作者：祝存奎，朱芳一，戴婧，邓勇，马生龙，刘楠楠，马元风，厍广东，霍建霞，桑明敏，张生红，马旭莲

单位：

810012 青海省西宁市，青海省心脑血管病专科医院；通信作者：祝存奎，E-mail：2706153232@qq.com

关键词：

心力衰竭；海拔；藏族；汉族；N 末端脑钠肽前体；超敏 C 反应蛋白；炎性因子；预后；青海

关键词（英文）：

Heart failure；Altitude；Zang nationality；Han nationality；N-terminal pro-brain natriureticpeptide；Hypersensitive C-reactive protein；Inflammatory cytokines；Prognosis；Qinghai

中图分类号：

R 541.6

DOI：

DOI：10.3969/j.issn.1008-5971.2020.04.007

基金项目：

青海省卫生系统科研重点课题（2017-wjzd-13）

摘要：

背景　心力衰竭患者血清 N 末端脑钠肽前体（NT-proBNP）、超敏 C 反应蛋白（hs-CRP）及炎性因子水平存在明显异常，但关于其在青海高原地区不同海拔世居藏族、汉族慢性心力衰竭患者中变化研究报道较少见。目的　探讨青海高原地区不同海拔世居藏族、汉族慢性心力衰竭患者血清 NT-proBNP、hs-CRP 及炎性因水平变化及其与预后的关系。方法　选取 2013 年 6 月—2015 年 6 月于青海省心脑血管病专科医院住院治疗及高原健康体检中心体检的藏族、汉族慢性心力衰竭患者 180 例，比较不同海拔、民族患者一般资料（包括性别、年龄、体质量、收缩压、舒张压）及血清 NT-proBNP、hs-CRP、肿瘤坏死因子 α（TNF-α）、白介素 6（IL-6）水平；随访 3 年，比较不同临床特征患者 3 年生存率；青海高原地区世居藏族、汉族慢性心力衰竭患者预后的影响因素分析采用多因素 Cox 比例风险回归分析，并绘制 Kaplan-Merier 生存曲线以分析青海高原地区世居藏族、汉族慢性心力衰竭患者生存情况。结果　不同海拔、民族患者舒张压及血清 NT-proBNP、hs-CRP、TNF-α 水平及不同海拔患者 IL-6 水平比较，差异有统计学意义（P<0.05）。不同纽约心脏病协会（NYHA）分级，血清 NT-proBNP、hs-CRP、TNF-α、IL-6 水平，海拔及有无高血压、糖尿病、冠心病、高原性心脏病、慢性肾衰竭、贫血患者3年生存率比较，差异有统计学意义（P<0.05）。多因素 Cox 比例风险回归分析结果显示，NT-proBNP〔HR=0.02，95%CI（0，0.23）〕、TNF-α〔HR=6.45，95%CI（1.47，28.25）〕及海拔 {3 001~4 000 m〔HR=0.23，95%CI（0.06，0.89）〕，>4 000 m〔HR=0.31，95%CI（0.11，0.84）〕}是青海高原地区世居藏族、汉族慢性心力衰竭患者预后的独立影响因素（P<0.05）。Kaplan-Merier 生存曲线分析结果显示，血清 NT-proBNP 水平 <258 ng/L 患者 3 年累积生存率高于血清 NT-proBNP 水平≥ 258 ng/L 者（χ 2 =7.824，P<0.05），血清 TNF-α 水平 <32 ng/L 患者 3 年累积生存率高于血清 TNF-α 水平≥ 32 ng/L 水平者（χ 2 =13.817，P<0.01）；不同海拔患者 3 年累积生存率比较，差异有统计学意义（χ 2 =55.445，P<0.01）。结论　青海高原地区海拔越高则世居藏族、汉族慢性心力衰竭患者血清 NT-proBNP、hs-CRP、TNF-α、IL-6 水平越高，且汉族患者高于藏族患者；高血清 NT-proBNP、TNF-α 水平及高海拔是青海高原地区世居藏族、汉族慢性心力衰竭患者预后不良的危险因素。

英文摘要：

Background　Serum levels of NT-proBNP，hs-CRP and inflammatory cytokines are obviously abnormalin patients with heart failure，but there are few reports about changes of the above index in Zang and Han nationality chronicheart failure patients with different living altitude in Qinghai Plateau. Objective　To investigate the changes and relationsto prognosis of serum levels of NT-proBNP，hs-CRP and inflammatory cytokines in Zang and Han nationality chronic heartfailure patients with different living altitude in Qinghai Plateau. Methods　From June 2013 to June 2015，a total of 180 Zangand Han nationality chronic heart failure patients were selected in Qinghai Provincial Cardiovascular and CerebrovascularDiseases Hospital，including some patients receiving physical examination in the Plateau Health Physical Examination Center.General information（including gender，age，body mass，SBP and DBP）as well as serum levels of NT-proBNP，hs-CRP，TNF-α and IL-6 were compared in patients with different living altitude and nationalities；3-year survival rate was comparedin patients with different clinical characteristics after the 3-year follow-up；multivariate Cox proportional hazards regressionanalysis was used to analyze the influencing factors of prognosis in Zang and Han nationality chronic heart failure patients livingin Qinghai Plateau，and Kaplan-Meier survivorship curve was draw to analyze the survival situation. Results　There wasstatistically significant differences in DBP，serum levels of NT-proBNP，hs-CRP，TNF-α in patients with different livingaltitude and nationalities，respectively，and there was statistically significant differences in IL-6 in patients with differentliving altitude and nationalities，respectively（P<0.05）.There was statistically significant difference in 3-year survival ratein patients with different NYHA grades，serum level of NT-proBNP，of hs-CRP，of TNF-α，of IL-6，living altitude，merged with hypertension，diabetes，coronary heart disease，high altitude heart disease，chronic renal failure and anemiaor not，respectively（P<0.05）.Multivariate Cox proportional hazards regression analysis results showed that，NT-proBNP〔HR=0.02，95%CI（0，0.23）〕，TNF-α〔HR=6.45，95%CI（1.47，28.25）〕and living altitude{3 001~4 000 m〔HR=0.23，95%CI（0.06，0.89）〕，>4 000 m〔HR=0.31，95%CI（0.11，0.84）〕} were independent influencingfactors of prognosis in Zang and Han nationality chronic heart failure patients living in Qinghai Plateau（P<0.05）.Kaplan-Merier survivorship curve showed that，3-year cumulative survival rate in patients with serum NT-proBNP level <258 ng/Lwas statistically significantly higher than that in patients with serum NT-proBNP level ≥ 258 ng/L（χ 2 =7.824，P<0.05），meanwhile 3-year cumulative survival rate in patients with TNF-α level <32 ng/L was statistically significantly higher thanthat in patients with serum TNF-α level ≥ 32 ng/L（χ 2 =13.817，P<0.01），moreover there was statistically significantlydifference in 3-year cumulative survival rate in patients with different living altitude（χ 2 =55.445，P<0.01）. Conclusion　Asthe living altitude increase，serum levels of NT-proBNP，hs-CRP，TNF-α and IL-6 increases in Zang and Han nationalitychronic heart failure patients in Qinghai Plateau，and the above four in Han nationality are significantly higher than those in Zangnationality patients；elevated serum levels of NT-proBNP and TNF-α as well as high altitude are risk factors of poor prognosisin Zang and Han nationality chronic heart failure patients in Qinghai Plateau.

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