影像科学与光化学  2019, Vol. 37 Issue (6): 584-590  DOI: 10.7517/issn.1674-0475.190525   PDF    
超声心动图结合心电图在鉴别扩张性和缺血性心肌病中的应用
简雅婷, 胡剑, 邓冰晴     
恩施土家族苗族自治州中心医院 超声诊断中心, 湖北 恩施 445000
摘要: 本文对超声心动图(UCG)结合心电图(ECG)在鉴别扩张性心肌病(DCM)和缺血性心肌病(ICM)中的应用价值进行了分析。研究对象为回顾性选取2015年12月~2018年12月本院DCM组和ICM组患者各80例,两组均给予UCG和ECG检查并分析比较其表现。结果显示,DCM组室壁节段性运动障碍、左室心尖圆而薄、左室圆拱门形、室壁矛盾运动发生率明显低于ICM组,DCM组弥漫性室壁运动障碍、左室球形发生率明显高于ICM组,差异有统计学意义(P < 0.05);DCM组左心房内径、左心室舒张期内径、左心室收缩期内径、右心室内径、二尖瓣E点至室间隔间距、E/A、RV6、RV6/RMAX明显高于ICM组,DCM组主动脉、左心室射血分数、每搏量明显低于ICM组,差异有统计学意义(P < 0.05);DCM组主动脉瓣、二尖瓣、三尖瓣反流程度明显高于ICM组,差异有统计学意义(P < 0.05);四格表法结果显示,UCG结合ECG鉴别DCM和ICM的敏感度、特异度、准确度为97.50%、96.25%和96.88%,与实际结果基本相同,差异无统计学意义(P>0.05)。本文证实了UCG结合ECG监测可为鉴别DCM和ICM提供重要的参考依据,可作为鉴别DCM和ICM的重要手段。
关键词: 超声心动图    心电图    鉴别    扩张性心肌病    缺血性心肌病    
The Application of Echocardiography Combined with Electrocardiogram in the Eifferential Diagnosis of Dilatation and Ischemic Cardiomyopathy
JIAN Yating, HU Jian, DENG Bingqing     
Ultrasound Diagnostic Center, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi 445000, Hubei, P. R. China
*Corresponding author: JIAN Yating, E-mail: 992165564@qq.com
Abstract: The application of echocardiography (UCG) combined with electrocardiogram (ECG) in the differential diagnosis of dilated cardiomyopathy (DCM) and ischemic cardiomyopathy (ICM) was analyzed. 80 cases of DCM (group DCM) and ICM (group ICM) in our hospital were selected as the subjects of study from December 2015 to December 2018. The two groups were examined by UCG and ECG and analyzed and compared. The results showed that the incidence of ventricular wall segmental dyskinesia, left ventricular apical round and thin, left ventricular circular arch, and ventricular wall motion of DCM group was significantly lower than ICM group, the incidence of diffuse ventricular wall movement disorder and left ventricle sphericity of group DCM was significantly higher than that ICM group, the difference was statistically significant (P < 0.05). The left atrial diameter, left ventricular diastolic diameter, left ventricular systolic diameter, right ventricular diameter, mitral valve E point to interventricular septum spacing, E/A, RV6 and RV6/RMAX of DCM group were significantly higher than those in ICM group, the aorta, left ventricular ejection fraction and stroke volume of DCM group were significantly lower than that in group ICM, the difference was statistically significant (P < 0.05). The degree of reflux of aortic valve, mitral valve and three tips of DCM group was significantly higher than that ICM group, the difference was statistically significant (P < 0.05). Table four showed that the sensitivity, specificity and accuracy of UCG combined with ECG to identify DCM and ICM were 97.50%, 96.25% and 96.88%, respectively. The results were basically the same as the actual results, the difference was not statistically significant (P>0.05). This study confirms that UCG combined with ECG monitoring can provide important reference for the identification of DCM and ICM, and can be used as an important means to identify DCM and ICM, which is worth for further clinical promotion.
Key words: echocardiography    electrocardiogram    identification    dilated cardiomyopathy    ischemic cardiomyo-pathy    

扩张型心肌病(dilated cardiomyopathy, DCM)是一种原因未明的弥散性心肌损伤,缺血性心肌病(ischemic cardiomyopathy, ICM)则是由冠状动脉粥样硬化、多支血管管腔狭窄引起长期心肌缺血,导致心肌弥漫性纤维化引起的原发性心肌疾病。两种疾病的特征均伴有心室收缩功能减退,伴或不伴充血性心力衰竭或房性心律失常,病情严重可引起心力衰竭,且临床诊断难以区分易造成误诊,同时随着我国开始进入老龄化时代,该病的发生率有明显上升的趋势,严重危及患者的生命安全[1, 2]。有研究显示,超声心动图(echocardiography, UCG)、心电图(electrocardiogram, ECG)可有效诊断及鉴别上述病情,但有关两者联合诊断的报道较少[3, 4]。对此,本研究通过回顾性分析DCM和ICM患者的UCG、ECG检查情况,探讨两者结合鉴别DCM和ICM的价值。

1 资料与方法 1.1 一般资料

研究对象纳入标准:1)符合中华医学会心血管病学分会《心肌病诊断与治疗建议》标准[5]; 2)无精神病病史; 3)无畸形心脏病等; 4)患者或其家属签署知情同意书。排除标准:1)妊娠及哺乳特殊人群; 2)体质过敏者; 3)有心、肝、肾等严重性疾病; 4)拒绝或终止本次研究者。

研究对象为2015年12月~2018年12月本院DCM和ICM患者各80例,其中DCM组:男43例,女37例,年龄35~72岁,平均年龄(50.01±5.64)岁;病程1~9年、平均(5.54±3.25)年;心功能分级:Ⅱ级22例,Ⅲ级30例,Ⅳ级28例。ICM组:男45例,女35例,年龄36~73岁,平均年龄(50.12±5.66)岁;病程2~10年、平均(6.24±3.19)年;心功能分级:Ⅱ级24例,Ⅲ级31例,Ⅳ级25例。本次研究经过我院伦理委员会审批且通过,两组在性别、年龄、病程、心功能分级方面比较无显著差异(P>0.05),具有可比性。

1.2 实验方法

所有患者在治疗前应保持充足的睡眠时间和良好的睡眠质量,均给予UCG、ECG检查。UCG:两组患者均采取左侧卧位,采用彩色多普勒超声诊断仪(Philips-IU22),设置探头频率3.5~5.0 MHz,对心底大血管短轴、乳头肌水平短轴、心尖四腔心、左心室长轴、二尖瓣水平短轴、心尖短轴、心尖两腔心切面进行扫查,仔细观察左心室乳头肌水平以下的心尖处心肌是否增厚及心脏内部结构、心肌回声有无改变;ECG:两组均采取平卧位,采用12导联心电图机(福田光电子,FX-740 Cardimax,12导),通过检查所得的T波伴随ST段的关系,判断患者的临床病症。以上指标和图像均由两名专业医务人员进行记录。

1.3 观察指标和标准 1.3.1 观察指标

包括各房室的大小、形态及大血管内径,室壁厚度、结构及室壁运动幅度,各组瓣膜形态及其开关功能,瓣口反流情况,并评价心脏收缩期至舒张期房室大小形态的变化,测量左心室舒张末期内径、左心室收缩末期内径、左心房内径、二尖瓣E点至室间隔间距、E/A、RV6、RV6/RMAX、主动脉左心室射血分数、每搏输出量等心功能各项指标。

1.3.2 瓣膜反流程度分级标准[6]

轻度:反流束面积<4 cm2,中度:4 cm2≤反流束面积≤8 cm2,重度:反流面积>8 cm2

1.3.3 阅片标准[7]

由两名高年资(从事该心血管病诊断3年以上且取得高级证书)的医师,在双盲下参照《心肌病诊断与治疗建议》标准,进行影像学评估以鉴别DCM和ICM。意见不一时由另一名同等资历医师参与评估,最终结果遵从少数服从多数原则。

1.4 统计学分析

采用SPSS 22.0统计软件处理数据,对计数资料以(%)表示,采用χ2检验;对计量资料以( x±s)表示,采用t检验;对等级资料采用秩和Z检验;对UCG结合ECG诊断新生儿DCM的效能采用四格表法分析,在P < 0.05时,认为差异有统计学意义。

2 结果 2.1 两组检测的心脏形态学表现

DCM组室壁节段性运动障碍、左室心尖圆而薄、左室圆拱门形、室壁矛盾运动发生率明显低于ICM组,DCM组弥漫性室壁运动障碍、左室球形发生率明显高于ICM组,差异有统计学意义(P < 0.05),见表 1

表 1 两组检测的心脏形态学表现比较[n(%)] Comparison of heart morphology between two groups [n(%)]
2.2 两组心功能指标及心电图测值比较

DCM组左心房内径、左心室舒张期内径、左心室收缩期内径、右心室内径、二尖瓣E点至室间隔间距、E/A、RV6、RV6/RMAX明显高于ICM组,DCM组主动脉、左心室射血分数、每搏量明显低于ICM组,差异有统计学意义(P < 0.05),见表 2

表 2 两组心功能指标及心电图测值比较(x±s) Comparison of cardiac function and ECG between two groups [n(%)]
2.3 两组各瓣膜反流情况比较

DCM组主动脉瓣、二尖瓣、三尖瓣反流程度明显高于CM组,差异有统计学意义(P < 0.05),见表 3

表 3 两组各瓣膜反流情况比较[n(%)] Comparison of valvular regurgitation between two groups [n(%)]
2.4 四格表法结果比较

四格表法结果显示,UCG结合ECG鉴别DCM和ICM的敏感度、特异度、准确度分别为97.50%(78/80)、96.25%(77/80)、96.88%(155/160);与实际金标准结果基本相同,差异无统计学意义(P>0.05),见表 4

表 4 UCG结合ECG鉴别DCM和ICM的效能分析(n) Efficiency analysis of UCG combined with ECG in identifying DCM and ICM (n)
3 分析与结论

心肌病是一组由于心脏下部分腔室的结构改变和心肌壁功能受损,导致心脏功能进行性障碍的病变。常见的心肌病型有DCM和ICM,两种病症无明显特异性且后期临床症状有明显的相似性,易造成误诊而导致病情迁延发展,加剧社会负担,影响患者的生存质量,故如何针对性地诊断患者病症具有重要的临床意义[8, 9]。近年来,随着医学技术的进一步发展,超声诊断在医疗领域内已被广泛应用,其中以UCG最为常见。可利用超声技术来检查心脏和血管状况,利用高频声波来显示心脏图像,有效判断血流速度和血流方向,得到心脏大小和形状、泵血能力、组织受损位置和范围[10]等信息。也有研究显示,ECG可将心脏部位以电压及波振的形式显像出来,通过观察ST段是否发生位移等情况进行鉴定。两种检测方法均有利于医生判断其病情[11, 12]

本研究通过回顾性分析DCM和ICM患者UCG、ECG检查结果,发现两种病症在UCG、ECG检查下均会出现心脏形态学的表现异常, DCM组室壁节段性运动障碍、左室心尖圆而薄、左室圆拱门形、室壁矛盾运动发生率明显低于ICM组,DCM组弥漫性室壁运动障碍、左室球形发生率明显高于ICM组,在其设备的检测下,可明显发现ICM发病累及左室,以左室扩大、心尖圆钝、圆拱门形的心脏形态等为主要表现[13, 14]。而DCM患者由于心肌松弛张力下降,累及多个房室,以球形左室、室壁活动呈弥漫性减弱等为主要表现[15]

同时,研究中DCM组左心房内径、左心室舒张期内径、左心室收缩期内径、右心室内径、二尖瓣E点至室间隔间距、E/A、RV6、RV6/RMAX明显高于ICM组,DCM组主动脉、左心室射血分数、每搏量明显低于ICM组,表明两种病症在心功能指标及心电图上也有明显的特异性。这有可能由于DCM患者的心肌松弛张力下降,原本的弥散性运动消减,造成心脏呈现扩张状态,导致多个房室的内径出现扩张现象,继而使心脏顺时针转位,心室除极向量向后增加,右室膈面向下的心电向量成分较多,从而使V6导联的R波振幅上升,同时由于心肌收缩功能受损,心肌本身粘弹性降低及细胞内钙离子失衡导致左心室的舒张功能受损,左心室的射血时间也相应减少,导致每搏量降低[16, 17]。而ICM发病时心脏仅发生局部扩张,缺血严重部位的节段性运动障碍及室壁矛盾运动更为凸显,缺血程度较轻部位的局部运动程度减弱或异常,供血正常部位则正常活动,且不会出现扩大情况,其各房室内径较为正常,同时加剧了左心室射血能力,继而导致主动脉每搏量上升。DCM组主动脉瓣、二尖瓣、三尖瓣反流程度明显高于ICM组,这有可能是由于DCM患者心脏大范围扩张从而导致各个瓣膜关闭不全,而ICM心脏一般只发生局部性扩大,反流才会更集中于各个尖瓣膜处[18, 19]

此外,本研究的四格表法结果显示,UCG结合ECG鉴别DCM和ICM的敏感度、特异度、准确度分别为97.50%、96.25%、96.88%,与实际结果基本相同,进一步提示UCG结合ECG检查在诊断DCM和ICM病情方面具有确切的准确度,其鉴别效果较为接近临床结果,且该方法具备无创、操作简单、重复性好、花费低等优点,能够为两种病症提供较为科学、准确的数值标准,有利于患者及时对症治疗[20]

综上所述,UCG结合ECG监测可为鉴别DCM和ICM提供重要的参考依据,可作为鉴别DCM和ICM的重要手段,值得临床作进一步推广。

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