主动脉脉压及脉压指数对女性冠心病的预测价值

目的 通过分析直接法测得的主动脉脉压（PP）及脉压指数（PPI）与女性冠心病发病及冠状动脉病变严重程度的相关性,探讨主动脉PP及PPI在预测女性冠心病中的价值.方法 对疑诊冠心病并行诊断性冠状动脉造影检查的717例女性患者进行回顾性分析.以冠状动脉造影阳性（主要血管直径狭窄≥50％）作为诊断冠心病的标准,以冠状动脉病变受累的支数评估冠脉病变程度.采用单因素方差分析及多因素回归分析观察主动脉PP及PPI与女性冠心病发病及冠状动脉病变严重程度的关系.结果 冠心病组患者主动脉PP[（62.55±22.65）mm Hg比（54.96±21.51）mm Hg,P＜0.001]和PPI[（0.44±0.10）比（0.40±0.11）,P＜0.001]明显高于非冠心病组患者.随着冠状动脉病变支数增加,PP及PPI逐渐增加.单因素相关性分析结果显示,主动脉PP及PPI与冠心病发病（r=0.166,0.190,P＜0.001）及冠状动脉受累支数（r=0.177,0.196,P＜0.001）呈正相关.多因素logistic回归分析结果显示,主动脉PPI对冠心病发病有独立预测价值（OR=8.065,95％ CI 1.628～39.951,P=0.003）.结论 主动脉PP及PPI水平与女性冠心病发病及冠状动脉病变严重程度相关.PPI是女性患者冠脉造影确诊冠心病的独立预测指标.     

A study of comparative blood pressure measures in predicting risk of coronary heart disease.

The Western Collaborative Group Study is a prospective study of 3,154 employed men, aged 39-59 years. Coronary heart disease (CHD) occurred in 257 subjects during 8.5 years of follow-up. The multiple logistic risk model was used to assess the comparative strength of systolic, diastolic, mean arterial and pulse pressure for the prediction of CHD in two age decades after adjustment for age, serum cholesterol, cigarette smoking, behavior pattern and weight. The risk of CHD was more strongly associated with the systolic than the diastolic pressure. The general practice of assessing the importance of blood pressure based only on the diastolic component should be reassessed.     

运动试验收缩压恢复比对冠心病的诊断价值研究

目的探讨运动试验中收缩压恢复比对冠心病的诊断价值。方法对苏州大学附属第一医院2003—2005年收治的88例冠状动脉造影的患者行平板运动试验,分析运动停止后3min收缩压恢复比与冠状动脉造影的相关性。结果3min收缩压恢复比对冠心病诊断的敏感性、特异性、准确性、阳性预测值分别为:55·6%、82·0%、73·9%、57·7%,与心电图ST段改变的标准相比,差异有显著性意义(P<0·05)。结论运动试验收缩压恢复比对冠心病的诊断,在特异性、准确性、阳性预测值等方面要明显优于心电图ST段压低标准。     

Diagnostic value of the ratio of recovery systolic blood pressure to peak exercise systolic blood pressure for the detection of coronary artery disease

It has been previously reported that at treadmill exercise testing an abnormal ratio of recovery systolic blood pressure (SBP) to peak exercise SBP is more sensitive than exercise-induced angina or ST segment depression for diagnosing coronary artery disease (CAD). To investigate whether the SBP ratio keeps its diagnostic value during upright bicycle exercise, we evaluated the ratio of postexercise SBP to peak SBP in 73 patients with angiographically documented CAD and in 48 patients with normal coronary arteries (OV group) undergoing maximal stress testing on a bicycle ergometer. Three minutes after exercise ended, SBP ratio was significantly higher in the CAD than in the OV group (0.79 +/- 0.1 vs 0.71 +/- 0.08; p less than .001). Setting the upper normal limits of the recovery SBP ratio at 2 SDs from the mean for the OV group (SBP ratio = 0.98 and 0.88 at 1 and 3 min after exercise, respectively), with an increase or no change in SBP ratio at between 1 and 3 min of recovery considered an abnormal response, the sensitivity of SBP ratio was 30%, the specificity was 83%, and the accuracy was 51%. The respective values for ST depression were 81% (p less than .0001 vs SBP ratio), 48% (p less than .001 vs SBP ratio), and 67% (p less than .01 vs SBP ratio). Thus, for bicycle ergometer exercise testing, ST segment depression seems to be more accurate than SBP ratio in diagnosing CAD.     

脉压与冠心病危险性的相关性研究

目的探讨脉压与冠心病危险性的关系。方法242例入院诊断为冠心病的患者,其中男性107例,女性135例,年龄38-80(58.4±9.2)岁。测量外周肱动脉压力计算脉压,并行冠状动脉造影术。冠状动脉病变的严重程度用冠状动脉病变的血管支数表示,分析脉压与冠状动脉病变的相关性。结果 与脉压<65 mmHg的患者相比,脉压≥65 mmHg患者冠状动脉3支血管病变的患病率显著增高(27.8％比12.6％,P<0.05),冠心病、心肌梗死、心力衰竭的发生率显著增高(P均<0.05)。结论 脉压是冠心病的一个重要和独立的相关因素,脉压增高可作为全身心血管病的一个危险信号,指导早期干预。     

脉压对老年患者冠脉病变严重程度的预测价值

目的探讨老年患者脉压与冠脉病变严重程度之间的关系。方法 268例行冠脉造影(CAG)检查的老年患者,按其临床表现和CAG的结果分为冠心病(CHD)组[包括不稳定性心绞痛(UAP)组、稳定性心绞痛(SAP)组]和对照组,采用袖带加压法连续测量患者入院后三天的晨起收缩压、舒张压,并计算脉压。依据Gensini评分以及冠状动脉病变的血管支数对冠脉病变严重程度进行评估,探讨其与血压不同成分之间关系。结果 CHD组收缩压和脉压水平明显高于对照组(P<0.05);单支病变组、双支病变组、三支病变组脉压均明显高于对照组(P<0.05),且随病变支数的增多,脉压水平逐渐增高,差异具有统计学意义(P<0.05);UAP组收缩压、脉压均高于对照组和SAP组(P均<0.05)。脉压水平与Gensini评分正相关(r=0.199,P<0.01)。结论脉压较收缩压、舒张压更能反映大动脉弹性,不仅与CHD及冠脉病变的严重程度关系密切,还可能与冠状动脉粥样斑块的不稳定性有关。     

Post-exercise response of the systolic blood pressure in the diagnosis of coronary artery disease: comparison of two exercise methods

We studied 81 angiographically documented coronary artery disease patients and 28 with normal coronary arteries, having paired exercise tests (the Bruce treadmill protocol and the jogging in place test) in order to investigate the value of the ratio of recovery systolic blood pressure to peak exercise systolic blood pressure (postexercise pressure ratio) compared to the classic ST depression. The postexercise pressure ratio was significantly higher in patients with coronary artery disease than in patients with normal coronary arteries for each of the 2 exercise tests (P < 0.001 − P < 0.00001). On the contrary, we obtained significantly lower sensitivities for the pathologic (> ± 2 SD of patients with normal coronary arteries) values of the post-exercise pressure ratio than for the positive electrocardiographic outcome 30% vs 58% (P < 0.00002) and 37% vs 64% (P < 0.0001) as well as lower accuracies 48% vs 63% (P < 0.03) and 52% vs 71% (P < 0.005), respectively.

Thus, we proved that the classic ST depression has much more diagnostic value than the post-exercise pressure ratio and this result is independent of the exercise methodology. Consequently this ratio is not recommended to replace the electrocardiographic exercise criteria.     

老年原发性高血压合并冠心病患者收缩压下降过程中J形曲线现象的分析

目的探讨老年原发性高血压合并冠心病患者不同收缩压水平与心脑血管事件发生的关系。方法回顾性分析老年原发性高血压合并冠心病患者750例,按不同收缩压水平,以10mm Hg(1mm Hg=0.133kPa)为界限分为6组:1组收缩压<120mm Hg;2组收缩压120¹29mm Hg;3组收缩压130129mm Hg;3组收缩压130¹39mm Hg;4组收缩压140139mm Hg;4组收缩压140¹49mm Hg;5组收缩压150149mm Hg;5组收缩压150¹59mm Hg;6组收缩压≥160mm Hg。统计终点事件数,采用Cox比例风险回归模型分析,观察不同收缩压水平对心脑血管事件的影响。结果与4组比较,5组和6组患者心脑血管事件发生相对风险明显增加(P<0.01);校正危险因素后,与4组比较,1组、5组和6组患者心脑血管事件发生相对风险明显增加(RR值分别为1.83、1.97、3.06 vs 1.0,P<0.05,P<0.01)。结论老年原发性高血压合并冠心病患者收缩压过高或过低,心脑血管事件发病率明显增加,收缩压下降过程中"J形曲线"现象是存在的。     

解读2005年《中国高血压防治指南(修订版)》(四)(续)高血压治疗中收缩压与脉压的意义

3收缩压及脉压增高对靶器官的损害3.1左心室肥厚高血压引起的左心室肥厚(left ven-tricular hypertrophy,LVH)是左室壁为平衡动脉血压的升高而发生的适应性改变过程,多种血液动力学和非血液动力学因素参与了LVH的形成。前者主要是压力负荷和容量负荷,后者包括遗传因素、交感神经张力、肾素-血管紧张素系统的活性、肥胖以及血液黏稠度等。无论对于总死亡率,还是对于心血管事件的发病率和死亡率,经超声心动图诊断的LVH都是一个很强的、独立的危险因素。Benetos等对12721例血压正常者和7324例高血压患者随访19.2年发现,脉压水平升高是心血…     

脉压与冠状动脉病变严重性的关系研究

目的　探讨脉压与冠状动脉病变严重程度的关系。方法　 374例经冠状动脉造影确诊的冠心病患者 ,其中男 30 6例 ,女 68例 ,年龄 31～ 81 (58 1± 1 0 1 )岁。外周肱动脉压力测定收缩压、舒张压。冠状动脉病变的严重程度用冠状动脉病变的血管支数表示。结果　合并高血压的患者冠状动脉双支 (37 5 %比 8 6 % )和三支 (2 7 2 %比 1 4 8% )血管病变的患病率显著高于未合并高血压组 (P<0 0 0 1 ) ;与脉压 <65mmHg (1mmHg=0 1 33kPa)的患者相比 ,脉压≥ 65mmHg的患者冠状动脉 3支血管病变的患病率显著增高 (35 9%比 1 9 4% ,P <0 0 5)。多因素分析结果显示 ,年龄和升主动脉内径是预测冠状动脉病变严重程度的最佳参数。结论　脉压是最为方便的反映大动脉弹性的参数 ,与冠状动脉病变的严重程度密切相关 ,可作为全身心血管病的一个危险信号 ,指导早期干预     

Angiotensin-converting enzyme genotype interacts with systolic blood pressure to determine coronary heart disease risk in healthy middle-aged men

The impact of the ACE I/D polymorphism on coronary heart disease (CHD) risk is modest at most, however it may act as a modifier gene. ACE genotype was determined in 2711 healthy middle-aged men (mean age 56 years) followed for 15 years. No genotype-CHD risk association was found, but when analyzed by quartiles of systolic blood pressure (SBP), compared with II homozygotes, carriage of each additional D allele was protective at lower SBP, but in the highest quartile (SBP >150 mm Hg) conferred almost 1.5 times the risk for CHD (genotype interaction P=0.003). When SBP was analyzed as a continuous variable, again a highly significant association was seen, with the hazard ratio ([95% CI]) for a 1 SD increase in SBP being 0.90 [0.70 to 1.15] for IIs and 1.40 [1.21 to 1.61] for ID/DD (genotype SBP interaction P=0.002). The D allele was protective against CHD at lower SBP but would overtake the II risk at higher SBP. In hypertension, the proinflammatory or prohypertrophic properties of angiotensin II may explain this association. The LPL S447X polymorphism also impacts on CHD risk through interaction with hypertension, and there was an additive action of these 2 polymorphisms and SBP on CHD risk (hazard ratio for 1 SD increase in SBP for combined genotypes 1.78 [1.30 to 2.45]). Thus in the presence of hypertension, common variation in "modifier" genes confers significant CHD risk.     

Lowering of blood pressure and coronary blood flow in isolated systolic hypertension.

BACKGROUND: In essential hypertension, the lower limit of autoregulation of coronary flow shifts to higher perfusion and the hypertensive ventricle is at a higher than normal risk of ischemia, and less able to tolerate acute reduction of coronary perfusion pressure. Little is known about pattern of coronary flow in isolated systolic hypertension, a pathologic condition in which the elevated systolic blood pressure is associated with a lower than normal vascular compliance and normal or slightly greater than normal mean arterial pressure and vascular resistance. OBJECTIVE: To evaluate the effects of rapid normalization of blood pressure on coronary blood flow in isolated systolic hypertension. METHODS: We subjected 20 patients with isolated systolic hypertension to intraoperative hemodynamic and transesophageal echocardiographic monitoring during peripheral vascular surgery. Coronary flow velocity integrals and diameters in the left anterior descending coronary artery were evaluated under baseline conditions and after normalization of blood pressure, which occurred spontaneously during anesthesia (10 cases; group 1A) or was induced by infusion of nitrate (10 cases, group 1B). RESULTS: After normalization of systolic blood pressure integrals decreased significantly only for patients in group 1A; percentage changes of diameter were significantly greater for patients in group 1B. Therefore, coronary blood flow after normalization of systolic blood pressure increased for patients in group 1B (by 28+/-25%) and decreased for patients in group 1A (by 30+/-21%). Changes in integrals were inversely related to those in diameter (r= -0.72, P < 0.001); for patients in group 1A changes in coronary perfusion pressure and diameter were related to those of integrals (r= 0.94; P < 0.0005). CONCLUSIONS: In isolated systolic hypertension, despite there being similar changes of the systolic blood pressure, administration of nitrates caused a marked increase of coronary flow through direct effects on coronary circulation, whereas spontaneous normotension was associated with a significant reduction of coronary flow.     

A model for predicting the future incidence of coronary heart disease within percentiles of coronary heart disease risk

BACKGROUND: We present a method (The CHD Prevention Model) for modelling the incidence of fatal and nonfatal coronary heart disease (CHD) within various CHD risk percentiles of an adult population. The model provides a relatively simple tool for lifetime risk prediction for subgroups within a population. It allows an estimation of the absolute primary CHD risk in different populations and will help identify subgroups of the adult population where primary CHD prevention is most appropriate and cost-effective. METHODS: The CHD risk distribution within the Australian population was modelled, based on the prevalence of CHD risk, individual estimates of integrated CHD risk, and current CHD mortality rates. Predicted incidence of first fatal and nonfatal myocardial infarction within CHD risk strata of the Australian population was determined. RESULTS: Approximately 25% of CHD deaths were predicted to occur amongst those in the top 10 percentiles of integrated CHD risk, regardless of age group or gender. It was found that while all causes survival did not differ markedly between percentiles of CHD risk before the ages of around 50-60, event-free survival began visibly to differ about 5 years earlier. CONCLUSIONS: The CHD Prevention Model provides a means of predicting future CHD incidence amongst various strata of integrated CHD risk within an adult population. It has significant application both in individual risk counselling and in the identification of subgroups of the population where drug therapy to reduce CHD risk is most cost-effective.     

Assessment of outcomes other than systolic and diastolic blood pressure: pulse pressure,arterial stiffness and heart rate

In recent years, studies have shown that parameters derived from the arterial pressure wave other than systolic and diastolic blood pressure provide important information on cardiovascular status. Among these parameters, pulse pressure, arterial stiffness and heart rate have emerged as independent markers of cardiovascular risk in different populations. Although a number of studies have used casual measurements of these parameters in a clinic setting, others have focused on their assessment under ambulatory conditions.The pulse pressure represents the amplitude of the pressure wave signal (systolic minus diastolic blood pressure), higher pulse pressure values having been reported in patients possessing cardiovascular risk factors. Close associations between a high pulse pressure and several surrogate end-points have been described. Furthermore, epidemiological studies have shown that a high pulse pressure is an independent predictor of hard end-points in several populations. Arterial stiffness represents one of the major haemodynamic factors determining pulse pressure.Pulse wave velocity, measured from the initial upstroke of the pressure wave, constitutes an established index of arterial stiffness. Studies have reported stiffer arteries in patients with cardiovascular pathology even at an early stage of disease. Close correlations between arterial stiffness and several surrogate markers have been reported, and arterial stiffness and its changes have recently been shown to be an independent predictor of hard end-points in patients with a high cardiovascular risk. Methods to evaluate arterial stiffness under ambulatory conditions are emerging.Heart rate represents the frequency of the cyclical strain of the arterial wall, clinical studies having shown that ambulatory heart rate is correlated to several surrogate markers. A few epidemiological studies have analysed the value of ambulatory heart rate as an independent predictor of hard end-points, but their positive findings need to be confirmed.The analysis of the pressure wave thus allows the determination of several haemodynamic indices other than systolic and diastolic blood pressure. Pulse pressure, arterial stiffness and heart rate constitute other outcomes that may be useful as additional factors in risk assessment for future therapeutic decision-making.