左室肥厚及其鉴别诊断-改版1.pptx

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2021/7/21,#,左室肥厚的诊断及其鉴别诊断,目 录,左室肥厚的诊断,左室肥厚的流行病学,左室肥厚的鉴别诊断,左室肥厚的临床意义,心电图诊断,敏感性,:20-50%,特异性,:60-80%,诊断,Prevention,Diagnosis,and Treatment of Hypertensive Heart Disease,Cardiol Clin 28(2010)675691,影像学诊断,评估手段：,心脏彩超（,UCG,）,心脏磁共振（,CMR,）,评估指标：,左室后壁和室间隔厚度,LV mass/LV mass index,：左室质量,/,左室质量指数,Relative wall thickness,（,RWT,）：相对壁厚度,诊断,左室后壁和室间隔厚度,影响学诊断,评估指标,M,型超声,2D,径线测量,2005UCG,指南,J,Am Soc Echocardiogr 2005;18:1440-1463.,LV mass,：左室质量,LV mass=,壳体容积*心肌密度,计算方法：,依赖几何假设来计算，需进行平面定位,将,LV,设定为扁长的椭圆形来计算（采用,M,型或,2D,的径线测值计算）,根据面积,-,长度（,AL,）公式或截顶的椭圆体（,TE,）公式进行计算（,2D,图像计测）,无需依赖几何假设计算,UCG,三维评估,（,在一系列,2D,横断面上进行脱机重构或实时,3D,超声心动图）,CMR,断面重构,影响学诊断,评估指标,LV mass index,：左室质量指数,采用体表面积或身高对,LV,质量进行校正，但对,LV,质量测量进行标准化的最佳方法仍存争议。,对于肥胖症和心血管病患者，使用,LV,质量身高指数（,LV,质量,/,身高,2.7,）可提高,LV,肥厚的检出率,2005UCG,指南,J,Am Soc Echocardiogr 2005;18:1440-1463.,影响学诊断,评估指标,各项评估指标的参考值范围（,UCG,）,2005UCG,指南,J,Am Soc Echocardiogr 2005;18:1440-1463.,影响学诊断,评估指标,Relative wall thickness,（,RWT,）,相对壁厚度,IVSD=,舒张末期室间隔厚度,PWTD=,舒张末期左室后壁厚度,LVIDD=,舒张末期左室内径,RWT,=,Imaging in hypertensive heart disease,Expert Rev Cardiovasc Ther.2011,9(2):199-209,影响学诊断,评估指标,判断肥厚的几何类型,Imaging in hypertensive heart disease,Expert Rev Cardiovasc Ther.2011,9(2):199-209,稳态自由进动序列,梯度回波成像序列,影响学诊断,评估指标,CMR,中左室质量指数的参考值范围,左室肥厚的形态学分类,2005UCG,指南,J,Am Soc Echocardiogr 2005;18:1440-1463.,影像学诊断,左室肥厚的形态学分类,increased mass and increased RWT,increased mass and normal RWT,normal mass and increased RWT,Imaging in hypertensive heart disease,Expert Rev Cardiovasc Ther.2011,9(2):199-209,影像学诊断,二、左室肥厚的流行病学,Regional differences in the prevalence of left ventricular hypertrophy within Germany,Eur J Cardiovasc Prev Rehabil 2009;16:392400,southwest Germany,northwest Germany,The study population comprised 2516 women and men(835 from KORA-southwest and 1681 from SHIP-,northeast,)aged 4574 years who had no history of myocardial infarction.,LVH was defined as an LVMI of more than 44 g/m in women and 48 g/m in men,自然人群中左室肥厚的流行情况,German,流行病学,The study was a community-based cross-sectional study,and comprised,4270 hypertension patients,withintegrated clinical and echocardiographic data.LVH was diagnosed by using the criteria of,over 49.2 g/m,2.7,for men and 46.7 g/m,2.7,for women.,LV mass was divided by height,2.7,to obtain LV mass index(LVMI,h2.7,),高血压患者中左室肥厚的,患病率,Prevalence and risk factors for left ventricular hypertrophy and left ventricular,geometric abnormality in the patients with hypertension among Han Chinese,Chin Med J 2012;125(1):21-26,流行病学,高血压患者中左室肥厚的,几何类型,The study was a community-based cross-sectional study,and comprised,4270 hypertension patients,withintegrated clinical and echocardiographic data.LVH was diagnosed by using the criteria of,over 49.2 g/m,2,for men and 46.7 g/m,2,for women.,LV mass was divided by height,2.7,to obtain LV mass index(LVMI,h2.7,),Prevalence and risk factors for left ventricular hypertrophy and left ventricular,geometric abnormality in the patients with hypertension among Han Chinese,Chin Med J 2012;125(1):21-26,流行病学,三、左室肥厚的鉴别诊断,左室肥厚的鉴别诊断,有明确的致肥厚因素,生理性肥厚：运动员心脏、妊娠妇女,病理性肥厚：,后负荷增加：如高血压、主动脉瓣狭窄,容量负荷增加：如二尖瓣反流,无明确的致肥厚因素,肥厚型心肌病,心脏淀粉样变性,其他少见原因,鉴别诊断,不同致肥厚因素与左室肥厚几何类型及纤维化、细胞功能的关系,Circulation.2010;122:2727-2735,鉴别诊断,胎儿基因的再表达,后负荷增加,容量负荷增加,解剖学特点,鉴别诊断,肥厚型心肌病,心脏淀粉样变性,Ann Intern Med.2010;152:513-520.,J Am Coll Cardiol 2008;51:102230,组织学特点,鉴别诊断,J Am Coll Cardiol 2011;57:891903,心脏淀粉样变性,肥厚型心肌病,阿尔新蓝染色,(alcian blue),H-E,染色,Progress in Cardiovascular Diseases,2010;52:347361.,常见左室疾病的临床特点,肥厚型心肌病,心脏淀粉样变性,肥厚,高血压,主动脉瓣狭窄,运动员,病史,猝死家族史,累积其他系统的表现（如多发性骨髓瘤,),高血压病史及家族史,无,症状,劳力性呼吸困难,心绞痛,晕厥,表现为限制性心肌病的特点，以右心功能不全表现为主（类似于缩窄性心包炎）,症状少见,部分以并发症为临床表现,劳力性呼吸困难,心绞痛,晕厥,无,体征,胸骨左缘,3-4,肋间或心尖区的机能性杂音,同上,A2,亢进,主动脉区收缩期杂音,无,心电图,左室高电压,病理性,Q,波,非特异性,ST-T,改变,快速性心律失常,低电压（分离现象）,束支传导阻滞,房颤多见,左室高电压,非特异性,ST-T,改变,快速性心律失常,左室高电压,非特异性,ST-T,改变,快速性心律失常,可能出现高电压,超声心动图,左心室,二尖瓣反流,收缩功能增强,左心室流出道压力阶差,双房大，室壁轻度增厚，收缩功能正常,二维：可,呈现闪烁的颗粒状结构（淀粉样蛋白沉积物）,左房大，均匀性左室肥厚,早期：舒张功能降低（E/A,峰降低）,后期：收缩功能障碍,瓣膜损害,均匀性左室肥厚,左室腔轻度增大，左室壁轻度肥厚,鉴别诊断,Br J Sports Med 2009 43:649-656,肥厚型心肌病,vs,运动员心脏肥厚,鉴别诊断,左室肥厚的鉴别诊断,影像学进展,心脏超声,二维：斑点追踪成像,功能上鉴别,三维：质量离散指数（,MDI,）,形态上鉴别,心脏磁共振,心脏磁共振电影成像序列,cine CMR imaging sequences,（如：平衡式稳态自由进动序列）,钆延迟显,像,late gadolinium enhancement,LGE,鉴别诊断,二维斑点追踪成像,two-dimensional speckle tracking imaging,（,STI,）,心脏超声,鉴别诊断,运动速度,应变及应变率,Am J Cardiol.2009;103:411 415,通过对高帧频二维图像的斑点回声进行逐帧追踪，每一个被追踪的斑,点,在,整个心动周期中它们可以跟随周围的心肌组织一起运动从而发生位置的改变，相邻两个斑点回声间距离的相对改变反映局部心肌的收缩和舒张，可以计算心肌的,运动速度和形变,，获得心肌组织的,运动速度、应变及应变率。,斑点追踪技术（,STI）-,正常人,Am J Cardiol.2009;103:411 415,心脏超声,鉴别诊断,斑点追踪技术（,STI）-,运动员心脏,Am J Cardiol 2007;100:128 132,心脏超声,鉴别诊断,斑点追踪技术（,STI）-,肥厚型心肌病,Am J Cardiol 2007;100:128 132,心脏超声,鉴别诊断,斑点追踪技术（,STI）-,心脏淀粉样变性,Am J Cardiol.2009;103:411 415,心脏超声,鉴别诊断,三维超声心动图计算,MDI,(mass dispersion index),Three Dimensional Echocardiography,Stefano Caselli,et al.,Am J Cardiol 2008;102:616-620,心脏超声,鉴别诊断,在心脏舒张末期，左室长轴平面上，将心脏划分为,3,个等距的层面：基底部、中间部及心尖部。每一层面都环形的分割成,4,个解剖部分：间隔部、前部、侧部、下部。这样，心脏一共被分为,12,个部分,，计算出每一部分的质量（,5mm,的层厚,）。然后得出总的,心肌质量,。同时可以得出每一层面的心肌质量,离散程度（,SD,）,。然后求三个平面,SD,的平均值，得出,MDI,（,mass dispersion index,）质量离散指数,Stefano Caselli,et al.,Am J Cardiol 2008;102:616-620,20,18,15,15,鉴别诊断,利用质量离散指数（,MDI,）对左室肥厚进行鉴别诊断,心脏超声,J of Cardiovasc Trans Res.2009;2:415-425,CMR,可清晰显示,HCM,的非对称性肥厚,鉴别诊断,心脏磁共振,-,钆延迟显,像,（,LGE,）,在延迟钆增强序列心脏核磁成像时，钆停留在细胞外间隙扩大的心肌区域，呈亮信号影像,(,高度强化,),。可用于检测肥厚型心肌病患者是否存在心肌纤维化或瘢痕。,HCM,呈现明显的局灶性的纤维化改变,HTN,没有看到明显的纤维化区域,Usefulness of Magnetic Resonance Imaging to Distinguish Hypertensive and Hypertrophic Cardiomyopathy.,Am J Cardiol 2010;106:1016-1022,鉴别诊断,心脏磁共振,中华心血管病杂志,.2009(37);12:1057-1063,心脏磁共振,鉴别诊断,肥厚型心肌病,-,钆延迟显,像,（,LGE,）,JACC.2004,;,12,:22604,肥厚型心肌病,LGE,与病理学的关系,心脏磁共振,鉴别诊断,J Am Coll Cardiol 2008;51:102230,心脏淀粉样变性钆延迟显像（,LGE,）与大体解剖,心脏磁共振,鉴别诊断,各种检查手段,在左室肥厚识别及评估中的价值,Expert Rev Cardiovasc Ther.2011,9(2):199209,鉴别诊断,心内膜心肌活检,在心血管疾病鉴别诊断中的价值,鉴别诊断,2007AHA/ACCF/ESC,心内膜心肌活检指南,四、左室肥厚的临床意义,高血压左室肥厚与全因死亡的关系,Framingham,队列研究,Prognostic implications of echocardiographically determined left ventricular mass in the Framingham heart study.,N Engl J Med 1990;322:1561-6,男性,女性,临床意义,N Engl J Med 1990;322:1561-6,男性,女性,临床意义,高血压左室肥厚与心血管疾病的关系,Framingham,队列研究,274,subjects were followed for up to,8.7 years,Prognostic Value of Left Ventricular Mass and Geometry in Systemic Hypertension with Left Ventricular Hypertrophy,.Am J Cardiol 1996;78:197-202,高血压左室肥厚与事件发生的关系,临床意义,Prognostic significance of electrocardiographic determined left ventricular hypertrophy and associated ST-segment depression in patients with nonST-elevation acute coronary syndromes.,Am Heart J 2011;161:878-85.,Left ventricular hypertrophy was diagnosed on the,admission ECG,A total of,7,761 patients,with NSTE-ACS in the Global Registry of Acute Coronary Events(GRACE)and ACS-I registries,ACS,患者左室肥厚与预后的关系,(,GRACE and ACS-I,临床意义,肥厚型心肌病,基因诊断的价值,不同表型的肥厚型心肌病的易感基因检出率不同,J Am Coll Cardiol 2009;54:20111,临床意义,echocardiography-guided genetic testing,肥厚型心肌病致病基因携带与预后的关系,J Am Coll Cardiol 2009;54:20111,A cohort of,203,unrelated patients,(,Italian)with HCM,followed up for a time of,4.01.7 years,testing of the,8,HCM-susceptibility genes,临床意义,高血压基因筛查：没有一个肯定的易感基因,惠汝太教授,:,PGC1-,polymorphisms,与高血压（不论有无心脏肥厚）无关，是,HCM,的修饰基因（增加肥厚）；,高血压肥厚与,HCM,的修饰基因不同。,高血压左室肥厚与肥厚型心肌病相关性,Clin Chem Lab Med.2007;45(8):962-7.,临床意义,2011 ACCF/AHA,肥厚型心肌病指南,肥厚型心肌病的危险分层,临床意义,谢 谢！,