高血压前期和高血压人群升主动脉弹性功能特征、相关危险因素及其对靶器官损害的预警价值研究

发布时间：2018-08-02 18:46

【摘要】：背景:升主动脉因解剖位置等原因其弹性功能评价的临床应用和普及一直受到制约。利用回顾性心电门控冠状动脉CT成像可直接评估升主动脉弹性,且无需增加造影剂用量、辐射剂量和医疗成本。升主动脉直面心脏,是心脏射血的主要缓冲器官,也是外周脏器持续血流灌注的重要保证,缓冲功能的实现主要依赖于动脉正常弹性。血压升高是动脉弹性减退重要的加速因子,但原发性高血压尤其高血压前期人群的升主动脉弹性特征及其危险因素,升主动脉弹性与高血压靶器官损害的关系及其预警价值尚不十分清楚。目的:通过分析基于冠状动脉CT回顾性心电门控成像的高血压前期和高血压人群升主动脉弹性指标和临床资料,并与理想血压人群对照,在第一部分探讨高血压前期和原发性高血压人群的升主动脉形态学和弹性功能特征、与其它临床指标相关性及其独立危险因素;在第二部分探讨升主动脉弹性指标与心、颈动脉、肾靶器官损害的相关性、敏感指标及其预警价值,并与脉搏传导速度(PWV)比较。为临床早期、准确评估高血压前期和高血压人群升主动脉弹性功能提供一种新方法的同时,为早期预防、诊治及预后估测高血压及其靶器官损害提供有价值的理论依据。材料与方法:接受冠状动脉CT成像检查的健康体检或临床怀疑冠心病所有患者。共398例患者(理想血压组85人,高血压前期组121人和原发性高血压组192人)纳入研究,男209例,女189例,年龄23~84岁,平均(53.1±11.7)岁。研究对象于CT检查前一周内收集临床基本资料,行实验室和特殊检查。均采用二代双源CT行回顾性冠状动脉CT成像检查,将原始数据每间隔5%RR间期进行全时相自动离线重建,共得到5%、10%、15%…100%等20个时相数据。分别测得升主动脉20个相位感兴趣层面(左冠状动脉主干发出水平上方25mm)管腔内径及截面积。最后确定感兴趣层面的最大面积和直径、最小面积和直径。采用三个较常见的指标评价升主动脉弹性特性,包括可扩张度(AD)、动脉顺应性(AC)、动脉僵硬度(ASI)。结果第一部分1.理想血压、高血压前期和原发性高血压三组间升主动脉形态学和弹性功能比较三组中,标化舒张期最小升主动脉直径(F=3.53,P0.05)和截面积(F=9.10,P0.001)逐步增大;进一步两两比较中,高血压前期和理想血压组间的标化舒张期最小直径和截面积无差异;高血压前期和高血压组标化截面积有显著统计学差异(P0.01),而最小直径无差异。三组中,AD(F=47.46,P0.001)和AC(F=34.51,P0.001)逐步减退,ASI(F=10.05,P0.001)逐步增加;进一步两两比较中,AD和AC指标在任意两组间差异均极显著(P0.001),而高血压前期和理想血压组ASI无差异;原发高血压组ASI明显大于高血压前期组(P0.01)。高血压组ba PWV高于高血压前期组(P0.05)。年龄和研究对象分类(是否存在高血压前期或高血压)为AD减退的独立预测因素。2.年龄与理想血压、高血压前期和原发性高血压组的升主动脉弹性指标的关系年龄与各弹性指标(AD、AC和ASI)相关关系显著,总体相关性为r=-0.617,-0.539和0.643(P0.001)。除AC外,理想血压组、高血压前期组和高血压组AD和ASI与年龄的相关系数逐渐减低。除高血压组AD指标外(三次相关),曲线拟合显示年龄与各组AD、AC和ASI指标等以复合模型(Compound)最佳。3.理想血压、高血压前期和原发性高血压组升主动脉弹性减退的危险因素以AD为因变量,以与弹性指标有关的影响因素为自变量进行多元逐步回归分析,结果显示,年龄和吸烟是理想血压组升主动脉AD指标降低的独立影响因子;年龄和收缩压是高血压前期组的独立影响因子;年龄、24小时平均舒张压和脉压是原发性高血压组的独立影响因子。4.原发性高血压患者不同高血压病程间的弹性指标和ba PWV比较高血压病程5年,5~10年和10年三组间和任意两组间ba PWV无差异。三组AD(P0.001)和AC(P0.001)逐步减退,ASI(P0.05)逐步增加。进一步两两比较中,除AC在5年组和5~10年组,ASI在5~10年组和10年组无差异外,AD、AC和ASI指标在任意两组间均具有统计学差异(P0.05)。第二部分1.靶器官损害不同程度间升主动脉形态、功能学及ba PWV比较随着靶器官损害严重程度的增加(损害个数,0、1、2、3),AD(F=40.74,P0.001)、AC(F=27.0,P0.001)、ASI(F=28.0,P0.001)、标化舒张期最小直径(F=2.89,P0.05)、标化舒张期最小面积(F=4.95,P0.01)和ba PWV(F=5.24,P0.01)具有统计学差异。两两比较中,靶器官损害0和靶器官损害1两组间的AD、AC和ASI指标具有显著性差异(P0.01);靶器官损害1和靶器官损害2两组间的AD和AC弹性指标具有显著性差异(P0.01),而ASI无显著性差异;靶器官损害2和靶器官损害3两组间的ASI弹性指标具有显著性差异(P0.01),而AD和AC无显著性差异。标化舒张期最小直径、最小面积在靶器官损害0和靶器官损害1,靶器官损害1和靶器官损害2,靶器官损害2和靶器官损害3间均无统计学差异。ba PWV在靶器官损害0和靶器官损害1组间具有显著性差异(P0.01),而在靶器官损害1和靶器官损害2,靶器官损害2和靶器官损害3组间均无统计学差异。2.高血压靶器官损害的独立危险因素探讨以原发性高血压是否伴靶器官损害为因变量,以已知危险因素分别和ba PWV、AD、AC及ASI指标为协变量进行多因素Logistic逐步回归分析,分别显示ba PWV及年龄、AD、AC及年龄和ASI为靶器官损害的危险因素。再以原发性高血压是否并发靶器官损害为因变量,以有统计学意义的年龄、ba PWV、AD、AC和ASI为协变量进行Logistic逐步回归分析,显示仅AD指标为靶器官损害的独立危险因素。3.高血压三组(AD三分位)的靶器官损害的危险度比较根据AD指标三分位值将全部研究对象分为三组,随着AD分位数的增加,靶器官损害有无及严重程度亦显著增高(P0.001),中间分位组患靶器官损害的比数比(OR)是低分位组的7.2倍。高分位组患靶器官损害的OR是中间分位组的9.84倍。中间分位组患2个以上靶器官损害的OR是低分位组的4.15倍。高分位组患2个以上靶器官损害的OR是中间分位组的23.33倍。结论第一部分1.利用回顾性心电门控冠状动脉CT成像检查,在不增加造影剂用量、辐射剂量和医疗成本的前提下,可获得反映高血压前期和原发性高血压人群升主动脉弹性功能减退的多个不同弹性指标。2.高血压前期人群升主动脉弹性功能较理想血压人群减退,但优于原发性高血压人群,且升主动脉弹性功能减退早于形态学改变。3.在所有升主动脉弹性指标中,AD指标反映高血压前期和高血压弹性功能减退的敏感性优于AC和ASI,AC和ASI指标也具有较大价值,应合理选择、综合分析三个弹性指标变化能在一定程度上提高评估血压升高对升主动脉弹性功能破坏的客观性和准确性。4.年龄仍是影响理想血压、高血压前期和高血压人群升主动脉弹性的主要决定因素,除年龄外,吸烟、收缩压水平和舒张压及脉压水平分别是影响理想血压、高血压前期和高血压人群升主动脉弹性功能减退的独立危险因素。除此之外,肥胖和血糖也是不可忽略的危险因素。第二部分1.升主动脉弹性功能是原发性高血压患者亚临床靶器官损害即左心室肥厚、颈动脉内-中膜增厚或斑块和蛋白尿的独立影响指标,且独立于传统ba PWV、升主动脉形态学和常规靶器官危险因素。2.在所有升主动脉弹性指标中,AD反映靶器官损害的敏感度最优,检测AD指标对早期预防高血压亚临床靶器官损害具有重要临床价值。此外,AC和ASI在反映靶器官损害情况上也具有较大价值,应合理选择、综合分析三个弹性指标变化有利于更加客观、准确和全面预测靶器官损害情况。3.在AD三分位中,高分位组较低一水平分位组具有更高的靶器官损害风险和严重程度,而且随着AD分位的增加,靶器官损害趋势更加明显。总之,早期检测高血压甚至高血压前期人群大动脉弹性指标尤其AD变化及其危险因素,有助于识别危险性较高的个体,进一步制定积极有效的预防和治疗措施,对延缓和控制高血压、高血压靶器官损害及心脑血管事件的发生、发展具有重要的临床意义。
[Abstract]:Background: the clinical application and popularity of the evaluation of the elastic function of the ascending aorta for anatomical location has been restricted. Using a retrospective electrocardiogram gated coronary CT imaging can directly evaluate the ascending aorta elasticity without increasing the dosage of contrast media, radiation dose and medical cost. The ascending aorta directly faces the heart, which is the main slow of the heart ejection. The impact of the organs is also an important guarantee for the continuous perfusion of the peripheral organs. The realization of the buffer function is mainly dependent on the normal elasticity of the arteries. The elevation of blood pressure is an important acceleration factor in the hypoplastic artery, but the ascending aorta elasticity and risk factors of the primary hypertension, especially in the prehypertensive population, the ascending aorta elasticity and the target of hypertension. The relationship of organ damage and its early warning value is still not very clear. Objective: To explore the prehypertensive and primary hypertension population in the first part by analyzing the elastic index and clinical data of the ascending aorta of prehypertensive and hypertensive people based on the coronary CT retrospective ECG gated imaging and the people with ideal blood pressure. The morphological and elastic characteristics of the ascending aorta, the correlation with other clinical indicators and their independent risk factors. In the second part, the correlation between the ascending aorta elasticity index and the damage of the heart, the carotid artery, the renal target organ, the sensitive index and the early warning value were discussed and compared with the pulse conduction velocity (PWV). It provides a new method for early prevention, diagnosis, treatment and prognosis of hypertension and target organ damage. Materials and methods: 398 patients (ideal blood) (ideal blood), 398 patients (ideal blood). The study was carried out in 85 people, 121 in prehypertensive group and 192 in primary hypertension group, 209 male and 189 female, with an average age of 23~84 years (53.1 + 11.7) years old. The study subjects were collected the basic data in the first week of the CT examination and performed the laboratory and special examination. The retrospective coronary artery CT imaging examination was performed with two generation double source CT. According to every interval 5%RR interval, the full time automatic off-line reconstruction was achieved, and 5%, 10%, 15%... The internal diameter and sectional area of the 20 phase of the ascending aorta were measured at 20 phases of the ascending aorta (25mm above the left coronary artery). The maximum area and diameter, the minimum area and diameter of the interesting level were determined. Three more common indexes were used to evaluate the elastic properties of the ascending aorta, including the extensibility. AD) arterial compliance (AC) and arterial stiffness (ASI). Results the first part 1. ideal blood pressure, prehypertensive and primary hypertension three groups of ascending aorta morphology and elasticity were compared in the three groups, the minimum ascending aorta diameter (F=3.53, P0.05) and cross-sectional area (F=9.10, P0.001) of the standardized diastolic phase were gradually increased; in the further 22 comparison, high blood pressure The minimum diameter and sectional area of the standardized diastolic period between pre pressure and ideal blood pressure group had no difference, and the standardized section area of prehypertension and hypertension group had significant statistical difference (P0.01), but the minimum diameter had no difference. In the three groups, AD (F=47.46, P0.001) and AC (F=34.51, P0.001) gradually decreased, ASI (F=10.05, P0.001) gradually increased; further 22 comparison was further compared. In all two groups, the differences in AD and AC were very significant (P0.001), while ASI in prehypertensive and ideal blood pressure group had no difference; ASI in primary hypertension group was significantly greater than prehypertensive group (P0.01). The BA PWV in hypertension group was higher than prehypertensive group (P0.05). Age and classification of subjects (whether there was prehypertension or hypertension) were AD hypocritical. Independent predictors of.2. age and ideal blood pressure, the relationship between age and elastic index of ascending aorta in prehypertensive and essential hypertension groups was significantly related to the elastic indexes (AD, AC and ASI), the overall correlation was r=-0.617, -0.539 and 0.643 (P0.001). Except AC, the ideal blood pressure group, the prehypertensive group and the hypertension group AD and ASI and year. The correlation coefficient of age decreased gradually. Except for the AD index of hypertension group (three correlation), the curve fitting showed that the age and AD, AC and ASI index were the best.3. ideal blood pressure in the compound model (Compound). The risk factors of the ascending aorta in prehypertension and primary hypertension group were dependent on the AD as the dependent variable. The results showed that age and smoking were independent influencing factors of the decrease in the AD index of ascending aorta in the ideal blood pressure group; age and systolic pressure were independent influencing factors of prehypertensive group; age, age, 24 hour mean diastolic pressure and pulse pressure were independent influencing factors of the primary hypertension group.4.. The elastic index of different hypertension course and BA PWV compared the course of hypertension for 5 years, 5~10 and 10 years between three groups and any two groups of BA PWV. Three groups AD (P0.001) and AC (P0.001) gradually decrease, ASI (P0.05) gradually increase. Further 22, except AC in 5 year group and 10 year group No difference, AD, AC and ASI were statistically different between the two groups (P0.05). Second part 1. target organ damage in different degrees of ascending aorta morphology, function and BA PWV compared with the increase in the severity of target organ damage (the number of damage, 0,1,2,3), AD (F=40.74, P0.001), AC (F=27.0,), standardized Shu The minimum diameter (F=2.89, P0.05), the minimum area of the standardized diastolic phase (F=4.95, P0.01) and BA PWV (F=5.24, P0.01) had statistical differences. 22 in comparison, the AD, AC and ASI indexes between target organ damage 0 and target organ damage 1 two groups were significantly different (P0.01), target organ damage 1 and target organ damage 2 two groups and elastic indicators There was significant difference (P0.01), but there was no significant difference in ASI. The ASI elasticity index of target organ damage 2 and target organ damage 3 two groups had significant difference (P0.01), but AD and AC had no significant difference. The minimum diameter of standardized diastolic phase, the minimum area in target organ damage and target organ damage 1, target organ damage 1 and target organ damage 2, target organ damage. There was no significant difference between the damage 2 and the target organ damage in 3 groups. The.Ba PWV had significant difference between the target organ damage 0 and the target organ damage (P0.01), while the target organ damage 1 and the target organ damage 2, the target organ damage 2 and the target organ damage 3 groups were independent of the independent risk factors of the target organ damage of the essential hypertension. Whether hypertension was associated with target organ damage as a dependent variable, the multivariate Logistic stepwise regression analysis was carried out with the known risk factors and BA PWV, AD, AC, and ASI as co variables. The risk factors for BA PWV and age, AD, AC, age and ASI were the risk factors for target organ damage, and whether the primary hypertension was associated with the target organ damage as the dependent variable At a statistically significant age, BA PWV, AD, AC, and ASI were used to carry out Logistic stepwise regression analysis, showing that the risk degree of target organ damage in three groups of.3. hypertension (AD three sub), the independent risk factor of AD index as target organ damage, was divided into three groups according to the AD index three points, along with AD quantiles. The target organ damage was also increased significantly (P0.001). The ratio of target organ damage to the target organ (OR) was 7.2 times that of the low fraction. The OR of the target organ damage in the high score group was 9.84 times as high as that in the middle division. The OR of 2 or more target organs in the middle division was 4.15 times that of the low score group. The high score group suffered from 2. The OR of the target organ damage above is 23.33 times as high as that in the middle division. Conclusion part 1. using a retrospective electrocardiogram gated coronary artery CT imaging, with no increase in the dosage of contrast agent, radiation dose, and medical cost, can be used to reflect the multiple dysfunction of the ascending aorta in prehypertension and primary hypertension. The elastic function of.2. in prehypertensive patients is lower than that of the ideal blood pressure population, but it is superior to those of the primary hypertension group, and the ascending aorta is earlier than the morphological change of.3. in all the ascending aorta elasticity indexes. The AD index reflects the sensitivity of the prehypertension and the hypotention of hypertension to be better than that of the AC. ASI, AC and ASI are also of great value, and should be selected rationally. Comprehensive analysis of three elastic indexes can improve the objectivity and accuracy of the evaluation of blood pressure rise to the aortic elastic function damage to a certain extent. The.4. age is still the main decision to affect the ideal blood pressure, prehypertension and the increase of the elasticity of the aorta in the prehypertensive and hypertensive people. Factors, except for age, smoking, systolic pressure level, diastolic pressure and pulse pressure level are independent risk factors that affect ideal blood pressure, prehypertension and hypertension in the ascending aorta. In addition, obesity and blood sugar are also not negligible risk factors. The second part of the 1. liter aortic elasticity is primary high. Subclinical target organ damage in patients with blood pressure is left ventricular hypertrophy, carotid intiptic thickening or independent plaque and proteinuria, independent of traditional BA PWV, ascending aorta morphology and conventional target organ risk factors.2. in all ascending aorta elasticity indexes, AD is the best to reflect target organ damage, and AD index is detected. The early prevention of subclinical target organ damage of hypertension has important clinical value. In addition, AC and ASI are also of great value in reflecting the damage of target organs, and should be selected rationally. The comprehensive analysis of the changes of three elastic indexes is beneficial to more objective, accurate and comprehensive prediction of target organ damage in the AD three division, the high score group is lower. There is a higher risk and severity of target organ damage in the horizontal division, and the target organ damage trend is more obvious with the increase of AD subdivision. In a word, early detection of high blood pressure, especially AD changes and its risk factors in high blood pressure and prehypertensive population, is helpful to identify higher risk individuals and further develop the product. The effective preventive and therapeutic measures have important clinical significance for delaying and controlling hypertension, the damage of target organs of hypertension and the occurrence of cardiovascular and cerebrovascular events.
【学位授予单位】：大连医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R544.1;R543

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