南宫授课金波pwvppt课件

动脉僵硬度和阻塞程度的临床应用,刘金波 北京大学首钢医院血管医学中心,评价大动脉僵硬度的方法,间接方法： 血压测量(SBP&PP) 脉搏波形分析（Pulse contour analysis） 直接方法： 多普勒超声 脉搏波速度（Pulse wave velocity）,脉压,心脏收缩沿血管壁产生前向波，前向波受阻产生综合性反射波,脉压,前向波和反射波共同构成了脉搏波形,脉压,当动脉僵硬度增高时，反射波速度加快,脉压,收缩压增高，舒张压降低，脉压明显增大,脉压,脉搏波速度 (pulse wave velocity，PWV),定义： 左室射血产生脉搏波以一定速度沿动脉壁向全身传播。,左室,脉搏波速度 血管内血液流动速度,脉搏波速度,脉搏波速度 血管内血液流动速度,通常，以颈总动脉搏动点作为脉搏波传导的起点,生理因素： 年龄：10岁以前大动脉僵硬度随年龄增长迅速下降，但随后的50年内则逐渐升高 性别：成年女性PWV略小于同龄男性，而在儿童和老年人群（即老年男性和绝经后女性）性别差异不明显。 基因：nitric oxide synthase 血压：无论是由于动脉性质改变，或是由于动脉内压力增大，均可致PWV增加 心率：长期心率较快可造成退行性改变加速,影响脉搏波速度的因素,临床疾病： 高血压 糖尿病 冠心病 心功能不全 肾功能不全,影响脉搏波速度的因素,The effects of aging on cf-PWV in males and females,The Anglo-Cardiff Collaborative Trial(ACCT) Subjects 4,001 healthy normotensives aged 19-90years.,J Am Coll Cardiol 2005;46:1753-60,高血压,AGE (Years) r = 0.48* ; y = 0.123x + 6.27,20 30 40 50 60 70 80 90,20 16 12 8 4,AGE (Years) NT HT y = 0.0628x + 5.728 y = 0.123x + 6.27,20 16 12 8 4,20 30 40 50 60 70 80 90,* * p 0.001 *,Asmar et al, Blood Pressure, 1995,HT,NT,n = 224,CAROTID-FEMORAL P.W.V. (m/s),CAROTID-FEMORAL P.W.V. (m/s),0,2,4,6,8,10,正常对照,糖耐量低减,糖尿病,颈股 PWV (m/s),*,*,糖尿病,Am J Hypertens，1995；8：426-428,糖尿病,(Adapted from Woolam et al., 1962),糖尿病相关蛋白尿,(Adapted from Tanokuchi et al., 1962),冠心病,冠心病以及家族史,NOR RISK CAD,Male,Female,Yamashina A et al. Hypertens Res 2002,NOR RISK CAD,心功能不全,adapted from Arnold et al.,动脉僵硬度和慢性肾功能不全,Hypertension，1992;20:10-19,cf-pwv：颈-股动脉 cr-pwv：颈-桡动脉 ff-pwv：股-足背动脉,Hypertension2005;45;1078-1082.,Patients with the metabolic syndrome had a greater aortic PWV(9.72.0 versus 9.02.0m/s;P0.03). This difference held after controlling for the confounding effect of age and mean arterial pressure.,动脉僵硬度和代谢综合征,147 mm Hg,动脉僵硬度和代谢综合征,Hypertension2005;45;1078-1082.,Hypertens Res 2005;28:125131,动脉僵硬度和代谢综合征,Question,动脉僵硬度升高意味着什么？ 1、动脉粥样硬化危险因素综合作用引起血管损害的早期指标 2、不同个体对动脉粥样硬化危险因素的易感性 3、对预后的预测,Arterial stiffness may predict coronary heart disease beyond classic risk factors,1045 hypertensives without known clinical cardiovascular disease mean follow-up was 5.7 years,Adapt from Hypertension. 2002;39:10-15.,Impact of Aortic Stiffness on Survival in End-Stage Renal Disease,Adapt from Circulation. 1999;99:2434-2439.,Conclusions The role of arterial stiffening was independent of other factors known to affect the outcome of uremic patients, namely age, overall duration of ESRD, preexisting cardiovascular disease, degree of LV hypertrophy, BP, and serum albumin and hemoglobin levels.,Impact of Aortic Stiffness on Survival in End-Stage Renal Disease,Adapt from Circulation. 1999;99:2434-2439.,Impact of Aortic Stiffness Attenuation on Survival in ESRD,The risk ratio for the absence of PWV decrease was 2.59 for all-cause mortality and 2.35 for cardiovascular mortality.,Impact of Aortic Stiffness Attenuation on Survival in ESRD,Conclusions Arterial stiffness is not only a risk factor contributing to the development of cardiovascular disease but also a marker of established, more advanced, less reversible arterial changes. In ESRF patients, the insensitivity of PWV to decreased BP is an independent predictor of mortality,Impact of Aortic Stiffness Attenuation on Survival in ESRD,PWV is strong surrogate marker of cardiovascular events or total death. A Systematic Review and Meta-Analysis,Vlachopoulos C et al. JACC 2010;55:1318-1327,Question,如何对动脉僵硬度增高进行干预？,pwv & treatment,长期药物治疗(28d),急性和短期药物治疗（28d）,PWV & ACEI,确诊的PAD患者40名：ABI0.9，并经血管超声证实 Ramipril(10 mg, once daily）VS. 安慰剂 疗程 ：24 w,Ramipril Reduces Large-Artery Stiffness in PAD,Ramipril Reduces Large-Artery Stiffness in PAD,cell culture,Ramipril Reduces Large-Artery Stiffness in PAD,Ramipril Reduces Large-Artery Stiffness in PAD,cell culture,Fluvastatin and arterial stiffness,22 diatetic patients with ESRD on haemodialysis Received fluvastatin(20mg/day) 6 months Index: LDL-C, CRP, PWV,Fluvastatin and arterial stiffness,Fluvastatin and arterial stiffness,The beneficial effect of fluvastatin may result from a statin-induced upregulation of endothelial nitric oxide synthase expression and/or activity.,Improved Vascular Compliance by AGE-Crosslink Breaker,Advanced Glycation End-Product Crosslink Breaker：ALT-711 共入选93人，随访56天 随机接受口服ALT-711 (210 mg, once per day)或安慰剂 入选标准： 50岁 有动脉僵硬度增高的证据：PP 60 mm Hg, SBP140 mm Hg, large artery compliance 1.25 mL/mm Hg 维持原有降压药物不变至少4周 （ACEI/ARB，-blocker，CCB，利尿剂） 排除标准：已知的心脑血管疾病、心脏瓣膜病、恶性高血压、1型或未控制稳定的2型糖尿病、严重肾脏疾病、活动性慢性肺部疾病、房颤、心功能不全等,Improved Vascular Compliance by AGE-Crosslink Breaker,Improved Vascular Compliance by AGE-Crosslink Breaker,day28 day 56,d