李景業(yè)　劉少偉　李新　郭雪原　張婷　阮燕菲　劉念　杜昕　董建增　馬長生

·臨床研究·

單純皰疹病毒感染與心房顫動(dòng)的相關(guān)性研究

李景業(yè)劉少偉李新郭雪原張婷阮燕菲劉念杜昕董建增馬長生

100029北京，首都醫(yī)科大學(xué)附屬北京安貞醫(yī)院心內(nèi)科

【摘要】目的觀察單純皰疹病毒(HSV)感染與心房顫動(dòng)(房顫)的相關(guān)性。方法嚴(yán)格篩選103例孤立性房顫患者，分為陣發(fā)性房顫組74例和持續(xù)性房顫組29例，從流行病學(xué)對照研究隊(duì)列中選取72例未合并房顫的健康人群作為對照組?？崭共杉o脈血，用ELISA法按試劑盒標(biāo)準(zhǔn)流程檢測血清HSV1 IgG抗體、HSV2 IgG抗體水平；運(yùn)用相關(guān)分析探討患者血清高敏C反應(yīng)蛋白(hs-CRP)水平與HSV1 IgG抗體、HSV2 IgG抗體滴度的關(guān)系。結(jié)果對照組、陣發(fā)性房顫組和持續(xù)性房顫組的血清HSV1 IgG抗體水平分別為(217.95±53.18)μg/ml、(304.76±57.58)μg/ml和(322.99±60.35)μg/ml，血清HSV2 IgG抗體水平分別為(307.25±64.02)μg/ml、(407.22±59.1)μg/ml和(406.63±50.67)μg/ml，hs-CRP水平分別為(2.16±0.70)mg/L、(3.90±0.59)mg/L和(3.90±0.63)mg/L；對照組的血清HSV1 IgG抗體、HSV2 IgG抗體、hs-CRP水平均顯著低于陣發(fā)性房顫組和持續(xù)性房顫組(均P<0.001)；陣發(fā)性房顫組與持續(xù)性房顫組的血清HSV1 IgG抗體、HSV2 IgG抗體、hs-CRP水平比較，差異均無統(tǒng)計(jì)學(xué)意義(均P>0.05)。血清HSV IgG抗體水平與hs-CRP水平呈正相關(guān)關(guān)系(rHSV1=0.532，P<0.001；rHSV2=0.446，P<0.001)。結(jié)論房顫患者的血清HSV IgG抗體水平顯著升高，且與血清hs-CRP水平呈正相關(guān)。

【關(guān)鍵詞】心房顫動(dòng)；單純皰疹病毒感染；高敏C反應(yīng)蛋白

單純皰疹病毒(herpes simplex virus，HSV)作為一類常見的皰疹病毒，全球分布廣泛，人群普遍易感[1]。據(jù)報(bào)道，HSV感染與高血壓病、冠心病和腦卒中等多種心腦血管疾病的發(fā)生發(fā)展相關(guān)[2-5]。雖有研究根據(jù)既往史診斷HSV感染，提出其是心房顫動(dòng)(房顫)發(fā)生的獨(dú)立危險(xiǎn)因素[6]，但目前尚無定論。因此，本研究選取血清HSV IgG抗體作為HSV感染的檢測指標(biāo)，通過分析房顫患者的血清HSV IgG抗體水平，探討HSV感染與房顫的相關(guān)性。

1對象與方法

1.1研究對象

連續(xù)入選2011年8月至2014年6月于北京安貞醫(yī)院等22家醫(yī)院住院治療的4148例房顫患者。根據(jù)2014年美國心臟協(xié)會(huì)(AHA)/美國心臟病學(xué)會(huì)(ACC)/美國心律學(xué)會(huì)(HRS)房顫管理指南[7]中孤立性房顫定義制定排除標(biāo)準(zhǔn)：冠心病、充血性心力衰竭、風(fēng)濕性心臟病、心肌病、先天性心臟疾病、瓣膜病、永久性起搏器植入、心臟術(shù)后、高血壓病、糖尿病、甲狀腺功能異常、慢性腎病、呼吸系統(tǒng)疾病(包括慢性阻塞性肺疾病、阻塞性睡眠呼吸暫停、慢性咽炎、支氣管炎、肺結(jié)核、其他肺部感染、肺氣腫、胸膜炎、肺栓塞)以及其他慢性炎癥性疾病和潛在惡性腫瘤等。此外，目前吸煙或體質(zhì)量指數(shù)(BMI)≥27 kg/m2者也予以排除。最終納入孤立性房顫患者103例(房顫組)，其中陣發(fā)性房顫74例，持續(xù)性房顫29例。同時(shí)，嚴(yán)格按照上述標(biāo)準(zhǔn)，從4209例流行病學(xué)對照研究隊(duì)列中選取72例未合并房顫的健康人群作為對照組。

1.2血樣采集與抗體檢測

采集患者外周靜脈血3 ml，乙二胺四乙酸(EDTA)抗凝充分混勻，離心(1000g，30 min)后留取上清液，于-80℃低溫冰箱中保存。血漿HSV1 IgG抗體和HSV2 IgG抗體水平采用ELISA法測定，試劑盒購自杰輝博高生物技術(shù)(北京)有限公司。各項(xiàng)生化指標(biāo)及高敏C反應(yīng)蛋白(high-sensitivity C-reactive protein，hs-CRP)水平測定嚴(yán)格按照標(biāo)準(zhǔn)步驟進(jìn)行，研究所用儀器為Hitachi 917自動(dòng)分析儀。

1.3統(tǒng)計(jì)學(xué)方法

2結(jié)果

2.1兩組患者的基線資料比較

與對照組比較，房顫組患者的年齡較小[(57.7±10.9)歲比(64.7±8.3)歲，P<0.001]，血清總膽固醇水平較低[(4.8±1.0)mmol/L比(5.3±1.0)mmol/L，P=0.001]，LDL水平較低[(2.9±0.8)mmol/L比(3.2±0.8)mmol/L，P=0.035]，血清hs-CRP水平顯著升高[(3.90±0.60)mg/L比(2.16±0.70)mg/L，P<0.001，表1)。陣發(fā)性房顫組與持續(xù)性房顫組的基線資料各項(xiàng)比較，差異均無統(tǒng)計(jì)學(xué)意義(均P>0.05，表2)。

表1　房顫組與對照組基線資料的比較

注：房顫，心房顫動(dòng)；BMI，體質(zhì)量指數(shù)；LDL，低密度脂蛋白；hs-CRP，高敏C反應(yīng)蛋白；ACEI，血管緊張素轉(zhuǎn)化酶抑制藥；ARB，血管緊張素Ⅱ受體拮抗藥；1 mmHg=0.133 kPa

表2　陣發(fā)性房顫組與持續(xù)性房顫組基線資料的比較

注：房顫，心房顫動(dòng)；BMI，體質(zhì)量指數(shù)；LDL，低密度脂蛋白；hs-CRP，高敏C反應(yīng)蛋白；ACEI，血管緊張素轉(zhuǎn)化酶抑制藥；ARB，血管緊張素Ⅱ受體拮抗藥；1 mmHg=0.133 kPa

2.2三組患者的血清HSV IgG抗體水平比較

HSV，單純皰疹病毒圖1　三組間HSV1 IgG抗體水平比較

HSV，單純皰疹病毒圖2　三組間HSV2 IgG抗體水平比較

對照組、陣發(fā)性房顫組和持續(xù)性房顫組的血清HSV1 IgG抗體水平分別為(217.95±53.18)μg/ml、(304.76±57.58)μg/ml和(322.99±60.35)μg/ml(圖1)，血清HSV2 IgG抗體水平分別為(307.25±64.02)μg/ml、(407.22±59.1)μg/ml和(406.63±50.67)μg/ml(圖2)；對照組的血清HSV1 IgG抗體、HSV2 IgG抗體水平顯著低于陣發(fā)性房顫組和持續(xù)性房顫組(均P<0.001)；陣發(fā)性房顫組與持續(xù)性房顫組的血清HSV1 IgG抗體、HSV2 IgG抗體水平比較，差異均無統(tǒng)計(jì)學(xué)意義(均P>0.05)。2.3血清HSV IgG抗體與hs-CRP的相關(guān)性

血清HSV1 IgG抗體水平、HSV2 IgG抗體水平與hs-CRP水平呈中度正相關(guān)(rHSV1=0.532，P<0.001；rHSV2=0.446，P<0.001；圖3、圖4)。

HSV，單純皰疹病毒；hs-CRP，高敏C反應(yīng)蛋白圖3　HSV1 IgG抗體與hs-CRP的相關(guān)性

HSV，單純皰疹病毒；hs-CRP，高敏C反應(yīng)蛋白圖4　HSV2 IgG抗體與hs-CRP的相關(guān)性

3討論

本研究結(jié)果表明，孤立性房顫患者的血清HSV IgG抗體水平顯著升高，且與血清hs-CRP水平呈正相關(guān)，提示HSV感染相關(guān)的血清IgG抗體水平升高可能與房顫的發(fā)生具有一定的相關(guān)性。

房顫的病理生理機(jī)制十分復(fù)雜，目前尚無定論。離子通道變異、心肌電重構(gòu)和心肌纖維化等多種機(jī)制均與房顫的發(fā)生發(fā)展相關(guān)[8-10]。近年來，炎癥反應(yīng)在房顫的發(fā)生與維持中發(fā)揮的重要作用已引起廣泛關(guān)注。一方面，機(jī)體炎癥反應(yīng)的持續(xù)存在可增加房顫的發(fā)病風(fēng)險(xiǎn)[11]；另一方面，房顫患者也常合并心肌炎癥反應(yīng)或血清炎癥介質(zhì)水平升高[12]。

HSV分HSV1和HSV2兩種血清型，是多種心血管疾病的潛在病原體之一。兒童及成年心肌炎患者的心肌組織標(biāo)本中均可發(fā)現(xiàn)HSV1、HSV2基因組的存在[13-14]，特發(fā)性或遺傳性擴(kuò)張型心肌病患者行心肌活檢時(shí)亦可檢出HSV DNA[15]。HSV感染人體后可侵犯血管內(nèi)皮細(xì)胞及平滑肌細(xì)胞[16]，引起血管炎癥反應(yīng)，促使動(dòng)脈管壁增厚、外周血管阻力增加，導(dǎo)致高血壓的形成[5]。同時(shí)，HSV感染誘導(dǎo)的炎癥因子釋放可干擾血管內(nèi)皮細(xì)胞的脂代謝過程，促進(jìn)脂質(zhì)沉積和血小板聚集，在動(dòng)脈粥樣硬化的進(jìn)程中發(fā)揮重要作用[2-4]。心力衰竭患者心肌組織中HSV基因組的持續(xù)存在提示主要心血管事件風(fēng)險(xiǎn)增加、短期預(yù)后不良[17]。而炎癥性擴(kuò)張型心肌病患者經(jīng)抗HSV治療后可出現(xiàn)左心室大小及左心功能的改善[18]。

HSV感染導(dǎo)致房顫發(fā)生發(fā)展，可能與以下機(jī)制相關(guān)。(1)系統(tǒng)性炎癥反應(yīng)：HSV進(jìn)入人體后通常不能被特異性細(xì)胞免疫清除，多潛伏于神經(jīng)細(xì)胞中，造成慢性持續(xù)性感染[19-20]。HSV的反復(fù)激活也可誘導(dǎo)C反應(yīng)蛋白(CRP)、白細(xì)胞介素-6(IL-6)、腫瘤壞死因子-α(TNF-α)及纖維蛋白原等炎癥因子釋放，引起系統(tǒng)性炎癥反應(yīng)[21-23]。血清炎癥因子水平升高可干擾心肌細(xì)胞的收縮力和電位穩(wěn)定性，誘導(dǎo)成纖維細(xì)胞活化，造成細(xì)胞外基質(zhì)纖維化，為折返性心律失常的發(fā)生提供潛在基質(zhì)[24]。(2)心肌局部炎性浸潤：研究表明，孤立性房顫患者行心肌活檢可見心肌細(xì)胞壞死、裂解，周圍出現(xiàn)單核細(xì)胞和淋巴細(xì)胞為主的炎性細(xì)胞浸潤[25]，這一改變與HSV感染性心肌炎的病理改變相符[26]。Yamashita等[27]對房顫患者的心房組織行免疫組化染色時(shí)也發(fā)現(xiàn)了大量聚集的CD68+巨噬細(xì)胞和CD3+T淋巴細(xì)胞，高度表達(dá)單核細(xì)胞趨化蛋白-1(MCP-1)、轉(zhuǎn)化生長因子-β(TGF-β)、IL-6等炎癥因子。Frustaci等[25]分析房顫患者不同部位心肌組織的CRP含量后指出，左心房心肌組織的CRP含量較冠狀竇組織顯著升高，提示心肌局部炎性浸潤參與房顫的形成。本研究組推測，HSV感染可能通過全身系統(tǒng)性炎癥反應(yīng)和心肌局部炎性浸潤雙重通路誘發(fā)房顫。

既往研究顯示，房顫患者的血清CRP水平可能受房顫類型和房顫病程的影響[28]。與陣發(fā)性房顫患者相比，持續(xù)性房顫及長程持續(xù)性房顫患者可出現(xiàn)血清CRP水平顯著升高[29]。近期一項(xiàng)Meta分析還指出，CRP水平雖與持續(xù)性房顫和永久性房顫的發(fā)生相關(guān)，卻與陣發(fā)性房顫無關(guān)[12]。本研究為明確房顫類型是否影響血清CRP水平，對陣發(fā)性房顫與持續(xù)性房顫患者行進(jìn)一步分析。與上述研究結(jié)果不同的是，本研究中陣發(fā)性房顫與持續(xù)性房顫患者各項(xiàng)指標(biāo)的差異均無統(tǒng)計(jì)學(xué)意義?？赡茉蛟谟诒狙芯繃?yán)格控制了包括高血壓病、糖尿病、冠心病、吸煙、肥胖和慢性系統(tǒng)性炎癥在內(nèi)的多種危險(xiǎn)因素，充分排除了其致血清CRP水平升高的潛在干擾。這一結(jié)果也表明，HSV感染引起的炎癥反應(yīng)在不同類型房顫的發(fā)生與維持中可能同樣發(fā)揮重要作用。

本研究中對照組年齡高于房顫組，可能與人群選擇有關(guān)，但因HSV IgG抗體水平有隨年齡增長逐漸升高的自然趨勢[30]，故仍能說明本組房顫患者HSV IgG抗體增高是有意義的。此外，為盡可能地嚴(yán)格控制房顫發(fā)生的危險(xiǎn)因素，本研究最終僅從4148例房顫人群中篩選出103例孤立性房顫患者，樣本量相對較小，未行多元回歸分析，結(jié)論有待進(jìn)一步研究證實(shí)。

綜上所述，本研究在嚴(yán)格控制房顫相關(guān)多種潛在危險(xiǎn)因素的基礎(chǔ)上，通過血清學(xué)檢測指標(biāo)證實(shí)HSV感染與房顫的發(fā)生相關(guān)。這一發(fā)現(xiàn)有助于合理防治病毒感染，控制房顫危險(xiǎn)因素，從而改善患者的臨床預(yù)后。

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The relationship between herpes simplex virus infection and atrial fibrillation

LIJing-ye,LIUShao-wei,LIXin,GUOXue-yuan,ZHANGTing,RUANYan-fei,LIUNian,DUXin,DONGJian-zeng,MAChang-sheng.

DepartmentofCardiology,BeijingAnzhenHospital,CapitalMedicalUniversity,Beijing100029,ChinaCorrespondingauthor:MAChang-sheng,Email:chshma@vip.sina.com

【Abstract】ObjectiveTo observe the correlation of herpes simplex virus (HSV) infection and atrial fibrillation (AF). Methods103 strictly selected homogenous lone AF patients were recruited, including 74 paroxysmal AF patients and 29 persistent AF patients. 72 healthy control subjects were selected from a population-based Chinese Arrhythmia Registry. Peripheral venous blood samples were collected and the concentration of IgG antibody against HSV was tested according to the standard procedure of the diagnostic ELISA kit. ResultsCompared to the control, AF patients were younger [(64.7±8.3) years vs. (58.2±10.6) years vs. (56.2±11.6) years，P<0.001] and had a significantly higher concentration of anti-HSV1 IgG [(217.95±53.18) μg/ml vs. (304.76±57.58) μg/ml vs. (322.99±60.35) μg/ml, P<0.001], anti-HSV2 IgG [(307.25±64.02) μg/ml vs. (407.22±59.1) μg/ml vs. (406.63±50.67) μg/ml, P<0.001] and high sensitivity C-reactive protein (hsCRP) [(2.16±0.71) mg/L vs. (3.90±0.59) mg/L vs. (3.90±0.63) mg/L，P<0.001]. There was a positive correlation between anti-HSV IgG levels and hsCRP levels (rHSV1=0.532，P<0.001；rHSV2=0.446，P<0.001). Conclusions The expression of IgG antibody against HSV was increased in AF patients, and it has a positive correlation with hsCRP levels.

【Key words】Atrial fibrillation;Herpes simplex virus infection;High sensitivity C-reactive protein

DOI:10.3969/j.issn.1004-8812.2016.05.005

通信作者：馬長生，Email: chshma@vip.sina.com

【中圖分類號】R541.75

(收稿日期:2016-02-13)