本文選題：缺血性腦卒中 + 短暫性腦缺血發(fā)作�。� 參考：《復(fù)旦大學(xué)》2013年碩士論文

【摘要】：背景：腦血管病具有高發(fā)病率、高復(fù)發(fā)率、高致殘率和高死亡率的特點(diǎn),早期進(jìn)行復(fù)發(fā)風(fēng)險(xiǎn)評(píng)估、并干預(yù)危險(xiǎn)因素可以預(yù)防腦血管病的復(fù)發(fā),對該病的整體防治具有十分重要的意義�，F(xiàn)在常用的對腦卒中復(fù)發(fā)風(fēng)險(xiǎn)分層的工具有ESRS和ABCD2評(píng)分,其中ABCD2評(píng)分主要用于評(píng)估TIA患者是否有早期腦卒中復(fù)發(fā)風(fēng)險(xiǎn)、是否需要緊急處理或住院觀察,ESRS評(píng)分主要用于預(yù)測缺血性腦卒中發(fā)病后1年的腦卒中復(fù)發(fā)風(fēng)險(xiǎn)；這兩個(gè)評(píng)分重在利用臨床癥狀和體征等進(jìn)行評(píng)分,雖然簡易,但沒有考慮到對腦卒中預(yù)后有重要影響的實(shí)驗(yàn)室及血管成像危險(xiǎn)因素,勢必影響對腦卒中復(fù)發(fā)的預(yù)判效果。本研究在ABCD2和ESRS評(píng)分的基礎(chǔ)上,綜合考慮臨床癥狀、體征、實(shí)驗(yàn)室和影像學(xué)危險(xiǎn)因素,建立新的腦卒中風(fēng)險(xiǎn)評(píng)估模型,提高對腦卒中復(fù)發(fā)的預(yù)測能力,以指導(dǎo)缺血性腦血管病的二級(jí)預(yù)防工作。 目的：(一)建立以缺血性腦血管病患者的臨床特征、影像學(xué)、實(shí)驗(yàn)室危險(xiǎn)因素為基礎(chǔ)的腦卒中風(fēng)險(xiǎn)評(píng)分模型——SRS (Stroke Risk Score);(二)對所建立的SRS評(píng)分模型與ESRS和ABCD2評(píng)分對缺血性腦血管病患者的復(fù)發(fā)預(yù)測進(jìn)行有效性評(píng)估。 方法：(一)SRS評(píng)分模型的建立：(1)SRS評(píng)分原始模型的潛在構(gòu)成包括：年齡、血壓、血糖、低密度脂蛋白膽固醇、同型半胱氨酸、C反應(yīng)蛋白、心房顫動(dòng)、頸動(dòng)脈成像、既往缺血性腦卒中或短暫性腦缺血發(fā)作史、既往心肌梗死史、外周動(dòng)脈疾病等危險(xiǎn)因素；(2)用單變量Cox比例風(fēng)險(xiǎn)回歸分析確定缺血性腦血管病后2年內(nèi)腦卒中復(fù)發(fā)的危險(xiǎn)因素,首先在集合變量模型A中引入單變量Cox比例風(fēng)險(xiǎn)回歸分析中顯著性為P≤0.10單變量危險(xiǎn)因素；所有其他沒有被納入A模型的、先前定義的腦卒中復(fù)發(fā)獨(dú)立預(yù)測因子,逐個(gè)考察其對腦卒中復(fù)發(fā)的預(yù)測價(jià)值,以P0.05為有顯著性差異,逐個(gè)納入能整體提高每個(gè)模型的C-統(tǒng)計(jì)值的獨(dú)立預(yù)測因子。通過逐步分析最終確定了SRS評(píng)分模型的獨(dú)立預(yù)測因子構(gòu)成及其最佳加權(quán)方案。(二)預(yù)測效果評(píng)價(jià),分組為：推導(dǎo)組300例患者為2009年9月1日至2010年8月31日缺血性腦血管病住院患者,隨訪2年；驗(yàn)證組315例患者為2010年9月1日至2011年8月31日缺血性腦血管病住院患者,隨訪1年；集合組為2009年9月1日至2011年8月31日住院的推導(dǎo)組和驗(yàn)證組615例患者；TIA組為2009年9月1日至2011年8月31日推導(dǎo)組和驗(yàn)證組中的65例TIA住院患者。分析：(1)計(jì)算各評(píng)分量表的C-統(tǒng)計(jì)值,以評(píng)估各評(píng)分量表的綜合預(yù)測效果。(2)應(yīng)用ROC曲線評(píng)價(jià)各評(píng)分將集合組患者評(píng)估為低危組和危險(xiǎn)組的敏感度、特異度,比較各評(píng)分模型對腦卒中復(fù)發(fā)高風(fēng)險(xiǎn)患者的辨別能力。(3)應(yīng)用Kaplan-Meier曲線法估計(jì)各模型評(píng)估為低危組和危險(xiǎn)組患者的生存曲線,比較低危組和危險(xiǎn)組患者的無腦卒中復(fù)發(fā)生存率高低。(4)考察觀察性風(fēng)險(xiǎn)與預(yù)測性風(fēng)險(xiǎn)的變化趨勢。 結(jié)果：(一)SRS評(píng)分模型的建立：SRS評(píng)分模型構(gòu)成為：年齡、糖尿病史、低密度脂蛋白膽固醇、同型半胱氨酸、纖維蛋白原、心房顫動(dòng)、頸動(dòng)脈成像、既往缺血性腦卒中或短暫性腦缺血發(fā)作史、外周動(dòng)脈疾病、冠狀動(dòng)脈疾病、充血性心力衰竭、吸煙；通過逐步分析,剔除了對推導(dǎo)組患者無預(yù)測價(jià)值的危險(xiǎn)因素變量,引入了對推導(dǎo)組患者有預(yù)測價(jià)值的危險(xiǎn)因素變量；并逐個(gè)分析了能夠使評(píng)分模型獲得最大C-統(tǒng)計(jì)值的每個(gè)危險(xiǎn)因素變量的最佳加權(quán)方案；最終建立了SRS評(píng)分模型,見下表所示。 (二)預(yù)測效果評(píng)價(jià)：在對推導(dǎo)組患者30天、90天、180天、1年、2年腦卒中復(fù)發(fā)預(yù)測中,ESRS評(píng)分預(yù)測價(jià)值良好(C-統(tǒng)計(jì)值0.6063-0.6936),ABCD2評(píng)分預(yù)測價(jià)值較低(G-統(tǒng)計(jì)值0.3970-0.5702),SRS評(píng)分(C-統(tǒng)計(jì)值0.5863-0.6940)與ESRS評(píng)分相似,均較ABCD2評(píng)分明顯提高。對驗(yàn)證組患者30天、90天、180天、1年腦卒中復(fù)發(fā)預(yù)測中,ABCD2評(píng)分預(yù)測價(jià)值適度(C-統(tǒng)計(jì)值0.5329-0.5790),SRS評(píng)分與ESRS評(píng)分相似(C-統(tǒng)計(jì)值分別為0.4726-0.5335,0.4656～0.5019)。在對集合組30天、90天、180天、1年腦卒中復(fù)發(fā)預(yù)測中,SRS與ESRS評(píng)分相似(C-統(tǒng)計(jì)值分別為0.5438-0.5925,0.5487～0.5884),兩者均較ABCD2評(píng)分提高(C-統(tǒng)計(jì)值0.4957-0.5728)。在對TIA組30天、90天、180天、1年腦卒中復(fù)發(fā)預(yù)測中,SRS評(píng)分與ABCD2評(píng)分相似(C-統(tǒng)計(jì)值分別為0.3047～0.5000,0.4703～0.5391),均較ESRS評(píng)分高(C-統(tǒng)計(jì)值0.1719-0.4209)。在對集合組患者腦卒中復(fù)發(fā)風(fēng)險(xiǎn)評(píng)估中,在30天、90天、180天、1年內(nèi)腦卒中復(fù)發(fā)高風(fēng)險(xiǎn)患者評(píng)估為危險(xiǎn)組的準(zhǔn)確性,SRS評(píng)分的敏感度和特異度分別為77.8～82.7%、33.2～35.2%,ESRS評(píng)分分別為66.7～73.0%、40.1～41.7%,ABCD2評(píng)分分別為89.2～100%、8.8～9.3%。除外驗(yàn)證組、TIA組,對于推導(dǎo)組、集合組患者腦卒中復(fù)發(fā)風(fēng)險(xiǎn)評(píng)估中,SRS與ESRS評(píng)分評(píng)估為危險(xiǎn)組的患者均較低危組有較高的腦卒中復(fù)發(fā)率(P0.05),但前者較后者區(qū)別更明顯；ABCD2評(píng)分評(píng)估為低危組和危險(xiǎn)組的患者腦卒中復(fù)發(fā)率無統(tǒng)計(jì)學(xué)差異(P0.05)。 結(jié)論：在以急性缺血性卒中為主體的急性缺血性腦血管病患者隊(duì)列中,SRS、ESRS評(píng)分對腦卒中復(fù)發(fā)風(fēng)險(xiǎn)的預(yù)測準(zhǔn)確性相似,SRS較ESRS評(píng)分整體預(yù)測準(zhǔn)確性稍高,而ABCD2評(píng)分的預(yù)測準(zhǔn)確性較低。SRS、ESRS評(píng)分對于急性缺血性腦血管病患者中腦卒中復(fù)發(fā)高風(fēng)險(xiǎn)患者的區(qū)別能力相似,SRS評(píng)分整體區(qū)別能力較ESRS評(píng)分稍高,ABCD2評(píng)分的區(qū)別能力較差。相關(guān)結(jié)果結(jié)論需進(jìn)一步前瞻性研究證實(shí)。
[Abstract]:Background : cerebrovascular disease has the characteristics of high incidence rate , high recurrence rate , high disability rate and high mortality rate , early relapse risk assessment and intervention of risk factors can prevent the recurrence of cerebral vascular disease .
This study , based on the ABCD2 and ESRS scores , comprehensively considers clinical symptoms , signs , laboratory and imaging risk factors , establishes a new risk assessment model of stroke , and improves the prediction ability of the recurrence of stroke to guide the secondary prevention of ischemic cerebrovascular disease .

Objective : ( 1 ) To establish a model _ SRS ( Stroke Risk Score ) based on clinical features , imaging and laboratory risk factors in patients with ischemic cerebrovascular disease .

Methods : ( 1 ) The establishment of SRS scoring model : ( 1 ) The potential constituents of the original SRS scoring model include : age , blood pressure , blood sugar , low density lipoprotein cholesterol , homocysteine , C - reactive protein , atrial fibrillation , carotid imaging , history of previous ischemic stroke or transient ischemic attack , history of previous myocardial infarction , peripheral arterial disease and other risk factors ;
( 2 ) Cox proportional hazards regression analysis was used to determine the risk factors of stroke recurrence within 2 years after ischemic cerebrovascular disease .
All the other independent predictors of stroke recurrence , which were not included in model A and previously defined , were investigated on a one - by - one basis to predict the predictive value of the recurrence of stroke . The independent predictors of the C - statistic value of each model were included one by one .
In the validation group , 315 patients were hospitalized for ischemic cerebrovascular disease from September 1 , 2010 to August 31 , 2011 , followed up for 1 year ;
The collection group was 615 patients in the derivation group and validation group , hospitalized from September 1 , 2009 to August 31 , 2011 ;
( 2 ) Using the Kaplan - Meier curve method to estimate the survival curves of patients with low risk group and risk group , compare the survival curves of each model to low risk group and risk group , compare the survival curves of the low risk group and the risk group , compare the low risk group and the risk group patient ' s survival curve , compare the low risk group and the risk group patient ' s survival curve , and ( 4 ) investigate the trend of the observational risk and the predictive risk .

Results : ( 1 ) The establishment of SRS scoring model : SRS scoring model consisted of age , diabetes history , low density lipoprotein cholesterol , homocysteine , fibrinogen , atrial fibrillation , carotid imaging , previous ischemic stroke or transient ischemic attack history , peripheral artery disease , coronary artery disease , congestive heart failure , smoking ;
By stepwise analysis , the risk factor variables of no predictive value in the derived group were excluded , and the risk factor variables with predictive value for the derived patients were introduced .
and analyzing the optimal weighting scheme of each risk factor variable which can make the scoring model obtain the maximum C - statistic value one by one ;
The SRS scoring model is finally established , as shown in the following table .

( C - Statistical value : 0.5329 - 0.6936 ) , the score of SRS was similar to that of ESRS ( 0.5438 - 0.5925 , 0.5487 - 0.519 ) .
The patients with low risk group and risk group had no statistical difference in the ABCD2 score ( P0.05 ) .

Conclusion : In the cohort of patients with acute ischemic cerebrovascular disease , the accuracy of SRS and ESRS is similar to that of the risk of recurrence of stroke , and the accuracy of the overall prediction of the SRS is slightly higher than that of the ESRS . The difference between the overall difference of the SRS and ESRS is slightly higher than that of the ESRS . The difference of the ABCD2 scores is poor . The conclusion of the relevant results is confirmed by further prospective studies .

【學(xué)位授予單位】：復(fù)旦大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類號(hào)】：R743.3

【參考文獻(xiàn)】

相關(guān)期刊論文 前1條

1 ;Outline of the Report on Cardiovascular Disease in China,2010[J];Biomedical and Environmental Sciences;2012年03期

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本文編號(hào)：1816060