积极管理肥胖，降低心血管疾病风险

doi:10.12114/j.issn.1007-9572.2021.02.116

摘要/Abstract

摘要： 2021-04-22美国心脏协会（AHA）发布了一项关于《肥胖和心血管疾病》的声明，总结了肥胖对动脉粥样硬化性心血管疾病、心力衰竭、心源性猝死以及心房颤动诊断、临床管理以及预后的影响。本文结合我国临床的实际情况对该声明内容进行解读，以期为我国心血管内科临床实践提供参考。

关键词: 心血管疾病, 肥胖, 冠心病, 心力衰竭, 猝死, 心脏, 心房颤动

Abstract:

Obesity and Cardiovascular Disease, a statement released by the American Heart Association on April 22, 2021, gives a summary of the impact of obesity on the diagnosis, clinical management and prognosis of atherosclerotic cardiovascular disease, heart failure, sudden cardiac death and atrial fibrillation. In view of the present clinical management of cardiovascular diseases in China, this paper interprets the content of the statement in detail, aiming to provide guidance relevant to domestic cardiovascular management practices.

Key words: Cardiovascular diseases, Obesity, Coronary disease, Heart failure, Death, sudden, cardiac, Atrial fibrillation

中图分类号:

R54 R589.25

郭雨阳,曾庆春. 积极管理肥胖，降低心血管疾病风险[J]. 中国全科医学, 2022, 25(06): 643-650. DOI: 10.12114/j.issn.1007-9572.2021.02.116.

GUO Yuyang, ZENG Qingchun.

Actively Managing Obesity to Reduce the Risk of Cardiovascular Disease [J]. Chinese General Practice, 2022, 25(06): 643-650.

图/表 1

参考文献 62

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诊断方式		优点	缺点	注意事项
非侵入性检查
	心电图	便捷，便宜	灵敏度、特异度低，受肥胖影响	肥胖可导致心率增快、QRS间期延长、QT间期延长、假阳性的下壁心肌梗死等心电图改变
	平板运动试验	便捷	患者可能会因为与心血管疾病无关的症状而停止	肥胖患者的峰值心率、心率恢复和变时指数均较低
	SPECT	精度高	有辐射，技术上对体型有限制，肥胖患者常见乳房和膈肌的衰减伪影，相对灌注显像对三支病变或左主干病变的检测能力降低	对于体质量较大的患者〔250~350磅（113~160 kg）〕，建议采用为期2 d、剂量较大的示踪剂方案，体质量上限约为350磅（160 kg）
	PET（铷）	较SPECT成像效果更好，辐射更小，伪影和衰减少；可绝对定量冠状动脉血流，适用于三支病变及左主干病变	对体型有限制	-
	负荷超声心动图	便捷，适用于肥胖患者，无辐射，无体质量/体型限制，功能性测试	对操作者要求高，受肺部疾病、乳房大小、肥胖、呼吸运动影响	-
	负荷心脏MRI	可准确评估慢性压力负荷和心排血量高的复杂心脏效应，肥胖对此项检查影响小	对体质量、体型等有限制，幽闭恐怖症患者不适用	MRI台的重量限制为335磅（152 kg）
	心脏CT钙扫描	经济、重复性好，可测定冠状动脉疾病程度	肥胖可能限制心脏CT钙扫描的诊断准确性和价值，仪器内径对体型有限制	CT设备的台面重量限制为350~450磅（160~204 kg）
	冠状动脉CT增强扫描	检测肥胖患者的灵敏度和阴性预测值较高	图像质量、信噪比随BMI的增加而下降，肥胖患者血管不可评估段的比例更高	-
侵入性检查
	冠状动脉造影	冠状动脉疾病诊断的金标准	肥胖患者血管通路不畅，并发症更多，为达到足够的透视度，肥胖患者和术者需要接受更高的辐射	肥胖患者首选桡动脉通路，桡动脉入路的并发症发生率比股动脉入路低3倍^[24]；如采用股动脉入路，应使用血管闭合装置缩短肥胖患者检查至下床活动时间
	血管内超声	可对斑块负荷、斑块形态（即斑块发展阶段、高风险斑块特征）进行体内评估	侵入性操作	-

诊断方式		优点	缺点	注意事项
非侵入性检查
	心电图	便捷，便宜	灵敏度、特异度低，受肥胖影响	肥胖可导致心率增快、QRS间期延长、QT间期延长、假阳性的下壁心肌梗死等心电图改变
	平板运动试验	便捷	患者可能会因为与心血管疾病无关的症状而停止	肥胖患者的峰值心率、心率恢复和变时指数均较低
	SPECT	精度高	有辐射，技术上对体型有限制，肥胖患者常见乳房和膈肌的衰减伪影，相对灌注显像对三支病变或左主干病变的检测能力降低	对于体质量较大的患者〔250~350磅（113~160 kg）〕，建议采用为期2 d、剂量较大的示踪剂方案，体质量上限约为350磅（160 kg）
	PET（铷）	较SPECT成像效果更好，辐射更小，伪影和衰减少；可绝对定量冠状动脉血流，适用于三支病变及左主干病变	对体型有限制	-
	负荷超声心动图	便捷，适用于肥胖患者，无辐射，无体质量/体型限制，功能性测试	对操作者要求高，受肺部疾病、乳房大小、肥胖、呼吸运动影响	-
	负荷心脏MRI	可准确评估慢性压力负荷和心排血量高的复杂心脏效应，肥胖对此项检查影响小	对体质量、体型等有限制，幽闭恐怖症患者不适用	MRI台的重量限制为335磅（152 kg）
	心脏CT钙扫描	经济、重复性好，可测定冠状动脉疾病程度	肥胖可能限制心脏CT钙扫描的诊断准确性和价值，仪器内径对体型有限制	CT设备的台面重量限制为350~450磅（160~204 kg）
	冠状动脉CT增强扫描	检测肥胖患者的灵敏度和阴性预测值较高	图像质量、信噪比随BMI的增加而下降，肥胖患者血管不可评估段的比例更高	-
侵入性检查
	冠状动脉造影	冠状动脉疾病诊断的金标准	肥胖患者血管通路不畅，并发症更多，为达到足够的透视度，肥胖患者和术者需要接受更高的辐射	肥胖患者首选桡动脉通路，桡动脉入路的并发症发生率比股动脉入路低3倍^[24]；如采用股动脉入路，应使用血管闭合装置缩短肥胖患者检查至下床活动时间
	血管内超声	可对斑块负荷、斑块形态（即斑块发展阶段、高风险斑块特征）进行体内评估	侵入性操作	-