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Ⅱ期高血压病的治疗目的主要包括预防心脏并发症的发生，阻止向Ⅲ期高血压病发展。Ⅱ期高血压患者心肌肥大的发展不仅使心脏收缩力降低而容易发生心功能不全，而且可引起显著的冠状循环血流量调节异常导致心肌缺血〔3〕。所以，Ⅱ期高血压病的治疗，不仅限于有效的控制血压，也应该考虑选择包括抗心肌肥大、促使高血压性心肌病变的康复。本文探讨应用心肌超声组织密度评价治疗过程中高血压性心肌病变康复的效果。
1 对象与方法
1.1 对象
按1979年全国高血压会议诊断标准确定为高血压病Ⅱ期的病例178例，年龄61～67(平均 65.5±7.2)岁；男120例，女58例，定为治疗前组。经过钙离子拮抗剂和(或)血管紧张素转换酶抑制剂（angiotensin-Ⅰ converting enzyme inhibitor, ACEI）等药物治疗1年后，其中20例发生心脏并发症，按标准诊断为Ⅲ期高血压病，年龄62～67( 66.2±4.2)岁；男15例，女5例；定为Ⅲ期高血压病组。158例按标准仍诊断为Ⅱ期高血压病，年龄61～66(64.5±6.3)岁，男105例，女53例；定为Ⅱ期高血压病组。分别对以上3组检测心肌超声组织密度。
1.2 心肌超声组织密度的检测
使用HP2500超声诊断仪，用2.5MHz探头记录标准切面于录像带上，通过视霸卡将舒张末心室二尖瓣水平及乳头肌水平短轴切面存入计算机待用。图像分析采用Photoshop3.05软件对录像资料进行分析（该软件将各像素的灰阶强度分为0～255,共256级），治疗前后的录像资料均在录像后1个月内进行分析，由同一人操作。首先将心腔的灰阶水平作为本底对图像进行矫正，然后测定心肌灰阶水平。分下列步骤：①分别在乳头肌水平及二尖瓣水平左室短轴切面选取数个直径1cm(121Pixels)的分析点域，在舒张末期正好贯穿整个室壁的厚度，注意不将心内膜和心外膜选入，但图像中心内膜和心外膜都清晰可见；②分析点域图像资料通过计算机系统量化分析；③记录包括心肌各个节段的心肌灰阶均值、优势灰价；局部平均灰阶水平在室间隔、前壁、侧壁和后壁取该心肌节段内3个不同分析点域分析结果的平均值，代表该节段心肌的组织密度，以节段灰阶均值表示；整体心肌组织密度为心脏4个节段的平均值，以整体灰阶均值表示。
1. 3 统计方法
采用SPSS统计软件包，计量资料用均数±标准差表示； 性别构成以卡方检验进行比较；运用方差分析进行治疗前组和治疗后组（包括Ⅲ期高血压病组和Ⅱ期高血压病组）间年龄和心肌组织密度观察指标的显著性检验。
2 结果
治疗前组与治疗后的Ⅲ期高血压病组、Ⅱ期高血压病组间年龄和性别构成无统计学差异(P＞0.05)。治疗前组与治疗后的Ⅲ期高血压病组、Ⅱ期高血压病组间整体灰阶水平的比较显示：二尖瓣水平左室短轴切面和乳头肌水平左室短轴切面的整体灰阶水平治疗后的Ⅱ期高血压病组显著低于治疗前组 (P＜0.05)，但是Ⅲ期高血压病组又显著高于Ⅱ期高血压病组(P＜0.05)，见附表。
附表 治疗前组与治疗后Ⅲ期高血压病组、Ⅱ期高血压病组间整体灰阶水平的比较
治疗前组 治疗后
Ⅱ期高血压病组 Ⅲ高血压病组
二尖瓣水平
灰阶均值 25.18±10.02①② 20.05±8.45 31.19±12.31
优势灰价 17.32±4.23①② 14.96±8.99 22.31±3.25
乳头肌水平
灰阶均值 24.33±5.42①② 19.66±7.38 29.61±3.41
优势灰价 17.0±5.2①② 15.70±8.14 21.05±6.33
注： ①治疗前组与治疗后Ⅱ期高血压病组比较，P＜0.05；
②治疗前组与治疗后Ⅲ期高血压病组比P＜0.05。
3 讨论
3.1 研究意义
超声组织密度（ultrasonsic tissue characterization，UTC）是近年来受到重视的反映心肌组织特性的技术。其应用已涉及多种心肌病理状态的诊断，在美国、欧洲和日本等国较多地用于临床〔1〕，本文研究使用视频分析法对Ⅱ期高血压病在治疗过程中稳定在Ⅱ期和恶化发展成Ⅲ期高血压病的心肌超声组织特性进行测定和对照分析，对于评价高血压病治疗过程中心肌病变的好转、稳定或恶化具有重要意义。
3.2 UTC原理以及与心肌纤维化的关系
UTC常用的方法有视频分析法和射频分析法〔1，2〕，视频分析法通过对计算机系统对超声二维图像资料的量化处理，计算出每个像素的灰阶值，分析心肌局部的灰阶分布，反映心肌的组织密度〔1，3〕，作为临床UTC的应用实用指标〔4〕。Aygen〔5〕等研究表明灰阶的强度取决于心肌纤维排列方向和瘢痕形成状况；Mimbs〔6〕等动物实验研究证实了胶原含量和心肌纤维化程度高者心肌UTC增高；Natio〔7〕等用射频分析法结合心肌心内膜下活检研究表明心肌纤维化程度高者心肌UTC增高。
3.3 高血压病的病理和UTC
高血压等使左心室压力负荷增加，代偿性地左心室向心性肥厚使心肌收缩力增强，保持正常的心功能；持续性后负荷增高，则使心脏逐渐扩大，心功能逐渐减退，进而发生心衰，长期的病变导致心肌细胞萎缩，间质纤维化〔8，9〕，这些病理改变使心肌的组织密度和灰阶强度发生改变。
3.4 高血压病治疗过程中心脏病变的发展
Dahlof〔9〕用心脏超声仪所作关于左室肥大退缩109例的研究证明，ACEI、钙拮抗剂-阻断剂均有抗心肌肥大效果，其中以ACEI效果最强。ACEI抑制了血管紧张素I向血管紧张素Ⅱ的变换，同时又抑制了激肽分解酶的作用，使舒缓激肽增加，血管扩张，从而达到降压目的〔10〕。Baker〔11〕等研究提示血管紧张素Ⅱ的直接的心肌肥大促进作用和间接地通过促使心脏内交感神经末梢释放去甲肾上腺素的促心肌肥大作用。ACEI抑制了血管紧张素Ⅱ的产生，能使心肌细胞缩小，细胞间质与血管周围组织的纤维化减少〔11〕，心肌的组织密度和灰阶强度发生相应改变。本文结果有20例发展成为Ⅲ期高血压病，其中有12例单独服用半衰期较短的钙离子拮抗剂（尼群地平、心痛定等），且未能按时服药把血压控制在正常范围内，最终并发心衰及心脑血管疾病；另8例是由于酗酒或家庭纠纷未能使血压长期稳定在正常范围内最终并发心衰及心脑血管疾病。长期心脏后负荷增高病变导致心衰，心肌细胞萎缩，间质纤维化〔8，9〕，使得心肌组织密度进一步增高。
4 结论
Ⅱ期高血压患者经过钙离子拮抗剂和(或)ACEI等药物治疗血压稳定在正常范围内1年后除部分发展成Ⅲ期高血压病的以外，心肌整体灰阶强度治疗后显著低于治疗前，表明心肌病变有不同程度的好转；未能把血压控制在正常范围内，而发展成Ⅲ期高血压病的部分患者心肌整体灰阶水平又显著高于治疗前，用UTC已能较敏感地进行心肌灰阶强度改变的组织识别。应用UTC评价高血压病治疗过程中心肌病变的康复、稳定或恶化切实可行。
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About the game:
USA as a world power? In E-Sim it is possible!
In E-Sim we have a huge, living world, which is a mirror copy of the Earth. Well, maybe not completely mirrored, because the balance of power in this virtual world looks a bit different than in real life. In E-Sim, USA does not have to be a world superpower, It can be efficiently managed as a much smaller country that has entrepreneurial citizens that support it's foundation. Everything depends on the players themselves and how they decide to shape the political map of the game.
Work for the good of your country and see it rise to an empire.
Activities in this game are divided into several modules. First is the economy as a citizen in a country of your choice you must work to earn money, which you will get to spend for example, on food or purchase of weapons which are critical for your progress as a fighter. You will work in either private companies which are owned by players or government companies which are owned by the state. After progressing in the game you will finally get the opportunity to set up your own business and hire other players. If it prospers, we can even change it into a joint-stock company and enter the stock market and get even more money in this way.
In E-Sim, international wars are nothing out of the ordinary.
Become an influential politician.
The second module is a politics. Just like in real life politics in E-Sim are an extremely powerful tool that can be used for your own purposes. From time to time there are elections in the game in which you will not only vote, but also have the ability to run for the head of the party you're in. You can also apply for congress, where once elected you will be given the right to vote on laws proposed by your fellow congress members or your president and propose laws yourself. Voting on laws is important for your country as it can shape the lives of those around you. You can also try to become the head of a given party, and even take part in presidential elections and decide on the shape of the foreign policy of a given state (for example, who to declare war on). Career in politics is obviously not easy and in order to succeed in it, you have to have a good plan and compete for the votes of voters.
You can go bankrupt or become a rich man while playing the stock market.
The international war.
The last and probably the most important module is military. In E-Sim, countries are constantly fighting each other for control over territories which in return grant them access to more valuable raw materials. For this purpose, they form alliances, they fight international wars, but they also have to deal with, for example, uprisings in conquered countries or civil wars, which may explode on their territory. You can also take part in these clashes, although you are also given the opportunity to lead a life as a pacifist who focuses on other activities in the game (for example, running a successful newspaper or selling products).
At the auction you can sell or buy your dream inventory.
E-Sim is a unique browser game. It's creators ensured realistic representation of the mechanisms present in the real world and gave all power to the players who shape the image of the virtual Earth according to their own. So come and join them and help your country achieve its full potential.
Invest, produce and sell - be an entrepreneur in E-Sim.
Take part in numerous events for the E-Sim community.
