本文選題：缺血性卒中 + 顱內(nèi)動(dòng)脈粥樣硬化��； 參考：《河北醫(yī)科大學(xué)》2014年碩士論文

【摘要】：目的：缺血性卒中已經(jīng)成為世界范圍內(nèi)疾病致死和致殘的最主要原因之一，而大動(dòng)脈粥樣硬化型卒中（large artery atherosclerosis，LAA）是引起缺血性卒中重要的病因類(lèi)型。大量研究已經(jīng)證實(shí)，歐美白種人以顱外動(dòng)脈粥樣硬化（Extracranial atherosclerosis，ECAS）最常見(jiàn)，而亞洲人、非洲裔美國(guó)人以及西班牙白人顱內(nèi)動(dòng)脈粥樣硬化（intracranialatherosclerosis，ICAS）的發(fā)病率更高。 導(dǎo)致不同種族動(dòng)脈粥樣硬化（atherosclerosis，AS）好發(fā)部位差異的因素很多，除了種族、基因易感性、生活環(huán)境等差異外，不同人種之間AS危險(xiǎn)因素的患病率差異，也可能影響了顱內(nèi)外不同部位AS的發(fā)生。近來(lái)的研究發(fā)現(xiàn)，日韓等亞洲人群由于生活習(xí)慣的西化，其ECAS的患病率呈逐年升高趨勢(shì)，這可能是由于生活方式的改變，導(dǎo)致日韓等亞洲國(guó)家高脂血癥、肥胖等患病率逐年升高導(dǎo)致的。既往的多數(shù)研究顯示，高血壓、糖尿病、代謝綜合征對(duì)ICAS的貢獻(xiàn)比更高，而脂代謝異常對(duì)ECAS的貢獻(xiàn)比更高。低高密度脂蛋白膽固醇（high-density lipoprotein cholesterol，HDL-C）血癥是華人脂代謝異常最主要的存在形式，華人低HDL-C血癥的患病率顯著高于美國(guó)和澳大利亞、新西蘭等亞太國(guó)家。低HDL-C血癥是否是LAA的獨(dú)立危險(xiǎn)因素，華人低HDL-C血癥的高患病率是否是其癥狀性ICAS高發(fā)的危險(xiǎn)因素之一，低HDL-C血癥對(duì)癥狀性顱內(nèi)、外AS的貢獻(xiàn)比是否存在差異仍未得到證實(shí)。 基于此，本研究探討低高密度脂蛋白膽固醇血癥與LAA的相關(guān)性，并進(jìn)一步探討低HDL-C血癥對(duì)癥狀性ICAS和ECAS的貢獻(xiàn)比是否存在差異。 方法： 1研究對(duì)象 依據(jù)經(jīng)典TOAST病因分型，入選2006年12月至2012年12月入住河北醫(yī)科大學(xué)第三醫(yī)院的明確診斷為L(zhǎng)AA和SVD的缺血性卒中患者1358例作為研究對(duì)象。 排除標(biāo)準(zhǔn)：a、心源性卒中、其他原因和未明原因的卒中；b、排除臨床資料不全者。 2動(dòng)脈粥樣硬化性狹窄的評(píng)價(jià)方法 所有入選患者通過(guò)TCD、頸動(dòng)脈彩超和（或）MRA明確顱內(nèi)外AS的診斷,以動(dòng)脈管腔狹窄≥50%者作為動(dòng)脈粥樣硬化性狹窄的診斷標(biāo)準(zhǔn)。TCD、頸動(dòng)脈彩超、MRA診斷動(dòng)脈狹窄標(biāo)準(zhǔn)參見(jiàn)相關(guān)文獻(xiàn)。 顱內(nèi)動(dòng)脈包括：雙側(cè)頸內(nèi)動(dòng)脈虹吸段、大腦中動(dòng)脈、大腦前動(dòng)脈和大腦后動(dòng)脈、椎動(dòng)脈顱內(nèi)段及基底動(dòng)脈；顱外動(dòng)脈包括：頸總動(dòng)脈、頸內(nèi)動(dòng)脈顱外段、無(wú)名動(dòng)脈、鎖骨下動(dòng)脈、椎動(dòng)脈顱外段。 3動(dòng)脈粥樣硬化危險(xiǎn)因素的評(píng)價(jià)方法 ①高血壓：收縮壓≥140mmHg和（或）舒張壓≥90mmHg和（或）因高血壓病應(yīng)用降壓藥物者；②糖尿病：空腹血糖≥7.0mmol/L和（或）餐后血糖≥11.1mmol/L和（或）因糖尿病應(yīng)用降糖藥物；③吸煙：正在吸煙或戒煙未超過(guò)5年者定義為吸煙；從未吸煙或者戒煙超過(guò)5年者為不吸煙者；④既往心血管病史：心絞痛或者心肌梗塞病史;房顫或者瓣膜病史。 依據(jù)美國(guó)ATP III標(biāo)準(zhǔn)，低HDL-C定義為:HDL-C≤1.03mmol/L；其他各成分脂代謝異常定義為：總膽固醇（tatal cholesterol，TC≥5.18mmol/L或（和）低密度脂蛋白膽固醇（LDL-C）≥2.59mmol/L或（和）甘油三酯（TG）≥1.7mmol/L或（和）既往因高脂血癥應(yīng)用降脂藥物者。 4統(tǒng)計(jì)學(xué)方法 以SPSS16.0軟件包進(jìn)行統(tǒng)計(jì)分析。所有動(dòng)脈危險(xiǎn)因素均采用計(jì)數(shù)資料，率的比較應(yīng)用χ2檢驗(yàn)。logistic回歸分析LAA、癥狀性ICAS和ECAS的危險(xiǎn)因素，比較低HDL-C血癥對(duì)癥狀性ICAS和ECAS的貢獻(xiàn)比。顯著性差異水準(zhǔn)為0.05。 結(jié)果：滿(mǎn)足入組標(biāo)準(zhǔn)的缺血性卒中患者1358例，其中，LAA患者795例，SVD患者563例。LAA患者組低HDL-C的發(fā)病率為57.2%，SVD患者組低HDL-C發(fā)病率為48.3%，差別具有統(tǒng)計(jì)學(xué)意義（X=10.54，P=0.001）。以LAA作為因變量，序貫行單因素及多因素logistic回歸分析，在調(diào)整了糖尿病、高LDL-C血癥、低HDL-C血癥及他汀類(lèi)藥物應(yīng)用史后，低HDL-C血癥為罹患LAA的獨(dú)立危險(xiǎn)因素（OR=1.526，95%CI1.220-1.909，P0.001）。以癥狀性ICAS、ECAS以及合并顱內(nèi)外動(dòng)脈粥樣硬化組患者作為因變量，行多元多因素Logistic回歸分析，在調(diào)整年齡、冠心病、糖尿病、高TC血癥、高LDL-C血癥、低HDL-C血癥、他汀應(yīng)用史后，低HDL-C血癥是癥狀性ICAS、ECAS的獨(dú)立危險(xiǎn)因素（OR=1.475，95%CI1.159-1.878，P=0.002；OR=2.716，95%CI1.543-4.779，P=0.001）。進(jìn)一步以癥狀性ICAS組患者為因變量，以癥狀性ECAS組患者為對(duì)照組行多因素Logistic回歸分析，結(jié)果顯示：低HDL-C血癥對(duì)癥狀性ICAS貢獻(xiàn)比小于癥狀性ECAS（OR=0.462，95%CI0.263-0.810，，P=0.007）。 結(jié)論：低HDL-C血癥是LAA的獨(dú)立危險(xiǎn)因素。同時(shí)，低HDL-C血癥也是癥狀性ICAS和ECAS的獨(dú)立危險(xiǎn)因素，低HDL-C血癥對(duì)癥狀性ECAS的貢獻(xiàn)比更高。
[Abstract]:Objective: ischemic stroke has become one of the most important causes of death and disability in the world, and large artery atherosclerosis (LAA) is an important cause of ischemic stroke. A large number of studies have proved that in European and American white people, the Extracranial atherosc (Extracranial atherosc) Lerosis, ECAS) are the most common, and the incidence of intracranialatherosclerosis (ICAS) is higher in Asians, African Americans, and white Spanish.
There are many factors that lead to the difference in the location of atherosclerosis (AS). In addition to race, genetic susceptibility, and living environment, the difference in the prevalence of AS risk factors between different races may also affect the occurrence of AS in different parts of the cranium. Recent studies have found that the Asian population such as Japan and South Korea are born because of their birth. The prevalence of ECAS is increasing year by year, which may be due to changes in lifestyle, leading to higher prevalence of hyperlipidemia and obesity in Asian countries such as Japan and South Korea. Most previous studies have shown that hypertension, diabetes, metabolic syndrome have a higher contribution to ICAS than ECAS. Low high density lipoprotein cholesterol (high-density lipoprotein cholesterol, HDL-C) is the most important form of lipid metabolism in Chinese, and the prevalence of low HDL-C in Chinese is significantly higher than that in the United States and Australia, and in New Zealand and other Asia Pacific countries. Low HDL-C is an independent risk factor for LAA, and the low HDL-C in Chinese is low HDL-C. The high prevalence of hyperemia is one of the risk factors for the high incidence of symptomatic ICAS, and the difference in the contribution ratio of hypoemia to symptomatic intracranial and external AS remains unknown.
Based on this, this study examines the correlation between low HDL and LAA, and further explores whether the contribution of hypoxemia to symptomatic ICAS and ECAS is different.
Method:
1 research objects
According to the classic TOAST etiological classification, 1358 cases of ischemic stroke, which were diagnosed as LAA and SVD in third hospitals of Hebei Medical University from December 2006 to December 2012, were selected as the subjects.
Exclusion criteria: A, cardiogenic stroke, other causes and unknown causes of stroke; B, excluding patients with incomplete clinical data.
2 evaluation method of atherosclerotic stenosis
All selected patients were diagnosed by TCD, carotid color Doppler ultrasound and (or) MRA in the diagnosis of intracranial and extracranial AS. The diagnostic criteria for atherosclerotic stenosis by arterial lumen stenosis more than 50% were used as diagnostic criteria for atherosclerotic stenosis, carotid color Doppler ultrasound, and MRA for the diagnosis of arterial stenosis.
The intracranial arteries include the siphon segment of the bilateral internal carotid artery, the middle cerebral artery, the anterior cerebral artery and the posterior cerebral artery, the intracranial segment of the vertebral artery and the basilar artery, and the extracranial arteries including the common carotid artery, the extracranial segment of the internal carotid artery, the innominate artery, subclavian artery, and the extracranial segment of the vertebral artery.
3 evaluation method of risk factors of atherosclerosis
Hypertension: systolic blood pressure more than 140mmHg and (or) diastolic pressure more than 90mmHg and / or the use of antihypertensive drugs for hypertension; diabetes: diabetes: fasting blood glucose above 7.0mmol/L and (or) postprandial blood glucose more than 11.1mmol/L and / or (or) diabetes using hypoglycemic drugs; (3) smoking: Smokers who are smoking or giving up smoking for less than 5 years are defined as smoking; never smoked. Or smokers who smoked for more than 5 years were nonsmokers.
According to American ATP III standard, low HDL-C is defined as: HDL-C less than 1.03mmol/L; other components of lipid metabolism are defined as total cholesterol (tatal cholesterol, TC more or less 5.18mmol/L or (and and) low density lipoprotein cholesterol (LDL-C) > 2.59mmol/L or (and) triglycerides (TG) more or less than or (and) the use of lipid lowering drugs for hyperlipidemia.
4 statistical method
Statistical analysis was carried out with the SPSS16.0 software package. All the arterial risk factors were counted, and the rate was compared with the x 2 test of.Logistic regression analysis of LAA, the risk factors of symptomatic ICAS and ECAS, and the comparison of the contribution of low HDL-C to symptomatic ICAS and ECAS. The significant difference in water was 0.05.
Results: 1358 cases of ischemic stroke patients were satisfied with the standard of entry, of which 795 were LAA patients and 57.2% in.LAA patients with SVD. The incidence of low HDL-C in SVD patients was 48.3%. The difference was statistically significant (X=10.54, P=0.001). LAA was used as a dependent variable, sequential single factor and multiple factor Logistic regression analysis were used. After adjusting the history of diabetes, hyperLDL-C, low HDL-C, and statins, low HDL-C was an independent risk factor for LAA (OR=1.526,95%CI1.220-1.909, P0.001). Symptomatic ICAS, ECAS, and patients combined with intracranial and external atherosclerosis were used as the dependent variable, and multiple multivariate regression analysis was performed in the year of adjustment. Age, coronary heart disease, diabetes, hyperTC, high LDL-C, low HDL-C, after the history of statins, low HDL-C is an independent risk factor for symptomatic ICAS and ECAS (OR=1.475,95%CI1.159-1.878, P=0.002; OR=2.716,95%CI1.543-4.779, P=0.001). Further symptomatic ICAS group is the dependent variable, and the symptomatic ECAS group is the control group. Multivariate Logistic regression analysis showed that the contribution rate of low HDL-C to symptomatic ICAS was lower than that of symptomatic ECAS (OR=0.462,95%CI0.263-0.810, P=0.007).
Conclusion: low HDL-C is an independent risk factor for LAA. At the same time, low HDL-C is also an independent risk factor for symptomatic ICAS and ECAS, and low HDL-C has a higher contribution to symptomatic ECAS.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R589.2;R743.1

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