卡托普利与美托洛尔治疗慢型克山病的临床效果评价

Evaluation of curative effect of chronic Keshan disease treated by captopril and metoproiol

目的观察卡托普利和美托洛尔对慢型克山病患者的治疗效果。方法2007年在山东省莒县、五莲县、沂水县、平邑县、泗水县和邹城市6个克山病病区县（市），根据《克山病诊断标准》选择195例慢型克山病病例，按美国纽约心脏病学会心功能分级随机分为对照组、卡托普利组和美托洛尔组，3组患者均给予利尿剂、洋地黄、血管扩张刺等基础治疗，卡托普利组与美托洛尔组分别在此基础上加服卡托普利或美托洛尔，随访12个月．观察心脏原因死亡情况以及住院次数、住院天数、心脏大小、心电图、血压、心率变化情况。结果卡托普利组和美托洛尔组死亡率（4．76％（3／63）、5．00％（3／60）]均低于对照组[10．61％（7／66）]，但差异无统计学意义（P〉0．05）。卡托普利组、美托洛尔组年住院时间[（19．12±20．35）、（18．86±21．52）d／年]均低于对照组[（21．45±21．74）d／年，q=3．17、3．38，P〈0．05]。治疗后卡托普利组与美托洛尔组患者心胸比率缩小的检出率分别为45．0％（27／60）和40．4％（23／57），均明显高于对照组[18．6％（11／59），χ^2=9．51、6．59，P均〈0．0125]，而3组的心胸比率增大和不变的检出率组间比较差异均无统计学意义（χ^2=2．50、4．75，P均〉0．05）。美托洛尔组异位心律消失率[56．5％（13／23）]高于对照组与卡托普利组[23.8％（5／21）、22．7％（5／22）]，但差异无统计学意义（χ^2=5．35、4．86，P均〉0．0125）。3组患者治疗前后收缩压、舒张压及心率差异均有统计学意义（F=47．51、44．23、80．66，P均〈0．01），治疗时间与药物的交互作用对收缩压和心率有影响（F=3．19、37．44，P均〈0．05），对舒张压无影响（F=2．21，P〉0．05）。治疗前3组收缩压、舒张压及心率组间差异均无统计学意义（F=0．28、0．57、1．80，P均〉0．05）。卡托普利组、美托洛尔组及对照组治疗后收缩压及舒张压[（109．0±10．9）、（112．2±12．8）、（114．7±13．2）mmHg，（69．3±7．2）、（72．1±9．5）、（73．3±9．3）mmHg]均低于1冶疗前[（117．1±13．4）、（119．0±14．4）、（117．6±14．1）mmHg，（74．2±10．2）、（76．3±10．8）、（75．4±11．1）mmHg，t=4．79、4．47、2．08，5．12、4．32、2．15，P均〈0．05]。美托洛尔组治疗后心率[（66．2±7．7）次／min]明显低于治疗前[（75．9±11．5）次／min，t=10．81，P〈0．01]，卡托普利组与对照组心率[（70．6±8．0）、（72．6±10．5）次／minJ较治疗前[（71．9±10．4）、（73．8±12．2）次／min]均无明显变化（t=1．77、1．74，P均〉0．05）。治疗后，卡托普利组收缩压与舒张压明显低于对照组（q=3．52、3．56，P均〈0．05）；美托洛尔组心率显著低于对照组与卡托普利组（q=5．44、3．73，P均〈0．01）。结论卡托普利与美托洛尔治疗慢型克山病，有降低心脏原因死亡的趋势，并可逆转或延缓心肌重构，减少住院率，且安全可靠，医疗费用少，具有重要的临床推广价值。

Objective To observe the curative effect of captopril and metoprolol in the treatment of chronic Keshan disease （CKD）. Methods One hundred and ninty-five patients with CKD chosen from Juxian, Wulian, Yishui, Pingyi, Sishui and Zoucheng in Shandong Province were randomly assigned to control group, captopril group and metoprolol group according to NYHA cardiac functional grading. All cases were given diuretics, digitalis and vasodilating agents as routine treatment. On this basis, captopril and metoprolol was administered in captopril group and metoprolol group respectively. After 1 2 months of follow-up visit, the causes of cardiac death, hospitalization status and the changes of heart size, electrocardiogram, blood pressure and heart rate were all observed. Results It was found that the mortality of captopril group and metoprolol group was 4.76% （3/63）,5.00% （3/60） respectively,both lower than the control group 10.61% （7/66）. But this difference had no statistically significance （P = 0.39 ）. Besides, the hospitalization days of each year in captopril group and metoprolol group was respectively （19.12 ± 20.35） and（18.86 ± 21.52）days, much more reduced than in the control group[（21.45 ± 21.74）days, q = 3.17, 3.38, P 〈 0.05]. The detection rate of cardiothoracic ratio decreased in captopril group and metoproM group[45% （27/60） and 40.4%（23/57）] After treatment showed more pronounced amelioration than the control group [ 18.6% （11/59）, χ^2 = 9.51,6.59, all P 〈 0.0125 ], still the detection rate of cardiomegaly and invariability had no significant difference among three groups （χ^2 = 2.50,4.75, all P 〉 0.05）. The elimination coefficient of ectopic rhythm in metoprolol group[56.5% （13/23）]was pronounced higher than the control group and captopril group[23.8%（5/21 ）, 22.7% （5/22） ], but differences had no statistically significance （P = 0.0358,0.0331, all P 〉 0.0125）. Significant differences were found in systolic blood pressure（SBP）, diastolic blood pressure（DBP） and heart rate（HR） in three groups prior and post-treatment（F=47.51,44.23,80.66, all P 〈 0.01 ）. The interaction of therapy and treatment time had influence on SBP and HR（F = 3.19,37.44, all P 〈 0.05）, but had no influence on DBP（F = 2.21, P 〉 0.05 ）. There was no difference in SBP, DBP or HR among three groups before treatment（F = 0.28,0.57,1.80, all P 〉 0.05）. After treatment, SBP and DBP in captopril group, metoprolol group and the control group [ （109.0 ± 10.9）, （112.2 ± 12.8）, （114.7 ±13.2）mm Hg, （69.3 ± 7.2）, （72.1 ± 9.5）, （73.3 ± 9.3）mm Hg] were all lowered compared with pre-treatment[ （117.1 ± 13.4）,（119.0 ±14.4）, （117.6±14.1）mm Hg and （74.2 ±10.2）, （76.3± 10.8）, （75.4 ± 11.1 ）mm Hg, t = 4.79,4.47,2.08,5.12, 4.32,2.15, all P 〈 0.05]. HR was reduced in metoprolol group, being[ （66.2 ± 7.7）, （75.9 ±11.5）times/min] before and after treatment（t = 10.81, P 〈 0.01 ）, while it remained unchanged in captopril group and control group[ （70.6 ±8.0）, （72.6 ± 10.5） times/rain and （71.9 ±10.4）, （73.8± 12.2）timcs/min, t = 1.77,1.74, all P 〉 0.051. After treatment, both SBP and DBP of captopril group were significantly lower than that in the control group（q = 3.52,3.56, all P〈 0.05）; HR was reduced in metoprolol group, lower than that in captopril group and control group（q = 5.44,3.73, all P 〈 0.0l ）. Conclusions Having a tendency of depressing mortality, captopril and metoprolol can reverse or delay myocardial remodeling and reduce admission rate in a safe,reliable and economie way, and are worth to be widely used in the treatment of chronic Keshan disease.