【摘要】：目的:研究接受冠狀動(dòng)脈旁路移植術(shù)(Coronary Atery Bypass Graft,CABG)的冠心病(CHD)患者的平均血小板體積(Mean Platelet Vomlume,MPV)與其橋血管病變的關(guān)系,探討移植橋血管病變的危險(xiǎn)因素。分析患者行CABG術(shù)前和術(shù)后的臨床指標(biāo)變化,探究變化因素與橋血管通暢性的關(guān)系,以指導(dǎo)患者CABG術(shù)后長(zhǎng)期的藥物治療。在合并2型糖尿病、心力衰竭、心律失常三種不同情況的冠心病患者中,分析MPV對(duì)橋血管通暢性的影響。旨在探索MPV以及其聯(lián)合其他因素預(yù)測(cè)橋血管遠(yuǎn)期通暢率的價(jià)值。方法:依照入選標(biāo)準(zhǔn),回顧性分析2008年01月01日至2014年9月30日就診于天津市胸科醫(yī)院,既往經(jīng)冠脈造影(Coronary Angiography,CAG)確診為嚴(yán)重冠狀動(dòng)脈病變,于我院或其他醫(yī)院實(shí)施CABG治療,本次再發(fā)可疑心肌缺血事件而入院治療的患者514例。其中CABG術(shù)前、術(shù)后病歷搜集信息均完整者164例患者。收集2014年01月01日至2015年01月01日就診于天津市胸科醫(yī)院行CAG證實(shí)冠脈正常者194例作為對(duì)照組。根據(jù)橋血管是否狹窄將橋血管組分成橋血管通暢組和橋血管病變組。此外,分別根據(jù)患者是否具有2型糖尿病、是否具有收縮性心力衰竭、是否具有心律失常,將橋血管組分成糖尿病亞組、心功能不全亞組、心律失常亞組三個(gè)組別。入組患者均于入院時(shí)收集一般臨床資料、既往病史(高血壓病史、糖尿病病史)、個(gè)人史(吸煙史、飲酒史)、搭橋時(shí)間、心肌梗死病史、家族史;采集入院第一次空腹靜脈血檢測(cè)結(jié)果,記錄超聲心動(dòng)圖和胸片結(jié)果。根據(jù)Syntax評(píng)分評(píng)價(jià)冠狀動(dòng)脈血管的嚴(yán)重程度。結(jié)果:(1)比較橋血管組與對(duì)照組,高齡、糖尿病病史、NYHA分級(jí)Ⅱ級(jí)、射血分?jǐn)?shù)(ejection fraction,EF)50%和心胸比例50%是嚴(yán)重冠狀動(dòng)脈病變的冠心病患者接受CABG術(shù)的易感因素(均p0.05)。(2)CABG術(shù)后橋血管發(fā)生病變的獨(dú)立危險(xiǎn)因素是MPV值(OR 1.550,95%OR 1.248~1.926)、LP(α)值(OR6.218,95%OR 1.624~23.810)和靜脈橋支數(shù)(OR 2.131,95%OR 1.427~3.181),HDL水平(OR 0.179,95%OR 0.057~0.560)是患者橋血管通暢的保護(hù)因素(均p0.05)。(3)對(duì)比cabg術(shù)前、術(shù)后的臨床資料,橋血管通暢組中,紅細(xì)胞壓積(hct)、紅細(xì)胞平均體積(mcv)、紅細(xì)胞分布寬度(rdw)、血糖(glu)、載脂蛋白(apro-a1)、ef均有變化。hct、mcv、apro-a1水平術(shù)后較術(shù)前降低,rdw、glu、ef水平較術(shù)前增加(均p0.05)。在橋血管病變組紅細(xì)胞計(jì)數(shù)(redbloodcell,rbc)、hct、血小板計(jì)數(shù)(platelet,plt)、mpv、總膽固醇(totalcholesterin,tc)、低密度脂蛋白(low-densitylipoprotein,ldl)、ef有變化,rbc、hct水平術(shù)后較術(shù)前降低,plt、mpv、tc、ldl、ef水平較術(shù)前增加(均p0.05)。(4)在橋血管組中,高水平mpv組的橋血管狹窄率明顯高于低、中水平mpv組(均p0.05)。相比搭橋早期復(fù)查者(搭橋術(shù)后時(shí)間12個(gè)月)的橋血管狹窄率明顯高于中晚期者(搭橋術(shù)后時(shí)間≥12個(gè)月)(p0.05),其中plt水平較早期復(fù)查者升高,但是兩組之間的差異無(wú)統(tǒng)計(jì)學(xué)意義,同時(shí),mpv與pdw無(wú)統(tǒng)計(jì)學(xué)差異(均p0.05)。(5)在2型糖尿病亞組中,共220例患者,橋血管病變組中mpv范圍處于12fl以上的患者人數(shù)多于橋血管通暢組(p0.05),但是兩組之間的其他血小板參數(shù)(plt、pdw、pct水平)無(wú)統(tǒng)計(jì)學(xué)意義。心功能不全亞組中共98例患者,橋血管病變組mpv水平高于橋血管通暢組(p0.05)。心律失常亞組中共84例患者,其中房顫患者32例,右束支傳導(dǎo)阻滯患者30例,室性早搏患者12例,竇緩患者10例。橋血管通暢組與病變組中的血小板參數(shù)之間的差異無(wú)統(tǒng)計(jì)學(xué)意義(均p0.05)。(6)對(duì)橋血管病變組患者分別應(yīng)用mpv水平、lp(α)水平、靜脈橋支數(shù)和hdl水平進(jìn)行橋血管預(yù)后的預(yù)測(cè),繪制受試者工作特征曲線(roc曲線),其下面積(areaunderthecurve,auc)分別為0.657,95%ci(0.586~0.727);0.618,95%ci(0.544~0.692);0.628,95%ci(0.552~0.705);0.606,95%ci(0.529~0.692)。mpv最佳截點(diǎn)是10.45,敏感性為0.497,95%ci(0.472~0.522),特異性為0.757,95%ci(0.719~0.795);lp(α)最佳截點(diǎn)是0.175,敏感性為0.717,95%ci(0.681~0.753),特異性為0.500,95%ci(0.475~0.525);靜脈橋最佳截點(diǎn)是1.500,敏感性為0.845,95%ci(0.803~0.887),特異性為0.686,95%ci(0.652~0.720);hdl最佳截點(diǎn)是1.085,敏感性為0.620,95%ci(0.589~0.651),特異性為0.614,95%ci(0.583~0.645);結(jié)合mpv值、lp(α)值、靜脈橋支數(shù)和hdl值二元logistic回歸系數(shù)。擬合聯(lián)合診斷方程=0.439×mpv+1.827×lp(α)+0.757×(靜脈橋支數(shù))-1.718×hdl-3.565,應(yīng)用聯(lián)合診斷的roc曲線下面積高于mpv、lp(α)值、靜脈橋支數(shù)和hdl,為0.770(95%ci0.706~0.833),具有統(tǒng)計(jì)學(xué)意義(p0.05)。其在最佳截點(diǎn)的0.881,敏感性為0.706,95%CI(0.671~0.741),特異性為0.714,(0.678~0.750)。結(jié)論:高齡、2型糖尿病病史、NYHA分級(jí)Ⅱ級(jí)、射血分?jǐn)?shù)(ejection fraction,EF)50%、心胸比例50%的具有嚴(yán)重冠狀動(dòng)脈病變的患者更傾向于通過(guò)CABG以達(dá)到血運(yùn)重建,改善心肌供血的目的。橋血管發(fā)生病變的獨(dú)立危險(xiǎn)因素是MPV水平、LP(α)水平和靜脈橋血管支數(shù),HDL水平是橋血管通暢性的保護(hù)因素。通過(guò)CABG術(shù)開通血管后,患者的心臟泵功能可以得到改善。CABG術(shù)后仍需抗血小板和調(diào)脂治療。無(wú)論2型糖尿病亞組還是心功能不全,MPV值的變化均與橋血管病變有關(guān)。對(duì)橋血管病變組患者應(yīng)用MPV值、LP(α)值、靜脈橋支數(shù)和HDL值四者聯(lián)合預(yù)測(cè),具有辨識(shí)度。其在最佳截點(diǎn)的0.881,敏感性為0.706,特異性為0.714。
[Abstract]:Objective: To study the relationship between mean platelet volume (MPV) and graft vascular lesions in patients with coronary heart disease (CHD) undergoing coronary artery bypass grafting (CABG), and to explore the risk factors of graft vascular lesions. The relationship between MPV and patency of bridging vessels was analyzed in patients with coronary heart disease (CHD) complicated with type 2 diabetes mellitus, heart failure and arrhythmia. According to the enrollment criteria, 514 patients who had been admitted to Tianjin Thoracic Hospital from January 1, 2008 to September 30, 2014 were retrospectively analyzed. They were diagnosed as severe coronary artery disease by coronary angiography (CAG). They were treated with CABG in our hospital or other hospitals. Of them, 514 patients were admitted to the hospital for treatment of recurrent suspicious myocardial ischemic events. A total of 164 patients were enrolled in the study. 194 patients with normal coronary artery confirmed by CAG in Tianjin Thoracic Hospital from January 01, 2014 to January 01, 2015 were enrolled as control group. The bridge vessels were divided into two groups according to whether the bridge vessels were stenosed: the patency group and the lesion group. Patients with type 2 diabetes mellitus, with or without systolic heart failure, with or without arrhythmia were divided into three groups: diabetes subgroup, cardiac insufficiency subgroup and arrhythmia subgroup. Bypass time, history of myocardial infarction, family history, fasting venous blood test results, echocardiographic and chest radiographic results were recorded. F) 50% and 50% of cardiothoracic ratio were susceptible factors to CABG. (2) MPV (OR 1.550,95% OR 1.248-1.926), LP (alpha) value (OR 6.218,95% OR 1.624-23.810) and the number of venous bridges (OR 2.131,95% OR 1.427-3.181), HDL level (OR 0. 179,95% OR 0.057-0.560 was the protective factor for patency of bridging vessels (all p0.05). (3) Compared with the clinical data before and after cabg, the levels of hematocrit (hct), mean volume of red blood cells (mcv), red blood cell distribution width (rdw), blood glucose (glu), apolipoprotein (apro-a1), EF in the group with patency of bridging vessels decreased after operation. The levels of red blood cell (rbc), hct, platelet, mpv, total cholesterol (tc), low-density lipoprotein (ldl), ef, RBC and HCT were lower than those before operation, and the levels of plt, mpv, tc, ldl, EF were lower than those before operation. (4) the stenosis rate of high-level MPV group was significantly higher than that of low-level MPV group (all p0.05). the stenosis rate of bridging vessels was significantly higher in the high-level MPV group than in the medium-level MPV group (all p0.05). There was no significant difference between the two groups. Meanwhile, there was no significant difference between MPV and PDW (p0.05). (5) In type 2 diabetes mellitus subgroup, 220 patients, the number of patients whose MPV range was above 12 FL in bridge vascular disease group was more than that in bridge vascular patency group (p0.05), but other platelet parameters (plt, pdw, PCT level) between the two groups were not statistically significant. Significance. There were 98 patients in the subgroup of cardiac insufficiency, and the MPV level in the group of bridge vascular disease was higher than that in the group of bridge vascular patency (p0.05). There were 84 patients in the subgroup of arrhythmia, including 32 patients with atrial fibrillation, 30 patients with right bundle branch block, 12 patients with ventricular premature beats and 10 patients with sinus bradycardia. There was no significant difference between the two groups (p0.05). (6) the prognosis of patients with bridge vascular disease were predicted by MPV level, LP (a) level, the number of venous bridge branches and HDL level, and the receiver operating characteristic curve (roc curve) was drawn. the area under the curve (auc) were 0.657, 95% CI (0.586-0.727), 0.618, 95% CI (0.544-0.692) respectively. 0.628,95% CI (0.552-0.705); 0.606,95% CI (0.529-0.692); 0.606,95% CI (0.529-0.692). The best cut-off point of MPV was 10.45, the sensitivity was 0.497,95% CI (0.497,95% CI (0.472-0.522), specificwas 0.757,95% CI (0.757,95% CI (0.719-0.795); LP (a) was 0.175, 0.175, 0.717, 95% CI (0.717, 95% CI (0.681-0.681-0.753), specificwas 0.500, 95% CI The cut-off point is 1.500 and the sensitivity is 0.845,9. 5% CI (0.803-0.887), specificity is 0.686,95% CI (0.652-0.720); the best cut-off point of HDL is 1.085, sensitivity is 0.620, 95% CI (0.589-0.651), specificity is 0.614, 95% CI (0.583-0.645); combined with MPV value, LP (a) value, venous bridge number and HDL value binary logistic regression coefficient. The area under the ROC curve of combined diagnosis was higher than mpv, LP (a), the number of venous bridges and hdl, 0.770 (95% CI 0.706-0.833), which was statistically significant (p0.05). the best cut-off point was 0.881, the sensitivity was 0.706, 95% CI (0.671-0.741), the specificity was 0.714 (0.678-0.750). conclusion: the elderly, the history of type 2 diabetes mellitus, the NYHA classification Level II, ejection fraction (EF) 50%, and cardiothoracic 50% of patients with severe coronary artery disease were more likely to achieve revascularization and improve myocardial blood supply through CABG. Protective factors. Cardiac pump function can be improved after CABG. Antiplatelet and lipid-lowering therapy are still needed after CABG. The changes of MPV are related to pontine vascular disease in both type 2 diabetes mellitus subgroup and cardiac insufficiency. The joint prediction has the identification. Its sensitivity is 0.706 and specificity is 0.714 at the best cut-off point of 0.881.
【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】：2015
【分類號(hào)】：R654.2

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