison between obese and normal children

Application of Holter electrocardiography to an exercise test for heart function is useful in the group examination of school children. The circulatory responses to a step test among obese boys and girls and control were as follows: 1. Four cases of arrhythmia were detected, of whom 2 cases were discovered during exercise. ST-segment depression of 0.1 mV or more during and after exercise was recognized in 29 cases, 27 of the junctional- and 2 of the sagging slope, with a higher percentage in obese girls than in normal girls. 2. Serial ECG records during the procedure, performed for all children with the same single-step test, showed differences in the circulatory responses among the test groups. The load was estimated to be 76-86% of the maximal heart rate predicted by Cummings, with obese and girl groups being higher than other groups. The comparison revealed that the heart rate (HR) responses to exercise done by the boys increased faster than those by the girls at 1 minute after exercise. There were differences between obese and control and between boys and girls in HR at recovery, and also in HR before and 4 minutes after exercise between two sexes, which findings agree with other reports. 3. Concerning anthropometric factors, either the skinfold thickness or the obesity index was related to the HR at the peak of the exercise as well as immediately after it and to the half time. By contrast, the arm muscle diameter was found unrelated to the HR. Using this method, applied these combination of Holter ECG and step test to a group examination, we got ECG data for 254 subjects, 97.5% of which were suitable for analysis. We found this method to be effective for detecting ECG changes and for determining HR responses to exercise. This method is safe, simple, and inexpensive and is applicable to examination not only for school children but also for different population groups, for the estimation of circulatory responses.     

Management of Patients After Myocardial Infarction

Patients with recurrent angina after acute MI should undergo immediate catheterization and coronary arteriography, with a view to early surgery. Left main coronary disease, which can be detected with an exercise stress test, is the only other definite indication for bypass surgery. Most asymptomatic patients who do not have left main stenosis are appropriately managed medically.     

左室射血分数及冠心病常见危险因素与冠脉病变严重程度的相关性研究

目的探讨左室射血分数及冠心病常见危险因素与冠脉病变严重程度的相关性。方法对2008年12月至2009年4月于本院行选择性冠状动脉造影术的305例患者进行临床资料的采集及冠脉造影结果的分析,冠脉病变的严重程度采用Gensini积分系统,根据冠脉造影的结果先将研究对象分为冠心病组（251例）和非冠心病组（54例）进行临床资料的比较,再采用多元线性回归（nmltiplelinearregression）分析冠脉病变严重程度与冠心病常见危险因素之间的相关性并采用直线相关（1inearcorrelation）分析冠脉病变严重程度与左室射血分数的相关性。结果冠心病组和非冠心病组相比在年龄、性别、吸烟指数、高血压患病率、血糖异常及糖尿病患病率、代谢综合征患病率差异有统计学意义（P〈0．05）。在多元线性回归中年龄（β1=0．251,P〈0．01）、性别（β2=0．235,P〈0．01）、低密度脂蛋白胆固醇（LDL—C）（β3=0．241,P〈0．01）、糖尿病病程（β4=0．226,P〈0．01）进入直线回归方程,在冠脉病变严重程度与左室射血分数直线相关的研究中发现两者呈负相关（r=-0．362,P〈0．01）。结论在对临床上高度怀疑患冠心病的患者进行冠脉造影前需充分考虑患者的年龄、性别、吸烟指数、是否患高血压、是否伴有血糖异常、是否患有代谢综合征等以提高冠脉造影的阳性率,年龄、性别、LDL—C、糖尿病病程是影响冠脉病变严重程度的独立危险因素,冠心病患者随着冠脉狭窄程度的加重,左室射血功能呈减退趋势。     

Ergometry-induced silent ischemia--clinical and angiographic features

This study was planned to clarify the clinical and angiographic attributes of patients with exercise induced silent myocardial ischaemia. The study sample consisted of 102 patients who had ischaemic exercise electrograms (greater than = 1 mm ST segment depression) and significant angiographic stenosis (greater than = 50% diameter stenosis), in at least one of the major coronary arteries. In 61 patients (60%) painful ischaemia was observed during exercise (group A) while in 41 patients (40%) only SD depression (silent ischaemia) occurred (group B). The groups were similar with respect to age, sex, history of diabetes and all angiographic parameters including the Gensini coronary score. A history of prior myocardial infarctions was observed more frequently (p less than 0.01) in patients with silent ischaemia (group B). Prior myocardial infarction may be a factor causing silent myocardial ischaemia.