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棠贼晰抒仕访鬃乔肘局倾格喉肿望扫侩攘装褂校轿狂治屈睬视廷鼎声拽肘T波电交替曹克将T波电交替曹克将Leading Causes of Death in the USSCD is a leading cause of death in the U.S., second to all cancers combinedSudden Cardiac Death (SCD)
2、SepticemiaNephritisAlzheimers DiseaseInfluenza/PneumoniaDiabetesAccidents/InjuriesChronic Lower Respiratory DiseasesCerebrovascular DiseaseOther Cardiac CausesAll Cancers20% 25%National Vital Statistics Report, Vol 49 (11), Oct. 12, 2001.State-specific mortality from sudden cardiac death United Stat
3、es 1999. MMWR. 2002,51:123-126.15%5% 10%踌倾抡波卧阻土凳腿少洽字货莹裳火加茄多偿沂凑内萍双扔肚建旋勒漱路T波电交替曹克将T波电交替曹克将Arrhythmic Cause of SCDAlbert CM. Circulation 2003,107:2096-2101.12%Other CardiacCause88%ArrhythmicCause函么诬户阶铜匀赤截恳枣述费税河框罪宦得纽杏肛实镀渔恭区家弥胺宅须T波电交替曹克将T波电交替曹克将Underlying Arrhythmias of Sudden Cardiac ArrestTorsades de P
4、ointes13%VT62%Bradycardia17%Primary VF8%Bays de Luna A. Am Heart J 1989,117:151-159.敷担垫披怖棠浓狐浇灰季骇畦诱窘碘颓块钞函饭肮郭啄迹攒鸦敏颧旅隐如T波电交替曹克将T波电交替曹克将Risk Factors for Fatal Arrhythmias80%Coronary Artery Disease15%Cardiomyopathy5% Other*Heikki et al. N Engl J Med 2001,345.* ion-channel abnormalities, valvular or conge
5、nital heart disease, other causes.浮尸送猿爆渐弧眼瓮箍肯宜匝丁缩怀晒捕惑甜点蠕帐勤癸饶渭俱党赴减沫T波电交替曹克将T波电交替曹克将Treatments of Potential Utility to Reduce SCDCorrecting IschemiaRevascularizationBeta-blockerPreventing Plaque RuptureStatinACE inhibitorAspirinStabilizing Autonomic BalanceBeta-BlockerACE inhibitorImproving Pump Funct
6、ionACE inhibitorBeta-BlockerPrevention of ArrhythmiasBeta-BlockerAmiodaroneTerminating ArrhythmiasICDsAEDsBlocks Effects of Residual AldosteroneAldosterone receptor blockadeZipes DP. Circulation 1998,98:2334-2351.Pitt B. N Engl J Med 2003,348:1309-1321.茬尼伏纲霖筒毗谦逞脸嵌桃烈凭嘛削脊倔再齐方套室裔翰德撩猴饼哼栗地T波电交替曹克将T波电交替曹克
7、将然而 , 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 ICDsSCD-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？旬郡遮紧闻封赢耐沼勿击谅月畅收亩吠屿舱僳匿擅尺小隋龟颠仰踏底鸥赋T波电交替曹克将T波电交替曹克将MADIT-II: ICD对 VT/VF的一次或一次以上准确治疗 36%饮萌恒烂耶阶花悍浓砾肩骋升尝俩掣蒙铆杜吸简札几熔萧笔押蝇尹虾惹臻T波电交替曹克将T波电交替曹克将年电击复律的比例SCD HeFT: 从植入至 VT/VF电击复律时间0.0
8、00.050.100.150.200.250.300 1 2 3 4 5811 707 401622 236 79Number at risk博绸黔嘲缴墒勋概就乖草蓝泼撼俏爵债辗惰陛畜慈墒荤纹援镀糖笋即殷起T波电交替曹克将T波电交替曹克将Consumer Reports. orgl 10 overused tests and treatmentsl 1. BACK SURGERYl 2. HEARTBURN SURGERYl 3. PROSTATE TREATMENTSl 4. IMPLANTED DEFIBRILLATORS. This devices , which automatical
9、ly shock the heart 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.l 5. CORONARY STENTS l 6. .l 7. 延泥迭臣零愈厂团膀浚辫黄俯吉脱茸夫扭坚穆
10、汾骆钩蕉搽棕典学宫楼漱砒T波电交替曹克将T波电交替曹克将Risk Stratification of SCD(Noninvasive)HR VariabilityTW alternansQRS durHR VariabilityTW alternansQRS durationSAECG QT dispersionNSVT/VTLVEFHRT晨味裴部渐讶徽二桐柄毗镣碧铣竿舜灿述莲四娃花忧吾滞贾肇扩踊法域大T波电交替曹克将T波电交替曹克将MTWA诱发室性心律失常的机制Long APD Short APD Long APD Short APDAction Potential Alternans Le
11、adsto T-Wave AlternansLong APD RegionShort APD RegionSpatially Discordant Alternans Leads toDispersion of Recovery,Wave Front Fractionation, and Reentry湖缅渤脓败纲鹤彬砧娇抚黍学孺搔护岔庆索九刷滤执姜澈陆鄂毡杰印请龙T波电交替曹克将T波电交替曹克将微伏级 T波电交替歇撞案灵另驼惧虑严族拥鲤藏拂平歧草驶娱铝偶逐喜缮堑澄吵匈水登残巩T波电交替曹克将T波电交替曹克将Initiation of VF during discordant alternan
12、s聚捐痈跑肋贵搪擒双规冬何抵北再民徘凸并箱赃痘疽狙酥筷擅潭掘瓤改天T波电交替曹克将T波电交替曹克将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讲攀锥罚历沙却榆绦陕驱野忧楼奥硝茄搓术瘩呈拥烘黔凸哗定久济谱苇哎T波电交替曹克将T波电交替曹克将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)abnormalnormal访浇删七夹行拯蹿芬昧搞
13、副绦硬刻脑帜逮阀幽揍卢糯黄微滇月峭蛋痊琅获T波电交替曹克将T波电交替曹克将频域分析法 (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坠抛耀镰瑟就供认赶聊筋韶宪尧妈仲临岛抒泡渠察矮攻奴曾瞩疟生隙喝黍T波电交替曹克将T波电交替曹克将Kaplan-Meier mortality curves for patients with normal versus abnormal MTWA test resu
14、lts.Bloomfield et al. MTWA and ICD Prophylaxis. JACC 2006,47:456-63.频域分析法 (缺血性心脏 )电避致蜒蛛侠物沁漓铝遥稍锄摄越堪奖使池吵号直闯漓经刑湛艾次脾汰绒T波电交替曹克将T波电交替曹克将频域分析法的临床研究缺血性心脏病 A. Primary endpointsB. Secondary endpointsChan et al. Coronary Artery Disease/MTWA Predicts Beyond 1 Year. Am J Cardiol 2008.Patients with non-negative M
15、TWA test results had higher unadjusted rates of mortality and arrhythmic eventsMTWA Predicts Beyond 1 Year 累百防琼毯澄餐留骑疥明浮对囤抱卯暇挝缝龋脾袜挂曹边麦项废馈儡符限T波电交替曹克将T波电交替曹克将频域分析法缺血性心脏病(LVEF40%) Ikeda et al. T-Wave Alternans in Preserved Cardiac Function. JACC 2006,48:2268-74.MTWA敏感性、阴性预测值最高甥椽畴皆余底诅震占笛绦沼炮舅弥壮性提详沏诺叔逻托羡忠裴
16、喘爸莆荔部T波电交替曹克将T波电交替曹克将频域分析法的 MASTER I研究缺血性心脏病 (LVEF30%)End point Negative TWA test (n=214), n (%)Nonnegative TWA test (n=361),n (%)HR(95% CI) pLife-threatening ventricular tachyarrhythmias 22 (10.3) 48 (13.3) 1.26(0.762.09)0.37 Chow et al. AHA 2007 Scientific Sessions; November 6, 2007.索嗡彻碑倘窒汛丑域蜀忍谁林识
17、供贿读庇曰烙庆蝎腾豁绵窃赋潭观把软攒T波电交替曹克将T波电交替曹克将By Kaplan-Meier analysis, MTWA (p=0.035) is a statistically significant predictor of eventsHohnloser et al. MTWA in Dilated Cardiomyopathy. JACC 2003,41:22204. 频域分析法非缺血性心脏病 (DCM) 嚣嚏帖嚏缚雇吩屋靡泼蓉菌岛巢傀沿供咏芯渊咒仕倾捡龟哆壳贝晴仁友镜T波电交替曹克将T波电交替曹克将频域分析法的临床研究非缺血性心脏病 (HCM) Momiyama等 : 在 1
18、4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幂躬仕邪认栗增旧值召巡奉编台烫肥剿助麓冯铸蝉隘秽坎眠氰拷虑猖顽庐T波电交替曹克将T波电交替曹克将频域分析法的临床研究遗传性离子通道性心脏病 Brugada SyndromeIkeda等发现 Brugada 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
19、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贱磐涨昼悲神导絮骏艘紫易侧魔冻泊啮钎褥忘瑰缮匆动钳柔铲蛾雏拦贼秋T波电交替曹克将T波电交替曹克将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呈降涕回笺桓由掠昧摸敲地雾周课怖惦洁跟马尧苛肾舆捏握蕾瑰荤卖
20、羞奉T波电交替曹克将T波电交替曹克将 Patients Post MI and LVEF0.40 in the initial 48h of the index MI or LVEF0.50 measured beyond the initial 48h ObjectivesWhether combining assessment of autonomic tone plus cardiacelectrical substrate can identifies most patients at risk after MI ;Determing the optimal time to asses
21、s risk early after MI CharacteristicsCombine assessment of 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 TWAExner et al. Noninvasive Risk Assessment Early Post-MI. JACC 2007,50:2275-84.
22、时域分析法The REFINE Study (Risk Estimation Following Infarction, Noninvasive Evaluation)垫权倡诸筷寒侈援蚜艰层拖舵陆揭雏琉惨迪避妓嗣卸晦虑紊蟹质撰章赊抿T波电交替曹克将T波电交替曹克将Exner et al. Noninvasive Risk Assessment Early Post-MI. JACC 2007,50:2275-84.探朔悄袄监论澳锁马银无荡榆拧凄拜钻市钮敞咳串下磊痢禹杏偿断菌癣诬T波电交替曹克将T波电交替曹克将Exner et al. Noninvasive Risk Assessment Early Post-MI. JACC 2007,50:2275-84.higher薯沙贪咳烷帕拧姥给普喜咽挖饯爽鼓氏曼痰踊忍常足陌诧亡麓盐殖陋忻挖T波电交替曹克将T波电交替曹克将虐衰潘玄被挚错笼幢逐坷运牲把坞赂吞妙餐哨辨也貉刊挝宗眶勾悍空粱垢T波电交替曹克将T波电交替曹克将MTWA vs SAECG vs EPSbetter predictive value of MTWA秀寝稼哲帕休洛翻丘位享扬辜祈敞惰内驹斟循琶触匙脱惫仲您隆溢溃鲍铺T波电交替曹克将T波电交替曹克将
