冠状动脉小血管病变：986例病人回顾性研究和Meta分析

发布时间：2018-05-28 01:16

本文选题：冠状动脉小血管病变 + 病变特点　；参考：《浙江大学》2017年博士论文

【摘要】：第一部分冠状动脉小血管病变的特点、危险因素及预后分析:986例病人回顾性研究背景与目的:目前冠状动脉小血管病变的发病率逐年上升,已有文献提示小血管病变患者往往合并有较多的其他疾病,且病变复杂,术中操作更加困难,远期预后不佳,但也有部分研究显示其远期预后与非小血管病变相当。目前的研究大多来自于欧美人群,缺乏中国人群相关的研究。因此,我们设计了此回顾性研究,旨在阐明冠状动脉小血管病变特点、危险因素及进行预后分析,这将有助于早期识别高危患者,协助相关治疗方案的制定,加强患者术后随访管理,从而改善预后。方法:纳入了全部986例2015年在浙江大学医学院附属第一医院心内科接受冠脉造影并植入支架的患者,按照是否植入≤2.5mm的支架,分为冠状动脉小血管病变组(308例)与非小血管病变组(678例)。记录患者临床基线资料、冠脉造影及手术情况、出院及长期随访情况。采用多因素Logistic回归分析筛选冠状动脉小血管病变、PCI术后再狭窄的独立危险因素。使用Kaplan-Meier法绘制累积无MACE生存曲线,并通过log-rank法检验两组患者无MACE生存曲线的差异。运用Cox回归模型(风险比例模型),探究不同变量对MACE事件、再次血运重建的影响作用,筛选出终点事件的独立预测因子。结果:高龄(OR=1.022,95%CI:1.009-1.036,P=0.001)、糖尿病(OR=1.742,95%CI:1.278-2.373,P0.001)、外周血管疾病(OR=2.484,95%CI:1.487-4.148,P0.001)、高水平低密度脂蛋白(OR=1.245,95%CI:1.060-1.461,P=0.007)、以及高同型半胱氨酸水平(OR=1.017,95%CI:1.002-1.033,P0.001)是冠状动脉小血管病变的独立危险因素,而饮酒史(OR=0.420,95%CI:0.299-0.588,P0.001)却是其独立保护因素。冠状动脉小血管病变累及回旋支的比例较非小血管病变高(31.9%vs 17.3%,P0.001),而且,更易合并多支病变(79.2%vs 49.4%,P0.001)、分叉病变(24.0%vs 12.4%,P0.001)、慢性完全性闭塞病变(29.5%vs 9.4%,P0.001)以及弥漫性病变(55.2%vs35.7%,P0.001),术中前扩(95.8%vs68.7%,P0.001)、后扩(94.2%vs89.4%,P=0.016)的比例显著高于非小血管病变组,而术后完全血运重建比例低于非小血管病变组(70.1%vs 85.1%,P0.001)。长期随访发现,冠状动脉小血管病变患者术后再狭窄的比例(6.5%vs 3.2%,P=0.019)显著高于非小血管病变患者,不良心血管事件的发生率(心因性死亡(2.3%vs 0.4%,P=0.008)、卒中(1.9%vs 0.3%,P=0.007)、靶病变血运重建(5.8%vs 2.9%,P=0.029)、靶血管血运重建(6.8%vs 3.4%,P=0.016)、非靶血管血运重建(7.8%vs 4.0%,P=0.012))也明显高于非小血管病变患者。完全血运重建(OR=0.351,95%CI:0.136-0.901,P=0.029)是冠脉小血管病变PCI术后再狭窄的独立保护因素;而较高的 TSH 水平(OR=1.203,95%CI:1.059-1.366,P=0.004)则是其独立危险因素。Cox回归分析可得,冠状动脉小血管病变组患者MACE终点事件的独立预测因素包括心率(OR=0.952,95%CI:0.919-0.987,P=0.008)、室壁瘤(OR=8.750,95%CI:1.861-41.134,P=0.006)、白细胞计数(OR=1.117,95%CI:1.001-1.246,P=0.049)、TSH 水平(OR=1.158,95%CI:1.046-1.282,P=0.005)、后扩(OR=0.223,95%CI:0.063-0.782,P=0.019)、IVUS/OCT(OR=4.772,95%CI:1.666-13.66,P=0.004)、术中出血量(OR=1.016,95%CI:1.004-1.028,P=0.009)、完全血运重建(OR=0.405,95%CI:0.169-0.971,P=0.043)、服用阿司匹林(OR= 0.101,95%CI:0.015-0.685,P=0.019);而再次血运重建的独立预测因素包括胸闷胸痛(OR=5.117,95%CI:1.206-21.723,P=0.027)、心功能等级(OR=1.622,95%CI:1.049-2.507,P=0.030)、心率(OR=0.959,95%CI:0.934-0.986,P=0.002)、脑卒中(OR=3.535,95%CI:1.153-10.834,P=0.027)、分叉病变(OR=3.047,95%CI:1.499-6.196,P=0.002)、完全血运重建(OR=0.329,95%CI:0.169-0.641,P=0.001)。结论:本研究证实了相关研究所得的冠脉小血管病变的特征,并且发现饮酒史为其发病的独立保护因素。高TSH水平是冠状动脉小血管病变患者PCI术后再狭窄的独立危险因素,而完全血运重建则是其独立保护因素。室壁瘤、高白细胞计数水平、高TSH水平、术中使用IVUS/OCT、较多的术中出血量是冠状动脉小血管病变患者MACE终点事件的独立危险因素,而较高的心率水平、后扩、完全血运重建、服用阿司匹林则是其独立保护因素。胸闷胸痛症状、心功能差、脑卒中病史、合并分叉病变是冠状动脉小血管病变患者再次血运重建的独立危险因素,而较高的心率水平、完全血运重建则是其独立保护因素。第二部分不同药物洗脱支架对冠状动脉小血管病变患者预后的影响——Meta分析目的与背景:对于冠状动脉小血管病变患者,目前治疗首选经皮冠脉介入(PCI)药物洗脱支架植入术(DES)。然而,优先选用何种DES,目前仍无定论。因此,我们设计了此Meta分析,旨在回顾既往相关研究,并将结果进行合并,比较莫司类药物洗脱支架(LES)与紫杉醇洗脱支架(PES)在冠状动脉小血管病变患者中的疗效。方法:本研究通过 PubMed、MEDLINE(Web of science)以及 Cochrane Central Register of Controlled Trials数据库对发表至2017年3月并且与本次研究主题相关的文献进行检索。对于不同事件的发生率通过计算相对危险度以及95%可信区间,进行数据的合并以及比较。本研究对结果的合并分析采用Mantel-Haenzel法,并使用固定效应模型。结果:8项研究共4738例患者纳入此研究。结果显示:相较于PES,植入LES能显著降低主要心血管不良事件(RR:0.64,95%CI:0.53-0.77;P0.00001;12=39%)、心肌梗死(RR:0.61,95%CI:0.45-0.82;P=0.001;I2=0%)、支架内血栓(RR:0.22,95%CI:0.13-0.37;P0.00001;I2=6%)以及靶病变血运重建(RR:0.56,95%CI:0.44-0.71;P0.00001;12=7%)的事件率。LES 未能较 PES 显著减少全因死亡(RR:0.98,95%CI:0.65-1.48;P=0.92;12=0%)、心因性死亡(RR:1.08,95%CI:0.62-1.88;P=0.80;I2=23%)以及靶血管血运重建(RR:0.80,95%CI:0.45-1.44;P=0.46;I2= 54%)的发生。结论:冠状动脉小血管病变行PCI支架植入术的患者,LES较PES有更好的长期疗效,显著减少不良心血管事件的发生,可能是该类患者的首选支架。
[Abstract]:Part 1 the characteristics, risk factors and prognosis of coronary arteria small vascular disease: the background and objective of the retrospective study of 986 cases: the incidence of coronary arteria small vascular disease is increasing year by year. It is suggested that patients with small vascular lesions often have many other diseases, and the disease is complicated, and the operation is more difficult and far more difficult. The prognosis is poor, but some studies have shown that the long-term prognosis is similar to that of non small vascular lesions. Most of the current studies are from the European and American population and lack of Chinese related studies. Therefore, we have designed this retrospective study to clarify the specific points, risk factors and prognostic analysis of coronary artery disease, which will help. Early identification of high-risk patients, assisting the formulation of related treatment schemes, strengthening postoperative follow-up management, and improving prognosis. Methods: all 986 patients who received coronary angiography and stent implantation at the Department of Cardiology, the First Affiliated Hospital of Zhejiang University Medical College in 2015, were divided into coronary arterioles according to whether the stent implantation was less than 2.5mm. Tube lesion group (308 cases) and non small vascular disease group (678 cases). Record patients' clinical baseline data, coronary angiography and operation, discharge and long-term follow-up. Multifactor Logistic regression analysis was used to screen small coronary artery lesions and independent risk factors for restenosis after PCI. Kaplan-Meier method was used to draw the cumulative MACE survival Line, and log-rank method was used to test the difference between the two groups of patients without MACE survival curve. Using the Cox regression model (risk proportion model), we explored the effect of different variables on MACE events and revascularization, and screened out the independent predictors of the terminal events. Results: OR= 1.022,95%CI:1.009-1.036, P=0.001, diabetes mellitus (OR=1.742,95%CI:1.). 278-2.373, P0.001), peripheral vascular disease (OR=2.484,95%CI:1.487-4.148, P0.001), high level low density lipoprotein (OR=1.245,95%CI:1.060-1.461, P=0.007), and high homocysteine levels (OR=1.017,95%CI:1.002-1.033, P0.001) are independent risk factors for coronary arteriopathy, and the history of alcohol consumption (OR=0.420,95%CI:0.299-0.588, P0.) 001) it was an independent factor. The proportion of the small coronary artery lesions involving the gyrations was higher than that of the non small vascular lesions (31.9%vs 17.3%, P0.001), and the multiple branch lesions (79.2%vs 49.4%, P0.001), bifurcation lesions (24.0%vs 12.4%, P0.001), chronic complete occlusion (29.5%vs 9.4%, P0.001), and diffuse lesions (55.2%vs35.) were more likely. 7%, P0.001), the proportion of pre operation (95.8%vs68.7%, P0.001) and postenlargement (94.2%vs89.4%, P=0.016) was significantly higher than that of non small vascular disease group, and the proportion of complete revascularization after operation was lower than that of non small vascular disease group (70.1%vs 85.1%, P0.001). Long term follow-up showed that the proportion of postoperative restenosis in patients with coronary arteria small vascular lesions (6.5%vs 3.2%, P=0.019) The incidence of adverse cardiovascular events (cardiac death (2.3%vs 0.4%, P=0.008), stroke (1.9%vs 0.3%, P=0.007), target vascular revascularization (5.8%vs 2.9%, P=0.029), target vascular revascularization (6.8%vs 3.4%, P=0.016), non target vascular revascularization (7.8%vs 4%, P=0.012)) were also significantly higher than non small vascular lesions. Patients. Complete revascularization (OR=0.351,95%CI:0.136-0.901, P=0.029) is an independent protective factor for restenosis after PCI, while higher TSH (OR=1.203,95%CI:1.059-1.366, P=0.004) is an independent risk factor.Cox regression analysis, and independent preconditioning of MACE endpoint in patients with coronary arteria small vascular lesions The factors included heart rate (OR=0.952,95%CI:0.919-0.987, P=0.008), ventricular aneurysm (OR=8.750,95%CI:1.861-41.134, P=0.006), white blood cell count (OR=1.117,95%CI:1.001-1.246, P=0.049), TSH level (OR=1.158,95%CI:1.046-1.282, P=0.005), posterior extension (OR=0.223,95%CI:0.063-0.782, P=0.019). OR=1.016,95%CI:1.004-1.028 (P=0.009), complete blood transport (OR=0.405,95%CI:0.169-0.971, P=0.043), taking aspirin (OR= 0.101,95%CI:0.015-0.685, P=0.019); and the independent predictors of re revascularization include chest pain (OR=5.117,95%CI:1.206-21.723, P=0.027), cardiac function grade (OR=1.622,95%CI:1.049-2.507, P). =0.030) heart rate (OR=0.959,95%CI:0.934-0.986, P=0.002), stroke (OR=3.535,95%CI:1.153-10.834, P=0.027), OR=3.047,95%CI:1.499-6.196 (P=0.002), complete blood transport (OR=0.329,95%CI:0.169-0.641, P=0.001). Conclusion: This study confirmed the characteristics of small coronary angiopathy, and found drinking alcohol. High TSH level is an independent risk factor for restenosis after PCI operation in patients with small coronary artery disease, and complete blood revascularization is an independent protective factor. Ventricular aneurysm, high white blood cell count, high TSH level, IVUS/OCT in operation, and large amount of intraoperative bleeding are small coronary artery disease. The independent risk factors of the patient's MACE endpoint, higher heart rate, posterior expansion, complete revascularization, and aspirin are independent protective factors. Chest distress, chest pain, poor heart function, stroke history, and bifurcated lesions are independent risk factors for revascularization in patients with small coronary artery disease, and higher heart rate. Rate level, complete blood transport reconstruction is an independent protective factor. Second the effect of different drug eluting stents on the prognosis of patients with coronary arteria microangiopathy - Meta analysis objective and background: for patients with coronary arteria microangiopathy, the first choice of percutaneous coronary intervention (PCI) drug eluting stent implantation (DES) is the first choice. The first choice of DES is still unsettled. Therefore, we designed this Meta analysis to review previous related studies and to combine the results to compare the efficacy of the drug eluting stents (LES) and paclitaxel eluting stents (PES) in patients with small coronary artery disease. Methods: This study was conducted through PubMed, MEDLINE (Web of Science). And the Cochrane Central Register of Controlled Trials database retrieves the literature published to March 2017 and is related to the subject of this study. The occurrence rate of different events is combined and compared by calculating the relative risk and 95% confidence interval. This study uses Mantel- for the combined analysis of the results. Haenzel method, and use the fixed effect model. Results: 4738 patients in 8 studies were included in this study. The results showed that compared with PES, the implantation of LES significantly decreased major cardiovascular adverse events (RR:0.64,95%CI:0.53-0.77; P0.00001; 12=39%), myocardial infarction (RR:0.61,95%CI: 0.45-0.82; P=0.001; I2=0%), and thrombus in stents (RR:0.22,95%CI:0.13-0.37; The event rate of P0.00001; I2=6%) and target lesion revascularization (RR:0.56,95%CI:0.44-0.71; P0.00001; 12=7%) was not significantly lower than PES in all causes of death (RR:0.98,95%CI:0.65-1.48; P=0.92; 12=0%), psychogenic death (RR:1.08,95%CI:0.62-1.88; P=0.80; P0.00001) and blood vessel revascularization (54%). Conclusion: PCI stent implantation in patients with small coronary artery lesions, LES has a better long-term effect than PES, significantly reducing the incidence of adverse cardiovascular events, and may be the preferred stent for this type of patients.
【学位授予单位】：浙江大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R543.3

【参考文献】