射血分数保留的高血压性心力衰竭患者左心室收缩失同步的影响因素

The influencing factors of left ventricular systolic asynchrony in patients with heart failure and preserved ejection fraction

目的探讨单纯高血压、高血压性左心室肥厚(LVH)、高血压所致的射血分数保留的心力衰竭(HF-pEF)患者左心室收缩同步性变化,分析HF-pEF左心室收缩失同步的主要影响因素。方法回顾性分析2011年6月至2014年5月天津市胸科医院心内科住院诊治的原发性高血压患者352(男性160、女性192)例的资料,年龄(67.6±7.8)岁。按相应诊断标准将患者分为单纯高血压组(n=182)、LVH组(n=74)和HF-pEF组(n=96),采用心脏超声及门控心肌灌注显像相位分析技术测定并比较各组患者心脏结构功能参数、左心室质量指数(LVMI)、相位直方图带宽(PHB)和相位直方图标准差(PSD),测定血清脑钠尿肽值。对于高血压所致的HF-pEF患者,分别对PHB、PSD按照四分位法进行分组,行多元线性回归分析以阐明PHB、PSD的影响因素。结果与单纯高血压组相比,LVH组和HF-pEF组LVMI增高[(121.1±9.8)、(123.2±10.9)比(94.4±10.1)g/m^2,P<0.05];舒张早期和舒张晚期二尖瓣血流速率比值(E/A)降低(0.80±0.28、0.67±0.17比1.19±0.23,P<0.05);3组间左心室射血分数(LVEF)差异无统计学意义。HF-pEF组存在明显的左心室收缩失同步:PHB[(88.4±8.6)°比(33.3±7.7)°、(52.2±6.9)°]、PSD[(23.6±1.9)°比(9.2±2.1)°、(16.3±1.6)°]高于单纯高血压组和LVH组(均P<0.01);HF-pEF组血清脑钠尿肽水平高于LVH组[(228.4±69.7)比(92.5±13.6)ng/L,P<0.01]。HF-pEF组患者年龄、高血压病程、左心房内径(LAD)、LVEF、LVMI、E/A和QRS时限在PHB、PSD四分位分组中差异有统计学意义(均P<0.05)。多元线性回归分析结果表明,HF-pEF患者左心室收缩失同步程度取决于LVMI和QRS时限。以PHB为因变量时LVMI和QRS时限的B值分别为0.711、0.164(均P<0.01);以PSD为因变量时LVMI和QRS时限的B值分别为0.159、0.048(均P<0.01)。结论高血压所致HF-pEF患者存在明显的左心室收缩失同步,LVMI增加及QRS时限延长是左心室收缩失同步的独立相关因素。

Objective To investigate the systolic synchrony of the left ventricle in patients with hypertension,hypertensive left ventricular hypertrophy,heart failure and preserved ejection fraction（HF-pEF）induced by hypertension respectively and to analyze the influencing factors of left ventricular systolic asynchrony in HF-pEF patients.Methods During June 2011 to May 2014,a total of 352 cases with essential hypertension（EH）were enrolled in this retrospective study,which consisted of 160 males and 192 females with average age of（67.6±7.8）years old.All cases were divided into hypertension group（n=182）,left ventricular hypertrophy group（LVH,n=74）and HF-pEF group（n=96）according to the corresponding diagnostic criterions. Ultrasonic and gated myocardial perfusion imaging（G-MPI）were performed for the assessment of left ventricular remodeling and systolic synchrony.Cardiac structure and function parameters,left ventricular mass index（LVMI）,phase histogram bandwidth（PHB）,phase standard deviation（PSD）and serum brain natriuretic peptide values were compared among groups.Patients within HF-pEF group were further divided into 4 groups in terms of different quartiles of PHB and PSD.Multivariable linear regression was used to analyze the influencing factors of PHB and PSD. Results Compared with hypertension group,the LVMI increased[（121.1±9.8）,（123.2±10.9）vs（94.4±10.1）g/m^2,P〈0.05]and E/A decreased（0.80±0.28,0.67±0.17 vs 1.19±0.23,P〈0.05）in LVH and HF-pEF groups. No significant difference was detected in left ventricular ejection fraction（LVEF）among 3 groups（F=2.89,P〈0.05）. Dramatic left ventricular systolic asynchrony occurred in HF-pEF group：PHB [（88.4±8.6）°vs（33.3±7.7）°,（52.2±6.9）°]and PSD [（23.6±1.9）°vs（9.2±2.1）°,（16.3±1.6）°]were higher than hypertension and LVH groups（all P〈0.01）. Serum brain natriuretic peptide level in HF-pEF group was higher than LVH group[（228.4±69.7）vs（92.5±13.6）ng/L,P〈0.01]. The differences of age,hypertension course,left atrial diameter（LAD）,LVEF,LVMI,E/A and QRS durations were significant among PHB and PSD quartiles（all P〈0.05）.Multiple linear regression analysis showed that LVMI and QRS duration were influencing factors of systolic asynchrony of left ventricles within HF-pEF group（B=0.711 and 0.164 when PHB as dependent variable;B=0.159 and 0.048 when PSD as dependent variable,respectively,all P〈0.01）. Conclusion The patients of HF-pEF induced by essential hypertension are characterized with typical left ventricular systolic asynchrony,which may be related to increased LVMI and prolonged QRS duration.