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题名:
老年射血分数保留性心力衰竭临床病理特点研究——基于1485例尸检资料分析
作者: 柴坷
答辩日期: 2016-05-10
导师: 杨杰孚
专业: 内科学
授予单位: 北京大学
授予地点: 北京大学第五临床医学院
学位: 博士
关键词: 心力衰竭 ; 射血分数保留 ; 老年 ; 冠心病 ; 尸检
其他题名: The clinical and pathological acteristics of elderly patients with heart failure and preserved ejection fraction
分类号: R541.6
摘要:

背景

射血分数保留性心力衰竭(heart failure with preserved ejection fraction, HFpEF)患者约占心力衰竭(心衰)患者总数的50%,病情的严重程度与射血分数降低性心衰(heart failure with reduced ejection fraction, HFrEF)相当,预后也并不优于HFrEF,目前对于HFrEF有效的治疗手段未能被证实使HFpEF患者获益。HFpEF存在不同于HFrEF的病理生理机制,目前认为HFpEF是一种以舒张功能不全为核心的、多系统参与的、高度异质性的疾病。HFpEF患者普遍年龄偏大且合并症众多,但包括冠状动脉粥样硬化性心脏病(冠心病)在内的诸多合并症在HFpEF中发挥的确切作用还不明确。阐明HFpEF与这些疾病的相互关系有助于进一步揭示HFpEF的病理生理机制,寻找能够改善预后的治疗方法。

目的

本研究旨在通过收集和整理老年HFpEF病例的临床资料和系统病理解剖资料,阐述其临床特征、心脏病理改变和冠状动脉病变的特点,分析上述因素在HFpEF中发挥的作用,寻找与HFpEF相关的独立危险因素。

方法

在1485例行尸体解剖的死亡病例中,研究无选择地纳入其中有临床资料可查的60岁~99岁(含)病例共862例,收集相关临床和病理资料。根据病史和相关辅助检查结果筛选出HFpEF组(154例)和非心衰组(450例),并从非心衰组中选取年龄、性别与HFpEF组匹配的非心血管性死亡的141例患者作为对照组。通过与非心衰组和对照组的比较,总结HFpEF病例的临床特征、心脏结构改变、冠心病及冠脉病变特点和死亡原因等。根据是否达到冠心病的病理诊断标准,将HFpEF病例分为HFpEF合并冠心病组和HFpEF无冠心病组,根据年龄将HFpEF病例分为>85岁组和≤85岁组,比较不同分组方式下两组别之间的临床病理特点。

结果

1. HFpEF病例共154例,占有超声心动图资料的心衰患者的68.8%(154/224),HFpEF组的平均年龄85.7±7.4岁,随年龄增长HFpEF患者增多(P<0.001)。

2. HFpEF组有高血压病124例(80.5%)、糖尿病90例(58.4%)、高脂血症50例(32.5%)、心房颤动(房颤)101例(65.6%)、病态窦房结综合征60例(39%)、慢性阻塞性肺疾病(onic obstructive pulmonary disease, COPD)41例(26.6%)和慢性肾脏病(onic kidney disease, CKD)78例(50.6%),合并上述疾病的比例较非心衰组和对照组高(P值均<0.05)。

3. HFpEF组心脏平均质量(439.9±90.9)g,左右心室的平均厚度分别为(1.44±0.3)cm和(0.35±0.14)cm,检出左室肥厚38例(24.7%)、左室扩大40例(26%)、右室肥厚15例(9.7%)和右室扩大36例(23.4%)。与非心衰组相比,HFpEF组的心脏质量更大(P<0.001),检出左右心室肥厚和扩大的比例更高(P值均<0.05)。与对照组相比,同样是HFpEF组的心脏质量更大(P<0.001),检出右室肥厚和左右心室扩大的比例更高(P值均<0.05)。

4.心血管性死亡是老年HFpEF病例的首要死因,占41%。

5. HFpEF组冠心病的检出率为68.2%(105/154),急性心肌梗死(acute myocardial infarction, AMI)检出率12.3%(19/154)、陈旧性心肌梗死(old myocardial infarction, OMI)检出率50.6%(78/154),存在IV级狭窄冠脉的比例为20.1%(31/154),多支病变的比例为33.8%(52/154),平均冠脉积分7.5±3.0,均高于非心衰组和对照组(P值均<0.05)。以病理诊断为金标准,HFpEF病例中临床诊断冠心病的误诊率达63.3%,AMI的漏诊率达57.9%,OMI的漏诊率达57.7%。

与HFpEF无冠心病病例相比,HFpEF合并冠心病者患糖尿病、高尿酸血症和贫血的比例更高(分别为65.7%比42.9%、15.2%比4.1%、70.5%比49%、P值均<0.05),检出左室扩大更多(32.4%比12.2%,P=0.008)。

6. 与≤85岁HFpEF患者(73例,47.4%)相比,>85岁HFpEF患者(81例,52.6%)合并房颤、COPD和老年退行性心脏瓣膜病的比例高(分别为72.8%比57.5%、37%比15.1%、33.3%比15.1%,P值均<0.05),心脏病理改变中检出慢性心肌缺血和小灶性OMI更多(24.7%比11%,P=0.027;13.6%比4.1%,P=0.041)。

7. HFpEF的危险因素:经Logistic回归分析,发现年龄、高血压病、糖尿病、房颤、COPD、心脏质量和冠脉积分是HFpEF的独立危险因素(P值均<0.05)。

结论

1.随年龄增长HFpEF患者增多。

2. HFpEF患者存在心脏质量增加、心室肥厚和心室扩大等心脏结构改变。

3.心血管性死亡是老年HFpEF患者的首要死因。

4. HFpEF患者合并冠心病特别是OMI的比例高,但临床上冠心病的误诊率和MI的漏诊率较高。

5.年龄、高血压病、糖尿病、房颤、COPD、心脏质量和冠脉积分是HFpEF的独立危险因素。

英文摘要:

Background

Nearly half of the HF patients are heart failure with preserved ejection fraction (HFpEF). The severity and outcomes of HFpEF are similar to heart failure with reduced ejection fraction (HFrEF). Current treatment has been proven not to improve the prognosis of patients with HFpEF. The pathophysiology of HFpEF is quite different from HFrEF. HFpEF is considered to be predominantly caused by diastolic dysfunction with complex, multi-factorial pathophysiology and clinical heterogeneity. HFpEF is more common in older persons and with many cardiovascular and noncardiovascular comorbidities, including coronary artery disease (CAD), hypertension, diabetes mellitus (DM), onic obstructive pulmonary disease (COPD), renal dysfunction, anemia, etc. The exact pathophysiology is unknown. The relationship between HFpEF and these comorbidities will provide new mechanistic insights and opportunities for progress in management. But there are limited studies focusing on the clinical and pathological acteristics in the elderly patients with HFpEF.

Objections

This study was designed to investigate the clinical and pathological acteristics of elderly patients with HFpEF, describe their clinical features and pathological changes of heart and coronary arteries, and explore the risk factors of HFpEF.

Methods

It was a retrospective study involving 862 subjects aging from 60 to 99 with clinical data from 1485 autopsy cases. 154 HFpEF patients (LVEF≥50%), 450 non-HF patients and 141 age-sex-appropriate control subjects (noncardiovascular death from non-HF patients) were identified according to medical history and echocardiography. The subjects with HFpEF were stratified into two categories: 1) with (n=105) and without CAD (n=49), and 2) ≤85 years (n=73) and >80 years (n=81). Clinical features, cardiac structure, other organs’ pathological alterations, CAD severity and death causes were examined.

Results

1. Of the 862 cases, 154 had HFpEF with echocardiogram-proven LVEF≥50%. The proportion of HFpEF increased with advancing age (P<0.001).

2. Compared with non-HF and control patients, subjects with HFpEF were more likely to have cardiovascular and non-cardiovascular comorbidities (all P<0.05), including HT (80.5%), DM (58.4%), hyperlipidemia (32.5%), atrial fibrillation (65.5%), sick sinus syndrome (39%), COPD (26.6%) and CKD (50.6%).

3. The average heart weight of subjects with HFpEF was 439.9±90.9 g. The average left ventricular thickness was 1.44±0.3 cm and right was 0.35±0.14 cm. Subjects with HFpEF displayed 24.7% left ventricular hypertrophy, 9.7% right ventricular hypertrophy, 26% left ventricular enlargement and 23.4% right ventricular enlargement. Compared with non-HF, HFpEF subjects displayed heavier heart (P<0.001), more ventricular hypertrophy and ventricular enlargement (all P<0.05). Compared with control patients, HFpEF subjects displayed heavier heart (P<0.001), more right ventricular hypertrophy, left ventricular enlargement and right ventricular enlargement (all P<0.05).

4. The majority of deaths in HFpEF were cardiovascular deaths (41%).

5. 65.7% HFpEF subjects had ≥1 vessel with >50% diameter coronary artery stenosis while 12.3% had AMI and 50.6% had OMI. Compared with non-HF and control patients, HFpEF subjects had more severe coronary artery stenosis (20.1% with ≥1 vessel with >75% diameter stenosis, 33.8% with ≥2 vessel with >50% diameter stenosis, and average coronary artery score 7.5±3.0; all P<0.05). 63.3% patients with HFpEF-CAD were clinically misdiagnosed. 57.9% patients with HFpEF-AMI and 57.7% patients with HFpEF-OMI were missed diagnosed.

6. HFpEF subjects with CAD were more likely to have DM (65.7% vs. 42.9%, P=0.007), hyperuricemia (15.2% vs. 4.1%, P=0.045) and anemia (70.5% vs. 49%, P=0.01) and displayed more left ventricular enlargement (32.4% vs. 12.2%, P=0.008) compared with non-CAD HFpEF subjects.

7. Of the 154 patients with HFpEF, 81(52.6%) were aged over 85 years-old. This group had more atrial fibrillation (72.8%, P=0.046), COPD (37%; P=0.002) and senile degenerative heart valvular disease (33.3%, P=0.009) and displayed more onic myocardial ischemia (24.7%, P=0.027) and mini-focal OMI (13.6%, P=0.041) compared with patients with HFpEF aged ≤85 years.

8. By multivariable analysis, increasing age, HT, DM, atrial fibrillation, COPD, heart weight and coronary artery score were independent risk factors (all P<0.05).

Conclusions

HFpEF is common in older persons and the proportion of HFpEF increases with advancing age. HFpEF displays cardiac structural alterations including heart weight increase, ventricular hypertrophy and enlargement. Cardiovascular deaths are the majority of deaths in HFpEF. CAD especially OMI is common in patients with HFpEF, but is misdiagnosed and missed diagnosed a lot. HFpEF is associated with many comorbidities. Increasing age, HT, DM, atrial fibrillation, COPD, heart weight and coronary artery score may be independently related to HFpEF.

语种: 中文
相关网址: 查看原文
内容类型: 学位论文
URI标识: http://ir.bjmu.edu.cn/handle/400002259/124785
Appears in Collections:北京大学第五临床医学院_学位论文

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作者单位: 北京大学第五临床医学院

Recommended Citation:
柴坷. 老年射血分数保留性心力衰竭临床病理特点研究——基于1485例尸检资料分析[D]. 北京大学第五临床医学院. 北京大学. 2016.
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