心肺功能測(cè)定與冠心病的診斷和預(yù)后評(píng)價(jià)-王寧夫課件

1、心肺功能測(cè)定與冠心病的診斷和預(yù)后評(píng)價(jià)南京醫(yī)科大學(xué)附屬杭州醫(yī)院心內(nèi)科王寧夫Cardiopulmonary Exercise Test And CAD心肺運(yùn)動(dòng)試驗(yàn)與心電圖運(yùn)動(dòng)試驗(yàn)對(duì)比European Heart Journal 2003Volume 24, Number 14 P0.0001P0.00010102030405060708090特異性%敏感性%心肺運(yùn)動(dòng)試驗(yàn)心電圖運(yùn)動(dòng)試驗(yàn)Detection of exercise induced ischaemia:a new role for CEPTThe prognostic and diagnostic value of the exercis

2、e 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 2003Volume 24, Number 14 Edit

3、orialThe 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 exce

4、llent 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 te

5、st results have been established as outstanding prognostic information.心肺運(yùn)動(dòng)試驗(yàn)(CPET)定義CPET可提供一個(gè)包括呼吸系統(tǒng)，心血管系統(tǒng)，造血系統(tǒng)以及骨骼肌系統(tǒng)綜合運(yùn)動(dòng)反應(yīng)的整體評(píng)估，這是測(cè)定單一器官系統(tǒng)功能所無法充分反應(yīng)的。該試驗(yàn)具有無創(chuàng)、動(dòng)態(tài)、生理性的特點(diǎn)。 慢性心力衰竭心預(yù)后的評(píng)估目前最常用的是Weber-Janicki 分級(jí)Peak oxygen pulse during exercise as a predictor for coronary heart disease and all cause death

6、 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

7、 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). 預(yù)后的評(píng)估整個(gè)隊(duì)列隨訪信息完成了98.3%，在平均四年的隨訪過程中，187 病人死亡(29%) ，101進(jìn)行了心臟移植，精確的1和5年生存率分別為90.5% 和 73.4%，運(yùn)動(dòng)峰值氧耗量(VO2)是獨(dú)立的危險(xiǎn)因子，比達(dá)到的運(yùn)動(dòng)功率和其他運(yùn)動(dòng)和臨床變量?jī)r(jià)值更大，生存率近20%的差別主要在于10 17 mL/kg/min范圍外，在范圍之外生存率變化具有差別(P .01)

8、，之間的數(shù)值其意義是相似的。慢性心力衰竭心預(yù)后的評(píng)估結(jié)果： 心肺運(yùn)動(dòng)試驗(yàn)(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%； 心臟超聲 (LVDV 6.11.1) cm, LVSD( 4.7 1.5)cm. 隨訪結(jié)束時(shí), 26病人死亡.生存者中位隨訪時(shí)間為 47.7 月 (31.553.5月). 第一年死亡率：18% 第二年死亡率：29%. total populationHeart. 2000 Feb；83(2):147-51. 正常人冠造正常組predicted oxygen consumption (VO2)E

9、ur J Cardiovasc Prev Rehabil. 2006 Apr;13(2):249-53.Cardiopulmonary evidence of exercise-induced silent ischaemia.68+/-1991+/-1986+/-1740%50%60%70%80%90%100%冠心病組The effects of PTCA on the time constant of Vo2, the gas-exchange threshold (GET)Chest. 2000; 118(2): 329-35評(píng)價(jià)冠心病介入治療的效果Lan等的研究也證實(shí)了PTCA術(shù)后的病

10、人，在無氧閾水平上進(jìn)行6周到3個(gè)月的運(yùn)動(dòng)訓(xùn)練，無再狹窄的病人，他們的峰O2，峰氧脈搏，峰ratepressure product，峰運(yùn)動(dòng)功率顯著改善，這些效果在大多數(shù)病人訓(xùn)練6周時(shí)既可取得。心肺運(yùn)動(dòng)試驗(yàn)試驗(yàn)還發(fā)現(xiàn)，PTCA也可改善左心室收縮功能正常的冠心病病人的肺功能以及可改善運(yùn)動(dòng)耐量。 病例1 患者，男，61歲，因“反復(fù)胸悶、胸痛十余年，PCI術(shù)后4月，再發(fā)2月”入院。既往史：無高血壓、糖尿病病史，長(zhǎng)期吸煙30年10支/天四月前因“急性心肌梗塞，心房纖顫”行冠脈造影: 左主干遠(yuǎn)端狹窄90%,回旋支開口狹窄99，OM開口狹窄90，前降支開口狹窄90?！比朐涸\斷：冠狀動(dòng)脈粥樣硬化性心臟病 陳舊性高側(cè)壁心肌梗死 前降