初診斷高血壓的左心室舒張性機能障礙與其不同步舒張功能之相關性研究

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初診斷高血壓的左心室舒張性機能障礙與其不同步舒張功能之相關性研究

Diastolic Dyssynchrony is Associated with Diastolic Dysfunction of the Left Ventricle in Untreated Hypertension

蔡蕙如 , Masters　　Advisor：徐怡強　　Co-advisor ：蔡惟全

繁體中文

高血壓；舒張性機能障礙；左心室早期舒張應變率； hypertension ； diastolic dyssynchrony ； early diastolic strain rate

Abstract │ Reference (22) │ Altmetrics

Abstract 〈TOP〉

背景: 舒張性機能障礙，是高血壓病人常見的異常左心室舒張表現。目前已知因素有左心房壓力變化、二尖瓣瓣膜性疾病、以及心肌梗塞。但心肌舒張不同步對高血壓性心臟疾病的異常舒張機轉，尚未闡明。
研究目的: 此研究在探討左心室不同步舒張功能對初診斷高血壓病人左心室舒張性機能障礙的影響。
研究方法: 此研究包含43位門診初診斷高血壓的病人，平均年齡51.28 ± 12.54歲，55.8%為男性。在開始治療前完成充分的心臟超音波檢查。運用傳統心臟超音波對左心室舒張功能的系統性評估，輔以組織杜普勒影像，與心肌形變影像的二維斑點跟蹤超音波圖分析，
將肉眼仍無法辨識的心肌機械性活動量化。根據2016年由美國心臟超音波學會與歐洲心血管學會所共同更新的左心室舒張功能之心臟超音波評估準則，來診斷左心室舒張功能異常與否。
心臟各區段心肌在主動脈關閉後，早期舒張心肌達最大伸展速度、或應變率（strain rate）的時間，均以心電圖的QRS波起點為基礎計算。分別從心尖四腔切面圖（apical-4-chamber view）、心尖二腔切面圖（apical-2-chamber view）、與心尖長軸圖(apical long-axis view)，運用組織杜普勒超音波，量出6個QRS起點至最大二尖瓣環壁早期舒張速度（Time to Peak Early Diastolic Mitral Annular Velocity, Te’)的區間。另以二維斑點追蹤心臟超音波圖分析3個心尖切面圖內18個心肌區段的整體縱向應變（Global Longitudinal Strain）、收縮期後縮短(Post-Systolic Shortening, PSI)、與縱向的應變率（Longitudinal Strain Rate）。從心電圖QRS 波起點量測到最大早期舒張應變率（Time to Peak Early Diastolic Strain Rate, TDSr），取得另一個評估心肌達早期舒張應變率的時間長短。透過以上的時間長短，定義以下三個舒張不同步參數：1）Te’-SD為6個Te’的標準差，2) TDSr-SD為18個TDSr的標準差，3) MaxD-TDSr為18個TDSr中，任兩個相減的最大差異值。
研究結果: 研究結果顯示，所有的高血壓病人無結構性心臟疾病或心肌肥厚。根據2016年更新的心臟超音波舒張功能診斷準則，有六位（14%）高血壓病人有異常的舒張功能。正常與異常舒張功能的病人之間，在年紀、收縮壓、舒張壓、左心室質量指數、與左心室射出分率等特色上並無統計上的差異。MaxD-TDSr在正常與異常舒張功能的高血壓病人間則有顯著性的差異(139.14±46.31 ms vs. 195.50±20.57 ms, p=0.006)，另一方面，Te’-SD、TDSr-SD與PSI參數在高血壓兩類舒張功能病人間，則無差異性存在。三個舒張不同步參數中，唯二的TDSr與收縮壓(r = -0.364, p = 0.016)及舒張壓(r = -0.447, p = 0.003)，還有Max-TDSr與收縮壓(r = -0.457, p = 0.002)及舒張壓(r = -0.576, p<0.001)分別具備有意義的關聯性。在控制血壓下進行多變量分析，MaxD-TDSr (OR 1.038; 95% CI 1.005-1.073; p=0.023)仍是預測舒張性機械障礙有意義的因子。
總結: 在各項舒張不同步參數中，Maximal Difference of Time to Early Diastolic Strain Rate (MaxD-TDSr)是尚未接受治療的初診斷高血壓病人出現異常舒張功能的獨立預測因子。並且，該預測因子與血壓有很好的關聯性。因此，MaxD-TDSr是左心室舒張機械性障礙在高血壓影響下的早期標記。

Reference ( 22 ) 〈TOP〉

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