【摘要】：目的:腦卒中(Stroke)又稱腦血管意外或中風(fēng),是因腦血管阻塞或破裂引起的腦血流循環(huán)障礙和腦組織功能或結(jié)構(gòu)損害為表現(xiàn)的急性腦血管疾病。它是全球第二大、中國(guó)第一大致死性病。在中國(guó),腦卒中發(fā)病率逐漸攀升,已經(jīng)成為我國(guó)嚴(yán)重的醫(yī)學(xué)和公共衛(wèi)生問題。為遏制腦卒中高發(fā)態(tài)勢(shì),我國(guó)已于2009年啟動(dòng)了“腦卒中篩查和防治工程”(CSSPP),旨在通過項(xiàng)目的實(shí)施,提高我國(guó)居民腦卒中危險(xiǎn)因素知曉率、控制率,降低腦卒中的發(fā)生率、復(fù)發(fā)率、死亡率和致殘率,從而減輕腦卒中給社會(huì)和家庭帶來的經(jīng)濟(jì)負(fù)擔(dān)和疾病負(fù)擔(dān),提高國(guó)民健康水平。該工程對(duì)年齡在40歲及以上的人群進(jìn)行八大危險(xiǎn)因素的篩查,若具有3項(xiàng)及以上危險(xiǎn)因素者可列為腦卒中高危人群。目前該高危人群篩查策略的效力依舊未知,它僅僅通過對(duì)危險(xiǎn)因素的個(gè)數(shù)進(jìn)行計(jì)數(shù)來判斷高危與否,并沒有考慮到每個(gè)危險(xiǎn)因素對(duì)于腦卒中發(fā)生的影響各不相同。為了更有效地評(píng)估個(gè)體腦卒中發(fā)生概率,本研究旨在在通過Meta分析這八種危險(xiǎn)因素是否與腦卒中的發(fā)生相關(guān)聯(lián)及其關(guān)聯(lián)強(qiáng)度,探索基于健康風(fēng)險(xiǎn)評(píng)價(jià)模型(HRA)篩查腦卒中高危人群的策略,并與CSSPP篩查結(jié)果進(jìn)行比較,為優(yōu)化我國(guó)腦卒中高危人群篩查策略提供依據(jù)。方法:通過對(duì)CNKI知識(shí)網(wǎng)絡(luò)服務(wù)平臺(tái),萬(wàn)方數(shù)據(jù)庫(kù)以及PubMed數(shù)據(jù)庫(kù)的檢索,收集1990-2015年國(guó)內(nèi)外發(fā)表的有關(guān)中國(guó)漢族人群腦卒中八種發(fā)病危險(xiǎn)因素(包括高血壓,糖尿病,心臟病,高血脂,腦卒中家族史,超重,吸煙及體育鍛煉)的文獻(xiàn)。本文用Nos量表對(duì)符合入選標(biāo)準(zhǔn)的文獻(xiàn)進(jìn)行質(zhì)量評(píng)價(jià),若評(píng)分大于5則納入該文獻(xiàn)。采用Reviewer manager 5.3以及Stata 12.0進(jìn)行分析。健康風(fēng)險(xiǎn)評(píng)價(jià)模型(HRA)篩查高危人群策略是在對(duì)腦卒中8個(gè)危險(xiǎn)因素進(jìn)行薈萃分析基礎(chǔ)上,獲得各因素與腦卒中發(fā)生的合并效應(yīng)值,再結(jié)合各年齡組腦卒中發(fā)病率,采用數(shù)學(xué)模型計(jì)算出個(gè)體未來5年腦卒中發(fā)病概率;應(yīng)用ROC曲線計(jì)算高危人群發(fā)病概率的界值點(diǎn),以此篩查出高危人群,并比較HRA和CSSPP兩種篩查策略的結(jié)果。結(jié)果:本文共納入了 178篇病例對(duì)照研究和15篇隊(duì)列研究。我國(guó)篩查策略所納入的八個(gè)危險(xiǎn)因素中,高血壓是最主要的腦卒中獨(dú)立危險(xiǎn)因素(OR=3.50,95%CI:3.18-3.85;RR=2.68,95%CI=2.20-3.26);糖尿病、心臟病、腦卒中家族史、高血脂、超重以及吸煙為發(fā)生腦卒中的中等關(guān)聯(lián)強(qiáng)度的危險(xiǎn)因素,其合并比值比介于1.82-2.68之間,合并危險(xiǎn)度介于1.27-2.47之間;體育鍛煉是防止腦卒中發(fā)生的保護(hù)因素(OR=0.49,95%CI:0.29-0.83),P值均小于0.05。亞組分析結(jié)果顯示,高血脂與缺血性腦卒中發(fā)作有關(guān),而與出血性腦卒中發(fā)作的關(guān)聯(lián)分析無(wú)統(tǒng)計(jì)學(xué)意義;高血壓和腦卒中家族史與出血性腦卒中發(fā)作的關(guān)聯(lián)強(qiáng)度高于缺血性腦卒中組。應(yīng)用HRA篩查策略評(píng)估了 4196名參加體檢的個(gè)體。5年腦卒中發(fā)病平均概率為1.33‰,男性發(fā)病概率高于女性。5年腦卒中發(fā)病平均概率隨危險(xiǎn)因素的個(gè)數(shù)增多有上升趨勢(shì)。按照CSSPP項(xiàng)目的篩查策略,可篩查出918名(21.9%)高危個(gè)體。按照HRA篩查策略,有219人的腦卒中發(fā)病平均概率超過高危界值(2.5%),但因其危險(xiǎn)因素的個(gè)數(shù)不足3個(gè),而被CSSPP項(xiàng)目的篩查策略判定為低危個(gè)體。但是,這些被CSSPP項(xiàng)目的篩查策略判定為低危者中有10.5%的個(gè)體有高血壓,有9.4%的個(gè)體有糖尿病。結(jié)論:Meta結(jié)果分析顯示不同危險(xiǎn)因素對(duì)于腦卒中發(fā)作影響各不相同,我國(guó)目前僅計(jì)數(shù)危險(xiǎn)因素的個(gè)數(shù)而不考慮其關(guān)聯(lián)強(qiáng)度的腦卒中高危人群篩查策略可能會(huì)導(dǎo)致其篩查的效力有所降低�；贖RA模型的篩查策略可以定量評(píng)估個(gè)體腦卒中發(fā)病風(fēng)險(xiǎn),綜合考慮了各因素的影響。結(jié)合CSSPP項(xiàng)目篩查策略,HRA模型可能會(huì)改善腦卒中的篩查效果。值得注意的是,由于高血壓和糖尿病是腦卒中的獨(dú)立危險(xiǎn)因素,因此應(yīng)采取更多的措施來控制個(gè)體的血壓和血糖。期望本研究將有助于提高腦卒中高危人群篩查的成本效果,有助于相關(guān)機(jī)構(gòu)采取更為有效的干預(yù)措施。
[Abstract]:Objective: Stroke, also known as cerebrovascular accident or apoplexy, is an acute cerebrovascular disease characterized by cerebral blood flow disturbance caused by cerebral vascular obstruction or rupture and impairment of brain tissue function or structure. In order to curb the high incidence of stroke, China has launched the Stroke Screening and Prevention Project (CSSPP) in 2009, aiming to improve the awareness rate of stroke risk factors, control rate, reduce the incidence of stroke, recurrence rate, mortality and disability rate, thereby reducing the death rate of stroke in Chinese residents through the implementation of the project. The project screens people aged 40 years and over for eight major risk factors. Those with three or more risk factors can be classified as high-risk groups for stroke. The effectiveness of the screening strategy for high-risk groups is still unknown, and it only passes. Counting the number of risk factors does not take into account that each risk factor has a different impact on the incidence of stroke. To explore the strategy of screening high-risk population of stroke based on health risk assessment model (HRA), and to compare the results with the results of CSSPP screening, so as to provide the basis for optimizing the screening strategy of high-risk population of stroke in China. Methods: By searching CNKI knowledge network service platform, Wanfang database and PubMed database, collecting the published data from 1990 to 2015 at home and abroad. Literatures on eight risk factors for stroke in Chinese Han population (including hypertension, diabetes, heart disease, hyperlipidemia, family history of stroke, overweight, smoking and physical exercise) were evaluated by Nos scale. Literatures that met the inclusion criteria were included if the score was greater than 5. Reviewer manager 5.3 and Stata 12.0 analysis. Health Risk Assessment Model (HRA) screening strategy for high-risk population was based on meta-analysis of 8 risk factors for stroke, and combined with the incidence of stroke in each age group, the incidence of stroke in the next five years was calculated by mathematical model. Results: A total of 178 case-control studies and 15 cohort studies were included. Of the eight risk factors included in the screening strategy in China, hypertension was the most important independent risk factor for stroke. Factors (OR = 3.50, 95% CI: 3.18-3.85; RR = 2.68, 95% CI = 2.20-3.26); diabetes mellitus, heart disease, family history of stroke, hyperlipidemia, overweight and smoking were moderate risk factors for stroke. The combined ratio was between 1.82 and 2.68, and the combined risk was between 1.27 and 2.47; physical exercise was the insurance against stroke. Protective factors (OR = 0.49, 95% CI: 0.29-0.83), P values were all lower than 0.05. Subgroup analysis showed that hyperlipidemia was associated with ischemic stroke attack, but there was no significant correlation between hyperlipidemia and hemorrhagic stroke attack. The average 5-year stroke incidence rate in males was higher than that in females. The average 5-year stroke incidence rate increased with the number of risk factors. According to the CSSPP screening strategy, 918 (21.9%) high-risk individuals were screened. According to the HRA screening strategy, 219. The average incidence of stroke in humans exceeded the high-risk threshold (2.5%), but was judged as low-risk individuals by the screening strategy of CSSPP because the number of risk factors was less than three. However, 10.5% of the individuals identified as low-risk by the screening strategy of CSSPP had hypertension and 9.4% had diabetes. The results show that different risk factors have different effects on stroke onset. At present, the screening strategy for high-risk stroke patients who only count the number of risk factors without considering their correlation strength may reduce the effectiveness of screening. Considering the influence of various factors, the HRA model may improve the screening effect of stroke in combination with the CSSPP project screening strategy. It is worth noting that since hypertension and diabetes are independent risk factors for stroke, more measures should be taken to control individual blood pressure and glucose. It is hoped that this study will help to increase the risk of stroke. The cost effectiveness of crowd screening will help relevant institutions to take more effective intervention measures.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R743.3

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