脈壓/平均動(dòng)脈壓比率與冠狀動(dòng)脈病變程度的相關(guān)性研究

脈壓/平均動(dòng)脈壓比率與冠狀動(dòng)脈病變程度的相關(guān)性研究

汪莉汪海婭

目的探討脈壓/平均動(dòng)脈壓比率(PP/MAP)與冠狀動(dòng)脈病變程度的相關(guān)性，并探討其在冠心病(CAD)診斷與治療中的臨床意義。方法選自2014年10月至2015年12月于我院心內(nèi)科住院行冠狀動(dòng)脈造影術(shù)的病人90例,根據(jù)造影結(jié)果分為CAD組(56例)及對(duì)照組(34例)。術(shù)前分別測(cè)定病人的身高、體質(zhì)量、甘油三酯(TG)、膽固醇(TC)、高密度脂蛋白膽固醇(HDL-C)、低密度脂蛋白膽固醇(LDL-C)、空腹血糖(FBG)、肌酐(Scr)、尿酸(UA)等指標(biāo),術(shù)中測(cè)量主動(dòng)脈血壓值,計(jì)算身體質(zhì)量指數(shù)(BMI)、脈壓(PP)、平均動(dòng)脈壓(MAP),通過Gensini評(píng)分系統(tǒng)對(duì)病人冠狀動(dòng)脈病變嚴(yán)重程度進(jìn)行評(píng)分。結(jié)果2組病人的BMI、LDL-C、PP、PP/MAP差異具有統(tǒng)計(jì)學(xué)意義,CAD組明顯高于對(duì)照組(P<0.01)。PP/MAP與冠狀動(dòng)脈造影Gensini評(píng)分呈正相關(guān)(r=0.371,P<0.01),校正LDL-C、BMI后,兩者仍呈明顯的正相關(guān)(r=0.361,P<0.01)。Logistic回歸分析顯示，BMI、LDL-C、PP/MAP是CAD的獨(dú)立相關(guān)因素。結(jié)論P(yáng)P/MAP與CAD明顯相關(guān),PP/MAP可能是評(píng)價(jià)冠狀動(dòng)脈病變程度的指標(biāo)之一。

冠狀動(dòng)脈; Gensini評(píng)分; 脈壓/平均動(dòng)脈壓比率

隨著社會(huì)經(jīng)濟(jì)的發(fā)展,冠心病(coronary artery disease,CAD)已成為當(dāng)今世界危害人類身體健康的主要?dú)⑹种?。近年?病人的生存率雖然有了大幅的提高,但是CAD發(fā)病率卻在增加,對(duì)于CAD的預(yù)防和康復(fù),現(xiàn)在仍處于起步階段。越來越多的臨床研究表明,脈壓(pulse pressure,PP)升高是導(dǎo)致心血管疾病的獨(dú)立危險(xiǎn)因素。但是,單純PP大小無法判斷動(dòng)脈硬化的程度和心腦血管疾病危險(xiǎn)性的大小,必須和收縮壓、舒張壓等其他危險(xiǎn)因素一起分析[1]。脈壓/平均動(dòng)脈壓比率(pulse pressure/mean artery pressure,PP/MAP) 同時(shí)采用了脈壓差、收縮壓、舒張壓進(jìn)行計(jì)算,有一定的理論依據(jù),能相對(duì)全面地反映3種血壓因素評(píng)估動(dòng)脈硬化的程度[2]。Gensini評(píng)分對(duì)于冠狀動(dòng)脈嚴(yán)重程度也是一項(xiàng)非常有意義的的評(píng)估方法[3]。本研究通過對(duì)病人進(jìn)行冠狀動(dòng)脈造影及Gensini評(píng)分,比較分析CAD病人PP/MAP的變化,探討PP/MAP對(duì)CAD的臨床意義及其與冠狀動(dòng)脈病變程度的相關(guān)性。

1 對(duì)象與方法

1.1 對(duì)象 選擇2014年10月至2015年12月于上海交通大學(xué)醫(yī)學(xué)院附屬仁濟(jì)醫(yī)院心內(nèi)科住院并行冠脈造影術(shù)的病人90例,其中男63例，女27例。根據(jù)冠脈造影結(jié)果分為2組,CAD組56例,平均年齡(66.5±8.9)歲,對(duì)照組34例,平均年齡(67.2±5.2)歲。所有入選對(duì)象均有完整的心電圖資料并疑診CAD,且均為初次行冠脈造影術(shù)檢查。排除近3月內(nèi)有重大手術(shù)、外傷、出血史、存在抗凝及抗血小板禁忌證、出血性疾病、造影劑過敏、急性代謝紊亂、甲狀腺功能亢進(jìn)、慢性感染、自身免疫性疾病、惡性腫瘤、心功能衰竭及既往有明確心肌梗死病史的病人。

1.2 方法

1.2.1 一般臨床資料及各項(xiàng)指標(biāo)的測(cè)定:檢測(cè)前記錄所有病人的臨床基線資料,包括性別、年齡、吸煙史、飲酒史、糖尿病、血脂異常等資料,并計(jì)算體質(zhì)量指數(shù)(BMI)。吸煙者定義為每日吸煙≥1支、時(shí)間≥半年者。飲酒者定義為每周至少飲酒1次,連續(xù)半年以上。抽取10～12 h空腹靜脈血6 ml以測(cè)定血糖、甘油三酯(TG)、總膽固醇(TC)、高密度脂蛋白膽固醇(HDL-C)、低密度脂蛋白膽固醇(LDL-C)、空腹血糖(FBG)、肌酐(Scr)、尿酸(UA)指標(biāo)。

1.2.2 血壓的測(cè)量和計(jì)算:所有病人在橈動(dòng)脈穿刺成功置入橈動(dòng)脈鞘管后,術(shù)中進(jìn)行有創(chuàng)大動(dòng)脈血壓測(cè)量,待Judkins造影導(dǎo)管進(jìn)入主動(dòng)脈根部,電子血壓監(jiān)測(cè)曲線穩(wěn)定后記錄主動(dòng)脈血壓值。讀取收縮壓(systolic blood pressure,SBP)、舒張壓(diastolic blood pressure,DBP),并計(jì)算PP(PP=SBP-DBP)、PP/MAP[PP/MAP=3×PP/(2×SBP+DBP)]。

1.2.3 冠狀動(dòng)脈造影方法及Gensini評(píng)分判斷標(biāo)準(zhǔn):全部病人在住院期間均行冠狀動(dòng)脈造影檢查,由心內(nèi)科兩名經(jīng)驗(yàn)豐富的冠脈介入醫(yī)師操作,冠狀動(dòng)脈造影采用Judkins法穿刺右橈動(dòng)脈。CAD病人定義為冠狀動(dòng)脈造影顯示左前降支、左回旋支、右冠狀動(dòng)脈及其主要分支中至少有1支血管管腔狹窄程度≥50%。對(duì)照組病人定義為上述血管管腔狹窄程度均<50%。冠狀動(dòng)脈病變程度評(píng)定:采用Gensini積分系統(tǒng)[4]對(duì)狹窄程度進(jìn)行定量評(píng)分。冠狀動(dòng)脈管腔狹窄≤25% 記1分,26%～50% 記2分,51%～75% 記4分,76%～90%記8分,91%～99%記16分,100%記32分,每例病人冠狀動(dòng)脈狹窄Gensini積分為各分支積分之和。

2 結(jié)果

2.1 一般指標(biāo)比較 與對(duì)照組相比,CAD組病人PP、PP/MAP、BMI、LDL-C水平明顯升高,差異有統(tǒng)計(jì)學(xué)意義(P<0.01),而吸煙、飲酒史、糖尿病及性別比例差異無統(tǒng)計(jì)學(xué)意義,此外年齡、血糖、SBP、DBP、TC、TG、HDL-C、Scr及UA水平之間差異亦無統(tǒng)計(jì)學(xué)意義。見表1。

表1 CAD組和對(duì)照組之間危險(xiǎn)因素的比較()

注:與對(duì)照組比較,**P<0.01

2.2 冠狀動(dòng)脈病變程度與PP/MAP的相關(guān)性分析 Spearman相關(guān)分析顯示,Gensini積分與PP/MAP呈明顯正相關(guān),相關(guān)系數(shù)(r)為0.371(P<0.01)。校正LDL-C及BMI,進(jìn)一步采用偏相關(guān)分析Gensini積分與PP/MAP的相關(guān)性,結(jié)果顯示二者仍有明顯相關(guān)性,r=0.361(P<0.01)。

2.3 CAD危險(xiǎn)因素的Logistic回歸分析 多因素Logistic回歸分析顯示PP/MAP是冠心病最顯著的獨(dú)立相關(guān)危險(xiǎn)因素(P<0.01),其次分別為BMI、LDL-C(P<0.05)。見表2。

表2 CAD影響因素的Logistic回歸分析

3 討論

PP是反映外周血管阻力和大動(dòng)脈彈性的重要指標(biāo),臨床上正常PP為20～60 mmHg(2.67～8 KPa)。很多研究表明,SBP升高及PP增大是反映大動(dòng)脈彈性降低的一個(gè)重要標(biāo)志[5-6]。通常情況下,大動(dòng)脈可以緩沖左心室射血產(chǎn)生的流動(dòng)波動(dòng)和壓力波動(dòng),其動(dòng)脈擴(kuò)張性降低的主要表現(xiàn)為動(dòng)脈僵硬性增加,因?yàn)閴毫Σ▌?dòng)的發(fā)生部位距升主動(dòng)脈較近,隨主動(dòng)脈瓣關(guān)閉到達(dá)主動(dòng)脈根部,壓力波動(dòng)增加,主動(dòng)脈和心室收縮期壓力也隨之增加,降低了舒張期壓力,因此大動(dòng)脈緩沖功能的降低會(huì)導(dǎo)致SBP水平升高,DBP水平降低,脈壓差增大,這是大動(dòng)脈彈性降低、僵硬度增加的一個(gè)信號(hào)。另一方面,PP增寬,導(dǎo)致動(dòng)脈血管的更大牽拉,加快彈力纖維的退行性變和斷裂,血管壁彈性成分容易疲勞和斷裂，易發(fā)展為動(dòng)脈瘤并最終導(dǎo)致破裂, 導(dǎo)致內(nèi)膜損傷,加劇了動(dòng)脈硬化程度及血栓事件的發(fā)生[7]。

越來越多的流行病學(xué)調(diào)查及臨床研究證實(shí)，PP不僅是評(píng)價(jià)動(dòng)脈硬化的指標(biāo),而且與心血管事件的發(fā)生密切相關(guān),其重要性已經(jīng)超過SBP和DBP,被認(rèn)為是急性心血管事件的獨(dú)立危險(xiǎn)因子。美國Framingham心臟研究中心的一項(xiàng)隨訪20年結(jié)果顯示,年齡50～79歲的中老年人,SBP≥120 mmHg者,CAD的風(fēng)險(xiǎn)隨著DBP的降低而升高,提示PP是一重要的危險(xiǎn)因子[8]。Mitchell等[9]研究表明PP升高是再發(fā)急性心肌梗死的有效預(yù)測(cè)因子。盡管如此,PP畢竟是一個(gè)相對(duì)值,同一個(gè)PP可以有多個(gè)SBP和DBP的結(jié)合,僅以一個(gè)PP來評(píng)判不同個(gè)體間的CAD危險(xiǎn)性仍存在一定的局限性。因此有人提出PP/MAP的概念,即同時(shí)采用了PP、SBP、DBP進(jìn)行計(jì)算,有一定的理論依據(jù),能夠相對(duì)全面地反映3種血壓因素評(píng)估動(dòng)脈硬化的程度,相同和不同個(gè)體之間均有可比性。根據(jù)彈性腔理論,在理想狀態(tài)下,彈性腔的壓強(qiáng)和體積呈拋物線關(guān)系。當(dāng)血壓和固定成分、波動(dòng)成分之間的關(guān)系為線性關(guān)系時(shí),可推導(dǎo)出動(dòng)脈順應(yīng)性和PP/MAP 存在著函數(shù)關(guān)系,PP/MAP 越大,動(dòng)脈的順應(yīng)性越小,反之就越大。

本研究將入選的90例病人臨床狀態(tài)下測(cè)定的各個(gè)參數(shù)計(jì)算出來的PP/MAP 值在CAD組和對(duì)照組進(jìn)行比較,發(fā)現(xiàn)2組差異存在統(tǒng)計(jì)學(xué)意義,PP/MAP與PP有較強(qiáng)的一致性。通過進(jìn)一步探討PP/MAP與冠狀動(dòng)脈病變Gensini積分的關(guān)系,發(fā)現(xiàn)兩者相關(guān)系數(shù)為0.371,有統(tǒng)計(jì)學(xué)意義,校正LDL-C及BMI的影響后,兩者仍呈正相關(guān)(r=0.361),初步證實(shí)了PP/MAP作為無量綱值,對(duì)CAD的預(yù)測(cè)價(jià)值以及與冠狀動(dòng)脈病變程度的相關(guān)性。將病人的年齡、年齡、糖尿病、吸煙、飲酒、BMI、LDL-C、PP/MAP作為自變量,通過對(duì)冠脈造影診斷是否為CAD進(jìn)行二分類多因素Logistics回歸分析,結(jié)果顯示PP/MAP是CAD最顯著的獨(dú)立相關(guān)危險(xiǎn)因素,其顯著性超過BMI、LDL-C,進(jìn)一步表明PP/MAP的增大可能促進(jìn)了冠脈血管粥樣硬化的形成,通過PP/MAP評(píng)價(jià)冠狀動(dòng)脈病變程度有一定臨床指導(dǎo)意義。

綜上所述,PP/MAP是判斷CAD血管病變嚴(yán)重程度的重要指標(biāo),研究CAD危險(xiǎn)人群PP/MAP相關(guān)規(guī)律對(duì)心血管病的二級(jí)預(yù)防,降低心血管病的致殘率、病死率有著積極的作用。本研究尚存在不足,調(diào)查的對(duì)象僅限于60～75歲的老年人群,樣本總數(shù)有限,研究結(jié)果適用范圍相對(duì)較窄,未來需更進(jìn)一步大樣本的研究。

[1] Mosley WJ 2nd, Greenland P, Garside DB, et al. Predictive utility of pulse pressure and other blood pressure measures for cardiovascular outcomes[J]. Hypertension, 2007, 49(6):1256-1264.

[2] Robles NR, Martín-Agueda B, López-Muoz F, et al. Effectiveness and safety of eprosartan on pulse pressure for the treatment of hypertensive patients[J]. Int J Clin Pract, 2005,59(4):478-484.

[3] Acet H, ErtaF, Bilik MZ, et al. The relationship of TIMI risk index with SYNTAX and Gensini risk scores in predicting the extent and severity of coronary artery disease in patients with STEMI undergoing primary percutaneous coronary intervention[J]. Ther Adv Cardiovasc Dis, 2015,9(5):257-266.

[4] Barthel P, Schneider R. Bauer A, et al. Risk stratification after acute myocardial infarction by heart rate turbulence[J]. Circulation, 2003, 108(10): 1221-1226.

[5] Gurunathrao PS, Manjunatha A, Kanti DK. Evaluation of arterial stiffness in elderly with prehypertension[J]. Indian J Physiol Pharmacol, 2015,59(1):16-22.

[6] Carlsen RK, Peters CD, Khatir DS, et al. Estimated aortic blood pressure based on radial artery tonometry underestimates directly measured aortic blood pressure in patients with advancing chronic kidney disease staging and increasing arterial stiffness[J]. Kidney Int, 2016,90(4):869-877.

[7] 劉振兵, 楊文霞. 脈壓與頸動(dòng)脈硬化關(guān)系及對(duì)患者預(yù)后的影響[J]. 內(nèi)蒙古醫(yī)學(xué)雜志, 2011, 43(7):812-814.

[8] Franklin SS, Larson MG, Khan SA, et al. Does the relation of blood pressure to coronary heart disease risk change with aging? The Framingham Heart Study[J]. Circulation, 2001,103(9):1245-1249.

[9] Mitchell GF, Moyé LA, Braunwald E, et al. Sphygmomanometrically determined pulse pressure is a powerful independent predictor of recurrent events after myocardial infarction in patients with impaired left ventricular function. SAVE investigators. Survival and Ventricular Enlargement[J]. Circulation, 1997,96(12):4254-4260.

CorrelationstudybetweenPP/MAPratioandcoronarystenosisdegree

WANGLi,WANGHai-ya.

DepartmentofGeriatrics,RenJiHospitalAffiliatedtoMedicalCollegeofShanghaiJiaoTongUniversity,Shanghai200001,China

ObjectiveTo evaluated the clinical significance of PP/MAP ratio in coronary artery disease (CAD), and to investigate the correlation between PP/MAP ratio and coronary stenosis degree.MethodsA total of 90 patients undergoing selective coronary angiography, they were enrolled in this prospective study from October 2014 to December 2015 in our Hospital. According to the results of the angiography, they were divided into two groups, the CAD group (n=56) and the control group (n=44). The body height, weight, total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), fasting blood glucose (FBG), serum creatinine (Scr), uric acid (UA) were detected at the beginning of the study. Aortic blood pressure was measured during coronary angiography. The levels of body mass index (BMI), pulse pressure (PP) and mean aortic pressure (MAP) were calculated, and the severity of coronary atherosclerosis was evaluated using the Gensini score.ResultsBMI, LDL-C, PP and PP/MAP ratio in the CAD group were significantly higher than those in the control group (P<0.01). The Gensini score was positively associated with PP/MPA ratio(r=0.371,P<0.01), even after adjusting for confounding factors such as LDL-C and BMI (r=0.361,P<0.01). Logistic regression analysis showed that BMI, LDL-C and PP/MAP were prominent predictors of CAD.ConclusionsThe level of PP/MAP is significantly correlated with CAD, It may be one of the parameters to evaluate the severity of CAD.

coronary artery; Gensini score; PP/MAP

200001 上海市，上海交通大學(xué)醫(yī)學(xué)院附屬仁濟(jì)醫(yī)院老年病科

汪海婭，Email:why7848@163.com

R 735.3

A

10.3969/j.issn.1003-9198.2017.12.007

2017-03-14)