高血压患者清晨高血压与颈动...膜厚度增加及斑块形成的关系_王飞.pdf

第 22 卷第 6 期2022 年12月泰州职业技术学院学报Journal of Taizhou Polytechnic CollegeVol.22 No.6Dec.2022作者简介：王飞（1987-），女，江苏泰州人，主管护师.高血压患者清晨高血压与颈动脉内中膜厚度增加及斑块形成的关系王飞，鲍婷婷，龚梅，高琳琳，阮中宝（南京医科大学附属泰州人民医院，江苏泰州225300）摘要：目的 分析高血压患者清晨高血压(morning hypertension，MH)与颈动脉内中膜厚度(intima-media thickness，IMT)增加和颈动脉斑块（Carotid artery plaque，CAP）的关系。方法 选取 2020年1月至2021年12月泰州市人民医院门诊或住院的原发性高血压患者 168 例，根据 24 h 动态血压测量（ambulatory blood pressure measurement，ABPM）结果，分为 MH 组和对照组，比较两组 IMT 和 CAP。结果 41 例患者存在 MH，占24.4%。与对照组比较，MH组年龄大（54.213.4 vs 48.615.4，P=0.035），高血压病程较长6（2，14）vs 3（1，6），P=0.028。同时清晨血压，包括清晨6:0010:00时间段的收缩压（systolic blood presume，SBP）(145.712.8 vs 132.011.6，P=0.005)、舒张压（diastolic blood presume，DBP）(84.811.5 vs 74.510.9，P=0.014)和醒后2小时的SBP(149.214.8 vs 134.612.5，P=0.013)、DBP(91.210.6 vs 79.28.5，P=0.000)均高于对照组，存在统计学差异。IMT厚度(1.380.46 vs 1.220.39，P=0.000)和CAP发生率23（56.1）vs 39（30.7），P=0.003明显高于对照组，有显著差异。结论 原发性高血压病人存在MH现象，MH促进颈动脉粥样硬化和CAP形成。关键词：高血压；清晨高血压；颈动脉内中膜厚度；颈动脉粥样硬化中图分类号：R544.1文献标志码：B文章编号：1671-0142（2022）06-0084-03高血压是危害人类健康最大的危险因素之一，其所造成的一些心脑血管恶性事件发生率在不断的提升，22.3%的心血管疾病和死亡都与高血压密切相关1。血压存在昼夜节律及生理波动规律，即24小时血压呈双峰双谷或双峰谷改变，血压白昼升高，夜间下降，这在正常血压者已得到证实并且普遍存在，但是高血压病人的血压昼夜变化规律就要复杂得多。清晨醒后1h内、服药前、早餐前的家庭血压测量结果或动态血压记录的起床后2h或早晨6:0010:00间的血压称为清晨血压。大量证据显示，清晨高血压（morning hypertension，MH）与亚临床靶器官损伤和不良心血管结局相关，是心血管疾病的有力预测因子，从07:00到 09:00，中风和冠状动脉事件比其他时间多70%2。一项队列研究表明，清晨血压升高1毫米汞柱，心血管死亡风险增加2.1%3。清晨血压临床管理中国专家指导建议明确指出，清晨血压是血压管理的切入点。颈动脉内中膜厚度(intima-media thickness，IMT)增加和颈动脉斑块（Carotid artery plaque，CAP）形成是高血压患者靶器官损害之一4。目前，关于MH与颈动脉粥样硬化的相关性研究报道较少。24 h动态血压测量（ambulatory bloodpressure measurement，ABPM）可以对高血压患者进行全天的血压监测和评估，分析患者血压昼夜变化规律，与诊室血压测量相比，更能预测心脑血管不良事件发生5。本研究通过ABPM监测分析高血压患者MH发生及其与IMT增加及CAP形成之间的关系,以期为高血压患者清晨血压管理、减少靶器官损害提供临床依据。第 6 期王飞，鲍婷婷，龚梅，等：高血压患者清晨高血压与颈动脉内中膜厚度增加及斑块形成的关系1资料与方法1.1一般资料选取 2020年1月至2021年12月泰州市人民医院门诊或住院的首次诊断的原发性高血压患者168例，其中男98例，女70例。所有患者进行ABPM监测，根据监测结果分为MH组和对照组。高血压符合原发性高血压临床诊断标准6。MH定义为起床后2小时或或早晨6:0010:00间动态血压记录的血压135/85 mmHg7。排除标准：继发性高血压；合并糖尿病、肾功能不全、严重感染、恶性肿瘤等；近3个月服用过降压药者；过敏体质、精神疾病等。1.2颈动脉多普勒超声检查使用GE彩色多普勒超声诊断仪,病人取仰卧位，旋转探头行纵切颈动脉监测,在双侧颈总动脉分叉处下方10mm处，取后壁测量IMT。IMT1.2 mm 视为CAP 形成8。1.3统计学处理采用SPSS 26.0进行统计分析,定量资料以均数标准差（x s）表示，采用t 检验;定性资料采用2检验。高血压病程为偏态分布以M（Q1，Q3）表示，采用Mann-Whitney U秩和检验。采用Pearson相关分析分析MH和CA相关参数的关系。以P0.05为差异有统计学意义。2结果2.1MH组和对照组基线特征168例患者，根据 ABPM 结果，分为 MH 组和对照组。MH 组 41例，男性 20 例，女性 21 例，年龄 54.213.4 岁。对照组127例，男性82例，女性45例，年龄48.615.4 岁。两组患者基线比较见表1。2.2MH 组和对照组 CA 相关参数比较MH 组IMT明显厚于对照组，CAP发生率也高于对照组，具体见表2。表1MH组和对照组基线特征比较注：MH为清晨高血压，TC为总胆固醇，LDL-C为低密度胆固醇，HDL-C为高密度胆固醇，TG为甘油三酯，Scr为血清肌酐，SBP为收缩压，DBP为舒张压。基线特征男例,%年龄（岁）体质量指数（kg/m2）吸烟例,%高血压病程年，M（Q1，Q3）糖尿病例,%TC(mmol/L)LDL-C(mmol/L)HDL-C(mmol/L)TG(mmol/L)SCr(mol/L)24 h SBP(mmHg)24 h DBP(mmHg)白天 SBP(mmHg)白天 DBP(mmHg)夜间 SBP(mmHg)夜间 DBP(mmHg)清晨（6:00-10:00）SBP(mmHg）清晨（6:00-10:00）DBP(mmHg）清晨（醒后2小时）SBP(mmHg）清晨（醒后2小时）DBP（mmHg）MH组（n=41）20(48.78)54.213.426.33.16(14.6)6(2,14)9(21.9)4.451.142.730.861.160.261.681.0868.420.2141.313.577.68.1142.614.480.48.2128.416.371.68.9145.712.884.811.5149.214.891.210.6对照组（n=127）82(64.57)48.615.425.64.919(15)3(1,6)28(22.1)4.260.792.510.641.180.341.460.9279.984.8134.412.879.78.4138.414.881.98.4124.915.673.49.2132.011.674.510.9134.612.579.28.5t/x2/U值3.332.221.040.002.320.001.031.641.031.411.441.27-0.940.61-0.660.43-0.673.002.622.644.55P值0.0730.0350.2320.3980.0280.3980.2340.1040.2340.1470.1410.1780.2560.3300.3200.3630.3180.0050.0140.0130.00085泰州职业技术学院学报第6 期表2MH组和对照组CAP相关数据比较参数IMT（mm）CAP例,%MH组（n=41）1.380.4623（56.1）对照组（n=127）1.220.3939（30.7）t/x2值28.38.58P值0.0000.003注：MH为清晨高血压，IMT为颈动脉内中膜厚度，CAP为颈动脉斑块。3讨论高血压患者血压增高程度与血压变异性、靶器官损害密切相关，IMT增加和CAP形成是高血压靶器官损害之一。有研究表明，未治疗高血压患者24小时血压不断变化，清晨时段血压水平最高，未控制的MH是心血管事件“早顶峰”幕后推手，通过损伤血管内皮，导致内皮功能障碍、靶器官损伤，发生急性心肌梗死、卒中等心脑血管事件9。因此，MH是心血管事件发生和高血压管理的关键因素10。正常人相比，高血压患者清晨时间段血压上升幅度显著高于全天时段11。已知颈动脉粥样硬化患者有中度至高度的心血管事件风险12，而目前关于清晨血压与颈动脉粥样硬化的相关性研究报道较少。本研究中，对168例原发性高血压患者进行ABPM监测，并根据清晨血压情况进行分组。结果显示有41例患者存在MH，占24.4%，提升高血压患者存在MH现象。同时，与对照组比较，MH组年龄大，高血压病程较长。同时清晨血压，包括清晨6:0010:00时间段的SBP、DBP和醒后2小时的SBP、DBP均高于对照组，存在统计学差异。进一步分析MH和CA的关系，结果提示MH组IMT厚度和CAP发生率明显高于对照组。这一发现与之前的研究一致，支持清晨血压增高会促进颈动脉粥样硬化和CAP发生13。综上所述,原发性高血压病人存在MH现象，MH促进颈动脉粥样硬化和CAP形成，诱发心脑血管事件。高血压患者应有效控制清晨血压，减少高血压靶器官损害。参考文献：1Yusuf S,Joseph P,Rangarajan S,et al.Modifiable riskfactors,cardiovasculardisease,andmortalityin 155722individuals from 21 high-income,middle-income,andlow-income countries(PURE):a prospective cohortstudyJ.Lancet,2020,395(10226):795-808.2Wang JG,Kario K,Park JB,et al.Morning blood pressure monitoring in the management of hypertensionJ.J Hypertens,2017,35(8):1554-1563.3Brito LC,Peanha T,Fecchio RY,et al.Morning versus Evening Aerobic Training Effects on Blood Pressure in Treated HypertensionJ.Med Sci Sports Exerc,2019,51(4):653-662.4燕虹,张燕青,刘利平,等.老年人清晨高血压对左室肥厚和动脉粥样硬化影响的临床研究J.中国药物与临床,2016,16(11):1626-1628.5Yang WY,Melgarejo J D,Thijsl L,et al.Association of officeandambulatorybloodpressurewithmortalityandcardiovascularoutcomesJ.JAMA,2019,322(5):409-420.6中国高血压防治指南修订委员会,高血压联盟(中国),中华医学会心血管病学分会中国医师协会高血压专业委员会,等.中国高血压防治指南(2018年修订版)J.中国心血管杂志,2019,24(1):24-56.7Wang JG,Kario K,Chen HC,et al.Management ofmorning hypertension:a consensus statement of anAsian expert panelJ.J Clin Hypertens(Greenwich).2018,20(1):39-44.8丁士芳,张运,张梅.颈动脉粥样斑块稳定性与急性脑梗死发病机制关系的临床研究 J.中华超声影像学杂志,2006,15(8):597-600.9Lehmann MV,Zeymer U,Dechend R,et al.Ambulatory blood pressure monitoring:is it mandatory forblood pressure control in treated hypertensive patients?:prospective observational studyJ.Int J Cardiol,2013,168(3):2255-2263.10Wang JG,Kario K,Park JB,et al.Morning bloodpressure monitoring in the management of hypertension J.J Hypertens,2017(35):1554-1563.11Liu M,Wu B,Wang WZ,et a1.Stroke in China:EpidemiologY,Prevention,and Management StrategiesJ.Lancet Neurol,2007,6(5):456-464.12Praew K,Satoshi H,Kazuomi K.Carotid atherosclerosis and the association between nocturnal blood pressure dipping and cardiovascular events J.J Clin Hypertens,2018,20(1):450-455.13Ni RH,Chu L,Xu DF,et al.Risk factors of cerebral microbleeds in young and middle-aged patients with hypertensionJ.NeurologicalResearch,2018,40(5):413-418.（责任编辑刘红）（下转第93页）86第 6 期肖珊珊：康复护理在膝关节内侧骨性关节炎患者胫骨高位截骨术后护理中的效果探讨or Survival of a Total Knee Arthroplasty(TKA)?J.Arch Bone Jt Surg,2018,6(1):19-22.4van Outeren MV,Waarsing JH,Brouwer RW,et al.Isa high tibial osteotomy(HTO)superior to non-surgicaltreatment in patients with varus malaligned medialknee osteoarthritis(OA)?A propensity matched studyusing 2 randomized controlled trial(RCT)datasetsJ.Osteoarthritis Cartilage,2017,25(12):1988-1993.（责任编辑杨荔晴）Postoperative Nursing of High Tibial Osteotomy in the Treatment of Medial Knee OsteoarthritisPostoperative Nursing of High Tibial Osteotomy in the Treatment of Medial Knee OsteoarthritisXIAO Shan-shanXIAO Shan-shan(The Affiliated Taizhou Peoples Hospital of Nanjing Medical University,Taizhou Jiangsu 225300,China)AbstractAbstract:Objective To explore the effect of postoperative rehabilitation nursing of medial knee osteoarthritistreated by high tibial osteotomy(HTO).Methods 64 patients with medial knee osteoarthritis were randomly divided into control group and observation group.Both groups underwent HTO surgery.After operation,the patients in the observation group received not only routine nursing,but also scientific,standardized and systematicrehabilitation nursing.The patients in the control group only received routine rehabilitation nursing.The postoperative rehabilitation nursing of the two groups was compared.Results After nursing,the Lysholm knee jointscore of the patients in the observation group was significantly higher than that of the control group(P0.05).Conclusion Scientific,standardized and systematic rehabilitation nursing is helpful to the recovery of knee jointfunction in patients with medial knee osteoarthritis treated by HTO,indicating its great significance.Key wordsKey words:osteoarthritis;high tibial osteotomy;rehabilitation nursingAdvances in Targeted Therapy and Immune Checkpoint Inhibitor Therapy for Esophageal CancerAdvances in Targeted Therapy and Immune Checkpoint Inhibitor Therapy for Esophageal CancerYANG Can-linYANG Can-lin,REN Yuan-yuanREN Yuan-yuan,LI FeiLI Fei,YU LeiYU Lei,HUANG Jun-xingHUANG Jun-xing(The Affiliated Taizhou Peoples Hospital of Nanjing Medical University,Taizhou Jiangsu 225300,China)AbstractAbstract:Esophageal cancer is one of the deadliest cancers in the world and has a high incidence and mortalityrate in China.Targeted therapy such as vascular endothelial growth factor receptor(VEGFR)inhibitors and immune checkpoint inhibitors such as programmed cell death protein 1(PD-1)/programmed cell death ligand-1(PD-L1)inhibitors have been shown to play an important role in the treatment of esophageal cancer as noveltherapeutic approaches.Their combination with chemoradiotherapy has become a routine treatment in clinicalpractice nowadays.Following the recent therapeutic innovations,we have reviewed the available literature dataabout esophageal cancer management,with a focus on the drug mechanism,efficacy,safety,and recent advancesof targeted drugs and immune checkpoint inhibitors for esophageal cancer.Key wordsKey words:esophageal cancer;targeted therapy;immune checkpoint inhibitors（上接第58页）Clinical Study of Increased intima-media thickness and plaque formation in Patients with Morning HypertensionClinical Study of Increased intima-media thickness and plaque formation in Patients with Morning HypertensionWANG FeiWANG Fei,BAO Ting-tingBAO Ting-ting,GONG MeiGONG Mei,GAO Lin-linGAO Lin-lin,RUAN Zhong-baoRUAN Zhong-bao(The Affiliated Taizhou Peoples Hospital of Nanjing Medical University，Taizhou Jiangsu 225300,China)AbstractAbstract:Objective To analyze the relationship between morning hypertension(MH)and increased carotid arteryintima-media thickness(IMT)and carotid artery plaque(CAP)in patients with hypertension.Methods FromJanuary 2020 to December 2021,168 patients with essential hypertension who were outpatients or hospitalized atthe affiliated Taizhou Peoples Hospital of Nanjing Medical University were selected and divided into MH andcontrol groups based on the results of 24h ambulatory blood pressure measurement(ABPM).The IMT and CAPof the two groups were compared.The findings revealed that 41 patients(24.4%)had MH.Patients in MHgroup were older than those in the control group and had a longer period of hypertension.The morning bloodpressure of patients in MH group,including systolic blood presume(SBP)and diastolic blood presume(DBP)in6:0010:00am were statistically higher than those in the control group.Furthermore,SBP and DBP at 2 hoursafter awakening were also higher than those in the control group.IMT thickness and CAP incidence were alsosignificantly higher in the MH group than those in the control group.Conclusion MH is present in essential hypertension patients,which is correlated with the increased IMT and CAP formation.Key wordsKey words:hypertension;morning hypertension;carotid artery intima-media thickness;carotid atherosclerosis（上接第86页）93