1 / 58

中心动脉压与血管功能

中心动脉压与血管功能. 大连医科大学附属一院心内科 姜一农. 动脉压 相关因素. 心搏量 末梢阻力 血管壁硬度 反射波. 中心动脉压. 主动脉顺应性(大血管硬度) 反射波 时间 幅度. Aortic compliance and pulse pressure. Windkessel function. Normal. 60%. Diastole. Systole. 60%. 40%. Decreased aortic compliance. 50%. Diastole. 50%. Systole. 50%.

azuka
Télécharger la présentation

中心动脉压与血管功能

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. 中心动脉压与血管功能 大连医科大学附属一院心内科 姜一农

  2. 动脉压相关因素 • 心搏量 • 末梢阻力 • 血管壁硬度 • 反射波

  3. 中心动脉压 • 主动脉顺应性(大血管硬度) • 反射波 时间 幅度

  4. Aortic compliance and pulse pressure Windkessel function Normal 60% Diastole Systole 60% 40% Decreased aortic compliance 50% Diastole 50% Systole 50% London and Guerin. Am Heart J 1999;138:220-224

  5. 主动脉顺应性下降 • 大动脉顺应性降低,弹性降低,收缩压力在动脉内不能得到缓冲,使收缩压升高。 • 舒张期大血管弹性回缩减低,使舒张压降低。 • 结果:脉压增大

  6. Augmentation andreflection wave Incident wave Reflection wave McDonald’s fourth edition

  7. Arterial pressure waveform and reflection wave Systolic BP Augmentation Index Diastolic BP Arrival of reflection wave

  8. 反射波机制对中心动脉压的影响 • 脉搏波传导速度(PWV) --反射波速度 • 阻力微、小动脉—反射位点 • 动脉弹性--反射波幅度  心率--反射波在收缩期叠加的幅度

  9. AI与主动脉压、脉压的测量

  10. Attenuation of peripheral augmentation effect by arterial stiffness Peripheral BP and central BP 150 100 68 years old (mmHg) 50 150 24 years old 100 (mmHg) 50 Nichols WW et al. 1993

  11. Age and central blood pressure Radial BP was matched as 150 mmHg in all age groups (mmHg) 160 140 Reflection component 120 100 Incident component Estimated aortic blood pressure 80 60 Aortic diastolic BP 40 20 31 31 49 32 0 -49 50-59 60-69 70- Age Kohara K et al. J Am Geriatr Soc, 1999

  12. Arterial stiffness Reduced compliance Impaired Windkessel function augmentation by reflection pressure wave Central hypertension Systolic hypertension Wide pulse pressure

  13. The Great Hemodynamic Divide Mean Pressure Pulse Pressure Anatomy Heart, small arteries Aorta Physiology ↑ Cardiac output ↑ Stiffiness↑ Peripheral resistance BP ↑ SBP ,↑ DBP↑ SBP ↓ DBPEvent ↑Risk ↑↑↑Risk

  14. The Strong Heart Study Central Blood Pressure Better predicts Cardiovascular Events than Does Peripheral Blood Pressure 2662 patients, 63yrs, follow-up 3.4y Roman MJ, et al. AHA Sept. 2005

  15. The Strong Heart Study: Cox regression analyses(校正年龄、性别、体重指数、吸烟、LDL-C、DM) • 主动脉SBP和PP与CVD发生率独立相关,RR/10mmHg分别为1.07与1.10, p分别为0.043与0.009。 • 进一步校正颈动脉粥样硬化病变,主动脉PP仍然与CVD显著独立相关。

  16. Reflection of pressure wave as risk factor ESRD patients PWV<9.4m/s 1.0 1.0 Augmentation index 1 群 Augmentation index 2 群 9.4≦PWV≦12.0m/s 0.75 0.75 Even free rate for cardiovascular accidents Survival rate for cardiovascular death 0.50 0.50 12.0m/s <PWV Augmentation index 3 群 Augmentation index 4 群 0.25 0.25 0 0 0 35 70 140 105 0 35 70 105 140 Time (month) Time (month) London GM et al. Hypertension, 2001 Blacher et al. Circulation, 1999

  17. 中心动脉压和脉压升高对 心血管系统影响 • 左室后负荷增加,左室重构 • 冠状动脉灌注下降,储备功能下降, 心肌缺血 • 内皮损伤和功能紊乱,动脉硬化性疾病 进展

  18. AIand coronary heart disease Association between aortic AI and coronary arteriogram 12 11 10 9 8 7 6 5 4 3 Augmented pressure mmHg NO lesions Two vessels Three vessels One vessel Circulation 2004;109:184-189

  19. 160 140 120 100 80 60 Smulyan H et al. Ann Intern Med 2000

  20. Elderly Middle age Adolescence Ascending Aortic BP (mmHg) 160 160 160 120 120 120 80 80 80 Ascending Aortic blood flow (ml/s) 500 500 500 0 0 0 Coronary blood flow (ml/min) 150 150 150 0 0 0 McDonald’s fourth edition

  21. 吸烟对中心动脉压和周围动脉压的影响 * Non-smoker (n=116) Smokers (n=41) 140 2 130 1 120 0 * -1 110 -2 100 Blood pressure (mmHg) Aortic AI (%) -3 90 -4 80 -5 70 -6 60 -7 * p<0.05 50 -8 Aortic BP Brachial BP Hypertension. 2003;41:183-187

  22. Hyperlipidemia and central BP 160 150 140 130 120 110 100 90 80 70 0.01 Peripheral BP Central BP Blood pressure (mmHg) * Control subjects (n=68) Hyperlipidemia (n=68) J Am Coll Cardiol 2002;39:1005

  23. Glucose intolerance and arterial stiffness The Hoorn Study Control Impaired glucose tolerance Type 2 DM 60 55 50 45 40 34 33 32 31 30 1.2 1.0 0.8 0.6 * * * * Transmission time from carotid artery to femoral artery(msec) Total arterial compliance (SV/carotid PP, ml/mmHg) Augmentation index (%) 120 74 125 243 129 256 261 170 188 Hypertension 43:176–181, 2004

  24. Effect of antihypertensive drugs on brachial BP and central BP Diastolic BP on brachial artery was matched for 1 year 0 4 0 3 -0.2 -2 2 * -0.4 1 Change in PWV(m/sec) -4 0 Change in AI (%) Change in HR (bpm) -0.6 -1 -6 -2 -0.8 -3 -8 -1 -4 ** -5 -1.2 -10 Mean±SD. *p<0.05, ** p<0.001 vs atenolol. Perindopril / indapamide(n=204) atenolol (n=202) Asmar RG, et al. Hypertension. 2001;38:922

  25. Effect of antihypertensive drugs double blind and cross-over study 170 32 elderly hypertensive patients (age 65-80) were treated for 4 weeks each drugs in double blind and cross-over fashion. 160 * 150 * * * * 140 130 peripheral central Blood pressure (mmHg) 120 * * * * * 110 100 90 80 * * 70 Ca channel blocker ACE inhibitor Placebo b-blocker diuretics Am J Hypertens 17:118–123, 2004

  26. Effect of antihypertensive drugs on AI and central BP AI Central BP diuretics ↓→ ↓ b-blocker↑→ ↓→ ACE inhibitor/ARB ↓ ↓↓ Ca channel blocker ↓↓↓

  27. CAFÉ:肱动脉和中心动脉收缩压 肱动脉收缩压 平均差异(AUC)=0.7mmHg 氨氯地平 阿替洛尔 140 135 133.9 133.2 mm Hg 130 P=.07 125 125.5 121.2 120 中心动脉收缩压 平均差异(AUC)=4.3mmHg P<.0001 115 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 AUC 时间(年) 阿替洛尔86 243 324 356 445 372 462 270 339 128 85 1031 氨氯地平88 248 329 369 475 406 508 278 390 126 101 1042

  28. CAFÉ: 血压对终点事件的影响(未校正的多因素分析) (经校正的多因素分析)

  29. GREAT DEBATES IN HYPERTENSION:2007ACC • Antihypertensive Therapy Should be Tailored to Measures of Arterial Stiffness Still not enough data to make this assertion. However, there is need to develop such data.

  30. 动脉血管功能改变 • 中、大动脉顺应性下降 • 舒缩功能下降 • 小动脉阻力增加,顺应性下降 • 储备能力下降 • 动脉血管痉挛

  31. Methods for Detecting Vessel Disease • Pulse contour analysis (C1,C2) • Pulse Wave Velocity (PWV) • Aortic pressure augmentation (reflected waves), Pulse pressure • Flow-mediated vasodilation • Flow reserve • Biopsy • Urinary protein excretion

  32. 乙酰胆碱试验 给予乙酰胆碱后出现反常的血管收缩反应 在基线期无严重的梗阻性缺损

  33. 血流介导的血管扩张(FMD)测量

  34. 动脉血管舒张功能 非内皮依赖性舒张功能 (endothelium-independent dilatation, EID) 内皮依赖性舒张功能 (endothelium-dependent dilation, EDD) 药物: 乙酰胆碱 生理性刺激: 反应性充血,FMD 硝普钠、 硝酸甘油等 外源NO 内皮由来NO 血管舒张

  35. Survival without ischemic heart disease in hypertensive patients with MA or normoalbuminuria (MONICA study) 100 <30mg/24h 95 90 P<0.003 Proportion without ischemic heart disease (%) 85 >30mg/24h 80 75 70 0 6 5 10 years 1 2 3 4 7 8 9 (Jensen et al: Hypertension, 2000)

  36. 24小时动态血压与动脉内皮功能相关性的研究 • “非杓型”原发性高血压患者靶器官的损伤远较 “杓型”患者严重,心脑血管事件的发生率更高。动脉内皮功能的变化? • 原发性高血压患者46名,“杓型”31名,“非杓型”15名 • 测定FMD(Flow mediated-dilation)

  37. “杓型”和“非杓型”两组FMD比较 12 10 8 6 FMD(%) 4 2 0 “非杓型”组 “杓型”组 注:“杓型”和“非杓型”两组FMD比较,p<0.001

  38. FMD与24hSBP的相关性 r=-0.438 FMD

  39. FMD与年龄的相关性 r=-0.409 FMD

  40. 阿托伐他汀对血脂正常高血压患者血管内皮功能的影响阿托伐他汀对血脂正常高血压患者血管内皮功能的影响 • 高血压病患者早期即有血管内皮功能失调。 • 他汀类药物对血脂正常高血压患者是否改善血管内皮功能?与剂量的关系?

  41. p<0.05 p<0.01 阿托伐他汀对血脂正常高血压 患者FMD/ EID影响 30 25 20 0周FMD FMD/EID(%) 4周后FMD 15 0周EID 4周后EID 10 5 0 normal ator10mg ator20mg

  42. 结 论 • 高血压病患者内皮功能失调表现为以内皮依赖性血管舒张反应减弱为特征。 • 阿托伐他汀能改善血脂正常高血压患者血管内皮功能,可能具有剂量依赖性。

  43. 小 结 • 中心动脉压与脉压相关密切;与心血管事件相关性好;不同降压药对周围血压和中心动脉压降低不同,对评价不同降压药物作用有一定意义。 • 动脉功能评价方法多,不同侧面反映血管功能。有一定临床应用价值。

  44. 谢 谢

  45. 血管的重要性——VHP概念 • Vascular disease • Hypertension • Prevention • 将血管疾病(Vascular disease)、高血压(Hypertension)和预防(Prevention)三者 • 作为一个整体来对待

More Related