亚洲免费av电影一区二区三区,日韩爱爱视频,51精品视频一区二区三区,91视频爱爱,日韩欧美在线播放视频,中文字幕少妇AV,亚洲电影中文字幕,久久久久亚洲av成人网址,久久综合视频网站,国产在线不卡免费播放

        ?

        峰值氧耗量和無氧代謝閾值對慢性心力衰竭患者預(yù)后的預(yù)測價值

        2015-04-21 08:14:50沈玉芹王樂民徐文俊宋浩明馬文林嚴(yán)文文蔣金法李廣鶴張啟萍
        中華老年多器官疾病雜志 2015年3期
        關(guān)鍵詞:心血管病心肌病心血管

        沈玉芹,倪 奕,王樂民,徐文俊,宋浩明,龔 朱,馬文林,車 琳,嚴(yán)文文,蔣金法,李廣鶴,張啟萍

        ?

        峰值氧耗量和無氧代謝閾值對慢性心力衰竭患者預(yù)后的預(yù)測價值

        沈玉芹,倪 奕,王樂民*,徐文俊,宋浩明,龔 朱,馬文林,車 琳,嚴(yán)文文,蔣金法,李廣鶴,張啟萍

        (同濟(jì)大學(xué)附屬同濟(jì)醫(yī)院心內(nèi)科,上海 200065)

        通過心肺運(yùn)動試驗(yàn)(CPET)檢測慢性心力衰竭(CHF)患者峰值氧耗量(peak VO2)和無氧代謝閾值氧耗量(VO2AT),并隨訪其預(yù)后價值。選擇入住同濟(jì)大學(xué)附屬同濟(jì)醫(yī)院心內(nèi)科并經(jīng)心臟超聲確定左室射血分?jǐn)?shù)(LVEF)<0.49的CHF患者129例(經(jīng)冠狀動脈造影確診的缺血性心肌病74例,擴(kuò)張型心肌病55例)。對入選患者實(shí)施CPET,并對患者隨訪心血管死亡原因(時間中位數(shù)為33.7個月)。(1)19例CHF患者因心血管原因死亡,死亡患者和非死亡患者在年齡、性別、BMI、峰值吸呼比(peak RER)差異無統(tǒng)計學(xué)意義的情況下(>0.05),死亡患者較非死亡患者左室射血分?jǐn)?shù)(LVEF)減低[(0.33±0.09)(0.38±0.09),<0.05];左心室質(zhì)量指數(shù)(LVMI)增高[(158.3±53.9)(133.2±40.1),<0.05];peak VO2減低[(11.8±4.3)(14.4±3.7)ml/(kg·min),<0.05];VO2AT減低[(9.3±3.2)(10.7±2.1)ml/(kg·min),<0.05]。(2)peak VO2的ROC曲線下面積(AUC)為0.640(<0.05),靈敏度為0.590,特異度為0.667,最佳閾值為peak VO2≤13.4ml/(kg·min);VO2AT的AUC為0.600(>0.05),靈敏度為0.886,特異度為0.360,最佳閾值為VO2AT≤8.2ml/(kg·min)。peak VO2及VO2AT對CHF患者心血管原因死亡具有一定的預(yù)測價值,peak VO2的預(yù)測價值優(yōu)于VO2AT。

        心力衰竭;心肺運(yùn)動試驗(yàn);峰值氧耗量;無氧代謝閾值氧耗量

        峰值氧耗量(peak oxygen consumption,peak VO2)是指受試者不能維持功率繼續(xù)增加而達(dá)到最大運(yùn)動狀態(tài),此時的攝氧量稱為peak VO2。無氧代謝閾值(anaerobic threshold,AT)是指當(dāng)運(yùn)動負(fù)荷增加到一定量后,組織對氧的需求超過了循環(huán)所能提供的供氧量,因而組織必須通過無氧代謝以提供能量,有氧代謝到無氧代謝的臨界點(diǎn)稱之為AT,通常以無氧代謝閾值氧耗量(oxygen uptake at anaerobic threshold,VO2AT)表示。VO2AT正常值應(yīng)大于peak VO2的40%以上,一般是50%~60% peak VO2,VO2AT所代表的是亞極量的運(yùn)動負(fù)荷。目前國際上采用VO2AT與peak VO2對慢性心力衰竭(chronic heart failure,CHF)進(jìn)行心功能定量分級[1,2],有助于判斷心力衰竭患者的嚴(yán)重程度。對于CHF患者預(yù)后的判斷,目前國際上peak VO2結(jié)合二氧化碳通氣當(dāng)量斜率報道較多,但是peak VO2結(jié)合VO2AT對我國CHF患者心血管原因死亡的預(yù)測價值尚未見報道。本研究通過心肺運(yùn)動試驗(yàn)(cardiopulmonary exercise testing,CPET)對CHF患者peak VO2和VO2AT進(jìn)行檢測并隨訪其對心血管原因死亡的預(yù)測作用,以探討peak VO2和VO2AT在我國CHF患者心血管原因死亡預(yù)測價值。

        1 對象與方法

        1.1 對象

        納入2007年8月至2013年6月期間同濟(jì)大學(xué)附屬同濟(jì)醫(yī)院心內(nèi)科住院和門診就診的CHF患者129例,缺血性心肌病患者74例(經(jīng)冠狀動脈造影確診),擴(kuò)張型心肌病患者55例,男113例(87.6%),女16例,年齡(59.1±11.4)歲,NYHAⅠ~Ⅲ級(NYHA Ⅰ級5例,NYHA Ⅱ級68例,NYHA Ⅲ級56例);左室射血分?jǐn)?shù)(left ventricular ejection fraction,LVEF)為(0.38±0.09);體質(zhì)量指數(shù)(body mass index,BMI)為(24.7±3.7)kg/m2,患者一般情況詳見表1。

        診斷標(biāo)準(zhǔn)參照2007年中國心肌病診斷與治療建議工作組頒布的心肌病診斷和治療建議[3]。根據(jù)AHA規(guī)定的運(yùn)動試驗(yàn)禁忌證標(biāo)準(zhǔn)進(jìn)行排除后納入[4],無慢性阻塞性肺病、肌肉骨骼病變、神經(jīng)系統(tǒng)疾病、血液系統(tǒng)疾病,無肝腎功能不全、電解質(zhì)紊亂、甲狀腺功能亢進(jìn)或減退、急性感染等。CHF患者各類藥品使用率β受體阻滯劑89.0%、血管緊張素轉(zhuǎn)換酶抑制劑(angiotensin converting enzyme inhibitor,ACEI)或血管緊張素受體拮抗劑(angiotensin receptor blocker,ARB)91.0%、地高辛43.0%、利尿劑51.0%、硝酸酯類45.0%。在CPET前1天停用β受體阻滯劑、利尿劑、地高辛及ACEI或ARB、硝酸酯類藥物,CPET完成后即恢復(fù)此類藥物繼續(xù)應(yīng)用。所有入選者均征得同意并簽署知情同意書。該研究通過醫(yī)院藥物臨床試驗(yàn)倫理委員會審批,中國臨床試驗(yàn)注冊中心注冊號:ChicTR-TRC-00000235。

        表1 CHF患者一般資料

        CHF : chronic heart failure; BP: blood pressure;LVMI: left ventricular mass index; ACEI: angiotensin converting enzyme inhibitor; ARB: angiotensin receptor blocker; peak VO2: peak oxygen consumption; VO2AT: oxygen consumption at anaerobic threshold; peak RER: peakrespiratory exchange ratio

        1.2 心功能檢測

        采用Vivid 7彩色多普勒超聲診斷儀(GE公司),用改良的Simpson雙平面法計算LVEF。

        1.3 心肺運(yùn)動試驗(yàn)

        包括3部分:心電圖負(fù)荷試驗(yàn)、血流動力學(xué)負(fù)荷試驗(yàn)和運(yùn)動氣體代謝分析。采用的儀器包括氣體再呼吸系統(tǒng)(Innovision公司,丹麥)、運(yùn)動測試系統(tǒng)CASE P2系列和Variobike 500的電力自行車(通用公司,美國)。(1)心電圖負(fù)荷試驗(yàn)。最低運(yùn)動負(fù)荷為20J/s,采用的運(yùn)動方案是修訂的Ramp10方案,即踏車上休息3min,無負(fù)荷狀態(tài)下踏車3min,然后從20J/s開始,踏車2min后每30s增加5J/s(恢復(fù)為Ramp10方案),直至患者出現(xiàn)運(yùn)動峰值或運(yùn)動終點(diǎn),踏車時保持均勻轉(zhuǎn)速60~70轉(zhuǎn)/min。運(yùn)動過程中監(jiān)測患者的心電圖、血壓以及全身反應(yīng),出現(xiàn)下列任一種情況時終止運(yùn)動:心率達(dá)到85%最大心率預(yù)計值,收縮壓>220mmHg,或出現(xiàn)嚴(yán)重的心律失常,ST壓低≥0.2mV或上抬≥0.2mV,患者出現(xiàn)胸痛、胸悶、氣短、心悸等癥狀,或者患者感到疲勞要求終止運(yùn)動。(2)血流動力學(xué)負(fù)荷試驗(yàn)。在開始的1min(靜息時)、9min(踏車運(yùn)動負(fù)荷為30J/s時)、12min(踏車運(yùn)動負(fù)荷為60J/s時)、15min(踏車運(yùn)動負(fù)荷為90J/s時)等進(jìn)行測定,以此類推,即每隔30J/s測定運(yùn)動時的心輸出量(cardiac output,CO)。(3)運(yùn)動氣體代謝分析?;颊咴囼?yàn)開始后的每一次呼出的氣體均被氣體再呼吸系統(tǒng)連續(xù)監(jiān)測。呼吸參數(shù)包括氧耗量(oxygen consumption,VO2)、二氧化碳生成量(CO2production,VCO2)、每分鐘通氣量(minute ventilation volume,VE)。AT由V斜率(slope)方法判定[5],CPET中連續(xù)監(jiān)測心電圖。每3min監(jiān)測血壓及Borg自感勞累評分。

        1.4 隨訪及隨訪初級終點(diǎn)

        隨訪時間中位數(shù)為33.7個月,最長達(dá)6年,隨訪初級終點(diǎn)為心血管死亡原因(依據(jù)病歷資料醫(yī)院出院診斷確定,最常見原因?yàn)樾呐K驟停、心肌梗死、終末期心力衰竭)。

        1.5 統(tǒng)計學(xué)處理

        2 結(jié) 果

        2.1 死亡與非死亡CHF患者一般情況比較

        在隨訪中,19例CHF患者因心血管原因死亡,死亡患者和非死亡患者年齡、性別、BMI、峰值吸呼比(peak respiratory exchange ratio,peak RER)差異無統(tǒng)計學(xué)意義(>0.05),死亡患者較非死亡患者LVEF低、左室質(zhì)量指數(shù)(left ventricular mass index,LVMI)高、peak VO2低、VO2AT低,差異均有統(tǒng)計學(xué)意義(<0.05;表2)。

        2.2 ROC AUC分析及單變量Cox回歸分析

        Peak VO2、VO2AT預(yù)測CHF患者心血管原因死亡ROC AUC分別為0.64和0.60,值分別為0.045和0.065,敏感度分別為0.590和0.886,特異度分別為0.667和0.360,最佳閾值分別為≤13.4ml/(kg·min)和≤8.2ml/(kg·min),值分別為0.02和0.04。peak VO2對CHF患者心血管原因死亡具有預(yù)測作用,優(yōu)于VO2AT(表3,圖1,圖2)。

        表2 死亡與非死亡CHF患者一般情況比較

        BMI: body mass index; LVMI: left ventricular mass index; LVEF: left ventricular ejection fraction; NYHA: New York Heart Association (Function Assessment); ACEI: angiotensin converting enzyme inhibitor; ARB: angiotensin receptor blocker; peak VO2: peak oxygen consumption; VO2AT: oxygen consumption at anaerobic threshold; peak RER: peakrespiratory exchange ratio

        3 討 論

        心力衰竭是由于任何心臟結(jié)構(gòu)和(或)功能性異常導(dǎo)致心室充盈或射血能力受損的一組復(fù)雜臨床綜合征,其主要臨床表現(xiàn)為呼吸困難、乏力(運(yùn)動耐量受限)和液體潴留。心力衰竭是各種心臟疾病的嚴(yán)重和終末階段,發(fā)病率高,是當(dāng)今最重要的心血管病之一[6]。在原有慢性心臟疾病基礎(chǔ)上逐漸出現(xiàn)心力衰竭癥狀、體征的為CHF[6]。peak VO2不僅是CHF患者運(yùn)動耐量評估的最常用指標(biāo),而且是死亡的獨(dú)立危險因素[7?10]。由于peak VO2檢測結(jié)果易受主觀因素影響,患者經(jīng)常未真正達(dá)到運(yùn)動終點(diǎn),而VO2AT不受主觀因素影響,因此結(jié)果較客觀。結(jié)合peak VO2和VO2AT評判CHF患者運(yùn)動耐量更科學(xué)[11]。

        目前以peak VO2及VO2AT對我國CHF患者心血管原因死亡的預(yù)測國內(nèi)未見報道。本研究對129例CHF患者進(jìn)行隨訪,隨訪時間中位數(shù)為33.7個月,最長達(dá)6年,19例因心血管原因死亡,死亡患者與存活患者在年齡、性別、BMI及抗心力衰竭治療藥物基礎(chǔ)差異上均無統(tǒng)計學(xué)意義的情況下(>0.05),死亡患者較存活患者peak VO2及VO2AT均低,差異有統(tǒng)計學(xué)意義(<0.05)。經(jīng)ROC曲線下面積分析及單變量Cox回歸分析,peak VO2和VO2AT預(yù)測CHF患者心血管原因死亡ROC曲線下面積分別為0.64和0.60(值分別為0.045和0.065),敏感度分別為0.590和0.886,特異度分別為0.667、0.360,最佳閾值分別為≤13.4和≤8.2ml/(kg·min),值分別為0.02和0.04。表明peak VO2及VO2AT對我國CHF患者心血管原因死亡具有一定的預(yù)測價值,根據(jù)ROC AUC、特異度及靈敏度綜合判斷,peak VO2預(yù)測價值優(yōu)于VO2AT。至于peak VO2對心血管相關(guān)事件預(yù)測的最佳閾值,同在peak RER在1.0~1.1情況下,與Chase等[12]研究相似。但是與日本Nakanishi等[13]研究不同[peak VO2≤16.0ml/(kg·min)可預(yù)測CHF患者的全因死亡]。其主要原因可能是隨訪的終點(diǎn)不一致,本研究peak RER為1.05±0.2,而他們報道peak RER>1.2。據(jù)報道,peak RER不同,peak VO2對CHF患者同一隨訪終點(diǎn)的預(yù)測最佳閾值不同[13]。目前VO2AT對CHF患者預(yù)后的預(yù)測價值報道很少,亦未見VO2AT對CHF預(yù)后預(yù)測的最佳閾值報道。不足點(diǎn):單中心小樣本研究;終點(diǎn)事件偏少,隨訪時間中位數(shù)為33.7個月,病死率14.7%,與納入患者病情偏輕有關(guān);隨訪終點(diǎn)單一。peak VO2及VO2AT對我國CHF患者心血管原因死亡具有一定的預(yù)測價值,peak VO2對我國CHF患者心血管原因死亡的預(yù)測價值優(yōu)于VO2AT。

        圖1 peak VO2 ROC曲線下面積

        Figure 1 ROC analysis of peak VO2

        peak VO2: peak oxygen consumption; VO2AT: oxygen consumption at anaerobic threshold; ROC: receiver operator characteristic

        圖2 VO2AT ROC曲線下面積

        Figure 2 ROC analysis of VO2AT

        peak VO2: peak oxygen consumption; VO2AT: oxygen consumption at anaerobic threshold; ROC: receiver operator characteristic

        表3 ROC曲線下面積及單變量Cox回歸分析peak VO2和VO2AT對心血管原因死亡預(yù)測價值

        ROC: receiver operator characteristic; peak VO2: peak oxygen consumption; VO2AT: oxygen consumption at anaerobic threshold; HR: hazard ratio

        [1] Weber KT, Kinasewitz GT, Janicki JS,. Oxygen utilization and ventilation during exercise in patients with chronic cardiac failure[J]. Circulation, 1982, 65(6): l2l3?1223.

        [2] Janicki JS, Weber KT, McElroy PA. Use of the cardiopulmonary exercise test to evaluate the patient with chronic heart failure[J]. Eur Heart J, 1988, 9(Suppl H): 55?58.

        [3] Chinese Society of Cardiology, Chinese Medical Association, Editorial Board of Chinese Journal of Cardiology, Consensus on the Diagnosis and Treatment of Cardiomyopathies from Chinese Expert Panel. Recommendations on diagnosis and treatment of cardiomyopathies[J]. Chin J Cardiol, 2007, 35(1): 5?16. [中華醫(yī)學(xué)會心血管病學(xué)分會, 《中華心血管病雜志》編輯委員會, 中國心肌病診斷與治療建議工作組. 心肌病診斷與治療建議[J]. 中華心血管病雜志, 2007, 35(1): 5?16.]

        [4] Fletcher GF, Ades PA, Kligfield P,. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association[J]. Circulation, 2013, 128(8): 873?934.

        [5] Beaver WL, Wasserman K, Whipp BJ. A new method for detecting anaerobic threshold by gas exchange[J]. J Appl Physiol, 1986, 60(6): 2020?2027.

        [6] Chinese Society of Cardiology, Chinese Medical Association, Editorial Board of Chinese Journal of Cardiology. Chinese Guideline for Diagnosis and Treatment of Heart Failure in 2014[J]. Chin J Cardiol, 2014, 40(2): 98?122. [中華醫(yī)學(xué)會心血管病學(xué)分會, 《中華心血管病雜志》編輯委員會. 中國心力衰竭診斷和治療指南2014[J]. 中華心血管病雜志, 2014, 40(2): 98?122.]

        [7] Corrà U, Giordano A, Mezzani A,. Prognostic significance of peak oxygen consumption ≤10ml/kg/min in heart failure: contextcriteria[J]. Int J Cardiol, 2013, 168(4): 3419?3423.

        [8] Arena R, Guazzi M, Myers J,. The prognostic utility of cardiopulmonary exercise testing stands the test of time in patients with heart failure[J]. J Cardiopulm Rehabil Prev, 2012, 32(4): 198?202.

        [9] O’Neill JO, Young JB, Pothier CE,. Peak oxygen consumption as a predictor of death in patients with heart failure receiving beta-blockers[J]. Circulation, 2005, 111(18): 2313?2318.

        [10] Mancini DM, Eisen H, Kussmaul W,. Value of peak exercise oxygen consumption for optimal timing of cardiac transplantation in ambulatory patients with heart failure[J]. Circulation, 1991, 83(3): 778?786.

        [11] Shen YQ, Jiang JF, Wang LM,. Effects of aerobic exercise on exercise tolerance in patients with chronic heart failure[J]. Natl Med J China, 2011, 91(38): 2678?2682. [沈玉芹, 蔣金法, 王樂民, 等. 有氧運(yùn)動康復(fù)對慢性心力衰竭患者運(yùn)動耐力的影響[J]. 中華醫(yī)學(xué)雜志, 2011, 91(38): 2678?2682.]

        [12] Chase PJ, Kenjale A, Cahalin LP,. Effects of respiratory exchange ratio on the prognostic value of peak oxygen consumption and ventilatory efficiency in patients with systolic heart failure[J]. JACC Heart Fail, 2013, 1(5): 427?432.

        [13] Nakanishi M, Takaki H, Kumasaka R,. Targeting of high peak respiratory exchange ratio is safe and enhances the prognostic power of peak oxygen uptake for heart failure patients[J]. Circ J, 2014, 78(9): 2268?2275.

        (編輯: 劉子琪)

        Prognostic value of peak VO2and anaerobic threshold for chronic heart failure patients

        SHEN Yu-Qin, NI Yi, WANG Le-Min*, XU Wen-Jun, SONG Hao-Ming, GONG Zhu, MA Wen-Lin, CHE Lin, YAN Wen-Wen, JIANG Jin-Fa, LI Guang-He, Zhang Qi-Ping

        (Department of Cardiology, Tongji Hospital Affiliated to Tongji University, Shanghai 200065, China)

        To measure the peak oxygen consumption (peak VO2) and oxygen uptake at anaerobic threshold (VO2AT) by cardiopulmonary exercise testing (CPET) in patients with chronic heart failure (CHF) and evaluate the prognostic values of the 2 indices.Totally 129 patients suffering from CHF with left ventricular ejection fraction (LVEF)<0.49 by echocardiography admitted in our department were recruited in this study. Coronary angiography indicated that there were 74 cases of ischemic cardiomyopathy and 55 cases of dilated cardiomyopathy. All subjects underwent CPET on the bicycle ergometer and were followed up for cardiac-related mortality in duration of median 33.7 months.(1) During the follow-up, 19 cardiac deaths were identified. There was no differences in the age, sex, body mass index (BMI) and peak respiratory exchange ratio (peak RER) between those dead patients and the survivors (>0.05). But LVEF (0.33±0.090.38±0.09), peak VO2[11.8±4.314.4±3.7ml/(kg·min)] and VO2AT [9.3±3.210.7±2.1ml/(kg·min)] were obviousty lower, while left ventricular mass index (LVMI, 158.3±53.9133.2±40.1) was significantly higher in the dead ones than in the survivors (all<0.05). (2) By receiver operating characteristic (ROC) curve analysis, the area under curve (AUC) of peak VO2was 0.640 in predicting cardiac-related mortality in CHF patients (<0.05), the sensitivity was 0.590, the specificity was 0.667, and the optimal threshold value of peak VO2was ≤13.4ml/(kg·min). The AUC of VO2AT was 0.600 (<0.05), the sensitivity was 0.886, the specificity was 0.360, and the optimal threshold value of VO2AT was ≤8.2ml/(kg·min).Peak VO2and VO2AT have certain predictive values for cardiac-related mortality in CHF patients, and the former is superior to the latter.

        heart failure; cardiopulmonary exercise test; peak VO2; anaerobic threshold

        R541.6

        A

        10.11915/j.issn.1671-5403.2015.03.041

        (SHDC12010117)(WSJ1324).

        2014?12?17;

        2015?01?18

        上海市市級醫(yī)院新興前沿技術(shù)聯(lián)合攻關(guān)項(xiàng)目(SHDC12010117);上海衛(wèi)生與計劃生育委員會項(xiàng)目(WSJ1324)

        王樂民, E-mail: wanglemin2003@163.com

        猜你喜歡
        心血管病心肌病心血管
        《心血管病防治知識》征稿啟事
        《心血管病防治知識》征稿啟事
        《心血管病防治知識》征稿啟事
        COVID-19心血管并發(fā)癥的研究進(jìn)展
        《心血管病防治知識》征稿啟事
        伴有心肌MRI延遲強(qiáng)化的應(yīng)激性心肌病1例
        擴(kuò)張型心肌病中醫(yī)辨治體會
        lncRNA與心血管疾病
        胱抑素C與心血管疾病的相關(guān)性
        TAKO-TSUBO心肌病研究進(jìn)展
        www.91久久| 人妻 色综合网站| 久久久久久久久888| 色狠狠一区二区三区香蕉蜜桃| 精品在线视频免费在线观看视频| 91久久国产香蕉视频| 国产丶欧美丶日本不卡视频| 日本丶国产丶欧美色综合| 18禁国产美女白浆在线| 手机免费高清在线观看av| 无码人妻精品一区二区三区9厂 | 国产无套内射久久久国产| 国产日韩欧美网站| 久久精品网站免费观看| 一二三区无线乱码中文在线| 小荡货奶真大水真多紧视频| 91久久久久无码精品露脸| 99国语激情对白在线观看 | 波多野结衣的av一区二区三区 | 夜夜添夜夜添夜夜摸夜夜摸 | 日韩国产精品一本一区馆/在线 | 欧美1区二区三区公司| 91色综合久久熟女系列| 国产成人无码av| 乱子真实露脸刺激对白| 国产不卡在线免费视频| 国产亚洲av成人噜噜噜他| 日日婷婷夜日日天干| 亚洲阿v天堂网2021| 少妇高潮精品正在线播放| 久久精品国产99国产精偷| 久久久无码一区二区三区| 亚洲成人av一区二区麻豆蜜桃| 日本一区二区三区人妻| 人人妻人人妻人人片av| 精品亚洲女同一区二区| 狼狼色丁香久久女婷婷综合| 国模雨珍浓密毛大尺度150p| 国产在线手机视频| 美女被搞在线观看一区二区三区| 人人超碰人人爱超碰国产|