| 摘要: |
| 目的 探讨心血管反射试验（CART）及心率变异性（HRV）诊断糖尿病心脏自主神经病变（DCAN）的应用价值。方法 纳入2020年2月至12月于上海中医药大学附属上海市中西医结合医院住院治疗的2型糖尿病（T2DM）患者154例作为研究对象，所有患者均接受CART和24 h动态心电图检查并分析HRV指标，比较CART与HRV这2种方法诊断DCAN的差异。结果 154例T2DM患者中，采用CART诊断的DCAN组有101例、非DCAN组有53例，DCAN发病率为65.58%（101/154）。DCAN组与非DCAN组患者的年龄、病程、糖尿病周围神经病变发病率的差异均有统计学意义（P均＜0.05），而性别、高血压、烟酒嗜好、BMI、腰臀比、糖化白蛋白、脑钠肽差异均无统计学意义（P均＞0.05）；DCAN组与非DCAN组患者的深呼吸心率差、立卧位心率变化、Valsalva动作指数、卧立位血压差差异均有统计学意义（P均＜0.05）；DCAN组与非DCAN组患者HRV指标所有正常R-R间期的标准差（SDNN）、每5 min正常R-R间期的标准差均值（SDANN）、相邻R-R间期差值均方根（RMSSD）、相差＞ 50 ms的相邻R-R间期占R-R间期总数的百分比（pNN50）、总功率（TP）、超低频（VLF）、低频（LF）、高频（HF）差异均有统计学意义（P均＜0.05）。根据24 h动态心电图的HRV指标诊断DCAN发病率为59.74%（92/154），HRV与CART诊断的总符合率为61.68%，Kappa值为0.184，HRV诊断的DCAN的灵敏度及特异度分别为66.34%、52.83%。按CART评分将T2DM患者分为4个等级（无DCAN、亚临床DCAN、确诊DCAN、严重DCAN），DCAN病变程度与SDNN、SDANN、RMSSD、pNN50、TP、VLF、LF、HF均呈负相关（r＝－0.252、－0.234、－0.260、－0.219、－0.315、－0.280、－0.316、－0.311，P均＜0.01）。CART诊断的DCAN组HRV指标相关性分析发现SDNN与SDANN相关性最强（r＝0.977，P＜0.001），提示DCAN患者交感神经受损明显；LF与VLF（r＝0.761，P＜0.001）、HF（r＝0.829，P＜0.001）相关性均较强，提示心脏自主神经损伤累及交感和副交感神经。CART联合HRV诊断DCAN有134例、非DCAN有20例，DCAN发病率为87.01%（134/154），CART与HRV联合诊断DCAN的灵敏度为100.00%，特异度为37.74%。结论 CART联合HRV在诊断DCAN时有较高的检出率，可对CART评分较低并处于DCAN早期的T2DM患者进一步行HRV分析以减少漏诊。 |
| 关键词: 糖尿病心脏自主神经病变 心血管反射试验 心率变异性 诊断 |
| DOI：10.16781/j.CN31-2187/R.20220221 |
| 投稿时间：2022-03-16修订日期：2022-12-22 |
| 基金项目:上海市虹口区卫生健康委员会中医药科研课题(HKQ-ZYY-2020-09),虹口区"国医强优"三年行动计划:区域中医优势专科及提升项目(HGY-YSZK-2018-13). |
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| Comparison of cardiovascular autonomic reflex test and heart rate variability in diagnosing diabetic cardiac autonomic neuropathy |
| ZHANG Shan1,XU Meng-zhu2,FAN Yue-yue1,XIANG Ying3,WU Jian4*,HAO Juan4 |
(1. Clinical Faculty of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China;
2. The First People's Hospital of Tancheng County, Tancheng 276100, Shandong, China;
3. Department of Electrocardiogram, Shanghai Traditional Chinese Medicine-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China;
4. Department of Endocrinology, Shanghai Traditional Chinese Medicine-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
*Corresponding author) |
| Abstract: |
| Objective To investigate the value of cardiovascular autonomic reflex test (CART) and heart rate variability (HRV) for the diagnosis of diabetic cardiac autonomic neuropathy (DCAN). Methods A total of 154 hospitalized patients with type 2 diabetes mellitus (T2DM) in Shanghai Traditional Chinese Medicine-Integrated Hospital, Shanghai University of Traditional Chinese Medicine from Feb. to Dec. 2020 were enrolled. All patients underwent CART and 24-h Holter monitoring, and HRV indexes were analyzed. The differences in diagnostic value of DCAN between CART and HRV were analyzed. Results Among the 154 T2DM patients, 101 in the DCAN group and 53 in the non-DCAN group were diagnosed using CART. The incidence of DCAN was 65.58% (101/154). The differences in age, diabetes mellitus duration and incidence of diabetic peripheral neuropathy were statistically significant between DCAN and non-DCAN groups (allP＜0.05), while the differences in gender, hypertension, smoking or drinking habits, body mass index, waist-to-hip ratio, glycated albumin or brain natriuretic peptide were not statistically significant (all P＞0.05). There were significant differences in expiration/inspiration difference, 30/15 ratio, Valsalva test and blood pressure differences after postural change between the 2 groups (all P＜0.05). There were significant differences in HRV indexes (standard deviation of all normal N-N interval ［SDNN］, mean standard deviation of the normal N-N interval every 5 min ［SDANN］, root mean square of successive differences between adjacent N-N intervals ［RMSSD］, percentage of the number of pairs of adjacent N-N intervals differing by more than 50 ms ［pNN50］, total power ［TP］, very low frequency ［VLF］, low frequency ［LF］, and high frequency ［HF］) (all P＜0.05). The incidence of DCAN was 59.74% (92/154) according to the HRV indexes of 24-h Holter. The total coincidence rate was 61.68% between HRV and CART, and Kappa value was 0.184. The sensitivity and specificity of HRV in diagnosing DCAN were 66.34% and 52.83%, respectively. According to the CART score, T2DM patients were divided into 4 grades: non-, sub-clinical, confirmed and severe DCAN. The degree of DCAN was negatively correlated with SDNN, SDANN, RMSSD, pNN50, TP, VLF, LF, and HF (r＝－0.252, －0.234, －0.260, －0.219, －0.315, －0.280, －0.316 and－0.311, all P＜0.01). The correlation analysis of HRV indexes in the DCAN patients diagnosed by CART found that SDNN and SDANN had the strongest correlation (r＝0.977, P＜0.001), suggesting that sympathetic nerve damage was obvious; correlations between LF and VLF (r＝0.761, P＜0.001) and HF (r＝0.829, P＜0.001) were strong, suggesting that sympathetic and parasympathetic nerves were involved in cardiac autonomic damage. CART combined with HRV diagnosed 134 cases in the DCAN group and 20 cases in the non-DCAN group, and the incidence of DCAN was 87.01% (134/154). The sensitivity and specificity of CART combined with HRV in diagnosing DCAN were 100.00% and 37.74%, respectively. Conclusion CART combined with HRV has a higher detection rate in the diagnosis of DCAN. HRV analysis can be further performed on T2DM patients with low CART score at the early stage of DCAN to reduce the incidence of missed diagnosis. |
| Key words: diabetic cardiac autonomic neuropathy cardiovascular autonomic reflex test heart rate variability diagnosis |
