【作者】 李冰；

【导师】 杨萍；

【作者基本信息】 吉林大学 ， 内科学， 2010， 硕士

【摘要】 目的:探讨原发性高血压伴2型糖尿病对心脏结构与左室舒张功能的影响,以及应用组织多普勒成像(TDI)评价左室舒张功能的优势。方法:回顾性研究2008年1月至2010年2月住院的高血压病及2型糖尿病患者的临床资料,将符合该研究标准的病例分为高血压病(EH)组(n=220)、2型糖尿病(T2DM)组(n=63)及高血压病伴2型糖尿病(EH+T2DM)组(n=108)。应用M模式测量左房内径、左室舒张末期内径、室间隔厚度及左室后壁厚度,利用Devereux公式计算左室质量指数及相对室壁厚度,并根据所得数值将患者进行左室构型分类。应用彩色血流多普勒测量二尖瓣血流舒张早期e峰与心房收缩期a峰的峰值速度。组织多普勒(TDI)主要通过测定心肌运动速度来评价心肌舒张功能。以TDI速度模式在心尖四腔心切面,记录舒张期二尖瓣环沿长轴方向的运动,其运动速度相对不受心脏负荷状态影响,是目前评价左心室整体舒张功能的主要指标之一。本研究应用TDI技术测量的舒张早期e峰(e’)与心房收缩期a峰(a’)峰值速度,并以二者比值<1为诊断左室舒张功能不全的标准。同时SPSS11.5软件对三组的一般资料、生化指标及超声心动图结果进行统计学分析与比较。结果:1 EH+T2DM组的年龄高于EH组及T2DM组(p<0.05),而SBP及DBP低于EH组(p<0.05),TG低于T2DM组(p<0.01);EH+T2DM组的糖尿病病程、SBP及DBP均高于T2DM组(p<0.05);T2DM组的TG高于EH组(p<0.001),而Cr低于EH组(p<0.01)。2 EH+T2DM组的室间隔厚度、左室后壁厚度、左室质量指数和相对室壁厚度均高于EH组及T2DM组(p<0.01)。EH组的左室后壁厚度、左室质量指数和相对壁厚度均高于T2DM组(p<0.05)。EH+T2DM组及EH组的左室构型均以向心性肥厚为主,而T2DM组的以向心性重构为主。三组左室构型比较,EH+T2DM组的向心性肥厚发生率明显高于EH组及T2DM组(p<0.001),而正常构型的发生率低于EH组及T2DM组(p<0.01)。T2DM组的正常构型及向心性重构发生率均明显高于EH组(p<0.05),而向心性肥厚的发生率则明显低于EH组(p<0.001)。3 EH+T2DM组的e’明显低于EH组及T2DM组,而左房内径明显高于EH组及T2DM组(p<0.05)。EH+T2DM组a’明显低于T2DM组,而a、e’/a’高于T2DM组(p<0.05)。T2DM组的a及a’均低于EH组(p<0.05);而e/a、e’/a’均高于EH组(p<0.05)。EH组及EH+T2DM组的e/a<1及e’/a’<1的人数均明显多于T2DM组(p<0.05)。且用e/a比值做舒张功能不全的诊断存在大量的“假性正常化”。4在校正性别、年龄、吸烟、饮酒、高血压病及2型糖尿病病程、高血压分级、体质量指数、血压、血脂、空腹血糖以及肌酐后,e’/a’值仍与糖尿病、左室肥厚、相对室壁厚度(p<0.05)及左室质量指数相关(p<0.01)。进一步以左室舒张功能不全为应变量,性别、年龄、高血压病病程、血压分级、超重、2型糖尿病、高脂血症为自变量,进行多元逐步Logistic回归,EH+T2DM组发生左室舒张功能不全的风险是T2DM组的1.8倍,EH组的风险是T2DM组的1.4倍。在EH组,与左室舒张功能不全发生相关的危险因素为高血压病病程;在T2DM组中,与左室舒张功能不全发生相关的危险因素为超重和高脂血症;在EH+T2DM组中,与左室舒张功能不全发生相关的危险因素为血压分级、高血压病病程及超重。结论:1 TDI所测二尖瓣环运动速度是一个相对不依赖于前负荷的评价舒张功能的参数,能较好的鉴别假性正常化血流,提供早期左室舒张功能受损的情况。2高血压病较2型糖尿病对左室舒张功能不全的影响更大。而当高血压病及2型糖尿病并发时,会使患者的左室肥厚、左室构型异常及左室舒张功能不全等改变最大化,加速病情的恶化。更多还原

【Abstract】 Backgrounds and Objections:With the improvement of living strandard, the incidence of hypertension and diabetes is higher than before. And hypertension associated with diabetes is common, especially in the older patients. This allows the proportion of people with left ventricular diastolic dysfunction in the population further increased, thus affects the quality of people’s daily lives. Then adverse diagnosis will delay the treatment, it will make the disease disorder, and the prognosis is poor.The main causes of diastolic dysfunction is age, hypertension and coronary heart disease. Hypertension can cause left ventricular hypertrophy, accompanied by the myocardial fibrosis which induced by myocardial interstitial edema, increasing of collagen metabolism and myocardial cells’necrosis. Then myocardial relaxation decreased while the stiffness increased, so that left ventricular diastolic dysfunction, causing the increasing of left ventricular filling pressure, leading to the increasing of left atrial afterload. The body meet the needs of left ventricular filling by increasing the atrial wall tension, thereby leading the myocardial hypertrophy and eventually left atrial enlargement. Studies also showed that the risk of diastolic dysfunction in patients with diabete is higher compared with non-diabetic people. Fuchenbush found that the high blood sugar and insulin resistance are directly related with diastolic dysfunction and heart failure, in addition to coronary heart disease and hypertension. And insulin resistance on cardiac structure and function may be associated with hemodynamic changes, the cardiac hypertrophy stimulated through the insulin receptor or insulin-like growth factor receptor, the increasing of myocardial cells’protein synthesis stimulated by the protein glycosylation leaded by the reduced insulin sensitivity and chronic hypoxia leaded by myocardial microvascular disease.TDI is a kind of innovative technologies by using ultrasonic technology to test wall motion, getting the direct frequenct shift signal of myocardial tissue, quantitative measurement of wall motion. It focuses on the reaction wall mechanical movement, rather than blood flow changes, relatively speaking, its assessment of diastolic function is not related with the load of heart , blood pressure, valve status and the impact of fluid dynamics. It is with high sensitivity and objective, and gradually becomes the“golden indicators”of noninvasive cardiac diastolic dysfunction.Since hypertension and type 2 diabetes on left ventricular diastolic function has been extensive research, and the impact of left ventricular diastolic dysfunction is assured. So the paper will no longer analyze it by compared with the control group, and targeted hypertension associated with diabete on left ventricular diastolic dysfunction. View to increasing attention with the patients with type 2 diabetes and hypertension, so that paying attention with the left ventricular diastolic dysfunction and left ventricular remodeling dued by diabete when making choice of drugs that can decrease the blood pressure. Emphasize on improving the abnormal glucose metabolism and improving insulin sensitivity when decreasing the blood pressure. And by comparing the color flow Doppler and TDI examination, described the advantage of TDI on the diagnosis of left ventricular diastolic dysfunction. Improved diagnostic methods and therapeutic levels will definitely improve.Methods: A retrospective study from January 2008 to February 2010 in hospital hypertension and type 2 diabetes clinical data, patients that meet the criteria of the study were divided into essential hypertension (EH) group (n = 220), 2 type diabetes mellitus (T2DM) group (n = 63) and hypertensive patients with type 2 diabetes mellitus (EH + T2DM) group (n = 108). Measure left atrial diameter, left ventricular end diastolic diameter, interventricular septum thickness and left ventricular posterior wall thickness in M-mode by echocardiography, using Devereux formula to calculate left ventricular mass index and relative wall thickness, and classified the patients into different left ventricular geometry. Measure e and a peak velocity with color flow Doppler Tissue Doppler imaging. Measure e ’and a’ peak velocity by using DTI, and use the ratios <1 for diagnostic criteria of left ventricular diastolic dysfunction. Then we used SPSS11.5 software to analyze and compare the general information, biochemical markers and echocardiogram results of the three groups.Results: The age of EH + T2DM group is higher than the EH group and T2DM group (p <0.05), while SBP and DBP of it are less than the EH group (p <0.05), TG of it is less than the T2DM group (p <0.01); the diabetes duration, SBP and DBP of EH + T2DM group were higher than the T2DM group (p <0.05); TG of T2DM group was higher than EH group (p <0.001), and Cr of it is less than EH group (p <0.01). The interventricular septum thickness, left ventricular posterior wall thickness, left ventricular mass index and relative wall thickness of EH + T2DM group were higher than the EH group and the T2DM group (p <0.01). The patients with concentric hypertrophy in EH + T2DM group were significantly more than the EH group and the T2DM group (p <0.001), while the incidence of normal configuration is less than the EH group and the T2DM group (p <0.01). The e ’ of EH + T2DM group is significantly lower than the EH group and T2DM group, whereas left atrial diameter was greater than the EH group and the T2DM group (p <0.05). The a ’ of EH + T2DM group significantly is less than the T2DM group, but a, e’ / a ’ of it were higher than the T2DM group (p <0.05). The patients with e/a<1 or e’/a’<1 in EH group and the EH+T2DM group are significantly greater than the number of T2DM group(p<0.05). Diagnosing diastolic dysfunction with the ratio of e/a do exist a large number of "pseudo-normalization." The risk of left ventricular diastolic dysfunction occurs in EH+T2DM group was 1.8 times as much as T2DM group. The risk of it in EH group is 1.4 times as much as T2DM group. The risk factors of left ventricular diastolic dysfunction is blood pressure classification, hypertension and overweight.Conclusion:1 Mitral annular velocity measured by TDI is a independent parameters for the assessment of diastolic function without considering preload, it can identify false normalization of blood flow, finding early left ventricular diastolic function impaired.2 The effect of type 2 diabetes on left ventricular diastolic dysfunction is more than that of hypertension. It will maximize left ventricular hypertrophy, left ventricular abnormalities and left ventricular diastolic dysfunction and so on, accelerate the progression of disease, when the hypertension and type 2 diabetes mellitus occur together.更多还原