T波电交替——曹克将.ppt

1、T波电交替预警恶性室性心律失常的价值Evaluation of TWA in the Prediction of Malignant Ventricular Arrhythmias,南京医科大学第一附属医院 江苏心血管病临床医学中心 曹克将,Leading Causes of Death in the US,SCD is a leading cause of death in the U.S., second to all cancers combined,20%,25%,National Vital Statistics Report, Vol 49 (11), Oct. 12, 2001.

2、 State-specific mortality from sudden cardiac death United States 1999. MMWR. 2002,51:123-126.,15%,5%,10%,Arrhythmic Cause of SCD,Albert CM. Circulation 2003,107:2096-2101.,12%Other CardiacCause,88%ArrhythmicCause,Underlying Arrhythmias of Sudden Cardiac Arrest,Torsades de Pointes13%,VT62%,Bradycard

3、ia17%,Primary VF8%,Bays de Luna A. Am Heart J 1989,117:151-159.,Risk Factors for Fatal Arrhythmias,80%Coronary Artery Disease,15%Cardiomyopathy,5% Other*,Heikki et al. N Engl J Med 2001,345. * ion-channel abnormalities, valvular or congenital heart disease, other causes.,Treatments of Potential Util

4、ity to Reduce SCD,Correcting Ischemia Revascularization Beta-blocker Preventing Plaque Rupture Statin ACE inhibitor Aspirin Stabilizing Autonomic Balance Beta-Blocker ACE inhibitor,Improving Pump Function ACE inhibitor Beta-Blocker Prevention of Arrhythmias Beta-Blocker Amiodarone Terminating Arrhyt

5、hmias ICDs AEDs Blocks Effects of Residual Aldosterone Aldosterone receptor blockade,Zipes DP. Circulation 1998,98:2334-2351. Pitt B. N Engl J Med 2003,348:1309-1321.,然而, ICD植入患者的绝对获益值相对较小，且ICD本身有潜在的不良反应 MADIT II 5.6% 20 months 18 ICDs SCD-HeFT 7.2% 5 years 14 ICDs,最大获益于ICD治疗的最高危人群,更理想的危险分层方案？,MADIT

6、-II: ICD对VT/VF的一次或一次以上准确治疗,36%,年,电击复律的比例,SCD HeFT: 从植入至VT/VF电击复律时间,811,707,401,622,236,79,Number at risk,Consumer Reports. org,10 overused tests and treatments 1. BACK SURGERY 2. HEARTBURN SURGERY 3. PROSTATE TREATMENTS 4. IMPLANTED DEFIBRILLATORS. This devices , which automatically shock the heart

7、back to normal rhythm, cost some $90000 over a lifetime. Yet one-third of people who get them might not really need them, according to research reported in 2007. This year Medicare will pay for an estimated 50 000 of the devices. 5. CORONARY STENTS 6. . 7. .,Risk Stratification of SCD(Noninvasive),H

8、R Variability,TW alternans,QRS dur,HR Variability,TW alternans,QRS duration,SAECG,QT dispersion,NSVT/VT,LVEF,HRT,MTWA诱发室性心律失常的机制,Long APD Short APD Long APD Short APD,Action Potential Alternans Leads to T-Wave Alternans,Long APD Region,Short APD Region,Spatially Discordant Alternans Leads to Dispers

9、ion of Recovery, Wave Front Fractionation, and Reentry,微伏级T波电交替,Initiation of VF during discordant alternans,MTWA检测方法,目前用于临床的MTWA检测方法主要有两种 频域分析法：逐渐被时域分析法所代替 时域分析法,TWA频域分析法,Cambridge Heart系统 快速傅立叶转换FFT 采样方案：利用平板运动试验使心率达到一定范围 MTWA诊断标准明确： 阴性(negative) 阳性(positive) 不确定性(indeterminate),abnormal,normal,频域

10、分析法(缺血性心脏病),Bloomfield et al. Microvolt T-Wave Alternans and ICD Therapy. Circulation 2004,110:1885-1889.,MTWA异常组的全因死亡风险显著高于正常组,Kaplan-Meier mortality curves for patients with normal versus abnormal MTWA test results.,Bloomfield et al. MTWA and ICD Prophylaxis. JACC 2006,47:456-63.,频域分析法(缺血性心脏),频域分析

11、法的临床研究缺血性心脏病,A. Primary endpoints,B. Secondary endpoints,Chan et al. Coronary Artery Disease/MTWA Predicts Beyond 1 Year. Am J Cardiol 2008.,Patients with non-negative MTWA test results had higher unadjusted rates of mortality and arrhythmic events,MTWA Predicts Beyond 1 Year,频域分析法缺血性心脏病(LVEF40%),Ik

12、eda et al. T-Wave Alternans in Preserved Cardiac Function. JACC 2006,48:2268-74.,MTWA敏感性、阴性预测值最高,频域分析法的MASTER I研究缺血性心脏病 (LVEF30%),Chow et al. AHA 2007 Scientific Sessions; November 6, 2007.,By Kaplan-Meier analysis, MTWA (p=0.035) is a statistically significant predictor of events,Hohnloser et al. M

13、TWA in Dilated Cardiomyopathy. JACC 2003,41:22204.,频域分析法非缺血性心脏病(DCM),频域分析法的临床研究非缺血性心脏病 (HCM),Momiyama等: 在14例HCM患者中，71%的高危患者TWA 异常，低危组和对照组中无一例TWA异常 Kon-No等: 对HCM和左室肥厚患者及健康人进行TWA监测，61%HCM患者和31%左室肥厚患者的TWA阳性 MTWA对HCM患者的危险分层作用的临床研究资料比较有限，目前尚缺乏大规模前瞻性研究,频域分析法的临床研究遗传性离子通道性心脏病,Brugada Syndrome Ikeda等发现Brugad

14、a Syndrome患者的TWA监测结果与对照组无明显统计学差异 TWA在该疾病患者中的应用价值尚需进一步评价 Long QT Syndrome 有报道曾涉及LQTS1-3型TWA，但其是否有预测价值尚缺乏证据 TWA在该疾病患者中的价值目前尚不清楚,TWA时域分析法,Verrier和Nearing研究发明 移动平均修正技术MMA Holter-TWA Exercise-TWA 相关临床研究尚不多 特点 无需固定心率和时间 被检查者可自由活动 可动态捕捉短暂而剧烈的心律失常 目前尚无统一的采样方案和阳性标准,Patients Post MI and LVEF0.40 in the initia

15、l 48h of the index MI or LVEF0.50 measured beyond the initial 48h Objectives Whether combining assessment of autonomic tone plus cardiac electrical substrate can identifies most patients at risk after MI ; Determing the optimal time to assess risk early after MI Characteristics Combine assessment of

16、 autonomic tone plus cardiac electrical substrate Compare assessment at 2 to 4 weeks versus 10 to 14 weeks after MI Compare assessment Holter TWA versus Exercise TWA,Exner et al. Noninvasive Risk Assessment Early Post-MI. JACC 2007,50:2275-84.,时域分析法The REFINE Study (Risk Estimation Following Infarct

17、ion, Noninvasive Evaluation),Exner et al. Noninvasive Risk Assessment Early Post-MI. JACC 2007,50:2275-84.,Exner et al. Noninvasive Risk Assessment Early Post-MI. JACC 2007,50:2275-84.,higher,MTWA vs SAECG vs EPS,better predictive value of MTWA,Dynamic changes of TWA before sustained VT in 2 subject

18、s,时域分析法,Shusterman et al. Repolarization Instability and Tachyarrhythmias. Circulation 2006,113:2880-2887.,42 patients with spontaneous sustained VT on Holter all had a history of cardiac arrest documented VF, sustained VT, or syncope,Changes in heart rate and TWA before the onset of VTA relative to

19、 the baseline period.,Shusterman et al. Repolarization Instability and Tachyarrhythmias. Circulation 2006,113:2880-2887.,P0.05,时域分析法,日本时域法T波电交替研究 (一),Circulation 2006;113:2880-2887.,日本时域法T波电交替研究 (二),295例左心衰竭患者(缺血性和非缺血性) Holter-TWA 记录心率120bpm时V5或V1导联的TWA最大值 TWA65V为阳性TWA 随访390212天 终点事件：心脏性死亡,Heart Rhy

20、thm 2009;6:332-337.,缺血组,非缺血组,Heart Rhythm 2009, 6:332-337,Finnish Cardiovascular Study,运动平板时域法TWA 1037例临床有行运动试验指针的患者 随访447个月 终点事件：全因死亡、心血管死亡、心脏性猝死,Eur Heart J 2007;28:2332-2337.,P=0.001,P0.001,P0.001,Eur Heart J 2007;28:2332-2337.,我中心已在部分人群中开展了若干时域法TWA临床研究 健康人 肥厚型心肌病患者 右室心肌病患者,健康人时域法T波电交替 (一),65例体检健

21、康人，平均年龄242.3岁 记录动态心电图 双极模拟导联：V5、V1、avF TWA检测 更新分割因子设为1/32 软件自动每15秒读值一次 采集2-4点、5-7点、8-10点全部的TWA读值 TWA值呈偏态分布，以P50 (P25，P75)描述交替电压分布,中华心律失常学杂志 2009, 2:144-146.,TWA分布：8-10点 5-7点 2-4点 三个时间段TWA比较：P值均 0.05,1 (0, 2),1 (0, 3),3 (2, 4),0 (0, 0),2 (0, 3),3 (1, 4),TWA分布：avF V1 V5 三个导联TWA比较：P值均 0.05,中华心律失常学杂志 20

22、09, 2:144-146,健康人时域法T波电交替 (二),120例体检健康者 平均年龄33.713.5岁 运动平板试验中检测TWA GE CASE8000平板运动系统 改良Bruce方案运动，维持心率90-125bpm，至少3min后减少运动至安静状态，心率恢复至90bpm，结束试验 常规平板运动检查导联：6个胸导，6个模拟肢导,中外健康文摘 2007;12:11-13.,中外健康文摘 2007;12:11-13.,胸前导联T波交替电压最大值Vmax第75百分数为11V,中外健康文摘 2007; 12: 11-13.,肥厚型心肌病患者时域法T波电交替,30例确诊HCM患者 记录24小时动态心

23、电图 模拟V5、V1、V3导联 TWA值采集 三个导联所有TWA读值中的最大值 发生心率125次/分,38 (25, 52),33 (23, 67),P = 0.52,P=0.38,P=0.54,P=0.87,P = 0.02,P = 0.02,P = 0.3,P = 0.3,P = 0.02,P = 0.02,P = 0.68,P = 0.04,P = 0.53,P=0.73,P=0.86,P=0.98,P = 0.16,P = 0.78,P = 0.39,右室心肌病患者的时域法T波电交替,35例右室心肌病患者 时域法TWA 检测 GE CASE8000平板运动系统 以改良Bruce方案进行平板运动试验 缓慢增加心率，维持心率在90-125bpm，至少3分钟 记录各人胸前导联 V1-V6的TWA值,中华心律失常学杂志 2009, 2: 117-120.,ARVC组与对照组比较,中华心律失常学杂志 2009, 2: 117-120.,* P 0.05,中华心律失常学杂志 2009, 2: 117-120,MaxValt,maxValt11.5V作为区别 ARVC患者与正常人的截断值，其准确诊断指数最大，敏感性74.3%，特异性88.3%,中华心律失常学杂志 2009, 2: 117-120,