缺血性卒中患者低高密度脂蛋白胆固醇血症的相关危险因素分析

发布时间：2018-05-30 18:19

本文选题：缺血性卒中高 + 密度脂蛋白胆固醇　；参考：《河北医科大学》2015年硕士论文

【摘要】：目的:生理状态下的高密度脂蛋白胆固醇(high density lipoprotein cholesterol,HDL-C)在体内发挥逆向转运胆固醇、抗炎及抗氧化作用;而在炎症和代谢异常等病理状态下,HDL-C经过氧化、糖基化或酪氨酰化等修饰作用,使HDL-C的结构、组成成分发生改变,并诱发低HDL-C血症产生。从而表现出促炎、促氧化等特性,成为动脉粥样硬化(Atherosclerosis,AS)发生、发展的危险因素。故低HDL-C血症作为国人脂代谢异常的最常见形式,应为缺血性卒中的危险因素,与卒中的发生、复发以及卒中急性期病情严重程度的密切相关。由此,关注低HDL-C血症,探讨低HDL-C血症的危险因素至关重要。基于此,本研究以缺血性卒中患者为研究对象,分析缺血性卒中患者低HDL-C血症的患病率,探讨缺血性卒中患者低HDL-C血症的相关危险因素。方法:1研究对象:以2006年12月至2012年12月入住河北医科大学附属第三医院神经内科,依据改良版TOAST卒中病因分型的诊断标准,将明确诊断为大动脉粥样硬化(large artery atherosclerosis,LAA)及小血管病变(Small artery disease,SAD)的患者作为研究对象,且所有入组患者均具有标准的人口构成情况及血管病危险因素登记。并排除心源性栓塞、其他原因及未明原因的缺血性卒中患者;患有严重肝、肾功能受损及临床资料不全者。2低高密度脂蛋白胆固醇血症的诊断标准:依据美国ATPIII标准,低HDL-C血症定义为:HDL-C≤1.03mmol/L;孤立低HDL-C血症:定义为HDL-C≤1.03mmol/L,且甘油三酯(triglycerides,TG)1.7mmol/L+低密度脂蛋白胆固醇(low-densitylipoprotein cholesterol,LDL-C)2.59mmol/L。其他各成分脂代谢紊乱定义为:总胆固醇(tatal cholesterol,TC≥5.18mmol/L和(或)TG≥1.7mmol/L和(或)LDL-C≥2.59mmol/L。3统计学方法:采用SPSS13.0软件进行统计学分析。以低HDL-C血症组患者作为因变量,各血管病危险因素如高血压、糖尿病、吸烟、饮酒等因素作为自变量,依次应用单因素及多因素Logistic回归分析,评估低HDL-C血症与各血管病危险因素的相关性。P0.05判定为差异有统计学意义。结果:1满足入选标准的缺血性卒中患者1358例,男性897例,女性461例,诊断为LAA患者795例,SAD患者562例。所有入组患者低HDL-C血症的患病率为64.2%,其中男性60.8%,女性39.2%,差别有显著性意义(χ2=29.074,P0.01);LAA组患者低HDL-C血症的患病率为61.0%,明显高于SAD组患者(39.0%),差异具有统计学意义(χ2=5.674,P0.01)。本研究入组患者中仅有HDL-C水平降低,而低密度脂蛋白和甘油三酯水平均正常的孤立低HDL-C血症的患病率为31.8%,成为亚洲人群常见的脂质表型。本研究说明缺血性卒中患者低HDL-C血症的发生率较高,尤其更常见于男性及LAA患者。2缺血性卒中患者发生低HDL-C血症的危险因素以低HDL-C血症为因变量,各血管病危险因素为自变量,经递次单因素、多因素logistic回归分析显示:增加低HDL-C血症发病风险的独立危险因素依次为:男性、高TG血症、糖尿病和他汀使用史(OR值分别为3.318、2.529、1.652、1.457;P值均0.05)。而年龄(P=1.131)、吸烟(P=0.471)、饮酒(P=0.101)、高血压(P=0.657)、卒中史(P=0.552)、冠心病史(P=0.937)、高LDL-C(P=0.075)与低HDL-C血症发生无显著相关性。TC与HDL-C水平呈正相关(OR=0.400,95%CI0.301-0.530,P=0.000)。高TC血症的存在往往伴有高HDL-C,说明两者之间存在互为转换的关系。对不同性别缺血性卒中患者低HDL-C血症的危险因素进行分析,结果显示:男性缺血性卒中患者组低HDL-C血症的独立危险因素依次是高TG、他汀类药物、糖尿病、吸烟、饮酒(OR值分别为2.384、1.715、1.535、1.475、1.455;P值均0.05);而女性组低HDL-C血症的独立危险因素仅有高TG和糖尿病(OR值分别为2.780、1.910;P值均0.05)。说明女性性别是低HDL-C的保护性因素,可能与雌激素具有增加成熟HDL2的含量的作用有关。而吸烟、饮酒史为男性缺血性卒中患者低HDL-C血症的独立危险因素,说明吸烟、饮酒等不良生活习惯可以诱发低HDL-C血症的产生,从而诱发动脉粥样硬化以及卒中的发生。对不同卒中亚型的缺血性卒中患者低HDL-C血症的危险因素进行分析发现:男性、高TG及糖尿病同样为不同亚型缺血性卒中患者低HDL-C血症的独立危险因素;而他汀使用史仅与SAD患者的低HDL-C血症密切相关(OR值=2.0202,P=0.002)。说明高TG血症同样为亚洲人群常见的脂代谢异常类型,而高TG血症可通过多种机制导致HDL-C水平减低:高TG血症可使卵磷脂胆固醇酰基转移酶(LCAT)、脂蛋白酯酶(LPL)活性减弱,从而使HDL-C成熟代谢受阻;而且高TG血症患者的胆固醇酯转移蛋白(CETP)活性增强,使HDL-C所运输的胆固醇脱失,导致HDL-C重构,血中HDL-C含量降低。而糖尿病作为低HDL-C血症的独立危险因素,不仅与高血糖情况下,HDL-C中的蛋白质发生直接糖基化修饰,使HDL-C水平降低有关,而且糖尿病时,胰岛素抵抗、糖利用障碍,一方面可促进脂肪分解和炎性反应使HDL-C水平的降低;另一方面通过促进TG分泌增加而发生高TG血症,进一步加剧HDL-C水平的降低。故临床上需积极控制患者血管病危险因素,尤其对于糖尿病合并高TG血症者更需早期干预。因本研究作为回顾性研究,所入选患者服用他汀药物的种类和期限各不相同,且不同他汀类药物作用不尽相同,故不能肯定他汀类药物应用史为低HDL-C血症的危险因素。3对孤立低HDL-C血症进行相关危险因素分析显示:男性、糖尿病及他汀使用史是孤立的低HDL-C血症发病风险的独立危险因素(OR值分别为2.557、1.754、2.152;P值分别为0.000、0.017、0.002)。说明孤立低HDL-C血症的危险因素、临床意义均等同于低HDL-C血症,其作为缺血性卒中的危险因素应予以重视。结论:本研究入组的缺血性卒中患者低HDL-C血症的患病率高达64.2%,尤其多见于LAA患者;男性、高甘油三酯血症及糖尿病为缺血性卒中患者低HDL-C血症的危险因素;而吸烟、饮酒史为男性缺血性卒中患者低HDL-C血症的独立危险因素。
[Abstract]:Objective: high density lipoprotein cholesterol (HDL-C) plays the role of reverse transport of cholesterol, anti-inflammatory and antioxidation in the body. In the pathological state of inflammation and metabolism, HDL-C has been modified by oxidation, glycosylation or tyemonylation to make the structure and composition of HDL-C occur. Change, and induce the production of hypoxemia, which shows the characteristics of proinflammatory and oxidation, which is the risk factor for the occurrence and development of atherosclerosis (Atherosclerosis, AS). Therefore, low HDL-C is the most common form of abnormal lipid metabolism in the country, which should be the risk factor of ischemic stroke, the occurrence of stroke, the recurrence, and the acute stage of stroke. It is closely related to the severity of the disease. Therefore, it is very important to pay attention to the hypotoxemia of HDL-C and to explore the risk factors of low HDL-C. Based on this, the incidence of hypoemia in ischemic stroke patients and the related risk factors of low HDL-C in ischemic stroke patients are analyzed in this study. Methods: 1 Research on the risk factors of hypoemia in ischemic stroke patients. Subjects: in the neurology department of the Third Affiliated Hospital of Hebei Medical University from December 2006 to December 2012, according to the diagnostic criteria of the modified TOAST apoplexy, the patients were diagnosed as large artery atherosclerosis (LAA) and small vascular disease (Small artery disease, SAD). All patients with a standard population composition and risk factors for vascular disease were registered. Cardiac embolism, other causes, and unexplained ischemic stroke patients; the diagnostic criteria for.2 low density lipoprotein cholesterol in patients with severe liver, renal impairment and clinical data were low, according to the American ATPIII standard. HDL-C is defined as HDL-C < 1.03mmol/L; isolated low HDL-C: HDL-C < 1.03mmol/L, and triglyceride (triglycerides, TG) 1.7mmol/L+ low density lipoprotein cholesterol (Low-densitylipoprotein cholesterol, LDL-C) is defined as total cholesterol. Statistical analysis of (or) TG > 1.7mmol/L and / or LDL-C > 2.59mmol/L.3: using SPSS13.0 software for statistical analysis. The risk factors of vascular disease, such as hypertension, diabetes, smoking, drinking and other factors as independent variables, were used as the dependent variable in the low HDL-C group, and the single factor and multiple factor Logistic regression analysis were used in order to evaluate the low H. The correlation between DL-C and the risk factors of vascular disease was statistically significant. Results: 1 the 1358 cases of ischemic stroke, 897 cases of male, 461 women, 795 cases of LAA and 562 cases of SAD were found to meet the criteria of admission. The prevalence rate of low HDL-C in all the patients was 64.2%, including 60.8% of men and 39.2% in women. The difference was significant (x 2=29.074, P0.01); the prevalence rate of hypoxemia in group LAA was 61%, significantly higher than that in group SAD (39%), and the difference was statistically significant (x 2=5.674, P0.01). In this study group, only HDL-C level decreased, and low density lipoprotein and triglyceride levels were all normal isolated and low HDL-C. The rate of 31.8% is a common lipid phenotype in Asian people. This study shows that the incidence of hypoxemia in patients with ischemic stroke is higher, especially in men and LAA patients with.2 ischemic stroke. The risk factors of hypoemia in.2 ischemic stroke are low HDL-C as the dependent variable, the risk factors of each vascular disease are independent variables, and the single cause of the recurrence of blood vessel disease is a single cause. Multivariate logistic regression analysis showed that the independent risk factors for increasing the risk of hypotheemia were: men, high TG, diabetes and statin use (OR values were 3.318,2.529,1.652,1.457, P, respectively 0.05). Age (P=1.131), smoking (P= 0.471), alcohol (P=0.101), hypertension (P=0.657), stroke history (P=0.552), coronary heart disease, coronary heart disease There was no significant correlation between high LDL-C (P=0.075) and hypoxemia,.TC was positively correlated with HDL-C levels (OR=0.400,95%CI0.301-0.530, P=0.000). The presence of high TC was often accompanied by high HDL-C, indicating the existence of mutual conversion between them. The risk factors for low HDL-C hyperemia in patients with different ischemic stroke were divided. The results showed that the independent risk factors of hypoxemia in male patients with ischemic stroke were high TG, statins, diabetes, smoking, drinking (OR value was 2.384,1.715,1.535,1.475,1.455, P value, respectively 0.05), while the independent risk factors of low HDL-C in female group were only high TG and diabetes (OR value was 2.780,1.910; P value was 0). .05). It shows that female sex is a protective factor of low HDL-C and may be associated with the role of estrogen in increasing the content of mature HDL2. Smoking and drinking history are independent risk factors for low HDL-C in male patients with ischemic stroke, indicating that smoking, drinking and other unhealthy habits can induce the production of low HDL-C, thus inducing the arteries. The risk factors of hypoxemia in patients with different stroke ischemic stroke were analyzed. The risk factors of hypoxemia in patients with different stroke ischemic stroke were analyzed. High TG and diabetes were also independent risk factors of low HDL-C in patients with different subtype ischemic stroke; the history of statin use was closely related to low HDL-C in SAD patients (OR value =2). .0202, P=0.002). It shows that hyperTG is also a common type of lipid metabolism in Asian people, while high TG can reduce HDL-C levels through a variety of mechanisms: hyperTG can weaken the activity of lecithin cholesterol acyl transferase (LCAT) and lipoprotein esterase (LPL), thus causing HDL-C metabolism to be blocked; and the cholera of patients with high TG emia The activity of alcohol ester transfer protein (CETP) is enhanced, which causes the loss of cholesterol transported by HDL-C, causing HDL-C remodeling and decreasing the content of HDL-C in blood. As an independent risk factor for low HDL-C, diabetes is not only direct glycosylation of protein in HDL-C with hyperglycemia, but also the decrease of HDL-C level, and diabetes, islets of pancreas. Factor resistance and impaired glucose utilization, on the one hand, can promote the decrease of HDL-C level in adipose and inflammatory reactions; on the other hand, it is necessary to actively control the risk factors of the patient's vascular disease by promoting the increase of TG secretion by promoting the increase of TG secretion, especially in the early stage of diabetes combined with high TG. Intervention. As a retrospective study, the types and duration of statins used in the selected patients were different, and different statins were different. Therefore, the risk factors of low HDL-C in the history of statins application were not sure, and the risk factors for.3 in isolated and low HDL-C were analyzed: male, diabetes mellitus History of the use of statins is an independent risk factor for isolated low HDL-C disease risk (OR value 2.557,1.754,2.152 respectively; P value is 0.000,0.017,0.002 respectively). It shows that the risk factors of isolated hypoxemia are equivalent to low HDL-C, which should be considered as a risk factor for ischemic stroke. The prevalence of hypoxemia in ischemic stroke patients was up to 64.2%, especially in LAA patients; males, hypertriglyceridemia and diabetes were risk factors for hypoxemia in ischemic stroke patients, and smoking and drinking history were independent risk factors for low HDL-C in male ischemic stroke patients.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R743.3

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