1、心臟指南針Cardiac Compass心衰患者接受CRT療法后如何評(píng)估CRT療效？與單純使用藥物治療有哪些不同？在整個(gè)的心衰管理當(dāng)中帶來什么變化？ 治療效果評(píng)估NYHA心功能分級(jí)6分鐘步行試驗(yàn)疾病進(jìn)展的評(píng)估癥狀惡化（HYHA心功能分級(jí)加重）因心衰加重需要增加藥物劑量或增加新藥治療因心衰或其它原因需住院治療死亡預(yù)后的評(píng)定有助于判斷心衰預(yù)后和存活的臨床參數(shù)：LVEF下降、NYHA分級(jí)惡化、靜息心動(dòng)過速、QRS波增寬、 隨訪時(shí)的臨床評(píng)價(jià)日常生活和運(yùn)動(dòng)能力容量負(fù)荷狀況并測(cè)量體重飲酒、違禁藥物及化療藥物應(yīng)用情況心衰治療評(píng)估植入患者體內(nèi)的Device，可以長(zhǎng)期監(jiān)測(cè)：心率（房、室）AT/AF事件、AF負(fù)荷

2、VT/VF事件AF期間的心室率心率變化性起搏百分比頻率應(yīng)答傳感器（活動(dòng)度）經(jīng)胸阻抗其它傳感器與心衰有什么關(guān)系？如何轉(zhuǎn)變成對(duì)患者、醫(yī)生的價(jià)值？50607080901001101207/30/978/13/978/27/979/10/979/24/9710/8/9710/22/9711/5/9711/19/97DateNight Heart Rate (bpm) and NYHA ClassI/IIIII/IVIIII/IIII/III/IIII第3次隨訪后4天因心衰惡化住院Night Heart Rate 與NYHA分級(jí)EXACT StudyHeart Rate Variability（心率變異

3、性）* ESC/NASPE Task Force. Circulation 1996;93(5):1043-65.計(jì)算頻率差異（bpm）計(jì)算時(shí)間差異（ms）對(duì)于24小時(shí)以上的監(jiān)測(cè)結(jié)果，二者呈現(xiàn)強(qiáng)相關(guān)*對(duì)于起搏器而言，計(jì)算時(shí)間差異更簡(jiǎn)單Heart Rate Variability（心率變異性）計(jì)算時(shí)間差異的方法（ms）SDNN： Standard Deviation of all Normal to Normal intervalsSDANN： Standard Deviation of 5 minute Average of Normal to Normal intervals二者具有強(qiáng)相關(guān)性

4、*SDNN/SDANN降低與HF加重相關(guān)* * Jiang, W, et. al. American Journal of Cardiology 1997;80(6):808-11* Casolo GC, et. al. European Heart Journal 1995;16(3):360-7.p0.001p0.001p0.001nsHeart Rate Variability 與NYHA分級(jí)EXACT Study0204060801001207/30/978/13/978/27/979/10/979/24/9710/8/9710/22/9711/5/9711/19/97DateHear

5、t Rate Variability (ms) and NYHA ClassI/IIIII/IVIIII/IIII/III/IIII第3次隨訪后4天因心衰惡化住院SDNN 可以是全原因死亡率和心衰進(jìn)展死亡的預(yù)測(cè)因子UK-HEART*HRV降低是CHF患者不良預(yù)后的獨(dú)立危險(xiǎn)因子 * * Nolan J, et. al. Circulation 1998;98(15):1510-16.* Ponikowski, P, et. al. American Journal of Cardiology 1997;79(12):1645-50.SDNN (ms) 100Patients Died / Pat

6、ients in Group11/2423/13920/268Annual Mortality Rate (%)51.412.75.5Cardiac DeathSurvivors p ValueSDNN8442114380.002SDANN7438107390.001HRV 作為預(yù)測(cè)因子* Casolo GC, et. al. European Heart Journal 1995;16(3):360-7.心率和心衰分級(jí)的關(guān)系日間和夜間休息心率隨心衰加重而增加*日間和夜間心率的差異隨心衰加重而減少*Patient Activity 與NYHA分級(jí)EXACT Study0.00.51.01.52

7、.02.53.03.54.04.55.05.56.06.57.007/30/9708/19/9709/08/9709/28/9710/18/9711/07/9711/27/97DateADL time (hr) per dayI/III/ IIIII/ IVII/ IIIIIIII/ II第3次隨訪后4天因心衰惡化住院Atrial High Rate (hours/day)Mean Night V. RateHeart Rate VariabilityPatient ActivityCardiac Compass: Insync IIINight Heart Rate TrendHeart R

8、ate Variability (HRV) TrendPatient Activity TrendVT/VF Episodes/dayV. Rate during VT/VFAT/AF total hours/dayV. Rate during AT/AF% Pacing/dayAvg. V. Rate (day and night)Patient ActivityHeart Rate VariabilityHeart Failure Management: Insync Marquis Pt. NameVisit DateProgram/InterrogateLast/Current Ses

9、sionPatient/Visit InformationVT/VF EpisodesShocksV. Rate during VT/VFVentricular Episode TrendsAT/AF BurdenV. Rate during AT/AFAtrial Episode TrendsPacing TrendsHeart Failure TrendsHeart Failure Management: Insync II Marquis 心臟指南針的用途評(píng)價(jià)CRT治療的有效性評(píng)價(jià)藥物治療的有效性評(píng)價(jià)、監(jiān)測(cè)患者的心衰嚴(yán)重程度回顧患者房性、室性心律失常類型、情況臨床實(shí)踐中的心臟指南針?biāo)矔r(shí)數(shù)

10、值沒有短期或長(zhǎng)期趨勢(shì)變化重要HRV = 80ms 意味什么?在過去的5周內(nèi)HRV下降的趨勢(shì)意味著什么?各種趨勢(shì)圖的相互關(guān)聯(lián)和單個(gè)趨勢(shì)圖同樣重要心房起搏增加與患者活動(dòng)度增加相關(guān)嗎? * Nul DR, et. al. Journal of the American College of Cardiology 1997;29(6):1199-205.* Goldsmith, RL, et. al. American Journal of Cardiology 1997;80(8):1101-4.心衰監(jiān)測(cè)趨勢(shì)圖的臨床應(yīng)用心率降低可以被用來評(píng)估胺碘酮的劑量*HRV 可以被用來評(píng)估卡維地絡(luò)的療效*卡維地

11、絡(luò)治療前: SDNN = 447卡維地絡(luò)治療中: SDNN = 616發(fā)生了什么?6月的隨訪發(fā)現(xiàn)上次隨訪后AT/AF顯著增加心室率增加活動(dòng)度降低心率變異性降低10月中旬的隨訪發(fā)現(xiàn)上次隨訪后AT/AF顯著降低起搏需求迅速上升活動(dòng)度和心室率回升到基礎(chǔ)水平心率變異性增加心臟指南針 Cardiac Compass的優(yōu)勢(shì)長(zhǎng)期監(jiān)測(cè)CRT-P：6個(gè)月 8042，其余都是14個(gè)月CRT-D：14個(gè)月“Free”不會(huì)因這些功能打開而影響工作年限EGM 存儲(chǔ)不降低自動(dòng)不需程控或調(diào)整任何參數(shù)打印后更容易解讀一張A4紙三張程控儀打印紙VentricularAtrialBrady / Heart FailureCase

12、 Study: Insync IIIAF的發(fā)現(xiàn)和管理Patient History67 year old maleIschemic heart diseaseCABG, Post-MILVEF 30%Normal sinusno history of AF160 ms QRS durationMaximum medsACE-I, -blocker, DiureticInSync III system implanted 25 April 2001Complains of feeling badly, admitted to hospital on 17 AugustFollow-up on 1

13、8 AugustDetection :18 August: Programmed Parameters & Significant Events AF Verified Effect on V Rate suspected 18 August: Atrial High Rate EpisodesAF Classified:FrequencyBurden18 August: Atrial High Rate TrendConfirmCause ofPatient Symptoms18 August: Ventricular Rate Histogram During Atrial High Ra

14、te Episodes Amiodarone (400 BID)HeparinMode Switch Turned ON18 August: Therapy Initiated22 October: Return for Follow-upMonitor Therapy: Ventricular Rate During AHRRx InitiatedFollow-upMonitor Therapy: Atrial High Rate TrendTherapyInitiated22 October Follow-upObservations on Autonomic ResponseBackup

15、 SlidesHRV and HFSDNN / SDANN 是功能性損傷增加的顯示器p0.001p0.001p0.001ns* Casolo GC, et. al. European Heart Journal 1995;16(3):360-7.How do Guidants Contak Renewal Diagnostics Compare?They Dont!Guidants FootprintLooks like an ink blotOpen to many interpretationsUseful for Clinical Decisions?Guidants HRV FootprintGuida