Hämodynamische Veränderungen bei kontrollierter Herzfrequenzsteigerung mittels Vorhofschrittmacher. Untersuchungen bei Herzgesunden und bei Coronarkranken
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Zusammenfassung
Vergleichende hämodynamische Untersuchungen wurden bei 38 Coronarkranken und ebensoviclen Herzgesunden aus einer Gruppe von 143 Untersuchungen mittels kontrollierter Herzfrequenzsteigerung angestellt. Schon bei Ruhe zeigten die Coronarkranken im Durchschnitt eine niedrigere Förderleistung des Herzens bei gleichem oder gar niedrigerem Füllungsdruck des Herzens und vergleichbarem arteriellem und pulmonal-arteriellem Druck. Das hypokinetische Syndrom war außerdem durch einen erhöhten peripheren Gefäßwiderstand gekennzeichnet. Bei der stufenweisen Erhöhung der Herzfrequenz sank der Füllungsdruck des rechten und des linken Herzens, um erst bei höheren Frequenzen wieder anzusteigen. Diese Drucksenkung war bei Coronarkranken weniger ausgeprägt. Während SVI und MSERI sanken, blieben Herzindex und TPR bei allen geprüften Herzfrequenzen unverändert, ebenso die arteriellen und pulmonal-arteriellen Drucke. Die Herzarbeit stieg bei den Coronarkranken etwas an.
Die sonst eine Sinustachykardie begleitende Sympathicusaktivierung blieb aus. Infolgedessen wurde die AV-Überleitungszeit zunehmend länger. Dadurch entwickelte sich sehr rasch eine Vorhofpfropfung, in deren Verlauf die Überhöhung dera-Welle besonners bei den Coronarkranken auffiel. — Die Dauer der mechanischen Systole nahm mit steigender Herzfrequenz ab. Bei Coronarkranken war diese Verkürzung weniger ausgeprägt. Das Phänomen der relativ zu langen Systole wird auf eine gestörte Kontraktionsmechanik zurückgeführt.
Bei 18 von 38 Patienten wurde ein pectanginöser Anfall durch die „Belastung“ ausgelöst. Die eintretenden hämodynamischen Veränderungen waren denjenigen im ergometrisch induzierten Anfall ähnlich, wahrscheinlich bedingt durch sekundäre Sympathicusaktivierung.
Das Verfahren der kontrollierten Herzfrequenzsteigerung erlaubt eine präzise und reproduzierbare Bestimmung der „Angina pectoris-Schwelle“. Die Methode ist sehr schonend und birgt sicher mancherlei noch ungenutzte, diagnostische und therapeutische Vorteile.
Schlüsselwörter
Angina pectoris Coronarinsuffizienz Belastungstest EKG Kreislaufphysiologie VorhofschrittmacherHemodynamic changes with rising heart rate induced by atrial pacing. Studies in normal subjects and in patients with coronary artery disease
Summary
38 patients with coronary artery disease and 38 control subjects out of a group of 143 patients examined with the atrial pacing technique underwent a hemodynamic study. Even at rest coronary patients exhibited lower cardiac output, while filling pressures and arterial as well as pulmonary arterial pressures were identical. The hypokinetic syndrome was furthermore characterized by elevated total peripheral resistance in the coronary patients. Atrial pacing initially led to a fall of right and left heart filling pressures. At higher rates this pressure rose definitely above normal in the coronary group, and particularly so if angina pectoris was present, or after sudden cessation of pacing. While cardiac index and TPR remained unchanged within the range of heart rates tested, cardiac work increased slightly in the coronary group. These cases required higher ventricular filling pressures to maintain cardiac output. Progressive prolongation of the PR-interval led to the development of gianta-waves in the right and probably also the left atrial pressure pulse. The height of thea-wave was conspicously exaggerated in the coronary disease group.
Left ventricular ejection time shortened progessively with rising heart rate. However, this was not observed in the diseased group. Here, a relative prolongation of the duration of mechanical systole was observed and interpreted as evidence of altered contractile properties of the ischemic myocardium.
18 of 38 patients developed angina pectoris during atrial pacing. Hemodynamic changes in this group resmbled those in exercise-induced angina, the reason being most likely a secondary activation of the sympathetic system.
Atrial pacing provides a precise and reproducible means for determination of the angina threshold. The hemodynamic alterations, however, appear to be fundamentally different of those occuring in spontaneous or exercise-induced angina. Diagnostic and therapeutic potentials of the atrial pacing method appear considerable, yet they are largely unexplored.
Key-words
Atrial pacing coronary artery disease ECG hemodynamics stress testingPreview
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