Arterinio kraujo spaudimo variabiliškumas: klinikinė ir prognostinė reikšmė

Arterinio kraujo spaudimo variabiliškumas: klinikinė ir prognostinė reikšmė

Įvadas

Arterinė hipertenzija (AH) yra vienas svarbiausių veiksnių, skatinančių kardiovaskulinės ligos išsivystymą ir organų taikinių pažeidimą [1, 2]. Negana to, sistoliniam arteriniam kraujo spaudimui (AKS) padidėjus per 20 mm Hg, o diastoliniam AKS – per 10 mm Hg, mirtingumas nuo išeminės širdies ligos ar insulto padidėja perpus [3]. Adekvati AKS korekcija yra labai svarbi, tačiau kyla klausimas, ką reikia vertinti? Matuoti vidutinį paros AKS ar AKS gydytojo kabinete? Remtis paciento matavimais, atliktais namie?

Geriausia taktika yra įvairių AKS matavimo būdų derinimas. AKS nėra pastovus rodiklis – jam būdingas spontaniškas kitimas (skaičiuojant tiek minutes, valandas, tiek mėnesius, metus). Šį nepastovumą apibrėžia terminas – AKS variabiliškumas. Yra skiriamas labai trumpas, trumpas ir ilgas AKS kitimas (1 lentelė).

1 lentelė. AKS variabiliškumo tipai

Kitimas

Trukmė

Įvertinimo metodas

Klinikinė reikšmė

Labai trumpas

Tarp širdies

susitraukimų

Tiesioginis intraarterinis AKS matavimas

Įvertinama neuro-humoralinės sistemos įtaka

Trumpas

Minutės–valandos

Tiesioginis intraarterinis AKS matavimas

Ambulatorinis AKS matavimas

Padidėjęs variabiliškumas dieną, naktį ar per parą yra susijęs su didesniu mirtingumu

Ilgas

Dienos– mėnesiai

Ambulatorinis AKS matavimas

Matavimas namuose

Dideli svyravimai yra susiję su didesne insulto rizika

 

AKS variabiliškumo tipai

AKS kitimas gali būti užfiksuojamas net tarp širdies susitraukimų. Šiam kitimui įtaką daro kardiovaskulinę sistemą reguliuojantys mechanizmai, pavyzdžiui, baroreceptorių refleksas, renino ir angiotenzino sistema, endotelio išskiriamas azoto oksidas ar kraujagyslių raumenų atsakas [4]. Ateityje šis matavimas gali būti prieinamas ir kasdienėje praktikoje, nes jis įgalina antihipertenzinės terapijos individualizavimą. AKS kitimai sukelia tam tikro dažnio virpesius, kurių kiekvienas atspindi vienos ar kitos reguliacinės sistemos aktyvumą. Tokiu būdu galima identifikuoti pacientus, kuriems AKS kitimus sukelia hiperaktyvi simpatinė sistema, ir skirti šią sistemą slopinančius medikamentus. Kitas pavyzdys – AKS kitimai dėl sutrikusios miogeninės funkcijos. Tokiu atveju neigiamai miogeninę funkciją veikiantys kalcio kanalų blokatoriai gali būti žalingi [5].

Paros AKS kitimai apibrėžiami kaip trumpalaikis variabiliškumas. Šį AKS svyravimą lemia centrinė ir autonominės nervų sistemos, elastinės kraujagyslių savybės [6]. Įtakos turi ir fizinis aktyvumas, emocijos, miegas. Net asmenims, kurių AKS yra normalus, per dieną stebimi šiokie tokie AKS svyravimai. Tai yra vadinamasis cirkadinis ritmas – žemiausios AKS vertės, stebimos naktį (dipping), didėja atsikėlus ryte ir pasiekia aukščiausias vertes per pirmąsias aktyvias dienos valandas [7]. Naktį AKS gali sumažėti 10–20 proc. Vystantis ir progresuojant arterinei hipertenzijai, šis mechanizmas sutrikdomas, stebimas AKS variabiliškumas, didelis AKS ryte, kuris nemažėja naktį…

Įdomu tai, kad AKS variabiliškumas gali būti stebimas per dienas, mėnesius ar net tam tikru sezonu. Deja, tokių svyravimų kilmė nėra visiškai aiški. Manoma, kad stebint variabiliškumą per keletą dienų galima įtarti paciento elgesio, rutinos pokyčius. Pavyzdžiui, savaitgaliais AKS yra mažesnis nei darbo dienomis. Tai yra susiję su streso, miego trukmės, druskos ir alkoholio vartojimo skirtumu. Nereikėtų atmesti galimybės, kad tokie pokyčiai kyla pacientui nevartojant medikamentų pagal sudarytą gydymo schemą. Šiuos pokyčius gali sukelti ir patologiniai kraujagyslių pakitimai, pavyzdžiui, padidėjęs arterijų standumas [8, 9]. Sezoninį AKS kitimą lemia kintanti temperatūra. Žiemą tiek ryte, tiek vakare AKS yra kiek didesnis, ypač sistolinis [10].

 

AKS variabiliškumo klinikinė reikšmė

AKS variabiliškumo sukeliamas neigiamas poveikis kraujagyslėms ir organams taikiniams yra tiriamas įvairiuose tyrimuose. Vieno jų, kuriame buvo vertinti paros intraarteriniai AKS matavimai, išvadose nurodoma, kad arterine hipertenzija sergantys asmenys turi didesnį AKS variabiliškumą, išreikštą didesniais dienos ir nakties AKS svyravimais, didesniu vidutinės reikšmės pasiskirstymu, palyginti su sveikais asmenimis [11].

AKS cirkadinis ritmas yra vienas greičiausiai pažeidžiamų fiziologinių mechanizmų progresuojant arterinei hipertenzijai. Nurodoma, kad 39 proc. arterine hipertenzija sergančių pacientų nėra būdingas AKS kritimo naktį fenomenas (non-dipper), o 14 proc. fiksuojamas itin didelis kraujo spaudimas ryte [12]. Staigus AKS kilimas ryte yra stiprus kardiovaskulinės rizikos rodiklis: 40 proc. didėja miokardo infarkto rizika, 49 proc. – insulto rizika, 29 proc. – staigios mirties rizika [13]. Kiekvienas AKS pakilimas per 10 mm Hg 24 proc. padidina insulto riziką [14]. Per parą svyruojantis sistolinis ar diastolinis AKS, nepriklausomai nuo demografinių ir klinikinių rizikos veiksnių, didina mirtingumą nuo širdies ir kraujagyslių ligų [15, 16]. Vienas mechanizmų, sukeliančių tokius rizikos pokyčius, yra svyruojančio sistolinio AKS įtaka miego arterijų intimos ir medijos storėjimui, kuris laikomas aterosklerozės progresavimo žymeniu [16].

Ryškus AKS variabiliškumas tarp kelių vizitų yra siejamas su didesne organų taikinių pažaida ir kognityvinės funkcijos blogėjimu [17, 18, 19, 20]. Beje, pacientai, kurių vidutinis AKS buvo pastovus, tačiau tarp kelių vizitų išmatuotos pakitusios AKS vertės, turėjo didesnę insulto riziką [21, 22]. Remiantis didelės apimties skandinavų tyrimu, insulto rizika didėja iki 5 kartų, ypač po buvusio praeinančiojo smegenų kraujotakos sutrikimo epizodo [23]. Metaanalizių duomenimis, AKS variabiliškumas tarp vizitų didina mirtingumo ir insulto riziką nepriklausomai nuo amžiaus ar vidutinio AKS [24]. Panašūs rezultatai buvo gauti tiriant ir specifines populiacijas (moteris po menopauzės, pacientus, sergančius lėtine inkstų liga ar 2 tipo cukriniu diabetu) [25, 26, 27]. Net dešimtmetį trukusiu vyresnio amžiaus asmenų AKS variabiliškumo tyrimu nustatyta, kad dideli AKS svyravimai yra susiję su mirtingumo rizika nepaisant to, ar bazinis AKS yra normalus ar padidėjęs [28].

Su padidėjusiu AKS variabiliškumu siejamas inkstų kraujagyslių pažeidimas. Yokota ir kolegų atliktas tyrimas rodo, kad kreatinino koncentracijos padidėjimas per pusę ar pakaitinės inkstų terapijos poreikis padvigubėja didėjant AKS variabiliškumui, išmatuotam tarp vizitų. Tiesa, šie rezultatai buvo gauti tiriant pacientus, sergančius 3–4 stadijos ne diabetine lėtine inkstų liga [29]. Tiriant cukriniu diabetu sergančius pacientus, šių rezultatų nepavyko patvirtinti [30]. Išanalizavus duomenis retrospektyviai, nurodoma, kad esant ryškiam sistolinio AKS varijavimui (vidutinio sistolinio AKS pasiskirstymas siekia 13,5 mm Hg ir daugiau), ryškėja inkstų pažeidimas, išreikštas mažėjančiu glomerulų filtracijos greičiu [31]. Analizuojant ASCOT ir ALLHAT studijas, nustatyta, kad didelis sistolinis AKS variabiliškumas yra labiau išreikštas tiems pacientams, kurių inkstų pažeidimas yra ryškesnis (3 stadijos ar labiau pažengusi lėtinė inkstų liga). Prie variabiliškumą didinančių veiksnių buvo priskirtas amžius, vyriškoji lytis ir rūkymas…

Daugiau skaitykite žurnalo „Internistas“ priede Inkstų ir širdies kraujagyslių ligos Nr.1, 2017


284 mintys apie “Arterinio kraujo spaudimo variabiliškumas: klinikinė ir prognostinė reikšmė

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  78. The new Zune browser is surprisingly good, but not as good as the iPod’s. It works well, but isn’t as fast as Safari, and has a clunkier interface. If you occasionally plan on using the web browser that’s not an issue, but if you’re planning to browse the web alot from your PMP then the iPod’s larger screen and better browser may be important.

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