【作者】 张凯；

【导师】 王秀萍；

【作者基本信息】 河北医科大学 ， 内科学（专业学位）， 2014， 硕士

【摘要】 高血压病是最常见的心血管系统疾病。房性心律失常，尤以房颤的发生显著增加血栓栓塞的危险性，房颤是临床常见的心律失常,可导致脑卒中和心力衰竭,为其致残和致死的主要原因。高血压病合并心律失常特指不伴有冠心病和其他心脏疾患所致的心律失常。但是高血压病合并房性心律失常的发生机制不明确，至今研究较多的是与心脏重构之间的关系。很多研究证实了内皮功能障碍在高血压病发生、发展的过程中有着重要的作用，但是对其在原发性高血压患者导致房性心律失常的影响研究不充分。内皮素（ET）主要由内皮细胞合成，作为重要的内皮依赖性缩血管因子，对维持正常心血管功能至关重要。血管性假血友病因子（vWF）是由内皮细胞和巨核细胞合成与分泌的。正常情况下，体内促凝与抗凝机制达到动态平衡，其对心脑血管功能有重要作用。血压昼夜变化规律即血压的昼夜节律，血压昼夜节律在正常情况下曲线呈现“双峰一谷”的特征，即“杓形”血压波动，这与机体的正常生理活动、心脑血管功能相适应。目的:通过对ET、vWF、EDD与LA等心脏结构指标、血压昼夜节律及高血压病程等在单纯高血压病及合并房性心律失常患者中水平的观察，探讨原发性高血压患者房性心律失常的发生机制中是否包含内皮功能障碍、心脏重构、血压昼夜节律及高血压病程方面的可能，同时研究高血压病程与房性心律失常发生之间关系，探讨单纯性高血压病患者及高血压病合并房性心律失常患者内皮功能及血压昼夜节律监测的临床意义。方法:主要选择2012年10月至2013年10月（2011年11月3例，12月1例，2012年2月1例，3月1例，5月1例）在河北省人民医院心内科住院治疗的64例原发性高血压患者，诊断均符合《中国高血压防治指南2010年修订版》的高血压诊断标准。根据动态心电图结果及Kleiger分级，将其分为单纯高血压病组（20例，男：女=8:12，55.35±10.94岁）、高血压病合并房性心律失常A组（Kleiger分级1-2级，即轻度房性心律失常）及B组（Kleiger分级3-6级，即复杂房性心律失常），其中A组20例（男：女=9:11，60.45±10.23岁），B组24例（男：女=14:10，62.75±13.26岁）。均经相关检查除外继发性高血压，排除有明确冠心病、心肌炎、心肌病等器质性心脏病及其他心律失常患者，且患有急性炎症、严重肝肾疾病、免疫系统疾病、恶性肿瘤、重度贫血、甲亢，使用过抗凝及溶栓疗法者不能入选，服用抗炎或抗心律失常药物未达到5个半衰期者亦排除。对所有入选患者进行身高、体重的测定，计算体重指数（BMI）；记录用药情况；常规检测空腹血糖(FPG)、胆固醇(TC)、甘油三酯(TG)；测定内皮素（ET）、血管性假血友病因子（vWF）；彩色多普勒超声心动图仪测量左房内径（LA）、左室舒张末期内径（EDD）、室间隔厚度(IVS)、左室后壁厚度(LVPW)、E峰、A峰，根据Devercux公式计算左室质量指数（LVMI）；进行24小时动态心电图、动态血压监测。最后进行统计学分析。结果：1高血压病合并房性心律失常组ET、vWF水平显著高于单纯高血压病组，且随房性心律失常的严重程度增加；高血压病合并房性心律失常组（A组及B组）高血压病程明显高于单纯高血压组，而A组与B组间无统计学差异。2单纯高血压病组、高血压病合并房性心律失常A组及B组之间EDD、LVMI、LA及E/A无统计学差异。3高血压病合并房性心律失常组（A组及B组）血压昼夜节律消失者构成比明显高于单纯高血压组，而A组与B组间无统计学差异。4在44例高血压病合并房性心律失常组病人中，Logistic回归方程预测有42例有房性心律失常，准确率95.5%（42/44），在20例高血压病组病人中，用Logistic回归方程预测有10例无房性心律失常，准确率50%（10/10），总准确率为81.3%。进入回归方程的自变量是血压昼夜节律及vWF两因素，卡方检验=35.357，P=.000,Logistic回归方程有统计学意义。Logistic回归方程为：logitP=-7.999+1.959X(昼夜节律)+4.247X(vWF)。本研究用2个危险因素（血压昼夜节律、vWF）的Logistic回归系数来反应2个危险因素对p/（1-p）（房性心律失常发生概率对不发生概率的比数即OR）的作用。血压昼夜节律异常对无血压昼夜节律异常的房性心律失常发生的比数比例为39.11，vWF高于平均值对vWF低于平均值的房性心律失常发生的比数比例为702.22。结论：1内皮功能障碍、高血压病程与原发性高血压患者房性心律失常的发生、发展有关。2与血压昼夜节律为杓型的原发性高血压患者相比，昼夜节律非杓型者易发生房性心律失常。3将单因素分析结果有意义的指标纳入二分类Logistic回归方程模型示血压昼夜节律、vWF为高血压病患者发生房性心律失常危险因素。4临床可以通过对内皮功能、高血压病程、血压昼夜节律三者的观察在一定程度上对高血压病患者的房性心律失常的发生及发展进行预测。由于本实验样本数偏少，相关结论仍需临床进一步研究阐述。更多还原

【Abstract】 Hypertension is the most common diseases of the cardiovascular system.atrial arrhythmia, especially the occurrence of AF significantly increased therisk of thromboembolism, Atrial fibrillation is the most common clinicalarrhythmia, can lead to stroke and heart failure, as the main causes ofdisability and death.Hypertension with arrhythmia specifically refers to thiscardiac arrhythmia without coronary heart disease and other cardiac disorders.But the mechanism of hypertension complicating atrial arrhythmia is not clear,the present study is much about the changes of cardiac structure. Many studieshave confirmed the endothelial dysfunction plays an important role in thedevelopment of hypertension, But endothelial dysfunction in patients withessential hypertension leads to atrial arrhythmia is short of enough research.Synthesis of endothelin (ET) is mainly composed of endothelial cells, asimportant vessels endothelial dependent shrinkage factor, is very important tomaintain normal cardiovascular function. False von willebrand factor (vWF) isthe synthesis and secretion of endothelial cells and megakaryocyte.Undernormal circumstances, the body reached dynamic balance mechanism ofcoagulation and anticoagulation, plays a important role in the cardiovascularand cerebrovascular function.Blood pressure circadian change is the circadianrhythm of blood pressure, blood pressure circadian rhythm in normalcircumstances the characteristics of the curve presents a "twin peaks valley",namely "scoop" blood pressure fluctuations, this has to do with the body’snormal physiological activity, cardiovascular function.Objective: through to the ET, vWF, EDD and LA heart structure index,blood pressure circadian rhythm and high blood pressure progression inpatients with primary hypertension and merging atrial arrhythmia in the levelof observation, explore the possibility of mechanism of atrial arrhythmia in patients with primary hypertension from endothelial dysfunction, cardiacremodeling, course of blood pressure circadian rhythm and high bloodpressure. at the same time, research relationship between hypertension courseand atrial arrhythmia occurred, explore the clinical significance of monitoringendothelial function and blood pressure circadian rhythm for primaryhypertension patients and patients with hypertension combined atrialarrhythmia.Methods: main choice in October2012to October2013(3cases inNovember2011,1case on December2011,1case in February2012,1case inMarch2012,1case in May2012) in hebei province people’s hospital ofcardiology hospital treatment of64patients with primary hypertension,thediagnosis is in line with the "2010China hypertension prevention andtreatment guidelines revision" diagnostic criteria of hypertension. Accordingto the result of dynamic electrocardiogram and Kleiger classification, it can bedivided into primary hypertension group (20cases, male: female=8:12,55.35±10.94years old), hypertension with atrial arrhythmia of group A (Kleigerclass1-2grade，namely mild atrial arrhythmia) and group B (Kleiger class3-6grade，namely complex atrial arrhythmia).in which group A of20patients(male: female=9:11,60.45±10.23years old), B group of24patients (14:10,62.75±13.26years old). Patients with secondary hypertension and clearstructural heart disease such as coronary heart disease, myocarditis,cardiomyopathy and other nature arrhythmia patients, and patients sufferingfrom acute inflammation, severe liver and kidney disease, immune systemdisorders, malignant tumors, severe anemia, hyperthyroidism, and usedanticoagulant and thrombolytic therapy can not be selected. Patients takinganti-inflammatory or anti-arrhythmic drugs which did not reach5half-liveswere also ruled out. the height, weight, and calculate body mass index (BMI),medication situation, fasting blood glucose, cholesterol, triglycerides,Endothelin (ET), von willebrand factor (vWF), left atrial internal diameter(LA), left ventricular end-diastolic internal diameter (EDD), interventricularseptum thickness (IVS), left ventricular posterior wall thickness (LVPW), E peak, A peak were deteced with Echocardiography, then formulated leftventricular mass index (LVMI)(according to Devercux),24hours dynamicelectrocardiogram, ambulatory blood pressure monitoring for all the selectedpatients. Finally the statistical analysis.Results:1Hypertension combined atrial arrhythmia group ET, vWF weresignificantly higher than that of pure hypertension group, and increases withthe severity of atrial arrhythmia; High blood pressure progression of hypert-ension with atrial arrhythmia group (group A and group B) were significantlyhigher than the pure hypertension group, but between group A and group Bwas no statistical difference.2EDD, LVMI, LA and E/A of pure hypertension group and hyper-tension complicating atrial arrhythmia between group A and group B was nostatistical difference.3Blood pressure circadian rhythm disappearances constitute ratio ofhypertension complicating atrial arrhythmia group (group A and group B)were significantly higher than the pure hypertension group, but no statisticaldifference between group A and group B.4In44cases of hypertension with atrial arrhythmia group of patients, theLogistic regression equation to predict42cases had atrial arrhythmia, accuraterate95.5%(42/44), in20patients with hypertension group, using logisticregression equation to predict with10cases without atrial arrhythmia, accuraterate50%(10/10), the total accuracy was81.3%. Enter the regression equationof the independent variables are the two factors, blood pressure circadianrhythm and vWF, chi-square=35.357, P=.000, Logistic regression equationwas statistically significant. Logistic regression equation for: logitP=7.999+1.959X(circadian)+4.247(vWF).This study used two risk factors (blood pressure circadian rhythm,vWF) Logistic regression coefficient to reflect the two risk factors on p/(1-p)(atrial arrhythmia occurrence probability of the occurrence probability of notscore the OR). Abnormal blood pressure circadian rhythm of blood pressure circadian rhythm abnormalities atrial arrhythmia occurrence ratio is39.11,thescore of vWF than average below average of vWF ratrial arrhythmia occur-rence score rate of702.22Conclusions:1Endothelial dysfunction and high blood pressure progression may berelated to occurrence and development of atrial arrhythmia in patients withessential hypertension.2Compared with blood pressure circadian rhythm to scoop type inpatients with primary hypertension, circadian rhythm non dipper type inpatients is prone to atrial arrhythmia.3The results of single factor analysis meaningful indicators into thebinary classification Logistic regression equation model in blood pressurecircadian rhythm, vWF for atrial fibrillation independent risk factors forhypertension in room.4Through the observation of the level of the endothelial function, highblood pressure progression, and blood pressure circadian rhythm in clinical,predict the occurrence and development of atrial fibrillation in patients withhypertension.更多还原