Zabel M, Klingenheben T, Hohnloser S H
Department of Cardiology, University of Freiburg, Germany.
J Cardiovasc Electrophysiol. 1994 Mar;5(3):211-8. doi: 10.1111/j.1540-8167.1994.tb01158.x.
Little data are available on changes in autonomic tone during the first 24 hours of acute infarction in patients undergoing thrombolytic therapy. Particularly, the association of changes in autonomic tone to reperfusion of the infarct-related artery has not been evaluated in man. Heart rate variability (HRV) is a noninvasive tool to assess cardiac autonomic tone, which carries prognostic information in postinfarction patients.
To assess changes in autonomic tone with angiographically assessed success of thrombolysis in patients with acute infarction, the proportion of adjacent RR intervals different by greater than 50 msec (pNN50) was analyzed from 24-hour Holter monitoring initiated before the start of thrombolytic therapy in 103 consecutive patients. Mean heart rate (HR) and pNN50 were available in 95 of 103 patients and were separately analyzed for the first hour after initiation of thrombolysis (reperfusion phase) and the first 24 hours. As assessed by coronary angiography 90 minutes after start of thrombolysis, 74 patients (78%) had successful coronary artery reperfusion. HR averaged 72 +/- 13/min for the first hour in all 95 patients and 74 +/- 13/min for the first 24 hours. The respective values for pNN50 were 11.2% +/- 11.7% for the first hour and 9.7% +/- 9.2% for the first 24 hours. Patients with inferior myocardial infarction (MI) had a lower mean HR of 72 +/- 12/min versus 76 +/- 13/min (P = 0.11) and a higher pNN50 (11.2% +/- 9.8% versus 7.6% +/- 8.3%, P = 0.01) compared to patients with anterior MI. The mean HR correlated weakly with pNN50 (r = -0.33, P < 0.01). For patients with coronary artery patency after 90 minutes, mean HR was 70 +/- 12/min for the first hour compared to 80 +/- 13/min for patients without (P = 0.003). For the first 24 hours, these values were 72 +/- 12/min compared to 80 +/- 14/min (P = 0.02). For the first hour, pNN50 averaged 12.6% +/- 12.4% for patients with successful reperfusion compared to 6.6% +/- 7.3% for patients without (P = 0.024). For the first 24 hours, these values were 9.2% +/- 8.5% compared to 11.5% +/- 11.3% (P = NS). Patients with in-hospital ventricular fibrillation (n = 8) had a higher mean HR throughout the first 24 hours (88 +/- 16/min vs 73 +/- 12/min, P = 0.008) compared to patients with an uneventful course. Additionally, there was a trend toward a lower HRV in patients with ventricular fibrillation.
Thrombolysis-induced reperfusion of the infarct-related artery results in a higher vagal tone during the early hours of MI as compared to failed reperfusion. This finding is independent from infarct location and associated with a trend toward a lower incidence of ventricular fibrillation during the acute phase of infarction.
关于接受溶栓治疗的患者在急性梗死最初24小时内自主神经张力变化的数据很少。特别是，自主神经张力变化与梗死相关动脉再灌注之间的关联在人体中尚未得到评估。心率变异性（HRV）是评估心脏自主神经张力的一种非侵入性工具，它在心肌梗死后患者中携带预后信息。
为了评估急性梗死患者溶栓血管造影成功时自主神经张力的变化，对103例连续患者在溶栓治疗开始前进行的24小时动态心电图监测中相邻RR间期相差大于50毫秒（pNN50）的比例进行了分析。103例患者中有95例可获得平均心率（HR）和pNN50，并分别在溶栓开始后的第一小时（再灌注期）和最初24小时进行分析。溶栓开始90分钟后通过冠状动脉造影评估，74例患者（78%）冠状动脉再灌注成功。所有95例患者第一小时的HR平均为72±13次/分钟，最初24小时为74±13次/分钟。pNN50的相应值在第一小时为11.2%±11.7%，最初24小时为9.7%±9.2%。与前壁心肌梗死患者相比，下壁心肌梗死（MI）患者的平均HR较低，为72±12次/分钟对76±13次/分钟（P = 0.11），pNN50较高（11.2%±9.8%对7.6%±8.3%，P = 0.01）。平均HR与pNN50弱相关（r = -0.33，P < 0.01）。90分钟后冠状动脉通畅的患者第一小时的平均HR为70±12次/分钟，而未通畅的患者为80±13次/分钟（P = 0.003）。最初24小时，这些值分别为72±12次/分钟对80±14次/分钟（P = 0.02）。第一小时，再灌注成功的患者pNN50平均为12.6%±12.4%，未成功的患者为6.6%±7.3%（P = 0.024）。最初24小时，这些值分别为9.2%±8.5%对11.5%±11.3%（P = 无显著性差异）。与病程平稳的患者相比，院内发生心室颤动的患者（n = 8）在最初24小时内的平均HR更高（88±16次/分钟对73±12次/分钟，P = 0.008）。此外，心室颤动患者的HRV有降低的趋势。
与再灌注失败相比，溶栓诱导的梗死相关动脉再灌注在心肌梗死早期导致更高的迷走神经张力。这一发现与梗死部位无关，并与梗死急性期心室颤动发生率降低的趋势相关。
