论文标题:心房颤动的相关因素研究
The Study on the Effects of Facts Correlating to Atrial Fibrillation
论文作者
论文导师 吕安林,论文学位 硕士,论文专业 内科学
论文单位 第四军医大学,点击次数 102,论文页数 77页File Size632K
2007-04-01论文网 http://www.lw23.com/lunwen_274833812/
atrial fibrillation;; C reactive protein;; homocysteine;; Angiotensin II;; electrical cardioversion;; left atrial dimension
实验背景 心房颤动是最常见的一种心律失常。心房颤动导致的心室律(率)紊乱、心功能受损和心房附壁血栓形成,是心房颤动患者的主要病理生理特点。目前心房颤动的确切发病机制仍不清楚。近年来,研究发现炎症、氧化应激、肾素-血管紧张素系统与心房颤动有关,加强对心房颤动的基础研究,建立有效的以发病机制为基础的治疗途径(mechanism-based therapeutic approaches)可能为心房颤动的治疗开辟一条新的道路。 心房颤动治疗策略主要包括心房颤动转复窦性心律、控制心室率以及预防血栓等并发症治疗。药物和外科手术复律有较高的复发率,射频消融术虽然降低了复发率但是费用较贵。同步直流电复律是一种有效的恢复窦性心律的方法,这种有效性可以通过抗心律失常的药物来加强,因而临床应用广泛。然而,部分患者通过电复律仍不能转复窦性心律,因此影响心房颤动复律的因素备受关注。 目的 1.以C反应蛋白、同型半胱氨酸、血管紧张素Ⅱ及左房内径为观察指标,探讨炎症反应、氧化应激、肾素-血管紧张素系统在心房颤动发生、发展的作用及相互关系。 2.探讨影响心房颤动电复律成功及维持窦性心律的因素。 方法 第一部分:按入选标准纳入房颤患者64人入试验组,门诊就诊的窦性心律患者30人入对照组。心房颤动患者分三亚组,分别为:阵发性房颤组;持续性房颤组;永久性房颤组。比较试验组、对照组以及试验组各亚组间在左房内径、左室舒张末期内径、左室射血分数、C反应蛋白水平、同型半胱氨酸水平、血管紧张素Ⅱ水平之间的差异。 第二部分:纳入拟行电复律的房颤患者43人入试验组,门诊就诊的窦性心律患者30人入对照组。根据电复律是否成功将试验组分为成功复律组和失败组两亚组。比较试验组、对照组以及试验组各亚组间在左心房内径、左心室舒张末期内径、左心室射血分数、C反应蛋白水平之间的差异,各亚组间还进行年龄、性别、房颤持续时间和伴发疾病的比较。复律成功患者进行门诊或电话随访,调查复发情况,比较复发组与未复发组复律前左房内径和C反应蛋白水平的差异。 实验结果 1.与对照组相比,房颤组左房内径大于对照组(P<0.05);持续性房颤左房内径大于阵发性房颤组(P<0.05),永久性房颤组左房内径大于阵发性房颤组(P<0.05)。与对照组相比,房颤组左室射血分数低(P<0.05),左室舒张末期内径无显著性差异(P>0.05)。 2.各房颤组血清hsCRP、Hcy浓度显著高于对照组(P<0.05);持续性和永久性房颤组hsCRP、Hcy浓度比阵发性房颤组高(P<0.05),持续性房颤和永久性房颤组hsCRP、Hcy浓度无显著性差异(P>0.05);阵发性房颤与对照组相比,AngⅡ水平无显著性差异(P>0.05),但两组水平均显著低于持续性房颤组及永久性房颤组(P<0.05),而持续性房颤组与永久性房颤组的AngⅡ水平无明显差异(P>0.05)。 3.与房颤电转复成功组相比,转复失败组年龄大(P<0.05),多合并瓣膜性病变(P<0.05),房颤持续时间长(P<0.05),左房内径大(P<0.05),hsCRP水平高(P<0.05)。经多因素分析,hsCRP水平OR为2.1 (95%CI 1.4-3.2, P=0.004)、左房内径OR为1.8 (95%CI 1.2-2.2, P=0.006)和房颤持续时间OR为2.8 (95%CI 1.6-4.0, P= 0.007)。 4. 23例成功转复患者共经随访9月(无失访),其中3月内复发5例,3～6月内复发3例,6～9月复发2例,平均复发时间5月。复发患者3人行再次电复律,2人转复成功,其他患者予控制心室率治疗。与未复发组比较,复发组hsCRP高于未复发组(P<0.05),两组左房内径无明显差异(P>0.05)。 结论 1.炎症、氧化应激及肾素-血管紧张素系统参与心房电生理重构及结构重构,在心房颤动的发生、维持与复发过程中起到了重要作用。 2.高敏感CRP、左房内径及房颤持续时间是影响房颤电复律成功的独立预测因素。
Backgroud Atrial fibrillation (AF) is the most commonly occurring arrhythmias. Impaired ventricular function,disorder of ventricular rate/ rhythm and mural thrombosis of atrium, are the chief pathophysiological characteristics of AF. Presently, the precise pathogenesy of AF is not clear. For the past few years, there were some reports about the relationship among inflammation, oxidative stress, renin-angiotensin system (RAS) and AF. The basic researchs on AF, and founding mechanism-based therapeutic approaches would find some way to treat AF. The therapeutic approaches of AF include cardioversion, controlling ventricular rate and precaution of complications. Some methods of cardioversion, such as antiarrhythmic and operation, are less effective. The fee of radio frequency catheter ablation is expensive in China. R-wave synchronized direct-current cardioversion is an effective method of cardioversion. Antiarrhythmic drug can strengthen that effectivity. However, part of patients cannot obtain sinus rhythm through electrical conversion. Presently, the effects that predict the electrical cardioversion restore sinus rhythm in patients with atrial fibrillation are paid close attention to. Aims 1. To study the relationship among the level of hsCRP, Homocysteine, Angiotensin II, left atrial dimension and AF in the blood-serum and clinic classifications of atrial fibrillation. 2. To study the effects that predict the electrical cardioversion restore sinus rhythm in patients with atrial fibrillation... Methods PARTⅠ: 64 patients with atrial fibrillation and 30 outpatients in sinus rhythm who were underwent routine physical examination were enrolled in test group and control group respectively. Test group was divided into three subgroups, (paroxysmal AF, persistent AF, permanent AF). The differences of left atrial dimension (LAD), left ventricular end-diastolic dimension (LVEDD), left ventricular ejection fraction (LVEF), the level of CRP, Hcy and Angiotensin II between test group and control group, as well as paroxysmal AF, persistent AF, permanent AF, were analyzed respectively. PARTⅡ: 43 patients with atrial fibrillation who underwent electrical cardioversion and 30 outpatients in sinus rhythm who were underwent routine physical examination were enrolled in test group and control group respectively. Test group was divided into two subgroups. One is the successful cardioversion group; the other is the failed cardioversion group according to the results of electrical cardioversion (CV). The differences of left atrial dimension (LAD), left ventricular end-diastolic dimension (LVEDD), left ventricular ejection fraction (LVEF), pre-CV CRP levels between test group and control group were analyzed. The differences of sex,age, coronary heart disease (CHD), hypertension, valvular heart disease (VHD), left atrial dimension (LAD), left ventricular end-diastolic dimension (LVEDD), left ventricular ejection fraction (LVEF), pre-CV CRP levels and the duration of AF between the successful cardioversion group and the failed cardioversion group, were analyzed respectively. Patients in successful electrical cardioversion group were followed up throght telephone or interview in clinic service . The differences of left atrial dimension, pre-CV CRP levels were analyzed. Results 1. Compared with the control group, LAD was lager (P<0.05) in the test group; compared with the cases of paroxysmal AF, LAD was lager (P<0.05) in the cases of persistent AF, compared with the cases of persistent AF, LAD was lager (P<0.05) in the cases of permanent AF. Compared with the control group, LVEF was lager (P<0.05) in the test group. There was no difference of LVEDD between the control group and the test group. 2. Compared with the control group, the level of hsCRP, Hcy in the blood-serum was higher in the test group (P<0.05); compared with the cases of paroxysmal AF, the level of hsCRP, Hcy in the blood-serum was higher in the cases of persistent AF and permanent AF, but there was no difference between persistent AF and permanent AF; compared with the control group, the level of Angiotensin II was higher in the cases of persistent AF and permanent AF, but there was no difference between persistent AF and permanent AF as well as control group and paroxysmal AF. 3. Compared with successful electroversion group, age was older (P<0.05), LAD was more lager (P<0.05), patients with VHD were more(P<0.05), the duration of AF were longer(P<0.05), and CRP level was higher (P<0.05) in the failed electroversion group. In a multivariable analysis, CRP lever OR was 2.1 (95%CI 1.4-3.2, P=0.004), LAD OR was 1.8 (95%CI 1.2-2.2, P=0.006) and the duration of AF OR was 2.8 (95%CI 1.6-4.0, P=0.007). 4. 23 cases were followed up for 9 months in successful electroversion group.5 cases recurred in 3 months, 3 cases recurred in 3 to 6 months, 2 cases recurred in 6 to 9 months. 3 cases in the cases that recurred selected electrical cardioversion, and 2 cases obtained successful electrical cardioversion again. The others controlled ventricular rate by antiarrhythmic. Compared with the unrecurred cases , LAD was no difference (P<0.05), and CRP level was higher (P<0.05) in the recurred cases. Conclusion 1. Inflammation, oxidative stress and RAS take part in electrical remodeling and structural remodeling of auricle and correlate with genesis, maintenance and recurrence of atrial fibrillation. 2. C-reactive protein level, LAD and the duration of AF were independent factors, which can predict whether the electrical cardioversion could restore sinus rhythm in patients with atrial fibrillation.
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