心肺功能测定与冠心病的诊断和预后评价王宁夫.ppt

心肺功能测定与冠心病的诊断和预后评价,南京医科大学附属杭州医院心内科 王宁夫,Cardiopulmonary Exercise Test And CAD,心肺运动试验与心电图运动试验对比,European Heart Journal 2003 Volume 24, Number 14,P0.0001,P0.0001,0,10,20,30,40,50,60,70,80,90,特异性%,敏感性%,心肺运动试验,心电图运动试验,Detection of exercise induced ischaemia:a new role for CEPT,The prognostic and diagnostic value of the exercise test is maximized, when multiple exercise findings are considered and it seems, that respiratory gas analysis offers new perspectives in this sense. Cardiologists should realise that with CPET we have an enormously powerful tool to our disposal. European Heart Journal 2003 Volume 24, Number 14,Editorial The predictive value of cardiorespiratory fitness Franz X. Kleber* Charit Medical School, Ukb Academic Teaching Hospital, Berlin, Germany, EHJ 2004 25: 1428-1437. Abstract Full Text,Furthermore, peak oxygen consumption is a more accurate and reproducible measure and has been shown to be an excellent predictor of outcome in various diseases. Recently, large scale investigations of exercise capacity derived from peak cardiorespiratory exercise data have been used to study the relationship between VO2max and risk of cardiac and all cause death and in heart failure cardiopulmonary exercise test results have been established as outstanding prognostic information.,心肺运动试验(CPET)定义,CPET可提供一个包括呼吸系统，心血管系统，造血系统以及骨骼肌系统综合运动反应的整体评估，这是测定单一器官系统功能所无法充分反应的。该试验具有无创、动态、生理性的特点。,慢性心力衰竭心预后的评估,目前最常用的是Weber-Janicki 分级,Peak oxygen pulse during exercise as a predictor for coronary heart disease and all cause death Heart 2006;92:1219-1224,Objective: To investigate the prognostic value of peak oxygen pulse and VO2 with respect to coronary heart disease and overall death. Design: Prospective population-based study based on 1596 men without CHD or the use of blockers at baseline. During an average follow up of 14 years, 267 men died, 67 of them due to CHD. The respective risk for overall death was 1.79 (95% CI 1.21 to 2.65).,心肺运动试验与冠心病及预后,P0.0001,P0.0001,0,10,20,30,40,50,60,70,80,90,VO2/pulse 13.5ml,死亡率,VO2/pulse 17.5ml,冠心病发病率,2.45倍(95% CI 1.10 to 5.45),1.79 (95% CI 1.21 to 2.65),VO2分层及预后的评估,Survival curves for patients achieving peak VO2 values above versus below 10, 12, 14, and 16 mL kg min,预后的评估,整个队列随访信息完成了98.3%，在平均四年的随访过程中，187 病人死亡(29%) ，101进行了心脏移植，精确的1和5年生存率分别为90.5% 和 73.4%， 运动峰值氧耗量(VO2)是独立的危险因子，比达到的运动功率和其他运动和临床变量价值更大， 生存率近20%的差别主要在于10 17 mL/kg/min范围外，在范围之外生存率变化具有差别(P .01)，之间的数值其意义是相似的。,慢性心力衰竭心预后的评估,结果： 心肺运动试验(峰值氧耗量）15.24.5ml/kg/min， VE/VCO2：38.7 11.8， 核素左心室造影LVEF32.814.3%； 心脏超声 (LVDV 6.11.1) cm, LVSD( 4.7 1.5)cm. 随访结束时, 26病人死亡.生存者中位随访时间为 47.7 月 (31.553.5月). 第一年死亡率：18% 第二年死亡率：29%.,total population,Heart. 2000 Feb；83(2):147-51.,predicted oxygen consumption (VO2),Eur J Cardiovasc Prev Rehabil. 2006 Apr;13(2):249-53.,Cardiopulmonary evidence of exercise-induced silent ischaemia.,68+/-19,91+/-19,86+/-17,40%,50%,60%,70%,80%,90%,100%,冠心病组,CEPT and cytokines in chronic heart failure. Comparison of patients with ischaemic and with dilated cardiomyopathy,Peak VO2,Pol Arch Med Wewn. 2004 Jun;111(6):693-701,p = 0.0069,20 15 10 5,TNF-alpha and sTNF-RI,缺血性心肌病,18.1 +/- 4.8 ml/kg/min,扩张型心肌病,14.1 +/- 3.7 ml/kg/min,评价冠心病介入治疗的效果,Klainman等在成功施行PTCA的冠心病病人，术后即进行心肺运动试验 结果显示：氧摄取量，氧脉搏，氧脉搏积分，无氧阈显著改善，但最大心率没有明显变化. 心肺运动试验是冠心病PTCA术后功能评价的一种有效的方 法。,The effects of PTCA on the peakVo2, and the maximal work rate,Chest. 2000; 118(2): 329-35,The effects of PTCA on the time constant of Vo2, the gas-exchange threshold (GET),Chest. 2000; 118(2): 329-35,评价冠心病介入治疗的效果,Lan等的研究也证实了PTCA术后的病人，在无氧阈水平上进行6周到3个月的运动训练，无再狭窄的病人，他们的峰O2，峰氧脉搏，峰ratepressure product，峰运动功率显著改善，这些效果在大多数病人训练6周时既可取得。 心肺运动试验试验还发现，PTCA也可改善左心室收缩功能正常的冠心病病人的肺功能以及可改善运动耐量。,病例1,患者，男，61岁，因“反复胸闷、胸痛十余年，PCI术后4月，再发2月”入院。 既往史：无高血压、糖尿病病史，长期吸烟30年10支/天 四月前因“急性心肌梗塞，心房纤颤”行冠脉造影: 左主干远端狭窄90%,回旋支开口狭窄99，OM开口狭窄90，前降支开口狭窄90。” 入院诊