不同类型的降压药物对高血压患者脉搏波速度的影响分析
高血压患者治疗12周后血压和baPWV
变化值比较(x±s)
组别△SBP(mm Hg)△DBP(mm Hg)△baPWV(cm/s)
A组-30.6±6.7-20.8±7.1-483.7±132.5
B组-20.7±5.3*-13.9±7.6*-456.9±165.3
C组-19.6±6.1*-14.1±6.8*-429.7±182.6
D组-21.5±4.3*-14.9±4.2*-453.2±176.7
注:与A组比较*P<0.05
3 讨论
PWV 作为早期评价动脉硬化的指标之一已经受到心血管基础和临床工作者的广泛关注,其对高血压预后的评估价值也得到充分肯定[3],欧洲高血压指南将PWV列为评价高血压靶器官损害新的诊断指标,并应用于高血压早期防治、延缓或逆转靶器官损害发生等的临床实践工作[4]。 血压升高、长期吸烟、糖尿病和血脂代谢紊乱等危险因素引起动脉壁脂肪退行性变,导致动脉粥样硬化形成,最终使动脉僵硬度增加,顺应性下降[1,5]。动脉弹性,取决于动脉的僵硬度或可扩张性和动脉腔径的大小。动脉的僵硬度主要取决于管壁中弹性蛋白和胶原蛋白的比例,但也受动脉斑块和动脉血压的影响。此外动脉内压越大,胶原纤维的作用就越大,动脉僵硬度就越高。PWV是脉搏在动脉系统的两点间传导一定距离的速度,是评价动脉僵硬度最常用的无创检测方法[5],在心脏收缩期左心室将血液射入升主动脉,主动脉壁急剧扩张,产生一个以一定速度沿动脉树传播的脉搏波。由于血液是不能压缩的液体,而动脉壁是有弹性的,因此,能量主要沿血管壁传输。脉搏波传导速度越快则表明动脉的僵硬度越高、可扩张性越小或顺应性越差;反之,则动脉的僵硬度越低、可扩张性越大或顺应性越好。国内外大量的研究证明,高血压[5,6]、脑卒中[7-9]、代谢综合征[10]、糖尿病及糖尿病前期[9-11]、血脂代谢紊乱[12]、肾功能不全[13]、冠心病[14,15]、甚至高血压前期[16]患者由于动脉硬化导僵硬度增高,顺应性下降引起PWV明显增快,本研究所收集的对象全部是居住在城市既往健康的中老年人,经体检发现的1~2级高血压患者,可以认为这部分患者受教育的程度,文明生活的素质相对较高,且都是每年来医院体检的健康人,他(她)们高血压的病程肯定是在1~2年之内,且无其他危险因素和合并症,而他们的baPWV已经明显高于正常对照组,说明即使早期高血压患者已同时存在大动脉弹性的下降,姚树勇等[16]观察高血压前期患者与理想血压者对比,baPWV已显著增加,合并其他心血管危险因素时,可通过协同作用使大动脉僵硬度进一步增加,本研究结论进一步证实在血压升高的早期已经存在大动脉顺应性下降,提示早期控制血压对改善大动脉顺应性的重要作用。
CCB、ACEI、β受体阻滞剂、ARB是美国、欧洲和中国高血压指南推荐的六大类降压药物中常用的四类,培多普利、苯磺酸左旋氨氯地平、琥珀酸美托洛尔缓释片、缬沙坦是前述四大类药物的常用代表性药物,其降压疗效已被许多循证医学的证据所证实。但其对PWV的影响文献报道不多,Kim等[15]报道CCB和ACEI类降压药物能有效改善心绞痛患者的动脉僵硬度;本研究表明,上述四种药物在降低血压的幅度上,苯磺酸左旋氨氯地平明显优于其他三种药物,在血压降低的同时都能明显降低baPWV,说明在扩血管降压的过程中,明显降低大动脉的僵硬度,改善大动脉的顺应性,对防止高血压的大动脉硬化具有一定的临床意义。但是本研究收集的对象全是既往健康,1~2年新近发现的高血压患者,高血压发病时间短,无其他合并症,动脉硬化可能较那些多重危险因素并存和有并发症的高血压患者轻,因此,baPWV的改变比较明显。对于高血压病程长、危险因素多、合并症多的大动脉硬化者,其baPWV得变化有无这样明显,有待于进一步的研究去证实。
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