臺灣博碩士論文加值系統

目的：輪班工作對高血壓患者血壓的危害作用仍不明確。本研究主要在探討輪班工作對高血壓勞工血壓分佈趨勢及血壓變異程度之影響，並與血壓正常勞工相互比較，探討其血壓變異程度之差異。期待提供更多血壓變化情形的證據，以協助患有高血壓並從事輪班工作的勞工，更有效控制血壓，減少心血管疾病的發生。
方法：本研究由工廠健康檢查中選出血壓異常(收縮壓>140mmHg或舒張壓>90mmHg)，並經三個月追蹤調查仍為異常，且尚未服用降血壓藥物之男性輪班(四班三輪制)勞工共7位，再依據性別、年齡、輪班年資、輪班班別、工作部門等條件，選定另7位血壓正常之輪班勞工做為對照組。利用由美國Pulse Metric Inc.所製造的血壓心脈儀(Dynapulse5000A)，分別於早班(0700-1500)第二天、夜班(2300-0700)第一天及夜班第三天，共進行三次24小時動態血壓連續監測。比較1.兩組個別於不同輪班方式之血壓變異；2.兩組間之血壓變異趨勢及程度的差別。
結果：1. 輪夜班工作會對高血壓勞工與血壓正常勞工之生物節律產生直接的影響，造成血壓全天分佈立即性的顛倒，且在此三班之輪班制度，輪幾天夜班睡眠醒著血壓差異會由dippers轉為non-dippers之趨勢，並以輪早班時睡眠血壓下降程度最為顯著；而高血壓勞工與血壓正常勞工之全天血壓分佈型態，並無顯著差異，但睡眠血壓下降程度高血壓勞工較血壓正常勞工為不顯著。2. 輪早班與輪夜班之24小時全天平均血壓及心跳速率沒有顯著差異，但24小時平均脈壓以輪早班時為最高，初輪夜班時為最低，經過幾天夜班後有上升之趨勢。3. 在血壓正常勞工中，初輪夜班工作於醒著時期之血壓變異顯著高於輪早班工作，且經過幾天夜班工作後，其24小時全天變異有下降之趨勢；於高血壓勞工之中亦有同樣的現象，但其差異程度較不明顯。4. 我們進一步控制年齡、BMI、抽煙、總膽固醇等條件後，輪班工作對高血壓勞工與血壓正常勞工其血壓變異程度並無顯著差別，但高血壓勞工相對變異程度有較大的趨勢，是否對高血壓勞工的健康產生危害 (標的器官損傷) ，值得進一步討論。
結論： 輪班工作對勞工血壓全天分佈產生立即性的影響，明顯改變其血壓變異程度，高血壓勞工與血壓正常勞工變異情形並無顯著差異，但此變異是否可能會增加高血壓勞工心血管事件發生之風險，則需要更多之研究來證實。

Objective：The association between blood pressure and shift work has been reported. However, it is not clear if shift work has more adverse effects on blood pressure in patients with hypertension. We conducted a study to investigate the blood pressure changes in hypertensive workers who underwent shift work.
Method：To evaluate the effect of shift work, we identified 7 male shift workers with hypertension (SBP>140mmHg or DBP>90mmHg) from routine health examination in a factory. 7 normotensive shift workers matched for sex, age, and work characteristics in the same plant were recruited. Noninvasive ambulatory BP monitoring was performed three times used automatic ambulatory BP monitoring (Dynapulse5000A, Pulse Metric Inc., San Diego, CA, US). Blood pressure was measured in each worker on the second day of day shifts (0700-1500), the first day and the third day of night shifts (2300-0700). We compared the BP variability between different shifts, and the difference of BP variability between hypertensive and normotensive groups.
Results： According to our research, we found: 1. Circadian variation of BP reversed to dippers on the first day and changed from dippers to non-dippers within few days of night shift. The dippers revealed markedly on the day shift. There were no different between hypertensive and normotensive shift workers on circadian variation of BP in day or night shift, but the dipper in hypertensive was less prominent than normotensive shift workers. 2. There were no significantly difference on the 24h mean BP and HR between day and night shift. On the average of 24h and wake period, PP was higher in day shift and was lower in the first day of night shift. It had a non-significant trend of PP rose after few days of night shift. 3. In the normotensive shift workers, the variability of BP (SD from the mean) in wake period was higher in the first day of night shift than the day of day shift. After few days of night shift, the 24h variability of BP decreased significantly. There were the same trends in the hypertensive shift workers, but all of the trends were no significant. 4. After controlling the age, BMI, smoking and total cholesterol, we found that the BP variability was not significant different between normotensive and hypertensive shift workers, although hypertensive were higher than normotensive shift workers.
Conclusion：Our results revealed that shift work directly impacted workers’ circadian rhythm of blood pressure and changed markedly the BP variability, but there were no significant different between normotensive and hypertensive shift workers. It still needed more studies to confirm whether this kind of BP variability could cause an increased risk of cardiovascular events.

摘 要 i
Abstract iii
目 錄 1
圖 目 錄 4
表 目 錄 5
第一章、緒論 6
第二章、文獻回顧 8
2.1 輪班之定義、形態與盛行率 8
2.2 輪班之健康效應 9
(1) 腸胃道不適 10
(2) 睡眠障礙 10
(3) 生殖系統危害 10
(4) 心血管相關疾病 11
2.3高血壓之定義與盛行率 12
2.4 血壓測定方法 13
(1) 聽診法(auscultation method)： 13
(2) 示波法(oscillometric method)： 13
(3) 動態血壓連續監測法(Ambulatory blood pressure monitoring，ABPM)： 14
2.5 動態血壓連續監測之應用 15
2.6 動態血壓變異相關研究 15
2.6.1 睡醒血壓上升 16
2.6.2 睡眠血壓下降 17
2.6.3 血壓變異 17
2.6.4 脈壓(pulse pressure) 18
2.7 動態血壓變異之影響因子 19
(1) 年齡 19
(2) 身體活動 19
(3) 食鹽量 20
(4) 餐後低血壓 20
(5) 抽煙 20
(6) 喝酒 21
(7) 咖啡因 21
(8) 心理因子 21
2.8 輪班工作對血壓變異影響相關研究 22
第三章、材料與方法 25
3.1 研究流程 25
3.2 研究設計 26
3.3 研究對象 26
3.3.1 工作內容(輪班方式) 26
3.3.2 樣本個案數估計 27
3.3.3 對象選擇 27
3.4 問卷與健檢 27
3.5 測量儀器 28
3.6 測量策略 29
3.7 資料處理與統計分析方法 29
第四章、結果 31
4.1基本資料統計 31
4.2血壓狀態及趨勢分析 32
4.2.1血壓狀態分析 32
4.2.2血壓趨勢分析 33
4.3血壓變異分析 34
4.3.1 睡眠與醒著差異值與差異比 34
4.3.2 脈壓(Pulse Pressure，PP) 35
4.3.3 絕對變異(SD)與相對變異(C.V.) 35
4.3.4 血壓異常比例分析 36
4.3.5 血壓心跳睡醒上升速率分析 37
第五章、討論 38
5.1 血壓型態 38
5.2 血壓睡醒上升趨勢 38
5.3 Dippers與non-dippers 39
5.4 血壓平均狀態 41
5.5 脈壓(PP) 42
5.6 血壓變異(SD、CV) 43
5.7 數據測量成功率、可靠性 45
5.8 研究限制： 46
5.9 結論與建議 48
參考文獻 78
附錄一、輪班人員血壓評估計畫同意書…………………………………84
附錄二、受測者健康問卷調查表…………………………………………85
附錄三、血壓監測誌………………………………………………………90

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