疑似冠心病患者冠状动脉粥样硬化斑块分布谱及无创筛查模型研究

发布时间：2018-06-09 12:17

本文选题：冠心病 + 斑块分布谱　；参考：《山东大学》2016年博士论文

【摘要】：研究目的：1.通过冠状动脉造影深入探讨疑似冠心病人群中冠状动脉粥样硬化斑块分布谱的情况,从而达到临床诊断,指导临床治疗。2.通过单因素和多因素分析多项血液指标与冠状动脉斑块负荷评分TPS(Total plaque score)、SSS (Segment-stenosis score)和CADS (coronary artery disease severity)的关系,尝试基于这些指标建立一个无创、简易的冠心病患者冠状动脉粥样硬化负荷筛查模型,减少患者的有创造影检查,降低漏诊率。材料和方法：共收集疑似冠心病症状住院患者1366例,确定其高险因素,行冠状动脉造影,按照美国心脏病学会(American Heart Association, AHA)对冠状动脉系统的划分规则将冠状动脉分为16段,通过造影结果,对冠状动脉狭窄程度和斑块进行图像分析,分别计算总斑块积分(TPS)、节段狭窄积分(SSS)、冠状动脉严重程度积分(CADS)来定量评估冠状动脉斑块负荷,并且详细描述粥样硬化斑块在冠状动脉系统内的分布谱。用平均值±标准差和中位数±四分位间距(interquartile range,IQR)来描述他们的平均值和变异水平,使用非参数Kruskal-Wallis检验(H-test)来进行多重比较检验进一步分析组间差异(不同性别组和年龄组间)。同时为了直观描述冠状动脉粥样硬化斑块在冠状动脉系统中的负荷程度,将每个冠状动脉节段斑块的发生率及不同狭窄程度发生的情况标示在冠状动脉树型模式图上。然后,使用校正过性别和年龄的logistic回归模型来确定粥样硬化斑块负荷的独立预测因子,将筛选出的独立预测因子放入多因素logistic模型,使用逐步回归法进一步筛选变量,构建针对疑似冠心病患者的筛查模型。最后,使用ROC (receiver operating characteristic)曲线评估筛选出的模型的判别效应。结果：1.纳入1366名进行冠状动脉造影的患者,其中造影结果显示无狭窄261人,出现狭窄1105人。无狭窄人群的平均年龄为55.6岁,狭窄人群的平均年龄为60.8岁,两者的差异具有统计学意义。狭窄人群的收缩压、舒张压、空腹血糖、血清总胆固醇、糖化血红蛋白均高于无狭窄人群,高密度脂蛋白胆固醇低于无狭窄人群,差异具有统计学意义。两组间甘油三酯与低密度脂蛋白胆固醇的差异无统计学意义。2.TPS和SSS评分都成显著右侧长尾的偏态分布,总体趋势为积分越高人数越少,高分人群占比较低,大部分患者的得分集中于相对偏低水平。有7.17%(98/1366)的人SSS评分20分,5.56%(76/1366)的人TPS评分8分,44.36%(606/1366)的人SSS评分≤5分,76.57%(1046/1366)的人TPS-5分。3.TPS和SSS评分在不同性别和年龄组间均存在明显的统计学差异。在不同性别组间,女性TPS评分平均值为2.81±2.81,中位数±四分位间距为2±2,男性TPS评分平均值为3.75±2.76,中位数±四分位间距为3±2.5,男性TPS评分高于女性,χ2=46.7659,差异有统计学意义(P0.0001)。女性SSS评分平均值为6.60±7.20,中位数±四分位间距为4±5.5,男性SSS评分平均值为9.11±7.24,中位数±四分位间距为8±5.5,男性SSS评分高于女性,χ2=51.6603,差异有统计学意义(P0.0001)。在不同年龄组间,52岁年龄组TPS评分平均值为2.45±2.52,中位数±四分位间距为2±2,52-59岁年龄组TPS评分为2.85±2.69,中位数±四分位间距为2±2.5,60-67岁年龄组TPS评分为3.51±2.86,中位数±四分位间距为3±2,=68岁年龄组TPS评分为4.60±2.69,中位数±四分位间距为5±1.5,可见TPS评分随年龄增长而增加,χ2=123.4456,差异有统计学意义(P0.0001)。SSS评分也显示出同样的趋势,52岁年龄组SSS评分平均值为5.73±6.23,中位数±四分位间距为4±4.5,52-59岁年龄组TPS评分为6.64±6.90,中位数±四分位间距为4±5.5,60-67岁年龄组TPS评分为8.43±7.56,中位数±四分位间距为7±5.5,=68岁年龄组TPS评分为11.37±7.22,中位数±四分位间距为11±5.5,可见TPS评分随年龄增长而增加,χ2=126.5659,差异有统计学意义(P0.0001)。4.在TPS评分图中,明确标注每个冠状动脉节段出现斑块的频率。在SSS评分图中,同样明确标注每个冠状动脉节段出现不同狭窄程度所占的百分比。通过TPS评分图可见,尽管冠状动脉的每个节段均有粥样硬化斑块出现,但最常出现的部位是前降支近段,发生率高达51.39%,其次是前降支中段(39.68%)、右冠状动脉近段(31.55%)、右冠状动脉中段(28.92%)和左回旋支近段(27.89%)等。在SSS评分图中,出现斑块频率最高的血管节段前降支近段的SSS评分分布为：0分：48.61%,1分：10.32%,2分：9.15%,3分：31.92%,其次的前降支中段的SSS评分分布为：0分：60.32%,1分：7.1%，2分：8.86%,3分：23.72%,随后的右冠状动脉近段的SSS评分分布为：0分：68.45%,1分：8.64%,2分：5.93%,3分：16.98%,右冠状动脉中段的SSS评分分布为：0分：71.08%,1分：7.54%,2分：5.49%,3分：15.89%,左回旋支近段的SSS评分分布为：0分：72.11%,1分：7.03%,2分：6,.3%，3分：14.57%。5.使用体检指标预测冠状动脉粥样硬化负荷积分的logistic回归分析结果发现,TPS评分5、SSS评分5、CADS0,均对收缩压、空腹血糖、甘油三酯、高密度脂蛋白胆固醇、糖化血红蛋白有预测价值。对TPS评分5的模型,ROC曲线下面积(Area Under roc Curve, AUC)为0.756(95%CI:0.717-0.793), SSS评分5的模型的AUC为0.728(95%CI:0.687-0.766), CADS评分0的模型的AUC为0.753(95%Cl：0.713-0.789)证明。上述三个模型均可较好地预测存在严重粥样硬化负荷的高危个体。结论：1.直观地通过冠状动脉树形模式图展示了疑似冠心病患者的冠状动脉粥样硬化斑块负荷的分布情况；最常出现病变的部位是左冠状动脉前降支近段,之后是右冠状动脉近段、左前降支中段、左回旋支近段和右冠状动脉中段。2.三种模型预测结果均较好,这表明三种模型可以在不进行CTA或DSA的情况下对疑似冠心病患者进行无创、简易的初步筛查,降低患者的经济负担和减少患者的有创检查,降低漏诊率。
[Abstract]:Objective: 1. the distribution spectrum of coronary atherosclerotic plaques in suspected coronary heart disease population was examined by coronary angiography, and the clinical diagnosis was achieved, and the clinical treatment of.2. was guided by single factor and multifactor analysis of multiple blood indexes and coronary plaque load score TPS (Total plaque score), SSS (Segment-stenos). Is score) and CADS (coronary artery disease severity) relationship, try to establish a non invasive, simple coronary atherosclerotic load screening model for patients with coronary heart disease, reduce the patient's creation examination, reduce the missed diagnosis rate. Materials and methods: a total of 1366 patients with suspected coronary heart disease symptoms were collected and determined. The high risk factor, coronary angiography, divided the coronary artery into 16 segments according to the rules of the American Heart Association (AHA) for the coronary artery system division. Through the results of the angiography, the degree of coronary stenosis and the plaque were analyzed. The total plaque score (TPS), the segment stenosis score (SSS), and the coronary artery were calculated. Pulse severity score (CADS) was used to quantify coronary plaque load, and the distribution of atherosclerotic plaque in the coronary artery system was described in detail. The mean values and interquartile range (IQR) were used to describe their average and variation levels, and the nonparametric Kruskal-Wallis test (H-t) was used. EST) to carry out multiple comparison tests to further analyze the differences between groups (different sex groups and age groups). In order to directly describe the degree of coronary atherosclerotic plaque in the coronary artery system, the incidence of each coronary atherosclerotic plaque and the incidence of different stenosis are marked in the coronary pattern pattern. Then, the independent predictor of atherosclerotic plaque load was determined by using the logistic regression model that corrected the sex and age. The independent predictors were selected into the multiple factor Logistic model, the stepwise regression method was used to screen the variables further, and the screening model for suspected coronary heart disease patients was constructed. Finally, the ROC (rece) was used. The iver operating characteristic) curve assessed the discriminant effect of the selected models. Results 1. included 1366 patients with coronary arteriography, among which 261 were not narrowed and 1105 were narrowed. The average age of the non stenosis population was 55.6 years and the average age of the narrow population was 60.8 years old. The systolic pressure, diastolic pressure, fasting blood glucose, serum total cholesterol and glycated hemoglobin were higher than those without stenosis, and the high density lipoprotein cholesterol was lower than that without stenosis. There was no statistical difference between the two groups of triglycerides and low density lipoprotein cholesterol (.2.TPS and SSS scores). The overall trend was a significant right long tail in the partial distribution, the overall trend was that the higher the higher the number of people, the higher the number of people, the high scores were relatively low, the scores of the majority of the patients were relatively low. The SSS score of 7.17% (98/1366) was 20, 5.56% (76/1366) was 8, 44.36% (606/1366) was less than 5, and 76.57% (1046/1366) was TPS-5.3. There were significant differences between TPS and SSS scores in different sex and age groups. The average value of TPS score was 2.81 + 2.81 for women, 2 + 2 in median, and 3.75 + 2.76 for male TPS score, and 3 + 2.5 in median + four. The TPS score of male was higher than that of women, and the difference was 2=46.7659. The mean value of P0.0001. The average value of female SSS score was 6.60 + 7.20, the median spacing of four division was 4 + 5.5, the average value of male SSS score was 9.11 + 7.24, the median spacing was 8 + 5.5, and the male SSS score was higher than that of the female, and the difference was statistically significant (P0.0001). The average value of the TPS score in the 52 age group was between the different age groups. The TPS score of 2.45 + 2 + 2,52-59 age group was 2.85 + 2.69, the median + four division spacing was 2 + 2.5,60-67 years, the TPS score was 3.51 + 2.86, the median spacing was 3 + 2, and the TPS score of the =68 age group was four. Long and increased, the difference was statistically significant (P0.0001).SSS score also showed the same trend, the average value of SSS score in the 52 year age group was 5.73 + 6.23, the median + four division spacing was 4 + 4.5,52-59 age group TPS score was 6.64 + 6.90, the median + four division spacing was 4 + 5.5,60-67 age group TPS score was 8.43 + 7.56, The distance between the number and four division was 7 + 5.5, the TPS score of the =68 age group was 11.37 + 7.22, the median interval of the four division was 11 + 5.5, and the TPS score increased with the age, and the difference was statistically significant (P0.0001).4. in the TPS score map. The frequency of each plaque in the coronary artery segment was clearly marked. In SSS score map, the same The percentage of different stenosis in each segment of the coronary artery was clearly marked. The TPS score showed that although atherosclerotic plaques appeared in each segment of the coronary artery, the most frequent site was the proximal descending proximal segment, the incidence of which was up to 51.39%, followed by the anterior descending branch (39.68%) and the right coronary artery (31.55%). The middle segment of the right coronary artery (28.92%) and the left circumflex proximal segment (27.89%). In the SSS score, the SSS score of the proximal descending segment of the vascular segment with the highest plaque frequency was 0: 48.61%, 1: 10.32%, 2: 9.15%, 3: 31.92%, followed by 0 points: 60.32%, 1: 7.1%, 60.32% %, 3: 23.72%, the SSS score of the proximal right coronary artery was divided into 0 points: 68.45%, 1: 8.64%, 2: 5.93%, 3: 16.98%, and 0 points: 71.08%, 1: 71.08%, 1. 6,.3%, 3 points: 14.57%.5. using logistic regression analysis of coronary atherosclerotic load integral using physical examination indicators found that TPS score 5, SSS score 5, CADS0, have predictive value for systolic blood pressure, fasting blood glucose, triglyceride, high-density lipoprotein cholesterol, glycosylated hemoglobin, and the area under ROC curve (Area Un) for TPS score 5 Der ROC Curve, AUC) the AUC of the model of 0.756 (95%CI:0.717-0.793), SSS score 5 is 0.728 (95%CI:0.687-0.766), the AUC of the CADS score 0 model is 0.753 (95%Cl:0.713-0.789). The above three models can better predict high-risk individuals with severe atherosclerosis load. Conclusion 1. intuitively passes the coronary artery tree pattern. The map shows the distribution of coronary atherosclerotic plaque load in patients with suspected coronary heart disease. The most frequently occurring lesion is the proximal part of the left anterior descending branch of the coronary artery, followed by the right coronary proximal segment, the middle of the left anterior descending branch, the left circumflex proximal segment and the right coronary artery in the middle segment of the.2. three models, which indicate the three models. In the case of no CTA or DSA, the type of patients with suspected coronary heart disease can be noninvasive, simple and preliminary screening, reduce the patient's economic burden and reduce the patient's invasive examination, and reduce the missed diagnosis rate.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R541.4

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