發(fā)布時(shí)間：2018-01-30 17:44

  本文關(guān)鍵詞： 急性對(duì)比劑腎損傷 急性冠脈綜合征 脈壓 冠狀動(dòng)脈介入治療　出處：《山東大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：1·背景和目的:隨著冠狀動(dòng)脈粥樣硬化性心臟病的診斷與治療技術(shù)蓬勃發(fā)展,冠狀動(dòng)脈造影術(shù)(coronary angiography,CAG)及冠狀動(dòng)脈介入治療術(shù)(percutaneous coronary intervention,PCI)不斷普及,其并發(fā)癥也越來(lái)越受到關(guān)注。對(duì)比劑導(dǎo)致的急性腎損傷(Contrast-induced acute kidney injury,CIAKI)作為冠脈介入治療術(shù)后常見并發(fā)癥之一,是臨床醫(yī)師近年來(lái)研究熱點(diǎn)。CIAKI延長(zhǎng)患者住院治療時(shí)間,增加住院費(fèi)用,同時(shí)增加患者短期及長(zhǎng)期死亡率,成為醫(yī)院獲得性腎功能衰歇第三位原因。目前臨床上常用血清肌酐值(serum creatinine,Scr)作為冠脈介入術(shù)前預(yù)測(cè)及術(shù)后確診CIAKI常用指標(biāo),但Scr變化往往滯后于腎臟病理?yè)p傷并多種腎外因素影響(如營(yíng)養(yǎng)狀態(tài)、性別、年齡)。因此需要尋找更為可靠的臨床早期預(yù)測(cè)腎功能變化的指標(biāo)并進(jìn)行有效干預(yù),從而降低CIAKI發(fā)生率及病死率,減少心血管不良事件。脈壓(pulse pressure,PP)為收縮壓(systolic blood pressure,SBP)與舒張壓(diastolic blood pressure,DBP)差值,是患者住院期間常規(guī)測(cè)量指標(biāo)。最近大量臨床研究表明,PP增高是心血管不良事件及死亡的獨(dú)立預(yù)測(cè)因素。PP升高往往反映了大動(dòng)脈管壁硬化,動(dòng)脈脈搏波傳播速度加快,對(duì)血管剪切力加大,引起動(dòng)脈血管內(nèi)膜損傷及功能紊亂。而且,PP影響腎小球小動(dòng)脈壓力,影響腎血管血壓自主調(diào)節(jié)能力,從而影響早期腎功能改變。目的:本研究旨在明確急性冠脈綜合征(Acute coronary syndrome,ACS)患者住院外周肱動(dòng)脈PP是否成為冠脈介入術(shù)后CIAKI發(fā)生的預(yù)測(cè)因素;并探討肱動(dòng)脈PP與ACS患者冠脈介入術(shù)后短期心血管不良事件的相關(guān)性。2.研究方法:2.1研究對(duì)象本研究連續(xù)入選自2016年4月至2016年11月于山東大學(xué)齊魯醫(yī)院心內(nèi)科、心內(nèi)保健病房診斷為ACS并進(jìn)行冠狀動(dòng)脈介入治療術(shù)患者共427人。2.2資料收集詳細(xì)采集并記錄每位入選患者臨床資料;冠脈介入術(shù)前24h連續(xù)規(guī)范測(cè)量3次外周肱動(dòng)脈血壓參數(shù),記錄SBP、DBP、PP及平均動(dòng)脈壓(mean blood pressure,MBP)平均值;由本院兩名介入醫(yī)師記錄術(shù)中CAG結(jié)果、對(duì)比劑(contrast medium,CM)類型及用量、介入手術(shù)時(shí)間、支架置入過(guò)程及結(jié)果、靶血管部位及支數(shù)、支架置入個(gè)數(shù);于介入治療術(shù)后24h-48小時(shí)復(fù)查Scr。利用中國(guó)改良的腎臟病膳食試驗(yàn)MDRD公式計(jì)算冠脈術(shù)前、術(shù)后腎小球率過(guò)濾估計(jì)值(estimated glomerular filtration ratee,eGFR)。定義 CIAKI 為:術(shù)后 24-72h 血清 Scr 水平上升0.5mg/dl或上升了基礎(chǔ)血清Scr水平的25%以上,將入選患者分為CIN組(29例)、非CIN組(398例),比較兩組PP水平、臨床資料。2.3術(shù)后隨訪按入選患者冠脈介入術(shù)前基線肱動(dòng)脈PP水平將患者分為:高PP組(H-PP組,PP≥90mmHg),中 PP 組(M-PP 組,PP60-89mmHg),低 PP 組(L-PP 組,PP60mmHg)。所有患者于出院后1個(gè)月、3個(gè)月、6個(gè)月通過(guò)電話或門診進(jìn)行隨訪,隨訪內(nèi)容為主要心臟不良事件(main adverse cardiovascular events,MACE),包括全因死亡、非預(yù)期的血運(yùn)重建和非致命性心肌梗死、缺血性腦卒中、需血液透析的腎功能衰竭。2.4統(tǒng)計(jì)分析利用SPSS19.0軟件比較CIN組與非CIN組一般臨床特征及PP水平,通過(guò)二元多因素logistic回歸分析評(píng)估相關(guān)危險(xiǎn)因素對(duì)CIAKI的預(yù)測(cè)價(jià)值,并以受試者工作曲線(receiver operation characteristic,ROC)曲線來(lái)評(píng)價(jià)PP對(duì)CIAKI診斷的敏感性和特異性;比較不同PP組主要不良心血管事件發(fā)生率及影響因素,二元多因素logistic歸因分析脈壓與冠脈介入術(shù)后不良事件相關(guān)性。3.結(jié)果:3.1一般臨床資料:共入選患者427例,其中男性302例(70.6%),女性125 例(29.4%)。均年齡(61.85±9.814)歲、平均體重指數(shù) BMI(25.74±3.23)、平均血壓 SBP/DBP(135.76±17.85)/(76.48±11.31)mmHg,平均 PP(59.28±15.73)mmHg;術(shù)前 Scr 值(73.9±18.21)umol/L,術(shù)后 Scr(74.75±20.46)umoI/L,術(shù)后 Scr 值升高(1.89±9.52umol/L,P0.01);術(shù)前 eGFR(96.41±21.56)ml/min/1.73m2,術(shù)后 eGFR(94.15±20.98)ml/min/1.73m2,術(shù)后 eGFR 下降(2.25±11.63ml/min/1.73m2,P0.01)。3.2 CIN組共29例,發(fā)病率為6.8%,其中女性12例(41.38%),男性17例(58.62%)。通過(guò)對(duì)CIN組、非CIN組差異進(jìn)行比較,其中PP(CIN組70.48±18.45mmHg vs 非 CIN 組 58.46±15.23mmHg,P0.01)、SBP(144.17±20.17mmHg vs 135.15±17.54mmHg,P=0.008)、CM 使用量(183.97±76.28mlvs148.5±70.2ml,P=0.009)、血紅蛋白 HBG(134.36±17.85g/L vs140.6±16.08g/L,P=0.049)、糖尿病病史(48.3%vs27.6%,P=0.018)、慢性腎臟病病史(10.3%vs1.5%,P=0.029)、住院服用 ACEI/ARB 藥物(27.6%vs48.5%,P=0.029)有統(tǒng)計(jì)學(xué)差異。3.3二元多因素logistic回歸分析:對(duì)PP、SBP、HBG、CM使用量、慢性腎臟病病史、糖尿病病史、ACEI/ARB服用史進(jìn)行多因素logistic分析后,PP仍有統(tǒng)計(jì)學(xué)差異,OR 值為 1.05(95%CI,1.005-1.100;P = 0.03);CM 使用量 OR 值為 1.008(95%CI,1.002-1.013;P = 0.005)。3.4受試者工作曲線(ROC)分析:PP曲線下面積(AUC)為0.705(95%CI,0.597-0.813;P0.01),計(jì)算 PP 臨界值(cut-off point)63.5mmHg,敏感度75.9%,特異度 70.9%。3.5隨訪結(jié)果:所有患者均于出院后第1月、3月、6月、9月完成隨訪,隨訪過(guò)程10名患者失訪,隨訪率為97.66%,其中共發(fā)生MACE事件共60例(14.1%),其中全因死亡2例(0.5%),腦卒中16例(3.7%),非致命性心肌梗死40例(9.4%),其中非預(yù)期靶血管重建4例(0.9%)。H-PP組、M-PP組MACE事件(P0.01)、全因死亡率(P=0.011)、非致命性心肌梗死(P=0.038)發(fā)生率均顯著高于L-PP組。腦卒中、終末期腎衰竭無(wú)明顯統(tǒng)計(jì)學(xué)差異。對(duì)年齡、性別、SBP、DBP、冠脈介入術(shù)前后Scr、血甘油三脂、血紅蛋白量、高血壓病史、糖尿病病史、陳舊性心肌梗死病史、二氫吡啶類CCB藥物進(jìn)行回歸分析后,高PP組Mace事件發(fā)生率依然明顯高于低 PP 組,OR 值為 4.42(95%CI,1.575-12.412;P0.01)。4.結(jié)論:ACS患者行冠狀動(dòng)脈介入治療術(shù),術(shù)前肱動(dòng)脈PP升高是發(fā)生CIAKI及介入術(shù)后短期發(fā)生MACE事件的獨(dú)立預(yù)測(cè)因素。未來(lái)需要進(jìn)一步研究降低基礎(chǔ)PP的藥物是否能預(yù)防PCI術(shù)后CIAKI發(fā)生及短期MACE事件發(fā)生率。
[Abstract]:1 background and objective: with the rapid development of coronary atherosclerotic heart disease diagnosis and treatment technology, coronary artery angiography (coronary angiography CAG) and percutaneous coronary intervention (percutaneous coronary, intervention, PCI) the growing popularity of its complications is also more and more attention. The acute renal injury caused by contrast agent (Contrast-induced acute kidney injury, CIAKI) as one of the common complications of coronary artery interventional therapy after surgery, doctors research in recent years.CIAKI treatment prolonged hospitalization, increased hospitalization costs, while increasing in patients with short-term and long-term mortality, a hospital acquired renal failure third reasons. At present the common clinical value of serum creatinine (serum creatinine. Scr) as coronary intervention preoperative and postoperative diagnosis of CIAKI prediction indexes, but Scr changes often lag behind the Kidney Pathological Damage Effect of various external factors (such as kidney and nutritional status, gender, age). So we need to find a more reliable prediction of renal function changes in early clinical indicators and effective intervention, so as to reduce the incidence of CIAKI and mortality, reduce cardiovascular adverse events. Pulse pressure (pulse pressure, PP blood (systolic) for systolic blood pressure pressure SBP, diastolic blood pressure (diastolic) and blood pressure, DBP) the difference was hospitalized patients during conventional measures. Recently many clinical studies showed that PP increased the adverse cardiovascular events and mortality were independent predictors of elevated.PP often reflect large arterial wall hardening, pulse wave propagation speed on vascular shear stress increase, cause arterial intimal injury and dysfunction. Moreover, PP influence glomerular arteriolae pressure, renal blood pressure self regulating ability, thus affecting the changes in renal function. Objective: the purpose of this research It aims to clear the acute coronary syndrome (Acute coronary, syndrome, ACS) peripheral brachial artery PP is a predictor of the occurrence of CIAKI after percutaneous coronary intervention in patients; and to investigate the correlation between.2. and PP of the brachial artery in patients with ACS after percutaneous coronary intervention of short-term cardiovascular events research method: 2.1 subjects in this study are continuous from from April 2016 to November 2016 in the Department of Cardiology of Qilu Hospital of Shandong University, heart care ward diagnosed ACS and coronary artery.2.2 with a total of 427 people to collect data to collect and record each patients clinical data of interventional treatment in patients with coronary intervention; preoperative 24h continuous specification 3 measurement of peripheral brachial artery blood pressure parameters, DBP, PP and SBP records. Mean arterial pressure (mean, blood pressure, MBP) average; by the two interventional physicians record CAG results, the contrast agent (contrast medium, CM) type and dosage, intervention The operation time, in the process and results of stent, target vessel location and number, the number of stent; interventional therapy in 24h-48 hours after review by Scr. MDRD formula Chinese test of diet in renal disease improved calculation of coronary artery before operation, postoperative estimated glomerular filtration rate (estimated, glomerular filtration ratee, eGFR). CIAKI was defined as: postoperative serum Scr level of 24-72h 0.5mg/dl increased or increased serum level of Scr of more than 25%, the patients were divided into group CIN (29 cases) and non CIN group (398 cases), the level of PP between the two groups, the clinical data of postoperative.2.3 were selected according to coronary intervention in patients with baseline brachial artery PP level patients were divided into high PP group (group H-PP, PP = 90mmHg), PP group (group M-PP, PP60-89mmHg), low PP group (group L-PP, PP60mmHg). All patients were discharged after 1 months, 3 months, 6 months were followed up by telephone or outpatient follow-up content The main adverse cardiac events (main adverse cardiovascular events, MACE), all-cause death, unplanned revascularization and non fatal myocardial infarction, ischemic stroke,.2.4 renal failure statistics for hemodialysis were analyzed by SPSS19.0 software between CIN group and non CIN group clinical characteristics and PP level by logistic two multivariate regression analysis to assess the value of risk factors related to the prediction of CIAKI, and the receiver operating curve (receiver operation, characteristic, ROC) curves to assess the sensitivity of PP for the diagnosis of CIAKI and specificity; incidence and influencing factors of different PP group of major adverse cardiovascular events, two yuan logistic multivariate attribution analysis pulse pressure and coronary intervention after adverse events between.3. results: 3.1 clinical data: a total of 427 patients, including 302 cases of male (70.6%), 125 cases were female (29.4% years). 榫，

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