【作者】 曹霞；

【导师】 谢秀梅；

【作者基本信息】 中南大学 ， 临床医学， 2013， 博士

【摘要】 第一章长沙地区职业人群正常高值血压的现况研究目的：通过对长沙地区职业人群进行现况调查,了解正常高值血压的流行现状,探讨多种危险因素与其的相关性,量化评估相关因素对正常高值血压的影响,为高血压防治策略的制定提供依据。方法：采取分层整群抽样方法,于2011年9月～11月对长沙地区辖区内5204名在职工作人员进行包括问卷调查、体格检查和实验室检测在内的现况调查。研究对象根据诊室血压水平分为正常血压组、正常高值血压组和高血压组。采用单因素方差分析或χ2检验比较各组之间特点,采用多因素logistic回归分析相关危险因素对正常高值血压的影响。结果：①长沙地区职业人群中正常高值血压患病率为33.17%(男性46.63%、女性14.84%),高血压患病率为22.44%。②正常高值血压组平均年龄及男性、高学历人员、吸烟者、经常饮酒者、高脂饮食者比例均明显高于正常血压组(P<0.001)。其空腹血糖、血尿酸、总胆固醇、甘油三酯、低密度脂蛋白胆固醇水平也均明显高于正常血压组,而高密度脂蛋白胆固醇水平则明显低于正常血压组(P<0.001)。高血压组以上趋势更为明显。③正常高值血压人群中,高值亚组的男性所占比例、体重、腰围、目前吸烟率、总胆固醇、甘油三酯水平均明显高于低值亚组(P<0.001)。④正常高值血压组中,代谢综合征患病率为30.01%。⑤经多因素logistic回归分析,年龄增长、男性、中心性肥胖及高脂饮食与正常高值血压密切相关(P<0.001)。结论：①长沙地区职业人群正常高值血压患病率较高(33.17%)。②正常高值血压人群代谢综合征患病率为30.01%。③年龄增长、男性、中心性肥胖及高脂饮食是正常高值血压的主要危险因素,提示高血压病一级预防中应重视体重、饮食及运动等生活方式的干预。第二章长沙地区职业人群中正常高值血压合并慢性肾脏病的现况及前瞻性队列研究目的：了解长沙地区职业人群中正常高值血压者合并慢性肾脏病的现况及相关危险因素；观察职业人群中正常高值血压向高血压及慢性肾脏病的转归,探讨影响其转归的因素,为预防高血压病、慢性肾脏病提供防治参考。方法：①现况调查采用整群抽样方法,对2011年3月～5月在中南大学湘雅三医院健康管理中心参加年度健康体检的长沙地区区内企事业单位在职工作人员11274人进行包括问卷调查、体格检查和实验室检测在内的现况调查,慢性肾脏病定义为肾小球滤过率下降和蛋白尿阳性；②选择2006年8月在该健康管理中心进行健康体检符合入选条件的1703人作为观察队列,于2006年8月～2011年12月间对观察队列进行定期随访,观察其1年后血压转归情况及随访5年间慢性肾脏病的发生及其影响因素。采用独立样本T检验、单因素方差分析或χ2检验比较各组之间的特点；采用多因素logistic回归分析了解相关危险因素对正常高值血压者合并慢性肾脏病的影响；用生存分析(Kaplan-Meier法)比较各血压水平分组间慢性肾脏病患病风险的差异,并经Log-rank检验。应用多变量Cox比例风险回归模型,校正相关因素后,分析影响正常高值血压者合并慢性肾脏病的可能危险因素。结果：①符合慢性肾脏病判定标准的共780例,整体CKD患病率为6.92%(男性10.67%,女性1.77%),其中蛋白尿阳性476例,占4.22%(男性6.26%,女性1.43%),无论是慢性肾脏病患病率或蛋白尿阳性率,男性均显著高于女性。②慢性肾脏病患病率随血压水平分组递增,分别为3.82%、6.93%、11.45%和18.85%。③仅在男性中发现经校正如年龄、肥胖、糖代谢异常、高脂血症、高尿酸血症等因素后,正常高值血压明显增加慢性肾脏病患病风险(OR：1.29595%CI：1.030～1.627,P<0.05)。④高尿酸血症是男性正常高值血压者合并慢性肾脏病的独立危险因素(OR：2.25295%CI：1.592-3.186,P<0.05)。⑤前瞻性队列研究中正常高值血压组1年后有110例进展至高血压(转归率30.77%),168例转归为正常血压(转归率20.15%)。影响其血压转归的因素包括性别、基线血压水平及有无危险因素聚集(代谢综合征)。⑥在平均54个月随访期间,有194例检出患慢性肾脏病,其中131例仅为eGFR<60mL/min/1.73m2,占67.53%；42例仅为蛋白尿阳性,占21.65%；二者兼存在的有19例,占10.82%。⑦经Kaplan-Meier法分析,不同血压分组间CKD的累积发病率有明显差异(P<0.001)。⑧经COX比例风险模型进行逐步回归分析,结果显示影响CKD发病风险的因素包括年龄、估算肾小球滤过率、收缩压和舒张压。结论：①长沙地区职业人群中整体CKD患病率为6.92%(男性10.67%,女性1.77%),在正常高值血压组中患病率为6.93%,显著高于正常血压组(P<0.001)；②男性经校正相关因素后,正常高值血压明显增加慢性肾脏病患病风险；③高尿酸血症是男性正常高值血压者合并慢性肾脏病的独立危险因素；④正常高值血压及高血压可显著增加患慢性肾脏病的风险；⑤影响慢性肾脏病发病风险的主要因素包括年龄、性别、估算肾小球滤过率、收缩压和舒张压。第三章以脑力劳动为主职业人群隐匿性高血压的特点及与职业紧张关系的研究目的：了解本地区以脑力劳动为主职业人群中隐匿性高血压患者的特点及靶器官损害情况；探讨隐匿性高血压与职业紧张的关系。方法：2011年4月～2012年3月采用方便抽样方法,调查对象来自长沙地区区内四个机关事业单位在职工作人员,其中选取符合入选标准的375人作为调查对象。调查方法主要有①通过诊室血压测量及动态血压测量诊断隐匿性高血压；②通过左室重量指数(LVMI)、颈动脉内中膜厚度(carotid IMT)测定评估其靶器官损害；③通过职业紧张问卷(中文版Karasek工作内容问卷JCQ)评估其职业紧张程度。计量资料检验采用t检验,计数资料采用χ2检验,运用χ2检验比较各组社会人口学特征、个体行为特征；运用协方差分析,校正相关因素后比较各组靶器官损害情况；运用二分类logistic回归分析、多因素logistic回归分析各变量与隐匿性高血压患病率关系。P<0.05说明差异有统计学意义,P<0.01说明有显著性差异。结果：①在正常血压组中检出10例(4.6%)隐匿性高血压,而在正常高值血压组中检出36例(22.6%)。②隐匿性高血压患者颈动脉IMT、LVMI、均高于血压正常组(P<0.001),且其中诊室正常高值血压亚组的隐匿性高血压患者心血管重构更为明显。③隐匿性高血压在被动型中患病率较高(32.6%),而在放松型中患病率较低(17.4%)。④高工作需求为隐匿性高血压独立的危险因素(OR：1.84；95%CI：1.45-2.32)；另外男性、肥胖、经常吸烟和经常饮酒也是隐匿性高血压的危险因素。⑤男性职业紧张类型中主动型与隐匿性高血压有相关性(OR：2.04；95%CI：1.17-3.58),而女性未见各职业紧张类型与隐匿性高血压有明显相关性。结论：①隐匿性高血压患者较正常血压者靶器官损害程度有一定增加,鉴于其在诊室正常高值血压者中患病率较高,临床上应重视对诊室正常高值血压人群,特别是已携带心血管危险因素者进行隐匿性高血压的风险筛查。②职业人群中男性且体型肥胖、同时生活方式不良者患隐匿性高血压的风险较高,临床上应关注这类人群并进行职业卫生健康宣教中普及隐匿性高血压知识及家庭自测血压方法。第四章基于PDCA循环管理的对功能社区正常高值血压人群健康教育效果评价目的：在功能社区中对正常高值血压人群实施PDCA循环管理模式构建的健康教育计划,探讨其在实施高血压健康教育中的效果,为促进和完善包括高血压在内的慢性病健康教育策略提供实证依据。方法：采用整群配对随机对照设计,选取2010年4月～6月在中南大学湘雅三医院健康管理中心参加年度健康体检的长沙地区区内在职工作人员中正常高值血压者5585人作为调查对象。采用基于PDCA循环管理模式构建的健康教育计划对试验组进行为期2年的生活方式干预,同期对照组进行常规电话随访。两组间各次访视时各监测指标的变化值比较采用T检验,并进一步用协方差分析对降压效果(两组的净差值)进行调整；用χ2检验进行分类资料的组间比较。结果：①干预组在2年后收缩压平均水平净下降1.76mmHg,舒张压平均水平净下降6.31mmHg。同时2年后两组间血压转化率有显著性差异,干预组有20.28%转变为正常血压,明显高于对照组的15.59%；而且干预组较对照组高血压转化率降低了近10%。②干预组在2年后很少运动的人员比例明显低于对照组(P<0.05),而纵向比较其常吸烟、很少运动的人数也在减少；类似变化也出现于对照组,其常吸烟、很少运动的人员比例也低于基线水平(P<0.05)。③干预组2年后除空腹血糖外,其余各指标均较基线时有明显改善(P<0.05),而且其多数指标也较对照组有一定程度改善,组间总胆固醇和空腹血糖水平有显著性差异(P<0.05)。结论：基于PDCA循环管理的健康教育模式是一种良好的预防高血压生活方式干预模式；疾病预防与控制相关部门与功能社区紧密合作,对正常高值血压职业人群实施有序、有质健康教育,是预防职业人群高血压及其并发症的有效措施,值得推广应用。更多还原

【Abstract】 PART1Prevalence of high-normal blood pressure and associated risk factors among the occupational population in ChangshaObjective:As the pace of life of China speeds up, most of China’s elite workforce lead unhealthy lives, obesity and high-blood pressure occur at an earlier age. So it is important to estimate the prevalence of high-normal blood pressure and identify risk factors in the populations.Methods:Using a stratified cluster sampling method, a representative sample of5,204white collar workers aged20～60years in Changsha was selected between September2011and November2011. Anthropometry, blood pressure, and blood sample were measured with standard instruments and methodology for all the study subjects. Multiple logistic regression methods were used to identify risk factors for high-blood pressure.Results:The prevalence of high-blood pressure and hypertension was33.17%and22.44%, respectively, in all participants. It was higher in males (46.63%) than females (14.84%) for high-blood pressure. Multiple logistic regression showed that middle age (adjusted odds ratio [OR]=1.37,95%confidence interval [CI]:1.01-1.86), male sex (OR=13.40,95%CI:10.93-16.44), central obesity (OR=2.51,95%CI:2.15-2.93), and eating fried food (OR=1.22,95%CI:1.00-1.48) were risk factors for high-blood pressure.Conclusion:High-blood pressure is common among relatively young and apparently healthy white collar workers in urban China, and cardiovascular risk factors cluster during high-blood pressure. It is an important public health challenge that adopts appropriate interventions to prehypertensive occupational groups in different degrees effectively. PART2High-normal blood pressure, hyperuricemia, and risk of chronic kidney disease among the occupational population in ChangshaObjective:To investigate the relationship between high-normal blood pressure and chronic kidney disease (CKD) in a middle-aged occupational population in Changsha. Furthermore, is to evaluate whether high-normal blood pressure is related to the incidence of CKD during the six-year follow-up.Methods:①Using a cluster sampling method, a cross-sectional survey of representative sample of11274white collar workers was carried out in Changsha between March2011and May2011. Chronic kidney disease was defined as eGFR less than60mL/min per1-73m2or the presence of proteinuria. Anthropometry, blood pressure, blood sample and urine sample were measured with standard instruments and methodology for all the study subjects. Multiple logistic regression methods were used to identify risk factors for CKD.②A prospective cohort study was carried out in1703white collar workers without pre-existing CKD in Changsha in2006at baseline. The cohort population was followed for an average of54months by annual examinations. Kaplan-Meier estimates were calculated for CKD. The association of blood pressure, serum uric acid and CKD incidence was examined using a Cox regression model adjusted for relevant factors.Results:①The prevalence of CKD among those with high-normal blood pressure and undiagnosed hypertension were6.93%and11.45%, respectively, compared with18.85%with diagnosed hypertension and3.82%with normal blood pressure, and10.67%in men, and1.77%in women, with a significant difference between genders at each strata of blood pressure.②In men, but not in women, whose blood pressure was high-normal blood pressure, the CKD risk was significantly greater (0R=1.30,95%CI:1.03～1.63) than those with optimal blood pressure.③Hyperuricemia was significantly associated with an increased risk of CKD in men, but not in women (OR=1.79,95%CI:1.48～2.16), and there was an additive effect of hyperuricemia and high-normal blood pressure on CKD risk in men compared with men with optimal blood pressure.④There were3664high-normal blood pressure subjects during the first visit and110subjects developed hypertension during the second visit (30.77%) and multiple logistic regression analysis showed that gender(male), blood pressure at baseline, metabolic syndrome were the risk factors of blood pressure progression.⑤During the follow-up of cohort,194incidences of CKD were recorded. Kaplan-Meier curves showed there was a significant difference in the cumulative incidence of CKD between the different blood pressure categories (log-rank test, P<0.001).⑥The independent risk factors of CKD were age, eGFR, systolic blood pressure,and diastolic blood pressure according to the COX proportional hazard analysis.Conclusion:High-normal blood pressure, as well as hypertension, is significantly associated with CKD among occupational population in Changsha. High-normal blood pressure, particularly in conjunction with hyperuricemia, was found to be an independent risk factor of CKD in men. The results indicate that active control of the blood pressure of high-normal blood pressure individuals is needed to prevent deterioration of kidney function. PART3Characteristics of masked hypertension in normotensive and white collar workers with high-blood pressure and the association between masked hypertension and job strainObjective:To identify demographic, lifestyle, clinical and psychological characteristics of masked hypertension in occupational population in Changsha. Furthermore, is to evaluate whether job strain is associated with the prevalence of masked hypertension.Methods:Study population was drawn from the participants of four public institutions in Changsha between April2011and March2012. There were375white collar workers with normotensive or high-blood pressure underwent office and ambulatory blood pressure measurements, risk factors and target organ damage were evaluated as well. The Chinese version of Karasek’s Job Content Questionnaire (C-JCQ) was used to measure job strain. Masked hypertension was defined as normal office blood pressure (<140/90mm Hg) with elevated ambulatory blood pressure (≥135/85mmHg)Results:①The prevalence of masked hypertension among those with normotensive and high-normal blood pressure were4.6%and22.6%, respectively.②The carotid intima-media thickness and left ventricular mass index tended to increase from true normotensive through masked hypertension with normal office blood pressure to masked hypertension with high-normal office blood pressure.③In men, but not in women, being in the active group (high psychological demands and high decision latitude) was associated with MH (OR:2.04;95%CI:1.17～3.58)Conclusion:The prevalence of masked hypertension was high in the high-normal office blood pressure compared with those normotensives. The cardiovascular risk profile of masked hypertension was increased as well. Masked hypertension is associated with job strain in men and workers in "active" job situations may be more vulnerable to have hypertension. PART4Effect of follow-up management based on PDCA circulation in occupational population with high-blood pressureObjective:To evaluate the effect of follow-up management based on PDCA circulation in promoting lifestyle modification among occupational population with high-blood pressure.Methods:A parallel study base on a cluster-paired randomized trial was carried out in5585staff from36enterprises and public institutions of Changsha between April2010and March2012. The experimental group received the PDCA-based lifestyle intervention while the control group received the conventional follow-up conducted by doctors and nurse of the health management center.Results:After two-year intervention, the mean systolic blood pressure and diastolic blood pressure of the intervention group incrementally decreased by1.76mmHg and6.13mm Hg, respectively. Meanwhile, the progression is postponed from high-blood pressure to hypertension, which the rate of prognosis decreased by nearly10%. The intervention group had better behavior prevalence than the control group including quitting smoking and more frequent aerobic exercise (P<0.05).Most of the biochemical indexes in the experimental group were significantly better than those of control group as well (P<0.05)Conclusion:The follow-up management based on PDCA circulation is an interactive and flexible model, which resulted in improvement of the participants’blood pressure control and lifestyle.更多还原