中老年高血压病人心血管病多重危险因素及其相互关联的临床研究
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摘要
目的通过对中老年原发性高血压(EH)患者的心血管病多重危险因素的临床流行病学对照研究,探寻各个传统危险因素对影响临床终点事件发生的量化评估、研究各个危险因素间的交互关系,总结具有多重心血管病危险因素病人的中医证候表现规律以及对其管理、治疗与达到指南标准的距离和原因。
方法以2007年1月至2009年3月于北京中医药大学东直门医院心血管内科门诊及病区就医的EH高危险人群为对象,进行临床流行病学的随机、对照、横断面的队列研究。对于各个传统危险因素影响临床终点事件发生的量化评估和研究各个危险因素间的交互关系的研究,应用Logistic回归分析、偏相关分析、线性相关分析等统计方法,本着整体观,运用综合法和分析法研究多重危险因素的聚集特点,研究不同危险因素间的协同性、相关性;对于具有多重心血管病危险因素病人的中医证候表现规律的研究,应用国家中医行业颁布的中医证候诊断标准、中医学会、中华医学会、中国中西医结合学会等9个标准或指南进行病证结合研究,同时开展带有质量控制的实验室生物学测试研究:包括高敏C反应蛋白(Hs-CRP)、全血和富血小板血浆聚集实验(PAgT)、基质金属蛋白酶-9(MMP-9)等;对于具有心血管病多重危险因素病人管理、治疗与达到指南标准的研究,采用了对病人、医护人员宣讲指南、学习指南和实施指南与3个月对病人回访、检查的方法,利用现场问卷调查、病案调阅分析、电话回访等多种调查手段,采集病人的多重危险因素及相关中医证候,从中选取年龄在45～90岁的中老年患者202例,着眼于多重危险因素聚集的特点,研究不同危险因素间的协同性、相关性及其中医证候特点。
结果①Logistic回归分析显示:糖代谢异常、早发心血管病家族史、高敏C反应蛋白(Hs-CRP)、低HDL-C血症、高TG血症、缺乏运动与急性缺血性事件显著相关,是该抽样群体的主要危险因素,其逐步回归方程为:logit(P)≈-21.661+2.759~*糖代谢异常(1)+2.547~*高TG血症+1.836~*低HDL-C血症(1)-3.882~*糖代谢异常(2) -3.492~*运动量(3) -2.638~*Hs-CRP分层(2) -1.476~*早发家族史;对中老年EH人群临床常用的10个计量资料数据(Hs-CRP、全血PAgT、血浆PAgT、TC、TG、HDL-C、LDL-C、GLU、Cr、MMP-9等)回归方程为:logit(P)≈-1.090+0.264~* Hs-CRP+0.257~* GLU-1.62~* HDL-C- 0.866~*LDL-C;类间效应显示,Hs-CRP、TG、HDL-C分别以3.0mg/L、1.7mmol/L、1.04mmol/L为切入点分类时,对急性心脑血管事件的类间比较有显著性差异;②中老年EH病人多重危险因素的中医证候特点如下:糖尿病患者较血糖正常者相比,痰证发生率显著增高;Hs-CRP高者其风、痰、瘀证发生率均有显著增高,热证发生率也有增高趋势,与Hs-CRP正常者比较,P=0.088;回归分析显示,风、痰、瘀证与发生急性事件呈正相关,而虚证与其呈负相关;③Hs-CRP水平与危险分层密切相关;(④)Hs-CRP水平与血小板高聚集状态相关,高Hs-CRP时全血PAgT亦升高;⑤血脂异常与其他危险因素有交互作用,其中HDL-C与GLU呈负相关,LDL-C与Hs-CRP呈正相关;⑥糖代谢异常与性别、烟酒史、运动量有一定的相关性;其中,血糖水平与TC、TG、血浆PAgT呈正相关,与HDL-C呈负相关。⑦断面研究该抽样群体初诊时的规范治疗情况,其规范治疗率仅30.6%,在不同危险因素中,以患有血脂异常及糖尿病者血压达标率最低,分别是18.27%和29.41%,其余危险因素的血压达标率均在43%以上。
结论①中老年EH人群性别、年龄的影响相对弱化,除不可干预的早发心血管病家族史外,该抽样群体的主要危险包括糖代谢异常、炎症反应、脂质代谢异常、缺乏运动量;②中老年EH病人中医证候的形成与多重危险因素的聚集密切相关,各不同危险因素有其各自的证候特点,其中Hs-CRP高者风、痰、瘀、热证发生率均较高,其既与多危险集聚(危险分层)显著相关,亦与急性心脑血管事件发生时的中医证候相类似,可能是风、痰、瘀、热等实证联合发生时的生物学基础之一,与急性事件显著相关,是研究“毒邪”的可能的切入点之一;③炎性反应、血小板高聚集状态、脂质代谢异常、糖代谢异常等可干预的主要危险因素间有交互影响,其协同性、相关性可解释一些临床问题,提示用药方向;④目前对该群体的防治仍有所不及,现阶段殛待加强对于指南的执行力度,并努力寻找执行好指南的方法,同时发现,多重危险因素聚集患者血压控制较差,其综合管理显得尤为必要,考虑不同危险因素间的协同效应或相关效应,是规范化防治中的重点;进一步加强宣教、督促、指导,落实指南方案于患病群体中,病人是疾病防治的主体。
Objectives Through investigating 200 midaged patients with essential hypertension(EH ) of multiple risk factors and related detection index and chinese medicine syndrome,to analysis sample people characteristic of multiple risk factors and regular of chinese medicine syndrome,and through association analysis from different angles,to study interactive relationship of different risk factors,and explore the correlation coefficient,to pioneer thinking of prevention and treatment of integrated chinese and western medicine,and offer the date support.
Methods.The target is high risk population of essential hypertension(EH ) who visit clinic and ward of cardiovascular department of Dong Zhi Men hospital of bei jing chinese medicine from january 2007 to march 2009.On the basis of investigate epidemiology.Use the different means,such as questionnaire investigation,analysis of medical records,and telephone call interview and so on.To collect multiple risk factors and related chinese medicine syndrome,choose 202 midaged patients whose age is between 45 and 90 years old.Use statistical method,such as regression analysis, partial correlation analysis and so on.on the basis of whole view,use synthesis and analysis method to study the characteristic of multiple risk factors,study coo perativity and relativity of different risk factors;use diagnosis standard of chinese medicine which is enact by national chinese medicine.Meanwhile,carry out the test study with the quality control of laboratory biology:include Hs-CRP,PAgT,MMP-9,and so on.
Results.①Logistic regression analysis shows that there is significant correlation with impaired glucose metabolism,early onset family history,Hs-CRP,HDL-C,TG, lack of sports and acute ischemia,it's the main dangerous factor of sample people.the regression equation is logit(P)≈-21.661+2.759*Impaired glucose metabolism(1 ) +2.547* TG +1.836* HDL-C(1 ) -3.882* Impaired glucose metabolism(2 ) -3.492* sports(3 ) -2.638*Hs-CRP(2 ) -1.476* early onset family history.The other regression equation is logit(P)≈-1.090+0.264*Hs-CRP+ 0.257*GLU-1.62*HDL-C-0.866* LDL-C;Inter class effect shows that Hs-CRP,TG,HDL-C is classified by 3.0mg/L, 1.7mmol/L、1.04mmol/L,there is obvious different to the events of acute cardio-cerebral vascular.②The characteristic of Chinese Medicine Syndrome of multiple risk factor of midaged EH patients as follows:Comparing the diabetic patients to the normal,phlegm syndrome is obvious high;If the patient's Hs-CRP is high,wind,phlegm,stasis syndrome are obvious high,and the tendency of heat syndrome is increased.Comparing the diabetic patients to the normal patients of Hs-CRP,P=0.088;Regression analysis shows that there is positive correlation between acute events and wind,phlegm,stasis syndrome,while there is negative correlation between deficiency syndrome.③There is closely related between the level of Hs-CRP and risk stratification;④There is related between the level of Hs-CRP and the state of high aggregation of platelet.When the level of Hs-CRP is higher,the level of PAgT is also higher.⑤There is interact effect between lipid abnormality and other risk factors, HDL-C and GLU is negative correlation,LDL-C and Hs-CRP is positive correlation;⑥There is some relativity between impaired glucose metabolism and sex,drinking and smoking history,amount of exercise.For example,there is positive correlation between the level of glucose and TC、TG、plasm PAgT,while there is negative correlation between the level of glucose and HDL-C.⑦Cross-sectional study the standard treatment condition of sample people of the first visit clinic,the standard treatment rate is only 30.6%,in the different risk factors,the lipid abnormality and diabetic patients standardize rate is the lowest,18.27%and 29.41%,the blood standardize rate of other risk factors is more than 43%.
Conclusions.①Weaken the effect of sex,age of the midaged EH patients,except for the early onset family history of cardio-vascular disease,the main risk of this sample people include impaired glucose metabolism,inflammatory response,impaired lipid metabolism,lack of amount of exercise.②There is closely relation between the form of chinese syndrome of midaged patients and collection of multiple risk factors, there is respctive characteristic to the different risk factors,for example,if the Hs-CRP is high,the incidence of wind,phlegm,stasis,and heat syndrome is high.It is significant correlation with risk stratification and also same as the chinese medicine syndrome when the acute cardio-celebra vascular events happen,It is the one of the basis of biology when the wind,phlegm,stasis,and heat syndrome combined happen, It is significant correlation with acute events,it is one of the starting point to study the toxic pathogens③There are cooperativity and relativity between the main risk factors of inflammatory response,high coagulation condition of platelet impaired lipid metabolism,impaired glucose metabolism which can be intervene,it can explain the clinic question,point out the direction of using medicine;④It is still not enough to control and prevent this objects at present,the degree of execute guideline should be reinforced,and find the good way to execute the guideline,it is also find that it is bad control of multiple risk factors patient,it is necessary to comprehensive management. It is important things that consider the cooperate or relative effect to standard prevent and treatment;it should be furthermore enforce that propaganda,supervise,guide,and implement guidline into the patients,patients are the main part of prevent and treatment.
方法以2007年1月至2009年3月于北京中医药大学东直门医院心血管内科门诊及病区就医的EH高危险人群为对象,进行临床流行病学的随机、对照、横断面的队列研究。对于各个传统危险因素影响临床终点事件发生的量化评估和研究各个危险因素间的交互关系的研究,应用Logistic回归分析、偏相关分析、线性相关分析等统计方法,本着整体观,运用综合法和分析法研究多重危险因素的聚集特点,研究不同危险因素间的协同性、相关性;对于具有多重心血管病危险因素病人的中医证候表现规律的研究,应用国家中医行业颁布的中医证候诊断标准、中医学会、中华医学会、中国中西医结合学会等9个标准或指南进行病证结合研究,同时开展带有质量控制的实验室生物学测试研究:包括高敏C反应蛋白(Hs-CRP)、全血和富血小板血浆聚集实验(PAgT)、基质金属蛋白酶-9(MMP-9)等;对于具有心血管病多重危险因素病人管理、治疗与达到指南标准的研究,采用了对病人、医护人员宣讲指南、学习指南和实施指南与3个月对病人回访、检查的方法,利用现场问卷调查、病案调阅分析、电话回访等多种调查手段,采集病人的多重危险因素及相关中医证候,从中选取年龄在45～90岁的中老年患者202例,着眼于多重危险因素聚集的特点,研究不同危险因素间的协同性、相关性及其中医证候特点。
结果①Logistic回归分析显示:糖代谢异常、早发心血管病家族史、高敏C反应蛋白(Hs-CRP)、低HDL-C血症、高TG血症、缺乏运动与急性缺血性事件显著相关,是该抽样群体的主要危险因素,其逐步回归方程为:logit(P)≈-21.661+2.759~*糖代谢异常(1)+2.547~*高TG血症+1.836~*低HDL-C血症(1)-3.882~*糖代谢异常(2) -3.492~*运动量(3) -2.638~*Hs-CRP分层(2) -1.476~*早发家族史;对中老年EH人群临床常用的10个计量资料数据(Hs-CRP、全血PAgT、血浆PAgT、TC、TG、HDL-C、LDL-C、GLU、Cr、MMP-9等)回归方程为:logit(P)≈-1.090+0.264~* Hs-CRP+0.257~* GLU-1.62~* HDL-C- 0.866~*LDL-C;类间效应显示,Hs-CRP、TG、HDL-C分别以3.0mg/L、1.7mmol/L、1.04mmol/L为切入点分类时,对急性心脑血管事件的类间比较有显著性差异;②中老年EH病人多重危险因素的中医证候特点如下:糖尿病患者较血糖正常者相比,痰证发生率显著增高;Hs-CRP高者其风、痰、瘀证发生率均有显著增高,热证发生率也有增高趋势,与Hs-CRP正常者比较,P=0.088;回归分析显示,风、痰、瘀证与发生急性事件呈正相关,而虚证与其呈负相关;③Hs-CRP水平与危险分层密切相关;(④)Hs-CRP水平与血小板高聚集状态相关,高Hs-CRP时全血PAgT亦升高;⑤血脂异常与其他危险因素有交互作用,其中HDL-C与GLU呈负相关,LDL-C与Hs-CRP呈正相关;⑥糖代谢异常与性别、烟酒史、运动量有一定的相关性;其中,血糖水平与TC、TG、血浆PAgT呈正相关,与HDL-C呈负相关。⑦断面研究该抽样群体初诊时的规范治疗情况,其规范治疗率仅30.6%,在不同危险因素中,以患有血脂异常及糖尿病者血压达标率最低,分别是18.27%和29.41%,其余危险因素的血压达标率均在43%以上。
结论①中老年EH人群性别、年龄的影响相对弱化,除不可干预的早发心血管病家族史外,该抽样群体的主要危险包括糖代谢异常、炎症反应、脂质代谢异常、缺乏运动量;②中老年EH病人中医证候的形成与多重危险因素的聚集密切相关,各不同危险因素有其各自的证候特点,其中Hs-CRP高者风、痰、瘀、热证发生率均较高,其既与多危险集聚(危险分层)显著相关,亦与急性心脑血管事件发生时的中医证候相类似,可能是风、痰、瘀、热等实证联合发生时的生物学基础之一,与急性事件显著相关,是研究“毒邪”的可能的切入点之一;③炎性反应、血小板高聚集状态、脂质代谢异常、糖代谢异常等可干预的主要危险因素间有交互影响,其协同性、相关性可解释一些临床问题,提示用药方向;④目前对该群体的防治仍有所不及,现阶段殛待加强对于指南的执行力度,并努力寻找执行好指南的方法,同时发现,多重危险因素聚集患者血压控制较差,其综合管理显得尤为必要,考虑不同危险因素间的协同效应或相关效应,是规范化防治中的重点;进一步加强宣教、督促、指导,落实指南方案于患病群体中,病人是疾病防治的主体。
Objectives Through investigating 200 midaged patients with essential hypertension(EH ) of multiple risk factors and related detection index and chinese medicine syndrome,to analysis sample people characteristic of multiple risk factors and regular of chinese medicine syndrome,and through association analysis from different angles,to study interactive relationship of different risk factors,and explore the correlation coefficient,to pioneer thinking of prevention and treatment of integrated chinese and western medicine,and offer the date support.
Methods.The target is high risk population of essential hypertension(EH ) who visit clinic and ward of cardiovascular department of Dong Zhi Men hospital of bei jing chinese medicine from january 2007 to march 2009.On the basis of investigate epidemiology.Use the different means,such as questionnaire investigation,analysis of medical records,and telephone call interview and so on.To collect multiple risk factors and related chinese medicine syndrome,choose 202 midaged patients whose age is between 45 and 90 years old.Use statistical method,such as regression analysis, partial correlation analysis and so on.on the basis of whole view,use synthesis and analysis method to study the characteristic of multiple risk factors,study coo perativity and relativity of different risk factors;use diagnosis standard of chinese medicine which is enact by national chinese medicine.Meanwhile,carry out the test study with the quality control of laboratory biology:include Hs-CRP,PAgT,MMP-9,and so on.
Results.①Logistic regression analysis shows that there is significant correlation with impaired glucose metabolism,early onset family history,Hs-CRP,HDL-C,TG, lack of sports and acute ischemia,it's the main dangerous factor of sample people.the regression equation is logit(P)≈-21.661+2.759*Impaired glucose metabolism(1 ) +2.547* TG +1.836* HDL-C(1 ) -3.882* Impaired glucose metabolism(2 ) -3.492* sports(3 ) -2.638*Hs-CRP(2 ) -1.476* early onset family history.The other regression equation is logit(P)≈-1.090+0.264*Hs-CRP+ 0.257*GLU-1.62*HDL-C-0.866* LDL-C;Inter class effect shows that Hs-CRP,TG,HDL-C is classified by 3.0mg/L, 1.7mmol/L、1.04mmol/L,there is obvious different to the events of acute cardio-cerebral vascular.②The characteristic of Chinese Medicine Syndrome of multiple risk factor of midaged EH patients as follows:Comparing the diabetic patients to the normal,phlegm syndrome is obvious high;If the patient's Hs-CRP is high,wind,phlegm,stasis syndrome are obvious high,and the tendency of heat syndrome is increased.Comparing the diabetic patients to the normal patients of Hs-CRP,P=0.088;Regression analysis shows that there is positive correlation between acute events and wind,phlegm,stasis syndrome,while there is negative correlation between deficiency syndrome.③There is closely related between the level of Hs-CRP and risk stratification;④There is related between the level of Hs-CRP and the state of high aggregation of platelet.When the level of Hs-CRP is higher,the level of PAgT is also higher.⑤There is interact effect between lipid abnormality and other risk factors, HDL-C and GLU is negative correlation,LDL-C and Hs-CRP is positive correlation;⑥There is some relativity between impaired glucose metabolism and sex,drinking and smoking history,amount of exercise.For example,there is positive correlation between the level of glucose and TC、TG、plasm PAgT,while there is negative correlation between the level of glucose and HDL-C.⑦Cross-sectional study the standard treatment condition of sample people of the first visit clinic,the standard treatment rate is only 30.6%,in the different risk factors,the lipid abnormality and diabetic patients standardize rate is the lowest,18.27%and 29.41%,the blood standardize rate of other risk factors is more than 43%.
Conclusions.①Weaken the effect of sex,age of the midaged EH patients,except for the early onset family history of cardio-vascular disease,the main risk of this sample people include impaired glucose metabolism,inflammatory response,impaired lipid metabolism,lack of amount of exercise.②There is closely relation between the form of chinese syndrome of midaged patients and collection of multiple risk factors, there is respctive characteristic to the different risk factors,for example,if the Hs-CRP is high,the incidence of wind,phlegm,stasis,and heat syndrome is high.It is significant correlation with risk stratification and also same as the chinese medicine syndrome when the acute cardio-celebra vascular events happen,It is the one of the basis of biology when the wind,phlegm,stasis,and heat syndrome combined happen, It is significant correlation with acute events,it is one of the starting point to study the toxic pathogens③There are cooperativity and relativity between the main risk factors of inflammatory response,high coagulation condition of platelet impaired lipid metabolism,impaired glucose metabolism which can be intervene,it can explain the clinic question,point out the direction of using medicine;④It is still not enough to control and prevent this objects at present,the degree of execute guideline should be reinforced,and find the good way to execute the guideline,it is also find that it is bad control of multiple risk factors patient,it is necessary to comprehensive management. It is important things that consider the cooperate or relative effect to standard prevent and treatment;it should be furthermore enforce that propaganda,supervise,guide,and implement guidline into the patients,patients are the main part of prevent and treatment.
引文
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[1]中国高血压防治指南修订委员会.中国高血压防治指南(2005年修订版全文)[J].中华高血压杂志,2005,13(增刊):1-37.
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