心肌声学密度定量分析检测高血压心肌纤维化

目的 观察原发性高血压患者心肌声学密度和血清Ⅲ型前胶原末端肽(PⅢNP)含量的变化情况,以评估心肌声学密度定量分析技术检测高血压心肌纤维化的临床价值.方法 入选原发性高血压患者75例(高血压组),另选健康体检者75例为对照组.应用超声心动图测量声学密度各项值,采用放免法测定PⅢNP的浓度.结果 高血压组的声学强度(CAI)显著高于健康对照组(P＜0.01),而高血压组的背向散射积分周期变化值(CVIB)(室间隔:6.07±0.85,左室后壁:7.00±1.15)显著低于健康对照组(室间隔:8.60±3.12,左室后壁:11.85±3.06,P＜0.05);高血压组血清PⅢNP含量(109.9±7.5)μg/L显著高于健康对照组[(43.9±5.9)μg/L,P＜0.01];血清PⅢNP与室间隔和左室后壁声学强度呈显著正相关(P＜0.01),与室间隔和左室后壁CVIB呈显著负相关(P＜0.01).结论 心肌声学密度定量分析技术是检测高血压心肌纤维化的一项可靠技术.     

苯那普利和缬沙坦对原发性高血压患者心肌声学密度的影响

目的:观察原发性高血压患者应用苯那普利和缬沙坦前后心肌声学密度各指标的变化情况,以探讨苯那普利和缬沙坦对高血压心肌纤维化的作用。方法:共入选原发性高血压患者75例(A组),随机分为3个亚组:A1组(25例),给予苯那普利10mg/d;A2组(25例),给予缬沙坦160mg/d;A3组(25例),给予苯那普利和缬沙坦半剂量合用(苯那普利5mg/d加缬沙坦80mg/d),均治疗6个月,并设立正常对照组(B组)75例。应用超声心动图测量心肌声学密度各项值:室间隔矫正的声学强度(CAI1)和左室后壁矫正的声学强度(CAI2)及室间隔背向散射积分周期变化值(CVIB1)、左室后壁背向散射积分周期变化值(CVIB2)。结果:A组的收缩压和舒张压显著高于B组,A1、A2、A3亚组用药后的收缩压和舒张压均显著低于用药前(均P<0.01);A组的CAI1、CAI2(0.88±0.06,0.73±0.06)显著高于B组(0.66±0.19,0.54±0.06)(P<0.01),而A组的CVIB1、CVIB2(6.07±0.85),(7.00±1.15)dB显著低于B组(8.60±3.12),(11.85±3.06)dB(均P<0.05);A1和A2亚组用药后CAI1、CAI2、CVIB1、CVIB2比较均差异无统计学意义(均P>0.05);A3组用药后CAI1、CAI2显著低于A1、A2组用药后(P<0.01),而A3组用药后CVIB1、CVIB2显著高于A1、A2组用药后(P<0.01;P<0.05)。结论:心肌声学密度各参数可用于评价高血压心肌纤维化,苯那普利和缬沙坦都减轻心肌纤维化,两者合用在减轻心肌纤维化方面效果更明显。     

原发性高血压患者心肌声学密度与左室舒张功能的关系

目的 探讨原发性高血压患者不同左室构型的心肌声学密度(AD)和左室舒张功能的关系.方法 选择原发性高血压患者92例,根据左心室质量指数和相对室壁厚度分成4 组:正常构型组(20例)、向心性重构型组(22例)、向心性肥厚型组(30例) 和离心性肥厚型组(20例).健康体检者30例作为正常对照组.用AD技术测量室间隔和左室后壁矫正的声学强度(CAI1、CAI2)及背向散射积分周期变化值(CVIB1、CVIB2),LVW测定二尖瓣口血流速率E/A比值.结果 (1)正常构型组的CAI1、CAI2、CVIB1及CVIB2值与正常对照组比较均无显著性差异,高血压余组的CAI1、CAI2值显著高于正常对照组(P＜0.01),以向心性肥厚型组为最高,其次是向心性重构型组、离心性肥厚型组,CVIB1、CVIB2值显著低于正常对照组(P＜0.05),以向心性肥厚型组为最低,其次是离心性肥厚型组、向心性重构型组;(2)高血压各组E/A值均显著低于正常对照组(P＜0.01);(3)CAI1、CAI2与E/A比值呈显著负相关(P＜0.01),CVIB1、CVIB2与E/A比值呈显著正相关(P＜0.01).结论 心肌AD参数可用来评价高血压患者不同左室构型心肌纤维化程度,并且与左室舒张功能显著相关.     

hsCRP与原发性高血压心肌纤维化相关性分析

目的 观察原发性高血压患者血清高教C反应蛋白(hsCRP)与心肌声学密度的变化情况,探讨hsCRP与高血压心肌纤维化的关系.方法 将入选对象84例,分为健康对照组30名,原发性高血压无左心室肥厚组(NLVH) 28例及原发性高血压左心室肥厚组(LVH)26例.应用超声心动图测量声学密度各项值,采用免疫胶乳比浊法测定hsCRP.结果 NLVH组hsCRP与对照组相比有增高趋势,但无统计学意义(P＞0.05),LVH组hsCRP与NLVH组相比显著性升高(P＜0.01).NLVH组与对照组相比,矫正的声学强度(CAI1、CAI2)背向散射积分周期变化值(CVIB1、CVIB2)无统计学意义(P＞0.05),LVH组与NLVH组相比,CAI1、CAI2值显著性升高(P＜0.01),CVIB1、CVIB2值显著性降低(P＜0.01).hsCRP与CAI1、CAI2呈直线正相关(P＜0,01),hsCRP与CVIB1、CVIB2呈直线负相关(P＜0.01).结论 hsCRP与原发性高血压心肌纤维化之间有明显相关性.     

肥厚型心肌病与高血压性心脏病心肌超声组织定征的鉴别诊断

目的探讨肥厚型心肌病、高血压病患者与正常人左室后壁、室间隔心肌声学特性是否存在差异,以期将超声组织定征作为鉴别诊断的指标之一. 方法将被检者分成3组肥厚型心肌病组(HCM组)、高血压性心脏病组(EH组)及正常对照组,分别测定各组左室后壁、室间隔部位的心肌背向散射参数.结果左室后壁心肌HCM组与EH组的IBS、CVIB无显著性差异(P>0.05),而与正常对照组均有差异(P<0.05);室间隔部位3组IBS、CVIB均有显著性差异(P<0.05);HCM组室间隔、左室后壁均存在IBS、CVIB的跨壁梯度,而EH组、正常对照组则无上述异常存在.结论 HCM患者左室后壁心肌的声学特性与正常对照组有差异,室间隔与左室后壁均存在IBS、CVIB的跨壁梯度.因此背向散射参数测定可作为鉴别肥厚型心肌病和高血压性心脏病的一项指标.     

血清脂联素水平与高血压及心肌纤维化的关系

目的:研究血清脂联素与高血压的关系,探讨高血压患者血清脂联素水平对心肌纤维化的影响,阐明高血压患者血清脂联素水平与心肌纤维化的关系.方法:根据美国预防、检测、评估与治疗高血压全国联合委员会第七次报告(JNC-7)的血压标准,筛选出33例高血压患者(高血压组),并筛选出同期在我院体检中心观察的健康人33例(正常对照组).所有入选者清晨空腹抽取外周静脉血,用酶联免疫法测定血清脂联素、Ⅰ型前胶原羧基端肽(P Ⅰ CP)和Ⅲ型前胶原氨基端肽(P Ⅲ NP)水平.结果:与正常对照组相比,高血压组血清脂联素水平明显降低[(4.21±2.89)ng/ml比(2.69±1.00)ng/ml,P＜0.01];且1级高血压患者与2级高血压患者血清脂联素比较明显升高,差异有统计学意义(P＜0.05).与正常对照组相比,高血压组P Ⅰ CP和P Ⅲ NP水平显著增高,P Ⅰ CP分别为(13.10±6.56)ng/ml比(4.12±1.19)ng/ml,P Ⅲ NP分别为(128.94±56.37)ng/ml比(66.70±11.72)ng/ml,两组比较差异均有统计学意义(P均＜0.01).相关分析表明,血清脂联素水平与P Ⅰ CP及P Ⅲ NP水平呈明显负相关(r分别为-0.245和-0.275,P均＜0.05).结论:高血压患者血清脂联素水平明显降低,血压越高脂联素水平越低,血清脂联素水平与P Ⅰ CP及P Ⅲ NP水平呈明显负相关,推测低水平的脂联素血症在高血压心肌纤维化中可能起重要作用.     

喹那普利对缺血性心肌病患者血清胶原含量的影响

目的:观察喹那普利对缺血性心肌病(ICM)胶原合成的影响,探讨阻止ICM心肌纤维化方法。方法:采用放免方法测定12例正常者及46例ICM患者应用喹那普利治疗6周前后心肌纤维化指标:血清Ⅰ型胶原的前胶原氨基末端肽(PⅠNP)和Ⅲ型胶原的前胶原氨基末端肽(PⅢNP)含量,超声心动图测舒张末期左室内径(LVEDd),室间隔厚度(IVST),左室后壁厚度(LVPWT),计算左室重量(LVMW)及左室重量指数(LVMI)。结果:①ICM患者血清PⅠNP、PⅢNP含量较正常组显著增高,并随心功能等级增加而升高(P均0.01);②喹那普利治疗后PⅠNP[(41.28±5.33)μg/L:(74.22±12.08)μg/L]、PⅢNP[(3.96±0.99)μg/L:(10±1.13)μg/L]含量较治疗前显著下降,Ⅰ/Ⅲ较治疗前显著降低[(10.98±2.51):(12.44±1.90),P均0.01];③治疗后LVEF[(0.59±0.06)%:(0.37±0.06)%]、二尖瓣血流舒张早期流速(VE)和心房收缩期流速(VA)比值VE/VA较治疗前明显升高[(1.05±1.101):(0.78±0.102),P均0.01],LVMI较治疗前明显降低[(97.27±14.41)g/m2:(113.07±10.21)g/m2,P0.01],PⅠNP、PⅢNP与LVMI呈正相关(r=0.561,P0.01;r=0.316,P0.05),与VE/VA呈负相关(r=-0.497,P0.01),与LVEF无明显相关性。结论:喹那普利可以抑制PⅠNP、PⅢNP合成,阻止ICM心肌纤维化,从而减轻左室重量,改善心室舒张功能。     

老年高血压心肌背向散射成像声学密度定量的临床应用

目的　应用声学密度定量 (AD)方法对老年高血压病人心肌超声背向散射成像 (IBS)进行分析 ,探讨其临床诊断应用价值及意义。方法　按 1 999年 WHO高血压治疗标准并应用超声心动图仪检测 64例老年男性住院病人 ,其中正常组 31例 ,高血压组 33例 (高血压病史均 >3年且治疗时间均 >1年 ) ,比较各组室间隔心肌 IBS的 AD诸参数。结果　 Loop和两种触发方式声学密度曲线的峰值密度 (pi)、曲线下面积 (auc)高血压组均高于正常组 (均 P<0 .0 5)。结论　长期高血压和衰老致心肌组织纤维化进一步加重 ,致声学密度参数显著改变 ,其可作为简单、有效且无创的研究心肌病理学方面改变的辅助检测方法     

心衰患者心肌中NHE1 mRNA的表达与血浆内皮素及心肌胶原的相关性研究

目的:观察心力衰竭(HF)患者心肌组织中钠氢交换体1（natrium-hydrogen exchanger 1,NHE1）的表达及其与血浆内皮素-1(ET-1)及心肌胶原的相关性,探讨NHE1、ET-1在HF、心肌纤维化发生发展中的作用。方法: 采用实时荧光定量PCR（FQ-PCR）检测35例HF患者心肌组织中NHE1 mRNA的表达水平。采用放射免疫分析法分别测定受试者血浆ET-1及Ⅰ型前胶原羧基端肽Ⅰ（PⅠCP）和Ⅲ型前胶原氨基端肽（PⅢNP）的含量。同时用心脏多普勒超声检查心脏左房内径、左室射血分数（LVEF％）。结果: FQ-PCR检测心功能Ⅰ、Ⅱ、Ⅲ级组HF患者心肌组织中NHE1 mRNA的△Ct值,分别为6.29±0.66、5.01±0.60和4.40±0.74。心功能Ⅱ级、Ⅲ级组患者心肌组织中NHE1 mRNA的表达明显高于心功能Ⅰ级组（P<0.01）,心功能Ⅲ级组患者心肌组织中NHE1 mRNA的表达明显高于心功能Ⅱ级组（P<0.05）。HF组ET-1及PⅠCP、PⅢNP的含量较对照组明显升高（P<0.01）,并随着HF程度的加重而增加,心功能Ⅱ级和Ⅲ级组显著高于心功能Ⅰ级组（P<0.05,P<0.01）,心功能Ⅲ级组显著高于心功能Ⅱ级组（P<0.05）;且ET-1及PⅠCP、PⅢNP的含量与NHE1 mRNA的△Ct值（r=-0.587,P<0.01）呈显著的负相关。ET-1与PⅠCP、PⅢNP含量（r=-0.418,P<0.05）呈显著的正相关。结论: HF患者NHE1 mRNA的表达与ET-1及PⅠCP、PⅢNP的含量均密切相关。NHE1在HF、心肌纤维化的发生和发展过程中可能起着重要作用。     

超声背向散射积分量化犬心肌缺血再灌注致心肌纤维化程度的研究

目的应用超声背向散射测定结合胶原代谢物评估犬心肌缺血再灌注致心肌纤维化程度。方法 12只成年杂种犬随机分为2组:假手术组和缺血再灌注组,每组6只。测定两组血流动力学指标,于再灌注120 min后经颈内静脉采血,用超声背向散射测定技术检测室间隔和左心室后壁背向散射积分值(IBS)和背向散射积分周期变化值(CVIB)。以酶联免疫吸附法检测患者血清结缔组织生长因子(CTGF)和Ⅰ型前胶原氨基端肽(PⅠNP)。行Masson染色观察胶原纤维组织结构变化,用免疫组织化学方法检测Ⅰ型胶原蛋白表达。结果缺血再灌注组CTGF和PⅠNP水平均高于假手术组,差异有统计学意义(P0.05)。与假手术组比较,缺血再灌注组室间隔和左心室后壁的IBS明显增加,CVIB明显减小,差异有统计学意义(P0.05)。CTGF和PⅠNP水平与IBS呈正相关(P0.05),与CVIB呈负相关(P0.05)。Masson染色显示缺血再灌注组心肌纤维化明显增加。缺血再灌注组Ⅰ型胶原蛋白表达呈强阳性。结论缺血再灌注组犬超声背向散射参数IBS增加,CVIB减少,胶原代谢物CTGF和PⅠNP水平增加,心室肌纤维化参与了缺血再灌注损伤,导致心室重构。超声背向散射测定结合胶原代谢物可早期无创性检测缺血再灌注阶段心室肌纤维化程度。     

Myocardial Viability Detected by Myocardial Contrast Echocardiography—Prognostic Value in Patients after Myocardial Infarction

Objective: This study aimed to assess the role of myocardial contrast echocardiography (MCE) as a predictor of cardiac events and death in patients with acute myocardial infarction (AMI). Methods: Eighty‐six patients underwent primary percutaneous coronary angioplasty for AMI. Segmental perfusion was estimated by MCE in real time at mean 5 days after PCI using low MI (0.3) after 0.3–0.5 ml bolus injection of intravenous Optison. MCE was scored semiquantitatively as: (1) normal perfusion (homogenous contrast effect), (2) partial perfusion (patchy myocardial contrast enhancement), (3) lack of perfusion (no visible contrast effect). A contrast score index (CSI) was calculated as the sum of MCE scores in each segment divided by the total number of segments. The patients were followed up for cardiac events and death. Results: A CSI of >1.68 was taken to be a predictor of cardiac events and death. Death occurred only in patients with CSI >1.68. Patients with CSI >1.68 had a significantly (P = 0.03) higher incidence of cardiac death or cardiac events (75%) compared to those with CSI <1.68 (27%). The absence of residual perfusion within the infarct zone was an independent predictor of death and cardiac events (P = 0.02). Conclusions: The absence of residual myocardial viability in the infarct zone supplied by an infarct‐related artery is a powerful predictor of cardiac events in patients after AMI. (Echocardiography 2010;27:430‐434)     

心脏放射免疫显像进展

心脏放射免疫显像是将放射免疫显像用于心脏疾病诊断的技术。现就该技术在心肌梗死、心脏移植后排异反应、心肌炎及其它心脏疾病中的诊断作概要综述。     

负荷心肌灌注显像在心肌桥临床应用中的研究进展

负荷心肌灌注显像通过检测核素在心肌的分布,明确心肌缺血的部位和程度,因此,它能够评价冠状动脉心肌桥是否影响心肌供血及影响程度。负荷心肌灌注显像具有敏感性及特异性较高,且相对价廉、安全无创等优点,在评价心肌桥导致的心肌缺血及缺血的程度范围、判断预后及指导下一步治疗中具有重要的临床价值及应用前景。     

Assessment of Myocardial Viability in Patients With Postischemic Left Ventricular Dysfunction: Role of Myocardial Contrast Echocardiography

The distinction between viable and nonviable dysfunctional left ventricular (LV) segments after acute myocardial infarction is very important, because revascularization increases survival only in patients with viable myocardial tissue. Recent studies have highlighted a mismatch between two highly specific investigations for viability assessment: dobutamine echocardiography, which measures inotropic reserve, and myocardial contrast echocardiography (MCE), which measures microvascular perfusion. Viability and functional reserve are not synonymous. Maintenance of microvascular perfusion, independently of functional reserve, attenuates left ventricular remodelling, reduces the risk of major cardiac events, and increases survival. MCE provides similar perfusion information as myocardial blush, but image quality is much higher. Quantitative analysis of digital data provides more accurate diagnostic MCE information than qualitative analysis of video signal intensity. In a recent study relating MCE findings to histologic data, MCE-derived quantitative data were closely correlated with microvascular density and capillary area, and inversely correlated with collagen content. One of the contrast agents routinely used for MCE is SonoVue, a second generation microbubble contrast agent, which is characterized by high response to ultrasound energy, ease of destruction at high energy, and strong harmonic signal at low energy. Recommendations for the assessment of postischemic LV dysfunction: routine use of MCE, followed by dobutamine echocardiography if perfusion is documented. If MCE is negative, revascularization is not indicated; if both tests are positive, revascularization is strongly recommended; if they are discordant, useful information can be obtained by assessing the extent of ²⁰¹T1 viability. (ECHOCARDIOGRAPHY, Volume 20, Supplement 1, 2003)     

Myocardial stunning in man

Myocardial stunning refers to the contractile dysfunction that occurs following an episode of acute ischaemia, despite the return of normal blood flow. The phenomenon was initially identified in animal models, where it has been very well characterised, and there was initial doubt about whether a similar syndrome occurred in humans, and if it did, whether it was of any clinical relevance. This article outlines the conditions that must be met to diagnose myocardial stunning and why it has been difficult to confirm its presence in humans. The clinical scenarios where it has now been clearly identified and those others where it may also occur and be of clinical importance are also reviewed.     

急性心肌梗死心肌组织再灌注评价方法

急性心肌梗死后心肌组织再灌注程度与左心室功能和临床预后密切相关,因此,及时、准确的评估心肌梗死后心肌组织灌注水平对患者有着重要的意义.现就评价心肌组织再灌注的方法及应用做一综述.     

左-卡尼汀对缺血心肌的保护作用

左-卡尼汀又名肉碱,是脂肪酸进行β-氧化必不可少的载体。正常情况下,心肌能量总需量的60%～90%由游离脂肪酸进行β-氧化所提供。心肌细胞缺血缺氧时,氧化磷酸化功能下降,内源性左-卡尼汀合成障碍,引起心肌的一系列代谢改变。近年来研究认为左-卡尼汀通过不同的机制对缺血心肌具有保护作用。     

卡托普利对动脉粥样硬化家兔心肌缺血─再灌注心肌功能的影响

采用喂饲高脂饮食形成的动脉粥样硬化家兔开胸结扎左冠脉中点造成心肌缺血３０ｍｉｎ再灌注２ｈ，观察在有无动脉粥样硬化、是否用卡托普利以及不同给药时间等三因素二水平条件下，心肌舒缩功能和自由基方面的指标，显示卡托普利对动脉粥样硬化家兔心肌缺血－再灌注损伤有心肌保护作用，并提示这一作用与其抗自由基的能力有关。     

Transesophageal Echocardiographic Study of Right Atrial Myocardial Infarction and Myocardial Viability

In order to determine the effects of dobutamine on right atrial wall movement, two groups were studied using transesophageal echocardiography. Group A included six patients without ischemic heart disease. Group B included six patients with infarction of the inferior wall of both ventricles and abnormal wall movement of the right atrium. In group A, an increase in the amplitude of right atrial movement was observed with dobutamine at doses of 5 and 10 μ/kg per minute. In group B, infusion of dobutamine did not modify wall akinesis in three patients with right atrial infarction; in the remaining three, alterations of segmental atrial movement were evident, and their responses to dobutamine were related to the patency of right atrial coronary branches. The following conclusions were reached: (1) dobutamine has a positive inotropic effect on atrial myocardium; (2) right atrial ischemia appears in the echocardiogram as altered segmental or global wall movement; (3) dobutamine can be used in the evaluation of atrial myocardial viability.     

心肌桥最新研究进展

心肌桥是一种先天性解剖变异,临床意义一直是一个讨论和争议话题。以往认为心肌桥是一种良性解剖变异,目前越来越多的研究表明,心肌桥可导致急性心肌缺血、心肌梗死、心律失常甚至心源性猝死。因此,临床医生应该提高对心肌桥的认识,根本上理解心肌桥的发病机制及病理生理,及时发现与心肌桥有关的临床表现,早期诊断心肌桥,正确掌握心肌桥的治疗原则。现就心肌桥最新研究结果予以概述,目的在于提高对心肌桥的认识,优化心肌桥患者的治疗。