APP下载

非酒精性脂肪肝伴2型糖尿病患者左室舒张功能的影响

2014-08-30赵瑜等

心脑血管病防治 2014年4期
关键词:左室酒精性颈动脉

赵瑜等

[摘要]目的探讨非酒精性脂肪肝(NAFLD)对2型糖尿病患者左室舒张功能的影响。方法纳入596例2型糖尿病住院患者,进行腹部超声、颈动脉超声、心脏超声等检查,以E/A作为评估左室舒张功能的指标,分为NAFLD组和非NAFLD组,组内或组间差异比较用单因素方差分析或χ2检验,并采用多因素Logistic回归分析对可能影响舒张功能的因素进行分析。结果2型糖尿病合并NAFLD组的BMI、收缩压、丙氨酸氨基转移酶、甘油三酯、LDL胆固醇、HbA1c、HOMA_IR、颈动脉内膜中层厚度显著高于无NAFLD组(P<0.05),E/A值显著低于无NAFLD组(P<0.05);NAFLD与左室舒张功能减退的相关性经多因素Logistic回归分析进行校正后OR值为1.72(95%CI 1.26~2.75,P<0.05)。结论在2型糖尿病患者中,NAFLD是左室舒张功能减退的重要危险因素。

[关键词]非酒精性脂肪肝;2型糖尿病;左室舒张功能

中图分类号:R587.1文献标识码:A文章编号:1009_816X(2014)04_0293_03

[Abstract] Objective To evaluate the influence of non_alcoholic fatty liver disease (NAFLD) on left diastolic ventricular function in type 2 diabetes patients. Methods The type 2 diabetic patients were enrolled (n=596), tests like abdomen ultrasound, carotid artery ultrasound, cardiac uhrasonography were cawied out. E/A was used as an index to evaluate the left ventricular diastolic dysfunction, and patients were divided into NAFLD group and non_NAFLD group. Using one_way ANOVA or chi_square test as a method to analyze the differences between two groups. Using multi_factor Logistic regression analysis to analyze the factors that may influence the left ventricular diastolic function . P<0.05 considered statistically significant.Results Body mass index, systolic pressure, alanine aminotransferase, triglyceride, low density lipoprotein cholesterin, HbA1c, homeostasis model assessment of insulin resistance (HOMA_IR), intima_media thickness (IMT) were significantly higher in individuals with NAFLD than in those without NAFLD (P<0.05). Patients with NAFLD had a remarkably lower E/A(0.82±0.18, P<0.05). NAFLD remained independently associated with left ventricular dysfunction in multivariate logistic regression analysis (Odds Ratio 1.72, 95%CI 1.26~2.75, P<0.05). Conclusions NAFLD is an independent risk factor of decline of left ventricle diastole function in type 2 diabetes patients.

[Key words] Non_alcoholic fatty liver disease; Type 2 diabetes mellitus; Left ventricular diastolic function

近年研究发现,非酒精性脂肪肝(Non_alcoholic fatty liver disease,NAFLD)患者相较于正常人更易出现心功能减退[1,2]。而糖尿病作为目前高发的慢性内分泌代谢性疾病,与心脑血管疾病关系密切,本文拟探讨非酒精性脂肪肝对2型糖尿病患者左室舒张功能的可能影响。

1资料与方法

1.1一般资料:2012年6月至2013年12月期间在我院住院的2型糖尿病患者,排除高血压病、缺血性心脏病,服用噻唑烷二酮类降糖药物,过量酒精摄入(饮酒折合乙醇量<140g/周,女性<70g/周),病毒性肝炎、药物性肝病、全胃肠外营养、肝豆状核变性、自身免疫性肝病、甲状腺功能减退症等可导致脂肪肝的特定疾病,应激状态,严重的心、肝、肾疾病及其他糖尿病严重并发症等情况,将其分为合并NAFLD组与无NAFLD组。2型糖尿病的诊断采用《2010年中国2型糖尿病防治指南》中的诊断标准[3];NAFLD的诊断采用《2010年中华医学会非酒精性脂肪性肝病诊疗指南》中的诊断标准[4]。符合条件的2型糖尿病患者共596例,其中男332例(占55.70%),女264例(占44.30%)。符合诊断的NAFLD患者共404例(占67.78%),非NAFLD患者192例(占32.22%)。

1.2方法:记录其年龄、性别、BMI、血压情况、吸烟情况、糖尿病病程,丙氨酸氨基转移酶、血清肌酐、甘油三酯、低密度脂蛋白胆固醇(LDL_C)、糖化血红蛋白(HbA1c),行颈动脉超声测双侧颈动脉内膜中层厚度(记录较厚的一侧),禁食8~10小时后行腹部超声,行心脏超声检查测室间隔厚度、左室后壁厚度、左室舒张末期内径、左室收缩末期内径、左室射血分数,二尖瓣口舒张早期E峰速度峰值/二尖瓣口舒张晚期A峰速度峰值(E/A)。以E/A值作为对左室舒张功能评价的依据,E/A<1视为左室舒张功能减退。

1.3统计学处理:所测数据采用SPSS13.0版统计学软件进行统计学处理,计量资料用(x-±s)表示,组间差异如符合正态分布则采用t检验,不符合正态分布则采用秩和检验,定性资料组间差异用χ2检验。NAFLD与左室舒张功能的相关性应用多因素Logistic回归分析。P<0.05为差异有统计学意义。

2结果

2.1两组基础资料与影像学实验室检查结果比较:见表1。从表1可见,较于无NAFLD的2型糖尿病患者,合并NAFLD患者组的男性患者较多,糖尿病病程相对较短,平均年龄较小,BMI、收缩压、HOMA_IR、丙氨酸氨基转移酶、甘油三酯、LDL_C、游离脂肪酸、HbA1c、颈动脉内膜中层厚度值较高,差异有统计学意义(P<0.05)。血压、心率、当前吸烟状况、血肌酐水平两组间比较差异无统计学意义。NAFLD组E/A均值<1,且E/A<1患者人数与无NAFLD组间差异有统计学意义(P<0.05);左室舒张末期内径、左室收缩末期内径、左室射血分数、室间隔厚度、左室后壁厚度两组间比较差异无统计学意义。

3讨论

NAFLD是指除外过量饮酒和其他明确的肝损害因素所致的、以弥漫性肝细胞大泡性脂肪变为主要特征的临床病理综合征,它与2型糖尿病拥有共同的危险因素如过度的能量摄入、腹型肥胖、胰岛素抵抗等[5]。越来越多的证据也表明,NAFLD可能增加2型糖尿病患者的血糖控制难度、糖尿病慢性并发症如心血管疾病和慢性肾脏疾病的发病率[6]。在临床工作中,我们发现NAFLD与2型糖尿病常常共同存在,2型糖尿病患者NAFLD患病率可高达28%~55%[4]。本次研究对象中NAFLD患者占67.78%,患病率高于文献报道,可能与住院患者有更严重的代谢紊乱相关。此外,NAFLD组BMI、收缩压、HbA1c、甘油三酯、LDL胆固醇、HOMA_IR水平更高,体型、血糖控制、脂代谢情况更差,胰岛素抵抗更严重。

心血管疾病是2型糖尿病的主要致残和致死原因,而颈动脉内膜中层厚度与心血管事件密切相关,且对心血管风险有一定预测作用[7]。本研究显示合并NAFLD的2型糖尿病患者颈动脉内膜中层厚度明显增加,预示该组人群有更高的心血管意外风险。Targher[8]等进行的前瞻性研究也发现,经过5年随访后,伴有NAFLD的2型糖尿病患者其发生冠心病、缺血性脑卒中及心血管相关性死亡的风险显著增加。

心功能减退早期往往表现为心脏舒张功能减退,可通过心脏多普勒超声检测到,E/A<1可作为评估左室舒张功能减退的一项指标[9]。本次研究比较了两组间左室形态学指标及左室射血分数均未出现显著性差异,而合并NAFLD的2型糖尿病患者组E/A均值显著低于非NAFLD组,存在左室舒张功能减退的患者比例显著高于非NAFLD组,提示合并NAFLD的患者左室舒张功能减退更严重、患病率更高。糖尿病可引起心脏结构的变化如心肌肥厚、纤维化和脂质沉积,即使不患有缺血性心脏病或高血压的2型糖尿病患者,也可能出现心脏结构和功能的改变[10]。此外也有研究发现脂肪肝可能会增加心功能减退的风险,目前认为主要与脂质代谢紊乱、胰岛素抵抗、动脉粥样硬化等引起心肌代谢异常相关[1,2]。但在校正了年龄、性别、BMI、收缩压、血脂、HOMA_IR及HbA1c等多项因素后,NAFLD与左室舒张功能减退仍有较高的相关性,提示在2型糖尿病患者中NAFLD为左室舒张功能减退的独立危险因素。其具体机制目前尚不明确,从病理生理机制角度出发,可能与NAFLD患者肝脏及脂肪组织释放CRP、IL_6、TNF_α及其他炎症因子显著增多损伤血管内皮、影响心肌代谢有关[11]。

因此,我们认为,合并有NAFLD的2型糖尿病患者在尚无确切心功能不全的临床症状、左室的形态学及收缩功能尚基本正常时,已可检测到舒张功能不全的特征,此为心功能受损的早期表现,故对于2型糖尿病患者,应重视NAFLD的早期诊断和治疗,并对合并有NAFLD的患者及早进行心脏功能的评估。若能在2型糖尿病合并NAFLD患者心脏损害的亚临床阶段采取有效措施防止心脏功能进一步受损,对延缓病情进展有重要意义。

参考文献

[1]Goland S, Shimoni S, Zornitzki T, et al. Cardiac abnormalities as a new manifestation of nonalcoholic fatty liver disease: echocardiographic and tissue Doppler imaging assessment[J]. J clinical gastroenterology,2006,40(10):949-955.

[2]Fotbolcu H, Yakar T, Duman D, et al. Impairment of the left ventricular systolic and diastolic function in patients with non_alcoholic fatty liver disease[J]. Cardiology J,2010,17(5):457-63.

[3]杨文英,纪立农,陆菊明,等.2010年中国2型糖尿病防治指南[M].北京大学医学出版社,2011:1-300.

[4]范建高.非酒精性脂肪性肝病诊疗指南[J].临床肝胆病杂志,2010,26(2):120-124.

[5]Larter CZ, Chitturi S, Heydet D, et al. A fresh look at NASH pathogenesis. Part 1: the metabolic movers[J]. J gastroenterology and hepatology,2010,25(4):672-690.

[6]Targher G, Byrne CD. Clinical Review: Nonalcoholic fatty liver disease: a novel cardiometabolic risk factor for type 2 diabetes and its complications[J]. J clinical endocrin metabolism,2013,98(2):483-495.

[7]Lorenz MW, Markus HS, Bots ML, et al. Prediction of clinical cardiovascular events with carotid intima_media thickness a systematic review and meta_analysis[J]. Circulation,2007,115(4):459-467.

[8]Targher G, Bertolini L, Poli F, et al. Nonalcoholic fatty liver disease and risk of future cardiovascular events among type 2 diabetic patients[J]. Diabetes,2005,54(12):3541-3546.

[9]Galderisi M. Diastolic dysfunction and diabetic cardiomyopathy: evaluation by Doppler echocardiography[J]. J Ameri Cardi,2006,48(8):1548-1551.

[10]Maya L, Villarreal FJ. Diagnostic approaches for diabetic cardiomyopathy and myocardial fibrosis[J]. J molecul cellular cardiol,2010,48(3):524-529.

[11]Bhatia LS, Curzen NP, Calder PC, et al. Non_alcoholic fatty liver disease: a new and important cardiovascular risk factor[J]? European heart J,2012,33(10):1190-200.

(收稿日期:2014_3_21)

[4]范建高.非酒精性脂肪性肝病诊疗指南[J].临床肝胆病杂志,2010,26(2):120-124.

[5]Larter CZ, Chitturi S, Heydet D, et al. A fresh look at NASH pathogenesis. Part 1: the metabolic movers[J]. J gastroenterology and hepatology,2010,25(4):672-690.

[6]Targher G, Byrne CD. Clinical Review: Nonalcoholic fatty liver disease: a novel cardiometabolic risk factor for type 2 diabetes and its complications[J]. J clinical endocrin metabolism,2013,98(2):483-495.

[7]Lorenz MW, Markus HS, Bots ML, et al. Prediction of clinical cardiovascular events with carotid intima_media thickness a systematic review and meta_analysis[J]. Circulation,2007,115(4):459-467.

[8]Targher G, Bertolini L, Poli F, et al. Nonalcoholic fatty liver disease and risk of future cardiovascular events among type 2 diabetic patients[J]. Diabetes,2005,54(12):3541-3546.

[9]Galderisi M. Diastolic dysfunction and diabetic cardiomyopathy: evaluation by Doppler echocardiography[J]. J Ameri Cardi,2006,48(8):1548-1551.

[10]Maya L, Villarreal FJ. Diagnostic approaches for diabetic cardiomyopathy and myocardial fibrosis[J]. J molecul cellular cardiol,2010,48(3):524-529.

[11]Bhatia LS, Curzen NP, Calder PC, et al. Non_alcoholic fatty liver disease: a new and important cardiovascular risk factor[J]? European heart J,2012,33(10):1190-200.

(收稿日期:2014_3_21)

[4]范建高.非酒精性脂肪性肝病诊疗指南[J].临床肝胆病杂志,2010,26(2):120-124.

[5]Larter CZ, Chitturi S, Heydet D, et al. A fresh look at NASH pathogenesis. Part 1: the metabolic movers[J]. J gastroenterology and hepatology,2010,25(4):672-690.

[6]Targher G, Byrne CD. Clinical Review: Nonalcoholic fatty liver disease: a novel cardiometabolic risk factor for type 2 diabetes and its complications[J]. J clinical endocrin metabolism,2013,98(2):483-495.

[7]Lorenz MW, Markus HS, Bots ML, et al. Prediction of clinical cardiovascular events with carotid intima_media thickness a systematic review and meta_analysis[J]. Circulation,2007,115(4):459-467.

[8]Targher G, Bertolini L, Poli F, et al. Nonalcoholic fatty liver disease and risk of future cardiovascular events among type 2 diabetic patients[J]. Diabetes,2005,54(12):3541-3546.

[9]Galderisi M. Diastolic dysfunction and diabetic cardiomyopathy: evaluation by Doppler echocardiography[J]. J Ameri Cardi,2006,48(8):1548-1551.

[10]Maya L, Villarreal FJ. Diagnostic approaches for diabetic cardiomyopathy and myocardial fibrosis[J]. J molecul cellular cardiol,2010,48(3):524-529.

[11]Bhatia LS, Curzen NP, Calder PC, et al. Non_alcoholic fatty liver disease: a new and important cardiovascular risk factor[J]? European heart J,2012,33(10):1190-200.

(收稿日期:2014_3_21)

猜你喜欢

左室酒精性颈动脉
卡维地洛联合尼可地尔对冠心病心肌缺血及左室舒张功能的影响分析
心脏超声配合BNP水平测定在高血压左室肥厚伴心力衰竭诊断中的应用
中西医结合治疗非酒精性脂肪肝病的临床疗效研究
酒精性肝病的预防和治疗
颈动脉狭窄与脑梗或只一步之遥
探讨血清缺糖基转铁蛋白在酒精性肝病诊断中的价值
非酒精性脂肪肝更易变成肝硬化
颈动脉狭窄要手术吗
探究分析左室假腱索与心电图异常的关系
亲吻会致死,是真的吗