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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2017, Vol. 14 ›› Issue (12) : 927 -932. doi: 10.3877/cma.j.issn.1672-6448.2017.12.010

所属专题： 文献；

心血管超声影像学

心肺联合超声对重度左心衰竭伴肺动脉高压患者的临床意义
刘刚1, 韩彤亮1,†(), 杜丽珍1, 李睿1, 类婷婷1, 唐国璋2, 张司敏1, 马西顺1   
  1. 1. 266071　青岛大学医学院附属青岛市市立医院超声科
    2. 266071　青岛大学医学院附属青岛市市立医院心脏超声科
  • 收稿日期:2017-09-16 出版日期:2017-12-01
  • 通信作者: 韩彤亮
  • 基金资助:
    青岛市卫生科技计划项目(2015-WJZD004)

The clinical significance of combined heart lung ultrasound on severe left heart failure with pulmonary hypertension

Gang Liu1, Tongliang Han1,†(), Lizhen Du1, Rui Li1, Tingting Lei1, Guozhang Tang2, Simin Zhang1, Xishun Ma1   

  1. 1. Department of Ultrasound, Qingdao Municipal Hospital of Qingdao University, Qingdao 266071, China
    2. Department of Cardiac Ultrasound, Qingdao Municipal Hospital of Qingdao University, Qingdao 266071, China
  • Received:2017-09-16 Published:2017-12-01
  • Corresponding author: Tongliang Han
  • About author:
    Corresponding author: Han Tongliang, Email:
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刘刚, 韩彤亮, 杜丽珍, 李睿, 类婷婷, 唐国璋, 张司敏, 马西顺. 心肺联合超声对重度左心衰竭伴肺动脉高压患者的临床意义[J]. 中华医学超声杂志（电子版）, 2017, 14(12): 927-932.

Gang Liu, Tongliang Han, Lizhen Du, Rui Li, Tingting Lei, Guozhang Tang, Simin Zhang, Xishun Ma. The clinical significance of combined heart lung ultrasound on severe left heart failure with pulmonary hypertension[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2017, 14(12): 927-932.

目的

探讨心肺联合超声对重度左心衰竭伴肺动脉高压患者的临床意义。

方法

选择2016年3月至2017年6月青岛大学医学院附属青岛市市立医院收治的Ⅲ、Ⅳ级左心衰竭伴呼吸困难患者75例。其中33例患者肺动脉压力正常（肺动脉压力正常组），25例患者轻度肺动脉高压（轻度肺动脉高压组），17例患者中重度肺动脉高压（中重度肺动脉高压组）。检测患者血浆B型钠利尿肽（BNP），超声心动图测量患者左心室内径（LVD）、右心室内径（RVD）、左心室射血分数（LVEF），肺部超声检查观察患者肺部B线并记录其数量。采用单因素方差分析比较3组重度左心衰竭患者LVD、RVD、LVEF差异，进一步组间两两比较采用LSD-t检验；采用Kruskal-wallis H检验比较3组重度左心衰竭患者血浆BNP浓度、B线数目，进一步组间两两比较采用Mann-Whitney U检验。绘制血浆BNP浓度、B线数目诊断重度左心衰竭患者肺动脉高压的受试者工作特征（ROC）曲线。

结果

肺动脉压力正常组、轻度肺动脉高压组、中重度肺动脉高压组重度左心衰竭患者血浆BNP浓度分别为890（614，1516）、1460（1245，1950）、2660（1670，3279）ng/L，B线数目分别为12（9，16）、17（14，18）、26（20，28）条，RVD分别为（22.1±1.7）、（24.9±2.0）、（26.3±2.8）mm，血浆BNP浓度、B线数目、RVD均为中重度肺动脉高压组>轻度肺动脉高压组>肺动脉压力正常组，且任意两组间比较差异均有统计学意义（血浆BNP浓度：U=210.500，P<0.05；U=47.000、73.000，P均<0.001；B线数目：U=189.000，P<0.05；U=38.5000、64.000，P均<0.001；RVD：t=0.553、0.623，P均<0.001；t=0.656，P<0.05）。而3组重度左心衰竭患者LVD、LVEF差异均无统计学意义。ROC曲线显示，血浆BNP浓度诊断重度左心衰竭患者肺动脉高压的最佳阈值为1225 ng/L，敏感度为85.7%，特异度为69.7%，曲线下面积为0.814，95%CI为0.717~0.911；B线数目诊断重度左心衰竭患者肺动脉高压的最佳阈值为14条，敏感度为88.1%，特异度为66.7%，曲线下面积为0.836，95%CI为0.747~0.925。

结论

不同肺动脉压力水平下重度左心衰竭患者肺部B线表现具有差异性，且B线数目随着肺动脉高压程度的加重而增加，值得进一步研究应用。

关键词: 超声检查, 心力衰竭, 高血压，肺性
Objective

To investigate the clinical significance of combined heart and lung ultrasound in patients with severe left heart failure and pulmonary hypertension.

Methods

From March 2016 to June 2017, 75 patients with grade Ⅲ and Ⅳ heart failure and dyspnea were enrolled in Qingdao Municipal Hospital Affiliated to Qingdao University. Thirty-three patients had normal pulmonary artery pressure (normal pulmonary arterial pressure group), 25 patients had mild pulmonary hypertension (mild pulmonary hypertension group), and 17 patients had moderate to severe pulmonary hypertension (moderate to severe pulmonary hypertension group). The patient′s plasma B-type natriuretic peptide (BNP) was measured. Left ventricular diameter (LVD), right ventricular diameter (RVD), and left ventricular ejection fraction (LVEF) were measured by echocardiography. The patient′s lungs were observed by lung ultrasonography, and its number was recorded. One-way analysis of variance was used to compare the differences of LVD, RVD, and LVEF in three groups of patients with severe left heart failure. Further comparison between groups was performed using LSD-t test. Kruskal-wallis H test was used to compare the plasma BNP concentration and B-line number in three groups of patients with severe left heart failure. The Mann-Whitney U test was used to further compare the groups. The receiver operating characteristic (ROC) curve of pulmonary hypertension diagnosed by plasma BNP concentration and B line number in patients with severe left heart failure were drwan.

Results

The concentrations of BNP in patients with normal pulmonary arterial pressure, mild pulmonary hypertension, and moderate to severe pulmonary hypertension were 890 (614, 1516), 1460 (1245, 1950), and 2660 (1670, 3279) ng/L, respectively. The number of B line was 12 (9, 16), 17 (14, 18), 26 (20, 28), and the RVD was (22.1±1.7), (24.9±2.0), (26.3±2.8) mm, respectively. The number of B-line and RVD in the moderate-severe pulmonary hypertension group were both lager than those in the mild pulmonary hypertension group, and the number of B-line and RVD in the mild pulmonary hypertension group were both lager than those in the normal pulmonary artery pressure group. There was significant difference between any two groups (BNP concentration: U=210.500, P<0.05; U=47.000, 73.000, both P<0.001; B line number: U=189.000, P<0.05; U=38.5000, 64.000, both P<0.001; RVD: t=0.553, 0.623, both P<0.001; t=0.656, P<0.05). There was no significant difference in LVD and LVEF between the three groups of patients. The ROC curve showed that the optimal threshold for the diagnosis of pulmonary hypertension in patients with severe left heart failure with BNP concentration was 1225 ng/L. The sensitivity was 85.7%, the specificity was 69.7%, the area under the curve was 0.814, and the 95%CI was 0.717 to 0.911. The optimal threshold for diagnosis of pulmonary hypertension in patients with severe left heart failure was B line number 14, the sensitivity was 88.1%, specificity was 66.7%, the area under the curve was 0.836, and 95%CI was 0.747 to 0.925.

Conclusion

Patients with severe left heart failure at different pulmonary artery pressure levels have different B-line findings, and the number of B-line increases with the severity of pulmonary hypertension, which warrants further study and application.

Key words: Ultrasonography, Heart failure, Hypertension, pulmonary
图1 单侧胸壁分区示意图
表1 3组重度左心衰竭患者一般临床资料比较
组别 例数 性别（例，男性/女性） 年龄（岁，±s）
肺动脉压力正常组 33 21/12 77.0±8.9
轻度肺动脉高压组 25 13/12 77.1±8.2
中重度肺动脉高压组 17 10/7 76.9±0.1
检验值 ? χ2=2.253 F=0.003
P值 ? 0.133 0.997
图2 肺部超声声像图示B线（箭头所示）
表2 3组重度左心衰竭患者血浆BNP浓度、B线数目比较[M（QR）]
组别 例数 血浆BNP（ng/L） B线数目（条）
肺动脉压力正常组 33 890（614，1516） 12（9，16）
轻度肺动脉高压组 25 1460（1245，1950）a 17（14，18）c
中重度肺动脉高压组 17 2660（1670，3279）b 26（20，28）d
H值 ? 29.660 33.334
P值 ? <0.001 <0.001
表3 3组重度左心衰竭患者超声心动图参数比较（±s）
组别 例数 RVD（mm） LVD（mm） LVEF（%）
肺动脉压力正常组 33 22.1±1.7 51.3±8.6 42.2±11.4
轻度肺动脉高压组 25 24.9±2.0 a 53.4±5.3 42.0±8.6
中重度肺动脉高压组 17 26.3±2.8 b 54.7±7.1 40.3±10.7
F值 ? 25.857 1.296 0.233
P值 ? <0.001 0.280 0.792
图3 血浆B型钠利尿肽浓度及B线数目诊断重度左心衰竭患者肺动脉高压的受试者工作特征曲线。血浆B型钠利尿肽浓度诊断重度左心衰竭患者肺动脉高压的最佳阈值为1225 ng/L，敏感度为85.7%，特异度为69.7%，曲线下面积为0.814，95%CI为0.717~0.911；B线数目诊断重度左心衰竭患者肺动脉高压的最佳阈值为14条，敏感度为88.1%，特异度为66.7%，曲线下面积为0.836，95%CI为0.747~0.925
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