發(fā)布時間：2018-07-14 12:35

【摘要】：背景原發(fā)性高血壓是一種臨床常見疾病,以體循環(huán)動脈壓的增高為主要特點,可引起靶器官結(jié)構(gòu)和功能異常,如心、腦、腎等臟器的正常結(jié)構(gòu)功能損害。心室后負(fù)荷增加,可造成心腔內(nèi)血流流動規(guī)律改變,心腔內(nèi)正常流場紊亂。有研究表明,高血壓性心臟病是造成射血分?jǐn)?shù)保留心衰的重要因素之一,早期準(zhǔn)確評價左室功能改變具有重要意義,但心腔內(nèi)血流改變與舒張功能減退和心室重構(gòu)的關(guān)系尚需進(jìn)一步明確。血流向量成像技術(shù)(VFM)可對心腔內(nèi)血流動力學(xué)改變進(jìn)行定量評價,計算心腔血流流動過程中摩擦產(chǎn)生的能量損耗和渦流循環(huán)量等指標(biāo)。既往研究對于高血壓進(jìn)行左室構(gòu)型分析多采用符合歐美人群標(biāo)準(zhǔn)的Ganau分型,而針對中國高血壓人群構(gòu)型特點的血流動力學(xué)研究尚未見報導(dǎo),有待進(jìn)一步研究。目的1、比較中國標(biāo)準(zhǔn)和國際標(biāo)準(zhǔn)下高血壓構(gòu)型分布特點,觀察不同標(biāo)準(zhǔn)下左心功能和血流動力學(xué)表現(xiàn)是否存在差異。2、根據(jù)中國人群超聲正常值對高血壓患者進(jìn)行構(gòu)型分析,評估高血壓患者舒張期左室內(nèi)能量損耗及渦流循環(huán)量等血流變化特點。3、探討左心室血流動力學(xué)變化與舒張功能的關(guān)系,分析血流向量成像技術(shù)在評價高血壓患者左室舒張功能中的應(yīng)用價值。研究對象高血壓組:根據(jù)中國高血壓防治指南2010診斷標(biāo)準(zhǔn),在不同日進(jìn)行3次血壓測量,若未服用過降壓藥,收縮壓≥140mmHg(lmmHg=0.133kPa)和(或)舒張壓≥90mmHg,即診斷為高血壓;若血壓低于140/90mmHg,但既往有高血壓病病史,并正在使用降壓藥物,也診斷為高血壓。排除伴有冠心病、糖尿病、心力衰竭、高脂血癥、心包積液、肺氣腫、心律失常、腦卒中、心肌梗死、瓣膜病、甲狀腺疾病、先天性心臟病、貧血、心肌病、結(jié)締組織疾病、妊娠或哺乳期婦女、心電圖檢查異常、惡性腫瘤及其他系統(tǒng)嚴(yán)重疾病的患者,共63名高血壓患者。對照組:共23名健康志愿者,與高血壓組的年齡、性別相匹配。方法1、基本信息采集:包括受檢者的姓名、性別、年齡、身高、體重、血壓、心率、煙酒史、血脂、血糖、病史等基本信息。2、超聲圖像采集:(1)采用日本Hitachi公司Aloka Prosound F75型彩色多普勒超聲診斷儀,受檢者取左側(cè)臥位,連接肢體導(dǎo)聯(lián),同步記錄心電圖,采集胸骨旁左室長軸切面、心尖二腔心切面、心尖四腔心切面動態(tài)圖像,留取連續(xù)三個心動周期,測量左室收縮末期左房內(nèi)徑(LAD)、主動脈內(nèi)徑(AO)、左室舒張末內(nèi)徑(LVID)、左室后壁(LPW)及室間隔厚度(IVS),計算相對室壁厚度(RWT)、左室質(zhì)量(LVM)、左室質(zhì)量指數(shù)(LVMI)及左室射血分?jǐn)?shù)(LVEF)。用雙平面Simpson法測量左房容積(LAV),計算左房容積指數(shù)(LAVI)。(2)測量二尖瓣舒張早期E波血流速度(E)、二尖瓣舒張晚期A波血流速度(A)、二尖瓣舒張早期血流減速時間(DT),計算E/A。測量三尖瓣反流速度(TRV)。(3)測量舒張早期二尖瓣環(huán)室間隔、側(cè)壁心肌運動峰值速度,分別為e'(s)、e'(1),計算平均值e'和E/e'。3、血流向量成像測量:啟用VFM模式,采集心尖三腔心切面動態(tài)圖像,留取連續(xù)三個心動周期,導(dǎo)入工作站進(jìn)行脫機分析。參考圖像標(biāo)尺,將左室劃分為心尖段、中間段、基底段三個節(jié)段;結(jié)合時間-流量曲線和主動脈瓣、二尖瓣開閉情況,確定等容舒張期、快速充盈期、緩慢充盈期和心房收縮期,測量不同時期左室整體及各節(jié)段平均能量損耗,各時期渦流循環(huán)量及渦流面積。4、應(yīng)用SPSS23.0軟件進(jìn)行統(tǒng)計分析結(jié)果1、基本資料比較(1)依照中國標(biāo)準(zhǔn)進(jìn)行高血壓構(gòu)型分析,得到NG組27例(43%),CR組5例(8%),EH組21例(33%),CH組10例(16%)。依照國際標(biāo)準(zhǔn)進(jìn)行高血壓構(gòu)型分析,得到 NG 組 17 例(27%),CR 組 23 例(36%),EH 組 6 例(10%),CH 組 17例(27%),與中國人群構(gòu)型分析結(jié)果存在統(tǒng)計學(xué)差異(p0.05)。(2)高血壓組與對照組間心率無統(tǒng)計學(xué)差異(p0.05)。與對照組相比,高血壓組及各亞組收縮壓、舒張壓均增大(p0.05);各亞組間收縮壓、舒張壓無統(tǒng)計學(xué)差異(p0.05)。2、根據(jù)中國標(biāo)準(zhǔn)超聲檢查常用指標(biāo)比較(1)左室室壁厚度:高血壓組LPW、IVS、RWT較對照組增大,差異有統(tǒng)計學(xué)意義(p0.05)。(2)心腔內(nèi)徑:高血壓組LAD、AO較對照組增大,差異有統(tǒng)計學(xué)意義(p0.05)。高血壓組與對照組間LVID無統(tǒng)計學(xué)差異(p0.05)。(3)左室質(zhì)量:高血壓組LVM、LVMI較對照組增大,差異有統(tǒng)計學(xué)意義(p0.05)。(4)左房容積:高血壓組LAV、LAVI較對照組增大(p0.05);EH組和CH組左房容積較NG組增大,差異有統(tǒng)計學(xué)意義(p0.05)。(5)左室射血分?jǐn)?shù):高血壓組與對照組間LVEF無統(tǒng)計學(xué)差異(p0.05)。(6)舒張期二尖瓣口血流速度:高血壓組與對照組間E、DT無統(tǒng)計學(xué)差異(p0.05)。與對照組相比,高血壓組E/A減小(p0.05),NG組、EH組E/A減小(p0.05)。與對照組相比,高血壓組及各亞組A均增加(p0.05)。(7)舒張期二尖瓣環(huán)心肌運動速度:與對照組相比,高血壓組及各亞組e'(s)、e'(1)均減低(p0.05);EH組e'(s)、e'(1)較NG組增大(p0.05)。與對照組相比,高血壓及各亞組E/e'均增加(p0.05)。(8)三尖瓣血流反流速度:與對照組相比,高血壓組及各亞組間TRV均無統(tǒng)計學(xué)差異(p0.05)。3、根據(jù)中國標(biāo)準(zhǔn)能量損耗比較(1)等容舒張期:與對照組相比,高血壓組左室整體、基底段、中間段及心尖段平均能量損耗無統(tǒng)計學(xué)差異(p0.05)。(2)快速充盈期、緩慢充盈期:與對照組相比,高血壓組左室整體、基底段、中間段及心尖段平均能量損耗無統(tǒng)計學(xué)差異(p0.05)。(3)心房收縮期:與對照組相比,高血壓組左室整體、基底段、中間段平均能量損耗增大(p0.05);心尖段平均能量損耗與對照組相比無統(tǒng)計學(xué)差異(p0.05)。與對照組相比,高血壓NG組中間段能量損耗增大(p0.05),EH組基底段、中間段能量損耗增大(p0.05);CH組中間段能量損耗較NG組、EH組減小,差異有統(tǒng)計學(xué)意義(p0.05)。4、根據(jù)中國標(biāo)準(zhǔn)渦流比較(1)等容舒張期:高血壓組與對照組均無顯著渦流出現(xiàn)。(2)快速充盈期:與對照組相比,高血壓組二尖瓣前、后葉的渦流循環(huán)量和渦流面積無統(tǒng)計學(xué)差異(p0.05);各亞組間無統(tǒng)計學(xué)差異(p0.05)。(3)緩慢充盈期:與對照組相比,高血壓組渦流循環(huán)量、渦流面積無統(tǒng)計學(xué)差異(p0.05);各亞組間無統(tǒng)計學(xué)差異(p0.05)。(4)心房收縮期:與對照組相比,高血壓組二尖瓣后葉的渦流循環(huán)量和渦流面積增大(p0.05),NG組、EH組二尖瓣后葉的渦流循環(huán)量和渦流面積增大(p0.05)。高血壓組二尖瓣前葉的渦流循環(huán)量和渦流面積較對照組無統(tǒng)計學(xué)差異(p0.05)。5、構(gòu)型分析(1)對中國標(biāo)準(zhǔn)、國際標(biāo)準(zhǔn)結(jié)果進(jìn)行分析,在不同標(biāo)準(zhǔn)下對NG組、CH組進(jìn)行比較,心功能指標(biāo) LAVI、E、A、E/A、TRV、e'(s)、e'(1)、E/e'、LVEF 無統(tǒng)計學(xué)差異(p0.05)。中國標(biāo)準(zhǔn)與國際標(biāo)準(zhǔn)分組間左室整體及各節(jié)段平均能量損耗、左室渦流循環(huán)、渦流面積無統(tǒng)計學(xué)差異(p0.05)。(2)依照國際標(biāo)準(zhǔn)對能量損耗進(jìn)行高血壓亞組分析,各亞組間及與對照組間左室整體及各節(jié)段平均能量損耗無統(tǒng)計學(xué)差異(p0.05)。(3)依照國際標(biāo)準(zhǔn)對渦流進(jìn)行高血壓亞組分析,心房收縮期NG組、CR組二尖瓣后葉的渦流循環(huán)量和渦流面積較對照組增大(p0.05)。6、相關(guān)性分析(1)對高血壓組能量損耗和舒張功能進(jìn)行相關(guān)性分析,快速充盈期整體、中間段能量損耗與E、LAVI、E/e'呈顯著正相關(guān)(p0.05);基底段能量損耗與E、e'(s)、e'(1)呈顯著正相關(guān)(p0.05)。緩慢充盈期心尖段能量損耗與E、A、LAVI、E/e'存在顯著正相關(guān)(p0.05)。心房收縮期整體能量損耗與E/e'呈顯著正相關(guān)(p0.05),與e'(s)、e'(1)呈顯著負(fù)相關(guān)(p0.05);基底段能量損耗與E/e'呈顯著正相關(guān)(p0.05)。(2)對高血壓組渦流和舒張功能進(jìn)行相關(guān)性分析,快速充盈期二尖瓣后葉渦流循環(huán)量與E呈顯著正相關(guān)(p0.05)。心房收縮期前葉渦流循環(huán)與E/e'呈顯著負(fù)相關(guān)(p0.05),與e'(1)呈顯著正相關(guān)(p0.05);心房收縮期前葉渦流面積與e'(s)、e'(1)呈顯著正相關(guān)(p0.05),與E/e'呈顯著負(fù)相關(guān)(p0.05)。心房收縮期后葉渦流循環(huán)與與A呈顯著正相關(guān)(p0.05),與e'(s)呈顯著負(fù)相關(guān)(p0.05)。結(jié)論1、采用Ganau分型方法,分別依據(jù)歐美人群及中國人群超聲正常值進(jìn)行分型,得到的構(gòu)型分析結(jié)果不同。2、依照中國人群超聲正常值進(jìn)行高血壓構(gòu)型分析可以更敏感地反映左室內(nèi)能量損耗變化。3、原發(fā)性高血壓患者與正常對照相比心房收縮期能量損耗增加,渦流循環(huán)量增加,能量損耗和渦流改變與舒張功能變化相關(guān)。
[Abstract]:Background primary hypertension is a common clinical disease, which is characterized by higher body circulation pressure, which can cause abnormal structure and function of target organs, such as the normal structure and function of the organs such as heart, brain and kidney. The increase of ventricular post load may cause the change of flow pattern in the heart cavity and the normal flow field in the heart. Hypertensive heart disease is one of the important factors contributing to the retention of heart failure in ejection fraction. Early and accurate evaluation of left ventricular function changes is of great significance. However, the relationship between blood flow change in the heart and diastolic dysfunction and ventricular remodeling needs to be further clarified. Blood flow vector imaging (VFM) can quantify the hemodynamic changes in the heart cavity. Evaluation, calculation of the energy loss and eddy current circulation during the flow of blood flow in the heart. The analysis of the left ventricular configuration of hypertension in the past is mostly based on the Ganau classification that is in line with the standard of European and American population. However, there is no report on the hemodynamic study of the configuration characteristics of the hypertensive population in China, which needs further study. Objective 1 to compare the distribution characteristics of hypertensive configuration under Chinese and international standards, observe whether there is a difference in left heart function and hemodynamic performance under different standards.2. According to the normal values of Chinese people, the structure of hypertensive patients is analyzed, and the blood flow of left indoor energy and eddy circulation in the diastolic period of hypertensive patients is evaluated. .3, the relationship between left ventricular hemodynamic changes and diastolic function was discussed. The value of blood flow vector imaging technique in evaluating left ventricular diastolic function in hypertensive patients was analyzed. Study object hypertension group: according to the 2010 diagnostic criteria of Chinese hypertension prevention guide, 3 blood pressure measurements were carried out on different days, if no blood pressure was taken. Drugs, the systolic pressure is more than 140mmHg (lmmHg=0.133kPa) and (or) diastolic pressure more than 90mmHg, that is, the diagnosis of hypertension; if the blood pressure is lower than 140/90mmHg, there is a history of hypertension, and is using antihypertensive drugs, also diagnosed as hypertension. Excluding coronary heart disease, diabetes, heart failure, hyperlipidemia, pericardial effusion, emphysema, arrhythmia, stroke, Myocardial infarction, valvular disease, thyroid disease, congenital heart disease, anemia, cardiomyopathy, connective tissue disease, pregnancy or lactating women, abnormal electrocardiogram, malignant tumors and other severe systemic diseases, 63 hypertensive patients. A total of 23 healthy volunteers were matched with the age and sex of the hypertension group. Method 1, Basic information collection: including the subjects' name, sex, age, height, weight, blood pressure, heart rate, smoking and alcohol history, blood lipid, blood sugar, medical history and other basic information.2, ultrasonic image acquisition: (1) use Japanese Hitachi Aloka Prosound F75 color Doppler ultrasound diagnostic instrument, the subjects take the left lying position, connect the limb lead, and record the electrocardiogram synchronously, The long axis section of the parastenal left ventricle, the two cavities of the apical cavity, the dynamic image of the four cavities of the apex, left the left atrial diameter (LAD), the internal diameter of the left ventricle (AO), the left ventricular end diastolic diameter (LVID), the left ventricular posterior wall (LPW) and the thickness of the interventricular septum (IVS), and the calculation of the relative ventricular wall thickness (RWT) and left ventricular mass (LVM). Left ventricular mass index (LVMI) and left ventricular ejection fraction (LVEF). Left atrial volume index (LAV) was measured by biplane Simpson method and left atrial volume index (LAVI) was calculated. (2) measurement of early diastolic E wave velocity (E), late diastolic A wave velocity (A) of mitral valve, early diastolic blood flow deceleration time (DT) of mitral valve and E/A. measurement of three tip reverse flow velocity were measured. Degree (TRV). (3) measurement of the early diastolic mitral annular interventricular septum, the peak velocity of the lateral wall myocardial motion, respectively E'(s), E' (1), the mean value E'and E/e'.3, the blood flow vector imaging measurement: using the VFM mode, collecting the dynamic images of the three cavities of the apical three cavities, leaving the continuous three cardiac cycles, and introducing the workstation for offline analysis. Reference image scale, will be used The left ventricle was divided into three segments of the apical, middle and basal segments, combined with the time flow curve and the aortic valve, the opening and closing of the mitral valve, the constant volume diastolic phase, the rapid filling period, the slow filling period and the atrial systole, and the measurement of the energy loss of the left ventricle and Duan Ping in different periods, and the eddy circulation and the eddy area of.4 in each period. SPSS23.0 software was used to analyze the results of statistical analysis 1, basic data comparison (1) according to Chinese standards for hypertension configuration analysis, NG group 27 cases (43%), CR group 5 cases (8%), EH group 21 cases (33%), CH group 10 cases (16%). According to international standard, hypertension configuration analysis, NG group 17 cases (27%), CR group 23 cases (36%), EH group cases, CH group instances (27%) there were statistical differences (P0.05) with the results of Chinese population structure analysis. (2) there was no significant difference in heart rate between the hypertension group and the control group (P0.05). Compared with the control group, the systolic pressure and diastolic pressure in the hypertension group and the subgroups increased (P0.05); the systolic pressure and diastolic pressure between the subgroups were not statistically different (P0.05).2, according to the Chinese standard ultrasound examination. Comparison of common indexes (1) left ventricular wall thickness: LPW, IVS and RWT in hypertension group were larger than those of control group, the difference was statistically significant (P0.05). (2) the inner diameter of the heart cavity: hypertension group LAD, AO was larger than the control group (P0.05). There was no statistical difference between the hypertension group and the control group (P0.05). (3) the left ventricular mass: hypertension group LVM, LVMI was compared. The difference was statistically significant (P0.05). (4) left atrial volume: hypertension group LAV, LAVI higher than the control group (P0.05), EH group and CH group left chamber volume increased compared with the NG group, the difference was statistically significant (P0.05). (5) left ventricular ejection fraction: no statistical difference between the hypertension group and the control group (P0.05). (6) the diastolic mitral valve flow velocity: high There was no significant difference in E between the blood pressure group and the control group (P0.05). Compared with the control group, the E/A decreased (P0.05), the NG group, and the EH group E/A decreased (P0.05). Compared with the control group, the A of the hypertension group and the subgroups increased (P0.05). (7) the mitral annulus myocardium movement speed of the diastolic phase was lower than the control group, and the hypertension group and the sub group E'(1) were all reduced. 0.05); E'(s) and E' (1) increased in group EH (P0.05). Compared with the control group, the hypertension and each subgroup E/e'increased (P0.05). (8) three apical flow reverse flow velocity: compared with the control group, there was no statistical difference between the hypertension group and the subgroups (P0.05).3, according to the standard energy loss (1) in China (1) of the ISO diastolic phase: hypertension compared with the control group, hypertension The average energy loss in the left ventricle, basal segment, middle segment and apical segment was not statistically different (P0.05). (2) rapid filling period and slow filling period: compared with the control group, the average energy loss in the left ventricle, basal segment, middle segment and apical segment of the hypertension group was not statistically different (P0.05). (3) the systolic phase of the atrium was compared with the control group, left by the hypertension group The average energy loss in the basal segment and middle segment increased (P0.05). The mean energy loss of the apex segment was not significantly different from the control group (P0.05). Compared with the control group, the energy loss in the middle segment of the hypertensive NG group increased (P0.05), the basal segment of the EH group and the energy loss in the middle segment increased (P0.05); the energy loss in the middle segment of the CH group was higher than that in the NG group, and the EH group decreased. The difference was statistically significant (P0.05).4, according to Chinese standard eddy current comparison (1) ISO diastolic phase: there was no significant eddy current in both hypertension group and control group. (2) rapid filling period: compared with the control group, there was no statistical difference (P0.05) in the volume of eddy current and eddy current in the posterior lobe of the hypertension group (P0.05); there was no statistical difference between the subgroups (P0.05). 3) slow filling period: compared with the control group, there was no statistical difference in the volume of eddy current and the area of eddy current in the hypertension group (P0.05); there was no statistical difference between the subgroups (P0.05). (4) the atrial systolic phase: compared with the control group, the eddy circulation and the eddy area of the posterior lobe of the hypertension group increased (P0.05), the NG group, and the eddy circulation of the posterior lobe of the EH group The volume of eddy current and the area of eddy current increased (P0.05). There was no significant difference in eddy current circulation and eddy area in the anterior lobe of the hypertension group (P0.05).5. The configuration analysis (1) analyzed the Chinese standard and the international standard results, compared the NG group and CH group under different standards. The cardiac function indexes were LAVI, E, A, E/A, TRV, E'(s). The mean energy loss of the whole left ventricle and each segment between the Chinese standard and the international standard group (P0.05). There was no statistical difference between the left ventricular eddy current cycle and the area of the eddy current (P0.05). (2) the energy loss was analyzed according to the international standard. The average energy loss of the whole left ventricle and each segment between the subgroups and the control groups was no more. Study difference (P0.05). (3) according to the international standard, the eddy current hypertension subgroup analysis, the atrial systolic NG group, the CR group of the mitral valve posterior lobe, the eddy circulation volume and the eddy area increased (P0.05).6, correlation analysis (1) the correlation analysis of the energy loss and the relaxation function of the hypertension group, the rapid filling period, the middle segment energy. Loss was significantly positively correlated with E, LAVI and E/e'(P0.05); the energy loss in the basal segment was significantly positively correlated with E, E' (s) and E'(1). The energy loss in the bottom segment was positively correlated with the E/e'(P0.05). (2) the correlation between the eddy current and diastolic function of the hypertension group was analyzed. The eddy circulation in the posterior lobe of the mitral valve was significantly positively correlated with the E (P0.05). There was a significant negative correlation between the anterior lobe of the atrial systole and E/e' (P0.05), and the positive correlation with E'(1) (P0.05), and the atrial contraction. There was a significant positive correlation between E'(s), E' (1) and E/e'(P0.05). There was a significant positive correlation between the eddy circulation and A (P0.05) after the atrial systole (P0.05), and a significant negative correlation with E' (s). Conclusion 1, a Ganau classification method was used to classify the normal values of American and European populations and Chinese people, respectively. The results of the configuration analysis were different.2. According to the normal values of the Chinese people, the analysis of the hypertension configuration could be more sensitive to the change of the energy loss in the left indoor.3. The energy loss of the patients with primary hypertension and the normal contrast of the atrial systole increased, the volume of eddy circulation increased, and the energy loss and eddy current change were related to the diastolic function.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R544.1

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