肥厚型心肌病并发或未并发微循环障碍患者临床特征比较及其预后影响因素分析

doi:10.13481/j.1671-587X.20250618

摘要/Abstract

摘要：

目的探讨肥厚型心肌病（HCM）并发微循环功能障碍（CMD）患者的临床特征，分析并发CMD对HCM患者预后的影响。方法收集2019年1月1日—2023年9月30日诊断为HCM并有完整心脏磁共振成像（CMR）检查结果的患者211例。经CMR评定分为HCM并发CMD组68例，HCM未并发CMD组143例。比较2组患者年龄、性别、入院症状和既往史等临床资料及肌钙蛋白等血液相关检验资料，心电图、心脏彩超、CMR数据，包括异常Q波、压低ST段、倒置T波、PR间期、QRS波长、校正QT间期、射血分数（EF）、左心房内径（LAD）、左右心室舒张末期内径、心输出量、E峰、A峰和心肌最大肥厚程度（MWT）。采用Logistic回归分析HCM并发CMD患者的临床特征，多因素修正Poisson回归分析HCM患者出现主要不良心血管事件（MACE）的危险因素。结果与HCM未并发CMD组比较，HCM并发CMD组患者发生心悸患者百分率明显升高（P<0.05），发生心动过速患者百分率明显升高（P<0.05），肌钙蛋白水平明显升高（P<0.05），伴有高血压病史患者百分率明显降低（P<0.05）。与HCM未并发CMD组比较，HCM并发CMD组心电出现异常Q波患者百分率明显升高（P<0.05），心电出现倒置T波患者百分率和EF明显降低（P<0.05），LAD明显增大（P<0.05），MWT明显增加（P<0.05）。多因素Logistic回归分析，LAD增大［比值比（OR）=1.05，95%置信区间（CI）：1.00~1.11，P=0.048）］和MWT增加（OR=1.11，95%CI：1.03~1.19，P=0.007）是HCM患者并发CMD的危险因素；高血压病史（OR=0.40，95%CI：0.20~0.80，P=0.010）是HCM患者并发CMD的保护性因素。本研究平均随访时间为20.5个月，共有27例患者发生MACE，总发生率为12.80%，其中HCM并发CMD组患者12例，未并发CMD组患者15例。多因素修正Poisson回归分析，糖尿病病史［相对危险度（RR）=2.34，95%CI：1.09~5.06，P=0.030）］、心律失常病史（RR=4.00，95%CI：1.82~8.83，P=0.001）和EF降低（RR=0.96，95%CI：0.94~0.99，P=0.001）是HCM发生MACE的危险因素。结论 HCM并发CMD患者具有独特的临床特征，包括更高的症状负荷、左心房扩大、心肌肥厚和肌钙蛋白水平升高。并发CMD未增加短期不良事件风险，糖尿病、心律失常和EF降低是预后的关键危险因素，针对HCM并发CMD患者的早期干预和并发症管理可能改善HCM患者的长期预后。

关键词: 肥厚型心肌病, 微循环功能障碍, 临床特征, 不良心血管事件, 心脏磁共振成像

Abstract:

Objective To discuss the clinical characteristics of the patients with hypertrophic cardiomyopathy （HCM） complicated with microcirculatory dysfunction （CMD）， and to analyze the impact of concurrent CMD on the prognosis of the HCM patients. Methods A total of 211 patients diagnosed with HCM and having complete cardiac magnetic resonance imaging （CMR） examination results from January 1， 2019 to September 30， 2023 were collected. They were divided into HCM complicated with CMD group （68 cases） and HCM complicated without CMD group （143 cases） based on CMR assessment. The clinical data such as age， gender， admission symptoms， and past medical history， blood test data such as troponin， electrocardiogram， echocardiography， and CMR data including abnormal Q wave， ST segment depression， inverted T wave， PR interval， QRS wavelength， corrected QT interval， ejection fraction （EF）， left atrial diameter （LAD）， left and right ventricular end-diastolic diameters， cardiac output， E peak， A peak， and maximum wall thickness （MWT） of the patients were compared between two groups. Logistic regression was used to analyze the clinical characteristics of the HCM patients complicated with CMD； multivariate modified Poisson regression was used to analyze the risk factors for major adverse cardiovascular events （MACE） in the HCM patients. Results Compared with HCM complicated without CMD group， the percentage of palpitation patients in HCM complicated with CMD group was significantly increased （P<0.05）， the percentage of tachycardia episode patients was significantly increased （P<0.05）， the troponin level was significantly increased （P<0.05）， and the percentage with a history of hypertension patients was significantly decreased （P<0.05）. Compared with HCM complicated without CMD group， the percentage of abnormal Q wave on electrocardiogram in the patients in HCM complicated with CMD group were significantly increased （P<0.05）， the percentage of inverted T wave and the EF of the patients was significantly decreased （P<0.05）， the LAD was significantly increased （P<0.05）， and the MWT was significantly increased （P<0.05）. The multivariate Logistic regression analysis results showed that increased LAD （OR=1.05， 95%CI： 1.00-1.11， P=0.048） and increased MWT （OR=1.11， 95%CI： 1.03-1.19， P=0.007） were the risk factors for concurrent CMD in the HCM patients； history of hypertension （OR=0.40， 95%CI： 0.20-0.80， P=0.010） was a protective factor for concurrent CMD in the HCM patients. The average follow-up time in this study was 20.5 months. A total of 27 patients experienced MACE， with an overall incidence of 12.80%， including 12 patients in HCM complicated with CMD group and 15 patients in HCM complicated without CMD group. The multivariate modified Poisson regression analysis results showed that history of diabetes （RR=2.34， 95%CI： 1.09-5.06， P=0.030）， history of arrhythmia （RR）=4.00， 95%CI： 1.82-8.83， P=0.001）， and decreased ejection fraction （RR=0.96， 95%CI： 0.94-0.99， P=0.001） were risk factors for MACE in the HCM patients. Conclusion The HCM patients complicated with CMD have unique clinical characteristics， including higher symptom burden， left atrial enlargement， myocardial hypertrophy， and increased troponin levels. Concurrent CMD does not increase the short-term risk of adverse events； diabetes， arrhythmia， and decreased EF are key risk factors for prognosis； early intervention and complication management for HCM complicated with CMD patients may improve the long-term prognosis of the HCM patients.

Key words: Hypertrophic cardiomyopathy, Microcirculatory dysfunction, Clinical characteristics, Adverse cardiovascular events, Cardiac magnetic resonance imaging

中图分类号:

R542.2

吴楚文,彭梦玲,傅玉,周珊珊. 肥厚型心肌病并发或未并发微循环障碍患者临床特征比较及其预后影响因素分析[J]. 吉林大学学报(医学版), 2025, 51(6): 1630-1637.

Chuwen WU,Mengling PENG,Yu FU,Shanshan ZHOU. Comparison of clinical characteristics and prognostic influence factors between patients with or without hypertrophic cardiomyopathy complicated by microvascular dysfunction[J]. Journal of Jilin University(Medicine Edition), 2025, 51(6): 1630-1637.

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Group	n	Age (x±s， year)	Male [n(η/%)]	Palpitation [n(η/%)]	Hypertension [n(η/%)]	Diabetes [n(η/%)]	Tachycardia [n(η/%)]	Troponin [ρ_B/(μg·L^-1)]
HCM complicated with CMD	68	52.72±12.97	47 (69.12)	25 (36.76)	19 (27.94)	5 (7.35)	10 (14.71)	0.05 (0.05，0.07)
HCM complicated without CMD	143	55.48±14.56	88 (61.54)	33 (23.08)	66 (46.15)	20 (13.99)	5 (3.50)	0.05 (0.04，0.05)
t/Z/χ²		1.333	1.149	4.332	6.355	1.941	7.154	-2.346
P		0.184	0.284	0.037	0.012	0.164	0.007	0.019

Group	n	Abnormal Q wave[n(η/%)]	ST segment depression[n(η/%)]	Inverted T-wave[n(η/%)]	PR interval(t/ms)	QRS waveduration(t/ms)	Corrected QTinterval(t/ms)
HCM complicated with CMD	68	13 (19.12)	14 (20.59)	30 (44.12)	160 (148，181)	94 (86，104)	452 (431,469)
HCM complicated without CMD	143	8 (5.59)	27 (18.88)	84 (58.74)	158 (146，174)	94 (86，100)	453 (438,476)
Z/χ²		9.404	0.086	3.968	-1.447	-0.695	-1.434
P		0.002	0.770	0.046	0.148	0.487	0.152

Group	n	EF (η/%)	LAD (l/mm)	LVDD (l/mm)	RVDD (l/mm)
HCM complicated with CMD	68	61.50 (54.00，63.75)	41.15±6.77	46.00(43.00，50.00)	21.72±2.52
HCM complicated without CMD	143	63.00 (59.00，65.00)	38.68±6.12	47.00(44.00，50.00)	21.73±2.67
t/Z		-2.325	-2.646	-0.457	0.017
P		0.020	0.009	0.648	0.986
Group	n	CO (L·min^-1)	E peak (cm·s^-1)	A peak (cm·s^-1)	MWT (l/mm)
HCM complicated with CMD	68	4.60 (3.53，5.73)	65.50(52.00，72.00)	77.56±22.47	21.00 (18.00，25.75)
HCM complicated without CMD	143	4.80 (3.60，5.90)	65.50(59.00，79.00)	82.84±21.64	20.00 (17.00，23.00)
t/Z		-1.116	-1.645	1.637	-2.171
P		0.265	0.100	0.103	0.030

Risk factor	Univariate analysis		Multivariate analysis
Risk factor	OR(95%CI)	P	OR(95%CI)	P
Palpitation	1.94 (1.03-3.63）	0.039	1.72 (0.82-3.60)	0.153
Hypertension	0.45 (0.24-0.84）	0.013	0.40 (0.20-0.80)	0.010
Tachycardia	4.76 (1.56-14.53）	0.006	2.23 (0.60-8.23)	0.229
Troponin	1.07 (1.01-1.18）	0.018	1.05 (0.95-1.17)	0.355
Inverted T-wave	0.56 (0.31-0.99）	0.047	0.67 (0.35-1.30)	0.240
Abnormal Q wave	3.99 (1.57-10.16）	0.004	2.39 (0.85-6.72)	0.099
EF	0.96 (0.93-0.99）	0.014	0.97 (0.94-1.01)	0.146
LAD	1.06 (1.02-1.12）	0.010	1.05 (1.00-1.11)	0.048
MWT	1.09 (1.02-1.16）	0.010	1.11 (1.03-1.19)	0.007

Group	n	MACE	All-cause mortality	New/recurrent heart failure	New angina/MI	New arrhythmias	New stroke
HCM complicated with CMD	68	12 (17.65)	2 (2.94)	2 (2.94)	3 (4.41)	5 (7.35)	0 (0.00)
HCM complicated without CMD	143	15 (10.49)	3 (2.10)	3 (2.10)	3 (2.10)	4 (2.80)	2 (1.40)
P		0.146	1.000^*	1.000^*	0.616^*	0.244^*	1.000^#