摘要
目的利用超声心动图等方法,全面了解高血压患者心脏结构和左室舒张功能的改变,探讨心脏结构和功能改变的发生、发展规律。
方法高血压组选原发性高血压患者151例,根据高血压病程分为3个亚组即高血压1组(病程≤5年,n=72)、高血压2组(5年<高血压病程≤10年,n=38)和高血压3组(高血压病程>10年,n=41),并选正常对照54例。利用超声心动图测量心脏结构及多种心功能指标,同时测定血浆氨基末端B型脑钠肽前体(NT-proBNP)、血脂、血糖、尿素氮、肌酐、尿酸等生化指标。
结果(1)高血压患者心脏结构变化：与正常组比较,高血压组室间隔厚度(IVSTd)、左室后壁厚度(PWTd)、相对室壁厚度(RWT)、左室质量(LVM)、左室质量分数(LVMi)、左房内径(LAD)、左房容积(LAV)升高(P<0.05或P<0.01)；左室内径及其指数(LVIDd、LVIDi)、左室舒张末期容积及其指数(LVEDV、LVEDVi)等无明显差异。亚组分析显示：IVSTd、PWTd、RWT、LVM、LVMi在高血压1组、2组、3组依次升高,有显著差异(P<0.05或P<0.01); LAV、LAVi高血压1组与对照组相比无明显差异,高血压2组有增大趋势,高血压3组高于对照组及高血压1组、2组(P<0.05或P<0.01),LAD有相似改变；LVEDVi高血压1组小于对照组,高血压3组高于高血压1组(P<0.05),而与对照组无明显差异。(2)影响高血压患者心脏结构的因素分析：IVSTd、PWTd、RWT、LVM、LVMi与高血压病程、年龄、体重、收缩压等正相关(P<0.05或P<0.01)；LAV、LAVi与高血压病程、体重、体重指数、收缩压、LVMi、LVEDV、NT-proBNP等正相关(P<0.05或P<0.01),其中高血压病程、LVEDVi、LVIDi是其独立预测因素。(3)高血压患者心脏功能变化：与对照组相比,高血压组二尖瓣舒张早期最大充盈速度(E峰)与舒张晚期最大充盈速度(A峰)比值(E/A)、组织多普勒二尖瓣环侧壁E峰(E'L)、室间隔部E峰(E's)、E'L与二尖瓣环侧壁A峰比值(E'L/A'L)、E's与二尖瓣环室间隔A峰比值(E's/A's)减小(P<0.05或P<0.01)；高血压组A峰、A峰持续时间(durA)、E峰减速时间(DT)、等容舒张时间(IVRT)、E/E's及E/E'L与E/E's的均值(M-E/E')升高(P<0.05或P<0.01)；两组间二尖瓣E峰、肺静脉血流频谱及左室血流传播速度(FPV)等指标无明显差异。亚组分析：组织多普勒E'L、E's在高血压1组、2组、3组中依次减低,有显著性差异(P<0.05或P<0.01); E/E's、E/E'L、M-E/E'在高血压1组、2组、3组中依次升高,有显著性差异,高血压3组高于对照组及高血压1组、2组,但高血压1组、2组与对照组无显著差异(P<0.05或P<0.01)。(4) NT-proBNP与体重指数、腰围、E'L、E'L/A'L负相关,与年龄、高血压病程、收缩压、LADi、LAV、LAVi、E/E'(E/E's、E/E'L、M-E/E')正相关(P<0.05或P<0.01),其中年龄、腰围、LAVi是NT-proBNP的独立预测因素；E/E'(以E/E's为例)与高血压病程、年龄、体重指数、收缩压、脉压、LAV、LAVi、NT-proBNP正相关(P<0.05或P<0.01),其中高血压病程、LAVi、收缩压是E/E'的独立预测因素。
结论1.高血压患者存在心脏结构改变,表现为向心性重塑/肥厚,这种改变在发病早期就已出现,随病程延长改变更为明显,病程较长时(5-10年以上)累及左房,出现左房扩大。年龄、肥胖、高血压病程、收缩压等与心室结构改变有关,而左房结构主要受高血压病程、NT-proBNP、LVEDVi等因素的影响。2.高血压患者有左室舒张功能减退改变,可能在高血压发病早期就已存在(A、E/A、IVRT、E'、E'/A'等改变),但明显而可靠的舒张功能减退出现在发病5-10年以上(E/E'、LAV、LAVi、NT-proBNP升高)。舒张功能主要与高血压病程、收缩压、左房大小等有关。3.E'、LAVi与NT-proBNP相关性良好,是评价高血压患者左室舒张功能的有效指标。4.高血压患者心脏收缩功能无明显改变(左室射血分数与正常对照组无明显差异)
Objective To study the changes of heart structure and left ventricular diastolic function in patients with essential hypertension.
Methods One hundred and fifty one consecutive patients with primary hypertension were selected as hypertensive group, which was then divided into three subgroups:hypertensive group 1(the duration of hypertension≤5years, n:72), hypertensive group 2(5years Results (1) Compared with the controls interventricular septal thickness(IVSTd), posterior wall thickness(PWTd), relative wall thickness(RWT), left ventricular mass(LVM) and LVM index(LVMi), left atrial dimension(LAD), left atrial volume (LAV)of hypertensive group were singnificantly increased. IVSTd, PWTd, RWT, LVM, LVMi were increased group by group in those subgroups(P＜0.05-＜0.01). LAD, LAV, LAV index(LAVi) in hypertensive subgroup 1 have no difference with controls, but increased in hypertensive subgroup 2 and 3(P<0.05-<0.01). Left ventricular end-diastolic volume index(LVEDVi) of hypertensive subgroup1 was less than that of controls, which had no difference with hypertensive subgroup 2 but increased in hypertensive subgroup 3 (P＜0.05). (2) IVSTd, PWTd, RWT, LVM, LVMi were positively correlated with age, weight, the duration of hypertension(P<0.05-<0.01).LAV, LAVi were positively correlated with the duration of hypertension, weight, body mass index(BMI), systolic blood pressure, LVMi LVEDVi, and NT-proBNP(P<0.05-<0.01), among which, the duration of hypertension, LVEDVi, left ventricular diameter index(LVIDi) and NT-proBNP were independent predicators of LAV and LAVi (3) Compared with the controls E/A(the ratio of E wave(peak early diastolic mitral inflow velocity) with A wave (peak late diastolic mitral inflow velocity)), early velocities of lateral(E'L) and septal(E's) mitral annulus, E'L/A'L(the ratio of E'L with A'L(late velocities of lateral) mitral annulus), E's/A's(the ratio of E's with A's(late velocities of septal) mitral annulus) were singnificantly decreased(P<0.05-<.01). A wave, A wave duration(durA), deceleration time(DT) of E wave, isovolumic relaxation time(IVRT), E/E's, M-E/E'(average of E/E'L ratio and E/E's ratio) were singnificantly increased(P<0.05-<0.01). E'L, E's were decreased successively in hypertensive subgroup 1,2 and 3(P<0.05-<0.01).E/E's, M-E/E', E/E'L in hypertensive subgroup 3 were greater than those in hypertensive subgroup 1,2 and the controls (P<0.05-<0.01). NT-proBNP were negatively correlated with BMI, waist circumference, E'and E'/A'(P<0.05-<0.01), but positively correlated with age, the duration of hypertension, systolic blood pressure, LADi, LAV, LAVi and E/E'(P<0.05-<0.01), among which age, waist circumference and LAVi were independent predicators of NT-proBNP. E/E' were positively correlated with the duration of hypertension, systolic blood pressure, age, BMI, pulse pressure LAV, LAVi and NT-proBNP(P<0.05-<0.01), among which the duration of hypertension, systolic blood pressure and LAVi were independent predicators of E/E'.
Conclusion. 1.Patiens with essential hypertension showed left ventricular concentric remodeling/hypertrophy which existed even in the early stage of the desease. With the progress of the desease, the changes were more obvious. When the duration of hypertension approximately over 5-10years, left atrium was affected. Age, obesity, the duration of hypertension, systolic blood pressure were well related with left ventricular structure changes, but left atrial size was mainly influenced by the duration of hypertension, NT-proBNP, left ventricular end-diastolic volume index.2. There were left ventricular diastolic dysfunction in hypertensives, which may occurred in the early stage of the desease, but the definite and marked changes were appeared when the duration of hypertension was over 5-10years. Left ventricular diastolic dysfunction were related with the duration of hypertension, systolic blood pressure and left atrial size.3. Among the many parameters reflecting diastolic function in patients with hypertension, only E/E', LAV, LAVi were better ones, which were well related with NT-proBNP.4. Left ventricular systolic function were nomal in hypertensives(left ventricular ejection fraction was not different with the controls).
引文
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