郭 英,郭航遠(yuǎn),孫 勇,余 瑜,吳偉芳,許芬娟,呂巧霞
·專題研究·
早期康復(fù)對(duì)起搏器植入術(shù)后患者效果及安全性評(píng)價(jià)
郭 英,郭航遠(yuǎn)*,孫 勇,余 瑜,吳偉芳,許芬娟,呂巧霞
目的 探討早期康復(fù)對(duì)心臟起搏器植入術(shù)后患者生活質(zhì)量、肩關(guān)節(jié)并發(fā)癥及電極脫位事件發(fā)生的影響。方法 選取2013—2015年紹興市人民醫(yī)院心內(nèi)科行心臟永久起搏器植入術(shù)患者220例為研究對(duì)象。根據(jù)住院時(shí)間順序編號(hào),偶數(shù)為早期康復(fù)組(110例),奇數(shù)為傳統(tǒng)治療組(110例)。傳統(tǒng)治療組患者接受常規(guī)康復(fù)措施,早期康復(fù)組患者從術(shù)后6 h開(kāi)始由專人按照不同的程序、循序漸進(jìn)的功能鍛煉進(jìn)行術(shù)后康復(fù)干預(yù),術(shù)后12 h可下床活動(dòng)。于術(shù)后兩周、3個(gè)月時(shí),采用SF-36評(píng)價(jià)患者生活質(zhì)量,肩關(guān)節(jié)疼痛和功能障礙指數(shù)(SPADI)評(píng)價(jià)患者可能存在的肩關(guān)節(jié)疼痛、活動(dòng)障礙情況,通過(guò)X線片評(píng)估電極脫位事件。結(jié)果 早期康復(fù)組術(shù)后兩周SF-36生理功能、生理職能、軀體疼痛、總體健康、活力、社會(huì)功能、情感職能、心理健康、軀體健康總評(píng)及心理健康總評(píng)得分均高于傳統(tǒng)治療組(P<0.05)。早期康復(fù)組術(shù)后3個(gè)月生理功能、生理職能、軀體疼痛、總體健康、社會(huì)功能、情感職能、心理健康、軀體健康總評(píng)及心理健康總評(píng)得分均高于傳統(tǒng)治療組(P<0.05)。兩組術(shù)后兩周SPADI比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);早期康復(fù)組術(shù)后3個(gè)月SPADI低于傳統(tǒng)治療組(P<0.05)。兩組術(shù)后兩周及術(shù)后3個(gè)月電極脫位事件發(fā)生率比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 與傳統(tǒng)治療相比,起搏器植入術(shù)后6 h開(kāi)始進(jìn)行早期康復(fù)干預(yù)更有利于提高患者生活質(zhì)量,降低肩關(guān)節(jié)疼痛和活動(dòng)障礙,且并不增加電極脫位事件的發(fā)生。
心臟起搏器,人工;康復(fù);生活質(zhì)量;手術(shù)后并發(fā)癥
郭英,郭航遠(yuǎn),孫勇,等.早期康復(fù)對(duì)起搏器植入術(shù)后患者效果及安全性評(píng)價(jià)[J].中國(guó)全科醫(yī)學(xué),2017,20(20):2446-2450.[www.chinagp.net]
GUO Y,GUO H Y,SUN Y,et al.Evaluation of the effect and safety of early rehabilitation in patients with cardiac pacemaker implantation[J].Chinese General Practice,2017,20(20):2446-2450.
隨著人口老齡化加速和心臟起搏器適應(yīng)證的拓展,起搏器植入數(shù)量呈逐年增加趨勢(shì),而由于植入器械和技術(shù)的不斷改進(jìn),常見(jiàn)的手術(shù)并發(fā)癥,如穿刺并發(fā)癥、電極脫位、囊袋出血、囊袋感染等發(fā)生率則相對(duì)下降[1]。受高齡患者的增加以及術(shù)側(cè)肢體制動(dòng)、創(chuàng)口疼痛等因素的影響,起搏器植入術(shù)后發(fā)生術(shù)側(cè)肩部疼痛、活動(dòng)障礙、心功能減退、精神負(fù)擔(dān)加重等情況有增加的趨勢(shì),嚴(yán)重影響患者術(shù)后的生活質(zhì)量。本研究旨在通過(guò)對(duì)起搏器植入術(shù)后6 h的患者進(jìn)行循序漸進(jìn)的功能鍛煉干預(yù),選擇較佳的早期康復(fù)程序及時(shí)間點(diǎn),尋求規(guī)范、具體、操作簡(jiǎn)便的術(shù)后功能鍛煉方案,以探索對(duì)起搏器植入術(shù)后患者實(shí)施早期康復(fù)干預(yù)減少并發(fā)癥、促進(jìn)心理康復(fù)、提高生活質(zhì)量的效果。
1.1 研究對(duì)象 選取2013—2015年紹興市人民醫(yī)院心內(nèi)科行心臟永久起搏器植入術(shù)患者220例為研究對(duì)象,患者均符合2008年美國(guó)心臟病學(xué)會(huì)(ACC)/美國(guó)心臟協(xié)會(huì)(AHA)/美國(guó)心率學(xué)會(huì)(HRS)永久起搏器植入術(shù)的Ⅰ類或Ⅱa類適應(yīng)證[2],排除合并近期不適宜進(jìn)行康復(fù)鍛煉的身心疾病病史者,如急性腦梗死、急性心肌梗死、急性心肺功能衰竭、惡性心律失常及精神失常等?;颊呷虢M前均告之研究?jī)?nèi)容,并簽署知情同意書(shū),本研究通過(guò)紹興市人民醫(yī)院臨床試驗(yàn)倫理委員會(huì)批準(zhǔn)。
1.2 方法
1.2.1 起搏器植入術(shù) 術(shù)前完善相關(guān)實(shí)驗(yàn)室檢查及體格檢查,記錄心臟射血分?jǐn)?shù)、腦鈉肽(BNP)水平及肩周炎檢出率?;颊呔?jīng)左側(cè)或右側(cè)鎖骨下靜脈途徑植入永久起搏器,經(jīng)1%利多卡因局部麻醉后,Seldinger法穿刺并送入導(dǎo)引鋼絲,切開(kāi)皮膚,分離皮下組織制作囊袋,經(jīng)可撕開(kāi)鞘植入起搏電極,測(cè)試參數(shù)滿意后連接脈沖發(fā)生器,縫合皮下組織及皮膚。
1.2.2 干預(yù)措施 根據(jù)住院時(shí)間順序編號(hào),偶數(shù)為早期康復(fù)組(110例),奇數(shù)為傳統(tǒng)治療組(110例),術(shù)后3個(gè)月均接受常規(guī)起搏器程控隨訪。
傳統(tǒng)治療組:患者術(shù)后絕對(duì)臥床休息24 h,術(shù)側(cè)肢體制動(dòng)。術(shù)后2周內(nèi)避免術(shù)側(cè)手高舉過(guò)頭或過(guò)伸等動(dòng)作,以步行等簡(jiǎn)單的方式作為主要運(yùn)動(dòng)形式,從較低的基礎(chǔ)活動(dòng)量起始,每日逐漸適當(dāng)增加活動(dòng)量。2周后,患者可自由運(yùn)動(dòng),與術(shù)前無(wú)異。
早期康復(fù)組:患者從術(shù)后6 h始由專人按照不同的程序、循序漸進(jìn)的功能鍛煉進(jìn)行術(shù)后康復(fù)干預(yù),術(shù)后12 h可下床活動(dòng)。具體方法為:(1)術(shù)后6 h指導(dǎo)患者進(jìn)行患側(cè)腕的屈、伸運(yùn)動(dòng)及伸指、握拳運(yùn)動(dòng),5~10 min/次,1~2次/d;(2)術(shù)后第1天指導(dǎo)患者進(jìn)行患側(cè)屈肘、伸臂運(yùn)動(dòng),5~10 min/次,2~3次/d;(3)術(shù)后第2天指導(dǎo)患者握特制彈力球,繼續(xù)指導(dǎo)患者進(jìn)行患側(cè)屈肘、伸臂運(yùn)動(dòng),10~15 min/次,2~3次/d;(4)術(shù)后第3天指導(dǎo)患者進(jìn)行患側(cè)上肢肩關(guān)節(jié)前屈、后伸運(yùn)動(dòng)(前屈小于30°、后伸小于15°),10~15 min/次,2~3次/d;(5)術(shù)后第4天指導(dǎo)患者進(jìn)行患側(cè)上肢觸摸對(duì)側(cè)肩膀及同側(cè)耳朵運(yùn)動(dòng),10~15 min/次,2~3次/d,患側(cè)可洗臉、刷牙、進(jìn)食等;(6)術(shù)后第5天,患者呈站立位,上肢盡量向后伸,10~15 min/次,2~3次/d;(7)術(shù)后第6天,患者呈站立位,上肢以肩為軸用力旋前,再旋后,10~15 min/次,2~3次/d;(8)術(shù)后第7天指導(dǎo)患者患側(cè)上肢練習(xí)手指爬墻運(yùn)動(dòng)、梳頭(患肢越過(guò)頭頂梳對(duì)側(cè)頭發(fā)、捫及對(duì)側(cè)耳朵)等運(yùn)動(dòng),10~15 min/次,2~3次/d;(9)術(shù)后1周指導(dǎo)患者患側(cè)上臂緩慢抬臂動(dòng)作,并以肩為軸旋轉(zhuǎn)相配合,并采取一定的工具,給手臂一定的力量負(fù)荷,10~15 min/次,2~3次/d,允許患側(cè)上肢完成日常生活動(dòng)作。術(shù)后2周,患者可自由運(yùn)動(dòng),與術(shù)前無(wú)異。
1.3 觀察指標(biāo) 于術(shù)后兩周、3個(gè)月時(shí),采用SF-36量表評(píng)價(jià)患者生活質(zhì)量,該量表共有生理功能、生理職能、軀體疼痛、總體健康、活力、社會(huì)功能、情感職能、心理健康等8個(gè)維度,計(jì)算轉(zhuǎn)換的軀體健康總評(píng)、心理健康總評(píng)得分;采用肩關(guān)節(jié)疼痛和功能障礙指數(shù)(SPADI)評(píng)價(jià)患者可能存在的肩關(guān)節(jié)疼痛、活動(dòng)障礙情況,該問(wèn)卷包括13個(gè)條目,每個(gè)條目0~10分,得分越高表示該條目越嚴(yán)重,根據(jù)各條目得分換算為SPADI;通過(guò)X線片評(píng)估電極脫位事件。
2.1 基線情況 兩組患者性別、年齡、心臟射血分?jǐn)?shù)、BNP、肩周炎檢出率比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05,見(jiàn)表1)。
表1 兩組患者基線情況比較
Table1Comparisonofthebaselinecharacteristicsbetweenthetwogroups
組別例數(shù)性別(男/女)年齡(歲)心臟射血分?jǐn)?shù)(%)BNP(ng/L)肩周炎〔n(%)〕傳統(tǒng)治療組11051/5965±1153±13351±1325(4.5)早期康復(fù)組11046/6464±1051±10362±1067(6.4)t(χ2)值0.461a0.7061.2790.6850.353aP值0.4970.4810.2020.4940.553
注:BNP=腦鈉肽;a為χ2值
2.2 術(shù)后兩周及3個(gè)月SF-36得分比較 早期康復(fù)組術(shù)后兩周生理功能、生理職能、軀體疼痛、總體健康、活力、社會(huì)功能、情感職能、心理健康以及軀體健康總評(píng)、心理健康總評(píng)得分均高于傳統(tǒng)治療組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05,見(jiàn)表2)。兩組術(shù)后3個(gè)月活力得分比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。早期康復(fù)組術(shù)后3個(gè)月生理功能、生理職能、軀體疼痛、總體健康、社會(huì)功能、情感職能、心理健康以及軀體健康總評(píng)、心理健康總評(píng)得分均高于傳統(tǒng)治療組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05,見(jiàn)表3)。
2.3 術(shù)后SPADI比較 兩組術(shù)后兩周SPADI比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);早期康復(fù)組術(shù)后3個(gè)月SPADI低于傳統(tǒng)治療組,差異有統(tǒng)計(jì)學(xué)意義(P<0.05,見(jiàn)表4)。
Table4ComparisonofSPADIbetweenthetwogroupstwoweeksandthreemonthsafteroperation
組別例數(shù)術(shù)后兩周術(shù)后3個(gè)月傳統(tǒng)治療組1106.6±2.17.1±2.8早期康復(fù)組1106.1±1.96.2±2.4t值1.8522.560P值0.0650.011
2.4 術(shù)后電極脫位事件發(fā)生率 兩組術(shù)后兩周及術(shù)后3個(gè)月電極脫位事件發(fā)生率比較,差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05,見(jiàn)表5)。
表5 兩組患者術(shù)后兩周及3個(gè)月電極脫位事件發(fā)生率比較〔n(%)〕
Table 5 Comparison of incidence of electrode dislocation between the two groups two weeks and three months after operation
組別例數(shù)術(shù)后兩周術(shù)后3個(gè)月傳統(tǒng)治療組1102(1.8)3(2.7)早期康復(fù)組1101(0.9)2(1.8)χ2值0.3400.205P值0.5610.651
起搏器植入術(shù)是將起搏器的脈沖發(fā)生器埋置在人體胸大肌筋膜面,其電極固定于右心室的肌小梁和/或心房的右心耳[3],電極導(dǎo)線固定在胸前囊袋上方的皮下組織。起搏器在各種心律失常的治療中具有較好的應(yīng)用效果,但術(shù)后常出現(xiàn)各種并發(fā)癥,主要表現(xiàn)為電極脫位、囊袋積血、囊袋感染等,影響治療效果[4]。傳統(tǒng)觀點(diǎn)認(rèn)為,起搏電極植入后,由于電極刺激心肌和心內(nèi)膜,出現(xiàn)局部組織細(xì)胞水腫,使電極與心肌附著不牢,過(guò)早活動(dòng)容易因機(jī)械牽拉而致電極移位。目前認(rèn)為,患者過(guò)早起床活動(dòng)導(dǎo)致導(dǎo)管電極與心內(nèi)膜接觸不良,導(dǎo)管定位不當(dāng),導(dǎo)管與靜脈切口處固定不牢,引起電極脫落。因此傳統(tǒng)的護(hù)理方法是讓患者術(shù)后絕對(duì)臥床休息3 d,術(shù)側(cè)肢體制動(dòng),術(shù)后1個(gè)月內(nèi)(電極周圍的瘢痕組織一般需1個(gè)月的時(shí)間才能形成)避免術(shù)側(cè)手高舉過(guò)頭或過(guò)伸等動(dòng)作。
表2 兩組患者術(shù)后兩周SF-36得分比較±s,分)
表3 兩組患者術(shù)后3個(gè)月SF-36得分比較±s,分)
目前患者術(shù)后護(hù)理及康復(fù)方案仍多按照傳統(tǒng)方案進(jìn)行。但長(zhǎng)時(shí)間臥床使得患者出現(xiàn)腹脹、便秘、食欲減退、尿潴留、肩背肌僵硬、肺部感染、血栓形成或栓塞,以及肩關(guān)節(jié)不能活動(dòng)造成肩關(guān)節(jié)粘連、肩部麻木、腫脹、上肢抬舉活動(dòng)受限等癥狀[5]。隨著高齡患者的不斷增加,以及術(shù)側(cè)肢體制動(dòng)、創(chuàng)口疼痛等因素影響,起搏器植入術(shù)后發(fā)生術(shù)側(cè)肩部疼痛及活動(dòng)障礙的情況呈增加趨勢(shì),影響患者術(shù)后生活質(zhì)量[6]。
患者接受起搏器植入術(shù)后早期進(jìn)行循序漸進(jìn)的功能鍛煉干預(yù),增加了早期肢體活動(dòng),能減少因制動(dòng)而引起的并發(fā)癥,但有悖于傳統(tǒng)理念。由于起搏器主動(dòng)固定電極的發(fā)展以及植入技術(shù)方法的不斷改進(jìn),常見(jiàn)的手術(shù)并發(fā)癥,如穿刺并發(fā)癥、電極脫位、囊袋出血、囊袋感染等發(fā)生率相對(duì)下降[7-8]。有文獻(xiàn)報(bào)道,如果起搏器電極定位及固定正確,電極不會(huì)因體位的小幅度變動(dòng)而移位;肘關(guān)節(jié)及前臂的活動(dòng)與肩關(guān)節(jié)無(wú)關(guān);坐、立位比臥位更有利于電極固定于心尖部,可顯著減少電極脫位[9-10]。KORTE等[11]初步分析認(rèn)為,術(shù)中肌腱損傷可能為術(shù)后肩痛的原因之一。DANIELS等[12]認(rèn)為,由于術(shù)中或術(shù)后肌群牽拉等因素導(dǎo)致的肩袖損傷和肩峰撞擊綜合征是術(shù)后肩痛的主要發(fā)生機(jī)制。而根據(jù)李繼文等[13]的臨床觀察,考慮除上述機(jī)制外,由于術(shù)后肩關(guān)節(jié)周圍肌肉、肌腱、韌帶和關(guān)節(jié)囊等軟組織出現(xiàn)充血、水腫、滲出,長(zhǎng)時(shí)間制動(dòng)導(dǎo)致局部粘連和攣縮,形成粘連性關(guān)節(jié)囊炎(凍結(jié)肩和凝肩)等,也可能是肩關(guān)節(jié)并發(fā)癥發(fā)生的機(jī)制之一。該研究納入117例起搏器植入術(shù)患者,3個(gè)月后進(jìn)行早期功能鍛煉,結(jié)果并未發(fā)生電極脫位、創(chuàng)口延遲愈合、囊袋遲發(fā)性出血等并發(fā)癥,因此起搏器植入術(shù)后患者早期功能鍛煉可降低術(shù)后肩關(guān)節(jié)疼痛及活動(dòng)障礙的發(fā)生率,且不會(huì)增加電極脫位等并發(fā)癥風(fēng)險(xiǎn)。宋葆云等[14]研究同樣表明,實(shí)施早期康復(fù)護(hù)理能有效改善患者臨床癥狀,促進(jìn)患者肩功能恢復(fù),減少術(shù)后并發(fā)癥的發(fā)生,提高生活質(zhì)量。方惠玲[15]研究發(fā)現(xiàn),早期運(yùn)動(dòng)干預(yù)對(duì)起搏器植入術(shù)患者的起搏導(dǎo)線無(wú)損壞,起搏電極無(wú)移位,腹脹、便秘、尿潴留等并發(fā)癥減少,因此早期康復(fù)護(hù)理能有效預(yù)防起搏器植入術(shù)后并發(fā)癥的發(fā)生,促進(jìn)患者功能恢復(fù),提高生活質(zhì)量,并建議早期康復(fù)訓(xùn)練應(yīng)遵循個(gè)體化、漸進(jìn)的原則,嚴(yán)格按照康復(fù)程序?qū)嵤?,保證患者康復(fù)活動(dòng)安全、有效。對(duì)患者的各種危險(xiǎn)因素進(jìn)行評(píng)定,特別對(duì)高齡老年人及基礎(chǔ)疾病較重者應(yīng)加強(qiáng)觀察,酌情確定活動(dòng)時(shí)間,以保證取得最佳效果[16-17]。
本研究將起搏器植入術(shù)患者分為傳統(tǒng)治療組和早期康復(fù)組,按不同的康復(fù)程序進(jìn)行不同時(shí)間的康復(fù)指導(dǎo)及康復(fù)訓(xùn)練,于術(shù)后兩周、3個(gè)月對(duì)患者進(jìn)行生活質(zhì)量、肩關(guān)節(jié)疼痛和活動(dòng)障礙、電極脫位事件進(jìn)行評(píng)價(jià)。結(jié)果表明,與傳統(tǒng)治療組比較,術(shù)后6 h開(kāi)始進(jìn)行康復(fù)干預(yù)患者有更好的生活質(zhì)量,更低的肩關(guān)節(jié)并發(fā)癥發(fā)生風(fēng)險(xiǎn),且電極脫位事件并未增加。
綜上所述,與傳統(tǒng)治療相比較,起搏器植入術(shù)后6 h開(kāi)始進(jìn)行早期康復(fù)干預(yù)更有利于提高生活質(zhì)量,降低肩關(guān)節(jié)疼痛和活動(dòng)障礙,且并不增加電極脫位事件的發(fā)生。因此,對(duì)起搏器植入術(shù)后患者,實(shí)施系統(tǒng)、規(guī)范、具體、簡(jiǎn)便的早期術(shù)后功能鍛煉尤為重要。實(shí)施早期康復(fù)鍛煉可有效減少患者術(shù)后并發(fā)癥的發(fā)生,提高患者生活質(zhì)量,促使其及早回歸社會(huì),并減少相應(yīng)的醫(yī)療資源支出,減輕經(jīng)濟(jì)負(fù)擔(dān)。本研究觀察病例數(shù)有限、隨訪時(shí)間短,遠(yuǎn)期有效性尚未充分評(píng)估,結(jié)果存在一定的局限性,尚需進(jìn)一步的觀察研究。
作者貢獻(xiàn):郭英、郭航遠(yuǎn)進(jìn)行文章的構(gòu)思與設(shè)計(jì);孫勇進(jìn)行研究的實(shí)施與可行性分析;吳偉芳進(jìn)行數(shù)據(jù)收集;余瑜進(jìn)行數(shù)據(jù)整理;呂巧霞進(jìn)行統(tǒng)計(jì)學(xué)處理;許芬娟進(jìn)行結(jié)果的分析與解釋;郭英撰寫(xiě)論文,負(fù)責(zé)文章的質(zhì)量控制及審校,對(duì)文章整體負(fù)責(zé),并監(jiān)督管理。
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(本文編輯:吳立波)
Evaluation of the Effect and Safety of Early Rehabilitation in Patients with Cardiac Pacemaker Implantation
GUOYing,GUOHang-yuan*,SUNYong,YUYu,WUWei-fang,XUFen-juan,LYUQiao-xia
DepartmentofCardiology,ShaoxingPeople′sHospital,ShaoxingHospitalofZhejiangUniversity,Shaoxing312000,China
*Correspondingauthor:GUOHang-yuan,Professor,Doctoralsupervisor;E-mail:ghangyuan@hotmail.com
Objective To investigate the effect of early rehabilitation on quality of life,shoulder joint complications and electrode dislocation events in patients with cardiac pacemaker implantation.Methods From 2013 to 2015,a total of 220 patients accepted permanent pacemaker implantation in Department of Cardiology,Shaoxing People′s Hospital were selected as study subjects.The patients were numbered according to the order of hospitalization time,the even numbers were early rehabilitation group(n=110),the odd numbers were traditional treatment group(n=110).The patients in the traditional treatment group
routine rehabilitation program.The patients in early rehabilitation group were carried out the rehabilitation intervention by special personnel in accordance with different procedures and step-by-step functional exercise.After 12 h,the patients could get out of bed and exercise.After two weeks and 3 months postoperatively,the patients′ quality of life was evaluated by SF-36,the patients′ possible shoulder pain and motion disturbances were assessed by shoulder pain and disability index(SPADI),the electrode dislocation events were evaluated by X radiography.Results The scores of physical functioning,role-physical,bodily pain,general health,vitality,social functioning,role-emotional,mental health, physical component summary and mental component summary in the early rehabilitation group were higher than those in the traditional treatment group after two weeks postoperatively(P<0.05). The scores of physical functioning,role-physical,bodily pain,general health, social functioning,role-emotional,mental health, physical component summary and mental component summary in the early rehabilitation group were higher than those in the traditional treatment group after three months postoperatively(P<0.05).There was no significant difference in SPADI between the two groups after two weeks postoperatively(P>0.05).The SPADI of the early rehabilitation group was lower than that of the traditional treatment group after three months postoperatively(P<0.05).There were no significant differences between the two groups in the incidence of electrode dislocation after two weeks and three months postoperatively(P>0.05).Conclusion Compared with traditional treatment,early rehabilitation intervention 6 h after pacemaker implantation is more beneficial to improve the patients′ quality of life,reduce shoulder pain and joint movement disorder,and does not increase the incidence of electrode dislocation events.
Pacemaker,artificial;Rehabilitation;Quality of life;Postoperative complications
浙江省紹興市科技項(xiàng)目(2014B70059)
R 541.7
A
10.3969/j.issn.1007-9572.2017.20.004
2016-12-18;
2017-05-21)
312000浙江省紹興市人民醫(yī)院 浙江大學(xué)紹興醫(yī)院心內(nèi)科
*通信作者:郭航遠(yuǎn),教授,博士生導(dǎo)師;E-mail:ghangyuan@hotmail.com