【作者】 展英华；

【导师】 张梅；

【作者基本信息】 山东大学 ， 影像医学与核医学， 2009， 硕士

【摘要】 研究背景代谢综合征（Metabolic Syndrome,MS）做为严重威胁人类健康的疾病,是由胰岛素抵抗引发的一系列临床、生化、体液代谢失调的症候群。随着人们生活方式的改变和生活水平的提高,MS发病率目前在国内外呈上升趋势,高血压和肥胖是其主要特征,也是导致左室功能障碍的常见原因。研究MS患者心功能的改变,分析心肌室壁运动变化特点,对于心脏疾病的早期诊断、治疗、改善愈后具有重要的临床意义。心血管造影术、均衡核素扫描和磁共振技术已广泛用于左室功能的评价,但因这些检查价格昂贵、不易重复及有一定放射性等缺点,临床上难以广泛应用。与上述技术相比,超声心动图因其无创、敏感度高、可重复性好等优点得到了广泛的应用,已成为临床上室壁运动检测的首选方法。超声心动图研究的主要内容之一就是检测心脏室壁运动的变化,实时观察左室壁整体及局部各节段的运动,检出运动异常的区域,准确评价心脏功能。实时三维超声心动图（RT-3DE）及心肌应变（ε）、应变率（SR）是近年发展起来的超声检测新技术,因其实时性、高敏感性等特点使分析、研究心功能早期改变成为可能。研究表明代谢综合征患者常伴血清脂联素的降低,脂联素具有改善代谢及多重抗动脉硬化的作用,但脂联素水平的改变与代谢综合征患者心功能的关系如何尚未完全明了。研究目的:（1）联合应用实时三维超声心动图、应变及应变率技术评价代谢综合征患者左心整体、局部收缩功能及舒张功能改变,并对其运动同步性进行评估,从而进一步明确超声技术对代谢综合征患者心脏功能检测的重要意义。（2）观察代谢综合征组与对照组研究对象的脂联素水平,探讨代谢综合征患者心功能早期改变与脂联素之间的关系。研究方法入选病例共有120例,其中男性65例,女性55例,平均年龄58.2±11.4岁。根据患者是否符合IDF诊断代谢综合征标准分为代谢综合征组60例和对照组60例。代谢综合征组选自2002至2006年明确诊断为代谢综合征的患者,男性32例,女性28例,平均年龄59.1±10.5岁;对照组为非代谢综合征组,男性33例,女性27例,平均年龄56±15.7岁。仪器设备彩色多普勒超声显像仪:PHILIPS IE-33型,荷兰飞利浦公司生产,二维成像探头(S_5-1),探头频率1-5MHz。该机配备实时三维成像技术,三维成像探头(X_3-1)探头频率1-3MHz,仪器配有Qlab图像分析软件包。研究方法所有受检者均进行经胸二维超声、组织多普勒超声、实时三维超声心动图检查。组织多普勒超声检查取心尖两腔、心尖四腔、心尖左室长轴切面所得图像存储于硬盘,以备分析。实时三维超声心动图检查使用全容积显像方式,采集“金字塔”样的三维数据库存储于主机供脱机分析。统计学分析采用SPSS10.0分析软件,所有数据均采用均数±标准差（（?）±s）表示,计量资料采用非配对t检验,两组变量之间的相互关系采用直线相关分析,以P＜0.05为有统计学意义。结果1与对照组比较,代谢综合症组患者体重、腰围、体表面积、体重指数、吸烟饮酒指数升高,差异有统计学意义（P＜0.05）;代谢综合征组患者血清总胆固醇、甘油三脂和低密度脂蛋白水平增高,差异具有统计学意义（P＜0.05）。而身高及高密度脂蛋白在两组间无显著性差异（P＞0.05）;代谢综合征组空腹血糖增高（P＜0.05）;脂联素水平降低显著,差异具有显著性（P＜0.01）。2与对照组相比,代谢综合征组二尖瓣口舒张早期峰值速度（E）降低,舒张晚期峰值速度（A）升高,E/A＜1,差异具有显著统计学意义（P＜0.01）。三尖瓣口舒张早期峰值速度(E_TV)降低,舒张晚期峰值速度(A_TV)升高,E_TV/A_TV＜1,差异具有统计学意义（P＜0.05）。二尖瓣环组织多普勒频谱示二尖瓣环舒张早期峰值速度（E′）降低,舒张晚期峰值速度（A′）峰升高,E′/A′＜1及E/E′比值增高,较对照组变化明显（P＜0.05）,表明左室舒张功能受损。代谢综合征组左心房、心室舒张末期内径、室间隔及左室后壁舒张末期厚度,左房、左室舒张末期容积、收缩末期容积、左室整体射血分数,较对照组增大两组间比较无显著差异（P＜0.05）。3与对照组相比,代谢综合征组左室心肌各节段局部容积-时间曲线紊乱,达到收缩末期最小容积的时间参差不齐。部分室壁局部射血分数、心搏量及局-整射血分数、局-整心搏量降低有统计学意义（P＜0.05）。4本研究发现代谢综合征组与对照组相比较左室心肌16段、12节段达到收缩末期最小容积时间的标准差（Tmsvl6-SD,Tmsvl2-SD）和最大差值（即Tmsvl6-Dif,Tmsvl2-Dif）及其心率校正值（Tmsvl6-SD%,Tmsvl2-SD%,,Tmsvl6-Dif,Tmsvl2-Dif%）比较,前者高于后者（P＜0.05）。5对照组的心肌纵向应变曲线为一规则负向曲线,达到峰值应变的时间对应T波终点,而代谢综合征组左室壁节段心肌纵向应变曲线形态不规则,呈平直或双向。对照组左室各节段的纵向应变率（SR）曲线为一规则的一负两正波形,代谢综合征组与对照组比较有峰值减低,达峰时间延迟,曲线形态紊乱等特征。6血清脂联素与体重、腹围、血压（收缩压）、血清TG、LDL-C、血糖呈负相关（P＜0.05）;与左室壁舒张功能指标:二、三尖瓣口前向血流多普勒频谱E/A比值、二尖瓣环组织多普勒频谱E′/A′比值呈正相关、与E/E′比值呈负相关（P＜0.05）;与左室整体收缩功能指标EF无明显相关关系。结论1 MS组患者血清脂联素水平降低,说明MS组患者体内的保护因子水平低。2应用实时三维超声心动图及应变、应变率技术对MS组患者进行检测,在MS组患者左室整体射血分数正常时,即可早期发现左室整体舒张功能及局部的收缩、舒张功能改变,心肌收缩同步性降低。3心脏左室功能受损时,整体及局部舒张功能首先受损,E/E′及左室壁各节段舒张早期应变率达峰时间是比较敏感的指标。4脂联素和左室整体舒张、局部收缩及舒张功能改变关系密切,可能对心脏功能有一定影响。更多还原

【Abstract】 BackgroundMany clinical studies show that cluster of risk factors that include type 2 diabetes mellitus impaired glucose tolerance, hypertension, disorder of lipid and central obesity often assembled with the same patient. In 1988, Reaven brought out the definition of Metabolic syndrome, It included the insulin resistance, lipid dysfunction, and hypertension which is also called X syndrome or insulin resistance syndrome. The prevalence of metabolic syndrome is increased in developed and developing countries as a result of improved living standard. As hypertension and obesity are major abnormalities of metabolic syndrome, and also the common reason for cardiac dysfunction. Cardiac function evaluation is an important guidance in diagnosing、therapeutic effect and prognostic assessment of cardiovascular disease.Angiocardiography and magnetic resonance imaging are used to evaluate left ventricular function broadly, but these two methods have the shortage of invasion、too expensive and being difficult for repeating exam. Compared to these two methods, echocardiograpy can estimate the movements of ventricular wall and the changes of cardiac dynamic noninvasively , precise nature and lack of ionizing radiation make it more broad applicable than other accepted techniques. Estimating cardiac-function is one of the most important contents of echocardiography. Because of noninvasive and high repeatability, echocardiography plays an important role in diagnosing disease of cardiovascular system.Metabolic syndrome comes together with decreasing of serum adiponectin. And adiponectin has multiple anti-arteriosclerosis actions. It is very important for cardiac function nonage change to make clear the relationship between metabolic syndrome and adiponectin.Objective1.To investigate LV globe and regional heart function changes , systolic synchrony in patients with MS early by strain rate imaging(SRI),strain imaging(SI) and real-time three-dimensional echocardiography(RT-3DE) simultaneously.2. To evaluate relationship among the level of serum adiponectin and cardiac function change.Methods120 patients were studied which were divided into two groups. 60 cases are diagnosed as Metabolic syndrome according to the diagnostic standard of IDF, consisting of 32 males, 28 females, 45-70 years old, with a mean age (59.1±10.5) years old; 60 cases in control without Metabolic syndrome consists of 33 males, 27 females, 47-68 years old, with a mean age (56±15.7) years old. Then we collected patients’ history, had them take EKG examination and determined serum adiponectin by ELISA.Equipments and apparatus: PHILIPS IE-33 ultrasound scanner (Holland) was used to acquire 2DE, RT-3DE data, which has probe S5-1 and probe X3-1 with 2-4MHz array transducer. The data was analyzed using Qlab system .Measurement and calculate methods: Transthoracic two-dimensional, tissue Doppler and three-dimensional echocardiography examination were performed in all study objects .We use Qlab analysis software to analyze the data.Statistical analysis: All numeric data were displayed as mean±standard deviation and have been analyzed by SPSS 13.0. For all analysis, a p value of< 0.05 was considered significant.Results1 There was significant difference between two groups with metabolic syndrome and without metabolic syndrome in weight, waist, body surface area, body mass index, smoking index and alcohol consumption(p<0.05). The levels of TC, TG, LDL-C and glucose of groups with metabolic syndrome was higher than that of the groups without metabolic syndrome (p <0.05); No difference was found in the level of HDL-C and height between the two groups. SBP in patients with metabolic syndrome was higher than that of the objects without metabolic syndrome The level of adiponectin of the patients with metabolic syndrome was lower than that of the objects without metabolic syndrome (p <0.05).2 Research work proved that E/A of MV and TV was significantly decreased, while trans-mitral flow velocity to mitral annular velocity ratio (E/E’)was higher in patients with metabolic syndrome than that in group without metabolic syndrome (p <0.05).3 Compare the global function results by three echo examinations: there was no significant difference among the data acquired using three echo methods (p>0.05). EDV, ESV and EF of left ventricular in group with metabolic syndrome and group without metabolic syndrome are nearly same(P>0.05); some segments function reduced obviously in group with metabolic syndrome than that in group without metabolic syndrome.4 The 17 segment volume-time curves of group with metabolic syndrome have ill-defined appearances comparing with that of group without metabolic syndrome; the end systolic time reaching minimal systolic volume is irregular; the wall motion has bad synchronism.5 Tmsv16-SD, Tmsv16-Dif, Tmsv12-SD, Tmsv12-Dif Tmsv1-4Dif, Tmsv2-5Dif and heart rate correction value Tmsv16-SD%, Tmsv16-Dif%, Tmsv12-SD%, Tmsv12-Dif%, Tmsv1-4Dif%, Tmsv2-5Dif%in group with metabolic syndrome is higher than in group without metabolic syndrome (P<0.05).6 The analysis showed that the strain rate curve and strain curve of left ventricular in group with metabolic syndrome was chaotic. S, E and A of strain rate andεof some segments were lower significantly in group with Metabolic syndrome than in group without metabolic syndrome.7 There was significant negative correlation existed between adiponectin and weight, waist, TC, TG, LDL-C , glucose and E/E’(p<0.05). There was significant excellent linear correlation existed between adiponectin and E/A of mitral annulus (p <0.05).Conclusion1. The patients with metabolic syndrome have a lower level of adiponectin than the objects without metabolic syndrome. Some segments of left ventricular displayed bad synchronism. It suggests that the lower level of protective factor in body2. Trans-mitral flow velocity to mitral annular velocity ratio (E/E’) has a strong positive relationship with left ventricular filling pressure, which presents as a good indicator for evaluating left ventricular diastolic relaxation abnormality, the relaxation parameter (E/E’) by TDE changed earlier than contraction indices by TDE and conventional echocardiography witch provide a new sensitive and reliable method to evaluate LV relaxation function.3 From the study, it can be shown that the children with metabolic syndrome can be early examined by strain rate imaging and three-dimensional echocardiography, which can not be found by conventional echocardiography. The SRI and RT-3DE can detect the abnormal segments movement of regional cardiac and can completely evaluate the whole and regional systolic and diastolic function of left ventricular, which makes systolic asynchrony evaluation for left ventricular more exact and more rapid.4 Adiponect is closely related with global diastolic function, regional systolic and diastolic function of left ventricular, which might lead to a bad prognosis.更多还原