Uticaj dnevno-noćnog ritma arterijskog krvnog pritiska na funkciju i geometriju leve pretkomore i komore srca

Abstract

Cilj: Cilj ovog istraživanja bio je da se utvrde promene koje arterijska hipertenzija dvojakim mehanizmima (dnevno-noćnim ritmom i svojim trajanjem) ostavlja na funkciju i geometriju leve pretkomore i komore srca. Ispitanici i metode: u ovo istraživanje bilo je uključeno 180 ispitanika koji su bili podeljeni u ispitivane grupe u odnosu na dnevno-noćni ritam arterijskog krvnog pritiska tokom 24-časovnog monitoringa arterijskog krvnog pritiska i to na sledeći način: grupa ispitanika sa očuvanim dnevno-noćnim ritmom arterijskog krvnog pritiska sastojala se od ukupno 90 ispitanika, a grupu onih sa narušenim dnevno-noćnim ritmom arterijskog krvnog pritiska takođe je činilo 90 ispitanika. U svakoj od ovih grupa izvršena je dodatna podela ispitanika prema dužini trajanja arterijske hipertenzije na one kod kojih je arterijska hipertenzija trajala do 5 godina, one kod kojih je trajala od 5 do 10 godina i na one sa trajanjem arterijske hipertenzije više od 10 godina. Svim ispitanicima rađen je incijalno 24-časovni ambulantni monitoring arterijskog krvnog pritiska, a nakon toga i ehokardiografski pregled radi određivanja parametara morfologije leve pretkomore i komore, kao i dijastolne funkcije leve komore. Rezultati i diskusija: nakon statističke obrade podataka dobijeni su rezultati koji ukazuju da se dijastolna disfunkcija stepena većeg od I statistički značajno češće (p=0,011) uočava kod onih ispitanika koji nemaju očuvan dnevno-noćni ritam arterijskog krvnog pritiska. Narušen dnevno-noćni ritam arterijskog krvnog pritiska takođe dovodi do povećanja indeksirane mase miokarda leve komore prema površini tela ispitanika (LVM/BSA) – p=0,001; do zadebljanja zidova leve komore (IVS/PLW) – p=0,025, kao i do smanjenja sistolne brzine miokarda na nivou septalnog dela mitralnog anulusa (s’) - p<0,0005. Pored ovoga, u grupi onih sa narušenim dnevno-noćnim ritmom arterijskog krvnog pritiska primećeno je češće prisustvo ekscentrične hipertrofije miokarda leve komore (p=0,027). U odnosu na geometriju i funkciju leve pretkomore, narušen dnevno-noćni ritam arterijskog krvnog pritiska dovodi do promena u smislu povećanja antero-posteriornog dijametra leve pretkomore (LA)-p=0,003; maksimalnog volumena leve pretkomore u komorskoj sistoli (LAVs) –p=0,007; indeksiranog LAVs prema površini tela ispitanika (LAVs/BSA)-p<,0005; E/e’ odnosa –p=0,040; rezervoarnog strain-a leve pretkomore (PLAS)- p=0,004; krutosti leve pretkomore (stiffness)-p=0,047, kao i brzine propagacije talasa kroz mitralni otvor (Vp)-p=0,029. Sa povećanjem dužine trajanja arterijske hipertenzije takođe su pokazane promene u morfologiji i funkciji leve pretkomore i leve komore srca. Dijastolna disfunkcija stepena većeg od I retko je bila uočena u grupi onih koji su arterijsku hipertenziju lečili kraće od 5 godina, a njeno prisustvo u ispitivanim grupama trajanja od 5 do 10 godina i duže od 10 godina bilo je statistički značajno češće (p<0,0005). Takođe, sa trajanjem arterijske hipertenzije statistički značajno se menjaju i parametri leve komore za koje smo pokazali da su pogoršani kada dnevno-noćni ritam arterijskog krvnog pritiska nije očuvan, s tim što smo ovde uočili i značajne promene u smislu postojanja lošijih vrednosti strain-a leve komore (LVGS)-p<0,0005. Na sličan način kao i u odnosu na dnevno-noćni ritam arterijskog krvnog pritiska, menjao se predominantni oblik hipertrofije miokarda leve komore, te je uočeno značajno češće (p=0,017) prisustvo ekscentrične hipertrofije kod ispitanika koji su duže lečili arterijsku hipertenziju. Uz ove promene, sa trajanjem arterijske hipertenzije, uočene su i promene sledećih ehokardiografskih parametara leve pretkomore (p<0,0005): LA, LAVs, LAVs/BSA, E/e’, PLAS, stiffness, Vp. Na kraju, formiran je i model za dijagnostiku dijastolne disfunkcije stepena većeg od I koji je testiran na 30 novih ispitanika i koji se pokazao kao kvalitetan uz visoku senzitivnost i specifičnost. Zaključak: arterijska hipertenzija dnevno-noćnim oscilacijama (ritmom), ali i svojim trajanjem dovodi do promena u funkciji i geometriji leve pretkomore i komore srca. Noviji ehokardiografski parametri (PLAS, LVGS, stiffness) su dobri pokazatelji ranih promena na nivou leve pretkomore i komore srca kod pacijenata sa arterijskom hipertenzijom.

Objective: The aim of this study was to determine the changes that arterial hypertension by its dual mechanisms (circadian rhythm and its duration) leaves on the function and geometry of left atrium and left ventricle of the heart. Respondents and Methods: This study involved 180 subjects who were divided into examined groups in relation to the circadian arterial blood pressure rhythm during 24-hour monitoring of arterial blood pressure, as follows: group of subjects with preserved circadian rhythm of arterial blood pressure consisted of a total of 90 subjects, and a group of those with impaired circadian rhythm of arterial blood pressure also comprised 90 subjects. In each of these groups an additional division of subjects was performed according to the duration of arterial hypertension to those whose arterial hypertension lasted up to 5 years, those in whom it lasted 5-10 years and those with duration of arterial hypertension for more than 10 years. All participants received an incisional 24-hour ambulatory monitoring of arterial blood pressure, followed by an echocardiographic examination to determine the morphology parameters of the left atrium and ventricle, as well as the diastolic functions of the left ventricle. Results and discussion: after statistical data processing, results have been obtained indicating that diastolic dysfunction of a level greater than I statistically significantly more frequently (p = 0.011) was observed in those subjects who didn’t have preserved circardian rhythm of arterial blood pressure. A non-dipper circadian arterial blood pressure rhythm also led to an increase in the indexed left ventricular myocardial mass according to the body surface of the respondent (LVM / BSA) - p = 0.001; to the increase in the wall thickness of the left ventricle (IVS / PLW) - p = 0.025, as well as to the decrease in systolic myocardial velocity at the level of the septal portion of the mitral anulus (s') - p <0.0005. In addition, in the group of those with impaired circadian rhythm of arterial blood pressure, a more frequent presence of eccentric hypertrophy of the left ventricular myocardium (p = 0.027) was observed. In relation to the geometry and left atrial function, the circadian rhythm of arterial blood pressure led to a change in terms of an increase in the antro-posterior diameter of the left atrium (LA) -p = 0.003; maximum left ventricular volume in ventricular systole (LAVs) -p = 0.007; indexed LAVs according to the surface of the respondent’s body (LAVs / BSA) -p <, 0005; E / e 'ratio-p = 0.040; reservoar strain (PLAS) - p = 0.004; stiffness -p = 0.047, as well as the velocity propagation across the mitral opening (Vp) -p = 0.029. With increasing duration of arterial hypertension, changes in morphology and left atrial and left ventricular functions were also demonstrated. Diastolic dysfunction of a grade greater than I was rarely observed in the group of those who had been treating arterial hypertension for up to 5 years, and its presence in the investigated groups with duration of 5 to 10 years and for more than 10 years was statistically significantly more common (p <0.0005). Also, with the duration of arterial hypertension, the parameters of the left ventricle were also significantly changed-the same for which we showed that they were worsened when the circadian rhythm of arterial blood pressure was not preserved, but beside that we noticed significant changes in the sense of the existence of less negative values of strain- the left ventricle global strain (LVGS) -p <0.0005. In a similar way to the circadial rhythm of arterial blood pressure, the prevalent form of myocardial left ventricular hypertrophy changed, and the presence of eccentric hypertrophy in patients with longer arterial hypertension duration was significantly more frequent (p = 0.017). In addition to these changes, with duration of arterial hypertension, changes in the following echocardiographic parameters of the left atrium (p <0.0005) were observed: LA, LAVs, LAVs / BSA, E / e ', PLAS, stiffness, Vp. Finally, a model for the diagnosis of diastolic dysfunction of a degree greater than I was formed and afterwards tested on 30 new subjects and it proved to be of good quality with high sensitivity and specificity. Conclusion: arterial hypertension by its duration and day-night oscillations (rhythm) leads to changes in the function and geometry of the left atrium and left ventricle of the heart. The latest echocardiographic parameters (PLAS, LVGS, stiffness) are good indicators of early changes of left atrium and left heart ventricle in patients with arterial hypertension.