【作者】 李兵；

【导师】 杨笛；

【作者基本信息】 南京医科大学 ， 心血管内科， 2008， 硕士

【摘要】 背景:近年来,尽管对慢性心力衰竭的治疗已经得到了很大的改善,但是其发病率与死亡率仍然居高不下,其主要原因是慢性心衰的发病机制尚未完全阐明。遗传因素、免疫系统激活、心肌能量耗竭和神经体液因子等在慢性心力衰竭的病理过程中起重要作用。早在70年前,Herrmann和Decherd提出慢性心力衰竭时存在心肌能量耗竭的假说,此后慢性心力衰竭心肌能量代谢变化的临床和基础实验研究不断增多,有学者认为磷酸肌酸/三磷酸腺苷是较左室射血分数和纽约心功能分级更能反应慢性心衰患者预后的指标。研究显示直接改善心肌能量代谢药物曲美他嗪能够提高缺血性和非缺血性心力衰竭患者运动耐力、生活质量和左心功能、减少利尿剂和洋地黄的应用、降低血清中BNP含量。未来心衰治疗的一个目标就是改善心肌的能量代谢。自身免疫反应参与了慢性心力衰竭的发生发展,在扩张型心肌病患者血清中发现心脏自身抗体增高,包括抗肾上腺素能受体抗体、抗肌球蛋白抗体、抗胆碱能受体抗体等。临床研究发现,心脏自身抗体增高的患者在接受免疫吸附治疗后,其心功能可得到改善。有学者提出自身抗体可能通过直接或间接途径造成心肌损伤、心功能减退。心肌肌钙蛋白Ⅰ（cTnI）是心脏特异性蛋白质,心肌损伤后释放入血,可激活免疫系统产生cTnI自身抗体,后者长期存在于患者血清中。虽已有文献报道其可以导致心肌损害,腹腔注射可以诱导小鼠发生心力衰竭,但是不同病因的心力衰竭患者cTnI自身抗体滴度是否有差异?cTnI自身抗体对慢性心衰患者预后是否有影响等问题尚待阐明。第一部分:慢性心力衰竭大鼠心肌能量代谢变化及药物干预研究目的:研究异丙肾上腺素（ISO）所致慢性心力衰竭大鼠心肌能量代谢变化及曲美他嗪、培哚普利和丹参益气浸膏对其影响。方法:1.96只雄性SD大鼠,体重201.86±6.68g,随机分为对照组（18只）和CHF组（78只）,模型制备采用皮下多点注射ISO法,以每天20、10和5mg/kg递减剂量连续注射3天,再以每天3mg/kg剂量连续注射9天。2.4周后分别随机取8只对照组和模型组大鼠进行二维超声心动图检查,确定模型制备成功。再随机分为未治疗组和曲美他嗪组(10 mg·kg^-1·d^-1)、培哚普利组(0.42 mg·kg^-1·d^-1)、芪参益气浸膏组(39.1 mg·kg^-1·d^-1)三个治疗组。3.平均治疗5周后行心脏超声检查和病理形态学观察,并测定心肌组织高能磷酸化合物的含量和肌浆网Ca²⁺依赖型ATP酶（SERCA）活性。结果:1.皮下注射异丙肾上腺素4周后,与对照组比较,模型组大鼠EF和FS显著降低,IVS、LVPW明显减小,LVS、LVD明显增大。2.与对照组比较,未治疗组大鼠心肌ATP、AMP、TAN和乳酸含量显著降低。3.与未治疗组比较,药物治疗5周后,曲美他嗪治疗组大鼠EF和FS分别提高了6.5%和11.6%,心肌ATP/ADP升高了19.6%,AMP含量和SERCA活性明显增加;芪参益气浸膏治疗组大鼠心肌ATP、ADP、TAN含量和SERCA活性均显著增高;培哚普利治疗组大鼠心肌AMP含量显著升高。芪参益气浸膏治疗组、曲美他嗪治疗组和培哚普利治疗组大鼠心肌光镜与电镜结果均较未治疗组有改善。结论:异丙肾上腺素导致的慢性心力衰竭大鼠心功能和心肌能量代谢恶化,曲美他嗪、培哚普利和芪参益气浸膏均能不同程度的改善慢性心力衰竭大鼠心肌的能量代谢和形态学变化。第二部分:慢性心力衰竭患者心肌肌钙蛋白Ⅰ自身抗体的研究目的:观察失代偿性慢性心力衰竭患者血清cTnI自身抗体水平及其与临床预后和患者生活质量的关系,初步探讨cTnI自身抗体在慢性心力衰竭中的临床意义。方法:1.收集59例慢性失代偿性心力衰竭患者血清标本,所有患者均参照2007年中国慢性心力衰竭诊断指南,NYHA分级为Ⅲ～Ⅳ级。收集40例健康体检者血清标本作为对照。2.以人cTnI为抗原包被微孔板,以鼠抗人IgG为第二抗体,建立检测血清cTnI自身抗体的间接ELISA方法。通过检测不同样本和不同浓度的cTnI抗体对本实验室已建立的cTnI自身抗体间接ELISA测定法批间和批内差异进行评价。3.检测慢性心力衰竭患者及健康体检者血清cTnI自身抗体,以超过对照组（?）+3SD为阳性。4.对慢性心力衰竭患者进行平均6个月随访,观察患者再入院率、是否行器械及心脏移植、是否死亡和通过SF-36评价患者生活质量。结果:1.4.5ng/ml的cTnI抗体作为样品检测批间和批内差异分别为12%和6%,9.0ng/ml的cTnI抗体作为样品检测批间和批内差异分别为10%和12%,对4例不同患者样本cTnI自身抗体检测批间差异分别为23%、22%、15%和24%,批内差异分别为21%、9%、9%和9%。2.对照组cTnI自身抗体检测平均值为0.46±0.07,慢性心衰患者cTnI自身抗体检测平均值为0.55±0.24,59例慢性心力衰竭患者中cTnI自身抗体检出阳性9例,其中15例缺血性心肌病患者3例cTnI自身抗体阳性、27例扩张型心肌病患者3例cTnI自身抗体阳性、17例其它原因引起的慢性心力衰竭患者3例cTnI自身抗体阳性。3.对慢性心力衰竭患者出院后随访6个月,7例cTnI自身抗体阳性患者死亡3例,27例cTnI自身抗体阴性患者死亡2例;生活质量比较,cTnI自身抗体阳性组患者生活质量各指标均较阴性组患者有所降低。结论:1.在慢性失代偿性心力衰竭患者血清中可检测到cTnI自身抗体。2.慢性失代偿性心力衰竭患者cTnI自身抗体增高可能预示患者预后不良和生活质量降低。更多还原

【Abstract】 Background:Despite recent improvements in therapy, both incidence and mortality of the chronic heart failure patients are still very high. The main problem is its heterogeneous etiology. So far, four factors have been identified to be potentially important: neurohumour factors, immune mechanism, energy metabolism and genetic factors.The concept that the failing heart is an energy-starved engine that has run out of fuel is decades old. It was proposed in 1939 by Herrmann and Decherd, who, in their article entitled "The Chemical Nature of Heart Failure", described a significantly reduced creatine content in failing myocardium. Over the next 20 years, the energy-depletion hypothesis was pursued by various groups, and nowadays, energy metabolism in the heart—myocardial energetics—is a topic of considerable interest. In heart failure patients, a low myocardial phosphocreatine :ATP level predicts mortality better than left ventricular ejection fraction and New York Heart Association classes. And some studies demonstrated treatment with trimetazidine, an inhibitor of fatty acid oxidation, improved exercise tolerance, quality of life, left ventricular function and reduced diuretic/digitalis application in patients with heart failure of ischemic or nonischemic origin. Stephan et al presumed targets for future interventions in the chronic heart failure including energy imbalance. Many cardiac autoantibodies can be found elevated in the serum of dilated cardiomyopathy patients. As we know now, they are anti-adrenoceptor autoantibodies, myosin autoantibodies, anti-M₂ acetylcholine receptor autoantibodies and so on. It has been suggested that clinical improvements in patients with high cardiac autoantibodies titers are related to the disappearance of antibodies by immunoadsorption therapy. It is presumed now that these autoantibodies can damage the cardiomyocytes by some mechanisms and take part in the pathophysiological process of myocardial damage and myocardium dysfunction. Cardiac troponin I （cTnI）, a regulatory protein unique to heart muscle, is released to the bloodstream after myocardial necrosis. These findings suggested that antibodies to cTnI induced heart dysfunction and dilatation in mice. But many questions need further investigation. Such as whether there is a relationship between cTnI autoantibodies titers and origins of the CHF? And whether there is a relationship between the cTnI autoantibodies level and prognosis in the CHF patient?Section 1 The changes and the intervention of the drugs on myocardial energy metabolism in chronic heart failure ratsAIM:To investigate the changes and the intervention of the drugs, including trimetazidine, perindopril and QiShenYiQiJinGao, on myocardial energy metabolism in isoproterenol-induced heart failure rats.METHODS: 1. ninety six male SD rats （body weight 201.86±6.68g） were enrolled in this study. Firstly they were randomly divided into two groups, one was normal control group（n=18）, the other was CHF group（n=78）. Rats in CHF group were injected subcutaneously with isopreteronol（ISO） at a dose of 20mg/Kg at the first day of this study, 10mg/Kg at the second day, 5mg/Kg at the third day and 3mg/Kg at the following nine day.2. Four weeks later, in order to confirm whether the CHF model were successful, 8 rats from the control group and the model group were selected at random respectively performed 2-Dimensional echocardiography （2-DE）. Then the survived rats in CHF group were randomly re-divided into four groups, which were untreated group（Group M） , trimetazidine treated group(Group T, 10 mg·kg^-1·d^-1), perindopril treated group(Group P, 0.42 mg·kg^-1·d^-1) QiShenYiQi treated group(Group Q, 39.1 mg·kg^-1·d^-1).3. After an average treatment for five weeks, echocardiography and myocardial pathology were performed to assess the cardiac function and structure changes of these rats. And the level of ATP, ADP , AMP, lactic acid（LA） and sarcoplasmic reticulum Ca²⁺-ATPase（SERCA） activity in myocardium were determined by enzymatic analyses.RESULTS:1. Four weeks later, model group showed a significant decrease in LVPW,IVS, EF, FS and increase in LVS, LVD as compared with the control value. 2. Compared with the control group, the level of myocardial ATP, AMP, TAN and LA showed a significant decrease in group M.3. As compared with the group M values, the level of myocardial ATP , ADP, TAN and myocardial SERCA activity had a significant increase in Group Q; EF , FS and ATP/ADP of Group T were increased by 6.5%, 11.6% and 19.6% respectively, and the level of myocardial AMP and the myocardial SERCA activity showed a significant increase; the level of myocardial AMP had a significant increase in Group P. The microscope and electronic microscope analysis showed that the myocardial injury from the rats in Group T , Group P and Group Q was ameliorated in comparison with those from rats in Group M.CONCLUSION:In this study, the myocardial energy metabolism and heart function were to getworse in isoproterenol-induced heart failure rats. Trimetazidine, Perindopriland QiShenYiQiJinGao can improve myocardial energy metabolism, patho-and ultrastructure , but they do not enhance the cardiac function inisopreteronol-induced HF rats.Section 2 The preliminary study on cTnI autoantibodies in chronic heart failureAIM: To evaluate the serum cTnI autoantibodies level in the chronic uncompensated heart failure patients, discuss the relationship between the cTnI autoantibodies level and prognosis. To elucidate the pathological roles of human cTnI autoantibodies in the chronic heart failure（CHF） patients.METHODS:1. Enrolled the testees of 59 CHF patients and 40 healthy participants from the outpatient clinic. The CHF patients was diagnosed according to the CHF guideline of Chinese Medical Association and the NYHA of the CHF patients were III～IV.2. A sandwich ELISA method detecting cTnI autoantibodies was established with human cTnI and mouse anti-human IgG. Tested the interassay coefficient of variation and the intraassay coefficient of variation of a sandwich ELISA method detecting cTnI autoantibodies by detecting mouse anti-human antibodies of different concentrations and different samples.3. All the serum cTnI autoantibodies of the testees （CHF group and healthy control group） were measured by ELISA. Set the mean±3SD obtained from the healthy control to define positive for each group.4. Follow-up for discharged CHF patients was 6 months. Follow-up index included mortality rate, readmission rate, mechanical therapy rate, heart transplantation rate and the quality of life.RESULTS: 1. The interassay coefficient of variation and the intraassay coefficient of variation of this method were about 10% by detecting mouse anti-human antibodies of different concentrations, while which were 9%-24% by different samples.2. The mean value of the serum cardiac troponin I autoantibodies of the CHF group was 0.55±0.24, while the healthy control group was 0.46±0.07. 9 patients were identified as positive in the CHF group. We found that three patients from the 15 having ICM, three patients from the 27 having DCM and three patients from 17 having other origins had cTnI autoantibodies.3. After 6 months of follow-up, the mortality rate of cTnI autoantibodies positive patients had a trend to increase as compared with the negative group. Compared with the negative group, the indexes of the quality of life also had a trend to decrease in cTnI autoantibodies positive patients.CONCLUSIONS:1. The cTnI autoantibodies can be detected in the serum of chronic uncompensated heart failure patients.2. The elevated serum cTnI autoantibodies of some chronic uncompensated heart failure patients may be correlated with unfavorable prognosis and quality of life.更多还原