Danh gia Bieh Thien Nhip Tim d cac Benh Nhan sau

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TAP CHl TIM MACH HOC VI£T NAM - SO 56 - 2010

Danh gia Bieh Thien Nhip Tim d cac Benh Nhan sau Nhdi Mau Co Tim duoc Can Thiep Dpng Mach Vanh Thi Dau

Assessment Heart Rate Variability in Post Myocardial Infarction Patients with Primary PTCA

Ths. Tran Thai Ha*; PGS. TS Pham Nguyen San"

TdM TAT:

Suy giam diiic nang he than kinh ty ehu tim mach la nguy co doc lap gay ttr vong, dac biet la dot tii sau nhoi mau CO tim. Bioi thien nhip tim (BTNT) la xet n ^ e m khong xam nhAm danh gia tac dgng eiia than kinh tu chii tren tim. Giam BTNT sau nhdi mau CO tim (NMCT) phan anh sy tang tac dpng ciia than kinh giao dmi (TKGQ v;^

giam tac dong ciia th&i kinh pho giao cam (TKPGQ tren tim va dupc coi la tien lupng manh cho biai chiing loan nhip tim va tir vraig d nhdm benh nhan nay.

Nghien ciiu tiSi hanh danh gia BTNT tir phan tidi dien tim Holter 24 gid tren 44 benh nhan (BN) NMCT dupc can ttiifp maeh vanh tiu dau (6 giai doan on dinh, 12+5 ngay, truoc khi ra vien) va 32 nguoi binh thudng khong CO caclj^nh ly tim madi

Giam BTNT 6 nhom BN sau NMCT dupc can thi$p dpng mach vanh the hien cac chi so'LnSDNN, LnSDANN, LnTP d4c trung cho hoat dpng TKPGC la thap hon va cac chi so'LnVLF, LnLF, LnLF/HF dac trung cho hoat dgng TKGC la cao hon CO y nghia so voi iihom chiing. BTNT cung giam CO y ngKa 6 nhom sau NMCT CO kdn theo tang huy^t ap (THA) hoac dai thao dudng (DTD) typ 2 so vdi nhiing BN khong kem theo THA va DTD typ 2. Nhiing BN NMCT thanh trudc, kich thudc nhoi mau rpng (CPK > lOOOu/1) eo BTNT gjam ro so vdi nhom NMCT thanh sau, kidi thudc 6" nhoi mau nhd hon (CPK < lOOOu/I).

BAT VAN

BE:

Bie'n thien nhip tim (Heart Rate Variabil- ity) la sy thay ddi thdi khoang R-R tren dien tim, bieu hien su bie'n ddi thdi khoang mdt chu ehuyen tim dd'i vdi mdt ehu ehuyen tim tie'p theo. Thdng qua sy thay doi ciia eae chi so bien thien nhip tim (BTNT), chiing ta co the danh gia dupe hogt ddng than kinh tu ehu tim maeh (TKTCTM) vdi su tac dpng cua than kinh giao cam (TKGC) va than kinh phd giao cam (TKPGC) tren tim trong

cac trang thai sinh ly va benh ly khae nhau.

Giam BTNT sau NMCT, bieu hien bang sy thay ddi eiia eac chi so'BTNT so vdi BT, the hien sy tang truong lyc cua TKGC va/hoge giam truong lye TKPGC, tii dd gay ra su mat on dinh dien hpe ciia cae te'bao co tim va khdi phat eae rd'i loan nhip tim, dac biet la su xuat hien nhiing logn nhip that nguy hiem[l, 2, 9, 10]. Vdi cac BN dupe can thiep mach vanh sdm, van cdn mpt so trudng hgp ma giai quyet dupc chd tac nhung that bai trong viec cai thien vi tuan hoan dam

<•),(">• Benh viin TltQD li

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NGHIEN CCfU LAM SANS

bao su tuoi mau eho mo co tim on dinh toi miic te'bao, de lai nguy eo cao gay lan rpng viing ton thuong co tim eung mpt so cac bie'n ehiing khac sau tai tuoi mau. Ben canh viec danh gia roi loan nhip tim 6 cae BN sau NMCT, vi?c danh gia cae nguy eo gay roi loan nhjp tim la can thie't voi cac BN sau NMCT. Chinh vi vay, chiing loi thuc hien nghien cihi nay voi hai m\ic tieu:

(i) Khao sat su thay doi cae ehi so BTNT 6 BN sau NMCT duoc can thiep dpng mach vanh (DMV) thi dau thong qua ghi dien tim Holter 24 gio. (ii) Danh gia moi lien quan cua eae mpt so ye'u to lam sang va can lam sang vol s\f thay doi cac chi so BTNT 6 BN sau NMCT dupc can thiep §MV.

BOi T M VA PHIfdNG PHAP NGHIEN CtflT

D 6 | tiro'ng nghi&n cOu: Gdm 76 ngu'd'i duvc chia thanh 2 nhom:

Nhdm chiing: C^m 32 ngudi khoe mgnh dupc kham lam sang va lam eae xet nghiem eho tha'y khdng mac cac b?nh ly ve tim mach.

- Nhom sau NMCT: 44 BN de'n sdm tiude 12 gid ke tir liie xuat hien trieu chiing dau ngyc vdi ehan doan NMCT cap theo tieu ehuain ciia to chiie y te'the'gidi, dugc ean thiep DMV thi dau va tie'p tye dieu tri giai doan ca'p tai benh vien 108 tir thang 01 nam 2007 de'n thang 12 nam 2009.

Cac ddi tupng sau NMCT dupc dua vao nghien eiiu khi da qua giai doan ea'p, cae men tim da trd ve gidi hgn binh thudng, BN d giai dogn on d{nh ehuain bi ra vien.

PhiTO'ng phap nghien ciru: Mo ta, cit ngang c6 so sanh ddi chiPng.

Cac BN tham gia nghien ciiu dupc ti&

hanh hdi benh va kham lam sang ky ludng, lam eac xet nghiem can lam sang: CK, CK- MB, troponin - T, biland lipid, glucose mau, dien giai mau, dien tim, X- quang tim phoi, chyp ddng mgch vanh, sieu am Doppler tim, ghi Holter dien tim 24 gid (dupc ghi d thoi diem tiung binh 12 ± 5 ngay),...

BTNT dupc phan tich tu Holter dien tim 24 gid gdm eac ehi sd':

Cac chi sd'bie'n thien theo ttidi gian (time domain measurements);

SDNN (Standard deviation of all normal to normal intervals): dp lech ehuain eiia cac nhat bdp binh thudng tren toan bg ECG Holter 24 gid, dan vi la msec.

- SDANN (Standard deviation of the av- erages of normal to normal intervals in all 5 min segments of entire recording): dp lech chuan cua cae thdi khoang RR binh thucmg tiong moi 5 phiit ciia toan bd ECG Holter 24 gid, dan vi la msec.

- RMSSD (The square root of the mean of the sum of the squares of differences between adjacent normal to normal intervals): Can bae hai eiia so trung binh tdng cae binh phuong eiia sy khae biet giiia cae thdi khoang RRbinh thudng, dan vi la msec.

- SDNN index (Mean of the standard de- viations of all normal to normal intervals for 5 min segments of entire recording): Trung binh ciia dp lech chuan tat ea cac thdi khoang RR binh thudng eua tat ea cae doan 5 phut toan bd ECG Holter 24 gid, don vi la msec.

Nhiing chi sd'nay bieu thi truong lyc hoat dpng eiia than kinh PGC [1, 9].

Cac chi so phan tich phd tan so (Frequen- cy analyis measurements):

- VLF (Very Low Frequency): Viang tan so'

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TAP CHi TIM MACH HOC VIgT NAM - S6 56 - 2010

rat tha'p, tir 0-0,03Hz, don vi la ms^.

- LF (Low Frequency): Vimg tan so'thap, tir 0,03- 0,15Hz, don vi la ms^.

- HF (High Frequency): Vung tan sd'cao, tir 0,15- 0,40 Hz, dan vj la ms^

- TP (Total Power): Tdng dp Idn a i a BTNT theo phd tan sd; tii 0- 0,4 Hz, don vi la ms^

Ty so' LF/HF bieu hien cho miic can bang ctia thloi kinh GC va PGC.

Cac chi sd'VLF, LF dgc trung cho hogt ddng ctia TKGC, cdn eac ehi soHF, TP dae trung eho hogt dpng ctia TKPGC.[1,9]

Xifly s d lieu:

Cac so'Ueu dupc xii ly va phan tieh tren may tinh, sii dung p h & mem thdng ke SPSS 11.5. Tinh gia tri trungbinh, dp lech ehuan,...

va sir dung Idem dinh t-student de so sanh cae b i ^ dinh lugng va test x^ de so sanh eac bieh dinh tinh.

Vi cae chi so BTNT khong tuan theo lugt phan phdt ehuain nen chting tdi tie'n hanh logarit eo sd' tu nhien cac ehi sd' BTNT cho tuan theo luat phan phdi c h u & va eae ehi sd' nay dugc trinh bay dudi dgng logarit eo so' ty nhien (Ln).

KET QUA NGHIEN CUfU

Bang 1. Mpt sd' dac diem lam sang va xet nghiem d nhom ehung va nhom sau NMCT dupe can thiep DMV thi dau.

Dae diein lam sang va xet nghiem Tudi

Gidi (nam) Rdi loan lipid mau THA

DTD typ 2

Nhdm chting (n=31) 57,8 ±8,4 23 (74,2%) 13 (41,9%)

0 0

Nhom sau NMCT (n= 44)

61,7 ± 9,2 32 (77,3%) 26 (59,1%) 20 (45,4%) 14 (31,8%)

P

>0,05

<0,05

Vi tri NMCT

Miic do suy tim theo NYHA Nong dp dinh CPK trpng giai doan ea'p

Thanh sau Thanh trude

Tha't phai NYHA (1+2) NYHA (3+4) Gia tri trung binh (u/l) Miic dp CPK:

+ <1000UI + >1000UI

18 (40,9%) 25 (56,8%) 1 (2,3%) 38 (86,4%) 6 (13,6%) 2089,8 ± 1520,3

12 (27,3%) 32 (72,7%)

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NGHIEN CO'U L A M S A N G

Mue dp EF (%)

DMV thii pham gay NMCT

>40%.

<40%.

D/m lien that truoc D/mmii D/m vanh phai

36 (81,8%) 8 (18,2%) 22 (50,0%) 3 (6,8%) 19 (43,2%) - Giiia 2 nhom khong o6 su khac biet ve dp tupi va gioi (P > 0,05).

- Cae BN NMCT ehu yeii la nam gioi, tuoi trung binh kha eao.

- Ty le roi loan lipid 6 nhom NMCT (59,1%) eao hon so voi nhom chiing (41,9%) (P< 0,05).

- Nhom BN NMCT duoc can ihiep DMV, NMCT thanh trude ehiein ty 1? eao nhai (56,8%), NMCT tha't phai chiern ty le thap nhai (2,3%).

- Nong dp dinh men CPK trong giai doan cajj 6 BN NMCT la kha cao vdi tyle BNco miic dp CPK>

lOOCUI chiem 72,7%.

- DMV thii pham hay gap la DM lien that trude (50,0%), dm DMV phai (43,2%).

Bang 2. So sanh chi so'BTNT d nhdm sau NMCT dupc can thiep DMV va nhdm ehiing.

Chi so BTNT LnSDNN (ms) LnSDANN (ms) LnilMSSD (ms) LnSDNNin (ms) LnVLF (ms=) LnLF (ms») LnHF (ms=) LnLF/HF LnTP (ms^)

Nhdm chiing (n=31) 4,77 ±0,14 4,65 ±0,18 3,30 ± 0,39 3,79 + 0,24 5,00 + 0,13 2,71 ±0,17 1,87 ± 0,19 0,85 ±0,28 5,26 ±0,11

Nhdm sau NMCT (n=42) 4,27 ±0,27 3,98 ±0,34 3,23 ± 0,30 3,52 ±0,27 5,50 ±0,09 3,69 ± 0,36 1,05 ± 0,12 2,63 ±0,45 5,18 ±0,10

P

< 0,001

>0,05

< 0,001

>0,05 - Nhom BN NMCT dupe can Ihiep DMV ed hau he't cae chi so'BTNT (LnSDNN, LnSDANN, LnSDN- Nia LnHF, LnTP) la thap hon va cac chi so'BTNT (LnVLF, LnLF, LnLF/HF) lai eao hon so vdi nhom chiing vdi sv khac biet la rat co y nghia (P< 0,001).

Bdnj 3. So sanh dii so BTNT d nhdm BN sau NMCT dupe can thiep DMV cd DTD vdi nhdm khong coDTD.

Chi so'BTNT Nhdm NMCT

khong DTD typ 2 (n-30)

Nhdm NMCT

cdDTDtyp2(n=14) P

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TAP CHl TIM MACH HOC VIET NAM - SO 56 - 2010

LnSDNN (ms) LnSDANN (ms) LnRMSSD (ms) LnSDNNin (ms) LnVLF (ms=) LnLF (ms^) LnHF(ms') LnLF/HF LnTP (ms^)

4,30 ±0,24 4,03 ±0,27 3,26 ±0,28 3,58 ±0,27 5,49 ± 0,06 3,62 ± 0,29 1,07 ±0,12 2,55 ± 0,38 5,39 ±0,09

4,08 ±0,30 3,80 ±0,27 3,12 ± 0,30 3,42 ± 0,27 5,56 ± 0,1 3,93 + 0,44 1,00 ±0,09 2,90 ±0,50 5,29 ±0,07

<0,05

>0,05

<0,05

>0,05

<0,05

Bdng 4. So sanh chi sdBTNT d nhdm BN sau NMCT dugc ean thiep DMV cd THA vdi nhom khdng ed THA.

Chi so BTNT LnSDNN (ms) LnSDANN (ms) LnRMSSD (ms) LnSDNNin (ms) LnVLF (ms') LnLF (ms') LnHF (ms') LnLF/HF LnTP (ms')

Nhdm NMCT khong THA (n-24) 4,32 ± 0,27 4,00 ± 0,31 3,32 ±0,31 3,60 ±0,26 5,49 ± 0,08 3,62 ±0,29 1,09 ± 0,10 2,52 ±0,43 5,40 ± 0,09

Nhdm NMCT cd THA (n=20) 4,10 ±0,26 3,91 ± 0,33 3,09 ±0,20 3,42 ±0,24 5,56 ±0,10 3,84 ± 0,35 1,00 + 0,12 2,83 ± 0,43 5,31 ± 0,08

P

<0,05

>0,05

<0,05

<0,05 - Nhdm BN NMCT eo THA dupe ean thiep DMV ed cac chi sdBTNT (LnSDNN, LnRMSSD, LnSDNNin, LnHF, LnTP) la thap hon va cac chi so'BTNT (LnVLF, LnLF, LnLF/HF) la cao hon so vdi nhdm BN NMCT khong ed THA dupc can thiep DMV (P < 0,05).

Bang 5. So sanh chi so BTNT d nhdm sau NMCT dupc can thiep DMV vdi kieh thudc NMCT thong qua nong dp dinh men CPK huye't thanh trong giai doan cap.

Chi sdBTNT LnSDNN (ms) LnSDANN (ms)

Nhdm NMCT cd CPK <1000 U/l (n-15)

4,37 ±0,23 4,05 ±0,30

Nhdm NMCT cd CPK>1000UI(n-29)

4,17 ±0,28 3,90 ±0,34

P

<0,05

>0,05

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N G H | £ N CLfU LAM SANG

LnRMSSD (ms) LnSDNNin (ms) LnVLF (ms=) LnLF (ms') LnHF(ms') LnLF/HF LnTP(ms')

3,36 ±0,41 3,59 ± 0,27 5,48 ± 0,06 3,55 ±0,57 1,08 ± 0,12 2,48 ± 0,44 5,39 ± 0,09

3,07 ±0,28 3,42 ± 0,21 5,57 ±0,09 3,80 ±0,36 1,00 ±0,14 2,77 ± 0,43 5,34 ±0,09

<0,05

>0,05 - Nhdm BN NMCT co miic do ton thuong co tim vdi CPK > 1000 UI cd cac ehi sd BTNT (LnS- DNN, LnRMSSD, LnSDNNin, LnHF) la tha'p hon va cac chi so'BTNT (LnVLF, LnLF, LnLF/HF) la cao hon so vdi nhdm BN NMCT co CPK < 1000 Ul (P < 0,05).

Bdng 6. So sanh ehi so'BTNT 6 nhom BN NMCT d vi tri thanh trude vdi thanh sau.

Chi so'BTNT LnSDNN (ms) LnSDANN (ms) LnRMSSD (ms) LnSDNNin (ms) LnVLF (ms2) LnLF (ms2) LnHF (ms2) LnLF/HF LnTP (ms2)

Nhdm NMCT thanh sau (n=19)

4,35 ±0,24 4,05 + 0,29 3,26 ± 0,31 3,64 ± 0,28 5,48 ± 0,28 3,56 ± 0,34 1,07 ±0,11 2,47 ±0,43 5,38 ± 0,09

Nhdm NMCT thanh trudc (n- 25)

4,15 ±0,28 3,89 ±0,34 3,18 ±0,27 3,43 ±0,25 5,54 ±0,74 3,83 ±0,36 1,03 ±0,12 2,81 ± 0,44 5,34 ±0,10

P

<0,05

>0,05

<0,05

>0,05

<0,05

>0,05 Nhdm BN XMCT thanh trudc co eae chi so'BTNT (LnSDNN, LnSDNNin) la thap hon va cac chi so'BTNT (LnVLF, LnLF, LnLF/HF) la cao hon so vdi nhdm BN NMCT thanh sau (P < 0,05).

BAN H A N :

- BTNT CO tam quan trpng nhu la mpt ye'u to' du bao ddc lap trong cac benh ly maeh vanh, dac bi^l vdi XMCT, da dupc nhieu nghien ciiu de cap de'n. Vdi ky nguyen

"tieu spi huyet va tai maeh", nhieu nghien ciiu ve BTNT da xac nhan rSng theo ddi

BTNT van con la ye'u to tien luong cd gia tri cho til sua't sau NMCT. Ket qua nghien ciiu ciia chiing tdi cho tha'y BTNT giam the hien bang giam eae ehi so LnSDNN, LnSDANN, LnSDNNin, LnFlF dac trung eho truong lue TKPGC va tang cac chi so LnVLF, LnLF, LnLF/HF dae trung eho TKGC d eae BN sau NMCT cap dupc can thiep DMV thi dau so

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TAP CHl TIM MACH HQC VIET NAM - S6 56 - 2010

vdi nhdm ehiing (P< 0,001). Dieu do da eho tha'y mge dii dupc tai thdng mgeh nhung nhirng tae ddng trye tie'p len thu the hda hge va co hpe tgi viing nhdi mau cung sy ehe' tiet Adrenaline tir tiiy thupng than da lam thay doi su dieu hda ciia he than kinh t y ehii tai tim. Va dd chinh la co sd ciia rd'i loan TKTCTM d cac BN sau NMCT dupe ean thiep DMV thi dau. NMCT cap thanh sau t h u d n g dan tdi nhip chgm, ha huyet ap, la hipn tugng lien quan tdi phan xa Bezold-Jarich, trong khi do ton thuang d thanh trudc thi thudng gay nhip tim nhanh va THA. Ke't qua nghien ctiu eiia ehiing tdi cho tha'y nhdm NMCT thanh sau co cac chi so'BTNT (LnSDNN, LnSDNNin) dge trung cho hogt dpng TKPGC la eao hon va cac ehi so BTNT (LnVLF, LnLF, LnLF/HF) dgc trung cho hogt dpng TKGC la thap hon so vdi nhdm NMCT thanh trude (P <0,05). Ket qua nay tuong duong vdi ket qua phan tich cae chi sd'BTNT tir Holter dien tim 24 gid d thdi diem trude khi ra vien eiia Ulrich Lo- tze va es (1999) tren 64 BN sau NMCT cap.

[2, 5, 10]. Dong thdi chiing tdi ciing nhan tha'y CO md'i lien quan giiia BTNT vdi kich thudc nhdi mau dugc bieu hien qua nong dp dinh men CPK trong giai dogn cap dd la BTNT giam d eae BN cd CPK > lOOOu/1 so vdi cac BN cd CPK < lOOOU/1.

- Cae bie'n ehiing thudng gap d BN DTD dd la tdn thuang than kinh va mgeh mau.

NMCT cung vdi DTD typ 2 va rd'i loan TKTCTM la 3 ye'u td' chinh gdp phan lam tang le tii vong d nhiing BN nay. Qua nghien ciiu, ehiing tdi nhgn tha'y eac chi so'dge trung

eho TKPGC la LnSDNN, LnSDANN, LnTP tha'p hem va cac ehi sd' dge trung cho TKGC LnVLF, LnLF, LnLF/HF cao hon cd y nghia d nhdm NMCT cd DTD typ 2 so vdi nhdm khdng cd DTD typ 2. Victor Stoikov va Cs (2003) phan ti'ch BTNT tii dien tim Holter 24 gid eho tha'y BTNT giam rd d 35 BN NMCT ed kem tiieo DTD typ 2 so vdi 106 BN NMCT khdng cd kem theo DTD typ 2. [2,4, 7]

- Nhirng BN cd THA thudng kem theo sy rdi loan dieu hda etia TKTCTM dae trung bdi tang hogt GC va/hoge giam hogt PGC.

Phan tieh tu ket qua nghien ctiu, ehiing tdi nhan tha'y d nhiing BN NMCT kem theo THA ed BTNT giam ro thdng qua giam eac ehi sd LnSDNN, LnSDNNin, LnTP va tang cac chi so LnVLF, LnLF, LnLF/HF so vdi BN khong cd THA. Ket qua nay la tuong ty vdi nghien eiiu sy thay ddi eae ehi so'BTNT ctia Emily B va CS (2003) tren 2562 BN THA thay cd su tang truong lye ciia than kinh GC va giam truong lyc eiia than kinh PGC [3].

KET LUAN:

BTNT giam d eac BN sau NMCT dupe ean thiep DMV thi dau, va giam nhieu d eae BN ed kem DTD typ 2 hoac kem THA.

BTNT giam ro d eae BN NMCT thanh trude, hoac cd hoai tii co tim nang (CPK>1000UI) so vdi nhdm NMCT thanh sau va nhdm NMCT nhe (CPK <1000u/l).

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NGHIEN CLfU LAM SANK

SUMMARY

Background: Dysregulation of ttie autonomic nervous system is an independent risk factor for sudden cardiac death in post myocardial infaredOTi (MI). Heart Rate Variability (HRV) is a nonin\'asi\ e tool to quantitatively esti- mate cardiac autonomic acti\ity. Depressed HRV after MI may refled a increase in sympathetic and/or decrease in vagal acdvitj' to the heart and is a powerful predictor of arrhydimic complications and of mortalit}'

Method and Redts: We investigated HRV by analyzed Holter eleetroeardiograph) 24 hours of 32 heathl\- indi- viduals and 44 post MI patients wifli primary PTCA (12 ± 5 days after MI before discharge). After Ml patients had a sipiificantly lower values ( I J T S D N N , I J I S D A N N , LnSDNNin, LnHF) and higlier values (LnVLF, LnLF, LnLF/

HF) of HRV compared to those heathly group. The MI pahents with diabetic or h\'pertention had a lower values (LnSDNN, LnSDANN, LnTP) and higher values (LnVLF, LnLF, LnLF/HF) of HR\' compared to those u-ithout diabetic or without hypertention. The decrease in LnSDNN, LnSDNNin and increase in LnVLF, LnLf, LnLF/HF were more evident in anterior than in inferior ML The MI patients with peak aeatinine kinase > lOOOU/1 had a significantly lower values (LnSDNN, LnRMSSD, LnSDANN, LnTP) and higher values (LnVLF, LnLF, LnLF/HF) of HRV compared to those with CPK < 1000 U/l (P < 0,05).

Condusions: These resuls indicate that HRV is reduced, which may mdicate a shift of sympathovagal balance towart a sympathetic predominance and a reduced vagal tone in after Ml patients with primary PTCA.

TAI UEU THAM KHAO

1. N g u y i n Dlic Cong. (2000)." PMn tidi bien IhiBn nhip tim deddnh gia chuc n&ng lit dgng cm tim ".

Tap chi tim mach hpe Vi^t nam. 24:63 - 67.

2. Truong E>inh Cain. (2005). " N ^ e n cuu sy thay dw cac chi sdbieh thien nhip tmi o boih nhan dai thao dudng ^;^ 2" Luan an tieii sy khoa hoc Hoc

\'ienQuany.

3 Emily B va CS (2003). Hypertention, Blood pressure, and heart rate variability Hyperten- tion. 42:1106-1111.

4. Daniela Manzella. Cardiac autonomic activity and Typ II diabetes mellitus. Clinical sdence (2005) 108, 93 - 99.

5. Majercak. The use of heart rale vanability in cardiology. Bratisl Lek List> 2002; 103 (10):

368-377.

6. Gulmira Kudail)erdieva Heart rate variability as a predictor of sudden cardiac death An- adolu kardiyol Derg 2007: 7 Suppl 1; 68 - 70.

7. Victor Stoikov. (2005). Impact of diabetes

on heart rate variahilit\- a n d left ventricular funtion in p a t i e n t s after myocardial infarction. Medicine a n d biology. Vol 12, No 3, pp 130-134.

8. UMch Lotze. (1999) Early time course of heart rate variability after thrombolytic and delayed interventional therapy for acute myocardial infarction. Cardiology- 92.2?6-263.

9 Task force of the E u r o p e a n society of cardiology a n d the N o r t h A m e r i c a n sodety of pacing a n d electrophysiology. (1996). "Heari rate variability Slandaris of ineasiiremeni, physiological inierprctatwn and chmcnl iifc".

European Heart J o u m a l . 17: 354 - 381 10. T i m o H . & C S Prediction of s u d d e n cardiac

death after acute myocardial infarction, role of Holter m o n i t o r i n g in the m o d e r n treat- ment era. E u r o p e a n H e a r t Journal(2005) 26.

762-769.