本文選題：心房顫動 + 慢性腎功能不全�。� 參考：《中國人民解放軍醫(yī)學(xué)院》2015年博士論文

【摘要】：第一部分中老年非瓣膜性房顫患者腎功能不全對死亡、心腦血管死亡及血栓終點事件的影響目的：本研究擬探討腎功能不全是否為非瓣膜性房顫患者腦卒中等血栓栓塞性事件、全因死亡、心腦血管死亡等終點事件的獨立危險因素。方法：回顧性研究于2008年7月至2011年6月在中國人民解放軍總醫(yī)院住院治療的中老年非瓣膜性心房顫動患者825例,記錄一般情況、基礎(chǔ)疾病、實驗室檢查、超聲心動圖等基線特征及觀測期間內(nèi)全因死亡、心腦血管死亡及血栓終點事件發(fā)生情況。根據(jù)基線腎小球濾過率將入選患者分組,分別進(jìn)行Logistic多因素分析及Cox生存分析比較腎功能不全的危險因素及其對各終點事件的影響。結(jié)果：入選的825例未行抗凝治療的中老年非瓣膜性房顫患者慢性腎功能不全 (eGFR60ml/min/1.73m2)的患病率為21.09%,年齡≥75歲、女性、2型糖尿病、心力衰竭及左室肥厚是入選房顫患者發(fā)生慢性腎功能不全的獨立危險因素。入選患者平均隨訪時間為33.16±22.24月,共觀測2279.58人年。隨訪期間發(fā)生全因死亡209例、心腦血管死亡61例、血栓終點事件(腦卒中/TIA/外周動脈栓塞)139例及心血管事件(急性心肌梗死/急性左心衰)133例。合并慢性腎功能不全的房顫患者的全因死亡、心腦血管死亡、血栓事件及心血管事件發(fā)生率均顯著高于未合并慢性腎功能不全的房顫患者,在校正CHA2DS2-VASc評分后,慢性腎功能不全仍是全因死亡(HR:1.794,95%CI:1.330-2.419, P0.001),心血管死亡(HR:2.865, 95%CI:1.706-4.811, P0.001)、血栓事件(HR:1.636,95%CI:1.121-2.388, P=0.011)及心血管事件(HR:2.371,95%CI:1.651-3.404, P0.001)的獨立預(yù)測因素。此外,左房增大(LAVI40ml/m2)是血栓栓塞事件、全因死亡及心血管事件的獨立危險因素,而與心腦血管死亡無顯著相關(guān)。結(jié)論：慢性腎功能不全是中老年非瓣膜性房顫患者全因死亡、心腦血管死亡、血栓事件及心血管事件的獨立危險因素,且不依賴于CHADS2評分及CHA2DS2VASc評分。左房增大也與全因死亡、血栓事件及心血管事件獨立相關(guān)。第二部分血清胱抑素C對不伴有慢性腎功能不全的老年房顫患者的死亡及血栓終點事件的影響目的：本研究擬探討在不伴有慢性腎功能不全(eGFR60ml/min/1.73m2)的老年房顫患者中,血清胱抑素C對全因死亡、心腦血管死亡、血栓終點事件及心血管事件的影響。方法：回顧性研究于2008年7月至2010年6月在中國人民解放軍總醫(yī)院住院治療且基線資料完整的60歲以上老年非瓣膜性心房顫動患者356例,記錄基線特征及觀測期間內(nèi)全因死亡、心腦血管死亡及血栓終點事件發(fā)生情況。根據(jù)入選老年房顫患者基線血清胱抑素C水平的中位數(shù)(1.15mg/L)進(jìn)行分組,分別進(jìn)行Logistic多因素分析及Cox生存分析比較血清胱抑素C升高的危險因素及其對各終點事件的影響。結(jié)果：入選的356例不伴有慢性腎功能不全的老年非瓣膜性房顫患者平均隨訪37.83±21.87月,發(fā)現(xiàn)基線血清胱抑素c水平與尿酸氮、血肌酐及腎小球濾過率密切相關(guān),年齡≥75歲、吸煙、心力衰竭及左室肥厚是入選房顫患者血清胱抑素C升高的獨立危險因素。隨訪期間共發(fā)生全因死亡97例、心腦血管死亡27例、血栓終點事件共74例及心血管終點事件56例。在校正多種傳統(tǒng)心血管危險因素后,血清胱抑素C升高能夠獨立預(yù)測不伴有慢性腎功能不全的老年非瓣膜性房顫患者的全因死亡率(HR:1.936,95%CI:1.247-3.008, P=0.003)、心腦血管死亡率(HR:3.695, 95%CI:1.536-8.889, P=0.004)、血栓事件(腦卒中/TIA/外周動脈栓塞)(HR:1.725, 95%CI:1.055-2.819, P=0.030)和心血管事件(急性心肌梗死/急性左心衰)(HR:2.184, 95%CI:1.197-3984, P=0.011)的發(fā)生。結(jié)論：血清胱抑素c升高可以獨立預(yù)測不伴腎功能不全的老年非瓣膜性房顫患者的全因死亡、心腦血管死亡、血栓事件及心血管事件等終點事件的發(fā)生。第三部分心臟起搏器植入術(shù)后的老年陣發(fā)性房顫患者腎功能不全、左房容積指數(shù)及房顫負(fù)荷與血栓事件的相關(guān)研究目的：本研究擬了解植入起搏器的老年陣發(fā)性房顫患者再發(fā)房顫(包括無癥狀性房顫)的發(fā)生率及房顫負(fù)荷,探討房顫負(fù)荷的影響因素,初步分析腎功能不全、房顫負(fù)荷及左房容積指數(shù)對腦卒中等血栓事件的影響。方法：對2012年1月至2013年12月在我院起搏器門診長期隨訪的連續(xù)老年陣發(fā)性房顫患者148例進(jìn)行前瞻性觀察研究,記錄基線特征及隨訪期間內(nèi)房顫及血栓事件等臨床終點事件發(fā)生情況。根據(jù)照入選老年房顫患者的房顫負(fù)荷進(jìn)行分組,分別進(jìn)行Logistic多因素分析及Cox生存分析比較慢性腎功能不全、左房容積指數(shù)及房顫負(fù)荷對血栓終點事件的影響。建立新的血栓評分標(biāo)準(zhǔn),并應(yīng)用曲線下面積比較不同評分標(biāo)準(zhǔn)對血栓終點事件的預(yù)測能力。結(jié)果：所有患者平均隨訪時間為22.79±7.03月,85例患者再發(fā)房顫(57.43%),34例患者為房顫高負(fù)荷(22.97%),發(fā)生無癥狀房顫的患者為23例(15.54%)。多因素Logistic回歸分析發(fā)現(xiàn)左房增大分別是再發(fā)房顫(OR:3.524,95%CI: 1.339-9.276)及房顫高負(fù)荷(OR:8.110,95%CI:3.000-21.918)的獨立危險因素。在校正CHADS2評分基礎(chǔ)上,慢性腎功能不全(eGFR60 ml/min/1.73m2)和左房增大(LAVI28ml/m2)仍是血栓事件的獨立危險因素。將腎功能不全(R)和左房增大(L)引入CHADS2評分及CHA2DS2-VASc評分,發(fā)現(xiàn)R2CHADS2L評分和R2CHA2DS2-VAScL評分預(yù)測血栓事件的C值分別為0.740 (95%CI:0.655-0.826) 和0.749(95%CI:0.671-0.816),顯著高于CHADS2評分,但并不優(yōu)于CHA2DS2-VASc評分。而單獨將慢性腎功能不全納入CHADS2評分或CHA2DS2-VASc評分并不能提高血栓事件預(yù)測效能。結(jié)論：左房增大是預(yù)測房顫復(fù)發(fā)及房顫高負(fù)荷的危險因素,R2CHADS2L評分和R2CHA2DS2-VAScL評分預(yù)測血栓事件的效能高于CHADS2評分,但并不優(yōu)于CHA2DS2-VASc評分。
[Abstract]:Part 1: the effect of renal insufficiency on death, cardiac and cerebral vascular death and thrombus terminal event in middle-aged and elderly patients with non valvular atrial fibrillation. The purpose of this study is to explore whether renal insufficiency is an independent risk factor for thromboembolic events such as stroke in patients with non valvular atrial fibrillation, all causes of death, cardiac and cerebral blood tube death. Methods: a retrospective study was conducted in 825 patients with middle and old non valvular atrial fibrillation hospitalized in General Hospital of PLA from July 2008 to June 2011. The baseline features, basic diseases, laboratory tests, echocardiography, and all causes of death during observation, cardiac and cerebrovascular death and the occurrence of thrombus end point were recorded. Conditions. According to the baseline glomerular filtration rate, the patients were divided into groups. Logistic multivariate analysis and Cox survival analysis were used to compare the risk factors of renal insufficiency and their impact on the endpoint events. Results: 825 Cases of non valvular atrial fibrillation patients who were not treated with anticoagulant therapy were selected for chronic renal failure (eGFR60ml/min/1.7 The prevalence of 3M2 was 21.09%, age over 75 years, women, type 2 diabetes, heart failure and left ventricular hypertrophy were independent risk factors for chronic renal dysfunction in patients with atrial fibrillation. The average follow-up time was 33.16 + 22.24 months, and 2279.58 years were observed. 209 cases of total death, 61 cases of cardiovascular and cerebrovascular deaths, and thrombus were observed during the follow-up period. 139 cases and 133 cases of cardiovascular events (acute myocardial infarction / acute left heart failure) in 139 cases and 133 cases of cardiovascular events (acute myocardial infarction / acute left heart failure). Patients with atrial fibrillation with chronic renal insufficiency were dead, cardiac and cerebrovascular death, thrombus events and cardiovascular events were significantly higher than those without chronic renal failure. After the CHA2DS2-VASc score, chronic renal insufficiency was still an independent predictor of all causes (HR:1.794,95%CI:1.330-2.419, P0.001), cardiovascular death (HR:2.865, 95%CI:1.706-4.811, P0.001), thrombotic events (HR:1.636,95%CI:1.121-2.388, P=0.011) and cardiovascular events (HR: 2.371,95%CI:1.651-3.404, P0.001). Moreover, the left atrial enlargement (LAV) was enlarged (LAV). I40ml/m2) is a thromboembolism event that has no significant correlation with cardiovascular and cerebrovascular deaths due to independent risk factors for death and cardiovascular events. Conclusion: chronic renal insufficiency is an independent risk factor for patients with middle aged non valvular atrial fibrillation, cardiovascular and cerebrovascular death, thrombus events and cardiovascular events, and is not dependent on the CHADS2 evaluation. Scores and CHA2DS2VASc scores. Left atrial enlargement was also independent of all causes of death, thrombus events and cardiovascular events. Second the effect of serum cystatin C on death and thrombus terminal events in elderly patients with atrial fibrillation without chronic renal insufficiency (eGFR60ml/min/1.73m2): This study was to be explored without chronic renal insufficiency (eGFR60ml/min/1.73m2 In the elderly patients with atrial fibrillation, serum cystatin C was affected by all causes of death, cardiac and cerebrovascular death, thrombus terminal events and cardiovascular events. Methods: a retrospective study was conducted in 356 cases of non valvular atrial fibrillation who were hospitalized in General Hospital of PLA from July 2008 to June 2010, with complete baseline data of 60 years old and older non valvular atrial fibrillation. Baseline characteristics and total cause of death, cardiovascular and cerebrovascular death and the occurrence of thrombus terminal events during the observation period. According to the median of the baseline serum cystatin C (1.15mg/L) in the elderly patients who were selected, the Logistic multifactor analysis and Cox survival analysis were used to compare the risk factors for the increase of serum cystatin C and the risk factors for the increase of serum cystatin C Results: the average follow-up of 356 elderly non valvular atrial fibrillation patients without chronic renal insufficiency was 37.83 + 21.87 months. The baseline serum cystatin C level was closely related to uric acid nitrogen, blood creatinine and glomerular filtration rate, age more than 75 years, smoking, heart failure and left ventricular hypertrophy were selected as atrial fibrillation. An independent risk factor for elevated serum cystatin C. 97 cases of total cause of death, 27 cases of cardiovascular and cerebrovascular death, 74 cases of thrombus terminal event and 56 cases of cardiovascular endpoint events were observed during the follow-up period. After correcting a variety of traditional cardiovascular risk factors, serum cystatin C could be independently pretested for non chronic renal insufficiency All cause mortality (HR:1.936,95%CI:1.247-3.008, P=0.003), cardiac and cerebrovascular mortality (HR:3.695, 95%CI:1.536-8.889, P=0.004), thrombus event (/TIA/ peripheral arterial embolism) (HR:1.725, 95%CI:1.055-2.819, P=0.030) and cardiac vascular events (acute myocardial infarction / acute Zuo Xinshuai) (HR:2.184, 95%CI:1.197-3984). Conclusion: the rise of serum cystatin C can independently predict all causes of death, cardiovascular and cerebrovascular death, thrombus events and cardiovascular events in elderly patients with non valvular atrial fibrillation without renal insufficiency. Third patients with paroxysmal atrial fibrillation after cardiac pacemaker implantation in third patients have renal insufficiency, The correlation of left atrial volume index and atrial fibrillation load and thrombotic events. Objective: To investigate the incidence of recurrent atrial fibrillation (including asymptomatic atrial fibrillation) and atrial fibrillation load in patients with paroxysmal atrial fibrillation (PAF) implanted in the pacemaker, to explore the factors affecting the atrial fibrillation load, to analyze the renal insufficiency, the atrial fibrillation load and the left atrial volume index. Methods: a prospective study of 148 consecutive patients with paroxysmal atrial fibrillation in the outpatient department of pacemaker from January 2012 to December 2013. The baseline features and the occurrence of clinical endpoints such as atrial fibrillation and thrombotic events during the follow-up period were recorded. Logistic multifactor analysis and Cox survival analysis were used to compare the effects of chronic renal insufficiency, left atrial volume index and atrial fibrillation load on thrombus terminal events. A new standard of thrombus score was established, and the predictive ability of different scoring criteria on thrombus terminal events was applied. All patients were followed up with an average of 22.79 + 7.03 months, 85 patients with atrial fibrillation (57.43%), 34 patients with atrial fibrillation (22.97%), 23 patients with asymptomatic atrial fibrillation (15.54%). Multiple factor Logistic regression analysis found that the left atrial enlargement was OR:3.524,95%CI: 1.339-9.276 and the high load of atrial fibrillation (OR:8.110,95%CI: Independent risk factors of 3.000-21.918). On the basis of correction of CHADS2 score, chronic renal insufficiency (eGFR60 ml/min/1.73m2) and left atrial enlargement (LAVI28ml/m2) are still an independent risk factor for thrombus events. Renal dysfunction (R) and left atrial enlargement (L) were introduced into CHADS2 score and CHA2DS2-VASc score, and R2CHADS2L score and R2CHA2DS2-VAScL evaluation were found. The C values were 0.740 (95%CI:0.655-0.826) and 0.749 (95%CI:0.671-0.816), respectively, which were significantly higher than the CHADS2 score, but not better than the CHA2DS2-VASc score. However, it was not better to integrate the chronic renal insufficiency into the CHADS2 score or the CHA2DS2-VASc score. Conclusion: the left atrial enlargement is the prediction of atrial fibrillation. The risk factors of relapse and high load of atrial fibrillation, R2CHADS2L score and R2CHA2DS2-VAScL score were more effective than CHADS2 scores, but it was not better than the CHA2DS2-VASc score.

【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R541.75;R692

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4 ;中西醫(yī)結(jié)合治療慢性腎功能不全療效確切[N];中國中醫(yī)藥報;2004年

5 通訊員　 黃治才 寧習(xí)源 記者　 于莘明;慢性腎功能不全治療策略有望改變[N];科技日報;2006年

6 柳維剛;慢性腎功能不全誤診為慢性胃病淺析[N];農(nóng)村醫(yī)藥報（漢）;2006年

7 本報記者 譚允;飲食治療慢性腎功能不全[N];廣東科技報;2008年

8 ;腎衰寧膠囊延緩慢性腎功能不全[N];中國中醫(yī)藥報;2003年

9 北京大學(xué)人民醫(yī)院主任醫(yī)師 王少杰;慢性腎衰并非不可控[N];健康報;2009年

10 ;特色治療讓患者生存質(zhì)量更高[N];本溪日報;2009年

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