心率减速力的临床应用进展.docx

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1、心率减速力的临床应用进展覃珍花，俸艳英(广西医科大学附属肿瘤医院心肺功能中心，广西南宁530000)摘要:心率减速力是心源性猝死筛选和预警的有效检测技术,在其他心血管疾病如心力衰竭、 心肌病、心脏手术等的风险分层和治疗预后评估同样显示出优越的应用价值。除此之外，DC 与非心血管疾病如内分泌疾病、神经系统疾病、药物相关心脏毒性等疾病预后预测有紧密关 系。心率减速力的临床应用价值和发展潜力值得在临床广泛推广和深入探究。关键词：心率减速力，心率加速力，迷走神经，Progress i n Cli n i caI Applicat ion of DeceI erat i on CapacityAutho

2、r (s):Qin Zhen-Hua,Feng Yan-Ying(Guangx i Med i ca I University Cancer Hospita I Cardiopulmonary Center, Guangxi Nann i ng 530000)Abstract DeceI erat i on capacity i s an effect i ve detect i on techn i que for sudden card i ac death screen i ng and ear I y warn i ng. 11 a I so shows super i or app

3、I i cat i on va I ue i n r i sk stratification and treatment prognosis assessment of other cardiovascular d i seases such as heart fa i Iure, card iomyopathy and cardiac surgery. In add ition, DC i s cIoseIy re Iated to the prognos i s of non-card i ovascuI ar d i seases such as endocr i ne d i seas

4、es, nervous system d i seases, and drug-re Iated cardiotoxicity. The cl i n i ca I app I i cat ion va I ue and deve I opment potent i a I of heart rate deceleration are worthy of extens i ve promot ion and in-depth exp Iorat ion in the clinic.Key words DeceI erat i on Capac i ty (DC) ; AcceI erat i

5、on Capacity (AC) ;VagaI Tone;引言：心脏自主神经由交感神经和迷走神经两大分支组成，交感神经是心脏的加速神经，其兴 奋性增加时心率加快，心率加速力(acceleration capacity , AC)增强。而迷走神经是心 脏的减速神经，其在心脏自主神经调节中占据主导地位，兴奋性增加时心率变慢，心率减速 力(deceleration capacity DC)增强。2006年,德国 力uer教授通过三个队列研究 发现了比左室射血分数(left ventricular ejection fraction , LVEF)和心率变异性(heart variability, H

6、RV)更准确的心肌梗死后猝死率的预测因子，提出了用于评估迷走神经张力 的定量指标心率减速力的检测技术。心率减速力检测技术刚问世，就在猝死高危患者的检出 与预警方面显示出很大优势，国内外学者相继将这一技术应用于各种心血管疾病不良事件的 预测，也显示出其高特异性和敏感性。2012年，Schmidt教授在DC基础上提出了计算连续 搏动心率减慢发作次数的方法，即连续心率减速力(heart rate deceleration runs, DRs ), 是窦性心律在短时间内受迷走神经调节的具体表现，与DC结合，以风险值高的为标准，能 够提高心脏危险分层的精确度。随着临床积极应用及推广，DC在其他疾病的预后

7、预测作用 的研究也不断展开与深入，现将其在临床各个领域中的应用与研究进展做一综述。一、心血管疾病1. 1 DC与冠心病全球范围内心源性猝死(sudden cardiac death , SCD)仍然是目前人类死亡的主要原因， 约占所有心血管疾病死亡的一半，其主要病因为冠心病。面临流行病学这一严峻挑战，医 学科学家提出各种危险分层技术应用于临床进行猝死高危患者的筛选和预警，并被广为接 受。临床上,以左心室射血分数(left ventricular ejection fraction , LVEF)作为评 估心功能不全的主要指标，认为LVEFW40%为高危猝死患者，LVEF40%为非高危猝死患者。

8、 而对于心功能正常但合并心电功能或自主神经功能障碍的猝死高危患者的筛选与预警指标, 临床多应用HRV、HRT (窦性心率震荡)、心室晚电位等检测心脏自主神经功能，但其结果 受环境或生理等多因素重叠影响，无法直接检测自主神经张力。Bauer提出了能直接评估迷走神经张力的定量指标DC,是比LVEF和HRV更能准确地对 心肌梗死后猝死进行评估的预测因子。该研究将2. 5 ms和4.5ms作为截断点，将DC分为高 (DCW2. 5ms)、中(2. 5 ms4.5 ms)即低风险的患者适合门诊治疗。Buzea 32 等认为DC可能用于预测慢性阻塞性肺疾病患者室性和室上性心律失常的发生。Boehm加等研

9、究发现DC可用于急性恶性肿瘤患者的预后评估和风险分层，指导治疗方案。Stampalija34 等认为通过胎儿心电图的PRSA分析测量的平均加减速能力可评估胎儿自主神经系统从而为 胎儿宫内生长受限提供了一个有前途的方法。综上所述，DC评估迷走神经的张力以及受损程度的主要检测方法，心率减速力是定 量、无创监测自主神经功能的手段，不仅在心血管疾病方面的危险分层和预后预测具有很好 的应用价值，而且在非心血管疾病方面的预后预测也显示了其优越性。心率减速力这一心电 功能检测技术简便易行,可重复性好,其临床应用价值和临床意义值得广泛推广和探索研究。1 郭继鸿.心率减速力检测J,临床心电学杂志，2009, 1

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