1、海军军医大学学报2023 年 4 月第 44 卷第 4 期http:/Academic Journal of Naval Medical University,Apr.2023,Vol.44,No.4 446 论 著 收稿日期 2022-03-16 接受日期 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）Supported by Traditional Chinese Medicine Research Project of Shanghai
2、 Hongkou District Health Committee(HKQ-ZYY-2020-09)and Three-year Action Plan of“Guoyi Qiang You”in Hongkou District:Advantageous Specialty and Promotion Project of Regional Traditional Chinese Medicine(HGY-YSZK-2018-13).作者简介 张 珊，硕士生 E-mail:*通信作者（Corresponding author）.Tel:021-65415910,E-mail:心血管反射试验
3、与心率变异性诊断糖尿病心脏自主神经病变方法比较张 珊1，徐梦珠2，樊月月1，项 颖3，吴 坚4*，郝 娟41.上海中医药大学市中西医结合临床医学院，上海 201203 2.郯城县第一人民医院，郯城 2761003.上海中医药大学附属上海市中西医结合医院心电图室，上海 2000824.上海中医药大学附属上海市中西医结合医院内分泌科，上海 200082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
4、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
5、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
6、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（r0.252、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（r0.977，P0.001），提示DCAN患者交感神经受损明显；LF与VLF（r0.761，P0.001）、HF（r0.829，P0.001）相关性均较强，提示心脏自主神经损伤累及交感和副
7、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；诊断中图分类号 R 587.25文献标志码 A文章编号 2097-1338(2023)04-0446-08Comparison of cardiovascular autonomic re
8、flex test and heart rate variability in diagnosing diabetic cardiac autonomic neuropathyZHANG Shan1,XU Meng-zhu2,FAN Yue-yue1,XIANG Ying3,WU Jian4*,HAO Juan41.Clinical Faculty of Integrated Traditional Chinese and Western Medicine,Shanghai University of Traditional Chinese Medicine,Shanghai 201203,C
9、hina 2.The First Peoples 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,China4.Department of Endocrinology,Shanghai Traditional
10、Chinese Medicine-Integrated Hospital,Shanghai University of Traditional Chinese Medicine,Shanghai 200082,ChinaDOI：10.16781/j.CN31-2187/R.20220221 447 Abstract Objective To investigate the value of cardiovascular autonomic reflex test(CART)and heart rate variability(HRV)for the diagnosis of diabetic
11、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
12、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
13、 age,diabetes mellitus duration and incidence of diabetic peripheral neuropathy were statistically significant between DCAN and non-DCAN groups(all P0.05),while the differences in gender,hypertension,smoking or drinking habits,body mass index,waist-to-hip ratio,glycated albumin or brain natriuretic
14、peptide were not statistically significant(all P0.05).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 P0.05).There were significant differences in HRV indexes(standard devi
15、ation 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,ver
16、y low frequency VLF,low frequency LF,and high frequency HF )(all P0.05).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
