臺灣博碩士論文加值系統

背景­心電圖的T波代表了心室再偏極化的過程，由於心室再偏極化與心律不整是息息相關的，因此在此之前,有許多方法已被用來偵測 T-wave的型態.。T-wave alternans 已被顯示是個有效評估心臟衰竭病人的非侵襲性危險因子評估的工具，但需要運動測試；QT interval dispersion (QTd)被認為是一個評估心電圖心室再極化的多樣性的簡單指標，雖然初期有不錯的結果，但最新的證據顯示QTd缺乏可預測性。近年來，Acar等人已發展一個新的方法去計量心室再極化空間與時間變異，這個方法是基於一個名為單一值分解(singular value decomposition)的數學技術，導程心電圖的八個獨立電極(I, II, V1 to V6)被分解成三個導程的子空間且計算數個新的T波型態的新描述符號，這個新的測量方法中的一些描述符號在最近也被證實可以用來預測心肌梗塞後病人存活的預測指標.。 此外，根據同樣的數學方法，Malik從剩下的五個導程發展出一個名為T-wave residuum(TWR)的參數，且它的預測性更強。這個新的測量方法在最近也被證實可以用來預測嚴重心臟衰竭病人發生致命心室心律不整，因此用這些非侵襲性的方法來評估病人是否有心因猝死的危險是很有臨床意義的。 末期腎衰竭的病人有一半死於心臟血管疾病，但是心電圖的T波型態分析於末期腎衰竭病人臨床意義在文獻中從未被提及, 本研究是一個回溯性追蹤研究，目的在了解剛進入血液透析病人的十二導程心電圖其中的T波波形在做了新的T波型態分析後，其描述符號對這群病人之後的總死亡、心血管死亡與心律不整死亡率的相關性。
方法與結果­本研究收集了於1998年至2005年於恩主公醫院開始血液透析的末期腎衰竭病人，追蹤至2006年9月；總共有336個病人被納入研究，其心電圖中T波用新的T波分析方法來分析。在336位病人當中有159（47.3%）位於追蹤過程中死亡，其平均追蹤時間是25.47+21.5個月。在直接比較心血管死亡與非新血管死亡的病人後發現新的T波描述符號中的relative T-wave residium能預測心血管死亡(0.20+0.20% versus 0.25+0.21%, P=0.003)。在Cox regression模型中，relative T-wave residium是心血管死亡(relative risk [RR]=1.999; P =0.005)與心律不整死亡(RR=2.238; P =0.006)的獨立影響因子。
結論-本研究發現了在心電圖代表了心肌細胞再極化過程中的變異性的Relative T-wave residuum這個描述符號，對於血液透析的末期腎衰竭病人的心血管死亡與心律不整死亡是個獨立的預測因子。

Background—Cardiovascular disease remains the most common cause of death in end-stage renal disease (ESRD). Different attempts have been made to use the 12-lead surface electrocardiogram (ECG) for risk stratification of patients prone to cardiac mortality, in particular sudden cardiac death. Recently, novel descriptors of T-wave morphology have been suggested as measures of repolarization heterogeneity and adverse prognosis in nonuremic populations. However, whether these T-wave descriptors provide prognostic information in uremic populations has not been examined. The present study aimed to determine the prognostic value of novel T-wave morphology variables in predicting total, cardiovascular, and arrhythmia-related mortality in ESRD patients initiating hemodialysis.
Methods and Results—The study was a retrospective cohort of adult ESRD patients starting hemodialysis between 1998 and 2005; follow-up was until Sep. 2006. A total of 336 patients were studied. Novel ECG variables characterizing repolarization and the T-wave loop were analyzed. Of 336 patients with technically analyzable data, 159 (47.3%) died after a mean follow-up of 25.47+21.5 months. Direct comparison between cardiovascular death and non-cardiovascular death patients showed that the so-called relative T-wave residium (the relative amount of nondipolar contents within the T wave) predicted cardiovascular mortality (0.20+0.20% versus 0.25+0.21%, P=0.003). In Cox modeling, relative T-wave residium was an independent predictor of cardiovascular (relative risk [RR]=1.999; P =0.005) and arrhythmia-related mortality (RR=2.238; P =0.006).
Conclusions—The heterogeneity of myocardial repolarization, measured by the so-called relative T-wave residuum in the ECG, appears to be an independent predictor of cardiovascular and arrhythmia-related mortality in patients initiating hemodialysis.

口試委員會審定書..........................................1
中文摘要……………………………………………………………2
英文摘要…………………………………………….………………..4
目錄………………………………….…………..…………….…..6
圖目錄.…………………………………………………….………....34
圖1說明………………………………………………………………….34
圖1A……………..…………….…………..………………………….35
圖1B………...……………….………………..………………….…35
表目錄..…………………………………………………………………27
表 1......................................................27
表 2......................................................28
表 3......................................................30
表 4......................................................32
引言……..……………...……………….….……..……..........8
研究工具與方法……..………………….……………………........9
病人…..……………………………………………………...……...9
基本資料收集………..…………………………...…………………10
病人的結果………………………………………...…..……………11
QT間隔與QT變異的心電圖分析………….…………………..……12
分析新的T波型態的描述符號.…….……………..…….……………13
統計分析方法…..………………………………………………..15
結果….……………………………………………………….…………15
病人的統計學與追蹤資料………………….………...……..……16
T波分析資料………...…………..…………………………..……17
T波型態傳統，再極化指標與臨床變項的相關性…...………………17
生存分析： Kaplan-Meier 估計法與Cox回歸………………………18
討論…………………………………………………………………..…19
心室再極化非侵襲性的評估與它在預測風險的角色……..…………20
其他T波變相與危險預測……..…………………………….…………23
研究含意與未來方向………….……………………………………..25
研究限制……………………………………..…………………………25
致謝………………………………………………………….…………26
參考文獻..………………………………………………………....36

1. Morrison G, Michelson EL, Brown S, Morganroth J: Mechanism and prevention of cardiac arrhythmias in chronic hemodialysis patients. Kidney Int 1980; 17: 811-819.
2. Abe S,Yoshizawa M, Nakanishi N, Yazawa T, Yokota K, Honda M, Sloman G: Electrocardiographic abnormalities in patients receiving hemodialysis. Am Heart J 1996; 131: 1137-1144.
3. Pye MP, Cobbe SM: Mechanisms of ventricular arrhythmias in cardiac failure and hypertrophy. Cardiovasc Res 1992; 26: 740-750.
4. Han J, GK Moe: Non-uniform recovery of excitability in ventricular muscle. Cir Res 1964; XIV: 44-60.
5. Kuo CS, Munakata K, Reddy P, Surawicz B: Characteristics and possible mechanism of ventricular arrhythmia dependent on the dispersion of action potential durations. Circulation 1983; 67: 1355-1367.
6. Klingenheben T, Zabel M, D’Agostino RB, Cohen R J, Hohnloser S H: Predictive value of T-wave alternans for arrhythmic events in patients with congestive heart failure. Lancet 2000; 356: 651-652.
7. Day CP, McComb JM, RQ Campbell: QT dispersion: An indication of arrhythmia risk in patients with long QT intervals. Br Heart J 1990; 63: 342-344.
8. Hnatkova K, Malik M, Kautzner J, Gang Y, Camm AJ: Adjustment of QT dispersion assessed from 12 lead electrocardiograms for different numbers of analyzed electrocardiographic leads: Comparison of stability of different methods. Br Heart J 1994; 72: 390-396.
9. Barr CS, Naas A, Freeman M, Lang CC, Struthers AD: QT dispersion and sudden unexpected death in chronic heart failure. Lancet 1994; 343: 327-329.
10. Zareba W, Moss AJ, S Le Cessie: Dispersion of ventricular repolarization and arrhythmic cardiac death in coronary artery disease. Am J Cardiol 1994; 74: 550-553.
11. Beaubien ER, Pylypchuk GB, Akhtar J, Biem HJ: Value of corrected QT interval dispersion in identifying patients initiating dialysis at increased risk of total and cardiovascular mortality. Am J Kidney Dis 2002; 39: 834-842.
12.Wang CL, Lee WL, Wu MJ, Cheng CH, Chen CH, Shu KH: Increased QTc dispersion and mortality in uremic patients with acute myocardial infarction. Am J Kidney Dis 2002; 39: 539-548.
13. Zabel M, Klingenheben T, Franz MR, Hohnloser SH: Assessment of QT dispersion for prediction of mortality or arrhythmic events after myocardial infarction: results of a prospective, long-term follow-up study. Circulation 1998; 97: 2543-2550.
14. Glancy JM, Garratt CJ, Woods KL, de Bono DP: QT dispersion and mortality after myocardial infarction. Lancet 1995; 345: 945-948.
15. Brendorp B, Elming H, Jun L, Kober L, Malik M, Jensen GB, Torp-Pedersen C: QT dispersion has no prognostic information for patients with advanced congestive heart failure and reduced left ventricular systolic function. Circulation 2001; 103: 831-835.
16. Franz MR, Zabel M: Electrophysiological basis of QT dispersion measurements. Prog Cardiovasc Dis 2000; 42: 311-324.
17. Malik M, Batchvarov VN: Measurement, interpretation and clinical potential of QT dispersion. J Am Coll Cardiol 2000; 36: 1749-1766.
18. Malik M, Acar B, Gang Y, Yap YG, Hnatkova K, Camm AJ: QT dispersion does not represent electrocardiographic interlead heterogeneity of ventricular repolarization. J Cardiovasc Electrophysiol 2000; 11: 835-843.
19. Kors JA, van Herpen G, van Bemmel JH: QT dispersion as an attribute of T-loop morphology. Circulation 1999; 99: 1458-1463.
20. Lee KW, Kligfield P, Dower GE, Okin PM: QT dispersion, T-wave projection, and heterogeneity of repolarization in patients with coronary artery disease. Am J Cardiol 2001; 87: 148-151.
21. Zabel M, Portnoy S, Franz MR: Electrocardiographic indexes of dispersion of ventricular repolarization: An isolated heart validation study. J Am Coll Cardiol 1995; 25: 746-752.
22. Xue Q, Reddy S: New algorithms for QT dispersion analysis. Comput Cardiol 1996; 30 (suppl): 293-296.
23. Xue Q, Reddy S: Computerized QT analysis algorithms. J Electrocardiol 1997; 30(suppl): 181-186.
24. Kors JA, de Bruyne MC, Hoes AW, van Herpen G, Hofman A, van Bemmel JH, Grobbee DE: T axis as an indicator of risk of cardiac events in elderly people. Lancet 1998; 352: 601-605.
25. Acar B, Yi G, Hnatkova K, Malik M: Spatial temporal and wavefront direction characteristics of 12-lead T wave morphology. Med Biol Eng Comput 1999; 37: 574-584.
26. Zabel M, Acar B, Klingenheben T, Franz MR, Hohnloser SH, Malik M: Analysis of 12-lead T-wave morphology for risk stratification after myocardial infarction. Circulation 2000; 102: 1252-1257.
27. Zabel M, Malik M: Predictive value of T-wave morphology variables and QT dispersion for postmyocardial infarction risk assessment. J Electrocardiol 2001; 34(suppl): 27-35.
28. Batchvarov VN, Hnatkova K, Poloniecki J, Camm AJ, Malik M: Prognostic value of heterogeneity of ventricular repolarization in survivors of acute myocardial infarction. Clin Cardiol 2004; 27: 653-659.
29. Zabel M, Malik M, Hnatkova K, Papademetriou V, Pittaras A, Fletcher RD, Franz MR: Analysis of T-wave morphology from the 12-lead electrocardiogram for prediction of long-term prognosis in male US veterans. Circulation 2002; 105: 1066-1070.
30. Okin PM, Malik M, Hnatkova K, Lee ET, Galloway JM, Best LG, Howard BV, Devereux RB: Repolarization abnormality for prediction of all-cause and cardiovascular mortality in American Indians: the Strong Heart Study. J Cardiovasc Electrophysiol 2005; 16: 945-951.
31. Devereux RB, Alonso DR, Lutas EM, Gottlieb GJ, Campo E, Sachs I, Reichek N: Echocardiographic assessment of left ventricular hypertrophy: Comparison to necropsy findings. Am J Cardiol 1986; 57: 450-458.
32. Levy D, Savage DD, Garrison RJ, Anderson KM, Kannel WB, Castelli WP: Echocardiographic criteria for left ventricular hypertrophy: The Framingham Heart Study. Am J Cardiol 1987; 59: 956-960.
33. Stack AG, Bloembergen WE: Prevalence and clinical correlates of coronary artery disease among new dialysis patients in the United States: a cross-sectional study. J Am Soc Nephrol 2001; 12: 1516-1523.
34. Ohtake T, Kobayashi S, Moriya H, Negishi K, Okamoto K, Maesato K, Saito S: High prevalence of occult coronary artery stenosis in patients with chronic kidney disease at the initiation of renal replacement therapy: an angiographic examination. J Am Soc Nephrol 2005; 16:1141-1148.
35. MerriM, Benhorn J, AlbertiM, Locati E, Moss AJ: Electrocardiographic quantitation of ventricular repolarization. Circulation 1989; 80:1301-1308.
36. Antzelevitch C, Sicouri S, Litovsky SH, Lukas A, Krishnan SC, Di Diego JM: Heterogeneity within the ventricular wall: Electrophysiology and pharmacology of epicardial, endocardial, and M cells. Circ Res 1991; 69: 1427-1449.
37. Franz MR, Bargheer K, Rafflenbeul W, Haverich A, Lichtlen PR: Monophasic action potential mapping in human subjects with normal electrocardiograms: Direct evidence for the genesis of the T-wave. Circulation 1987; 75: 379-386.
38. Lux RL, Urie PM, Burgess MJ, Abildskov JA: Variability of the body surface distributions of QRS, ST, and QRST deflection areas with varied activation sequence in dogs. Cardiovasc Res 1980; 14: 607- 612.
39. Priori SG, Mortara DW, Napolitano C, Diehl L, Paganini V, Cantu F, Cantu G, Schwartz PJ: Evaluation of the spatial aspects of T-wave complexity in the long-QT syndrome. Circulation 1997; 96: 3006-3012.
40. De Ambroggi L, Aime E, Ceriotti C, Rovida M, Negroni S: Mapping of ventricular repolarization potentials in patients with arrhythmogenic right ventricular dysplasia: Principal component analysis of the ST-T waves. Circulation 1997; 96: 4314,-4318.
41. Devereux RB, Reichek N: Echocardiographic determination of left ventricular mass in man. Anatomic validation of the method. Circulation 1977; 55: 613-618.