[AF-FORUM] 64R AF时心率变异性检测. Dr. Makarov

[AF Symposium]

尊敬的Perez Riera医师,
感谢你详尽的回复。你提到的诊断标准不管对研究还 
是对临床应用都非常重要。目前各种Holter仪器都有检 
测心率变异性（HRV）的软件，但临床心脏病医生很少 
考虑这些指标。我认为目前HRV在临床应用中被低估， 
主要因为HRV的分析时基于正常窦性心律。在慢性AF 
时，心律不是窦性，但它也可以准确评估病人血流动 
力学指标的调整程度。

另外，即使窦性心律时，HRV也并不总能反应出自主神 
经系统的影响。Mayo Clinic的专家分析了最近20年有关 
HRV发表的论文，发现HRV即使考虑受各种内在和外在因 
素影响，本身也并不是自主神经系统的直接“窗 
口”参数。

从很早以前，有人试图利用数学分析模式评估非窦性 
心律的AF的HRV，1961年Braunstein和Frank (2)对AF病人的心律 
进行了自相关分析，他们发现在AF病人中HRV也是有用 
的。 同样，在Malik和Camm的专著《心率变异性》中， 
Schweizer等(3)进一步证明在异位心律的心脏病人，HRV是 
可靠的。Van den Berg 等 (4) 比较了慢性AF病人和窦性心 
律的健康人迷走和交感阻滞后HRV时间指标改变，发现 
两组有同样的动态改变过程。

HVR的主要参数 (平均心率, 平均夜间及白天心率, 昼夜 
波动比, 昼夜心率比) 即可以用于病人的临床评估， 
又可以评价临床治疗效果。我们的研究发现异位心律 
病人昼夜波动比改变低于正常参考值(1.32 + 0.06, 范围 
1.24-1.32) 可能是预后不良的指标，如完全性房室传导 
阻滞、持续AF等)。

参考文献:
1.Pieper.SJ., Hammill.SC. Heart rate variability: technique  and   
investigational   applications   in  cardiovascular  medicine.   
Mayo.Clin.Proc. 1995 Oct; 70(10): 955-64
2.Braunstein J., Frank E. Autocorrealtion of the ventricular  
response  in atrial fibrillation. Cir Res. 1961 ; 9:305-311
3.Schweizer M., da Silva K., Kubler W., Brachman J. Ventricular   
response in patients with sustained atrial fibrillation: relation to   
the underlying cardiovascular disease. In: Malik M., Camm A (eds.)   
Heart Rate Variability. Armonk, NY, Futura Publ.Co 1995. 533-538.
4.Van den Berg M., Haaksma J., Brouwer J., Tieleman R., Mulder J.,   
Crijns G. Heart rate variability in patients with atrial  
fibrillation  is related to vagal tone. Circulation. 1997;96(4): 
1209-1216.
5. Makarov L. Circadian index as indicator of stable organization of   
heart circadian rhythm  Klin Med (Mosk) 2000;78(1):24-7 PMID:   
10697369 [PubMed - indexed for MEDLINE]

Leonid Makarov M.D., Ph.D.教授
莫斯科儿科及儿外科研究所儿童心律失常诊断中心主任
125412 Taldomskaya str.2, Moscow, Russia.
E-mail: leo在oss.ru, copy: leonidmakarov在yahoo.com.
Fax: +7-495-483-3333

---------------------------------------------------------
Dear Dr. Perez Riera,
Thank you for your thorough answer. The criteria that you indicated
are very significant, not only for research, but also for daily
practice. Every modern Holter equipment has software to evaluate
heart rate variability (HRV). However, cardiologists very rarely take
these parameters into account. In my opinion, the role of HRV in
daily practice is somewhat underestimated, since in general, the
analysis of HRV is made in patients with sinus rhythm. In the case of
chronic AF, rhythm is not sinus; nevertheless, precisely this rhythm
determines the adaptation of the hemodynamic parameters of the patient.

However, even in patients with sinus rhythm, HRV not always reflects
the influences of the autonomous nervous system. Likewise, the
experts of the Mayo Clinic analyzed the papers related to HRV
(published over the last 20 years), and highlighted that, given
multiple endogenous and exogenous factors, HRV parameters are not a
direct "window" to the functional state of the autonomous nervous
system (1).

Since quite some time, physicians try to use the possibilities of
mathematical analysis of non-sinus rhythm in patients with AF. In
year 1961, J. Braunstein and E. Frank (2) made an autocorrelative
analysis of heart rhythm function in patients with AF, and they
showed the usefulness of HRV in patients with non-sinus rhythm. Also,
in the book "Heart Rate Variability" by M. Malik, A. Camm, M.
Schweizer et al (3), the clinical usefulness of assessing non-sinus
rhythm in cardiological patients became evident. M. Van den Berg et
al (4) compared time indicators of HRV, after vago-sympathetic block,
in patients with chronic AF, and healthy people with sinus rhythm,
and found the same dynamics for these indicators in both groups.

The main parameters of heart rhythm (mean HR, mean night and day HR,
circadian rate, ratio between day and night HR) may be used both in
assessing the clinical state of the patient, and to evaluate the
effectiveness of a treatment. We proved that the decrease of the
circadian rate under normal values (1.32 + 0.06, range 1.24-1.32) may
be useful as a predictor of bad prognosis (complete AV block,
permanent AF, etc.) in patients with non-sinus rhythm (5).

Bibliography:

1.Pieper.SJ., Hammill.SC. Heart rate variability: technique and
investigational   applications   in  cardiovascular  medicine.
Mayo.Clin.Proc. 1995 Oct; 70(10): 955-64

2.Braunstein J., Frank E. Autocorrealtion of the ventricular response
in atrial fibrillation. Cir Res. 1961 ; 9:305-311

3.Schweizer M., da Silva K., Kubler W., Brachman J. Ventricular
response in patients with sustained atrial fibrillation: relation to
the underlying cardiovascular disease. In: Malik M., Camm A (eds.)
Heart Rate Variability. Armonk, NY, Futura Publ.Co 1995. 533-538.

   4.Van den Berg M., Haaksma J., Brouwer J., Tieleman R., Mulder J.,
Crijns G. Heart rate variability in patients with atrial fibrillation
is related to vagal tone. Circulation. 1997;96(4):1209-1216.

5. Makarov L. Circadian index as indicator of stable organization of
heart circadian rhythm  Klin Med (Mosk) 2000;78(1):24-7 PMID:
10697369 [PubMed - indexed for MEDLINE]

prof. Leonid Makarov M.D., Ph.D.
Head of Department of Diagnostic of Arrhythmia Children Center for
Children Arrhythmia. Moscow Institute Pediatry and Children Surgery.
125412 Taldomskaya str.2, Moscow, Russia.
E-mail: leo在oss.ru, copy: leonidmakarov在yahoo.com.
Fax: +7-495-483-3333

--
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee