【作者】 叶岚；

【导师】 李广平；

【作者基本信息】 天津医科大学 ， 内科学， 2010， 博士

【摘要】 目的：随着社会进入老龄化,动脉硬化程度与心血管事件的相关性研究正越来越引起人们的关注。虽然传统的心血管病危险因素已为人们所熟识,但仍需开发其他的简便、无创、经济的方法来评价预后。随着科技的发展,无创评价动脉硬化程度成为研究热点,其最大优势是可以在大规模人群中推广使用,可以早期发现疾病并采用一级预防。故筛选合适的动脉硬化新指标并评价其对心血管疾病的预后的影响是人们迫切想解决的问题。国外已有这方面的观察研究来评价这些指标在高血压、冠心病、晚期肾功能不全、糖尿病甚至高脂血症中的应用。但国内对动脉硬化指标的研究却刚刚起步且数量较少。本研究的目的是采用两种无创检查动脉硬化程度的仪器(日本Colin公司生产的全自动动脉硬化检测仪(VP-2000)和日本欧姆龙血压脉搏检查仪(HEM-9000AI))评估四种动脉硬化指标(肱踝脉搏波传导速度(baPWV)、跺臂指数(ABI)、无创中心动脉压(CSBP)和桡动脉增强指数(rAI))在冠心病、高血压患者中的应用价值。内容：1.了解baPWV在冠心病和非冠心病者中有无不同,并确定其影响因素；2.评价低ABI者的临床特征及其对一年再住院率的影响；3.在住院患者中测量rAI和CSBP,了解无冠心病者rAI的影响因素及rAI对冠心病的判定作用；4.评价CSBP在高血压随访中的作用,分析CSBP与外周动脉收缩压(PSBP)降低程度对左室肥厚减退的影响。方法：1.用全自动动脉硬化检测仪(VP-2000)对398例患者行baPWV和ABI检查,同时收集病史、血生化、心脏彩超和造影检查等临床资料。对冠心病危险因素的分析采用logistic回归分析。对baPWV与各变量的相关分析采用Pearson相关性分析,对baPWV影响因素的分析采用多因素线性回归分析。2.用全自动动脉硬化检测仪(VP-2000)对行ABI检查的1002例患者随访一年,记录其因缺血性心脏病和缺血性脑卒中而需再住院的情况。采用Kaplan-Meier生存分析评估再住院率,采用Log-Rank法对其进行检验。3.采用欧姆龙血压脉搏检查仪(HEM-9000AI)对无冠心病患者45例和男性冠心病患者46例行rAI和CSBP检查,并行冠脉造影检查,对无冠心病者比较男女间rAI的不同。在男性冠心病者中分析rAI的影响因素。4.对心电图和心脏彩超提示左室肥厚的高血压病人在住院期间行CSBP检查,出院后规律服用降压药物,至出院后年时复查心电图和中心及外周血压,比较左室肥厚减退与未减退者外周及中心血压的不同变化。结果：1.与无冠心病者相比,有冠心病者baPWV高,ABI值低,经Logistic回归方程进行分析,对冠心病有预测作用的因素主要是年龄、性别、ABI值,而不是baPWV;经多元线性回归分析表明收缩压对baPWV影响最大。2.与正常ABI组相比,低ABI组患者中高龄女性多、高血压、糖尿病、脑梗死、慢性肾功能不全患病率高、多支血管病变发生率高、C-反应蛋白水平升高、肾素水平升高、纤维蛋白原升高。ABI<0.9组再住院率高于ABI≥0.9组,ABI<0.6组再住院率又进一步升高。同样为多支血管病变,ABI<0.9组因缺血性事件而再入院发生率依然高于ABI≥0.9组。3.女性rAI大于男性,正常人影响rAI的因素是性别、心率、身高、体重、体重指数(BMI)和主动脉根部内径(AoD)；男性冠心病者对rAI值有影响的是心率,左室射血分数(LVEF)、中心动脉脉压(CPP)和外周动脉脉压(PPP)。4.共有59例心电图表现为左室肥厚(LVH)的高血压患者完成一年随访,LVH减退者CSBP的降低更明显。结论：1.baPWV是代表动脉硬化的指标,在临床应用中有一定价值。但是baPWV对于冠心病的预测作用不及ABI,收缩压水平对其影响大,故用baPWV预测冠心病发生风险时要考虑上述因素对其的影响。2.低ABI者多伴有多种心血管危险因素和炎症标记物的增加,一年内因缺血性事件再住院的发生率要明显高于正常ABI者。低ABI是患者一年内因缺血性心脑血管事件再住院的独立预测因子。3.在正常男女之间rAI值即有不同,rAI值除受到性别、年龄、身高等影响外,在男性患者中还与心率、心功能有关,故用rAI预测冠心病时要考虑心功能对它的影响。4.高血压左室肥厚的减退与CSBP的降低有关,CSBP降低能解释LVH减退的机制。更多还原

【Abstract】 Objectives:In aging societies, most attention is focused on the relation between arterial stiffness and coronary vascular disease. Although traditional risk factors have been familiar to the people, simpler, noninvasive, and more economical methods are needed to evaluate progress. With the development of science and technology, people have started to pay more attention to evaluate degrees of arterial stiffness with noninvasive methods. The biggest advantage of these methods is that they can be used in large populations, so people with risk factors can be found early and effective methods can be adopted to prevent further progress, therefore, it is imperative to select new indices and evaluate their effect on the progress of coronary vascular disease. Some researches abroad have been completed on evaluating these indices on coronary heart disease, hypertension, chronic kidney disease, diabetes mellitus and hyperglycemia. However, the amount of domestic research is far less. The aim of this research is to study some indices among the patients with CHD and related risk factors using newest equipment available. These indices included: brachial-ankle pulse wave velocity (baPWV), ankle branchial index (ABI), central systolic blood pressure (CSBP), and radial augmentation index (rAI). Our goal is to compare the difference between normal people and patients, and thus predict the effect of these indices on future progress.Content:1. Compared the difference of baPWV between the patients with CHD and patients without CHD, and evaluated its influencing factors.2. Analyzed the relationship between low ABI and re-hospitalization within one year in CHD patients with ischemic heart disease or shock.3. Studied the differences in rAI between male and female patients without CAD and its influential factors; to assess the differences of peripheral and central pulse wave in men with and without CAD and the influential factors of rAI.4. Compared the different degree of peripheral BP and CSBP in regression of LVH, and evaluated the effect of CSBP on antihypertensive therapy.Methods:1. baPWV and ABI were measured in 398 patients consecutively by collecting their medical history, chemical tests, echocardiography and angiography. A multivariate logistic regression analysis was done for CHD factors. The relation between baPWV and other variables was studied using Pearson correction analysis, a multivarious linear regression demonstrated the influencial factors of baPWV.2. ABI was tested in 1002 patients using Omron volume plethysmographic apparatus, patients were followed up to 1 year. Kaplan-Meier method was used to produce the life table, and Long-rank analysis was adopted for the analysis.3. Radial arterial waveforms were obtained from 122 subjects using Omron HEM-9000AI. CSBP and rAI were tested in 45 people without CHD and 46 male CHD patients. We analyzed the difference between men and women. In male CHD patients, multivarious linear regression analysis was used to evaluate their influential factors.4. CSBP was measured in the hospital in left ventricular hypertrophy patients using an electrocardiograph of Cornell voltage-duration product criterion. Antihypertensive treatment lasted at least one year in outpatients; at the end of the follow-up, electrocardiography, CBP and peripheral blood pressure were measured again, and compared different degree of peripheral BP and CSBP in the regression of LVH.Results:1. baPWV was higher and ABI was lower in the CHD group compared with non-CHD groups. Based on the result from logistic regression analysis, baPWV was not a significant independent variable for the prevalence of CHD, rather, age, gender and ABI values were. The result also demonstrated that systolic blood pressure influenced baPWV the most.2. In the low ABI group, elderly people and women were more likely to have CHD, hypertension, diabetes mellitus, shock, multiple vessel disease, chronic kidney failure, C-reactive protein, rennin, and fibrinogen. The rate of re-hospitalization was much higher in the low ABI group, for example, the rate was higher in the group with ABI更多还原