川崎病合并冠脉瘤抗凝治疗的临床研究

发布时间：2018-06-06 14:28

  本文选题：川崎病 + 冠状动脉瘤　； 参考：《重庆医科大学》2017年硕士论文

【摘要】：目的:对川崎病合并巨大冠脉瘤华法林抗凝治疗的临床研究及冠脉瘤的远期转归的探讨。方法:本文收集2014年1月-2016年12月,在重庆医科大学附属儿童医院通过超声心动图诊断KD合并冠脉瘤的儿童,进行回顾性研究。最终符合纳入49例。分为小型冠脉瘤组、中型冠脉瘤组及巨大冠脉瘤组3组。巨大冠脉瘤组患儿给予华法林+阿司匹林的治疗,同时给予其他抗血小板药物。华法林组随访并维持国际标准化比值(INR)1.5-2.5之间。3组患儿均于出院后2周、1月、3月、6月及1年随访心脏彩超、心电图,观察冠脉瘤、血栓转归及心血管事件发生情况。结果:1.49例冠脉瘤,冠脉瘤最常累及左侧冠脉主干(LM)38支(77.6%)、右侧冠脉(RCA)36支(73.5%)、左侧冠脉前降支(LAD)32支(65.3%),其次LCX累及13支(26.5%)。2.小型冠脉瘤组冠脉瘤完全回缩(100%),中型冠脉瘤组冠脉瘤回缩率88.9%。巨大冠脉瘤组在给予华法林+阿司匹林抗凝治疗,发生回缩占40%,4例巨大冠脉瘤无变化;2例出现冠脉瘤增大,而其中1例有冠脉狭窄。小中冠脉瘤较巨大冠脉瘤更易回缩。巨大冠脉瘤组未出现心血管事件。3.小型冠脉瘤血栓形成有3例(14.3%)。中型冠脉瘤组9例冠脉内血栓形成(50%),而巨大冠脉瘤组10例(100%)患儿均有血栓形成,小型冠脉瘤、中型冠脉瘤与巨大冠脉瘤比较P0.05,在血栓形成方面差异有统计学意义,提示冠脉瘤内径越大更易形成血栓形成。血栓形成好发于左冠脉,更易出现在左前降支。3组总31支冠状动脉形成血栓,在冠脉内径4mm和4≤r5时各有3例形成血栓,冠脉直径≥5mm有25例形成血栓,提示冠脉瘤直径≥5mm可能是血栓形成的危险因素。4.中小冠脉瘤组总计11例(100%)血栓均消失。巨大冠脉瘤组10例(100%)血栓形成,4例(40%)血栓减小,5例(50%)血栓消失,1例(10%)出现血栓增大。随访期间6例患儿出现新增血栓。从两组血栓转归比较,同样给予抗凝治疗,巨大冠脉瘤血栓难消失。5.巨大冠脉瘤组中使用华法林抗凝期间有4例发生了少量鼻出血、磕碰后瘀斑,1例患儿外伤后严重出血。结论:1.巨大冠脉瘤预后差,可发生冠脉瘤进一步扩大、血栓形成、冠脉狭窄及心功能降低。2.冠状动脉瘤内径越大出现血栓的风险越高,冠脉瘤内径≥5mm可能是形成血栓的高危因素。3.对于巨大冠脉瘤应用华法林抗凝,在预防心血管事件的预后尚未得出结论,但华法林增加出血风险,需谨慎使用,应长期随访华法林不良反应及心脏彩超。
[Abstract]:Objective: to investigate the long-term outcome of warfarin anticoagulant therapy for Kawasaki disease complicated with giant coronary aneurysm. Methods: from January 2014 to December 2016, children with KD complicated with coronary artery aneurysm were diagnosed by echocardiography in affiliated Children's Hospital of Chongqing Medical University. Finally, 49 cases were included. The patients were divided into three groups: small coronary aneurysm group, medium coronary aneurysm group and giant coronary aneurysm group. Children with giant coronary aneurysms were treated with warfarin aspirin and other anti-platelet drugs. The patients in warfarin group were followed up and maintained the ratio of INRN 1.5-2.5. 3 children were followed up at 2 weeks, 1 month, 3 months, 6 months and 1 year after discharge to observe the coronary aneurysm, thrombus prognosis and cardiovascular events during the follow-up period of two weeks, one month, three months, six months and one year after discharge. Results in 1.49 cases of coronary aneurysms, 38 branches of left main coronary artery were involved most frequently, 36 branches of RCA of right coronary artery were involved and 73.5%, 32 branches of left anterior descending coronary artery were involved with 65.3 branches, and 13 branches of LCX were involved with 26. 5% of left coronary artery, 26. 5% of left anterior descending coronary artery, 26. 5% of left coronary artery and 26. 5% of left coronary artery. The total retraction of coronary aneurysm was 100% in small coronary aneurysm group, and 88. 9% in medium coronary aneurysm group. In the large coronary artery aneurysm group, 40% of the patients received warfarin aspirin anticoagulant therapy, 4 cases of giant aneurysm showed no change, 2 cases showed enlargement of coronary artery, and 1 case had coronary stenosis. Small, medium and small coronary aneurysms are more likely to shrink back than large ones. There was no cardiovascular event in giant coronary aneurysm group. Thrombosis of small coronary aneurysm occurred in 3 cases. 9 cases of moderate coronary artery aneurysm group and 10 cases of giant coronary artery aneurysm group had thrombus formation, small coronary aneurysm, medium coronary aneurysm and giant coronary artery aneurysm (P0.05), there was significant difference in thrombogenesis between 9 cases of moderate coronary aneurysm group and 10 cases of giant coronary artery aneurysm group (P 0.05). It is suggested that the larger the diameter of coronary artery aneurysm, the easier it is to form thrombosis. Thrombosis occurred in the left coronary artery, and was more likely to occur in the left anterior descending coronary artery group than in the left anterior descending coronary artery group. There were 3 cases of thrombosis at 4mm and 4 鈮，

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