【摘要】：心力衰竭(HF)是一種慢性進(jìn)展性疾病,一旦起病,即使沒(méi)有新的心肌損傷,自身仍不斷的在進(jìn)展,預(yù)后差。雖然藥物及器件治療不斷改進(jìn)的今天,但仍然難以使其逆轉(zhuǎn)。這樣,其早期預(yù)防、早期治療就顯得尤為重要。2001年美國(guó)心臟病學(xué)會(huì)(ACC)/美國(guó)心臟病協(xié)會(huì)(AHA)根據(jù)HF病理生理的發(fā)生發(fā)展過(guò)程將其分為四期,強(qiáng)調(diào)心衰的不可逆進(jìn)展過(guò)程及早期預(yù)防、早期治療的重要性。預(yù)防從A期(前心衰階段)的高危險(xiǎn)因素疾病進(jìn)展到B期,即出現(xiàn)心臟結(jié)構(gòu)的改變;預(yù)防B期進(jìn)展到C期,即出現(xiàn)心衰臨床癥狀。而A、B期屬于亞臨床心衰期,主要是高血壓病與冠心病,這些疾病對(duì)心功能的損傷直至出現(xiàn)臨床心衰癥狀的過(guò)程比較漫長(zhǎng),臨床上也缺乏能夠用于心衰進(jìn)展過(guò)程中心功能評(píng)價(jià)的客觀指標(biāo)。本研究通過(guò)觀察AHA/ACC心衰分期標(biāo)準(zhǔn)各期心衰患者的無(wú)創(chuàng)血流動(dòng)力學(xué)指標(biāo)及常規(guī)用的評(píng)估心功能指標(biāo)B型利鈉肽(BNP)、左心室射血分?jǐn)?shù)(LVEF)的變化規(guī)律,探討無(wú)創(chuàng)血流動(dòng)力學(xué)相關(guān)指標(biāo)在慢性心力衰竭(CHF)發(fā)生發(fā)展過(guò)程中的臨床實(shí)用意義,其變化趨勢(shì)是否與心衰不同發(fā)展階段具有一致性,并篩選出適用于心衰早期進(jìn)展過(guò)程中評(píng)估心功能的客觀指標(biāo),為早期對(duì)病情的評(píng)估以及防治措施提供科學(xué)依據(jù)。選取2014.3—2016.10空軍總醫(yī)院心臟中心因慢性心力衰竭及其高危險(xiǎn)因素疾病住院的患者共119例,其中男性76例,女性43例,年齡64±14.9歲。每位患者根據(jù)ACC/AHA心衰進(jìn)展分期標(biāo)準(zhǔn)進(jìn)行分期,然后將A期(前心衰階段)歸為A組,B期(前臨床心衰階段)為B組;C期(臨床心衰階段)為C組。另選同期我院39例健康體檢者作為正常對(duì)照組(記為O組)。再將A組患者根據(jù)不同的危險(xiǎn)因素疾病分為冠心病亞組(記為A1組)和高血壓亞組(記為A2組)。收集患者臨床資料及相關(guān)檢查,行無(wú)創(chuàng)血流動(dòng)力學(xué)檢查,記錄無(wú)創(chuàng)血流動(dòng)力學(xué)指標(biāo),包括心搏出量(SV)、心輸出量(CO)、心臟指數(shù)(CI)、C波波幅、心縮力指數(shù)(HI)、收縮功能指數(shù)(Q-B/B-X)、肺動(dòng)脈楔壓(PCWP)、左心室舒張末壓(LVEDP)、主動(dòng)脈順應(yīng)性(AC)、總外周阻力(TPR)。并記錄BNP血清水平、LVEF值做參考。比較分析各組無(wú)創(chuàng)血流動(dòng)力學(xué)相關(guān)指標(biāo)、BNP、LVEF的變化,通過(guò)統(tǒng)計(jì)學(xué)分析這些指標(biāo)變化趨勢(shì)與心衰不同發(fā)展階段的關(guān)系,并分別繪制出早期階段的受試者工作特征曲線(ROC曲線),篩選出適用于心衰早期進(jìn)展過(guò)程中評(píng)估心功能的客觀指標(biāo)。無(wú)創(chuàng)血流動(dòng)力學(xué)指標(biāo)SV、CO、CI、C波波幅、HI、Q-B/B-X、PCWP、LVEDP、AC、TPR、BNP、LVEF均與心衰不同發(fā)展階段具有顯著的線性相關(guān)性(P全部0.05);經(jīng)兩兩比較C、CI、HI在心衰早期階段顯著降低,Q-B/B-X顯著升高(P0.05),而無(wú)創(chuàng)血流動(dòng)力學(xué)其余指標(biāo)、BNP、LVEF值在心衰早期階段變化不顯著(P0.05);接受受試者工作特征曲線分析證明HI、Q-B/B-X敏感性、特異性均較其他指標(biāo)高,曲線下面積均優(yōu)于其他指標(biāo)。無(wú)創(chuàng)血流動(dòng)力學(xué)相關(guān)指標(biāo)的變化與心衰不同發(fā)展階段具有一致性,慢性心力衰竭患者在A期即高危險(xiǎn)因素期出現(xiàn)血流動(dòng)力學(xué)的變化,心功能就受到一定程度的影響。無(wú)創(chuàng)血流動(dòng)力學(xué)檢測(cè)指標(biāo)HI、Q-B/B-X可為臨床評(píng)估心衰早期心功能提供客觀參考指標(biāo)。
[Abstract]:Heart failure (HF) is a chronic progressive disease that is progressing and has a poor prognosis without new myocardial damage. Drug and device therapies continue to improve today, but it is still difficult to reverse. Thus, early prevention and treatment are particularly important. The American College of Cardiology (ACC)/2001 The American Heart Association (AHA) divides HF pathophysiology into four stages, emphasizing the irreversible progression of HF and the importance of early prevention and treatment. Phases A and B belong to subclinical heart failure, mainly hypertension and coronary heart disease. These diseases have a long process of impairing cardiac function until clinical heart failure symptoms appear. There is also a lack of objective indicators that can be used to evaluate cardiac function in the progression of heart failure. Non-invasive hemodynamic parameters and routine cardiac function parameters B-type natriuretic peptide (BNP) and left ventricular ejection fraction (LVEF) in patients with chronic heart failure (CHF) were evaluated. The clinical significance of non-invasive hemodynamic parameters in the occurrence and development of chronic heart failure (CHF) was discussed. In order to provide scientific basis for early evaluation and prevention of heart failure, 119 patients with chronic heart failure and its high risk factors were selected from the heart center of Air Force General Hospital from March 2014 to October 2016. Each patient was divided into group A (pre-HF stage), group B (pre-clinical HF stage) and group C (clinical HF stage). Another 39 healthy persons were selected as normal control group (group O) at the same time. Different risk factors were divided into coronary artery disease subgroup (group A1) and hypertension subgroup (group A2). Clinical data and related examinations were collected, and noninvasive hemodynamic examinations were performed. Noninvasive hemodynamic parameters including cardiac output (SV), cardiac output (CO), cardiac index (CI), C wave amplitude, cardiac contractility index (HI), systolic function were recorded. Index (Q-B/B-X), pulmonary wedge pressure (PCWP), left ventricular end-diastolic pressure (LVEDP), aortic compliance (AC), total peripheral resistance (TPR). Serum levels of BNP and LVEF were recorded for reference. Noninvasive hemodynamic indexes, BNP and LVEF were compared and analyzed in each group. Noninvasive hemodynamic parameters, such as SV, CO, CI, C wave amplitude, HI, Q-B/B-X, PCWP, LVEDP, AC, TPR, BNP, LVEF, had significant linear correlation with different stages of heart failure. (P 0.05); C, CI, HI in the early stage of heart failure significantly decreased, Q-B/B-X significantly increased (P 0.05), non-invasive hemodynamic other indicators, BNP, LVEF values in the early stage of heart failure did not change significantly (P 0.05); Subject work characteristic curve analysis showed that HI, Q-B/B-X sensitivity, specificity were higher than other indicators, below the curve. The changes of noninvasive hemodynamic indexes were consistent with the different stages of heart failure. The changes of hemodynamics in patients with chronic heart failure in stage A, i.e. high risk factors, affected cardiac function to some extent. Noninvasive hemodynamic indexes HI, Q-B/B-X can be used to evaluate the heart in clinical practice. Objective to provide an objective reference for cardiac function in early stage of decline.
【學(xué)位授予單位】：河北北方學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.6

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