本文選題：慢性心力衰竭 + 入院收縮壓��； 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:慢性心力衰竭(Chronic Heart Failure,CHF)是多種器質(zhì)性心臟病發(fā)展的終末期表現(xiàn)及最主要的死因。其發(fā)病率高,病情復(fù)雜,預(yù)后不佳。近年來我國(guó)每年新發(fā)慢性心力衰竭患者呈不斷上升趨勢(shì),嚴(yán)重威脅著患者的生活質(zhì)量及生存期,早期對(duì)其進(jìn)行危險(xiǎn)分層,盡早的給予有效合理的治療措施可改善心衰預(yù)后。心力衰竭多伴有神經(jīng)體液因素的改變,血壓作為一項(xiàng)綜合反映全身血流動(dòng)力學(xué)的指標(biāo),測(cè)量簡(jiǎn)便、無創(chuàng)、可重復(fù)操作,而且同樣受到神經(jīng)體液的調(diào)節(jié),提示血壓在心力衰竭的病情發(fā)展過程中具有一定的意義。本研究對(duì)119例慢性心力衰竭患者進(jìn)行入院時(shí)血壓測(cè)量及隨訪,探討慢性心力衰竭患者入院時(shí)血壓水平對(duì)預(yù)后的判斷價(jià)值。方法:連續(xù)入選2015年01月至2015年12月就診于河北醫(yī)科大學(xué)第二附屬醫(yī)院心血管內(nèi)三科的慢性心力衰竭患者共119人。入選標(biāo)準(zhǔn):臨床診斷為心力衰竭,有明確的基礎(chǔ)心臟病病史,病史均在半年以上,年齡大于18歲。以收縮功能障礙為主,符合NYHA心功能Ⅱ~Ⅳ級(jí)分級(jí)標(biāo)準(zhǔn),N端前腦鈉肽(NT-proBNP)2000ng/L。排除標(biāo)準(zhǔn):存在認(rèn)知障礙、意識(shí)不清者;肥厚性梗阻性心肌病、心臟瓣膜病、心包縮窄、心包積液、心肌炎、先天性心臟病等;急性心肌梗死、急性心力衰竭;合并惡性心律失常;繼發(fā)性高血壓、貧血、腦卒中、大量胸腔積液、肺炎、慢性阻塞性肺病等;伴有嚴(yán)重肝腎功能不全者;伴有其他影響預(yù)后的嚴(yán)重疾病(如惡性腫瘤等)。所有入選患者入院時(shí)均嚴(yán)格遵循中國(guó)血壓測(cè)量指南測(cè)量、記錄血壓,并記錄患者年齡、性別、體重、身高,依據(jù)紐約心臟病協(xié)會(huì)心功能分級(jí)標(biāo)準(zhǔn)對(duì)患者進(jìn)行心功能分級(jí);完善心臟超聲檢查測(cè)定左室射血分?jǐn)?shù)(LVEF)、左室舒張末徑(LVEDD);入院24小時(shí)內(nèi)檢測(cè)NT-proBNP、總膽紅素、白蛋白、血脂、肌酐等生化指標(biāo)。入院后按照中國(guó)心力衰竭防治指南給予相應(yīng)治療。出院后定期電話隨訪,以入院日為起始隨訪時(shí)間,以心源性死亡(包括心衰加重死亡及猝死)為隨訪終點(diǎn),隨訪日期截止至2016-6,隨訪時(shí)間至少6月。依據(jù)患者入院血壓,以不同血壓水平分組,用Kaplan-meier法繪制生存曲線并對(duì)其進(jìn)行l(wèi)og-rank統(tǒng)計(jì)檢驗(yàn)。將影響預(yù)后的因素依次進(jìn)行cox風(fēng)險(xiǎn)比例單因素分析,將單因素分析有意義的指標(biāo)進(jìn)行cox風(fēng)險(xiǎn)比例多因素分析,探討入院血壓對(duì)慢性心力衰竭患者預(yù)后的判斷價(jià)值。用spss21.0軟件進(jìn)行數(shù)據(jù)處理及分析。計(jì)量資料結(jié)果用“均數(shù)±標(biāo)準(zhǔn)差((?)±s)”或“中位數(shù)(第一四分位數(shù),第三四分位數(shù))[m(q1,q3)]”表示,計(jì)數(shù)資料采用“例數(shù)(百分比)”表示。首先對(duì)計(jì)量資料進(jìn)行正態(tài)及方差齊性檢驗(yàn),不滿足正態(tài)分布的計(jì)量資料如果對(duì)數(shù)轉(zhuǎn)換后符合正態(tài)分布,則使用計(jì)量資料的自然對(duì)數(shù)值,組間比較采用“t檢驗(yàn)”或“非參數(shù)mann-whitneyu檢驗(yàn)”。計(jì)數(shù)資料組間比較采用“χ2檢驗(yàn)”或“fish確切概率法”。相關(guān)分析采用“pearson相關(guān)系數(shù)”或“spearman相關(guān)系數(shù)”。三組間單因素分析用“kaplan-meier生存曲線”,組間比較采用“l(fā)og-rank檢驗(yàn)”。對(duì)發(fā)生終點(diǎn)事件的危險(xiǎn)因素分別采用“cox比例風(fēng)險(xiǎn)模型”進(jìn)行單變量和多變量生存分析。所有統(tǒng)計(jì)均是雙側(cè)檢驗(yàn),以p0.05為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果:共入選慢性心力衰竭患者119例,其中男性77例,女性42例,年齡44~90(67.3±10.0)歲,bmi23.8±2.6kg/m2。病因:缺血性心肌病(冠心)79例,擴(kuò)張性心肌病(擴(kuò)心)26例,高血壓心臟病(高心)14例。根據(jù)紐約心臟病協(xié)會(huì)(nyha)心功能分級(jí):Ⅱ級(jí)51例,Ⅲ級(jí)47例,Ⅳ級(jí)21例。1心源性死亡組與非死亡組臨床資料比較所有入選患者共119例,其中心源性死亡22例。以心源性死亡為隨訪終點(diǎn),將入選患者分為死亡組與非死亡組。兩組在年齡,性別比例,體重指數(shù)(bmi),病因構(gòu)成比,血清白蛋白、血清肌酐、血鉀、總膽固醇、低密度脂蛋白膽固醇、入院時(shí)心率差異均無明顯統(tǒng)計(jì)學(xué)意義(p0.05)。死亡組心功能Ⅳ級(jí)的患者明顯多于非死亡組(68.2%vs6.2%),心功能Ⅱ級(jí)的患者明顯少于非死亡組(4.5%vs51.5%),差異有統(tǒng)計(jì)學(xué)意義(p0.01)。死亡組患者nt-probnp[9750(7805,10980)vs3210(2022,5068)]、lnnt-probnp(9.15±9.16vs8.03±8.03)、tbil(21.8±10.5vs12.2±5.0)明顯高于非死亡組,差異有統(tǒng)計(jì)學(xué)意義(p0.01)。死亡組患者lvef(27.4±5.0vs42.1±9.1)、入院sbp(108.4±10.5vs122.5±8.9)、入院dbp(65.5±5.4vs72.4±7.7)、入院pp(42.9±12.3vs50.2±9.3)明顯低于非死亡組,差異有統(tǒng)計(jì)學(xué)意義(p0.01)。2將入院血壓與上述2組臨床資料比較有差異的因素進(jìn)行相關(guān)性分析經(jīng)pearson相關(guān)或spearman相關(guān)分析顯示:入院sbp與nt-probnp呈負(fù)相關(guān)(rs=㧟0.266,p0.01),與lvef呈正相關(guān)(rs=0.352,p0.01),與lvedd呈負(fù)相關(guān)(rs=㧟0.225,p0.05),與nyha分級(jí)呈負(fù)相關(guān)(rs=㧟0.201,p0.05),與tbil呈負(fù)相關(guān)(rs=㧟0.232,p0.05)。入院dbp與nt-probnp呈負(fù)相關(guān)(rs=㧟0.227,p0.05),與lvef呈正相關(guān)(r=0.188,p0.05),與lvedd呈負(fù)相關(guān)(r=㧟0.202,p0.05),與nyha分級(jí)呈負(fù)相關(guān)(rs=㧟0.219,p0.05),與tbil呈負(fù)相關(guān)(r=㧟0.202,p0.05)。3用kaplan-meier法對(duì)不同血壓水平分組繪制生存曲線并對(duì)其進(jìn)行l(wèi)og-rank統(tǒng)計(jì)檢驗(yàn)依據(jù)入院sbp,將入院sbp分為100mmhg,100~130mmhg,130mmhg三組。用kaplan-meier法繪制生存曲線,經(jīng)log-rank檢驗(yàn)3組間生存率存在差異(χ2=33.935,p0.01)。對(duì)其進(jìn)行兩兩比較,入院sbp100mmhg的慢性心力衰竭患者生存率明顯低于入院sbp在100~130mmhg、入院sbp130mmhg的慢性心力衰竭患者(χ2分別為27.659,17.922,p均0.01);而入院sbp在100~130mmhg的慢性心力衰竭患者生存率與sbp130mmhg的慢性心力衰竭患者的生存率差別無統(tǒng)計(jì)學(xué)意義(χ2=1.561,p0.05)。依據(jù)入院dbp,將入院dbp分為60mmhg,60~80mmhg,80mmhg三組。用kaplan-meier法繪制生存曲線,經(jīng)log-rank檢驗(yàn)3組間生存率不存在差異(χ2=3.324,p=0.190)。依據(jù)入院pp,將入院pp分為35mmhg,35~55mmhg,55mmhg三組。用kaplan-meier法繪制生存曲線,經(jīng)log-rank檢驗(yàn)3組間生存率存在差異(χ2=26.834,p0.01)。對(duì)其進(jìn)行兩兩比較,入院pp35mmhg的慢性心力衰竭患者生存率明顯低于入院pp在35~55mmhg、入院pp55mmHg的慢性心力衰竭患者(χ2分別為22.279,16.022,P均0.01);而入院PP在35~55mmHg的慢性心力衰竭患者生存率與入院PP55mmHg的慢性心力衰竭患者的生存率差別無統(tǒng)計(jì)學(xué)意義(χ2=0.367,P0.05)。4慢性心衰患者心源性死亡的單因素Cox比例風(fēng)險(xiǎn)回歸分析以心源性死亡為因變量,以年齡、病因構(gòu)成比、NYHA分級(jí)、lnNT-proBNP、TBIL、Alb、SCr、TG、LDL-c、LVEF、LVEDD、入院心率、入院SBP、入院PP為自變量,逐個(gè)引入Cox回歸模型,經(jīng)Wald檢驗(yàn),顯示NYHA分級(jí)(RR=8.938,95%CI 4.135~19.324),lnNT-pro BNP(RR=38.591,95%CI 11.129~133.822),TBIL(RR=1.159,95%CI 1.105~1.215),LVEF(RR=0.825,95%CI 0.776~0.878),LVEDD(RR=1.107,95%CI 1.059~1.156),入院SBP(RR=0.866,95%CI 0.823~0.910),入院PP(RR=0.935,95%CI 0.898~0.973)對(duì)慢性心力衰竭預(yù)后具有顯著性作用(P0.01)。而年齡、病因構(gòu)成比、Alb、SCr、TG、LDL-c、入院心率逐個(gè)引入Cox回歸模型,經(jīng)Wald檢驗(yàn)后,顯示均無統(tǒng)計(jì)學(xué)意義(P0.05)。5慢性心衰患者心源性死亡的多因素Cox比例風(fēng)險(xiǎn)回歸分析將上述慢性心力衰竭患者預(yù)后單因素Cox比例風(fēng)險(xiǎn)模型分析有意義的影響因素(NYHA分級(jí)、lnNT-proBNP、TBIL、LVEF、LVEDD、入院SBP、入院PP)進(jìn)行多因素Cox比例風(fēng)險(xiǎn)模型分析(Enter法),結(jié)果顯示只有l(wèi)nNT-proBNP(RR=12.921,95%CI 2.373~70.353,P0.01)、入院SBP(RR=0.891,95%CI 0.828~0.958,P0.01)是判斷慢性力衰竭患者預(yù)后的獨(dú)立預(yù)測(cè)因素。結(jié)論:1入院時(shí)SBP100mmHg,PP35mmHg的慢性心力衰竭患者生存率明顯降低。2慢性心力衰竭患者入院時(shí)低收縮壓預(yù)后較差,是判斷慢性心力衰竭患者預(yù)后的獨(dú)立預(yù)測(cè)因素。
[Abstract]:Objective: Chronic Heart Failure (CHF) is the end stage manifestation of the development of various organic heart diseases and the most important cause of death. Its incidence is high, the disease is complicated, and the prognosis is poor. In recent years, the new chronic heart failure patients in China have been increasing in recent years, which seriously threaten the quality of life and life of the patients. The risk stratification and effective and reasonable treatment as early as possible can improve the prognosis of heart failure. Heart failure is often accompanied by changes in neurohumoral factors. Blood pressure is a comprehensive indicator of systemic hemodynamics. It is easy to measure, noninvasive, repeatable, and the same pattern is regulated by neurohumoral, suggesting blood pressure in heart failure. The blood pressure of 119 patients with chronic heart failure was measured and followed up to explore the value of the blood pressure level on the prognosis of the patients with chronic heart failure. Methods: from 01 months to December 2015 2015, the blood pressure of the patients with chronic heart failure was examined in the Second Affiliated Hospital of Hebei Medical University. A total of 119 patients with chronic heart failure in the three families. Criteria: clinical diagnosis of heart failure and a clear history of basic heart disease, with a history of more than half a year, age more than 18 years old. Contractile dysfunction is the main criterion for NYHA cardiac function II to IV grading, and N terminal natriuretic peptide (NT-proBNP) 2000ng/L. exclusion criteria: Cognition Obstacles, poor awareness, hypertrophic obstructive cardiomyopathy, valvular heart disease, pericardial constriction, pericardial effusion, myocarditis, congenital heart disease, acute myocardial infarction, acute heart failure, combined malignant arrhythmia, secondary hypertension, anemia, stroke, large amount of pleural effusion, pneumonia, chronic obstructive pulmonary disease, and so on; accompanied by severe liver and kidney function All the patients with serious prognosis (such as malignant tumor, etc.). All the selected patients strictly follow the Chinese blood pressure measurement guide, record blood pressure, record the age, sex, weight, height of the patients, and classify the heart function according to the New York Heart Association's heart function classification standard; perfect the cardiac ultrasound examination. The left ventricular ejection fraction (LVEF) and left ventricular end diastolic diameter (LVEDD) were measured and the biochemical indexes such as NT-proBNP, total bilirubin, albumin, blood lipid and creatinine were detected within 24 hours. After admission, the treatment was given in accordance with the guidelines for the prevention and treatment of heart failure in China. Death and sudden death were followed up to 2016-6, the follow-up time was at least 2016-6, and the follow-up time was at least in June. According to the blood pressure of the patients, the survival curves were plotted and the log-rank statistical test was made by the Kaplan-meier method. The factors affecting the prognosis were analyzed by the single factor analysis of the risk ratio of the Cox, and the single factor was divided. The value of Cox risk ratio analysis was analyzed to evaluate the value of admission blood pressure to the prognosis of patients with chronic heart failure. Data processing and analysis were carried out by spss21.0 software. The results of measurement data were "mean + standard deviation ((?) + s" or "median (14 quantiles, three or four digits) [m (Q1, Q3)]" The number of data is represented by the "number of cases (percentage)". First, the measurement data are tested with normal and variance homogeneity. If the normal distribution is not satisfied after the logarithmic conversion, the natural pair value of the measured data is used, and the "t test" or "non parametric mann-whitneyu test" is used for the comparison between the groups. The "x 2 test" or "fish exact probability method" were used among the groups. The correlation analysis used "Pearson correlation coefficient" or "Spearman correlation coefficient". The "Kaplan-Meier survival curve" was used for the single factor analysis among the three groups, and the "log-rank test" was used among groups. The risk factors for the endpoint events were respectively used "Cox proportion risk". Model "single variable and multivariable survival analysis. All statistics were bilateral tests, and P0.05 was statistically significant. Results: 119 patients with chronic heart failure were selected, including 77 males, 42 females, age 44~90 (67.3 + 10) years, bmi23.8 + 2.6kg/m2.: ischemic cardiomyopathy (coronary heart) 79 cases, dilated cardiomyopathy (expansion). 26 cases, 14 cases of hypertension and heart disease (Gao Xin). According to the heart function classification of New York heart disease association (NYHA), 51 cases of grade II, 47 cases of grade III, 21 cases of.1 cardiac death and non death group were compared with all the patients in the non death group, including 22 cases of cardiogenic death. The cardiac death was the end point of the follow-up, and the selected patients were divided into death group. There was no significant difference in age, sex ratio, body mass index (BMI), serum albumin, serum creatinine, serum potassium, total cholesterol, low density lipoprotein cholesterol, and heart rate difference at admission (P0.05). The heart function of the death group was significantly more than that in the non death group (68.2%vs6.2%) and the heart function grade II. The patients were significantly less than the non death group (4.5%vs51.5%), the difference was statistically significant (P0.01). The patients in the death group were nt-probnp[9750 (780510980) vs3210 (20225068)], lnnt-probnp (9.15 + 9.16vs8.03 + 8.03), TBIL (21.8 + 10.5vs12.2 + 5) were significantly higher than those in the non death group, and the difference was statistically significant (P0.01). The mortality group was LVEF (27.4 + 5.0vs42.1 + 9.1). The admission of SBP (108.4 + 10.5vs122.5 + 8.9), admission to hospital DBP (65.5 + 5.4vs72.4 + 7.7), PP (42.9 + 12.3vs50.2 + 9.3) in hospital was significantly lower than that of non death group. The difference was statistically significant (P0.01) and the correlation analysis between the admission blood pressure and the above 2 groups of clinical data was analyzed by Pearson related or Spearman correlation analysis: admission SBP Negative correlation with NT-proBNP (rs=? 0.266, P0.01), positive correlation with LVEF (rs=0.352, P0.01), negative correlation with LVEDd (rs=? 0.225, P0.05), negative correlation with NYHA classification (rs=? 0.201, P0.05), negative correlation (0.232, 0.227). (r=? 0.202, P0.05), negative correlation with NYHA classification (rs=? 0.219, P0.05), negative correlation with TBIL (r=? 0.202, P0.05).3 (r=? 0.202, P0.05).3 using Kaplan-Meier method to plot the survival curve of different blood pressure levels and carry out log-rank statistical test based on admission SBP, which will be divided into three groups. The survival rates of the 3 groups were different between the 3 groups (x 2=33.935, P0.01). The survival rate of the patients with chronic heart failure in sbp100mmhg was significantly lower than that of SBP in 100~130mmhg, and the patients with chronic heart failure admitted to sbp130mmhg (27.659,17.922, P, respectively 0.01) were admitted to sbp130mmhg, while SBP in 100~130mmhg was in the chronic heart. There was no significant difference between the survival rate of the patients with stress failure and the survival rate of chronic heart failure patients with sbp130mmhg (x 2=1.561, P0.05). According to the admission DBP, the admission DBP was divided into groups of 60mmhg, 60~80mmhg, 80mmHg three. The survival curves were plotted by Kaplan-Meier method, and the survival rate between the 3 groups was tested by log-rank (x 2=3.324, p=0.190). PP, the hospitalized PP was divided into 35mmhg, 35~55mmhg, 55mmhg three groups. The survival curves were plotted by Kaplan-Meier, and the survival rates of the 3 groups were different by log-rank test (x 2=26.834, P0.01). The survival rate of the patients with chronic heart failure in the hospitalized pp35mmhg was significantly lower than that of PP in 35~55mmhg, and the chronic heart failure patients admitted to hospital. The rate of survival of patients with chronic heart failure in 35~55mmHg and the survival rate of chronic heart failure in PP55mmHg was not statistically significant (x 2=0.367, P0.05), and the 22.279,16.022.4 chronic heart failure patients had no statistical difference (x 2=0.367, P0.05).4 chronic heart failure patients with cardiac death, the single factor Cox proportional risk regression analysis was based on cardiac death as a cause of change. NYHA classification, lnNT-proBNP, TBIL, Alb, SCr, TG, LDL-c, LVEF, LVEDD, admission heart rate, admission SBP, and PP as independent variables. F (RR=0.825,95%CI 0.776~0.878), LVEDD (RR=1.107,95%CI 1.059~1.156), admission to SBP (RR=0.866,95%CI 0.823~0.910), admission PP (RR=0.935,95%CI 0.898~0.973) have a significant effect on the prognosis of chronic heart failure. Multiple factor Cox proportional risk regression analysis of cardiac death in chronic heart failure patients with no statistical significance (P0.05).5 analysis of the prognostic factors of the prognostic single factor Cox proportional risk model for the patients with chronic heart failure (NYHA classification, lnNT-proBNP, TBIL, LVEF, LVEDD, admission SBP, admission PP) to carry out a multi factor Cox proportional risk model The analysis (Enter method) showed that only lnNT-proBNP (RR=12.921,95%CI 2.373~70.353, P0.01) and admission SBP (RR=0.891,95%CI 0.828~0.958, P0.01) were independent predictors for predicting the prognosis of patients with chronic stress failure. Conclusion: 1 at admission, SBP100mmHg, PP35mmHg chronic heart failure patients significantly reduced the incidence of chronic congestive heart failure. Poor prognosis in patients with low systolic blood pressure is an independent predictor of prognosis in patients with chronic heart failure.

【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.6

【參考文獻(xiàn)】

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