本文選題：冠狀動脈小血管病變 + 病變特點　； 參考：《浙江大學》2017年博士論文

【摘要】：第一部分冠狀動脈小血管病變的特點、危險因素及預后分析:986例病人回顧性研究背景與目的:目前冠狀動脈小血管病變的發(fā)病率逐年上升,已有文獻提示小血管病變患者往往合并有較多的其他疾病,且病變復雜,術(shù)中操作更加困難,遠期預后不佳,但也有部分研究顯示其遠期預后與非小血管病變相當。目前的研究大多來自于歐美人群,缺乏中國人群相關(guān)的研究。因此,我們設(shè)計了此回顧性研究,旨在闡明冠狀動脈小血管病變特點、危險因素及進行預后分析,這將有助于早期識別高危患者,協(xié)助相關(guān)治療方案的制定,加強患者術(shù)后隨訪管理,從而改善預后。方法:納入了全部986例2015年在浙江大學醫(yī)學院附屬第一醫(yī)院心內(nèi)科接受冠脈造影并植入支架的患者,按照是否植入≤2.5mm的支架,分為冠狀動脈小血管病變組(308例)與非小血管病變組(678例)。記錄患者臨床基線資料、冠脈造影及手術(shù)情況、出院及長期隨訪情況。采用多因素Logistic回歸分析篩選冠狀動脈小血管病變、PCI術(shù)后再狹窄的獨立危險因素。使用Kaplan-Meier法繪制累積無MACE生存曲線,并通過log-rank法檢驗兩組患者無MACE生存曲線的差異。運用Cox回歸模型(風險比例模型),探究不同變量對MACE事件、再次血運重建的影響作用,篩選出終點事件的獨立預測因子。結(jié)果:高齡(OR=1.022,95%CI:1.009-1.036,P=0.001)、糖尿病(OR=1.742,95%CI:1.278-2.373,P0.001)、外周血管疾病(OR=2.484,95%CI:1.487-4.148,P0.001)、高水平低密度脂蛋白(OR=1.245,95%CI:1.060-1.461,P=0.007)、以及高同型半胱氨酸水平(OR=1.017,95%CI:1.002-1.033,P0.001)是冠狀動脈小血管病變的獨立危險因素,而飲酒史(OR=0.420,95%CI:0.299-0.588,P0.001)卻是其獨立保護因素。冠狀動脈小血管病變累及回旋支的比例較非小血管病變高(31.9%vs 17.3%,P0.001),而且,更易合并多支病變(79.2%vs 49.4%,P0.001)、分叉病變(24.0%vs 12.4%,P0.001)、慢性完全性閉塞病變(29.5%vs 9.4%,P0.001)以及彌漫性病變(55.2%vs35.7%,P0.001),術(shù)中前擴(95.8%vs68.7%,P0.001)、后擴(94.2%vs89.4%,P=0.016)的比例顯著高于非小血管病變組,而術(shù)后完全血運重建比例低于非小血管病變組(70.1%vs 85.1%,P0.001)。長期隨訪發(fā)現(xiàn),冠狀動脈小血管病變患者術(shù)后再狹窄的比例(6.5%vs 3.2%,P=0.019)顯著高于非小血管病變患者,不良心血管事件的發(fā)生率(心因性死亡(2.3%vs 0.4%,P=0.008)、卒中(1.9%vs 0.3%,P=0.007)、靶病變血運重建(5.8%vs 2.9%,P=0.029)、靶血管血運重建(6.8%vs 3.4%,P=0.016)、非靶血管血運重建(7.8%vs 4.0%,P=0.012))也明顯高于非小血管病變患者。完全血運重建(OR=0.351,95%CI:0.136-0.901,P=0.029)是冠脈小血管病變PCI術(shù)后再狹窄的獨立保護因素;而較高的 TSH 水平(OR=1.203,95%CI:1.059-1.366,P=0.004)則是其獨立危險因素。Cox回歸分析可得,冠狀動脈小血管病變組患者MACE終點事件的獨立預測因素包括心率(OR=0.952,95%CI:0.919-0.987,P=0.008)、室壁瘤(OR=8.750,95%CI:1.861-41.134,P=0.006)、白細胞計數(shù)(OR=1.117,95%CI:1.001-1.246,P=0.049)、TSH 水平(OR=1.158,95%CI:1.046-1.282,P=0.005)、后擴(OR=0.223,95%CI:0.063-0.782,P=0.019)、IVUS/OCT(OR=4.772,95%CI:1.666-13.66,P=0.004)、術(shù)中出血量(OR=1.016,95%CI:1.004-1.028,P=0.009)、完全血運重建(OR=0.405,95%CI:0.169-0.971,P=0.043)、服用阿司匹林(OR= 0.101,95%CI:0.015-0.685,P=0.019);而再次血運重建的獨立預測因素包括胸悶胸痛(OR=5.117,95%CI:1.206-21.723,P=0.027)、心功能等級(OR=1.622,95%CI:1.049-2.507,P=0.030)、心率(OR=0.959,95%CI:0.934-0.986,P=0.002)、腦卒中(OR=3.535,95%CI:1.153-10.834,P=0.027)、分叉病變(OR=3.047,95%CI:1.499-6.196,P=0.002)、完全血運重建(OR=0.329,95%CI:0.169-0.641,P=0.001)。結(jié)論:本研究證實了相關(guān)研究所得的冠脈小血管病變的特征,并且發(fā)現(xiàn)飲酒史為其發(fā)病的獨立保護因素。高TSH水平是冠狀動脈小血管病變患者PCI術(shù)后再狹窄的獨立危險因素,而完全血運重建則是其獨立保護因素。室壁瘤、高白細胞計數(shù)水平、高TSH水平、術(shù)中使用IVUS/OCT、較多的術(shù)中出血量是冠狀動脈小血管病變患者MACE終點事件的獨立危險因素,而較高的心率水平、后擴、完全血運重建、服用阿司匹林則是其獨立保護因素。胸悶胸痛癥狀、心功能差、腦卒中病史、合并分叉病變是冠狀動脈小血管病變患者再次血運重建的獨立危險因素,而較高的心率水平、完全血運重建則是其獨立保護因素。第二部分不同藥物洗脫支架對冠狀動脈小血管病變患者預后的影響——Meta分析目的與背景:對于冠狀動脈小血管病變患者,目前治療首選經(jīng)皮冠脈介入(PCI)藥物洗脫支架植入術(shù)(DES)。然而,優(yōu)先選用何種DES,目前仍無定論。因此,我們設(shè)計了此Meta分析,旨在回顧既往相關(guān)研究,并將結(jié)果進行合并,比較莫司類藥物洗脫支架(LES)與紫杉醇洗脫支架(PES)在冠狀動脈小血管病變患者中的療效。方法:本研究通過 PubMed、MEDLINE(Web of science)以及 Cochrane Central Register of Controlled Trials數(shù)據(jù)庫對發(fā)表至2017年3月并且與本次研究主題相關(guān)的文獻進行檢索。對于不同事件的發(fā)生率通過計算相對危險度以及95%可信區(qū)間,進行數(shù)據(jù)的合并以及比較。本研究對結(jié)果的合并分析采用Mantel-Haenzel法,并使用固定效應模型。結(jié)果:8項研究共4738例患者納入此研究。結(jié)果顯示:相較于PES,植入LES能顯著降低主要心血管不良事件(RR:0.64,95%CI:0.53-0.77;P0.00001;12=39%)、心肌梗死(RR:0.61,95%CI:0.45-0.82;P=0.001;I2=0%)、支架內(nèi)血栓(RR:0.22,95%CI:0.13-0.37;P0.00001;I2=6%)以及靶病變血運重建(RR:0.56,95%CI:0.44-0.71;P0.00001;12=7%)的事件率。LES 未能較 PES 顯著減少全因死亡(RR:0.98,95%CI:0.65-1.48;P=0.92;12=0%)、心因性死亡(RR:1.08,95%CI:0.62-1.88;P=0.80;I2=23%)以及靶血管血運重建(RR:0.80,95%CI:0.45-1.44;P=0.46;I2= 54%)的發(fā)生。結(jié)論:冠狀動脈小血管病變行PCI支架植入術(shù)的患者,LES較PES有更好的長期療效,顯著減少不良心血管事件的發(fā)生,可能是該類患者的首選支架。
[Abstract]:Part 1 the characteristics, risk factors and prognosis of coronary arteria small vascular disease: the background and objective of the retrospective study of 986 cases: the incidence of coronary arteria small vascular disease is increasing year by year. It is suggested that patients with small vascular lesions often have many other diseases, and the disease is complicated, and the operation is more difficult and far more difficult. The prognosis is poor, but some studies have shown that the long-term prognosis is similar to that of non small vascular lesions. Most of the current studies are from the European and American population and lack of Chinese related studies. Therefore, we have designed this retrospective study to clarify the specific points, risk factors and prognostic analysis of coronary artery disease, which will help. Early identification of high-risk patients, assisting the formulation of related treatment schemes, strengthening postoperative follow-up management, and improving prognosis. Methods: all 986 patients who received coronary angiography and stent implantation at the Department of Cardiology, the First Affiliated Hospital of Zhejiang University Medical College in 2015, were divided into coronary arterioles according to whether the stent implantation was less than 2.5mm. Tube lesion group (308 cases) and non small vascular disease group (678 cases). Record patients' clinical baseline data, coronary angiography and operation, discharge and long-term follow-up. Multifactor Logistic regression analysis was used to screen small coronary artery lesions and independent risk factors for restenosis after PCI. Kaplan-Meier method was used to draw the cumulative MACE survival Line, and log-rank method was used to test the difference between the two groups of patients without MACE survival curve. Using the Cox regression model (risk proportion model), we explored the effect of different variables on MACE events and revascularization, and screened out the independent predictors of the terminal events. Results: OR= 1.022,95%CI:1.009-1.036, P=0.001, diabetes mellitus (OR=1.742,95%CI:1.). 278-2.373, P0.001), peripheral vascular disease (OR=2.484,95%CI:1.487-4.148, P0.001), high level low density lipoprotein (OR=1.245,95%CI:1.060-1.461, P=0.007), and high homocysteine levels (OR=1.017,95%CI:1.002-1.033, P0.001) are independent risk factors for coronary arteriopathy, and the history of alcohol consumption (OR=0.420,95%CI:0.299-0.588, P0.) 001) it was an independent factor. The proportion of the small coronary artery lesions involving the gyrations was higher than that of the non small vascular lesions (31.9%vs 17.3%, P0.001), and the multiple branch lesions (79.2%vs 49.4%, P0.001), bifurcation lesions (24.0%vs 12.4%, P0.001), chronic complete occlusion (29.5%vs 9.4%, P0.001), and diffuse lesions (55.2%vs35.) were more likely. 7%, P0.001), the proportion of pre operation (95.8%vs68.7%, P0.001) and postenlargement (94.2%vs89.4%, P=0.016) was significantly higher than that of non small vascular disease group, and the proportion of complete revascularization after operation was lower than that of non small vascular disease group (70.1%vs 85.1%, P0.001). Long term follow-up showed that the proportion of postoperative restenosis in patients with coronary arteria small vascular lesions (6.5%vs 3.2%, P=0.019) The incidence of adverse cardiovascular events (cardiac death (2.3%vs 0.4%, P=0.008), stroke (1.9%vs 0.3%, P=0.007), target vascular revascularization (5.8%vs 2.9%, P=0.029), target vascular revascularization (6.8%vs 3.4%, P=0.016), non target vascular revascularization (7.8%vs 4%, P=0.012)) were also significantly higher than non small vascular lesions. Patients. Complete revascularization (OR=0.351,95%CI:0.136-0.901, P=0.029) is an independent protective factor for restenosis after PCI, while higher TSH (OR=1.203,95%CI:1.059-1.366, P=0.004) is an independent risk factor.Cox regression analysis, and independent preconditioning of MACE endpoint in patients with coronary arteria small vascular lesions The factors included heart rate (OR=0.952,95%CI:0.919-0.987, P=0.008), ventricular aneurysm (OR=8.750,95%CI:1.861-41.134, P=0.006), white blood cell count (OR=1.117,95%CI:1.001-1.246, P=0.049), TSH level (OR=1.158,95%CI:1.046-1.282, P=0.005), posterior extension (OR=0.223,95%CI:0.063-0.782, P=0.019). OR=1.016,95%CI:1.004-1.028 (P=0.009), complete blood transport (OR=0.405,95%CI:0.169-0.971, P=0.043), taking aspirin (OR= 0.101,95%CI:0.015-0.685, P=0.019); and the independent predictors of re revascularization include chest pain (OR=5.117,95%CI:1.206-21.723, P=0.027), cardiac function grade (OR=1.622,95%CI:1.049-2.507, P). =0.030) heart rate (OR=0.959,95%CI:0.934-0.986, P=0.002), stroke (OR=3.535,95%CI:1.153-10.834, P=0.027), OR=3.047,95%CI:1.499-6.196 (P=0.002), complete blood transport (OR=0.329,95%CI:0.169-0.641, P=0.001). Conclusion: This study confirmed the characteristics of small coronary angiopathy, and found drinking alcohol. High TSH level is an independent risk factor for restenosis after PCI operation in patients with small coronary artery disease, and complete blood revascularization is an independent protective factor. Ventricular aneurysm, high white blood cell count, high TSH level, IVUS/OCT in operation, and large amount of intraoperative bleeding are small coronary artery disease. The independent risk factors of the patient's MACE endpoint, higher heart rate, posterior expansion, complete revascularization, and aspirin are independent protective factors. Chest distress, chest pain, poor heart function, stroke history, and bifurcated lesions are independent risk factors for revascularization in patients with small coronary artery disease, and higher heart rate. Rate level, complete blood transport reconstruction is an independent protective factor. Second the effect of different drug eluting stents on the prognosis of patients with coronary arteria microangiopathy - Meta analysis objective and background: for patients with coronary arteria microangiopathy, the first choice of percutaneous coronary intervention (PCI) drug eluting stent implantation (DES) is the first choice. The first choice of DES is still unsettled. Therefore, we designed this Meta analysis to review previous related studies and to combine the results to compare the efficacy of the drug eluting stents (LES) and paclitaxel eluting stents (PES) in patients with small coronary artery disease. Methods: This study was conducted through PubMed, MEDLINE (Web of Science). And the Cochrane Central Register of Controlled Trials database retrieves the literature published to March 2017 and is related to the subject of this study. The occurrence rate of different events is combined and compared by calculating the relative risk and 95% confidence interval. This study uses Mantel- for the combined analysis of the results. Haenzel method, and use the fixed effect model. Results: 4738 patients in 8 studies were included in this study. The results showed that compared with PES, the implantation of LES significantly decreased major cardiovascular adverse events (RR:0.64,95%CI:0.53-0.77; P0.00001; 12=39%), myocardial infarction (RR:0.61,95%CI: 0.45-0.82; P=0.001; I2=0%), and thrombus in stents (RR:0.22,95%CI:0.13-0.37; The event rate of P0.00001; I2=6%) and target lesion revascularization (RR:0.56,95%CI:0.44-0.71; P0.00001; 12=7%) was not significantly lower than PES in all causes of death (RR:0.98,95%CI:0.65-1.48; P=0.92; 12=0%), psychogenic death (RR:1.08,95%CI:0.62-1.88; P=0.80; P0.00001) and blood vessel revascularization (54%). Conclusion: PCI stent implantation in patients with small coronary artery lesions, LES has a better long-term effect than PES, significantly reducing the incidence of adverse cardiovascular events, and may be the preferred stent for this type of patients.
【學位授予單位】：浙江大學
【學位級別】：博士
【學位授予年份】：2017
【分類號】：R543.3

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