运动负荷试验对2型糖尿病患者左室舒张功能变化的早期评估作用

252 中国临床康复 第9卷第19牌 2005-05-21出版 Chinese Journal of Clinical Rehabilitation, May 21 2005 Vol. 9 No. 19 ·BASIC RESEARCH · Early evaluation of exercise tolerance test on diastolic functional changes of left ventricle in patients with type 2 diabetes Wang,Ya-li', Xia Kai', Zhang are', Wang An-ning', Guo Fan' 'Department of Electrodiagnostics, 'Department of Endocrinology, Shenyang Red Cross Hospital, Shenyang 110013, Liaoning Province, China Correspondence to: Wang Ya-II, Associate chief physician, Department of Electrodiagnostics, Shenyang Red Cross Hospital, Shenyang 110013, Liaoning Province, China Received: 2005一01一25 WYL62@ 163. com Accepted* 2005一03一28 (12/NH) Abstract BACKGROUND: Color Doppler flow imaging can exam the early myocardial disorder in type 2 diabetic patients. What does exercise tolerance test work for the examination of such disorder in combination with color Doppler flow imaging (CDFI) ? OBJECTIVE: To analyze in comparison the early evaluation on reduced diastolic function in left ventricle in patients with type 2 diabetes between the examinations of exercise tolerance test combined with color Doppler flow image and simple color Doppler flow imaging. DESIGN: Cases-controlled comparison and self-comparison. SETTING: Department of electrodiagnosis and department of Endocrinology in a municipal hospital. PARTICIPANTS: Thirty-six cases of inpatients with type 2 diabetes were selected from Department of Endocrinology of Shenyang Red Cross Hospital from March to December in 2004, of which, 25 cases were males and 11 cases females. The diabetic patients included had no cardiac vascular com- plications and participated in the study in volunteer. Thirty-two patients who received annual routine health check at the same period were selected as the control, of which, 20 cases were males and 12 cases females. METHODS: Metronics treadmill exercise test equipment was used for exer- cise tolerance in two groups. Before exercise (at quiescent state) and after exercise tolerance, Vivid 4 CDFI was used to determine flow velocity at E and A peak values respectively, ratio between flow velocities at E peak value and A peak value as well as isovolumtric relaxation time (IRT). MAIN OUTCOME MEASURES: Comparison of cardiac functional indexes before and after exercise tolerance in two groups RESULTS: Thirty-four diabetic patients accomplished exercise tolerance test, of which, 1 case presented frequent ventricular extrasystole, another one presented precordial pain and stopped the test. In the control, all of 32 cases accomplished the test.①Before the exercise, in experimental group, the ratio between flow rates of E peak value and A peak value was remarkably lower than that in the control (0. 90士0.25, 1.40土0. 30, P<0.05); IRT was remarkably longer than that in the control [ (112. 07士20.16), (98.4518.55) ms, P<0.051.②After the exercise tolerance, in exper- imental group, the ratio between flow rates of E peak value and A peak value was remarkably lower than that in the control (0. 62土0. 12,1.28士0. 87, P <0.01);IRT was remarkably longer than that in the control [(138. 10 士19. 21), (97. 37土9. 61) ms, P<0.011. CONCLUSION: CDFI can supervise and evaluate at early stage the cardiac functional changes in type 2 diabetic patients. Due to the induction c1se tolerance accurate the combination of exercise tolerance test and CDFI objective and valuable conclusions at early stage. of exer- provides Wang YL, AnKZhang J, Wang XN, Guo F. Early evaluation of exercise tolerance test on diastolic functional changes of left ventricle in patients with type 2 diabetes. Zhongguo 6inchaang KangFu 2005; 9(19): 252一3 (China) Iwww. zglckf. comI INTRODUCTION The exercise tolerance test was used together with color Doppler flow imaging (CDFI) to determine diastolic function of left ventricle in type 2 diabetic patients so as to discover the cardiac functional al- ternations at early stage. Department of Endocrinology of Shenyang Red Cross Hospital from March to December in 2004, of which, 25 cases were males and 11 cases females; aged varied from 30 to 59 years, at average of (46 士8) years. Inclusion criteria: to comply with Diabetes Diagnostic Standards of 97' American Diagnostic Association and get rid of various complications of cardiac disease and hypertension. Exclusion criteria: hypertension, pressure>140/90 mm Hg(1 mm Hg =0. 133 kPa); abnormal electrocardiogram (ECG), shifting-down ST 〕0. 05 mV, auricular fibrillation, atrioventricular block and ar- rhythmia; Cardiac disorders, like congenital cardiac disease, coronary heart disease, valvulopathy and myocardial disease; renal dysfunc- tion; cerebral vascular accidents; arterial disorder in lower limbs; joint disorders of lower limbs; pulmonary dysfunction; lumbar disor- der, etc. Thirty-two patients who received annual routine health check at the same period were selected as the control, of which, 20 cases were males and 12 cases females, aged varied for 32 to 58 years, at average of(47土7) years. Methods Exercise tolerance was administrated in both groups. The concrete method of exercise tolerance: Metronics treadmill exercise test e- quipment was used. In the experiment, 10 stages were designed. 0 stage is quiescent state. In 2 to 7 stages, exercise speed and treadmill slope were increased gradually, meaning that the exercise started from low speed and tolerance amount and increased gradually. Eight to 10 stages represented recovery state. During exercise, blood pres- sure, heart rate and responses of acceptors were monitored and ECG was recorded before the exercise of every stage. The terminal stan- dards of exercise tolerance:①To reach target heart rate I according to predicted age( 190一age), 85% of the maximum heart rate].② Pressure change. The basic pressure was increased or decreased by 20 mm Hg.③ECG. ST segment was raised。:shifted down by 0. 1 mv.④To present typical angina pectoris.⑤To present severe arrhythmia.⑥To present symptoms in central neural system, such as motor disturbance, dizziness.⑦To present inadaptability0'. Vivid 4 CDFI diagnostic apparatus was used, with 1. 5 to 3. 6 MHz of prober. The patient was in left recumbence. The tetro-cavity sections of cardiac apex were collected. The sample capacity was placed in mitral orifice on the left ventricular side. The angle formed between sound velocity and blood flowing direction of mitral valve was near to 00. The frequent spectrum of blood flow at diastolic户ase in mitral orifice was recorded. The measured indexes included flow velocity of E peak value (E), flow velocity of A peak value (A) , ratio between flow velocities at E peak value and at A peak value(E/A) and isovolumtric relaxation time (IRT). The measured result of each index was the average of continuous 3 cardiac periods. The cardiac func- tional indexes were measured before exercise(at quiescent state) and right after the end of exercise tolerance. Statistical analysis: Data were managed statistically with SPSS 11.0 software by the first writer. The data were expressed with Mean士SD and t test was used for grouped difference. SUBJECTS AND METHODS Subjects Thirty-six cases of inpatients with type 2 diabetes were selected from RESULTS Descriptive statistics Thirty-six diabetic patients were included and 34 of them finished ISSNururu1671一5926 CN 21一1470/11zglrkf. com kf23385083@ sine. com 王亚丽，等.运动负荷试验对2型糖尿病患者左室舒张功能变化的早期评沽作用 253 exercise tolerance test. Two of them broke off the test, one was due to frequent attack of ventricular extrasystole and the other one was due to precordial pain. The rate of accomplishment was 94% (34/ 36), of which, 4 cases presented chest oppression, 2 cases occasional ventricular extrasystole and 2 cases occasional atrial extrasystole. In the control group, the rate of accomplishment was 100%，of which, 1 cases presented chest oppression, 1 cases occasional ventricular ex- trasystole and 1 cases occasional atrial extrasystole. The above-mentioned symptoms disappeared when the test ended. In ex- perimental group, 21 cases reached target heart rate at the 5" stage and 13 cases at the 6`h stage. In the control group, 8 cases reached target heart rate at the 5" stage, 22 cases at the 6th stage and 2 cases at the 7`" stage Statistica几inference The comparison of diastolic functional indexes of left ventricle in two groups was presented in Table 1. Table 1 Comparison of diastolic functional indexes of left ventricle in two groups _ (x t s ) crovascular disorder is complicated in mechanism. The basic etiology of it is chronic high blood glucose due to absolute and relative insulin deficiency. It is viewed generally that diabetic microvascular disorder results from the integrative factors151.The cases in this paper had been firmly diagnosed as type 2 diabetes, without cardiac disease and hypertension and had received exercise tolerance test. In the exer- cise, the heart rate was increased by the increased exercise amount. It is indicated that the increased heart rate presents linear correlation with cardiac intolerance and oxygen consumption amount, and the increased exercise tolerance prolongs the stable duration of heart rate. ndex Control group Experimental group Before exercise 76.36土9.85 51.31士9.11 1.40士0.30 98.45士8.55 After exercise E(cm/s) A(cm/s) E/A IRT(ms) 91.48 18. 92' 68.55土7. 88' 1.28士0.87 90.37士9.61 Before exercise 63. 13士8. 11' 66. 46 1 7. 56' 0.90土0. 25' 112. 07 1 20. 16' After exercise 51.68士9.011, 85. 19 1 8. 26' 0. 62 1 0. 12' Colwell JA. Antiplatelet agents for the prevention of cardiovascular disease in di- abetes mellitus. Am J Cardiovasc Drugs 2004; 4(2): 87一106 Liu H, Hong B, Xia N, et al. Correlation between serum level of adiponectin and type 2 diabetic cardiovascular disease. Zhongguo Linchuang Kangfu(中国临床 康复)2004;8(36):8214一5 Goo QJ, Lin QL, Zhou B, et al. Comparison of circadian heart rate variability between patients with type 2 diabetes complicated场cardiovascular diseases and healthy people. Zhongguo Linchuang Kang(u(中国临床康复)2004; 8(9): 1686一7 Secchi A. The incidence, clinical implications, and risk factors of diabetes melli- tus. G ltal Nefrol 2003; 20 Suppl 25: S7一10 Kirpichnikov D, McFarlane SI, Sowers JR. Heart failure in diabetic patients: utility of beta-blockade. J Card Fail 2003;9(4):333一44 138. 10士19. 21" E: flow velocity of E peak value; A: Flow velocity of A peak value; E /A: flow velocity of E peak value/ flow velocity of A peak value; IRT: isovolumtric relaxation time; 'P <0.05, us the control group before exercise; 'P<0. 05, vs the experimental group before exercise;' P<0. 01, vs the control group after exercise 运动负荷试验对2型糖尿病患者左室舒张功能 变化的早期评估作用 DISCUSSION Before occurrence of coronary arterial disorder, persistent metabolic disturbance of high blood glucose, by various approaches, leads to myocardial fibrosis, cardiac microvascular disorders and cardiac vegetative disorders. It has been further verified that such disorder may present early cardiac functional abnormity without clinical car- diac symptoms, which manifested at the early stage as declined di- astolic function of left ventricle 12, 31.Exercise tolerance increases cardiac tolerance, which results in strengthened myocardial contrac- tion, accelerated heart rate and increased oxygen consumption. Since cardiac relaxation is an active process in which a large amount of ATP is consumed. For diabetic patients, due to the metabolic dis- turbance, it is impossible for myocardium to utilize adequately free lipid acid. As a result, more triglycerides deposited, leading to de- generated stiffness and fibrosis of myocardium and decreased com- pliance. In addition, exercise tolerance test consumes even more en- ergies, which more sensitively reflexes the alternations of ventricular diastolic function in diabetic patients [41.It was indicated in the re- sults of this study that before exercise tolerance test, in diabetic pa- tients, the diastolic function of left ventricle was altered, the early diastolic filling speed in left ventricle slowed down, later diastolic compensatory contraction in left ventricle was strengthened, early diastolic rapid filling speed slowed down, early diastolic blood flow integral was reduced and later diastolic one was increased, E/A was decreased and less than 1, and IRT was prolonged. Since exercise tolerance consumes more energy, the diastolic functional indexes of left ventricle were decreased more significantly, which indicated significant difference in comparison with the control. Diabetes results in cardiac microvasicular disorder, extensive cardiac necrosis and decreased cardiac function. Terminally, it leads to diabetic myocar- dial disorder and induces cardiac failure. Therefore, it is importance to discover early the potential myocardial disorders in diabetic pa- tients to prevent from cardiac vascular complications. Diabetic mi- 王亚丽’，夏 凯’，张 杰‘，王欣宁’,郭 凡’‘沈阳市红十字会医院， ，电诊科，z内分泌科，辽宁省沈阳市 110013) 通讯作者:王亚丽，女，1962年生，辽宁省沈阳市人，汉族，副主任医师， 主要从事心血管超声检查的研究。 摘要 背景:彩色多普勒超声可检出2型糖尿病患者的早期心肌病变，运动负 荷试验配合彩色多普勒超声检查对于该病变的检出又能起到什么作用 呢? 目的:比较运动负荷试验加彩色多普勒超声检查与单纯彩色多普 勒超声检查对2型糖尿病患者左室舒张功能降低的早期评估作用。 设计:病例一对照及自身，前后对照观察。 单位:一所市级医院电诊科和内分泌科。 对象:选择2004-03/12沈阳市红十字会医院内分泌科住院的2型糖 尿病患者36例，男25例，女11例。纳人的糖尿病患者均无心血管疾病 并发症，且自愿参加。正常对照组32例，为同期本院体检健康自愿者， 男20例，女12例。 方法:应用美高仪平板运动试验仪给予两组运动负荷。运动前(静息状 态下)及运动负荷结束后即刻应用Vivid 4彩色多普勒超声诊断仪检测 E峰峰值流速、A峰峰值流速、E峰峰值流速/A峰峰值流速比值、等容 舒张期时间。 主要观察指标:两组运动负荷前后心功能指标比较。 结果:34例糖尿病患者完成了运动负荷试验,1例出现频发室性期前收 缩，另1例出现心前区疼痛中止试验。对照组犯例均完成试验。①患者 组运动前E峰峰值流速/A峰峰值流速比值明显低于对照组运动前 (0.90士0.25, 1.40士0.30,尸< 0. 05);等容舒张期时间明显大于对照 组运动前[(112.07土20.16), (98.45土8.55)ms, P<0.05]0②患者组 运动负荷后E峰峰值流速/A峰峰值流速比值明显低于对照组运动后 (0.62士0. 12, 1.28土0.87, P <0.01);等容舒张期时间明显大于对照 组运动后[(138.10士19.21), (97.37士9. 61) ms,尸<0.011。 结论:彩色多普勒超声检查可早期监测和评估2型糖尿病患者的心功 能变化;运动负荷试验并彩色多普勒超声检查，因加了运动负荷的诱发 作用，可使结论更准确客观，更有早期的价值。 主题词:心室功能，左;糖尿病，非胰岛素依赖型;运动试验 中图分类号:8587. 1文献标识码:A 文章编号:1671一5926(2005)19一0252一02 王亚丽，夏凯，张杰，王欣宁，郭凡.运动负荷试验对2型糖尿病患者左室舒张功 能变化的早期评沽作用L11.中国HE床康复,2005,91191:252一3 lwww. zglckf. coml (Edited by Wang F/Song LP/Xiao XL)