影响冠状动脉旁路移植术远期预后的基因多态性风险因素研究

发布时间：2018-01-08 19:26

本文关键词：影响冠状动脉旁路移植术远期预后的基因多态性风险因素研究　出处：《北京协和医学院》2017年博士论文　论文类型：学位论文

【摘要】：冠状动脉旁路移植术(Coronary artery bypass grafting,CABG)是冠心病治疗的主要手段之一,尤其是对于左主干病变、三支病变、合并糖尿病、左室功能不良等相对比较严重的冠心病患者。然而,.CABG患者远期出现死亡、心肌梗死、卒中及再次血运重建等不良事件仍是困扰外科医生及患者的主要难题。据报道,CABG术后5年内发生主要不良心脑血管事件的比例达11.8%～31.0%,预测患者出现CABG术后远期不良心脑血管事件对于患者二级预防策略的优化,提高患者远期预后具有重要意义。本研究对比了常用的临床评分体系,评价了其在中国患者中预测远期不良事件的效能,发现目前常用的临床评分体系对于我国冠心病搭桥患者远期不良事件的预测效果不甚理想,进而建立了针对中国患者评价远期不良事件发生的基因风险模型,并对基因风险模型与临床风险模型进行了对比比较,将基因模型和临床模型相结合,发现结合了临床信息和基因信息的模型对于预测患者CABG术后远期不良事件的发生具有更高的应用价值;进而探索了基因多态性引起CABG术后远期不良事件发生的可能机制;最后针对特殊类型的冠心病-左主干病变进行了进一步的研究,发现了与其发病相关的基因多态性同时与左主干患者行CABG后的不良事件发生具有关联。第一部分冠状动脉旁路移植术远期预后基因多态性风险评分的研究目的:评价现有主要的冠心病外科术后不良事件预测模型EuroSCORE、SinoSCORE和NYScore对于术后远期发生不良事件的预测价值;基于患者与术后远期发生不良事件相关的基因多态性,建立适用于我国CABG患者的风险评分体系,并对其进行验证与评价。方法:本部分研究利用在阜外医院行单纯CABG手术的一组患者,利用生存分析的方法研究不同的临床评分模型与术后远期不良事件发生之间的关联;通过C统计童和重分类分析比较不同评分模型对于不同术后不良事件的预测价值。进一步地,通过12个既往报道与冠心病患者不良事件发生相关的基因多态性位点,利用生存分析探索其与CABG术后远期不良事件发生的关联,进而采用其中与CABG术后不良事件发生相关的5个基因多态性位点建立预测患者CABG术后远期不良事件发生的基因风险评分体系,并对其做内部验证。还通过C统计量、重分类分析将其与临床风险评分对比,探索基因风险评分联合临床风险评分对患者术后远期发生不良事件的预测效能。结果:三种评分中,EuroSCORE预测患者术后远期出现MACCE的HR为1.066(95%CI:1.001～1.136,p=0.048);SinoSCORE 预测患者术后远期出现 MACCE 的 HR 为1.052(95%CI:1.016～1.088,p=0.004);NYScore 预测患者术后远期出现 MACCE的HR为1.078(95%CI:1.032～1.126,p=0.001)。然而,三种基于临床资料的评分体系对于预测术后发生MACCE的效能不高。在所有被研究的术后不良事件中,三种临床评分体系对于术后全因死亡的预测效能最高。然而,三种评分模型对预测CABG术后远期MACCE的价值较小(AUC均0.60);三者在预测患者术后远期全因死亡方面的C统计量相对较大,分别为EuroSCORE 0.629(95%CI:0.574～0.684,p0.001);SinoSCORE0.629(95%CI:0.574～0.684,p0.001);NYScore0.646(95%CI:0.591～0.701,p0.001),说明三种模型在预测全因死亡方面具有较好的区分度,预测效能好。SinoSCORE在预测CABG患者远期出现心肌梗死(C-index:0.613,95%CI:0.513～0.713,p=0.031)及再次血运重建(C-index:0.601,95%CI:0.532～0.670,p=0.006)方面的效能较好。通过生存分析发现IL-6Rrs1800796(HR=1.268,95%CI:1.083～1.483,p=0.003),GPIArs 1126643(HR= 1.277,95%CI:1.081～1.508:,p=0.004),THBDrs1042579(HR=1.225,95%CI:1.031～1.455,p=0.021),P2RY12 rs2046934(HR=1.236,95%CI:1.022～1.494,p=0.029)和 CYP2C19 rs4244285(HR=1.185,95%CI:1.008～1.392,p=0.040)与术后远期MACCE的发生显著相关。基于这五个基因多态性位点,建立针对CABG患者术后远期MACCE的风险评分体系,发现该评分对于患者发生远期MACCE的风险预测能力高于临床风险评分;通过C统计量、Hosmer-Lemeshow统计量与重分类分析研究发现,同时利用基因风险评分与临床风险评分评价患者术后MACCE的发生,其效能达到最佳。结论:相较而言,三种临床评分体系对于预测患者远期出现MACCE事件的能力并不强,需要对此内容的进一步研究以明确预测中国患者远期出现MACCE的模型,或加入其他关键变量提高对中国患者远期不良事件发生的预测能力。针对患者CABG术后远期风险的基因风险评分体系对于预测国人CABG术后MACCE发生的效能优于临床风险评分;同时应用临床风险评分和基因风险评分的预测效能最高。研究说明,基因风险评分能够提高对患者远期发生MACCE的预测能力,对于CABG术后患者的二级预防策略优化及防止不良事件发生具有重要意义。第二部分血小板膜糖蛋白GPIA的基因多态性对于冠状动脉旁路移植术后远期不良事件的作用及机制研究目的:2验证并研究GPIArs1126643位点对于CABG术后远期不良事件发生的作用和机制。方法:本部分研究通过发现队列和验证队列证实了 GPIArs1126643基因多态性T等位基因与CABG术后远期不良事件发生的关联;并通过另一组功能研究队列,对血小板聚集实验进一步研究了该基因多态性对于血小板聚集的影响,进而通过qRT-PCR和Western-blotting实验探索了该基因多态性引起患者CABG术后远期不良事件发生的可能机制。结果:发现队列中GPIArs1126643 T等位基因携带者发生MACCE的风险是CC纯合患者的1.27倍(p=0.033);在验证队列中,其多态性T等位基因携带者发生MACCE的风险是CC纯合型患者的1.74倍(p=0.020)。在功能研究对列中,T等位基因携带者血小板最大聚集率的平均值为68.3%,显著高于CC纯合型患者的58.8%(p=0.029),通过qRT-PCR实验,我们发现GPIArs1126643 T等位基因携带者的GPIAmRNA水平与CC纯合型患者无明显差异,而其多态性T等位基因携带者GpIa蛋白表达是CC纯合型患者的2.08倍,具有显著的统计学意义(p0.001)。结论:GPIArs1126643通过转录后调控影响患者GpIa蛋白质的表达,进而影响其血小板聚集率:T等位基因携带者的平均血小板聚集率更高。由此,GPIArs1126643T等位基因携带者CABG术后远期发生不良事件的可能性更高。第三部分环氧化酶COX-2基因多态性与冠心病左主干病变及其预后的研究目的:研究环氧化酶COX-2基因多态性与冠心病左主干病变的发生是否有关联,并研究这种关联是否影响患者行CABG术远期的预后。方法:本部分研究在一组阜外医院行CABG手术的患者中,探索了三个位于COX-2基因的基因多态性rs5275、rs689466和rs5277与冠心病左主干疾病发生之间的关联,并通过生存分析研究了其与患者行CABG手术远期预后的关联。结果:研究发现rs5275与rs689466都不增加冠脉左主干的发生风险(rs5275:单因素分析:OR=1.00,p=0.998;校正后:OR=1.00,p=0.994。rs689644:单因素分析:OR=1.08,p=0.577;校正后:OR=1.590,p=0.013)。而对于 rs5277 位点,其 C 等位基因携带者出现左主干病变的可能性为GG纯合型患者的1.58倍,95%置信区间为1.10～2.26,p=0.014,有显著的统计学意义。在经过多因素的校正后,C等位基因携带者出现左主干病变的可能性仍为GG纯合型患者的1.59倍,95%置信区间为1.10～2.29,p=0.013,具有显著的统计学意义。另外,rs5277C等位基因携带者发生MACCE的风险是GG纯合型患者的1.56倍(p=0.037),经过多因素校正后其风险仍是GG纯合型患者的1.56倍(p=0.038)。对于左主干病变患者,rs5277C等位基因携带者发生MACCE的风险是GG纯合型患者的2.04倍(p=0.033),经过多因素校正后其风险仍是GG纯合型患者的2.01倍(p=0.039);而在非左主干患者中,rs5277基因多态性则与CABG术后远期MACCE没有相关性(单因素生存分析p=0.273;多因素生存分析p=0.259)。结论:本部分研究通过环氧化酶COX-2的3个基因多态性位点与冠状动脉左主干疾病的关联性研究,发现COX-2 rs5277 C等位基因能够增加左主干疾病的发生风险,进一步的研究发现该等位基因增加冠心病左主干病变患者,行冠状动脉旁路移植术术后的远期主要不良心脑血管事件的发生风险,而不影响非左主干患者的预后。该部分研究的结论提示,对于COX-2rs5277C等位基因携带者,需要较多关注其左主干的病变状况,对于具有该等位基因的左主干疾病患者,应当给予强化的抗炎等相关治疗,以期提高患者预后。
[Abstract]:Coronary artery bypass grafting (Coronary artery bypass grafting, CABG) is one of the main means of treatment of coronary heart disease, especially for the left main coronary artery disease, diabetes mellitus and three lesions, and left ventricular dysfunction in patients with coronary heart disease is relatively serious. However, the long-term.CABG patients died of myocardial infarction, the main problem for surgeons and patients is still troubled by the stroke and revascularization and other adverse events. According to reports, occurrence of major adverse cardiovascular events within 5 years after CABG the proportion of 11.8% to 31%, forecast CABG patients postoperative long term cardiovascular events for patients with optimization of two grade prevention strategy, has important significance in improving the prognosis of the patients. This study compared the clinical scoring system used, evaluate its effectiveness in predicting long-term adverse events Chinese patients, found that the current commonly used clinical scoring system for The prediction effect of Chinese coronary artery bypass patients with long-term adverse events is not ideal, and set up the risk model for gene China patients evaluated the long-term adverse events, and the genetic risk model and clinical risk model have been compared, combined with the genetic model and clinical model, found a combination of clinical information and genetic information model the prediction has higher application value in patients with CABG long-term postoperative adverse events; and to explore the possible mechanism of CABG gene polymorphism caused by long-term postoperative adverse events; according to the special type of coronary heart disease - makes a further study of left main disease, found the gene polymorphism and pathogenesis related with adverse the event left main patients after CABG occurred. The first part is associated with coronary artery bypass graft prognosis gene polymorphism of wind Objective: To evaluate the risk score of major coronary surgery postoperative adverse events prediction model of EuroSCORE, SinoSCORE and NYScore in prediction of adverse events and long-term postoperative adverse events; gene polymorphism related to the long-term prognosis of patients with postoperative based on building suitable for Chinese CABG patients and the risk score system. Verification and evaluation on it. Methods: in a group of patients underwent CABG surgery in Fuwai Hospital using this part of the study, research and clinical scoring model operation after different long-term adverse events associated with hair between students by using the method of survival analysis; through C statistical children and re classification analysis and comparison of different scoring models to predict the value of different postoperative adverse events. Further, by 12 previous reports of adverse events in patients with coronary heart disease related gene polymorphism, using survival analysis to explore the Associated with the long-term incidence of adverse events after CABG, then the one with the CABG was established to predict the occurrence of long-term adverse events in patients with postoperative CABG risk score system associated gene 5 gene polymorphism after adverse events, and internal verification on it. Through the C statistics, analysis of the classification score with the comparison of clinical risk, explore genetic risk score combined with clinical risk score in the prediction of adverse events on the long-term efficacy of patients after surgery. Results: three scores, EuroSCORE predict postoperative long-term MACCE HR 1.066 (95%CI: 1.001 ~ 1.136, p=0.048); SinoSCORE predict postoperative long-term MACCE HR 1.052 (95%CI:1.016 - 1.088, p=0.004); NYScore predict postoperative long-term MACCE HR 1.078 (95%CI:1.032 - 1.126, p=0.001). However, the clinical data of three score system based on MACCE predicting postoperative effectiveness is not high. In all of the postoperative adverse events, three clinical scoring system for postoperative all-cause death of the highest prediction efficiency. However, the three score model for the value of small forward MACCE prediction after CABG (AUC < 0.60); three in the prediction of patients long term postoperative death from all aspects of the C statistic is relatively large, respectively 0.629 EuroSCORE (95%CI:0.574 - 0.684, p0.001); SinoSCORE0.629 (95%CI:0.574 - 0.684, p0.001); NYScore0.646 (95%CI:0.591 - 0.701, p0.001), shows three kinds of model test of all-cause death has good discrimination in the pre forecast performance of.SinoSCORE myocardial infarction in patients with long-term prediction CABG (C-index:0.613,95%CI:0.513 - 0.713, p=0.031) and revascularization (C-index:0.601,95%CI:0.532 - 0.670, p=0.006) the effect is good. The survival analysis showed that IL-6Rrs18 00796 (HR=1.268,95%CI:1.083 - 1.483, p=0.003), GPIArs 1126643 (HR= 1.277,95%CI:1.081 ~ 1.508:, p=0.004), THBDrs1042579 (HR=1.225,95%CI:1.031 - 1.455, p=0.021), P2RY12 rs2046934 (HR=1.236,95%CI:1.022 - 1.494, p=0.029) and CYP2C19 rs4244285 (HR=1.185,95%CI:1.008 - 1.392, p=0.040) was significantly associated with the occurrence of postoperative long-term MACCE sites of these five genes. Based on the established risk score for polymorphism, system long term MACCE CABG after surgery, found that the risk of patients with MACCE score for long-term prediction ability is higher than the clinical risk score; through C statistic, Hosmer-Lemeshow statistic and analysis of classification with gene risk score and clinical risk score evaluation of patients after MACCE, the to achieve the best performance. Conclusion: in contrast, three clinical scoring system for predicting long-term MAC patients CE event is not strong, needs further study of the content to determine predictive Chinese patients with long-term MACCE model, or the addition of other key variables to improve the ability to predict the occurrence of adverse events in patients with long-term Chinese. According to the long-term risk of wind gene in patients with CABG after risk scoring system for the prediction of Chinese CABG postoperative MACCE clinical risk the score is better than forecast performance; at the same time the application of clinical risk score and genetic risk score highest. Research shows that genetic risk score can improve the prediction ability of MACCE occurred in patients with long term, has important significance for patients after CABG two grade prevention strategy optimization and prevent adverse events. The second part gene polymorphism of platelet objective to study the membrane glycoprotein GPIA for coronary artery bypass graft long-term postoperative adverse events: the effect and mechanism of 2 verification and study G PIArs1126643 site for the effects and mechanisms of long-term adverse events after CABG. Methods: This study found that by cohort and a validation cohort confirmed the association of long-term adverse events GPIArs1126643 gene polymorphism of T allele and CABG after operation; and by another group to study cohort, further study of the gene polymorphism the effect of platelet aggregation experiments on platelet, and then through the qRT-PCR and Western-blotting experiments explored the possible mechanisms of long-term adverse events in patients with CABG after the gene polymorphism. Results: it was found that the risk of GPIArs1126643 T in a cohort of allele MACCE was 1.27 times CC homozygous patients (p=0.033) in the verification; in the queue, the risk of the polymorphism of T allele of MACCE was 1.74 times in patients with CC homozygous (p=0.020). To study the function of the column, T etc. The average value of gene carriers the maximum platelet aggregation rate was 68.3%, significantly higher than that of CC homozygous patients 58.8% (p=0.029), through qRT-PCR test, we found no significant difference between GPIAmRNA levels and CC GPIArs1126643 T allele homozygous, and the polymorphism of T allele of GpIa protein expression is 2.08 times in patients with homozygous CC, with significant statistical significance (p0.001). Conclusion: GPIArs1126643 can influence the regulation of the expression of GpIa protein in patients after transcription, thereby affecting the platelet aggregation rate of platelet T: the average allele aggregation rate higher. Thus, the long-term GPIArs1126643T allele carriers after CABG possibility adverse events more. Objective: third part of cyclooxygenase COX-2 gene polymorphism and coronary heart disease left main disease and prognosis: a study of cyclooxygenase COX-2 gene polymorphism Left main lesion and the occurrence of coronary heart disease is related, and to study whether this association affects the prognosis of CABG patients long-term. Methods: this part of the study in a group of patients underwent CABG surgery in Fuwai Hospital, explores three located in the COX-2 gene rs5275 polymorphism and the association between rs689466 and rs5277 and left main coronary heart disease the occurrence of disease, and through the analysis on the survival associated with the long-term prognosis of patients underwent CABG surgery. Results: the study found that rs5275 and rs689466 did not increase the risk of left main coronary rs5275: (single factor analysis: OR =1.00, p=0.998; OR=1.00, p=0.994.rs689644:: after correction of single factor analysis: OR=1.08, p=0.577; correction: OR=1.590, p=0.013). For the rs5277 locus, the C allele possibility of left main disease 1.58 times for patients with homozygous GG, 95% confidence interval was 1.10 ~ 2.26, p= 0.014, there was statistical significance. After adjustment for multiple factors, C allele possibility of left main coronary artery disease is still 1.59 times in patients with homozygous GG, 95% confidence interval was 1.10 ~ 2.29 p=0.013, with significant statistical significance. In addition, the risk rs5277C allele MACCE the 1.56 times in patients with GG homozygous (p=0.037), after multivariable adjustment after the risk is 1.56 times the GG homozygous patients (p=0.038). For patients with left main disease, the risk of rs5277C allele of MACCE was 2.04 times in patients with GG homozygous (p=0.033), after the adjusted risk is 2.01 times the GG homozygous patients (p=0.039); while in non left main patients, rs5277 gene polymorphism is not associated with long-term postoperative MACCE (CABG multi factor analysis p=0.273; univariate survival analysis p=0.259). Conclusion: the Association of research through the cyclooxygenase 3 COX-2 gene polymorphism and left main coronary artery disease, found that the COX-2 rs5277 C allele could increase the risk of left main disease, further research found that the allele increased in patients with coronary heart disease and left main disease, the risk of coronary artery bypass grafting after the long-term major adverse cardiovascular events, but does not affect the prognosis of patients with non left trunk. This part of research conclusion, the COX-2rs5277C allele carriers, need to pay more attention to the status of left main lesions, with the alleles of the left main coronary artery disease patients, should be given to strengthen anti-inflammatory and other related treatment and in order to improve the prognosis of the patients.

【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R654.2

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