低高密度脂蛋白胆固醇血症与症状性颅内外动脉粥样硬化的相关性研究

发布时间：2018-07-01 11:42

本文选题：缺血性卒中 + 颅内动脉粥样硬化　；参考：《河北医科大学》2014年硕士论文

【摘要】：目的：缺血性卒中已经成为世界范围内疾病致死和致残的最主要原因之一，而大动脉粥样硬化型卒中（large artery atherosclerosis，LAA）是引起缺血性卒中重要的病因类型。大量研究已经证实，欧美白种人以颅外动脉粥样硬化（Extracranial atherosclerosis，ECAS）最常见，而亚洲人、非洲裔美国人以及西班牙白人颅内动脉粥样硬化（intracranialatherosclerosis，ICAS）的发病率更高。导致不同种族动脉粥样硬化（atherosclerosis，AS）好发部位差异的因素很多，除了种族、基因易感性、生活环境等差异外，不同人种之间AS危险因素的患病率差异，也可能影响了颅内外不同部位AS的发生。近来的研究发现，日韩等亚洲人群由于生活习惯的西化，其ECAS的患病率呈逐年升高趋势，这可能是由于生活方式的改变，导致日韩等亚洲国家高脂血症、肥胖等患病率逐年升高导致的。既往的多数研究显示，高血压、糖尿病、代谢综合征对ICAS的贡献比更高，而脂代谢异常对ECAS的贡献比更高。低高密度脂蛋白胆固醇（high-density lipoprotein cholesterol，HDL-C）血症是华人脂代谢异常最主要的存在形式，华人低HDL-C血症的患病率显著高于美国和澳大利亚、新西兰等亚太国家。低HDL-C血症是否是LAA的独立危险因素，华人低HDL-C血症的高患病率是否是其症状性ICAS高发的危险因素之一，低HDL-C血症对症状性颅内、外AS的贡献比是否存在差异仍未得到证实。基于此，本研究探讨低高密度脂蛋白胆固醇血症与LAA的相关性，并进一步探讨低HDL-C血症对症状性ICAS和ECAS的贡献比是否存在差异。方法： 1研究对象依据经典TOAST病因分型，入选2006年12月至2012年12月入住河北医科大学第三医院的明确诊断为LAA和SVD的缺血性卒中患者1358例作为研究对象。排除标准：a、心源性卒中、其他原因和未明原因的卒中；b、排除临床资料不全者。 2动脉粥样硬化性狭窄的评价方法所有入选患者通过TCD、颈动脉彩超和（或）MRA明确颅内外AS的诊断,以动脉管腔狭窄≥50%者作为动脉粥样硬化性狭窄的诊断标准。TCD、颈动脉彩超、MRA诊断动脉狭窄标准参见相关文献。颅内动脉包括：双侧颈内动脉虹吸段、大脑中动脉、大脑前动脉和大脑后动脉、椎动脉颅内段及基底动脉；颅外动脉包括：颈总动脉、颈内动脉颅外段、无名动脉、锁骨下动脉、椎动脉颅外段。 3动脉粥样硬化危险因素的评价方法 ①高血压：收缩压≥140mmHg和（或）舒张压≥90mmHg和（或）因高血压病应用降压药物者；②糖尿病：空腹血糖≥7.0mmol/L和（或）餐后血糖≥11.1mmol/L和（或）因糖尿病应用降糖药物；③吸烟：正在吸烟或戒烟未超过5年者定义为吸烟；从未吸烟或者戒烟超过5年者为不吸烟者；④既往心血管病史：心绞痛或者心肌梗塞病史;房颤或者瓣膜病史。依据美国ATP III标准，低HDL-C定义为:HDL-C≤1.03mmol/L；其他各成分脂代谢异常定义为：总胆固醇（tatal cholesterol，TC≥5.18mmol/L或（和）低密度脂蛋白胆固醇（LDL-C）≥2.59mmol/L或（和）甘油三酯（TG）≥1.7mmol/L或（和）既往因高脂血症应用降脂药物者。 4统计学方法以SPSS16.0软件包进行统计分析。所有动脉危险因素均采用计数资料，率的比较应用χ2检验。logistic回归分析LAA、症状性ICAS和ECAS的危险因素，比较低HDL-C血症对症状性ICAS和ECAS的贡献比。显著性差异水准为0.05。结果：满足入组标准的缺血性卒中患者1358例，其中，LAA患者795例，SVD患者563例。LAA患者组低HDL-C的发病率为57.2%，SVD患者组低HDL-C发病率为48.3%，差别具有统计学意义（X=10.54，P=0.001）。以LAA作为因变量，序贯行单因素及多因素logistic回归分析，在调整了糖尿病、高LDL-C血症、低HDL-C血症及他汀类药物应用史后，低HDL-C血症为罹患LAA的独立危险因素（OR=1.526，95%CI1.220-1.909，P0.001）。以症状性ICAS、ECAS以及合并颅内外动脉粥样硬化组患者作为因变量，行多元多因素Logistic回归分析，在调整年龄、冠心病、糖尿病、高TC血症、高LDL-C血症、低HDL-C血症、他汀应用史后，低HDL-C血症是症状性ICAS、ECAS的独立危险因素（OR=1.475，95%CI1.159-1.878，P=0.002；OR=2.716，95%CI1.543-4.779，P=0.001）。进一步以症状性ICAS组患者为因变量，以症状性ECAS组患者为对照组行多因素Logistic回归分析，结果显示：低HDL-C血症对症状性ICAS贡献比小于症状性ECAS（OR=0.462，95%CI0.263-0.810，，P=0.007）。结论：低HDL-C血症是LAA的独立危险因素。同时，低HDL-C血症也是症状性ICAS和ECAS的独立危险因素，低HDL-C血症对症状性ECAS的贡献比更高。
[Abstract]:Objective: ischemic stroke has become one of the most important causes of death and disability in the world, and large artery atherosclerosis (LAA) is an important cause of ischemic stroke. A large number of studies have proved that in European and American white people, the Extracranial atherosc (Extracranial atherosc) Lerosis, ECAS) are the most common, and the incidence of intracranialatherosclerosis (ICAS) is higher in Asians, African Americans, and white Spanish.
There are many factors that lead to the difference in the location of atherosclerosis (AS). In addition to race, genetic susceptibility, and living environment, the difference in the prevalence of AS risk factors between different races may also affect the occurrence of AS in different parts of the cranium. Recent studies have found that the Asian population such as Japan and South Korea are born because of their birth. The prevalence of ECAS is increasing year by year, which may be due to changes in lifestyle, leading to higher prevalence of hyperlipidemia and obesity in Asian countries such as Japan and South Korea. Most previous studies have shown that hypertension, diabetes, metabolic syndrome have a higher contribution to ICAS than ECAS. Low high density lipoprotein cholesterol (high-density lipoprotein cholesterol, HDL-C) is the most important form of lipid metabolism in Chinese, and the prevalence of low HDL-C in Chinese is significantly higher than that in the United States and Australia, and in New Zealand and other Asia Pacific countries. Low HDL-C is an independent risk factor for LAA, and the low HDL-C in Chinese is low HDL-C. The high prevalence of hyperemia is one of the risk factors for the high incidence of symptomatic ICAS, and the difference in the contribution ratio of hypoemia to symptomatic intracranial and external AS remains unknown.
Based on this, this study examines the correlation between low HDL and LAA, and further explores whether the contribution of hypoxemia to symptomatic ICAS and ECAS is different.
Method:
1 research objects
According to the classic TOAST etiological classification, 1358 cases of ischemic stroke, which were diagnosed as LAA and SVD in third hospitals of Hebei Medical University from December 2006 to December 2012, were selected as the subjects.
Exclusion criteria: A, cardiogenic stroke, other causes and unknown causes of stroke; B, excluding patients with incomplete clinical data.
2 evaluation method of atherosclerotic stenosis
All selected patients were diagnosed by TCD, carotid color Doppler ultrasound and (or) MRA in the diagnosis of intracranial and extracranial AS. The diagnostic criteria for atherosclerotic stenosis by arterial lumen stenosis more than 50% were used as diagnostic criteria for atherosclerotic stenosis, carotid color Doppler ultrasound, and MRA for the diagnosis of arterial stenosis.
The intracranial arteries include the siphon segment of the bilateral internal carotid artery, the middle cerebral artery, the anterior cerebral artery and the posterior cerebral artery, the intracranial segment of the vertebral artery and the basilar artery, and the extracranial arteries including the common carotid artery, the extracranial segment of the internal carotid artery, the innominate artery, subclavian artery, and the extracranial segment of the vertebral artery.
3 evaluation method of risk factors of atherosclerosis
Hypertension: systolic blood pressure more than 140mmHg and (or) diastolic pressure more than 90mmHg and / or the use of antihypertensive drugs for hypertension; diabetes: diabetes: fasting blood glucose above 7.0mmol/L and (or) postprandial blood glucose more than 11.1mmol/L and / or (or) diabetes using hypoglycemic drugs; (3) smoking: Smokers who are smoking or giving up smoking for less than 5 years are defined as smoking; never smoked. Or smokers who smoked for more than 5 years were nonsmokers.
According to American ATP III standard, low HDL-C is defined as: HDL-C less than 1.03mmol/L; other components of lipid metabolism are defined as total cholesterol (tatal cholesterol, TC more or less 5.18mmol/L or (and and) low density lipoprotein cholesterol (LDL-C) > 2.59mmol/L or (and) triglycerides (TG) more or less than or (and) the use of lipid lowering drugs for hyperlipidemia.
4 statistical method
Statistical analysis was carried out with the SPSS16.0 software package. All the arterial risk factors were counted, and the rate was compared with the x 2 test of.Logistic regression analysis of LAA, the risk factors of symptomatic ICAS and ECAS, and the comparison of the contribution of low HDL-C to symptomatic ICAS and ECAS. The significant difference in water was 0.05.
Results: 1358 cases of ischemic stroke patients were satisfied with the standard of entry, of which 795 were LAA patients and 57.2% in.LAA patients with SVD. The incidence of low HDL-C in SVD patients was 48.3%. The difference was statistically significant (X=10.54, P=0.001). LAA was used as a dependent variable, sequential single factor and multiple factor Logistic regression analysis were used. After adjusting the history of diabetes, hyperLDL-C, low HDL-C, and statins, low HDL-C was an independent risk factor for LAA (OR=1.526,95%CI1.220-1.909, P0.001). Symptomatic ICAS, ECAS, and patients combined with intracranial and external atherosclerosis were used as the dependent variable, and multiple multivariate regression analysis was performed in the year of adjustment. Age, coronary heart disease, diabetes, hyperTC, high LDL-C, low HDL-C, after the history of statins, low HDL-C is an independent risk factor for symptomatic ICAS and ECAS (OR=1.475,95%CI1.159-1.878, P=0.002; OR=2.716,95%CI1.543-4.779, P=0.001). Further symptomatic ICAS group is the dependent variable, and the symptomatic ECAS group is the control group. Multivariate Logistic regression analysis showed that the contribution rate of low HDL-C to symptomatic ICAS was lower than that of symptomatic ECAS (OR=0.462,95%CI0.263-0.810, P=0.007).
Conclusion: low HDL-C is an independent risk factor for LAA. At the same time, low HDL-C is also an independent risk factor for symptomatic ICAS and ECAS, and low HDL-C has a higher contribution to symptomatic ECAS.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R589.2;R743.1

【参考文献】