以心室快速不整脈表現之到院前心跳停止病患的院前預測因子探究

(2016年台灣內科醫學會年會 口頭論文獎)

Yu-An Chen, Yen-Nien Lin, Shih-Sheng Chang, Ming-Fong Chen, Kuan-Cheng Chang

Background
Presentation with a shockable rhythm (ventricular tachycardia / fibrillation, VT/VF) is associated with the best survival in out-of-hospital cardiac arrest (OHCA), but there is significant regional variation in presentation and outcomes. We sought to identify the incidence and pre-hospital predictors of VT/VF as the initial arrhythmia in OHCA patients in central Taiwan.

Methods
The THUNDER program encompasses the Taichung metropolitan area in central Taiwan with a population size of 2.7 million and 17 destination hospitals for OHCA patients. We performed a detailed analysis of demographics, circumstances of cardiac arrest and emergency medical service records using the Utstein style.

Results
From May 1, 2013 to April 30, 2014, resuscitation was attempted in 2013 OHCA cases of which 384 cases were excluded due to trauma and non-cardiac etiologies. Of the 1629 patients with presumed cardiogenic OHCA, 7.9% had initial shockable rhythm. The proportion of shockable rhythm increased to 18.8% in witnessed arrest subgroup. Male gender (OR 2.45, 95% [CI] 1.46-4.12, P = 0.0007), age < 65 years (OR 2.39, 95% [CI] 1.58-3.62, P < 0.0001), public location of arrests (OR 4.61, 95% [CI] 2.86-7.44, P < 0.0001), and witnessed status (OR 3.98, 95% [CI] 2.62-6.05, P < 0.0001) were independent predictors of VT/VF rhythm.

Conclusions
Compared to the US and Western Europe, the proportion of OHCA patients presenting with VT/VF was lower in this East Asian population. Among the pre-hospital factors associated with VT/VF, public location of OHCA was the strongest predictor of VT/VF in this population, which may impact planning and deployment of emergency medical services in central Taiwan.

大學生接受心肺復甦術訓練成效探究

(刊登於 2016年台灣家庭醫學醫學會 學術研討會)

作者: 陳郁安, 許琬鑫, 許維邦 (平等澄清醫院)

研究目的

當一個人在倒地心跳停止後，若腦部失去血流超過4~6分鐘，細胞就會永久壞死。因此，如何在黃金時間內及早施行高品質的心肺復甦術(CPR)，不僅醫療人員需要熟練，對一般民眾而言，也是必須學習的急救技能。本篇研究是希望探究社區醫學舉辦大學生CPR授課及實作訓練之成效。

研究方法

本研究採橫斷式問卷研究法，在2016年3月至4月期間，於中興大學舉辦兩場CPR理論授課及CPR安妮模具實作，對象是大一到大四選修軍訓課的男學生。課前發放前測問卷共5題，做為評估學生對於CPR的了解程度。作答完畢收回問卷後，開始上課和實作。課程結束再發放後測問卷及調查是否應用所學救助他人。其中問卷皆採無記名式，前後測試題相同。最後再用統計方式比較前後測成績，以評估學生學習成效。評估指標將以(1)前、後測成績比較；(2)日後是否有意願應用所學救助他人為依據。

研究結果

有效回收問卷：前測81份，後測71份。年齡皆座落於16~25之間。其中高達93.8%的男大生課前已有接觸過急救相關課程，而且大多是在高中階段 (高中65.8%，國中30.3%，大學3.9%)。經由統計Student’s t-test, 2 tails算出整體前測與後測有顯著上的差異(p < 0.05)。亦即，整體而言，後測成績高於前測。另外，課後有52人(73%)表示願意應用所學救助他人；2人(3%)不願意；17人(24%)表示不確定。

結論

透過CPR理論授課及CPR安妮模具實作的急救訓練課程，對男大學生的急救知識、技能與願意執行CPR的態度有良好之學習成效。期待日後能夠引導更多醫師走入社區，在社區多舉辦此類CPR教育訓練課程，將所學之專業及經驗分享與傳承至更多社區民眾，以期能夠及時挽救更多寶貴的生命。

Prolonged D2B Time is Associated with Diastolic Dysfunction in STEMI Patients Undergoing Primary PCI

Yu-An Chen,  Kuan-Cheng Chang

Abstract (2011.06)

 

Background and Purpose

Primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) significantly reduces mortality and morbidity, particularly when the door-to-balloon (D2B) time is shortened to < 90 minutes. We sought to investigate whether D2B time correlates with in-hospital left ventricular (LV) function.

  

Materials and Methods

A total of 340 consecutive STEMI patients who received primary PCI were divided into two groups by patient aged ≥ 65 years old and < 65 years old. Conventional echocardiography and tissue Doppler imaging at the septal mitral annulus were performed during hospitalization. The ratio of early mitral inflow E to early diastolic velocity e’ greater than 15 was defined as LV diastolic dysfunction. LV systolic dysfunction was defined as LV ejection fraction < 50%.

  

Results

Risk factors significantly associated with LV diastolic dysfunction included age ≥ 65 years, female gender, hypertension, higher Killip (III+IV) status, and D2B time ≥ 90 minutes. Further analysis revealed that the adverse impact of prolonged D2B time on LV diastolic function was more prominent in patients aged ≥ 65 years than in the younger group.

  

Conclusions

Prolonged D2B time ≥ 90 minutes in acute STEMI patients undergoing primary PCI is associated with impaired LV diastolic function. Consequently, cardiologists should collaborate with the emergency physicians to improve D2B times, particularly for older patients.

  

Key words

Diastolic function; primary percutaneous coronary intervention; door-to-balloon times

Ascertaining the Hypothesis That Current of Injury Is Reliable for Adequate Active Fixation in 5076 Ventricular Lead

(2010 臺灣醫學發展基金會 得獎論文摘要)

Yu-An Chen,  Kuan-Cheng Chang

Background and Purpose

Current of injury (COI) has been proposed to be valuable guidance for adequate active fixation lead placement. The aim of this study was to ascertain the hypothesis and find clinical significance from other electrical parameters in acute lead performances.

  

Materials and Methods

Fifty-five patients for ventricular pacing indications were enrolled. Medtronic Inc. model 5076 lead implantation was performed under fluoroscopic guidance in catheterization laboratory. Model 2290 pacing system analyzer was utilized for measurements. Data of pacing parameters were grouped by COI extent and time course for analysis.

  

Results

Acute pacing parameter measurements compared between COI group (n=42) and non-COI group (n=13) in pre-screw-in stage indicated that only peak R wave showed statistical difference between the two groups (15.3 ± 5.7 versus 12.2 ± 3.7 mV, p=0.04). In screw-in stage, lead impedance and peak R wave were significantly higher of COI group than those of non-COI group (812 ± 161 versus 696 ± 143 ohms, p=0.02; 18.9 ± 8.8 versus 11 ± 4.5mV, p=0.001). In post-screw-in stage, all measured parameters did not show statistical differences between COI and non-COI groups. In addition, there was a positive linear correlation between screw-in lead impedance and ST-segment elevation (n=55, r=0.32, p=0.02).

  

Conclusions

The development of COI during initial lead fixation did not carry significant prediction for adequate lead placement in our research. In addition, relatively high screw-in impedance was not necessarily associated to poor lead fixation as long as it fell within acceptable values in the post-screw-in phase.

  

Key words

current of injury, active fixation, pacing lead, pacing parameters

Effects of Methadone on Cardiac Repolarization

(2009 臺灣醫學發展基金會 得獎論文摘要)

Yu-An Chen,  Kuan-Cheng Chang

Purpose

The aim of this study is to figure out whether there is a positive correlation between therapeutic methadone doses and QTc interval, thus evaluate a safe critical value of methadone dose for patients. While studying methadone effects on cardiac repolarization, assessing QT-related factors is equally important on the purpose to minimize errors in diagnoses and reduce the probability of developing torsade de pointes.

  

Materials and Methods

All cases in this study were available from China Medical University Hospital during September 2008 to April 2009. 12-lead ECG was utilized to evaluate drug response. The study was divided into three parts, respectively examined by regression analysis, Wilcoxon rank sum test, and Wilcoxon signed-rank test.

  

Results

The result of part I in this study showed there was a positive correlation between therapeutic methadone doses and QTc interval, [n = 209, rs = 0.36, p=0.001] and this relationship applied to both male [n = 165, rs = 0.34, p=0.001] and female individuals [n =44, rs =0.41, p=0.006]. Furthermore, 82 (49.7％) of 165 male patients and 14 (31.8％) of 44 female patients lived up to the standard of borderline QTc. The result of part II in this study showed that in the methadone group, male and female QTc values presented significant differences [p=0.02; Male: n= 165, mean ± S.D.= 431.13±21.54ms; Female: n= 44, mean ± S.D.= 438.82±22.34ms]. The result of part III in this study showed that among 30 fully traced cases, 25 (83.3％) patients’ QTc intervals lengthened after taking methadone, 4 (13.3％) patients’ QTc intervals shortened after taking methadone, and 1 (3.3％) patient’s QTc interval didn’t change after taking methadone. [n= 30, p=0.001]

  

Conclusions

There is a positive correlation between therapeutic methadone doses and QTc interval for both sexes. Cases of prolonged QTc are mainly associated with, but not limited to, higher doses of methadone maintenance treatment. As a result, factors contributing to QTc variations are worth to be considered to further assess QT prolongation more accurate.

  

Key words

ECG; HERG channel; methadone; QTc interval; QTc prolongation