非瓣膜性房颤患者慢性肾脏病对死亡、血栓终点事件及房颤负荷的影响

发布时间：2018-04-29 03:00

本文选题：心房颤动 + 慢性肾功能不全　；参考：《中国人民解放军医学院》2015年博士论文

【摘要】：第一部分中老年非瓣膜性房颤患者肾功能不全对死亡、心脑血管死亡及血栓终点事件的影响目的：本研究拟探讨肾功能不全是否为非瓣膜性房颤患者脑卒中等血栓栓塞性事件、全因死亡、心脑血管死亡等终点事件的独立危险因素。方法：回顾性研究于2008年7月至2011年6月在中国人民解放军总医院住院治疗的中老年非瓣膜性心房颤动患者825例,记录一般情况、基础疾病、实验室检查、超声心动图等基线特征及观测期间内全因死亡、心脑血管死亡及血栓终点事件发生情况。根据基线肾小球滤过率将入选患者分组,分别进行Logistic多因素分析及Cox生存分析比较肾功能不全的危险因素及其对各终点事件的影响。结果：入选的825例未行抗凝治疗的中老年非瓣膜性房颤患者慢性肾功能不全 (eGFR60ml/min/1.73m2)的患病率为21.09%,年龄≥75岁、女性、2型糖尿病、心力衰竭及左室肥厚是入选房颤患者发生慢性肾功能不全的独立危险因素。入选患者平均随访时间为33.16±22.24月,共观测2279.58人年。随访期间发生全因死亡209例、心脑血管死亡61例、血栓终点事件(脑卒中/TIA/外周动脉栓塞)139例及心血管事件(急性心肌梗死/急性左心衰)133例。合并慢性肾功能不全的房颤患者的全因死亡、心脑血管死亡、血栓事件及心血管事件发生率均显著高于未合并慢性肾功能不全的房颤患者,在校正CHA2DS2-VASc评分后,慢性肾功能不全仍是全因死亡(HR:1.794,95%CI:1.330-2.419, P0.001),心血管死亡(HR:2.865, 95%CI:1.706-4.811, P0.001)、血栓事件(HR:1.636,95%CI:1.121-2.388, P=0.011)及心血管事件(HR:2.371,95%CI:1.651-3.404, P0.001)的独立预测因素。此外,左房增大(LAVI40ml/m2)是血栓栓塞事件、全因死亡及心血管事件的独立危险因素,而与心脑血管死亡无显著相关。结论：慢性肾功能不全是中老年非瓣膜性房颤患者全因死亡、心脑血管死亡、血栓事件及心血管事件的独立危险因素,且不依赖于CHADS2评分及CHA2DS2VASc评分。左房增大也与全因死亡、血栓事件及心血管事件独立相关。第二部分血清胱抑素C对不伴有慢性肾功能不全的老年房颤患者的死亡及血栓终点事件的影响目的：本研究拟探讨在不伴有慢性肾功能不全(eGFR60ml/min/1.73m2)的老年房颤患者中,血清胱抑素C对全因死亡、心脑血管死亡、血栓终点事件及心血管事件的影响。方法：回顾性研究于2008年7月至2010年6月在中国人民解放军总医院住院治疗且基线资料完整的60岁以上老年非瓣膜性心房颤动患者356例,记录基线特征及观测期间内全因死亡、心脑血管死亡及血栓终点事件发生情况。根据入选老年房颤患者基线血清胱抑素C水平的中位数(1.15mg/L)进行分组,分别进行Logistic多因素分析及Cox生存分析比较血清胱抑素C升高的危险因素及其对各终点事件的影响。结果：入选的356例不伴有慢性肾功能不全的老年非瓣膜性房颤患者平均随访37.83±21.87月,发现基线血清胱抑素c水平与尿酸氮、血肌酐及肾小球滤过率密切相关,年龄≥75岁、吸烟、心力衰竭及左室肥厚是入选房颤患者血清胱抑素C升高的独立危险因素。随访期间共发生全因死亡97例、心脑血管死亡27例、血栓终点事件共74例及心血管终点事件56例。在校正多种传统心血管危险因素后,血清胱抑素C升高能够独立预测不伴有慢性肾功能不全的老年非瓣膜性房颤患者的全因死亡率(HR:1.936,95%CI:1.247-3.008, P=0.003)、心脑血管死亡率(HR:3.695, 95%CI:1.536-8.889, P=0.004)、血栓事件(脑卒中/TIA/外周动脉栓塞)(HR:1.725, 95%CI:1.055-2.819, P=0.030)和心血管事件(急性心肌梗死/急性左心衰)(HR:2.184, 95%CI:1.197-3984, P=0.011)的发生。结论：血清胱抑素c升高可以独立预测不伴肾功能不全的老年非瓣膜性房颤患者的全因死亡、心脑血管死亡、血栓事件及心血管事件等终点事件的发生。第三部分心脏起搏器植入术后的老年阵发性房颤患者肾功能不全、左房容积指数及房颤负荷与血栓事件的相关研究目的：本研究拟了解植入起搏器的老年阵发性房颤患者再发房颤(包括无症状性房颤)的发生率及房颤负荷,探讨房颤负荷的影响因素,初步分析肾功能不全、房颤负荷及左房容积指数对脑卒中等血栓事件的影响。方法：对2012年1月至2013年12月在我院起搏器门诊长期随访的连续老年阵发性房颤患者148例进行前瞻性观察研究,记录基线特征及随访期间内房颤及血栓事件等临床终点事件发生情况。根据照入选老年房颤患者的房颤负荷进行分组,分别进行Logistic多因素分析及Cox生存分析比较慢性肾功能不全、左房容积指数及房颤负荷对血栓终点事件的影响。建立新的血栓评分标准,并应用曲线下面积比较不同评分标准对血栓终点事件的预测能力。结果：所有患者平均随访时间为22.79±7.03月,85例患者再发房颤(57.43%),34例患者为房颤高负荷(22.97%),发生无症状房颤的患者为23例(15.54%)。多因素Logistic回归分析发现左房增大分别是再发房颤(OR:3.524,95%CI: 1.339-9.276)及房颤高负荷(OR:8.110,95%CI:3.000-21.918)的独立危险因素。在校正CHADS2评分基础上,慢性肾功能不全(eGFR60 ml/min/1.73m2)和左房增大(LAVI28ml/m2)仍是血栓事件的独立危险因素。将肾功能不全(R)和左房增大(L)引入CHADS2评分及CHA2DS2-VASc评分,发现R2CHADS2L评分和R2CHA2DS2-VAScL评分预测血栓事件的C值分别为0.740 (95%CI:0.655-0.826) 和0.749(95%CI:0.671-0.816),显著高于CHADS2评分,但并不优于CHA2DS2-VASc评分。而单独将慢性肾功能不全纳入CHADS2评分或CHA2DS2-VASc评分并不能提高血栓事件预测效能。结论：左房增大是预测房颤复发及房颤高负荷的危险因素,R2CHADS2L评分和R2CHA2DS2-VAScL评分预测血栓事件的效能高于CHADS2评分,但并不优于CHA2DS2-VASc评分。
[Abstract]:Part 1: the effect of renal insufficiency on death, cardiac and cerebral vascular death and thrombus terminal event in middle-aged and elderly patients with non valvular atrial fibrillation. The purpose of this study is to explore whether renal insufficiency is an independent risk factor for thromboembolic events such as stroke in patients with non valvular atrial fibrillation, all causes of death, cardiac and cerebral blood tube death. Methods: a retrospective study was conducted in 825 patients with middle and old non valvular atrial fibrillation hospitalized in General Hospital of PLA from July 2008 to June 2011. The baseline features, basic diseases, laboratory tests, echocardiography, and all causes of death during observation, cardiac and cerebrovascular death and the occurrence of thrombus end point were recorded. Conditions. According to the baseline glomerular filtration rate, the patients were divided into groups. Logistic multivariate analysis and Cox survival analysis were used to compare the risk factors of renal insufficiency and their impact on the endpoint events. Results: 825 Cases of non valvular atrial fibrillation patients who were not treated with anticoagulant therapy were selected for chronic renal failure (eGFR60ml/min/1.7 The prevalence of 3M2 was 21.09%, age over 75 years, women, type 2 diabetes, heart failure and left ventricular hypertrophy were independent risk factors for chronic renal dysfunction in patients with atrial fibrillation. The average follow-up time was 33.16 + 22.24 months, and 2279.58 years were observed. 209 cases of total death, 61 cases of cardiovascular and cerebrovascular deaths, and thrombus were observed during the follow-up period. 139 cases and 133 cases of cardiovascular events (acute myocardial infarction / acute left heart failure) in 139 cases and 133 cases of cardiovascular events (acute myocardial infarction / acute left heart failure). Patients with atrial fibrillation with chronic renal insufficiency were dead, cardiac and cerebrovascular death, thrombus events and cardiovascular events were significantly higher than those without chronic renal failure. After the CHA2DS2-VASc score, chronic renal insufficiency was still an independent predictor of all causes (HR:1.794,95%CI:1.330-2.419, P0.001), cardiovascular death (HR:2.865, 95%CI:1.706-4.811, P0.001), thrombotic events (HR:1.636,95%CI:1.121-2.388, P=0.011) and cardiovascular events (HR: 2.371,95%CI:1.651-3.404, P0.001). Moreover, the left atrial enlargement (LAV) was enlarged (LAV). I40ml/m2) is a thromboembolism event that has no significant correlation with cardiovascular and cerebrovascular deaths due to independent risk factors for death and cardiovascular events. Conclusion: chronic renal insufficiency is an independent risk factor for patients with middle aged non valvular atrial fibrillation, cardiovascular and cerebrovascular death, thrombus events and cardiovascular events, and is not dependent on the CHADS2 evaluation. Scores and CHA2DS2VASc scores. Left atrial enlargement was also independent of all causes of death, thrombus events and cardiovascular events. Second the effect of serum cystatin C on death and thrombus terminal events in elderly patients with atrial fibrillation without chronic renal insufficiency (eGFR60ml/min/1.73m2): This study was to be explored without chronic renal insufficiency (eGFR60ml/min/1.73m2 In the elderly patients with atrial fibrillation, serum cystatin C was affected by all causes of death, cardiac and cerebrovascular death, thrombus terminal events and cardiovascular events. Methods: a retrospective study was conducted in 356 cases of non valvular atrial fibrillation who were hospitalized in General Hospital of PLA from July 2008 to June 2010, with complete baseline data of 60 years old and older non valvular atrial fibrillation. Baseline characteristics and total cause of death, cardiovascular and cerebrovascular death and the occurrence of thrombus terminal events during the observation period. According to the median of the baseline serum cystatin C (1.15mg/L) in the elderly patients who were selected, the Logistic multifactor analysis and Cox survival analysis were used to compare the risk factors for the increase of serum cystatin C and the risk factors for the increase of serum cystatin C Results: the average follow-up of 356 elderly non valvular atrial fibrillation patients without chronic renal insufficiency was 37.83 + 21.87 months. The baseline serum cystatin C level was closely related to uric acid nitrogen, blood creatinine and glomerular filtration rate, age more than 75 years, smoking, heart failure and left ventricular hypertrophy were selected as atrial fibrillation. An independent risk factor for elevated serum cystatin C. 97 cases of total cause of death, 27 cases of cardiovascular and cerebrovascular death, 74 cases of thrombus terminal event and 56 cases of cardiovascular endpoint events were observed during the follow-up period. After correcting a variety of traditional cardiovascular risk factors, serum cystatin C could be independently pretested for non chronic renal insufficiency All cause mortality (HR:1.936,95%CI:1.247-3.008, P=0.003), cardiac and cerebrovascular mortality (HR:3.695, 95%CI:1.536-8.889, P=0.004), thrombus event (/TIA/ peripheral arterial embolism) (HR:1.725, 95%CI:1.055-2.819, P=0.030) and cardiac vascular events (acute myocardial infarction / acute Zuo Xinshuai) (HR:2.184, 95%CI:1.197-3984). Conclusion: the rise of serum cystatin C can independently predict all causes of death, cardiovascular and cerebrovascular death, thrombus events and cardiovascular events in elderly patients with non valvular atrial fibrillation without renal insufficiency. Third patients with paroxysmal atrial fibrillation after cardiac pacemaker implantation in third patients have renal insufficiency, The correlation of left atrial volume index and atrial fibrillation load and thrombotic events. Objective: To investigate the incidence of recurrent atrial fibrillation (including asymptomatic atrial fibrillation) and atrial fibrillation load in patients with paroxysmal atrial fibrillation (PAF) implanted in the pacemaker, to explore the factors affecting the atrial fibrillation load, to analyze the renal insufficiency, the atrial fibrillation load and the left atrial volume index. Methods: a prospective study of 148 consecutive patients with paroxysmal atrial fibrillation in the outpatient department of pacemaker from January 2012 to December 2013. The baseline features and the occurrence of clinical endpoints such as atrial fibrillation and thrombotic events during the follow-up period were recorded. Logistic multifactor analysis and Cox survival analysis were used to compare the effects of chronic renal insufficiency, left atrial volume index and atrial fibrillation load on thrombus terminal events. A new standard of thrombus score was established, and the predictive ability of different scoring criteria on thrombus terminal events was applied. All patients were followed up with an average of 22.79 + 7.03 months, 85 patients with atrial fibrillation (57.43%), 34 patients with atrial fibrillation (22.97%), 23 patients with asymptomatic atrial fibrillation (15.54%). Multiple factor Logistic regression analysis found that the left atrial enlargement was OR:3.524,95%CI: 1.339-9.276 and the high load of atrial fibrillation (OR:8.110,95%CI: Independent risk factors of 3.000-21.918). On the basis of correction of CHADS2 score, chronic renal insufficiency (eGFR60 ml/min/1.73m2) and left atrial enlargement (LAVI28ml/m2) are still an independent risk factor for thrombus events. Renal dysfunction (R) and left atrial enlargement (L) were introduced into CHADS2 score and CHA2DS2-VASc score, and R2CHADS2L score and R2CHA2DS2-VAScL evaluation were found. The C values were 0.740 (95%CI:0.655-0.826) and 0.749 (95%CI:0.671-0.816), respectively, which were significantly higher than the CHADS2 score, but not better than the CHA2DS2-VASc score. However, it was not better to integrate the chronic renal insufficiency into the CHADS2 score or the CHA2DS2-VASc score. Conclusion: the left atrial enlargement is the prediction of atrial fibrillation. The risk factors of relapse and high load of atrial fibrillation, R2CHADS2L score and R2CHA2DS2-VAScL score were more effective than CHADS2 scores, but it was not better than the CHA2DS2-VASc score.

【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R541.75;R692

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