冠狀動(dòng)脈多支病變患者心外膜脂肪層厚度與左房構(gòu)型的關(guān)系

冠狀動(dòng)脈多支病變患者心外膜脂肪層厚度與左房構(gòu)型的關(guān)系

呂雪芬1,朱向明2,劉駿3,葉天舟3

(1.蕪湖市第一人民醫(yī)院超聲科,安徽蕪湖241000; 2.皖南醫(yī)學(xué)院附屬弋磯山醫(yī)院超聲科,安徽蕪湖241001;3.蕪湖市第一人民醫(yī)院心內(nèi)科,安徽蕪湖241000)

【摘要】目的：評(píng)價(jià)冠狀動(dòng)脈多支病變患者心外膜脂肪層厚度和左房構(gòu)型的相關(guān)性。方法：根據(jù)冠狀動(dòng)脈造影結(jié)果選擇冠狀動(dòng)脈正常者26例為對(duì)照組，冠狀動(dòng)脈3支及3支以上病變組28例；超聲心動(dòng)圖測(cè)量心外膜脂肪層厚度、左房?jī)?nèi)徑(LAD)、左房容積(LAV)和左室射血分?jǐn)?shù)(LVEF)，用體表面積標(biāo)化出左房?jī)?nèi)徑指數(shù)(LADi)和容積指數(shù)(LAVi)。比較兩組心外膜脂肪層厚度及左房構(gòu)型指標(biāo)的差異，觀察冠狀動(dòng)脈多支病變組心外膜脂肪層厚度與左房構(gòu)型之間相關(guān)性。結(jié)果：冠狀動(dòng)脈多支病變組與對(duì)照組心外膜脂肪層厚度值分別為 (8.96±1.62)mm和(3.91±1.14)mm，冠狀動(dòng)脈多支病變組心外膜脂肪層厚度與LAV、LAVi增大(P<0.05)，心外膜脂肪層厚度與LAV、LAVi呈正相關(guān)。結(jié)論：冠狀動(dòng)脈多支病變組心外膜脂肪層厚度顯著增加，并且能夠反映左房構(gòu)型改變的程度。

【關(guān)鍵詞】超聲心動(dòng)描記術(shù)；冠狀動(dòng)脈疾?。恍耐饽ぶ窘M織；左心房

【文獻(xiàn)標(biāo)識(shí)碼】【中圖號(hào)】R 541.4A

DOI【】10.3969/j.issn.1002-0217.2015.02.027

文章編號(hào)：1002-0217(2015)02-0193-04

基金項(xiàng)目：國(guó)家級(jí)大學(xué)生創(chuàng)新創(chuàng)業(yè)訓(xùn)練計(jì)劃(AH201310368021)

收稿日期：2014-06-10

作者簡(jiǎn)介：陳磊(1990-)，男，2010級(jí)預(yù)防醫(yī)學(xué)本科生，(電話)18355358923，(電子信箱)9937755582@qq.com；

通訊作者袁慧，女，副教授，(電子信箱)yuanhui0553@163.com，.

Epicardial adipose tissue thickness and left atrial geometry pattern in patients with multiple coronary artery lesionsLüXuefen,ZHUXiangming,LIUJun,YETianzhou

Department of Ultrasonography,Wuhu No.1 People′s Hospital,Wuhu 241000,China

Abstract【】Objective：To assess the relationship between epicardial adipose tissue thickness and left atrial geometry patterns in patients with multiple coronary artery lesions.Methods:Twenty-six patients with normal coronary artery were included as controls and 28 with coronary artery lesions of three or above as lesion group.The epicardial fat thickness,inner diameter of the left atrium(LAD),volume of the left atrium (LAV) and left ventricular ejection fraction (LVEF) were measured with echocardiography.The indices of the diameter and volume in relation to body surface area(BSA) (LADi and LAVi,respectively) were calculated.The two groups were compared regarding the parameters measured for determination of the relationship between the qpicardial fat thickiness and left atrial geometry pattern.Results:The thickness of epicardial adipose tissue was (8.96±1.62)mm for the lesion group and (3.91±1.14)mm for the controls.The epicardial fat thickness,LAV and LAVi were increased in patients with multiple coronary artery disease(P<0.05),and the fat thickness was positively related to LAV and LAVi.Conclusion:Significantly increased epicardial adipose tissue thickness is seen in patients with multiple coronary artery lesions,and this may be an indicator to reflect the left atrial geometry change.

【Key words】 echocardiography;coronary artery disease;epicardial adipose tissue;left atrium

內(nèi)臟脂肪組織增加已被公認(rèn)為是動(dòng)脈粥樣硬化性疾病的一個(gè)重要危險(xiǎn)因素，心外膜脂肪層厚度是內(nèi)臟脂肪組織的簡(jiǎn)易量化指標(biāo)，與冠心病高危因素高度相關(guān)，超聲測(cè)量心外膜脂肪層厚度可預(yù)測(cè)冠心病的存在并可反映冠狀動(dòng)脈病變程度，但心外膜脂肪層厚度與冠心病心臟構(gòu)型改變的關(guān)系研究較少，本研究主要探討冠狀動(dòng)脈多支病變患者心外膜脂肪層厚度變化以及其與左房構(gòu)型之間的關(guān)系。

1資料與方法

1.1研究對(duì)象病例選自2012年1月～2014年3月我院住院患者。根據(jù)冠狀動(dòng)脈造影結(jié)果選擇無(wú)冠狀動(dòng)脈病變組，即對(duì)照組 26例；冠狀動(dòng)脈3支及以上病變組，并且病變冠狀動(dòng)脈內(nèi)徑減少>50%以上，即冠狀動(dòng)脈多支病變組 28例。對(duì)照組男17例，女9例，年齡40～76歲，平均(56.8±10.8)歲；冠狀動(dòng)脈多支病變組男21例，女7例，年齡40～77歲，平均(60.0±9.8)歲。對(duì)照組與冠狀動(dòng)脈多支病變組年齡、性別構(gòu)成、體質(zhì)量指數(shù)等差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。所有病例均進(jìn)行常規(guī)超聲心動(dòng)圖檢查。心臟瓣膜病及先天性心臟病排除在外。

1.2儀器方法采用Philips iE33彩色多普勒超聲診斷儀，探頭頻率1～5 MHz。二維超聲取胸骨旁左心長(zhǎng)軸切面和心尖兩腔、四腔切面，連接同步肢導(dǎo)聯(lián)心電圖，采集圖像時(shí)選擇左側(cè)臥位，心電觸發(fā)電影回放，T波終點(diǎn)作為心臟收縮末期，取樣線垂直于右室游離壁，放置于主動(dòng)脈瓣環(huán)處，心室收縮末期測(cè)量右室游離壁與心包膜臟層之間的脂肪厚度，測(cè)量3個(gè)心動(dòng)周期，取平均值，具體測(cè)量見圖1。測(cè)量左房前后徑(LAD)和容積(LAV)(Biplane面積-長(zhǎng)度法)。測(cè)量受檢者體質(zhì)量和身高，根據(jù)公式：BSA(m2)=0.006 1×身高(cm)+0.012 8×體質(zhì)量(kg)-0.152 9計(jì)算體表面積，再分別計(jì)算左房?jī)?nèi)徑指數(shù)(LADi)，左房容積指數(shù)(LAVi)。雙平面Simpson法測(cè)左室射血分?jǐn)?shù)(LVEF)。

胸骨旁左心長(zhǎng)軸切面，EAT表示心外膜脂肪層厚度

圖1心外膜脂肪層厚度超聲心動(dòng)圖測(cè)量示意圖

Fig 1Echocardiographic measurement of epicardial adipose tissue thickness

2結(jié)果

2.1冠狀動(dòng)脈多支病變組與對(duì)照組一般情況比較 冠狀動(dòng)脈多支病變組在年齡、性別構(gòu)成、身高、體質(zhì)量、體表面積和心率等指標(biāo)與對(duì)照組之間差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，收縮壓及舒張壓高于對(duì)照組，左室射血分?jǐn)?shù)低于對(duì)照組，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)，見表1。

表1冠狀動(dòng)脈多支病變組與對(duì)照組一般情況

Tab 1Baseline characteristics of group CAD with multi-vessel lesion and normal group

一般情況正常對(duì)照組(n=26)冠狀動(dòng)脈多支病變組(n=28)t(χ2)值P值性別(男/女)17/921/70.590>0.05年齡(歲)56.81±10.8460.00±9.761.139>0.05身高(cm)169.08±6.07167.32±6.551.019>0.05體質(zhì)量(kg)66.00±7.2269.71±9.671.589>0.05體質(zhì)量指數(shù)24.24±3.2625.01±3.380.857>0.05體表面積(m2)1.72±0.151.65±0.131.788>0.05心率(次/min)73.46±7.7972.71±9.780.309>0.05收縮壓(mmHg)128.27±13.90139.54±23.622.154<0.05舒張壓(mmHg)75.12±8.2485.18±12.053.603<0.05LVEF(%)63.96±8.1055.57±10.393.290<0.05

注：1 mmHg=0.133 kPa

2.2冠狀動(dòng)脈多支病變組心外膜脂肪層厚度及左房構(gòu)型變化冠狀動(dòng)脈多支病變組心外膜脂肪層厚度、LAV、LAVi均較正常對(duì)照組大，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，LAD、LADi差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，見表2，結(jié)果表明冠狀動(dòng)脈多支病變組左房容積及體表面積標(biāo)化的左房容積指數(shù)較對(duì)照組增大，心外膜脂肪層較對(duì)照組增厚。

2.3冠狀動(dòng)脈多支病變患者心外膜脂肪層厚度與左房構(gòu)形超聲表達(dá)指標(biāo)的關(guān)系冠狀動(dòng)脈多支病變組心外膜脂肪層厚度與LAV、LAVi相關(guān)系數(shù)分別為0.52、0.76，P<0.05，故認(rèn)為心外膜脂肪層厚度與LAV、LAVi呈線性相關(guān)關(guān)系，見圖2、3；心外膜脂肪層厚度與LAD、LADi Pearson相關(guān)系數(shù)分別為0.35、0.13，P>0.05，故認(rèn)為心外膜脂肪層厚度與LAD、LADi未發(fā)現(xiàn)線性相關(guān)關(guān)系。

超聲測(cè)值正常對(duì)照組(n=26)冠狀動(dòng)脈多支病變組(n=28)t值P值LAD(mm)3.82±0.454.03±0.431.7480.086LAV(mL)46.99±8.8057.94±5.955.3120.000LADi2.17±0.282.20±0.560.4490.655LAVi27.31±4.7834.91±2.767.0830.000EAT(mm)3.91±1.148.96±1.6213.3190.000

圖2冠狀動(dòng)脈多支病變組心外膜脂肪層厚度和LAV相關(guān)性散點(diǎn)圖

Fig 2The relationship between EAT and LAV(Scatterplot)

圖3冠狀動(dòng)脈多支病變組心外膜脂肪層厚度和LAVi相關(guān)性散點(diǎn)圖

Fig 3The relationship between EAT and LAVi(Scatterplot)

3討論

心外膜脂肪位于心肌和心包臟層之間，是緊貼心肌及冠狀動(dòng)脈的內(nèi)臟脂肪，主要位于右心室游離壁前壁。心外膜脂肪除了具有能量?jī)?chǔ)庫(kù)的作用，還產(chǎn)生許多影響能量代謝、免疫和血管炎性反應(yīng)的生物活性分子，作用于冠狀動(dòng)脈壁，在病理情況下影響代謝的平衡，從而加劇冠心病的進(jìn)展。目前心外膜脂肪的測(cè)量方法有CT、MRI和超聲。CT測(cè)量心外膜脂肪層具有較好的重復(fù)性，MRI有軟組織成像的優(yōu)勢(shì)，被認(rèn)為是測(cè)量心外膜脂肪層的金標(biāo)準(zhǔn)，但它們費(fèi)時(shí)較長(zhǎng)且價(jià)格昂貴。超聲最早用于心外膜脂肪的臨床研究。臨床研究證實(shí)[1-3]，超聲測(cè)量心外膜脂肪層厚度，觀察者間和觀察者內(nèi)均有很好的一致性，賴長(zhǎng)春等報(bào)道[4]，觀察者內(nèi)的相關(guān)系數(shù)為0.94，超聲重復(fù)測(cè)量心外膜脂肪層厚度，測(cè)量者內(nèi)變異很低[(0．58±0.37)mm]，并且超聲心動(dòng)圖測(cè)量的心外膜脂肪層厚度和MRI測(cè)量的內(nèi)臟脂肪高度相關(guān)[5-6]。近年研究顯示，心外膜脂肪與冠心病具有相關(guān)性并且是冠心病的獨(dú)立危險(xiǎn)因素。Eroglu等[7]報(bào)道，超聲心動(dòng)圖測(cè)量心外膜脂肪層厚度可作為嚴(yán)重冠心病存在的標(biāo)志。Ahn等[6]報(bào)道顯示冠心病患者心外膜脂肪層厚度較對(duì)照組增厚并且可評(píng)估冠心病風(fēng)險(xiǎn)、預(yù)測(cè)冠心病病變程度。Shemirani等[8]研究顯示超聲心動(dòng)圖測(cè)量心外膜脂肪層厚度與嚴(yán)重多支冠狀動(dòng)脈狹窄顯著相關(guān)。最近的單盲歷史性隊(duì)列研究認(rèn)為超聲心動(dòng)圖測(cè)量胸骨旁長(zhǎng)軸心外膜脂肪層厚度與冠心病存在及嚴(yán)重程度顯著相關(guān)，并且心外膜脂肪層厚度≥7mm高度即可認(rèn)為個(gè)體有冠狀動(dòng)脈硬化可能[9]。但心外膜脂肪層厚度與心臟構(gòu)型的關(guān)系研究較少，Lacobellis等[10]曾研究病態(tài)肥胖者心外膜脂肪層厚度與左室舒張功能及左房?jī)?nèi)徑的關(guān)系，結(jié)果顯示心外膜脂肪層厚度與左室充盈受損及左房增大相關(guān)(r= 0.65,P= 0.02)。Mookadam等[11]研究顯示心外膜脂肪層厚度>5 mm，與左房增大及左室舒張功能減退相關(guān)。心臟舒張?jiān)缙谑侵鲃?dòng)耗能過(guò)程，對(duì)心肌缺血非常敏感，左室舒張功能減退，左室舒張?jiān)缙诔溆繙p少，舒張晚期時(shí)左房必須通過(guò)代償性做功增加來(lái)保證心輸出量的正常，長(zhǎng)期心房做功增加，必然會(huì)引起左房的擴(kuò)大，冠狀動(dòng)脈多節(jié)段病變患者，心肌嚴(yán)重血供不足，顯著影響心臟舒張功能，左房構(gòu)型改變必然貫穿整個(gè)冠心病的病程。本研究試圖探討冠狀動(dòng)脈多支病變者心外膜脂肪層厚度與左房構(gòu)型的關(guān)系。研究結(jié)果顯示冠狀動(dòng)脈多支病變患者心外膜脂肪層厚度、LAV、LAVi增大，LAD、LADi與對(duì)照組差異無(wú)統(tǒng)計(jì)學(xué)意義，冠狀動(dòng)脈多支病變組心外膜脂肪層厚度與LAV、LAVi顯相關(guān)關(guān)系，可能是因?yàn)槿莘e的測(cè)定，特別是標(biāo)化指標(biāo)能夠較準(zhǔn)確地評(píng)價(jià)左房構(gòu)型。

以往的有些研究結(jié)果顯示心外膜脂肪層與冠心病無(wú)相關(guān)性，如Chaowalit等[12]報(bào)道超聲心動(dòng)圖測(cè)量心外膜脂肪層厚度預(yù)測(cè)冠心病及冠心病的嚴(yán)重程度無(wú)相關(guān)性，研究文獻(xiàn)發(fā)現(xiàn)，在這些報(bào)道中，入選病例均相對(duì)肥胖。Park等[13]研究了亞洲人群體質(zhì)量指數(shù)對(duì)心外膜脂肪層厚度與冠心病關(guān)系的影響，結(jié)論認(rèn)為，超聲心動(dòng)圖測(cè)量心外膜脂肪層厚度預(yù)測(cè)冠心病在體質(zhì)量指數(shù)<27的亞洲人群中的價(jià)值更大，根據(jù)以往研究結(jié)果，本研究排除了病態(tài)肥胖患者，選擇對(duì)象體質(zhì)量指數(shù)為25.01±3.38。有研究報(bào)道[14]心外膜脂肪層與血壓相關(guān)，高血壓組心外膜脂肪層厚度較正常組增大，本研究中冠狀動(dòng)脈多支病變組血壓高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義，可能會(huì)對(duì)本研究結(jié)果產(chǎn)生影響，夸大心外膜脂肪層厚度和左房大小的相關(guān)性。

經(jīng)胸超聲心動(dòng)圖是高危心臟病患者的常規(guī)檢查，可提供心臟大小、形態(tài)、結(jié)構(gòu)、功能等參數(shù)資料，獲取心外膜脂肪層厚度的測(cè)量值，了解心外膜脂肪層與心臟構(gòu)型的關(guān)系，在臨床研究和實(shí)踐中是一種無(wú)創(chuàng)、簡(jiǎn)便和實(shí)用的方法。

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