基于三维斑点追踪技术评估原发性高血压患者颈动脉粥样硬化对右心室–肺动脉耦联功能的影响

Evaluation of the Impact of Carotid Atherosclerosis on Right Ventricular-Pulmonary Artery Coupling in Patients with Essential Hypertension Using Three-Dimensional Speckle Tracking Echocardiography

摘要: 目的：探讨原发性高血压患者颈动脉粥样硬化(CAS)负荷与右心室–肺动脉耦联(right ventricular-pulmonary artery coupling, RVPAC)的关联；评估以三维斑点追踪技术(3D-STE)获得的右心室游离壁纵向应变(RVFWLS)与肺动脉收缩压(PASP)之比(RVFWLS/PASP)表征的无创耦联指标的应用价值。方法：连续纳入原发性高血压患者117例，按颈动脉超声结果分为无斑块组(n = 50)与有斑块组(n = 67)，另设健康对照组(n = 30)。所有受试者接受颈动脉超声检查测量内膜中层厚度(cIMT)并计算简易颈动脉斑块积分(carotid plaque score, CPS)评估CAS负荷。应用经胸超声心动图测量左心室舒张末期内径(LVEDD)、室间隔厚度(IVSd)、左心室后壁厚度(LVPWd)、舒张功能参数(E、A、e')及左心室射血分数(LVEF)，计算左心室质量指数(LVMI)，并测量右心室面积变化分数(RVFAC)；M型超声测量三尖瓣环收缩期位移(TAPSE)；连续多普勒测量三尖瓣最大反流速度(TRV)计算PASP (PASP = 4 × TRV² + RAP；RAP为右心房压，依据下腔静脉内径与吸气塌陷率估算)，应用3D-STE获得右心室室间隔纵向应变(RVSLS)与RVFWLS，并计算无创耦联指标RVFWLS/PASP。采用Spearman秩相关分析与多元线性回归评估RVPAC与CAS负荷等变量的关系。结果：有斑块组高血压患者的IVSd、LVMI、E/e'、PASP及cIMT均显著高于其他两组，E/A、RVFWLS、RVSLS、TAPSE、RVFAC及RVFWLS/PASP均显著降低(均P < 0.001)。Spearman秩相关分析显示，cIMT与CPS均与RVFWLS/PASP显著负相关(r_s分别为−0.761与−0.663，均P < 0.001)。在仅纳入高血压患者(n = 117)构建的多元线性回归模型中，校正年龄、体重、血压、LVMI与舒张功能参数(E/A、E/e')后，CAS程度(作为连续变量或有序分级)与RVFWLS/PASP仍呈独立负相关(均P < 0.001)，且随CAS负荷加重，RVPAC受损呈梯度性恶化。观察者内及观察者间重复性分析显示，RVFWLS、RVSLS及PASP的测量具有良好的一致性(ICC均 > 0.85)。结论：在原发性高血压患者中，CAS负荷与RVPAC受损独立相关。颈动脉超声量化的CAS负荷可作为提示需进一步右心功能评估的直接线索。

Abstract: Objective: To investigate the association between carotid atherosclerosis (CAS) burden and right ventricular-pulmonary arterial coupling (RVPAC) in patients with primary hypertension, and to assess the utility of a noninvasive coupling index (RVFWLS/PASP), where RVFWLS is derived from three-dimensional speckle-tracking echocardiography (3D-STE) and PASP denotes pulmonary artery systolic pressure. Methods: We consecutively enrolled 117 patients with primary hypertension, stratifying them by carotid ultrasound into a no-plaque group (n = 50) and a plaque group (n = 67); a healthy control group (n = 30) was also included. All participants underwent carotid ultrasound to measure carotid intima-media thickness (cIMT) and calculate the simplified carotid plaque score (CPS), thereby quantifying CAS burden. Transthoracic echocardiography was used to measure the left ventricular end-diastolic diameter (LVEDD), interventricular septal thickness in diastole (IVSd), left ventricular posterior wall thickness in diastole (LVPWd), diastolic function parameters (E, A, e'), and left ventricular ejection fraction (LVEF); to calculate the left ventricular mass index (LVMI); and to measure right ventricular fractional area change (RVFAC). M-mode echocardiography measured tricuspid annular plane systolic excursion (TAPSE). Continuous-wave Doppler measured the peak velocity of the tricuspid regurgitant jet (TRV) and calculated PASP (PASP = 4 × TRV² + RAP; right atrial pressure [RAP] was estimated from inferior vena cava diameter and inspiratory collapsibility). 3D-STE obtained right ventricular septal longitudinal strain (RVSLS) and right ventricular free-wall longitudinal strain (RVFWLS), from which the noninvasive coupling index RVFWLS/PASP was derived. Spearman’s rank correlation and multiple linear regression were used to assess associations between RVPAC and CAS burden, as well as other covariates. Results: Compared with the no-plaque and healthy control groups, hypertensive patients with carotid plaque had significantly higher IVSd, LVMI, E/e', PASP, and cIMT, and significantly lower E/A, RVFWLS, RVSLS, TAPSE, RVFAC, and RVFWLS/PASP (all P < 0.001). Spearman’s rank correlation showed that both cIMT and CPS were significantly inversely correlated with RVFWLS/PASP (rs = −0.761 and −0.663, respectively; both P < 0.001). In multiple linear regression models restricted to the hypertensive cohort (n = 117), after adjustment for age, body weight, blood pressure, LVMI, and diastolic function parameters (E/A, E/e'), CAS severity (modeled as a continuous variable or as ordinal categories) remained independently and inversely associated with RVFWLS/PASP (all P < 0.001). Moreover, increasing CAS burden was associated with progressively worse RVPAC, indicating graded deterioration. Intra-and inter-observer reliability analysis demonstrated good reproducibility for the measurements of RVFWLS, RVSLS, and PASP (all ICC > 0.85). Conclusions: In patients with primary hypertension, CAS burden is independently associated with RVPAC impairment. Quantifying systemic atherosclerotic burden using carotid ultrasound may provide a practical prompt to undertake further right ventricular functional assessment.