本文選題：甲狀腺功能亢進癥　切入點：肺動脈高壓　出處：《河北醫(yī)科大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:甲狀腺功能亢進癥(Hyperthyroidism,簡稱甲亢),是內(nèi)分泌專業(yè)最常見的疾病之一,在普通人群中的患病率達到0.5%,也有報道可達1%,男女患病比例為1:4-6,在女性人群中患病率在2%左右。臨床中,依據(jù)甲亢發(fā)生的病因不同,分為:彌漫性毒性甲狀腺腫、結(jié)節(jié)性毒性甲狀腺腫、甲狀腺自主高功能腺瘤和碘甲亢。在眾多病因?qū)е碌募卓褐?毒性彌漫性甲狀腺腫(Graves disease,GD)的比例可達85%左右,因GD患病率為最高,發(fā)病情況也最為普遍,所以一般意義上的甲亢都指的是GD。近些年來,較多報道都提示了甲狀腺功能亢進癥與肺動脈高壓(Pulmonary hypertension)可以同時合并出現(xiàn),這種現(xiàn)象,也在內(nèi)分泌專業(yè)醫(yī)生中,逐漸得到重視。第3次世界衛(wèi)生組織肺動脈高壓專家組會議,在關(guān)于肺動脈高壓新診斷分類標準中,針對特發(fā)性肺動脈高壓的病因,明確納入了甲狀腺疾病作為其中一個病因,且稱其為“不可忽視的”危險因素。報道中,尤其提到以甲亢合并肺動脈高壓的現(xiàn)象最為多見,其病因尚未能完全闡述明確,可能與甲亢導(dǎo)致的高心輸出量、高動力循環(huán)狀態(tài)密切相關(guān),也有人推斷,甲狀腺疾病的發(fā)生往往與自身免疫有密切的相關(guān)性,甲亢合并肺動脈高壓,也可能與自身免疫反應(yīng)導(dǎo)致的血管內(nèi)皮損傷,和由此引起的功能紊亂存在相關(guān)性。但對于甲亢患者何時發(fā)生肺動脈高壓,肺動脈壓力的變化與甲狀腺激素水平有何相關(guān),肺動脈壓力變化與甲狀腺相關(guān)抗體滴度是否相關(guān),國內(nèi)外尚無相關(guān)報道。血漿B型鈉尿肽(brain natriuretic peptide,BNP)是反映患者肺動脈壓力水平的良好指標,可以用來預(yù)測和評估肺動脈高壓的發(fā)生。本研究擬通過測定不同時期甲亢患者的肺動脈壓力、BNP水平、甲狀腺相關(guān)抗體水平,進一步探討甲亢患者的肺動脈壓力變化特點,了解肺動脈壓力水平與甲狀腺激素水平之間的聯(lián)系,分析肺動脈壓力與甲狀腺抗體水平是否存在關(guān)聯(lián),以期對甲亢患者肺動脈高壓的預(yù)防提供佐證。方法:篩選2013年12月至2014年10月就診于河北省承德市中心醫(yī)院內(nèi)分泌科門診、住院處甲亢患者,進行研究。所有研究對象根據(jù)甲狀腺功能狀態(tài)分為三個組:A組(臨床甲亢組)30例:年齡18-60歲,TSH0.55 m IU/m L、FT417.6 pg/m L、FT34.2 pg/ml,無心臟病史及其他慢性疾病史;B組(亞臨床甲亢組)30例:年齡18-60歲;TSH0.55 m IU/m L、FT3,FT4正常,無心臟病史及其他慢性疾病史;C組(臨床緩解組)30例:甲亢經(jīng)口服藥治療,已進入臨床癥狀緩解期,甲功已完全正常狀態(tài),在藥物維持期,以相同時期,在承德市中心醫(yī)院體檢中心體檢的健康人群30例作為對照組N組。研究對象均取得知情同意后,進行甲狀腺功能和相關(guān)抗體的檢測,同時測定血漿BNP濃度,于我院超聲室進行肺動脈壓水平檢測。血漿BNP濃度檢測方法:患者于空腹?fàn)顟B(tài)時,抽取靜脈血2ml,以依地酸(EDTA)抗凝管留取,立即送檢,采用干式快速免疫熒光法定量測定BNP值;檢測設(shè)備為美國克格儀器有限公司:M368456型號的BNP測試儀,可快速檢測,15分鐘報告,正常值為0-100pg/ml。肺動脈高壓診斷標準參照2009年歐洲心臟病學(xué)會(ESC)指南,依據(jù)超聲心動圖測得肺動脈收縮壓(PASP)值確定。肺高壓診斷標準為靜息時經(jīng)胸超聲心動圖估測PASP35mm Hg,35≤PASP50mm Hg為輕度,50≤PASP70mm Hg為中度,PASP≥70 mm Hg為重度肺高壓。然后進行統(tǒng)計學(xué)處理,把各組研究對象間甲狀腺激素水平、相關(guān)抗體、肺動脈壓力、血漿BNP值分別進行比較;進行肺動脈壓水平與甲狀腺激素水平、相關(guān)抗體以及血漿BNP的相關(guān)性分析。結(jié)果:1研究納入的120人中,其中對照組:男性7人,女性23人,年齡范圍(40.5±15.2)歲;A組:男性8人,女性22人,年齡范圍(43.2±16.3)歲;B組:男性6人,女性24人,年齡范圍(42.1±15.7)歲;C組:男性7人,女性23人,年齡范圍(41.8±14.9)歲。各組間年齡差異無統(tǒng)計學(xué)意義(P0.05),各組間性別差異無統(tǒng)計學(xué)意義(P0.05),各組間研究對象具有可比較性。2健康對照組人群平均肺動脈壓力為24.15mm Hg,肺高壓患病率為0%,臨床甲亢組患者平均肺動脈壓力為48.37mm Hg,肺高壓患病率為33%,亞臨床甲亢組患者平均肺動脈壓力為36.91mm Hg,肺高壓患病率為30.0%,臨床緩解組患者平均肺動脈壓力為34.58mm Hg,肺高壓患病率為26.7%,臨床甲亢組、亞臨床甲亢組和臨床緩解組的肺動脈壓水平和肺高壓患病率,與健康對照組相比,差異顯著(P0.05);臨床甲亢組較亞臨床甲亢組、臨床緩解組的肺動脈壓水平差異顯著(P0.05),亞臨床甲亢組、臨床緩解組肺動脈壓力、肺動脈高壓患病率組間比較差異不明顯(P0.05)。3肺動脈壓力分別與TSH、FT3、FT4、TPOAb、Tg Ab、TRAb進行相關(guān)性分析,結(jié)果顯示肺動脈壓力水平與TSH呈輕度負相關(guān)(r=-0.452,P0.05),與甲狀腺激素水平表現(xiàn)出正相關(guān)性,與其他指標無線性相關(guān)性(P0.05)。4血漿BNP檢測值的比較,臨床甲亢組、亞臨床甲亢組和臨床緩解組的各血漿BNP平均值分別為:317.13pg/ml、298.12 pg/ml、259.41 pg/ml,健康對照組為20.12 pg/ml,相比之下,甲亢患者BNP水平與健康對照組差異顯著(P0.05);臨床甲亢組、亞臨床甲亢組和臨床緩解組的血漿BNP值組間比較,差異不明顯(P0.05),結(jié)果顯示肺動脈壓力水平與血漿BNP值成中度正相關(guān)(r=0.557,P0.05)。結(jié)論:甲亢患者肺動脈壓力水平和肺動脈高壓患病率較正常人群為高,肺動脈高壓在亞臨床甲亢階段即可發(fā)生,不同時期的甲亢患者肺動脈高壓患病率不同,肺動脈壓力水平隨甲亢的嚴重程度增高。甲狀腺抗體水平并沒有表現(xiàn)出與肺動脈高壓水平的明顯的相關(guān)性。肺動脈壓力水平與血漿BNP值呈中度正相關(guān)性,可用來評估甲亢患者肺動脈高壓的發(fā)生風(fēng)險。
[Abstract]:Objective: hyperthyroidism (hyperthyroidism, referred to as Hyperthyroidism) is one of the most common endocrine professional disease in the general population prevalence rate of 0.5%, there are reports of up to 1%, the ratio between men and women was 1:4-6, the prevalence rate of around 2% in women. The clinical and etiology of hyperthyroidism in patients according to the different, divided into: diffuse toxic goiter, nodular toxic goiter, thyroid adenoma and the function of the independent high iodine hyperthyroidism. Resulted in numerous causes of hyperthyroidism, diffuse toxic goiter (Graves disease, GD) the proportion of up to about 85%, due to the prevalence of GD was the highest, the incidence is most common. So the general sense of hyperthyroidism refers to GD. in recent years, many reports have suggested that hyperthyroidism and pulmonary arterial hypertension (Pulmonary hypertension) can also occur, this phenomenon also in endocrinology The doctor, gradually get attention. The third WHO expert pulmonary hypertension group meeting on pulmonary arterial hypertension diagnostic classification standard, according to the etiology of idiopathic pulmonary arterial hypertension, clear into thyroid disease as a cause, and called it "the risk can not be ignored in the report" factors. In particular, to mention hyperthyroidism complicated with pulmonary hypertension is the most common phenomenon, its etiology is still not fully explain clearly, high cardiac output may lead to high power and hyperthyroidism, closely related to the circulating state was also inferred that the thyroid disease often is associated with autoimmune hyperthyroidism complicated with pulmonary hypertension may also lead to vascular endothelial injury, reaction and autoimmune disorders, and the resulting correlation exists. But for the patients with hyperthyroidism when pulmonary hypertension, pulmonary arterial pressure changes What is the level of thyroid hormone and thyroid, and whether the change of pulmonary artery pressure related antibody titer, there is no relevant reports at home and abroad. Plasma B type natriuretic peptide (brain natriuretic, peptide, BNP) is a good indicator to reflect the level of patients with pulmonary arterial pressure, can be used to predict and evaluate the occurrence of pulmonary hypertension. This study through the determination of pulmonary arterial pressure in patients with hyperthyroidism in different periods of BNP level, thyroid related antibody level, to further explore the changes of pulmonary arterial pressure in patients with hyperthyroidism, understanding between pulmonary artery pressure level and thyroid hormone levels, analysis of pulmonary artery pressure and thyroid antibody level is associated, in order to prevent the pulmonary artery in patients with hyperthyroidism the pressure to provide evidence. Methods: from December 2013 to October 2014 screening clinic in Chengde Central Hospital of Hebei province outpatient department of Endocrinology, hospital department of hyperthyroidism All patients were studied. The research object according to the thyroid function was divided into three groups: group A (clinical hyperthyroidism group) 30 cases: age 18-60 years, TSH0.55 m IU/m L, FT417.6 pg/m L, FT34.2 pg/ml, had no history of heart disease and other chronic diseases; group B (subclinical hyperthyroidism group) 30 cases: 18-60 years of age; TSH0.55 m IU/m L, FT3, FT4 normal, no history of heart disease and other chronic diseases; group C (remission group) 30 cases of hyperthyroidism: oral drug treatment, has entered the clinical remission period, thyroid function is completely normal, the maintenance period in medicine, in the same period, in healthy physical examination center of Chengde Central Hospital, 30 cases of group N as the control group. The research object was obtained after informed consent for detection of thyroid function and antibody, simultaneous determination of plasma concentration of BNP in our hospital, Department of ultrasonography for pulmonary arterial pressure level detection method. To detect the concentration of plasma BNP in patients with: The fasting state, venous blood 2ml, with EDTA (EDTA) anticoagulant tube specimens, inspection immediately, quantitative determination of BNP value by fluoroimmunoassay; testing equipment for America's Instrument Co. Ltd.: BNP tester model M368456, rapid detection, 15 minutes report, normal value as the standard pressure 0-100pg/ml. diagnosis of pulmonary artery in reference to the 2009 European Society of Cardiology (ESC) guidelines, according to echocardiography measured pulmonary artery systolic pressure (PASP) values. For the diagnosis of pulmonary hypertension standard resting echocardiography to estimate PASP35mm Hg, 35 PASP50mm Hg 50 PASP70mm Hg for mild, moderate, PASP = 70 mm Hg for severe pulmonary hypertension. Then were statistically related to each research object between the antibody level of thyroid hormone, and pulmonary artery pressure, plasma BNP values were compared; pulmonary artery pressure levels and thyroid hormone levels, resistance 浣撲互鍙婅嫻咮NP鐨勭浉鍏蟲，

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