臺灣博碩士論文加值系統

背景與目的：高血壓已被證實與心血管疾病有持續的相關性，而動脈硬化及自律神經失調被認為是引起高血壓之重要危險因子。近年有研究指出有一些人休息血壓正常，但於劇烈運動時血壓則急促地增加，而有運動高血壓的現象，有研究認為運動高血壓為日後高血壓之早期警訊，但其與休息高血壓之致病機轉是否一致至今仍尚未明瞭。本研究目的為比較運動高血壓、休息高血壓與正常血壓者之交感迷走神經活性、動脈硬化指數及相關危險因子的異同。方法：本研究為橫斷式相關性研究，納入65位男性受測者，平均年齡為50.6±6.5歲，平時血壓皆低於160/100 mmHg及尚未開始接受藥物控制，也沒有罹患心血管疾病或腦血管病變、糖尿病、周邊血管病變或有服用影響自律神經表現之藥物及有任何進行運動測試之禁忌者。本研究測量主要包含：動脈硬化檢測(臂踝動脈波速﹔baPWV)、休息及壓力刺激下之心率變異度、次大運動測試及心血管相關危險因子問卷調查，並依臨床定義將受測者分為無休息高血壓組(n=55)及高血壓組(休息血壓≧140/90 mmHg者，n=10)，或分為無運動高血壓組(n=25)及運動高血壓組(次大運動測試時之運動最大收縮壓≧200 mmHg者，n=40)，另亦合併休息及運動血壓反應分為血壓正常組(n=25)、無休息高血壓而有運動高血壓組(n=30)、及有休息及運動高血壓組(n=10)。利用獨立樣本t檢定(independent-samples t test)、單因子變異數分析(one-way analysis of variance)、卡方檢定、逐步複迴歸(stepwise multiple regression)及邏輯性迴歸(logistic regression)等進行資料統計分析，顯著程度皆訂於0.05。結果：55位休息血壓正常者中有30位(54.5%)出現運動高血壓，而10位有休息高血壓者也都合併有運動高血壓。比較有無休息高血壓的異同發現，高血壓組有50%的受測者有高血壓家族史且有80%為高鹽飲食，baPWV為1616.6±250.5 cm/s，明顯高於無高血壓組(p<0.05)。有運動高血壓者之心血管危險因子分數4.7±1.6分、單位運動量之收縮壓變化斜率為17.9±7.5 mmHg/MET、baPWV為1538.4±215.2 cm/s，及baPWV的異常比例(70%)皆明顯高於無運動高血壓組(p<0.05)。合併休息及運動高血壓發現在”有休息及運動高血壓”組之高血壓家族史比例、高鹽飲食比例、心血管危險因子分數、單位運動量之收縮壓變化率及baPWV皆明顯高於僅運動高血壓組及血壓正常組(p<0.05)。由逐步複迴歸分析發現baPWV、心血管危險因子分數及高血壓家族史對休息收縮壓有顯著影響，解釋力(調整後R2)為43%﹔對運動收縮壓有顯著影響的因子為心血管危險因子分數、baPWV及壓力-休息之LF%，解釋力(調整後R2)為32%。以邏輯性迴歸分析發現，有高血壓家族史者及baPWV較高者發生休息高血壓的危險性分別為11.4(95%CI 1.9-68.8)及1.005(95%CI 1.001-1.010)，可解釋有無休息高血壓之35%的總變異性，心血管危險因子分數及baPWV較高者與壓力-休息之RR mean較低者則發生運動高血壓的危險性分別為1.7(95%CI 1.2-2.6)、1.004(95%CI 1.001-1.008)及0.991(95%CI 0.98-0.999)，可解釋有無運動高血壓之41%的總變異性。結論：休息血壓正常者仍有相當高比例的人會發生運動高血壓，而本研究發現運動高血壓和休息高血壓都與心血管危險因子分數及動脈硬化度有顯著相關性，但高血壓家族史對休息高血壓的發生影響較大，休息及壓力刺激之心率變異度的自主神經功能反應則對運動高血壓的發生較有影響，顯示運動高血壓與休息高血壓間仍有不盡相同的機轉特性，結果有助於增進瞭解運動高血壓的臨床意義，並可作為納入早期健康篩檢防治項目的參考。

Background and purpose : Hypertension is a prevalent worldwide problem. Besides the major risk factors, arterial stiffness and autonomic nervous system (ANS) dysfunction have also important roles on the pathophysiology of hypertension. Exercise hypertension, an exaggerated rising of blood pressure (BP) during physical activity, has been found to be a strong predictor of cardiovascular mortality and may be an early marker of essential hypertension. However, the exact mechanism of exercise hypertension is unclear. The purpose of this study was to compare the differences of arterial stiffness, vagosympathetic activity and risk factors in subjects with exercise hypertension, resting hypertension and normotension. Methods : This was an exploratory cross-sectional study. Sixty-five men (50.6±6.5 years old) with resting BP below 160/100 mmHg were included. Those who had the history of chronic diseases, exercise contraindications and taking any medicines affecting BP or ANS were excluded. All subjects received noninvasive arterial stiffness test, submaximal exercise test, heart rate variability test (HRV) at rest and under mental stress, and were interviewed the related risk factors by questionnaires. All subjects were grouped as resting hypertension (BP≧140/90mmHg, n=10), or not (BP<140/90mmHg, n=55), exercise hypertension (SBP≧200mmHg, n=40), or not (SBP<200mmHg, n=25), and also grouped into normotension (n=25), only exercise hypertension (n=30), or both resting and exercise hypertension (n=10). Results : Thirty of fifty-five subjects (54.5%) with normal resting BP appeared exercise hypertension, while all subjects with resting hypertension had exercise hypertension. Subjects in the resting hypertension group had higher proportion of having hypertensive family history and high-sodium diet, and higher brachial-ankle pulse wave velocity (baPWV) compared to those without resting hypertension (p<0.05). Subjects with exercise hypertension had higher cardiovascular risk factor score, exercise SBP slope, and baPWV compared to those without exercise hypertension (p<0.05). Subjects with both resting and exercise hypertension had higher proportion of hypertensive family history, high-sodium diet, the cardiovascular risk factor score, exercise SBP slope and baPWV than those with only exercise hypertension or normotension. In the results of multiple regression, the higher resting SBP were association with having hypertensive family history and the higher baPWV and cardiovascular risk factor score (adjusted R2=43%). Exercise SBP was significantly associated with cardiovascular risk factor score, baPWV and the change of HRV in normalized low frequency power (LF%) under mental stress and at rest (adjusted R2=32%). In logistic regression, subjects with higher baPWV (OR:1.005, 95%CI:1.001-1.010) and having of hypertension family history (OR:11.4, 95%CI:1.9-68.8) had higher risk to have resting hypertension (adjusted R2=35%). Subjects with exercise hypertension had higher cardiovascular risk factor score (OR:1.7, 95%CI:1.2-2.6), baPWV (OR:1.004, 95%CI:1.001-1.008), and lower change of HRV in the mean of R-R intervals under mental stress and at rest (OR:0.991, 95%CI:0.98-0.999), R2=41%. Conclusion : High prevalence of exercise hypertension could be found in the middle-aged men with normal resting BP. Cardiovascular risk factor score and baPWV were associated with both resting and exercise hypertension. Hypertensive family history was a major risk factor of resting hypertension, but heart rate variability at rest and under mental stress affected exercise hypertension more. Therefore, exercise hypertension may be an early sign of resting hypertension but some different underlying mechanisms may exist between both hypertension. Our results may highlight the clinical significance of exercise hypertension in the early health screening program.

目錄..............Ι
表目錄............Ⅳ
圖目錄............Ⅵ
附錄..............Ⅶ
摘要..............Ⅷ
Abstract..........Ⅹ

第一章 緒論...............................................1
第一節 研究背景.........................................1
第二節 研究目的.........................................4
第三節 研究假說.........................................4
第四節 研究重要性.......................................5
第二章 文獻回顧...........................................6
第一節 高血壓...........................................6
1-1 休息血壓...........................................6
1-2 運動血壓...........................................8
第二節 動脈硬化與血壓的關係............................11
第三節 心率變異度與血壓的關係..........................14
第三章 研究方法..........................................18
第一節 研究設計........................................18
第二節 研究對象........................................18
第三節 測量工具與方法..................................19
3-1 休息血壓..........................................19
3-2 運動血壓..........................................19
3-3 臂踝動脈波速度....................................20
3-4 心率變異度........................................21
3-5 中國人健康問卷....................................22
3-6 七日回顧活動量問卷................................23
3-7 其他相關資料的收集................................24
第四節 研究步驟........................................25
第五節 資料處理與統計分析..............................26
第四章 結果..............................................28
第一節 研究對象........................................28
第二節 有無休息高血壓者之交感迷走神經活性、動脈硬化及危險
因子的特性......................................29
第三節 有無運動高血壓者之交感迷走神經活性、動脈硬化及危險
因子的特性......................................31
第四節 合併有休息及運動高血壓者、無休息高血壓但有運動高血
壓者與血壓正常者彼此間之交感迷走神經活性、動脈硬化
及危險因子的特性................................32
第五節 休息血壓及運動血壓之相關因素的探討..............33
第五章 討論..............................................35
第一節 運動高血壓的發生比例............................35
第二節 休息高血壓之交感迷走神經活性、動脈硬化及危險因子的
特性............................................37
第三節 運動高血壓之交感迷走神經活性、動脈硬化及危險因子的
特性............................................40
第四節 合併休息及運動高血壓之交感迷走神經活性、動脈硬化
及危險因子的特性................................42
第五節 休息及運動血壓之相關因素........................44
第六節 臨床應用........................................46
第七節 研究限制........................................47
第八節 未來研究建議....................................47
第六章 結論..............................................49
參考文獻..................................................50

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