脉压在患者冠脉介入术后急性对比剂肾损伤及早期预后相关性的研究

发布时间：2018-01-30 17:44

  本文关键词： 急性对比剂肾损伤 急性冠脉综合征 脉压 冠状动脉介入治疗　出处：《山东大学》2017年硕士论文　论文类型：学位论文

【摘要】：1·背景和目的:随着冠状动脉粥样硬化性心脏病的诊断与治疗技术蓬勃发展,冠状动脉造影术(coronary angiography,CAG)及冠状动脉介入治疗术(percutaneous coronary intervention,PCI)不断普及,其并发症也越来越受到关注。对比剂导致的急性肾损伤(Contrast-induced acute kidney injury,CIAKI)作为冠脉介入治疗术后常见并发症之一,是临床医师近年来研究热点。CIAKI延长患者住院治疗时间,增加住院费用,同时增加患者短期及长期死亡率,成为医院获得性肾功能衰歇第三位原因。目前临床上常用血清肌酐值(serum creatinine,Scr)作为冠脉介入术前预测及术后确诊CIAKI常用指标,但Scr变化往往滞后于肾脏病理损伤并多种肾外因素影响(如营养状态、性别、年龄)。因此需要寻找更为可靠的临床早期预测肾功能变化的指标并进行有效干预,从而降低CIAKI发生率及病死率,减少心血管不良事件。脉压(pulse pressure,PP)为收缩压(systolic blood pressure,SBP)与舒张压(diastolic blood pressure,DBP)差值,是患者住院期间常规测量指标。最近大量临床研究表明,PP增高是心血管不良事件及死亡的独立预测因素。PP升高往往反映了大动脉管壁硬化,动脉脉搏波传播速度加快,对血管剪切力加大,引起动脉血管内膜损伤及功能紊乱。而且,PP影响肾小球小动脉压力,影响肾血管血压自主调节能力,从而影响早期肾功能改变。目的:本研究旨在明确急性冠脉综合征(Acute coronary syndrome,ACS)患者住院外周肱动脉PP是否成为冠脉介入术后CIAKI发生的预测因素;并探讨肱动脉PP与ACS患者冠脉介入术后短期心血管不良事件的相关性。2.研究方法:2.1研究对象本研究连续入选自2016年4月至2016年11月于山东大学齐鲁医院心内科、心内保健病房诊断为ACS并进行冠状动脉介入治疗术患者共427人。2.2资料收集详细采集并记录每位入选患者临床资料;冠脉介入术前24h连续规范测量3次外周肱动脉血压参数,记录SBP、DBP、PP及平均动脉压(mean blood pressure,MBP)平均值;由本院两名介入医师记录术中CAG结果、对比剂(contrast medium,CM)类型及用量、介入手术时间、支架置入过程及结果、靶血管部位及支数、支架置入个数;于介入治疗术后24h-48小时复查Scr。利用中国改良的肾脏病膳食试验MDRD公式计算冠脉术前、术后肾小球率过滤估计值(estimated glomerular filtration ratee,eGFR)。定义 CIAKI 为:术后 24-72h 血清 Scr 水平上升0.5mg/dl或上升了基础血清Scr水平的25%以上,将入选患者分为CIN组(29例)、非CIN组(398例),比较两组PP水平、临床资料。2.3术后随访按入选患者冠脉介入术前基线肱动脉PP水平将患者分为:高PP组(H-PP组,PP≥90mmHg),中 PP 组(M-PP 组,PP60-89mmHg),低 PP 组(L-PP 组,PP60mmHg)。所有患者于出院后1个月、3个月、6个月通过电话或门诊进行随访,随访内容为主要心脏不良事件(main adverse cardiovascular events,MACE),包括全因死亡、非预期的血运重建和非致命性心肌梗死、缺血性脑卒中、需血液透析的肾功能衰竭。2.4统计分析利用SPSS19.0软件比较CIN组与非CIN组一般临床特征及PP水平,通过二元多因素logistic回归分析评估相关危险因素对CIAKI的预测价值,并以受试者工作曲线(receiver operation characteristic,ROC)曲线来评价PP对CIAKI诊断的敏感性和特异性;比较不同PP组主要不良心血管事件发生率及影响因素,二元多因素logistic归因分析脉压与冠脉介入术后不良事件相关性。3.结果:3.1一般临床资料:共入选患者427例,其中男性302例(70.6%),女性125 例(29.4%)。均年龄(61.85±9.814)岁、平均体重指数 BMI(25.74±3.23)、平均血压 SBP/DBP(135.76±17.85)/(76.48±11.31)mmHg,平均 PP(59.28±15.73)mmHg;术前 Scr 值(73.9±18.21)umol/L,术后 Scr(74.75±20.46)umoI/L,术后 Scr 值升高(1.89±9.52umol/L,P0.01);术前 eGFR(96.41±21.56)ml/min/1.73m2,术后 eGFR(94.15±20.98)ml/min/1.73m2,术后 eGFR 下降(2.25±11.63ml/min/1.73m2,P0.01)。3.2 CIN组共29例,发病率为6.8%,其中女性12例(41.38%),男性17例(58.62%)。通过对CIN组、非CIN组差异进行比较,其中PP(CIN组70.48±18.45mmHg vs 非 CIN 组 58.46±15.23mmHg,P0.01)、SBP(144.17±20.17mmHg vs 135.15±17.54mmHg,P=0.008)、CM 使用量(183.97±76.28mlvs148.5±70.2ml,P=0.009)、血红蛋白 HBG(134.36±17.85g/L vs140.6±16.08g/L,P=0.049)、糖尿病病史(48.3%vs27.6%,P=0.018)、慢性肾脏病病史(10.3%vs1.5%,P=0.029)、住院服用 ACEI/ARB 药物(27.6%vs48.5%,P=0.029)有统计学差异。3.3二元多因素logistic回归分析:对PP、SBP、HBG、CM使用量、慢性肾脏病病史、糖尿病病史、ACEI/ARB服用史进行多因素logistic分析后,PP仍有统计学差异,OR 值为 1.05(95%CI,1.005-1.100;P = 0.03);CM 使用量 OR 值为 1.008(95%CI,1.002-1.013;P = 0.005)。3.4受试者工作曲线(ROC)分析:PP曲线下面积(AUC)为0.705(95%CI,0.597-0.813;P0.01),计算 PP 临界值(cut-off point)63.5mmHg,敏感度75.9%,特异度 70.9%。3.5随访结果:所有患者均于出院后第1月、3月、6月、9月完成随访,随访过程10名患者失访,随访率为97.66%,其中共发生MACE事件共60例(14.1%),其中全因死亡2例(0.5%),脑卒中16例(3.7%),非致命性心肌梗死40例(9.4%),其中非预期靶血管重建4例(0.9%)。H-PP组、M-PP组MACE事件(P0.01)、全因死亡率(P=0.011)、非致命性心肌梗死(P=0.038)发生率均显著高于L-PP组。脑卒中、终末期肾衰竭无明显统计学差异。对年龄、性别、SBP、DBP、冠脉介入术前后Scr、血甘油三脂、血红蛋白量、高血压病史、糖尿病病史、陈旧性心肌梗死病史、二氢吡啶类CCB药物进行回归分析后,高PP组Mace事件发生率依然明显高于低 PP 组,OR 值为 4.42(95%CI,1.575-12.412;P0.01)。4.结论:ACS患者行冠状动脉介入治疗术,术前肱动脉PP升高是发生CIAKI及介入术后短期发生MACE事件的独立预测因素。未来需要进一步研究降低基础PP的药物是否能预防PCI术后CIAKI发生及短期MACE事件发生率。
[Abstract]:1 background and objective: with the rapid development of coronary atherosclerotic heart disease diagnosis and treatment technology, coronary artery angiography (coronary angiography CAG) and percutaneous coronary intervention (percutaneous coronary, intervention, PCI) the growing popularity of its complications is also more and more attention. The acute renal injury caused by contrast agent (Contrast-induced acute kidney injury, CIAKI) as one of the common complications of coronary artery interventional therapy after surgery, doctors research in recent years.CIAKI treatment prolonged hospitalization, increased hospitalization costs, while increasing in patients with short-term and long-term mortality, a hospital acquired renal failure third reasons. At present the common clinical value of serum creatinine (serum creatinine. Scr) as coronary intervention preoperative and postoperative diagnosis of CIAKI prediction indexes, but Scr changes often lag behind the Kidney Pathological Damage Effect of various external factors (such as kidney and nutritional status, gender, age). So we need to find a more reliable prediction of renal function changes in early clinical indicators and effective intervention, so as to reduce the incidence of CIAKI and mortality, reduce cardiovascular adverse events. Pulse pressure (pulse pressure, PP blood (systolic) for systolic blood pressure pressure SBP, diastolic blood pressure (diastolic) and blood pressure, DBP) the difference was hospitalized patients during conventional measures. Recently many clinical studies showed that PP increased the adverse cardiovascular events and mortality were independent predictors of elevated.PP often reflect large arterial wall hardening, pulse wave propagation speed on vascular shear stress increase, cause arterial intimal injury and dysfunction. Moreover, PP influence glomerular arteriolae pressure, renal blood pressure self regulating ability, thus affecting the changes in renal function. Objective: the purpose of this research It aims to clear the acute coronary syndrome (Acute coronary, syndrome, ACS) peripheral brachial artery PP is a predictor of the occurrence of CIAKI after percutaneous coronary intervention in patients; and to investigate the correlation between.2. and PP of the brachial artery in patients with ACS after percutaneous coronary intervention of short-term cardiovascular events research method: 2.1 subjects in this study are continuous from from April 2016 to November 2016 in the Department of Cardiology of Qilu Hospital of Shandong University, heart care ward diagnosed ACS and coronary artery.2.2 with a total of 427 people to collect data to collect and record each patients clinical data of interventional treatment in patients with coronary intervention; preoperative 24h continuous specification 3 measurement of peripheral brachial artery blood pressure parameters, DBP, PP and SBP records. Mean arterial pressure (mean, blood pressure, MBP) average; by the two interventional physicians record CAG results, the contrast agent (contrast medium, CM) type and dosage, intervention The operation time, in the process and results of stent, target vessel location and number, the number of stent; interventional therapy in 24h-48 hours after review by Scr. MDRD formula Chinese test of diet in renal disease improved calculation of coronary artery before operation, postoperative estimated glomerular filtration rate (estimated, glomerular filtration ratee, eGFR). CIAKI was defined as: postoperative serum Scr level of 24-72h 0.5mg/dl increased or increased serum level of Scr of more than 25%, the patients were divided into group CIN (29 cases) and non CIN group (398 cases), the level of PP between the two groups, the clinical data of postoperative.2.3 were selected according to coronary intervention in patients with baseline brachial artery PP level patients were divided into high PP group (group H-PP, PP = 90mmHg), PP group (group M-PP, PP60-89mmHg), low PP group (group L-PP, PP60mmHg). All patients were discharged after 1 months, 3 months, 6 months were followed up by telephone or outpatient follow-up content The main adverse cardiac events (main adverse cardiovascular events, MACE), all-cause death, unplanned revascularization and non fatal myocardial infarction, ischemic stroke,.2.4 renal failure statistics for hemodialysis were analyzed by SPSS19.0 software between CIN group and non CIN group clinical characteristics and PP level by logistic two multivariate regression analysis to assess the value of risk factors related to the prediction of CIAKI, and the receiver operating curve (receiver operation, characteristic, ROC) curves to assess the sensitivity of PP for the diagnosis of CIAKI and specificity; incidence and influencing factors of different PP group of major adverse cardiovascular events, two yuan logistic multivariate attribution analysis pulse pressure and coronary intervention after adverse events between.3. results: 3.1 clinical data: a total of 427 patients, including 302 cases of male (70.6%), 125 cases were female (29.4% years). 榫，

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