【摘要】：背景:升主動(dòng)脈因解剖位置等原因其彈性功能評(píng)價(jià)的臨床應(yīng)用和普及一直受到制約。利用回顧性心電門(mén)控冠狀動(dòng)脈CT成像可直接評(píng)估升主動(dòng)脈彈性,且無(wú)需增加造影劑用量、輻射劑量和醫(yī)療成本。升主動(dòng)脈直面心臟,是心臟射血的主要緩沖器官,也是外周臟器持續(xù)血流灌注的重要保證,緩沖功能的實(shí)現(xiàn)主要依賴(lài)于動(dòng)脈正常彈性。血壓升高是動(dòng)脈彈性減退重要的加速因子,但原發(fā)性高血壓尤其高血壓前期人群的升主動(dòng)脈彈性特征及其危險(xiǎn)因素,升主動(dòng)脈彈性與高血壓靶器官損害的關(guān)系及其預(yù)警價(jià)值尚不十分清楚。目的:通過(guò)分析基于冠狀動(dòng)脈CT回顧性心電門(mén)控成像的高血壓前期和高血壓人群升主動(dòng)脈彈性指標(biāo)和臨床資料,并與理想血壓人群對(duì)照,在第一部分探討高血壓前期和原發(fā)性高血壓人群的升主動(dòng)脈形態(tài)學(xué)和彈性功能特征、與其它臨床指標(biāo)相關(guān)性及其獨(dú)立危險(xiǎn)因素;在第二部分探討升主動(dòng)脈彈性指標(biāo)與心、頸動(dòng)脈、腎靶器官損害的相關(guān)性、敏感指標(biāo)及其預(yù)警價(jià)值,并與脈搏傳導(dǎo)速度(PWV)比較。為臨床早期、準(zhǔn)確評(píng)估高血壓前期和高血壓人群升主動(dòng)脈彈性功能提供一種新方法的同時(shí),為早期預(yù)防、診治及預(yù)后估測(cè)高血壓及其靶器官損害提供有價(jià)值的理論依據(jù)。材料與方法:接受冠狀動(dòng)脈CT成像檢查的健康體檢或臨床懷疑冠心病所有患者。共398例患者(理想血壓組85人,高血壓前期組121人和原發(fā)性高血壓組192人)納入研究,男209例,女189例,年齡23~84歲,平均(53.1±11.7)歲。研究對(duì)象于CT檢查前一周內(nèi)收集臨床基本資料,行實(shí)驗(yàn)室和特殊檢查。均采用二代雙源CT行回顧性冠狀動(dòng)脈CT成像檢查,將原始數(shù)據(jù)每間隔5%RR間期進(jìn)行全時(shí)相自動(dòng)離線重建,共得到5%、10%、15%…100%等20個(gè)時(shí)相數(shù)據(jù)。分別測(cè)得升主動(dòng)脈20個(gè)相位感興趣層面(左冠狀動(dòng)脈主干發(fā)出水平上方25mm)管腔內(nèi)徑及截面積。最后確定感興趣層面的最大面積和直徑、最小面積和直徑。采用三個(gè)較常見(jiàn)的指標(biāo)評(píng)價(jià)升主動(dòng)脈彈性特性,包括可擴(kuò)張度(AD)、動(dòng)脈順應(yīng)性(AC)、動(dòng)脈僵硬度(ASI)。結(jié)果第一部分1.理想血壓、高血壓前期和原發(fā)性高血壓三組間升主動(dòng)脈形態(tài)學(xué)和彈性功能比較三組中,標(biāo)化舒張期最小升主動(dòng)脈直徑(F=3.53,P0.05)和截面積(F=9.10,P0.001)逐步增大;進(jìn)一步兩兩比較中,高血壓前期和理想血壓組間的標(biāo)化舒張期最小直徑和截面積無(wú)差異;高血壓前期和高血壓組標(biāo)化截面積有顯著統(tǒng)計(jì)學(xué)差異(P0.01),而最小直徑無(wú)差異。三組中,AD(F=47.46,P0.001)和AC(F=34.51,P0.001)逐步減退,ASI(F=10.05,P0.001)逐步增加;進(jìn)一步兩兩比較中,AD和AC指標(biāo)在任意兩組間差異均極顯著(P0.001),而高血壓前期和理想血壓組ASI無(wú)差異;原發(fā)高血壓組ASI明顯大于高血壓前期組(P0.01)。高血壓組ba PWV高于高血壓前期組(P0.05)。年齡和研究對(duì)象分類(lèi)(是否存在高血壓前期或高血壓)為AD減退的獨(dú)立預(yù)測(cè)因素。2.年齡與理想血壓、高血壓前期和原發(fā)性高血壓組的升主動(dòng)脈彈性指標(biāo)的關(guān)系年齡與各彈性指標(biāo)(AD、AC和ASI)相關(guān)關(guān)系顯著,總體相關(guān)性為r=-0.617,-0.539和0.643(P0.001)。除AC外,理想血壓組、高血壓前期組和高血壓組AD和ASI與年齡的相關(guān)系數(shù)逐漸減低。除高血壓組AD指標(biāo)外(三次相關(guān)),曲線擬合顯示年齡與各組AD、AC和ASI指標(biāo)等以復(fù)合模型(Compound)最佳。3.理想血壓、高血壓前期和原發(fā)性高血壓組升主動(dòng)脈彈性減退的危險(xiǎn)因素以AD為因變量,以與彈性指標(biāo)有關(guān)的影響因素為自變量進(jìn)行多元逐步回歸分析,結(jié)果顯示,年齡和吸煙是理想血壓組升主動(dòng)脈AD指標(biāo)降低的獨(dú)立影響因子;年齡和收縮壓是高血壓前期組的獨(dú)立影響因子;年齡、24小時(shí)平均舒張壓和脈壓是原發(fā)性高血壓組的獨(dú)立影響因子。4.原發(fā)性高血壓患者不同高血壓病程間的彈性指標(biāo)和ba PWV比較高血壓病程5年,5~10年和10年三組間和任意兩組間ba PWV無(wú)差異。三組AD(P0.001)和AC(P0.001)逐步減退,ASI(P0.05)逐步增加。進(jìn)一步兩兩比較中,除AC在5年組和5~10年組,ASI在5~10年組和10年組無(wú)差異外,AD、AC和ASI指標(biāo)在任意兩組間均具有統(tǒng)計(jì)學(xué)差異(P0.05)。第二部分1.靶器官損害不同程度間升主動(dòng)脈形態(tài)、功能學(xué)及ba PWV比較隨著靶器官損害嚴(yán)重程度的增加(損害個(gè)數(shù),0、1、2、3),AD(F=40.74,P0.001)、AC(F=27.0,P0.001)、ASI(F=28.0,P0.001)、標(biāo)化舒張期最小直徑(F=2.89,P0.05)、標(biāo)化舒張期最小面積(F=4.95,P0.01)和ba PWV(F=5.24,P0.01)具有統(tǒng)計(jì)學(xué)差異。兩兩比較中,靶器官損害0和靶器官損害1兩組間的AD、AC和ASI指標(biāo)具有顯著性差異(P0.01);靶器官損害1和靶器官損害2兩組間的AD和AC彈性指標(biāo)具有顯著性差異(P0.01),而ASI無(wú)顯著性差異;靶器官損害2和靶器官損害3兩組間的ASI彈性指標(biāo)具有顯著性差異(P0.01),而AD和AC無(wú)顯著性差異。標(biāo)化舒張期最小直徑、最小面積在靶器官損害0和靶器官損害1,靶器官損害1和靶器官損害2,靶器官損害2和靶器官損害3間均無(wú)統(tǒng)計(jì)學(xué)差異。ba PWV在靶器官損害0和靶器官損害1組間具有顯著性差異(P0.01),而在靶器官損害1和靶器官損害2,靶器官損害2和靶器官損害3組間均無(wú)統(tǒng)計(jì)學(xué)差異。2.高血壓靶器官損害的獨(dú)立危險(xiǎn)因素探討以原發(fā)性高血壓是否伴靶器官損害為因變量,以已知危險(xiǎn)因素分別和ba PWV、AD、AC及ASI指標(biāo)為協(xié)變量進(jìn)行多因素Logistic逐步回歸分析,分別顯示ba PWV及年齡、AD、AC及年齡和ASI為靶器官損害的危險(xiǎn)因素。再以原發(fā)性高血壓是否并發(fā)靶器官損害為因變量,以有統(tǒng)計(jì)學(xué)意義的年齡、ba PWV、AD、AC和ASI為協(xié)變量進(jìn)行Logistic逐步回歸分析,顯示僅AD指標(biāo)為靶器官損害的獨(dú)立危險(xiǎn)因素。3.高血壓三組(AD三分位)的靶器官損害的危險(xiǎn)度比較根據(jù)AD指標(biāo)三分位值將全部研究對(duì)象分為三組,隨著AD分位數(shù)的增加,靶器官損害有無(wú)及嚴(yán)重程度亦顯著增高(P0.001),中間分位組患靶器官損害的比數(shù)比(OR)是低分位組的7.2倍。高分位組患靶器官損害的OR是中間分位組的9.84倍。中間分位組患2個(gè)以上靶器官損害的OR是低分位組的4.15倍。高分位組患2個(gè)以上靶器官損害的OR是中間分位組的23.33倍。結(jié)論第一部分1.利用回顧性心電門(mén)控冠狀動(dòng)脈CT成像檢查,在不增加造影劑用量、輻射劑量和醫(yī)療成本的前提下,可獲得反映高血壓前期和原發(fā)性高血壓人群升主動(dòng)脈彈性功能減退的多個(gè)不同彈性指標(biāo)。2.高血壓前期人群升主動(dòng)脈彈性功能較理想血壓人群減退,但優(yōu)于原發(fā)性高血壓人群,且升主動(dòng)脈彈性功能減退早于形態(tài)學(xué)改變。3.在所有升主動(dòng)脈彈性指標(biāo)中,AD指標(biāo)反映高血壓前期和高血壓彈性功能減退的敏感性?xún)?yōu)于AC和ASI,AC和ASI指標(biāo)也具有較大價(jià)值,應(yīng)合理選擇、綜合分析三個(gè)彈性指標(biāo)變化能在一定程度上提高評(píng)估血壓升高對(duì)升主動(dòng)脈彈性功能破壞的客觀性和準(zhǔn)確性。4.年齡仍是影響理想血壓、高血壓前期和高血壓人群升主動(dòng)脈彈性的主要決定因素,除年齡外,吸煙、收縮壓水平和舒張壓及脈壓水平分別是影響理想血壓、高血壓前期和高血壓人群升主動(dòng)脈彈性功能減退的獨(dú)立危險(xiǎn)因素。除此之外,肥胖和血糖也是不可忽略的危險(xiǎn)因素。第二部分1.升主動(dòng)脈彈性功能是原發(fā)性高血壓患者亞臨床靶器官損害即左心室肥厚、頸動(dòng)脈內(nèi)-中膜增厚或斑塊和蛋白尿的獨(dú)立影響指標(biāo),且獨(dú)立于傳統(tǒng)ba PWV、升主動(dòng)脈形態(tài)學(xué)和常規(guī)靶器官危險(xiǎn)因素。2.在所有升主動(dòng)脈彈性指標(biāo)中,AD反映靶器官損害的敏感度最優(yōu),檢測(cè)AD指標(biāo)對(duì)早期預(yù)防高血壓亞臨床靶器官損害具有重要臨床價(jià)值。此外,AC和ASI在反映靶器官損害情況上也具有較大價(jià)值,應(yīng)合理選擇、綜合分析三個(gè)彈性指標(biāo)變化有利于更加客觀、準(zhǔn)確和全面預(yù)測(cè)靶器官損害情況。3.在AD三分位中,高分位組較低一水平分位組具有更高的靶器官損害風(fēng)險(xiǎn)和嚴(yán)重程度,而且隨著AD分位的增加,靶器官損害趨勢(shì)更加明顯�？傊�,早期檢測(cè)高血壓甚至高血壓前期人群大動(dòng)脈彈性指標(biāo)尤其AD變化及其危險(xiǎn)因素,有助于識(shí)別危險(xiǎn)性較高的個(gè)體,進(jìn)一步制定積極有效的預(yù)防和治療措施,對(duì)延緩和控制高血壓、高血壓靶器官損害及心腦血管事件的發(fā)生、發(fā)展具有重要的臨床意義。
[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.
【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類(lèi)號(hào)】：R544.1;R543

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