nghiên cứu vai trò dự báo đột tử do tim bằng kết hợp luân phiên sóng t và nt probnp ở bệnh nhân suy tim

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NGHIÊN CU VAI TRÒ D T T DO TIM BNG KT HP LUÂN
PHIÊN SÓNG T VÀ NT-PROBNP  BNH NHÂN SUY TIM





nh

TWA, NT-
-


-
-ProBNP.
nghiên
- 




  -       31,38±12,14     83,24±30,98 
     -        
3595,41±5252,15 pg/ml (p<0,0001).
 µV;
AUC = 0,77 (95% CI: 0,66 - - 
(95% CI: 55,6- 79,1).
2. -
pg/ml; AUC = 0,82 (95% CI: 0,71 - -
- 80,4).

3. Luân p   <0,001); NT-

và NT- 15,03 (p<0,001).
--


ABSTRACT
Background: Decades of research now link TWA with inducible and spontaneous clinical
ventricular arrhythmias. This bench-to-bedside foundation makes TWA, NT-ProBNP a very
plausible index of susceptibility to ventricular arrythmia, and motivates the need to define
optimal combination of TWA and NT-ProBNP in predicting ventricular arrythmia in heart
failure patients. We research this study with 2 target: 1. Evaluate the role of TWA in predicting
sudden cardiac death in heart failure patients. 2. Evaluate the role of NT-ProBNP in predicting
sudden cardiac death in heart failure patients 3. Evaluate the role of the combined NT-ProBNP
and TWA in predicting sudden cardiac death in heart failure patients
Methods: Prospective study: 82 chronic heart failure patient admitted to hospital from
5/2007 to 5/2008 and 50 healthy person was done treadmill test to caculate TWA, ECG,
echocardiography, NT-ProBNP
Results: Cut-off point of NT-ProBNP in predicting sudden cardiac death is 2175 pg/ml;
AUC = 0,82 (95% CI: 0,71 - 0,89); Cut-off point of TWA in predicting sudden cardiac death is
93 µV; AUC = 0,77 (95% CI: 0,66 - 0,85.
551
NT-ProBNP can predict sudden cardiac death with OR= 9,72 (p<0,001); TWA can predict
sudden cardiac death with OR= 4,28 (p<0,01). The combined NT-ProBNP and TWA in
predicting ventricular arrythmia in heart failure patients: OR= 15,03, p<0,001.
Conclusions
The combined NT-ProBNP and TWA have the best predict value of sudden cardiac death in
heart failure patients, compare with NT-ProBNP or TWA alone.



                  

[1]
[10]-
[21]
nh
[20].

[29][18] 
 [3],[5]         



[19],[23],[26] 
[4],[8],[14]

[24].
NT- 
-
-

[12].

-

luân phiên sóng T và NT-
- 
- Nghiên -ProBNP.
- -ProBNP.




-    

- 


2.2. 




552


- 
- 
máu, luân phiên sóng T, NT-ProBNP

III





p

48,82±11,50
51,54±13,22

>0,05

Nam
26 (52,00%)
43 (52,43%)
>0,05

24 (48,00%)
39 (47,57%)
>0,05

77,24±10,95
100,74±18,18
< 0,001
HATT (mmHg)
113,20±8,44
132,20±29,13
< 0,001
HATTr (mmHg)
76,10±4,98
75,37±18,74
>0,05
BMI (kg/m
2
)
22,58±2,51
20,11±2,74
< 0,001

71,30±6,99

72,35±6,96
>0,05
VB/VM
0,85±0,06
0,82±0,04
<0,001
Creatinin máu (µmol/l)
63,00 ±12,25
90,28±17,26
< 0,001
NT-ProBNP (pg/ml)
52,69±25,46
3595,41±5252,15
< 0,001
TWA (µV)
31,38±12,14
83,24±30,98
< 0,001








p
EF (%)
71,84±7,72
40,65±13,11

< 0,0001
FS (%)
42,20±4,70
21,07±8,19
< 0,0001
AO (mm)
28,53±3,88
29,77±4,40
>0,05
AVO (mm)
19,89±2,67
19,33±3,07
>0,05
LA (mm)
32,48 ±5,42
38,54±8,99
< 0,0001
LVDd (mm)
44,76±4,53
58,92 ± 11,21
< 0,0001
LVDs (mm)
26,02±3,60
46,38 ± 12,39
< 0,0001
RV (mm)
22,01±1,81
25,96 ± 4,85
< 0,0001
N



-
-



SDX 
)(1)
Nam (
SDX 
)(2)
p(1)và (2)
17-
966,47 ±872,13
3243,26±2611,10
>0,05
30-
1675,90±1189,46
958,80±216,66
>0,05
40- 
1095,54±964,70
3162,50±2458,14
<0,05
50- 
6218,51±5120,74
2199,94±1381,85
<0,01
60- 

3209,69±2171,27
7011,43±6528,59
>0,05
p
>0,05
>0,05


3699,14±3420,04
3501,10±2157,83
>0,05
553
--49 3162,50±2458,14 pg/ml cao
h -
-


  



SDX 
)
Nam (
SDX 
)
p
17-
81,50±40,48
97,00±20,12

>0,05
30- 
90,00±35,59
67,50±7,78
>0,05
40- 
73,78±36,67
86,33±41,72
>0,05
50- 
78,93±25,51
94,86±39,51
>0,05
60- 
76,42±22,26
83,70±22,32
>0,05
p
>0,05
>0,05


78,16±26,22
88,85±33,23
>0,05

3.5. NT-
NT_ProBNP
0 20 40 60 80 100
100-Âäü âàûc hiãûu

100
80
60
40
20
0
Âäü nhaûy

3.-
-
2175 pg/ml; AUC = 0,82 (95% CI: 0,71 - 
54,3- - 80,4).
3.6. Luân phi
TWA
0 20 40 60 80 100
100-Âäü âàûc hiãûu
100
80
60
40
20
0
Âäü nhaûy

3.

µV; AUC = 0,77 (95% CI: 0,66 - (95% CI: 54,3- 
68,2 % (95% CI: 55,6- 79,1).
554
3.7. Kt hp NT-ng t vong tim mch

-

OR
p

(%)

(%)
PPV
(%)
NPV
(%)
Luân phiên sóng T
9,72
<0,001
89,29
53,85
80,65
70,00
NT-proBNP
4,28
<0,01
78,57
53,85
78,57
53,85
Luân phiên sóng T(-) NT-
proBNP (-)
0,19
>0,05

<50
76,92
<50
<50
Luân phiên sóng T(-) NT-
proBNP (+)
0,13
>0,05
<50
69,23
<50
<50
Luân phiên sóng T(+) NT-
proBNP (-)
0,43
>0,05
<50
68,29
<50
<50
Luân phiên sóng T(+) NT-
proBNP (+)
15,03
<0,001
73,21
84,62
91,11
59,46
 9,72,
p<0,01; NT- 4,28, p<0,01. Khi

- 
15,03 (p<0,001).
3.8. So sánh tn sut sinh tn gia 3 nhóm phân theo luân phiên sóng T và NT-proBNP
0 5 10 15 20 25 30
Thaïng
100
90
80
70
60
50
40
30
Táön suáút sinh täön (%)

3.-ProBNP
        - 26
 
-





-proBNP trong
t

phiên sóng T và NT-

Theo Gold M.R. [7] 




TWA(+)NT-ProBNP(+)
TWA(-)NT-ProBNP(-)
-ProBNP(+)
555



 [27],[28]

[13].

                    

[9],[15],[22].

-

-



 µV;
AUC = 0,77 (95% CI: 0,66 - - 
(95% CI: 55,6- 79,1).
2. -
pg/ml; AUC = 0,82 (95% CI: 0,71 - -
- 80,4).

    <0,001); NT-
T
và NT- 15,03 (p<0,001).


-


1. American Heart Association (2005), "Heart Disease and Stroke Statistics - 2008 Update".
2. Antonis A.Armoundas, Gordon F. Tomaselli (2002), "Pathophysiological basis and
clinical application of T-wave alternans", AmCollCardiol, 40, pp.207-217.
3. Bardy GH, Lee KL, Mark DB, et al, (2005), "Amiodarone or an implantable cardioverter-
defibrillator for congestive heart failure", N Engl J Med, 352, pp.225-237.
4. Bloomfield DM, Steinman RC, Namerow PB, et al, (2004), "Microvolt T-wave alternans
distinguishes between patients likely and patients not likely to benefit from implanted
cardiac defibrillator therapy: a solution to the Multicenter Automatic Defibrillator
Implantation Trial (MADIT) II conundrum", Circulation 110, pp.1885-1889.
5. Bristow MR, Saxon LA, Boehmer J, et al, (2004), "Cardiac-resynchronization therapy
with or without an implantable defibrillator in advanced chronic heart failure", N Engl J
Med, 350, pp.2140 -2150.
6. GE Medical Systems (2006), "T-wave Alternans physician's Guide".
7. Gold MR, Bloomfield DM, Anderson KP et al. (2000), "A comparison of T-wave
alternans, signal averaged electrocardiography and programmed ventricular stimulation
for arrhythmia risk stratification", J Am Coll Cardiol, 36, pp.22472253.
8. Gold MR, Bloomfield DM, Anderson KP, et al, (2000), "A comparison of T-wave
alternans, signal averaged electrocardiography and programmed ventricular stimulation
for arrhythmia risk stratification", J Am Coll Cardiol, 36, pp.2247-2253.
9. Ho KK, Anderson KM, Kannel WB et al. (1993), "Survival after the onset of congestive
heart failure in Framingham Heart Study subjects", Circulation, 88, pp.107-115.
556

10. Đột tử do tim và hội chứng Brugada,

11. James A de Lemos (20088), Biomakers of heart failure, The AHA Clinical Series.
12. Januzzi, JL, van Kimmenade, R, Lainchbury, J, et al. (2006), "NT-proBNP testing for
diagnosis and short-term prognosis in acute destabilized heart failure: an international
pooled analysis of 1256 patients: The International Collaborative of NT-proBNP Study",
Eur Heart J, 27, pp.330.
13. Kannel WB, Wilson PWF, D'Agostino RB et al. (1998), "Sudden coronary death in
women", Am Heart J, 136, pp.205-212.
14. 
Circulation 55, pp.574 -577.
15. Macintyre K, Capewell S, Stewart S et al. (2000), "Evidence of improving prognosis in
heart failure: trends in case fatality in 66 547 patients hospitalized between 1986 and
1995", Circulation, 102, pp.1126-1131.
16. McKee PA, Castelli WP McNamara PM (1971), "The nature history of congestive heart
failure: the Framingham study", N Engl J Med 285, pp.1441-1446.
17. MorrowDA, Braunwald E (2003), "Future of biomarkers in acute coronary syndromes:
moving toward a multimarker strategy", Circulation, (108), pp.250-252.
18. Moss AJ, Zareba W, Hall WJ, et al, (2002), "Prophylactic implantation of a
19. defibrillator in patients with myocardial infarction and reduced ejection
20. fraction", N Engl J Med, 346, pp.877- 883.
21. Narayan SM, Smith JM (2000), "Exploiting rate hysteresis in repolarization alternans to
optimize the sensitivity and specificity for ventricular tachycardia", J Am Coll Cardiol.
22. 
23. Remme W.J., Swedberg K (2001), "Guidelines for the diagnosis and treatment of chronic
heart failure", European Society of Cardiology
24. Rodeheffer RJ, Jacobsen SJ, Gersh BJ et al. (1993), "The incidence and prevalence of
congestive heart failure in Rochester, Minnesota", Mayo Clin Proc, 68(12), pp.1143-1150.
25. Rosenbaum DS, Jackson LE, Smith JM, Garan H, Ruskin JN, Cohen RJ, (1994), " Electrical
alternans and vulnerability to ventricular arrhythmias." N Engl J Med, 330, pp.235- 241.

26. Sanjiv M. Narayan (2006), "T-Wave Alternans and the Susceptibility to Ventricular
Arrhythmias", JACC, 47(2), pp.269-281.
27. Sergei Jofy, Mitchell H. Rosner (2005), "Natriuretic peptides in ESRD", American
Journal of Kidney Diseases, 46(1), pp.1-10.
28. Smith JM, Clancy E, Valeri C, Ruskin J, Cohen R, (1988), "Electrical alternans and
cardiac electrical instability", Circulation, 77, pp.110 -121.
29. The CONSENSUS Trial Study Group (1987), "Effects of enalapril on mortality in severe
congestive heart failure. Results of the Cooperative North Scandinavian Enalapril
Survival Study (CONSENSUS)", N Engl J Med, 316(23), pp.1429-1435.
30. The SOLVD Investigators (1991), "Effect of enalapril on survival in patients with
reduced left ventricular ejection fractions and congestive heart failure", N Engl J Med,
325(5), pp.293-302.
31. Zheng Z-J, Croft JB, Giles WH, Mensah GA, (2001), "Sudden cardiac death
32. in the United States 1989 to 1998." Circulation 104, pp.21582163.
33. Zipes DP, Camm AJ, Borggrefe M, et al, (2006), "ACC/AHA/ESC 2006 Guidelines for
Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden
Cardiac Death: a report of the American College of Cardiology/American Heart
Association Task Force and the European Society of Cardiology Committee for Practice
Guidelines (writing committee to develop Guidelines for Management of Patients With
Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in
collaboration with the European Heart Rhythm Association and the Heart Rhythm
Society", Circulation, 114(e385).