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[摘要] 目的 探讨老年高血压病患者颈动脉粥样硬化、肱动脉内皮依赖性血管舒张功能与脑梗死发生的关系。方法 100例患者分为高血压组(EH组)、脑梗死组(CI组)各50例,并与正常对照组(对照组)50例进行比较,分析血压、血脂、颈动脉内膜-中层厚度(IMT)、肱动脉内皮依赖性血管舒张(FMD)功能等变化。结果 CI组表现为老年性高血压,舒张压降低明显,脉压增大;空腹血糖较对照组升高明显,但与EH组尚无显著差异;TG显著升高;CI组IMT显著增厚,斑块数及发生率显著增高,FMD下降明显。三组IMT与FMD均呈显著负相关,FMD与年龄呈负相关。结论 CI组颈动脉粥样硬化程度显著增加,推测脉压增大、高TG 是导致CI组患者斑块数增加引发脑梗死的直接重要危险因素。颈动脉粥样硬化、肱动脉FMD下降与脑梗死发生有密切相关性,IMT与FMD检查对预测脑梗死的发生并且对临床预防和治疗脑梗死提供重要依据。
[关键词] 颈动脉粥样硬化;内皮依赖性血管舒张;内膜-中层厚度;脑梗死
[中图分类号] R541.4 [文献标识码] A[文章编号] 1673-9701(2010)10-08-03
Association Study on Ultrasonic Measurement of Carotid Atherosclerosis and Vasodilation of Brachial Artery in Patients with Cerebral Infarction
XIA ManWU Hong
The First Chinese Medicine Hospital of Yiyang in Hunan Province,Yiyang 413002,China
[Abstract] Objective To investigate the correlation between carotid atherosclerosis,endothelium-dependent vasodilatation of brachial artery and cerebral infarction occurrence in senile hypertension patients. Methods 100 patients were divided into 50 cases of hypertension(EH group) and cerebral infarction(CI group),which compared with 50 Patients of control grou pse parately. They were analyzed on the aspects of change in blood pressure,plasma lipids,the intima-media thickness(IMT) of carotid artery and endothelium-dependent vasodilation function(FMD) of brachial artery. Results Of CI group,senile high blood pressure showed up,diastolic pressure reduced distinctly and fasting blood glucose was significantly higher than the control grou pp,but there is no significant difference when compared with EH group;TG was higher and IMT were thicker markedly;Plaque block number and incidence rate was higher evidently but FMD decreased obviously. Three groups of IMT were negatively correlated with FMD,which was also negatively correlated with age. Conclusion The degree of carotid atherosclerosis significantly increased in CI group,which suggested that the increased pulse pressure and high level of TG in blood were direct and important risk factors leading to increase plaque block number which caused cerebral infarction in CI group. Carotid atherosclerosis and decreased FMD of brachial artery are closely related to cerebral infarction. The examination of IMT and FMD provided the important evidence predicting the occurrence,prevention as well as treatment of cerebral infarction.
[Key words] Carotid atherosclerosis;Endothelium-dependent vasodilation function;IMT; Cerebral infarction
脑梗死(cerebral infarction,CI)是老年人常见的致残和死亡原因,颈动脉粥样硬化与CI密切相关,肱动脉内皮依赖性血管舒张(flow-mediated dilatation,FMD)功能是反映局部或周围动脉粥样硬化的发生、发展的公认无创性指标。本文观察并探讨超声检测老年高血压病患者颈动脉粥样硬化、肱动脉内皮依赖性血管舒张功能与脑梗死发生的关系,以期为临床提供诊断治疗依据。
1资料与方法
1.1观察对象
选择本院自2005年1月～2009年6月的住院患者共100例为观察对象,分为高血压组(Essential hyPertension,EH组)、脑梗死组(CI组)各50例,其中EH组男27例、女23例,平均年龄(61.5±6.4)岁;CI组男28例、女22例,平均年龄(60.3±6.2)岁;另选50例为健康对照组(对照组),来源同期完成了健康体检中心各项检查者,均无高血压、糖尿病、高血脂及心、肝、肾等疾病,男24例、女26例,平均年龄(59.8±8.6)岁。
1.2入选标准
高血压(EH)的诊断根据2003年ESH/ESC高血压指南标准,收缩压/舒张压≥140/90mmHg;脑梗死(CI)诊断均符合第四届全国脑血管病学术会议修订诊断标准,并经头颅CT和(或)MRI证实确诊为动脉粥样硬化性脑梗死。
1.3仪器与方法
血脂测定采用北京贝斯特公司SABA自动生化分析仪,全部受试者均于清晨空腹静脉取血,检测血浆总胆固醇(TC)、甘油三酯(TG)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)和载脂蛋白-B(APoB)。
颈动脉超声检测仪器为美国惠普HP5500型彩色多普勒超声仪,血管超宽频探头,频率7.5MHz,患者取仰卧位头略向后仰,偏向检查区对侧,充分暴露检查一侧的颈部,自颈动脉起始处纵横扫查,依次显示颈总动脉(CCA)、颈内动脉(ICA)、颈外动脉(ECA),注意观察内膜是否连续,有无增厚及斑块。
测量颈总动脉内膜-中层厚度(intima-media thickness of the carotid artery,IMT):受试者平卧休息10min以上,纵向探查颈总动脉,在同步心电图R波顶点停帧,观察颈总动脉分叉处近心侧1cm处的二维图像,后壁表现为由相对较低回声分隔的2条平行线,测平行线上缘间的垂直距离,每侧测试3个心动周期,计算两侧6次检测的平均值即为IMT。测量时注意避开粥样硬化斑块。颈动脉(CCA、ICA、ECA)血流阻力指数;血流阻力指数=(收缩期最快流速-舒张期最慢流速)/收缩期最快流速。动脉斑块标准:局部隆起、增厚,向管腔内突出,厚度>1.2mm。斑块数:指在相同范围内检测出的数量。
肱动脉内皮功能超声检测?参照Celermaijer等介绍的方法(1)进行,检查前患者在安静遮光的房间中平卧15min以上,在右肘窝上方2～5cm处超声显示肱动脉长轴图像然后冻结,测量静息时心室舒张末期肱动脉内径(D1),然后在同一部位以血压计袖带加压,压力设为原收缩压基础上加50 mmHg,加压5 min后放气,待45～75 s后再次检测舒张期肱动脉内径(D2)。加压放气后肱动脉内径增宽即血流介导的内皮依赖性血管扩张(FMD),FMD(%)=(D2-D1)/D1×100%。以FMD大小判断肱动脉内皮功能受损情况。
1.4统计学处理
计量资料以均数±标准差表示,均数差异性比较用方差分析F检验,两两比较经q检验;计数资料组间比较用χ2检验,组内两变量间关系用直线相关分析,P0.05),具有可比性。收缩压:对照组低于其他两组(P0.05)。舒张压:EH组高于对照组(P0.05),CI组显著低于EH组(P0.05)。空腹血糖:对照组低于EH组(P0.05)。
2.2血脂变化
表2 结果TC比较显示:EH组、CI组显著高于对照组(P0.05)。TG比较:CI组显著高于对照组(P0.05)。APoB比较:三组间无显著差异(P>0.05)。
2.3颈动脉超声变化
表3显示血流阻力指数:CCA、ICA、ECA各组间无差异(P>0.05)。IMT比较:对照组显著低于EH组、CI组(P0.05)。
斑块数比较:EH组、CI组显著高于对照组(P0.05),FMD与年龄呈负相关(r=-0.384,P 总之,脑梗死伴有较严重的外周血管重塑和血管内皮舒张功能障碍,并随增龄而加重,脉压增大及高TG血症是直接重要危险因素。高分辨超声检测的IMT和FMD与脑梗死显著相关,对预测脑梗死的发生并且对临床预防和治疗脑梗死提供重要依据[9-12]。
[参考文献]
[1] Celermajer DS, Sorensen KE, Gooch NM, et al. Non-invasive detection of endothelial dysfunction in child and adults at risk of atherosclerosis[J]. Lancet,1992,340(8828):1111-1115.
[2] 范晓红,王春. 动脉粥样硬化的发病情况及其影响因素的调查与相关分析[J]. 中华心血管病杂志,2006,34(2):174.
[3] Tsai WC, Li YH, Lin CC, et al. Effects of oxidative stress on endothe-lial function after a high-fat meal[J]. Clin Sci,2004,106(3):315-319.
[4] Holaj r,SPacil J, Petrasek J, et al. Intima-media thickness of the common carotid artery is the significant predictor of angiogra phically proven coronary artery disease[J]. Can J cardiol,2003,19(6):670- 676.
[5] 李相芬,刘新群. 高血压对血管内皮功能的影响[J]. 心血管康复医学杂志,2005,14(2):145-146.
[6] Pannier BM,Avolio A P,Hoeks A,et al. Methods and devices for measuring arterial com pliance in humans[J]. Am J Hypertens,2002,15(8):743-753.
[7] 何辉,陈长春,李建华,等. 高频超声检测高血压及高血压合并高胆固醇血症患者血管内皮依赖性舒张功能[J]. 中国超声诊断杂志,2005, 6:409-412.
[8] 邢玉,高丽,万国华. 老年原发性高血压患者动态脉压与颈动脉重构、粥样硬化及缺血性脑卒中的关系[J]. 中国临床康复,2005,9(31):34- 36.
[9] 李有忠,胡爱云,单秀琴. 颈动脉粥样硬化与脑梗死的关系[J]. 中国超声医学杂志,1998,14(10):25-27.
[10] 黄铮,龚兰生,施中伟. 冠心病者颈动脉粥样硬化斑块的好发部位及超声分型[J]. 中国超声医学杂志,1996,12(5):34-37.
[11] 周永昌,郭万学. 超声医学[M]. 第3版. 北京:科学技术出版社,1998:715-721.
[12] 王新房. 彩色多普勒诊断学[M]. 北京:人民卫生出版社,1991:217- 218.
(收稿日期:2010-02-08)
