更新CARDIAC-COMPASS.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,|Cardiac Compass,*,|MDT Confidential,*,|MDT Confidential,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,心脏指南针,Cardiac Compass,心衰患者接受CRT疗法后,如何评估CRT疗效？,与单纯使用药物治疗有哪些不同？,在整个的心衰管理当中带来什么变化？,治疗效果评估,NYHA,心功能分级,6,分钟步行试验,疾病进展的评估,症状恶化（,HYHA,心功能分级加重）,因心衰加重需要增加药物剂量或增加新药治疗,因心衰或其它原因需住院治疗,死亡,预后的评定,有助于判断心衰预后和存活的临床参数：,LVEF,下降、,NYHA,分级恶化、静息心动过速、,QRS,波增宽、,随访时的临床评价,日常生活和运动能力,容量负荷状况并测量体重,饮酒、违禁药物及化疗药物应用情况,心衰治疗评估,植入患者体内的Device，可以长期监测：,心率（房、室）,AT/AF,事件、,AF,负荷,VT/VF,事件,AF,期间的心室率,心率变化性,起搏百分比,频率应答传感器（活动度）,经胸阻抗,其它传感器,与心衰有什么关系？,如何转变成对患者、医生的价值？,50,60,70,80,90,100,110,120,7/30/97,8/13/97,8/27/97,9/10/97,9/24/97,10/8/97,10/22/97,11/5/97,11/19/97,Date,Night Heart Rate (bpm)and NYHA Class,I/II,III/IV,II,II/III,I/II,I/II,II,第,3,次随访后,4,天因心衰恶化住院,Night Heart Rate 与NYHA分级,EXACT Study,Heart Rate Variability（心率变异性）,*ESC/NASPE Task Force.Circulation 1996;93(5):1043-65.,计算频率差异（bpm）,计算时间差异（ms）,对于24小时以上的监测结果，二者呈现强相关*,对于起搏器而言，计算时间差异更简单,Heart Rate Variability（心率变异性）,计算时间差异的方法（,ms,）,SDNN,：,S,tandard,D,eviation of all,N,ormal to,N,ormal intervals,SDANN,：,S,tandard,D,eviation of 5 minute,A,verage of,N,ormal to,N,ormal intervals,二者具有强相关性*,SDNN/SDANN,降低与,HF,加重相关*,*,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.,p0.001,p0.001,p0.001,ns,Heart Rate Variability 与NYHA分级,EXACT Study,0,20,40,60,80,100,120,7/30/97,8/13/97,8/27/97,9/10/97,9/24/97,10/8/97,10/22/97,11/5/97,11/19/97,Date,Heart Rate Variability(ms)and NYHA Class,I/II,III/IV,II,II/III,I/II,I/II,II,第,3,次随访后,4,天因心衰恶化住院,SDNN,可以是全原因死亡率和心衰进展死亡的预测因子,UK-HEART*,HRV,降低是,CHF,患者不良预后的独立危险因子*,*,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),100,Patients Died/Patients in Group,11/,24,23/,139,20/,268,Annual Mortality Rate(%),51.4,12.7,5.5,Cardiac Death,Survivors,p Value,SDNN,8442,11438,0.002,SDANN,7438,10739,0.001,HRV 作为预测因子,*,Casolo GC,et.al.European Heart Journal 1995;16(3):360-7.,心率和心衰分级的关系,日间和夜间休息心率随心衰加重而增加*,日间和夜间心率的差异随心衰加重而减少*,Patient Activity 与NYHA分级,EXACT Study,0.0,0.,5,1.0,1.,5,2.0,2.,5,3.0,3,.5,4.0,4.,5,5.,0,5.,5,6.0,6.,5,7.,0,07/30/97,08/19/97,09/08/97,09/28/97,10/18/97,11/07/97,11/27/97,Date,ADL time(,hr),per day,I/II,I/II,III/IV,II/III,II,II,I/II,第,3,次随访后,4,天因心衰恶化住院,Atrial High Rate(hours/day),Mean Night V.Rate,Heart Rate Variability,Patient Activity,Cardiac Compass:,Insync III,Night Heart Rate Trend,Heart Rate Variability(HRV)Trend,Patient Activity Trend,VT/VF Episodes/day,V.Rate during VT/VF,AT/AF total hours/day,V.Rate during AT/AF,%Pacing/day,Avg.V.Rate(day and night),Patient Activity,Heart Rate Variability,Heart Failure Management:,Insync Marquis,Pt.Name,Visit Date,Program/Interrogate,Last/Current Session,Patient/Visit Information,VT/VF Episodes,Shocks,V.Rate during VT/VF,Ventricular Episode Trends,AT/AF Burden,V.Rate during AT/AF,Atrial Episode Trends,Pacing Trends,Heart Failure Trends,Heart Failure Management:,Insync II Marquis,心脏指南针的用途,评价CRT治疗的有效性,评价药物治疗的有效性,评价、监测患者的心衰严重程度,回顾患者房性、室性心律失常类型、情况,临床实践中的心脏指南针,瞬时数值没有短期或长期趋势变化重要,HRV=80ms,意味什么,?,在过去的,5,周内,HRV,下降的趋势意味着什么,?,各种趋势图的相互关联和单个趋势图同样重要,心房起搏增加与患者活动度增加相关吗,?,*,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.,心衰监测趋势图的临床应用,心率降低可以被用来评估胺碘酮的剂量*,HRV,可以被用来评估卡维地络的疗效*,卡维地络治疗前,:SDNN=447,卡维地络治疗中,:SDNN=616,发生了什么?,6,月的随访发现上次随访后,AT/AF,显著增加,心室率增加,活动度降低,心率变异性降低,10,月中旬的随访发现上次随访后,AT/AF,显著降低,起搏需求迅速上升,活动度和心室率回升到基础水平,心率变异性增加,心脏指南针 Cardiac Compass的优势,长期监测,CRT-P,：,6,个月,CRT-D,：,14,个月,“,Free”,不会因这些功能打开而影响工作年限,EGM,存储不降低,自动,不需程控或调整任何参数,打印后更容易解读,一张,A4,纸,三张程控仪打印纸,Ventricular,Atrial,Brady/Heart Failure,Case Study:Insync III,AF,的发现和管理,Patient History,67 year old male,Ischemic heart diseaseCABG,Post-MI,LVEF 30%,Normal sinusno history of AF,160 ms QRS duration,Maximum medsACE-I,-blocker,Diuretic,InSync III system implanted 25 April 2001,Complains of feeling badly,admitted to hospital on 17 August,Follow-up on 18 August,Detection:,18 August:Programmed Parameters&Significant Events,AF Verified,Effect on V Rate suspected,18 August:Atrial High Rate Episodes,AF Classified:,Frequency,Burden,18 August:Atrial High Rate Trend,Confirm,Cause of,Patient,Symptoms,18 August:Ventricular Rate Histogram During Atrial High Rate Episodes,Amiodarone(400 BID),Heparin,Mode Switch Turned ON,18 August:Therapy Initiated,22 October:Return for Follow-up,Monitor Therapy:Ventricular Rate During AHR,Rx Initiated,Follow-up,Monitor Therapy:Atrial High Rate Trend,Therapy,Initiated,22 October Follow-up,Observations on Autonomic Response,Backup Slides,HRV and HF,SDNN/SDANN,是功能性损伤增加的显示器,p0.001,p0.001,p0.001,ns,*,Casolo GC,et.al.European Heart Journal 1995;16(3):360-7.,How do Guidants,Contak Renewal Diagnostics Compare?,They Dont!,Guidants Footprint,Looks like an ink blot,Open to many interpretations,Useful for Clinical Decisions?,Guidants HRV Footprint,Guidant says:X%change in footprint=patient improvement?,The Footprint is a,24-hour,“snapshot”of HRV,Guidants Activity Trend,Displays%of Day Active.what does that equate in Hours?,Daily average for last 7 days,weekly average for 12 months,