高血压病和冠心病患者脉搏波传导速度分析

脉搏波传导速度(pulse wave velocity, PWV)是 心脏收缩时产生的脉搏波在动脉血管中的传播速度, 是无创性检测动脉僵硬度最常用的指标。 研究表明 脉搏波传导速度在高血压、冠心病等心血管疾病的初 步筛查诊断、危险分层及疾病预后中具有重要的临床 应用价值,2013 年欧洲高血压指南中将颈鄄股动脉脉 搏波传导速度(carotid femoral pulse wave velocity,CF鄄 PWV)作为评价高血压患者靶器官损害的一项指标 ,而我国的《中国高血压防治指南 2010》中也提 出脉搏波传导速度增快是心血管事件的独立预测因 素并将其作为评价靶器官损害的指标之一 。 影响 脉搏波传导速度的因素除了动脉血管的弹性外,年 龄、血压、血脂、心率等其他心血管疾病的危险因素也 能影响脉搏波传导速度,故本研究采用横断面研究方 法,分析脉搏波传导速度在正常人群、高血压患者及 冠心病患者之间的分布特点,探讨影响脉搏波传导速 度的因素,为高血压、冠心病等心血管疾病的早期预 防和临床干预治疗提供理论基础。

一 对象与方法

1. 1 研究对象

选取 2014 年 5 月至 2014 年 11 月在兰州大学 第一医院心内科住院行冠状动脉造影术( coronary angiography,CAG)检查的患者。 病例入选标准: 无 CAG 术禁忌症并且能够配合完成 PWV 检测的患 者;于窦性心律。 排除标准:淤各种类型心律失常 患者;于起搏器植入术后患者;盂动脉闭塞患者;榆 严重肝肾功能不全或心功能不全患者;虞糖尿病患 者;愚继发性高血压患者。 高血压的诊断符合《中 国高血压防治指南 2010》诊断标准:在未使用降压 药物的情况下,非同日 3 次测量血压,收缩压逸140 mmHg 和/ 或舒张压逸90 mmHg。 患者既往有高血 压史,目前正在使用降压药物,血压虽然低于 140 / 90 mmHg,也诊断为高血压。 冠心病的诊断标准 为 CAG 检查结果示左前降支、左回旋支、右冠状动 脉及其主要分支中至少有一支血管腔狭窄程度逸 50% 即诊断为冠心病。

1. 2 一般资料收集

患者入院后详细记录性别、年龄,计算体质指 数(body mass index, BMI),测量血压并计算脉压和 平均压等;空腹抽取静脉血检测生化指标,包括:总 胆固醇( total cholesterol, TC)、甘油三酯( triglyceride, TC)、低密度脂蛋白胆固醇(low density lipoprotein-cholesterol, LDLC)、高密度脂蛋白胆固醇( high density lipoprotein鄄cholesterol, HDLC)、尿素氮(blood urea nitrogen, BUN)、肌酐(creatinine, Cr)、尿酸(u- ric acid, UA)、血糖(blood glucose,BG)、同型半胱氨 酸(homocysteine, Hcy)。

1. 3 冠状动脉造影检查

按标准 Judkins 法采用 5F 造影导管经右侧桡动 脉/ 股动脉分别行左、右冠状动脉造影,显示左前降 支、左回旋支、右冠状动脉及其主要分支。

1. 4 脉搏波传导速度测定

使用 Arteeh Medical 公司研制生产的脉搏波速度 测定仪检测颈鄄股动脉脉搏波传导速度(carotidfemo ral pulse wave velocity, CFPWV)、颈-桡动脉脉搏波传 导速度(carotidradial pulse wave velocity, CRPWV)和 颈鄄足背动脉脉搏波传导速度(carotiddorsal artery of foot pulse wave velocity, CDPWV)。 测量时患者仰卧 位,使用皮尺分别测量颈动脉至桡动脉、股动脉和足 背动脉的体表距离,并将数值输入计算机,随后将压 力传感器置于 4 个动脉搏动点上,仪器自动连续记录 16 个 PWV 测值,舍弃 3 个最大值和最小值,留 10 个 测值取其平均值即为 PWV 的最后测值。 PWV 由计 算机根据输入的体表测量点之间的距离及两个波形 之间的时间差进行计算:PWV(m/ s) = L/ T (T 为两 个波形的时间差,L 为两个探测器间的距离)。

1.5 统计学方法

采用 SPSS19- 0 软件进行数据统计。 对一般资料进行正态性检验,符合正态分布的计量资料以x 依 s 表示,多组间比较采用单因素方差分析,组间两两 比较采用 q 检验;偏态资料以中位数和四分位间距 表示,多组间比较采用秩和检验;因素间相关分析 采用多元逐步线性回归分析,入选和剔除标准为 0. 05 和 0.1。 P < 0.05 为差异有统计学意义。

二 结 果

2. 1 一般资料

四组间年龄、体质指数、尿素氮、血糖及甘油三 酯的差异无统计学意义,其余观察指标在多组间比 较差异有统计学意义(表 1)。

2.2 脉搏波传导速度

高血压组、单纯冠心病组和冠心病合并高血压 组的 CFPWV 及 CDPWV 较正常对照组显著升高。 CFPWV 和 CDPWV 在高血压组和单纯冠心病组间 的比较差异无统计学意义。 冠心病合并高血压组 的 CFPWV 高于高血压组和单纯冠心病组 ( P <0.05);冠心病合并高血压组的 CDPWV 较单纯冠心 病组明显升高(P < 0. 05)。 每组内部 CFPWV、CRP- WV、CDPWV 三组数据的比较差异有统计学意义(P < 0. 05)。 CRPWV 在多组间比较差异无统计学意 义(P = 0. 634;表 2)。

2.3 影响脉搏波传导速度的因素

分别以表 2 中组间差异有统计学意义的 CFPWV 和 CDPWV 作为应变量,以表1 中差异有统计学 意义的观察指标作为自变量,应用多元逐步线性回 归分析研究影响 PWV 的因素。 以 CFPWV 为应变 量时,心率、Hcy、HDLC 和脉压进入回归方程;以 CDPWV 为应变量时,HDLC 和平均压进入回归方程 (表 3)。

三 讨 论

目前 PWV 作为评估动脉弹性的一种简便、无 创的检测方法,在临床实践中得到了广泛的应用, 2013 年欧洲高血压指南将 CFPWV > 1200 cm / s 作 为评价高血压患者靶器官损害的一项指标。 MattaceRaso 等的研究结果显示随着 PWV 的增加, 心血管疾病发生的风险显著升高,PWV 在预测心血 管病的发生中有着重要的临床价值。 PWV 与动脉 弹性密切相关,动脉弹性降低,僵硬度增加,PWV 加 快。 本研究结果显示高血压患者的 PWV 要高于正 常对照组,这提示高血压患者已经发生了动脉硬 化,而杨娉婷等的研究结果显示随着血压的升 高,动脉硬化情况逐步加重,其可能的机制为血压 升高是内皮损伤的因素之一,动脉血管内皮损伤导 致动脉管壁结构和舒缩功能发生改变,致使动脉弹 性下降,管壁僵硬度增加, PWV 升高。 Boutouyrie 等研究发现,高血压人群中 PWV 显著升高的患 者其心血管事件的发生率较 PWV 增快不明显的人 显著升高,对高血压患者而言 PWV 可以作为心血 管事件发生的独立预测因子。 冠心病患者的 PWV 值较正常对照组升高,与张子新等 的研究结果一 致,动脉粥样硬化的本质是血管壁的炎症反应,在 血管壁损伤与修复的过程中导致内皮功能障碍,血 管壁中间的胶原纤维含量增加,伴随着中间纤维化及钙化的弹性纤维断裂,进而致使动脉管壁硬化和 斑块形成,动脉弹性下降,PWV 加快。 我们的研究 结果发现,冠心病合并高血压患者的 PWV 较单纯 冠心病和高血压患者显著升高,这与倪琦等的研 究结果一致,提示冠心病合并高血压患者在动脉硬 化程度上有协同作用,而对于单纯冠心病和高血压 患者而言,研究中并没有发现 PWV 在两者间有显 著差异。

另外本研究中发现 CFPWV、CDPWV 和 CRP鄄 WV 在同组内有明显的差异。 根据 PWV 检测的原 理,CFPWV 主要用来反应主动脉的弹性,其值增大 提示主动脉硬度增加,而 CDPWV 和 CRPWV 主要 用来评估外周动脉的弹性功能,在正常情况下,主 动脉管壁的可扩张性较外周动脉大,因而主动脉的 PWV 较外周动脉低,如本研究中所示正常对照组的 CFPWV 要低于 CRPWV。 而我们的研究中发现高血 压和冠心病患者的 CFPWV 要显著高于 CDPWV 和 CRPWV,这提示高血压和冠心病的发生与主动脉弹 性功能下降的关系较外周动脉更为密切,CFPWV 在 心血管疾病的筛查诊断、危险分层及预测中具有更 高的临床应用价值,于安忠等的研究结果也显示 CFPWV 较 CRPWV、CDPWV 在反映动脉硬化方面 更为敏感。

许多因素能够影响 PWV 值,本研究中发现心率、Hcy、HDLC、脉压和平均压是 PWV 独立的影响 因素。 陶杰等 等研究结果显示静息心率加快与 PWV 增加独立相关,但其确切的机制尚在研究之 中,有学者认为可能的机制为随着心率的增加,动 脉管壁回缩时间变短导致管壁顺应性下降和机械 张力增加,从而导致动脉管壁僵硬度增加 。 研究 结果显示 Hcy 水平的升高与 PWV 的增加显著相 关,高 Hcy 有致动脉粥样硬化作用,破坏动脉弹力 层,促进血管平滑肌细胞的增殖和迁移,促进胶原 在动脉中膜的沉积;自发氧化生产超氧化物,致使 血管内皮受损,最终会导致动脉张力增加,弹性下 降,PWV 增快。 多元逐步回归分析显示脉压是 影响 PWV 的因素之一,张会珍等的研究结果显 示 24 h 脉压与 CFPWV 独立相关,脉压的增加导致 血管壁所受压力增大,管壁弹性成分容易断裂和疲 劳,导致内膜损伤,动脉壁弹性下降,僵硬度增加。 研究还发现 HDLC 与 CFPWV 及 CDPWV 呈负相关 性,其原因可能与 HDLC 通过抗动脉粥样硬化起到 对动脉血管壁的直接保护作用有关。 本研究结果 提示 PWV 作为评价动脉弹性的一种无创、简易、有 效的检测方法,具有重要的临床应用价值,如能在早期进行检测则能够为心血管疾病的预防和干预 治疗提供可靠的判别指标。

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