原发性高血压患者心房除极波研究.docx

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1、 学校代码 10459 学号或申请号 201322453710 密级 公开 专业硕士学位论文 原发性高血压患者心房除极波研究 作 者 姓 名 ： 聂 连 涛 导 师 姓 名 ： 李 中健 教 授 李 世 锋 副 教 授 学 科 门 类 ： 临 床医学 专业名称：内科学 （心 电学相关检查研究） 培 养 院 系 ：第 二 临 床 学 院 完成时间： 2016年 5 月 A thesis submitted to Zhengzhou University for the degree of Master The Study On Atrial Depolarization Wave In Pati

2、ents Of Essential Hypertension By Liantao Nie Supervisor: Prof. Zhongjian Li A.Prof. Shifeng Li Clinical Medicine The Second Affiliated Hospital of Zhengzhou University May,2016 原创性声明 本人郑重声明：所呈交的学位论文，是本人在导师的指导下，独立进行研 究所取得的成果。除文中已经注明引用的内容外，本论文不包含任何其他个人 或集体已经发表或撰写过的科研成果。对本文的研究作出重要贡献的个人和集 体，均已在文中以明确方式标

3、明。本声明的法律责任由本人承担。 学位论文作者 : 曰期：年月曰 学位论文使用授权声明 本人在导师指导下完成的论文及相关的职务作品，知识产权归属郑州大学。 根据郑州大学有关保留、使用学位论文的规定，同意学校保留或向国家有关部 门或机构送交论文的复印件和电子版，允许论文被查阅和借阅；本人授权郑州 大学可以将本学位论文的全部或部分编入有关数据库进行检索，可以采用影印、 缩印或者其他复制手段保存论文和汇编本学位论文。本人离校后发表、使用学 位论文或与该学位论文直接相关的学术论文或成果时，第一署名单位仍然为郑 州大学。保密论文在解密后应遵守此规定。 学 位 论 文 作 者 ： 曰 期 ： 年 f月 0

4、 曰 原发性高血压患者心房除极波研究 研究生聂连涛 导师李中健教授李世锋副教授 郑州大学第二附属医院心电图科 河 南 郑 州 450014 摘要 背景和目的 原发性高血压病严重危害人类健康，因其发病初期症状轻微，进展缓慢， 甚至隐匿，患者常无不适反应，加之人体强大的代偿能力，往往在早期诸多形 态学、实验室检查中无法显现和表现出来。随着原发性高血压病程的进展，可 造成不同程度心、脑、肾等靶器官损害，这些脏器的急性或慢性损害也常常是 患者首诊（或就诊）的主要原因，可是，此时疾病已变得错综复杂，或病情凶 险，甚至导致人体器官功能不可逆改变，给社会、患者及家属带来巨大的经济 和心理压力。因此，早期发现

5、、早期诊断、早期干预、治疗未病是原发性高血 压病预防和治疗的关键，同时也是提高患者生存质量、延长患者寿命的重点。 原发性高血压病有多种分型，如有按真性高血压和隐匿性高血压之分，也有按 血流动力学分为高动力型、高阻抗型、高排血量型、高容量型高血压或其他分 型，但究其诊断，多依靠诊室血压、动态血压、心功能诊断仪、动态心电图划 分。而动态血压、心功能、动态心电图为特殊检查，目前在绝大部分医院还未 广泛普及应用，所以，不可避免的给原发性高血压患者早期发现、早期诊断、 早期治疗带来了困难。心 电图技术（采集方便、快捷、无创伤、重复性好，为 绿色检查，目前已成为健康体检、门诊和住院患者了解心脏情况的常规检

6、查项 目）应用于临床迄今已有 113年，在心血管疾病诊断方面尤为重要。与形态学检 查 （ 超声、 X线、 CT、磁共振 ） 相比，心电图为心脏的电学检查，在早期发现 高血压对心脏的损害方面具有一定（明显 ） 的优势。因每位患者高血压类型不 同、轻重不同、合并症不同、发病时间长短不同，反映在形态学检查和心脏电 I 学检查也会有不同表现，尤其在原发性高血压病的早期阶段，心脏尚 未出现形 态学改变时，心脏电学可能已有改变，因此，我们可以依据反应心脏电学改变 的心电图来早期发现高血压对心脏的影响。但目前全球并未重视心电图检查在 原发性高血压病诊断中的作用，或者还处在理论与实践脱节的状态，或许也知 晓高

7、血压可以引起心电图改变，但真正遇到原发性高血压患者时，很少有人让 患者做心电图检查 （ 更无人结合动态血压、动态心电图、心功能），并通过心 电图来评判高血压对心脏的影响。从上个世纪至今，众多学者分别拿 X线、超 声或 CT、 磁共振与心电图对比，认为在诊断高血压所致的房室肥大方面，准确 性不及前者 。临床工作发现：心电图、心电向量图、动态心电图系心脏电学检 查，而 X线、超声、 CT、 磁共振系心脏形态学检查，二者均可通过检查了解高 血压对心脏的影响，但二者检查的方法、手段迥异。在诊断房室肥大方面，应 该是心脏电学改变在前，形态学改变在后，故二者在了解早期高血压对心脏影 响方面应该是前后关系，

8、所以我们不应该拿二者进行对比。从本课题的前期研 究至今，我们发现原发性高血压病不同阶段对心脏会有不同程度的影响，心电 图可表现为：房室肥大、各类传导阻滞、 ST-T改变等，然而在原发性高血压病 早期，心房除极波一心电图 P波时限、形态的异常改变 （ 此时形态学检查尚无 任何阳性发现 ） 已经存在，但未被重视，文献检索鲜见报道。故此，我们认为 有必要开展 “ 原发性高血压患者心房除极波研究 ” 。 资料与方法 1研究对象：选取门诊及住院原发性高血压患者 108例，所有患者均满足 以下标准： 既往有明确的高血压病史，无论是否规律服药； 否认高血压病 史，但诊室血压结合动态血压符合中国高血压防治指南

9、 2010诊断标准，收 集详细的临床资料，包括性别、年龄、高血压病史、糖尿病病史、空腹血糖、 糖化血红蛋白、胆固醇、甘油三酯、低密度脂蛋白、高密度脂蛋白、肌酐、尿 素、动态血压、动态心电图（心律失常）及常规 12 (15、 18)导联心电图（纸 速 25mm/s， 增益 10mm/mV， 频响范围 0.05150Hz)，所有检查结果均经专业 医师核实和校正。 2分组方法 （ 1)根据高血压病程分成三组： 0 5年组； 5 10年组 ; 10 年组，比较各组心电图异常率； （ 2)根据心电图 P波时限及 Ptfvl分为 4 组： P波时限正常+PtfvlE常组； P波时限正常 +?1,1异常组；

10、 P波时限延 长 +PtfvlE常组； P波时限延长 +Ptfvl异常组，总结不同组别之间高血压病程、 高血压类型等特点，绘制心电图 P波时限及 Ptfvl改变在原发性高血压病进展中 的分布图，分析 P波时限延长在原发性高血压病诊断中的意义； （ 3)根据心电 图 P波形态分为 2组： 形态规则组； 形态不规则组；分析心电图 P波形态 学改变的相关因素，绘制心电图 P波形态改变致心律失常分布图。 3统计学方法所有收集到的数据经 Excel表格整理，采用 SPSS 16.0 统计学软件进行统计学分析，计量资料采用均数 标准差 （ S)表示，计数资 料采用百分比（ )表示，两组计量资料比较，方差齐

11、性时，采取 t检验，方差 不齐采用校正 t检验，两组计数资料比较，采取 Z2检验，三组以上计量资料比 较，方差齐性时，采用方差分析，比较各组间的差异，三组样本均数之间的两 两比较则采用 Bonferrom分析方法，方差不齐时，采用非参数检验，采用检验 水准 a=0.05。 结果 1随着原发性高血压病程进展，心电图异常率增高，且每个阶段以 P波时 限延长多见 (59.6%、 66.7%、 90.0%)，尤其在原发性高血压病早期更为明显（ 59.6% VS 7.7% VS 7.7% VS 5.8% VS 19.2%)。 2多重线性回归分析显示，心电图 P波时限长短与原发性高血压病程相关， 回归系数

12、 0.704, P = 0.005， 其他参数无统计学意义。 Person相关分析显示，心 电图 P波时限长短与原发性高血压病程相关系数 r = 0.35,呈正相关。 3心电图 P波时限延长诊断原发性高血压病的敏感性为 67.6% (73/108)。 其中，80.8%(59/73)患者血压昼夜节律的正常 “ 杓型 ” 消失， 57.5%(42/73)呈 “ 非杓 型 ” 改变， 23.3% (17/73)呈 “ 反杓型 ” 改变； 19.2% (14/73)患者否认高血压病 史， 6.8% (5/73)患者表现为单纯夜晚血压增高； 4随着原发性高血压病程的进展，可引起心房除极波 -P波改变：

13、P波时限正常：病史短，血压可短暂增高； 穴 异常：病史稍长，以昼夜收缩压增高为主； P波时限延长：病史长短不一，当血压控制较好时可无 Ptfvl异常，当血 压未控制或控制差时，可有 Ptfvl异常。 5原发性 _血压患者合并糖尿病病程长者 (6.317.64 年 )，心电图 P波形态 多呈不规则改变，男性居多；病程短者 (2.7U2.86年 )，心电图 P波形态多呈规 ill 则改变； 心电图 P波不规则改变中，后切迹（降支切迹）所占比例最大丨 39.7% (29/73)丨，其改变与糖尿病病史、空腹血糖、糖化血红蛋白水平有高度相关性 ; P波低平改变时，患者年龄偏大； P波前切迹改变时，糖尿病

14、病史（ .140.05 年 ） 、 P波时限 （ l 5.6015.42 ms)最短，若 P波时限延长 +时限正常的 P波前 切迹改变，原发性高血压病诊断敏感性可由 67.6%增加到 73.1%; P波双峰改变 时， P波时限最长； 6原发性高血压患者房性心律失常发生率大于室性心律失常，且 P波形态 不规则者更易发生房性心律失常。 结论 1心电图 P波时限延长诊断原发性高血压病敏感性较高，是原发性高血压 病早期心脏电学改变的佐证，且 P波时限长短与高血压病程有关； 2原发性高血压患者合并糖尿病时，心电图多以 P波后切迹改变为主； 3原发性高血压患者心电图 P波不规则改变易发生房性心律失常。 关

15、键词 原发性高血压糖尿病心电图心房除极波 P波 Ptfvl心律失常 The study on atrial depolarization wave in patients of Essential hypertension Postgraduate: Liantao Nie Tutor: Zhongjian Li Shifeng Li Department of Electrocardiogram, The Second Affiliated Hospital,Zhengzhou University Zhengzhou, Henan ,450014,China Abstract Backgr

16、ound and Objective Hypertension is seriously harmful to human health, because the early mild symptoms and the slow progress seldom make many patients feel uncomfortable . Human have so strong compensatory ability that many morphological and laboratory examinations are normal in the early stage. With

17、 the developing of hypertension , it can cause damage in different degree of heart, brain, kidney and other target organs ,which is often the main reason patients appearing in hospital.However, the disease has become complicated, or dangerously, even more the body organ function may change irreversi

18、bly, which bring tremendous economic and psychological pressure to society, patients and their families. Therefore, early detection, early diagnosis, early intervention is the key to the prevention and treatment of hypertension, which will not only improve the hypertension patients quality of life,b

19、ut also prolong living of patients. Hypertension has a variety of types, such as the true hypertension , the masked hypertension, high power type hypertension, high impedance type hypertension, high output type hypertension, high capacity type hypertension or other types according to different class

20、ification methods. However, the definite diagnosis need to rely on clinic blood pressure, ambulatory blood pressure, heart function diagnosis instrument, dynamic electrocardiogram. The latter three are special inspection,which have not yet widespread popularization and application in most hospitals

21、at present ,so it is difficult to discovery, diagnosis and cure for the hypertension patients in early stage.ECG technique (acquisition convenient, fast, non-invasive, good repeatability. At present, it has become routine inspection project for healthy， outpatient and hospitalized patients to unders

22、tand their heart condition) has been used in clinical for 113 years, which is important,especially in the diagnosis of cardiovascular disease . Compared with morphological examination (ultrasound, X-ray, CT, MRI) , ECG is electrical inspection, which has obvious advantages in the hypertension early

23、stage on cardiac damage. Due to different patients have different hypertension types ,different severity, different complications, different lengths, which will lead to different performances reflected in morphological examination and cardiac electricity examination.Especially in the early stage of

24、hypertension, the heart has not yet appeared morphological changes, while might have appeared cardiac electrical changing, so we can base on electrocardiogram changes to early detection the effect of hypertension on the heart. But the world did not attach importance to the role of ECG in the diagnos

25、is of hypertension, or is still in a state of separation between theory and practice, perhaps many also know that hypertension can cause the ECG changes, but really encountered in hypertensive patients, there are few people let patients do electrocardiogram examination (no more use ambulatory blood

26、pressure, dynamic electrocardiogram, heart function)to evaluate the effects of hypertension on cardiac. Since the last century, many scholars have made X-ray, ultrasound or CT, magnetic resonance and ECG contrast, got the conclusion that the accuracy of the former is better than latter in the diagno

27、sis of atrioventricular hypertrophy caused by the hypertension . From the previous studies of this topic, we found that different stages of hypertension (early, middle and late stage) would have varying degrees of impact on the heart, ECG can be as follows: atrial and ventricular hypertrophy, all ki

28、nds of conduction block, ST-T changes. However, in the early stage of hypertension, ECG can be performance as atrial depolarization - P wave duration, morphological abnormalities (at a time when morphological examination has no positive findings), document retrieval has not been reported. Therefore,

29、 we think it is necessary to carry out the study of the change of atrial depolarization in patients with essential hypertension n. Materials and methods 1 research object: 108 essential hypertension cases were selected from out-patient and in-patient, all patients met the following criteria:The hist

30、ory of hypertension is clear, whether or not get regular medication; The history of hypertension was unclear, but the ambulatory blood pressure with clinical blood pressure met Chinese hypertension Prevention Guide 2010 diagnostic criteria.Clinical data were collected including gender, age, history

31、of hypertension and diabetes, fasting blood glucose, glycosylated hemoglobin, cholesterol, triglyceride, low density lipoprotein, high density lipoprotein, creatinine, urea, dynamic blood pressure,dynamic electrocardiogram ( arrhythmia ) and the conventional 12 (15、 18) lead electrocardiogram (paper

32、 speed 25mm/s , gain 10mm/mV， frequency range 0.05 150Hz), all the results are verified and corrected by professional doctors. 2 grouping methods: (1) All patients were divided into three groups according to the hypertension history: 0 _ 5 years group; 5_ 10 years group; above 10 years group, compar

33、ed the ECG abnormal rate; (2) All patients were divided into 4 groups according to ECG P wave duration and Ptfvi :normal P wave duration +normal Ptfyi group; normal P wave duration+abnormal Ptfvi group; prolonging P wave duration +normal Ptfvi group; prolonging P wave duration+abnormal Ptfvi group,

34、summed up hypertension and other types of features between the different groups, drew the electrocardiogram P wave duration and Ptfvi distribution in the development of hypertension, and analysed the significance in the diagnosis of essentioal hypertension with the prolonging P wave duration ; (3)A1

35、1 patients were divided into 2 groups according to ECG P wave form: regular shape group; irregular shape group; analysed the related factors on morphological changes of ECG P wave, drew arrhythmia distribution map. 3 statistical methods:All the data were collected by Excel form, the statistical anal

36、ysis was performed using SPSS 16.0 statistical software, measurement data used the mean and standard deviation (x+ S), count data used percentage (%).When two groups measurement data were compared, t test or t test were used. When two groups count data were compared, x test was used.When three group

37、s measurement data were compared,variance analysis was used. When two groups between the three were compared, Bonferroni analysis non parametric test were used .the test level alpha =0.05 Results 1 In the progression of essential hypertension, abnormal rate of ECG was elevated, and prolonging P wave

38、 duration in each stage was the most common (59.6%, 66.7%， 90.0%), especially in the early stage of essential hypertension was more obvious (59.6% vs 7.7% vs 7.7% vs 5.8% vs. 19.2%). 2 Multiple linear regression analysis shows that the duration of ECG P wave duration was correlated with the essentia

39、l hypertension history, the regression coefficient was 0.704, P = 0.005, and other parameters were not statistically significant. Person correlation analysis showed that the length of ECG P wave duration and the duration of hypertension related coefficient r = 0.35( positive correlation). 3 The sens

40、itivity of essential hypertension diagnosis using prolonging ECG P wave duration was 67.6% (73/108). The dipper rhythm of blood pressure in 80.8% (59/73) hypertension patients disappeared, 57.5% (42/73) showed non dipperchanging , 23.3% (17/73) showed anti dipper changing; 19.2% (14/73) patients den

41、ied with hypertension history. 6.8% (5/73) hypertension patients performanced increasing night blood pressure alone. 4 In the progression of essential hypertension, atrial depolarization wave - ECG P wave could chang as follows: normal P wave duration : a short hypertension history, blood pressure c

42、an be briefly increased; (DPtfyi abnormalities: a slightly longer hypertension history,the day and night systolic blood pressure increased; prolonging P duration: hypertension history ranged different lengths. When the blood pressure was controled better, there was normal Ptfvi, when the blood press

43、ure was not controled or poor controled, there could be abnormal Ptfvi . 5 When combined with longer diabetes history (6.31 士 7.64 years), ECG P wave morphology showed irregular changing, mostly in male;Conversely, ECG P wave morphology showed regular changing; In the all irregular changing, the not

44、ch (descending notch)was the largest proportion 39.7% (29/73), the change was highly correlated with the diabetes history, fasting blood glucose, glycated protein level; When the P wave showed flat changing, the older patients was most;When the P wave showed ascending notch changing,diabetes history

45、(0.14 + 0.05years), P wave duration (105.60 + 15.42ms) were the shortest, if prolonging P duration + ascending notch changing, the sensitivity of hypertension diagnosis can be increased from 67.6% to 73.1%; When the P wave showed bimodal changing ,P wave duration was longest. 6 the incidence of atri

46、al arrhythmias in patients with essential hypertension is greater than that of ventricular arrhythmias, and P wave morphology irregular was more likely to occur atrial arrhythmias. Conclusions 1 The sensitivity in diagnostic of essential hypertension with prolonging ECG P wave duration is higher.lt

47、may be the early cardiac electrical changes in essential hypertension, and P wave duration was related with hypertension history; 2 Essential hypertension patients combined with diabetes, ECG P wave mostly appear descending notch changing; 3 Essential hypertension patients with irregular ECG P wave

48、morphology are easy to occur atrial arrhythmias. Key words ： Essential hypertension diabetes ECG P wave Ptfvi arrhythmia 缩略词表 EH Essential hypertension 原发性高血压 ECG electrocardiogram 心电图 AECG ambulatory electrocardiogram 动态心电图 ABP Ambulatory blood pressure 动态血压 SBP Systolic blood pressure 收缩压 DBP Diastolic blood pressure 舒张压 目录 论文部分 、 产 S- - 目 !J g . 1 资料和方法 . 3 關 . 7 i寸论 . 1