Clinical characteristics and risk factors of ventricular enlargement in cardiac insufficiency patients living at high altitude
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摘要: 目的 分析平均海拔在4000 m地区的世居藏族人群中心功能不全患者的临床特征及其心室扩大的危险因素。方法 选取2019年3月—2020年12月日喀则市人民医院心血管内科收治的心功能不全患者216例，回顾性分析患者的临床资料及超声心动图检查指标。依据欧美超声心动图协会建议成人心腔定量标准，左室舒张末期直径>55 mm作为左室扩大，右室横径>23 mm作为右室扩大。将所有患者按照心室扩大情况分为双室大小正常组即对照组(31例)、左室扩大组(7例)、右室扩大组(122例)和双室扩大组(56例)，并对超声心动图参数与各相关临床变量进行相关分析，观察患者临床特征并探讨影响心室扩大的危险因素。结果 216例患者中，NYHA分级以Ⅲ级心功能不全患者(60%)最常见。与对照组比较，右室扩大组和双室扩大组患者的心功能显著下降(P< 0.05)。一般临床资料显示，右室扩大组患者红细胞计数(RBC)较对照组显著增高(P< 0.05)。与右室扩大组比较，双室扩大组的高密度脂蛋白胆固醇(HDL-C)降低，低密度脂蛋白胆固醇(LDL-C)显著升高(P< 0.05)。与对照组比较，左室扩大组、右室扩大组和双室扩大组的心率和NT-proBNP显著升高(均P< 0.05)。超声心动图参数显示，与对照组比较，右室扩大组和双室扩大组的肺动脉主干直径和肺动脉收缩压显著升高(P< 0.05)。多因素logistic回归分析结果显示，HDL-C(OR＝0.177，95%CI：0.032~0.988)、NT-proBNP(OR＝1.000，95%CI：1.000~1.000)、肺主动脉干直径(OR＝1.123，95%CI：1.021~1.236)、肺动脉收缩压(OR＝0.960，95%CI：0.927~0.995)是高原右室扩大的心功能不全患者并发左室扩大的危险因素。结论 高原心功能不全患者以右室扩大最为常见，其次为双室扩大。HDL-C降低、NT-proBNP升高、肺动脉主干直径增宽和肺动脉压降低是高原右室扩大的心功能不全患者并发左室扩大的独立危险因素。Abstract: Objective To analyze the clinical characteristics and risk factors of ventricular enlargement in Tibetan patients with cardiac dysfunction at an average altitude of 4000 m.Methods A total of 216 patients with cardiac insufficiency admitted to the department of Cardiology of Tibetan Shigatse People's Hospital from March 2019 to December 2020 were enrolled and basic clinical data were collected. According to the quantitative standards of heart chamber recommended by the European and American echocardiography association, left ventricular end-diastolic diameter>55 mm was considered as the left ventricular enlargement and right ventricular diameter>23 mm was considered as the right ventricular enlargement. All patients were divided into four groups according to ventricular enlargement: control group(31 patients), left ventricular enlargement group(7 patients), right ventricular enlargement group(122 patients) and bi-ventricular enlargement group(56 patients). Correlation analyses between echocardiogram parameters and related clinical variables were carried out to observe the clinical characteristics and ventricular structure changes, as well as to explore the risk factors for ventricular enlargement.Results Among 216 patients with cardiac insufficiency, NYHA grade Ⅲ(60%) are the most common. Compared to the control group, the heart function of patients was significantly decreased in right ventricular enlargement group and bi-ventricular enlargement group(P< 0.05). General clinical statistics showed that red blood cell count(RBC) in the right ventricular enlargement group was significantly higher than in the control group(P< 0.05). The mean value of high-density lipoprotein cholesterol(HDL-C) in the bi-ventricular enlargement group was lower compared to the right ventricular enlargement group, while the mean value of low-density lipoprotein cholesterol(LDL-C) was higher(P< 0.05). The heart rate and the mean value of NT-proBNP in the ventricular enlargement groups were significantly increased compared with the control group(P< 0.05). Echocardiographic parameters showed that pulmonary artery trunk diameter and pulmonary artery systolic pressure in the right ventricular enlargement group and the bi-ventricular enlargement group were significantly increased compared with the control group(P< 0.05). Multivariate Logistic regression analysis showed that HDL-C(OR＝0.177, 95%CI: 0.032-0.988), NT-proBNP(OR 1.000, 95%CI: 1.000-1.000), pulmonary artery trunk diameter(OR＝1.123, 95%CI: 1.021-1.236), and pulmonary artery systolic pressure(OR＝0.960, 95%CI: 0.927-0.995) were the risk factors of bi-ventricular enlargement.Conclusion Right ventricular enlargement was predominantly common in patients with high altitude cardiac insufficiency, followed by biventricular enlargement. In addition, HDL-C, NT-proBNP, pulmonary aortic trunk width and pulmonary artery pressure were independent risk factors of bi-ventricular enlargement.
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表 1 4组一般临床资料的比较
Table 1. Comparison of general clinical data in four group
例(%), X±S 项目 对照组
(31例)左室扩大组
(7例)右室扩大组
(122例)双室扩大组
(56例)F/χ2 P 男性 18(58.06) 4(57.14) 68(55.74) 20(35.71) 2.14 0.545 年龄/岁 64±16 61±19 65±14 64±14 0.75 0.522 BMI/(kg·m-2) 23.15±3.98 21.03±1.36 23.66±3.90 22.97±3.80 1.27 0.286 海拔高度/m 4039.94±210.42 4076.86±198.14 4147.69±354.73 4092.11±368.51 0.65 0.581 吸烟 5(16.13) 3(42.86) 24(19.67) 15(26.79) 3.98 0.263 平时用药 RAAS抑制剂 3(9.68) 2(28.57) 8(6.56) 5(8.93) 4.39 0.222 美托洛尔 1(3.23) 0(0) 3(2.46) 8(14.29) 10.05 0.018 利尿剂 2(6.45) 0(0) 14(11.48) 10(17.86) 3.88 0.274 NYHA分级 159.67 < 0.001 Ⅰ级 4(12.90) 0(0) 3(2.46) 2(3.57) Ⅱ级 6(19.35) 1(14.29) 31(25.41) 15(26.79) Ⅲ级 19(61.29) 6(85.71) 72(59.02) 32(57.14) Ⅳ级 2(6.45) 0(0) 16(13.11) 7(12.50) 心率/(次·min-1) 83.69±11.06 84.29±16.711) 86.13±18.231) 94.64±24.331) 6.68 0.010 收缩压/mmHg△ 126.07±22.72 131.29±30.53 129.97±25.54 125.02±22.86 0.38 0.770 舒张压/mmHg 82.62±14.11 86.43±18.85 84.04±16.30 85.84±16.83 0.54 0.656 CRP/(mg·L-1) 25.45±30.63 11.41±6.37 28.25±78.43 15.63±15.43 0.72 0.542 WBC/(×109·L-1) 6.05±2.35 5.43±1.26 6.01±2.47 5.74±1.86 0.44 0.729 中性粒细胞/% 72.40±9.91 60.97±9.76 69.61±14.42 66.02±16.44 2.63 0.051 红细胞计数/(×1012·L-1) 5.10±1.09 4.66±0.79 5.15±1.161) 4.77±0.973) 4.07 0.045 血红蛋白/(g·L-1) 150.14±39.32 150.57±30.07 150.66±35.13 140.88±32.25 0.86 0.461 血肌酐/(μmol·L-1) 74.50±22.33 79.56±16.77 88.78±49.44 92.82±33.581) 3.98 0.047 血尿酸/(μmol·L-1) 391.00±174.23 439.86±177.50 410.17±189.64 454.70±185.44 0.83 0.479 血尿素氮/(mmol·L-1) 4.92±4.00 4.36±1.68 5.62±4.13 6.04±4.24 1.41 0.241 谷丙转氨酶/(U·L-1) 81.27±155.51 58.27±49.72 88.85±178.40 67.67±132.91 0.44 0.726 谷草转氨酶/(U·L-1) 84.77±181.23 69.14±73.18 91.71±201.31 63.55±107.28 0.17 0.918 总胆固醇/(mmol·L-1) 2.97±0.88 3.26±0.87 2.93±1.02 3.24±1.04 1.02 0.383 甘油三酯/(mmol·L-1) 0.96±0.33 0.82±0.16 0.90±0.35 0.87±0.27 0.79 0.500 HDL-C/(mmol·L-1) 0.99±0.34 1.13±0.30 0.98±0.37 0.92±0.303) 3.71 0.026 LDL-C/(mmol·L-1) 1.76±0.65 1.70±0.59 1.65±0.70 1.93±0.713) 4.73 0.031 NT-proBNP/(pg·mL-1) 3113.10±3812.73 3613.63±2773.181) 5080.19±5638.541) 10104.99±7706.531)2)3) 9.03 < 0.001 △1 mmHg=0.133 kPa；与对照组比较，1)P < 0.05；与左室扩大组比较，2)P < 0.05；与右室扩大组比较，3)P < 0.05。 
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表 2 4组超声心动图参数的比较
Table 2. Comparison of echocardiographic parameters in four group
X±S 项目 对照组
(31例)左室扩大组
(7例)右室扩大组
(122例)双室扩大组
(56例)F P 右房横径/mm 40.61±6.56 40.57±11.32 53.26±10.271) 50.54±5.641) 18.66 < 0.001 右房上下径/mm 42.86±10.59 39.71±8.99 61.54±10.751)2) 58.81±10.571)2) 31.08 < 0.001 右室横径/mm 18.09± 2.77 19.00±2.45 48.38±8.421)2) 48.93±7.151)2) 178.41 < 0.001 右室上下径/mm 18.88±5.65 19.00±2.45 63.08±8.721)2) 64.56±8.831)2) 311.10 < 0.001 左房横径/mm 32.78±11.55 44.57±9.25 33.38±13.08 50.48±8.751)3) 29.12 < 0.001 左房上下径/mm 33.86±13.20 48.57±12.33 41.36±20.85 58.60±12.001)3) 15.57 < 0.001 左室舒张末期内径/mm 41.47±5.58 64.57±7.371) 46.27±4.841)2) 61.19±4.431)2)3) 166.96 < 0.001 左室收缩末期内径/mm 26.94±4.99 48.43±11.53 1) 34.19±13.321) 63.04±15.121)3) 76.11 < 0.001 肺动脉主干宽/mm 25.17±5.18 27.75±5.19 30.10±6.981) 32.42±5.601) 10.50 < 0.001 肺动脉收缩压/mmHg 37.47±17.42 61.83±31.991) 52.91±23.391) 48.48±18.911) 4.13 0.007 LVEF/% 59.47±9.03 41.03±7.461) 59.59±10.462) 45.50±10.131)3) 28.37 < 0.001 与对照组比较，1)P < 0.05；与左室扩大组比较，2)P < 0.05；与右室扩大组比较，3)P < 0.05。
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