86 b/min may be a reliable clinical indicator between hypertensive emergency and hypertensive urgency
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摘要:
目的 分析在急诊科首诊的高血压危象的患者的心率及血压参数，探讨心率在高血压急症与高血压亚急症的不同变化。 方法 选取2019年1~12月于我院急诊科首诊的高血压危象患者186例，根据是否存在急性靶器官损害将患者分为高血压急症组(n=82)及高血压亚急症组(n=104)，分析两组间的临床特点、服用药物种类及数量、服药依从性、血压参数与心率的差异；分析主要不同类型的高血压急症患者的血压参数和心率的组间差异；分析高血压急症组及高血压亚急症组中存在差异的因素对高血压危象中高血压急症患者的预测价值及心率对高血压危象患者中高血压急症的诊断价值。 结果 186例急诊科首诊的窦性心律并高血压急象患者中，高血压急症占44.1%，高血压亚急症占55.9%。女性平均心率高于男性(93±16.7次/min vs 85±18.2次/min，P=0.002)。高血压急症组的平均心率高于亚急症组(98±20.5次/min vs 82 ±12.7次/min，P < 0.001)。与亚急症组相比，高血压急症组中合并糖尿病比例高、服药依从性较差；两组收缩压、舒张压、平均动脉压、脉压差等血压参数比较，差异均无统计学意义(P>0.05)。糖尿病史与心率对高血压危象患者发生高血压急症存在预测价值，心率诊断高血压急症的最佳切点为86次/ min，曲线下面积为0.813。 结论 高血压急症特别是合并急性心衰的患者的平均心率高于高血压亚急症的平均心率，以心率86次/min为阈值可能是鉴别高血压危象中高血压急症或亚急症的简易临床指标，特别适合急诊科诊治思维特点；合并糖尿病的高血压危象患者，更易发生高血压急症。 Abstract:Objective To explore differences of heart rate between hypertensive emergency and hypertensive urgency. Methods The data of patients with hypertensive crisis presenting to emergency department of Shantou Central Hospital between January 2019 and December 2019 was documented. Based on the presence or absence of acute target organ involvement, clustering of hypertensive crisis into emergency or urgency. The relationship between clinical characteristics, types and quantities of medications taken, medication compliance, blood pressure parameters and heart rate were analyzed. The differences in blood pressure parameters and heart rate among different types of hypertensive emergency patients were analyzed. The different predictors between hypertensive emergency and hypertensive urgency were used to analyze the predictive value for hypertensive emergency patients in hypertensive crisis. The value of heart rate in diagnosing hypertensive emergency was analyzed. Results A total of 186 patients of hypertensive crisis in sinus rhythm presenting to emergency department were enrolled. Hypertensive emergency accounted for 44.1%, and hypertensive urgency accounted for 55.9%. The average heart rate of women was higher than men (P=0.002). The average heart rate of the hypertensive emergency was higher than those with urgency (P < 0.001). Compared with urgency, hypertensive emergency has a higher proportion of diabetes and poor medication compliance; and hemodynamic parameters including systolic blood pressure, diastolic blood pressure, mean arterial pressure, and pulse pressure relates neither to urgency nor to emergency. Finally, hypertensive emergency in hypertensive crisis patients may be predicted by diabetes mellitus and heart rate. The area under the curve and optimal cut-off value of heart rate to diagnose hypertensive emergency were 0.813 and 86 b/min. Conclusion Hemodynamic parameters relate neither to hypertensive emergency nor to urgency. The mean heart rate of hypertensive emergencies, especially those with acute heart failure, is higher than that of hypertension urgencies. The heart rate threshold of 86 b/min may be a reliable clinical indicator for distinguishing hypertensive emergency or urgency in hypertensive crisis. It is especially suitable for the clinical thinking of diagnosis and treatment in emergency department. In addition, hypertensive crisis patients with diabetes are more prone to emergency. -
Key words:
- hypertensive crisis /
- heart rate /
- hypertensive emergency /
- hypertensive urgency
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图 2 左侧放射冠斑片状新近脑梗塞1例
A: T2WI显示左侧放射冠斑片状呈稍高信号; B: T1WI显示左侧放射冠斑片状呈稍低信号; C: DWI显示左侧放射冠斑片状呈高信号; D: ADC显示左侧放射冠斑片状呈低信号.
Figure 2. A case of patchy recent cerebral infarction in the left radial crown.
表 1 高血压急症组与亚急症组临床特点比较
Table 1. Clinical characteristics between hypertensive emergency and urgency
变量 HE组(n=82) HU组(n=104) F/t/χ2 P 性別(男/女, n) 52/30 63/41 0.156 0.692 年龄(岁，Mean±SD) 58.6±12.5 53.4±11.4 2.103 0.412 是否吸烟[是，n(%)] 67(81.7) 83(79.8) 0.106 0.745 BMI(kg/m2, Mean±SD) 22.7±5.2 21.3±7.2 1.653 0.502 高血压病程(月) 42(1-250) 45(1-280) 2.634 0.308 合并糖尿病[n(%)] 53(64.6) 23(22.1) 34.3 < 0.001 服用药物种类[n(%)] β-RB 26(31.7) 28 (26.9) 0.509 0.475 ACEI 12(14.6) 17(16.3) 0.102 0.749 ARB 28(34.1) 29(27.9) 0.846 0.358 CCB 29(35.4) 33(31.74) 0.273 0.602 α-RB 6(7.3) 8(7.7) 0.009 0.923 阿司匹林 12(14.6) 9(8.7) 1.637 0.201 氯吡格雷 18(22.0) 15 (14.4) 1.780 0.182 他汀类 11(13.4) 10(9.6) 0.661 0.416 服用药物种类数量[n(%)] 未服药 9(8.4) 10(9.6) 0.092 0.761 服1种药物 34(41.5) 42(40.4) 0.022 0.882 服2种药物 28(34.1) 37(35.6) 0.041 0.839 服3种或以上药物 11(13.4) 12(11.5) 0.149 0.700 服药依从性差 22(26.8) 13(12.5) 6.163 0.013 合并的急性靶器官损害类型[n(%)] AS 26(31.7) 0 - - AHF 22(26.8) 0 - - ACS 16(19.5) 0 - - ACH 12(14.6) 0 - - AAD 5(6.1) 0 - - AKI 6 (7.3) 0 - - 2种及以上靶器官损害 5(6.1) 0 - - HE: 高血压急症; HU: 高血压亚急症; β-RB: β受体阻滞剂; ACEI: 血管紧张素转化酶抑制剂; ARB: 血管紧张素Ⅱ受体拮抗剂; CCB: 钙通道阻滞剂; α-RB: α受体阻滞剂; AS: 急性脑卒中; AHF: 急性心力衰竭; ACS: 急性冠脉综合征; ACH: 急性脑出血; AAD: 急性主动脉夹层; AKI: 急性肾损伤. 
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表 2 高血压急症与亚急症的心率及血压参数的比较
Table 2. Heart rate and hemodynamic parameters between hypertensive emergency and urgency (Mean±SD)
组别 心率(次/min) 收缩压(mmHg) 舒张压(mmHg) 平均动脉压(mmHg) 脉压差(mmHg) HE组(n=82) 98±20.5 201±17.7 112±16.5 142±14.5 87±21.3 HU组(n=104) 82±12.7 204±16.4 108±12.5 139±15.3 84±22.4 t 6.530 1.216 1.881 1.358 0.927 P < 0.001 0.226 0.062 0.176 0.355
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表 3 不同主要高血压急症类型亚组心率及血压参数的比较
Table 3. Heart rate and hemodynamic variables among different main types of hypertensive emergency groups (Mean±SD)
不同主要高血压急症 心率(次/min) 收缩压(mmHg) 舒张压(mmHg) 平均动脉压(mmHg) 脉压差(mmHg) AS(n=26) 89±18* 198±11.2 106±18.1 136±11.9 89±16.1 AHF(n=22) 108±17 202±19.6 108±17.4 139±13.8 86±16.2 ACS(n=16) 90±16* 196±16.4 106±12.4 134±12.8 90±19.8 ACH(n=12) 92±21* 199±11 106±17.4 138±11.6 94±15.2 F 6.622 0.741 0.924 1.345 1.512 P < 0.001 0.445 0.700 0.423 0.565 *P < 0.05 vs AHF(LSD法多重两两比较). AS: 急性脑卒中; AHF: 急性心力衰竭; ACS: 急性冠脉综合征; ACH: 急性脑出血.
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表 4 高血压急症多因素回归分析
Table 4. Multivariate regression analysis of hypertensive emergency
因变量 β SE Wald χ2 P OR 95%CI 糖尿病史 0.762 0.286 7.099 0.008 2.413 1.223~3.753 心率 0.567 0.234 15.798 0.002 2.346 1.789~5.542
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