本文選題：冠心病 + 斑塊分布譜��； 參考：《山東大學(xué)》2016年博士論文

【摘要】：研究目的：1.通過冠狀動脈造影深入探討疑似冠心病人群中冠狀動脈粥樣硬化斑塊分布譜的情況,從而達到臨床診斷,指導(dǎo)臨床治療。2.通過單因素和多因素分析多項血液指標(biāo)與冠狀動脈斑塊負荷評分TPS(Total plaque score)、SSS (Segment-stenosis score)和CADS (coronary artery disease severity)的關(guān)系,嘗試基于這些指標(biāo)建立一個無創(chuàng)、簡易的冠心病患者冠狀動脈粥樣硬化負荷篩查模型,減少患者的有創(chuàng)造影檢查,降低漏診率。材料和方法：共收集疑似冠心病癥狀住院患者1366例,確定其高險因素,行冠狀動脈造影,按照美國心臟病學(xué)會(American Heart Association, AHA)對冠狀動脈系統(tǒng)的劃分規(guī)則將冠狀動脈分為16段,通過造影結(jié)果,對冠狀動脈狹窄程度和斑塊進行圖像分析,分別計算總斑塊積分(TPS)、節(jié)段狹窄積分(SSS)、冠狀動脈嚴重程度積分(CADS)來定量評估冠狀動脈斑塊負荷,并且詳細描述粥樣硬化斑塊在冠狀動脈系統(tǒng)內(nèi)的分布譜。用平均值±標(biāo)準差和中位數(shù)±四分位間距(interquartile range,IQR)來描述他們的平均值和變異水平,使用非參數(shù)Kruskal-Wallis檢驗(H-test)來進行多重比較檢驗進一步分析組間差異(不同性別組和年齡組間)。同時為了直觀描述冠狀動脈粥樣硬化斑塊在冠狀動脈系統(tǒng)中的負荷程度,將每個冠狀動脈節(jié)段斑塊的發(fā)生率及不同狹窄程度發(fā)生的情況標(biāo)示在冠狀動脈樹型模式圖上。然后,使用校正過性別和年齡的logistic回歸模型來確定粥樣硬化斑塊負荷的獨立預(yù)測因子,將篩選出的獨立預(yù)測因子放入多因素logistic模型,使用逐步回歸法進一步篩選變量,構(gòu)建針對疑似冠心病患者的篩查模型。最后,使用ROC (receiver operating characteristic)曲線評估篩選出的模型的判別效應(yīng)。結(jié)果：1.納入1366名進行冠狀動脈造影的患者,其中造影結(jié)果顯示無狹窄261人,出現(xiàn)狹窄1105人。無狹窄人群的平均年齡為55.6歲,狹窄人群的平均年齡為60.8歲,兩者的差異具有統(tǒng)計學(xué)意義。狹窄人群的收縮壓、舒張壓、空腹血糖、血清總膽固醇、糖化血紅蛋白均高于無狹窄人群,高密度脂蛋白膽固醇低于無狹窄人群,差異具有統(tǒng)計學(xué)意義。兩組間甘油三酯與低密度脂蛋白膽固醇的差異無統(tǒng)計學(xué)意義。2.TPS和SSS評分都成顯著右側(cè)長尾的偏態(tài)分布,總體趨勢為積分越高人數(shù)越少,高分人群占比較低,大部分患者的得分集中于相對偏低水平。有7.17%(98/1366)的人SSS評分20分,5.56%(76/1366)的人TPS評分8分,44.36%(606/1366)的人SSS評分≤5分,76.57%(1046/1366)的人TPS-5分。3.TPS和SSS評分在不同性別和年齡組間均存在明顯的統(tǒng)計學(xué)差異。在不同性別組間,女性TPS評分平均值為2.81±2.81,中位數(shù)±四分位間距為2±2,男性TPS評分平均值為3.75±2.76,中位數(shù)±四分位間距為3±2.5,男性TPS評分高于女性,χ2=46.7659,差異有統(tǒng)計學(xué)意義(P0.0001)。女性SSS評分平均值為6.60±7.20,中位數(shù)±四分位間距為4±5.5,男性SSS評分平均值為9.11±7.24,中位數(shù)±四分位間距為8±5.5,男性SSS評分高于女性,χ2=51.6603,差異有統(tǒng)計學(xué)意義(P0.0001)。在不同年齡組間,52歲年齡組TPS評分平均值為2.45±2.52,中位數(shù)±四分位間距為2±2,52-59歲年齡組TPS評分為2.85±2.69,中位數(shù)±四分位間距為2±2.5,60-67歲年齡組TPS評分為3.51±2.86,中位數(shù)±四分位間距為3±2,=68歲年齡組TPS評分為4.60±2.69,中位數(shù)±四分位間距為5±1.5,可見TPS評分隨年齡增長而增加,χ2=123.4456,差異有統(tǒng)計學(xué)意義(P0.0001)。SSS評分也顯示出同樣的趨勢,52歲年齡組SSS評分平均值為5.73±6.23,中位數(shù)±四分位間距為4±4.5,52-59歲年齡組TPS評分為6.64±6.90,中位數(shù)±四分位間距為4±5.5,60-67歲年齡組TPS評分為8.43±7.56,中位數(shù)±四分位間距為7±5.5,=68歲年齡組TPS評分為11.37±7.22,中位數(shù)±四分位間距為11±5.5,可見TPS評分隨年齡增長而增加,χ2=126.5659,差異有統(tǒng)計學(xué)意義(P0.0001)。4.在TPS評分圖中,明確標(biāo)注每個冠狀動脈節(jié)段出現(xiàn)斑塊的頻率。在SSS評分圖中,同樣明確標(biāo)注每個冠狀動脈節(jié)段出現(xiàn)不同狹窄程度所占的百分比。通過TPS評分圖可見,盡管冠狀動脈的每個節(jié)段均有粥樣硬化斑塊出現(xiàn),但最常出現(xiàn)的部位是前降支近段,發(fā)生率高達51.39%,其次是前降支中段(39.68%)、右冠狀動脈近段(31.55%)、右冠狀動脈中段(28.92%)和左回旋支近段(27.89%)等。在SSS評分圖中,出現(xiàn)斑塊頻率最高的血管節(jié)段前降支近段的SSS評分分布為：0分：48.61%,1分：10.32%,2分：9.15%,3分：31.92%,其次的前降支中段的SSS評分分布為：0分：60.32%,1分：7.1%，2分：8.86%,3分：23.72%,隨后的右冠狀動脈近段的SSS評分分布為：0分：68.45%,1分：8.64%,2分：5.93%,3分：16.98%,右冠狀動脈中段的SSS評分分布為：0分：71.08%,1分：7.54%,2分：5.49%,3分：15.89%,左回旋支近段的SSS評分分布為：0分：72.11%,1分：7.03%,2分：6,.3%，3分：14.57%。5.使用體檢指標(biāo)預(yù)測冠狀動脈粥樣硬化負荷積分的logistic回歸分析結(jié)果發(fā)現(xiàn),TPS評分5、SSS評分5、CADS0,均對收縮壓、空腹血糖、甘油三酯、高密度脂蛋白膽固醇、糖化血紅蛋白有預(yù)測價值。對TPS評分5的模型,ROC曲線下面積(Area Under roc Curve, AUC)為0.756(95%CI:0.717-0.793), SSS評分5的模型的AUC為0.728(95%CI:0.687-0.766), CADS評分0的模型的AUC為0.753(95%Cl：0.713-0.789)證明。上述三個模型均可較好地預(yù)測存在嚴重粥樣硬化負荷的高危個體。結(jié)論：1.直觀地通過冠狀動脈樹形模式圖展示了疑似冠心病患者的冠狀動脈粥樣硬化斑塊負荷的分布情況；最常出現(xiàn)病變的部位是左冠狀動脈前降支近段,之后是右冠狀動脈近段、左前降支中段、左回旋支近段和右冠狀動脈中段。2.三種模型預(yù)測結(jié)果均較好,這表明三種模型可以在不進行CTA或DSA的情況下對疑似冠心病患者進行無創(chuàng)、簡易的初步篩查,降低患者的經(jīng)濟負擔(dān)和減少患者的有創(chuàng)檢查,降低漏診率。
[Abstract]:Objective: 1. the distribution spectrum of coronary atherosclerotic plaques in suspected coronary heart disease population was examined by coronary angiography, and the clinical diagnosis was achieved, and the clinical treatment of.2. was guided by single factor and multifactor analysis of multiple blood indexes and coronary plaque load score TPS (Total plaque score), SSS (Segment-stenos). Is score) and CADS (coronary artery disease severity) relationship, try to establish a non invasive, simple coronary atherosclerotic load screening model for patients with coronary heart disease, reduce the patient's creation examination, reduce the missed diagnosis rate. Materials and methods: a total of 1366 patients with suspected coronary heart disease symptoms were collected and determined. The high risk factor, coronary angiography, divided the coronary artery into 16 segments according to the rules of the American Heart Association (AHA) for the coronary artery system division. Through the results of the angiography, the degree of coronary stenosis and the plaque were analyzed. The total plaque score (TPS), the segment stenosis score (SSS), and the coronary artery were calculated. Pulse severity score (CADS) was used to quantify coronary plaque load, and the distribution of atherosclerotic plaque in the coronary artery system was described in detail. The mean values and interquartile range (IQR) were used to describe their average and variation levels, and the nonparametric Kruskal-Wallis test (H-t) was used. EST) to carry out multiple comparison tests to further analyze the differences between groups (different sex groups and age groups). In order to directly describe the degree of coronary atherosclerotic plaque in the coronary artery system, the incidence of each coronary atherosclerotic plaque and the incidence of different stenosis are marked in the coronary pattern pattern. Then, the independent predictor of atherosclerotic plaque load was determined by using the logistic regression model that corrected the sex and age. The independent predictors were selected into the multiple factor Logistic model, the stepwise regression method was used to screen the variables further, and the screening model for suspected coronary heart disease patients was constructed. Finally, the ROC (rece) was used. The iver operating characteristic) curve assessed the discriminant effect of the selected models. Results 1. included 1366 patients with coronary arteriography, among which 261 were not narrowed and 1105 were narrowed. The average age of the non stenosis population was 55.6 years and the average age of the narrow population was 60.8 years old. The systolic pressure, diastolic pressure, fasting blood glucose, serum total cholesterol and glycated hemoglobin were higher than those without stenosis, and the high density lipoprotein cholesterol was lower than that without stenosis. There was no statistical difference between the two groups of triglycerides and low density lipoprotein cholesterol (.2.TPS and SSS scores). The overall trend was a significant right long tail in the partial distribution, the overall trend was that the higher the higher the number of people, the higher the number of people, the high scores were relatively low, the scores of the majority of the patients were relatively low. The SSS score of 7.17% (98/1366) was 20, 5.56% (76/1366) was 8, 44.36% (606/1366) was less than 5, and 76.57% (1046/1366) was TPS-5.3. There were significant differences between TPS and SSS scores in different sex and age groups. The average value of TPS score was 2.81 + 2.81 for women, 2 + 2 in median, and 3.75 + 2.76 for male TPS score, and 3 + 2.5 in median + four. The TPS score of male was higher than that of women, and the difference was 2=46.7659. The mean value of P0.0001. The average value of female SSS score was 6.60 + 7.20, the median spacing of four division was 4 + 5.5, the average value of male SSS score was 9.11 + 7.24, the median spacing was 8 + 5.5, and the male SSS score was higher than that of the female, and the difference was statistically significant (P0.0001). The average value of the TPS score in the 52 age group was between the different age groups. The TPS score of 2.45 + 2 + 2,52-59 age group was 2.85 + 2.69, the median + four division spacing was 2 + 2.5,60-67 years, the TPS score was 3.51 + 2.86, the median spacing was 3 + 2, and the TPS score of the =68 age group was four. Long and increased, the difference was statistically significant (P0.0001).SSS score also showed the same trend, the average value of SSS score in the 52 year age group was 5.73 + 6.23, the median + four division spacing was 4 + 4.5,52-59 age group TPS score was 6.64 + 6.90, the median + four division spacing was 4 + 5.5,60-67 age group TPS score was 8.43 + 7.56, The distance between the number and four division was 7 + 5.5, the TPS score of the =68 age group was 11.37 + 7.22, the median interval of the four division was 11 + 5.5, and the TPS score increased with the age, and the difference was statistically significant (P0.0001).4. in the TPS score map. The frequency of each plaque in the coronary artery segment was clearly marked. In SSS score map, the same The percentage of different stenosis in each segment of the coronary artery was clearly marked. The TPS score showed that although atherosclerotic plaques appeared in each segment of the coronary artery, the most frequent site was the proximal descending proximal segment, the incidence of which was up to 51.39%, followed by the anterior descending branch (39.68%) and the right coronary artery (31.55%). The middle segment of the right coronary artery (28.92%) and the left circumflex proximal segment (27.89%). In the SSS score, the SSS score of the proximal descending segment of the vascular segment with the highest plaque frequency was 0: 48.61%, 1: 10.32%, 2: 9.15%, 3: 31.92%, followed by 0 points: 60.32%, 1: 7.1%, 60.32% %, 3: 23.72%, the SSS score of the proximal right coronary artery was divided into 0 points: 68.45%, 1: 8.64%, 2: 5.93%, 3: 16.98%, and 0 points: 71.08%, 1: 71.08%, 1. 6,.3%, 3 points: 14.57%.5. using logistic regression analysis of coronary atherosclerotic load integral using physical examination indicators found that TPS score 5, SSS score 5, CADS0, have predictive value for systolic blood pressure, fasting blood glucose, triglyceride, high-density lipoprotein cholesterol, glycosylated hemoglobin, and the area under ROC curve (Area Un) for TPS score 5 Der ROC Curve, AUC) the AUC of the model of 0.756 (95%CI:0.717-0.793), SSS score 5 is 0.728 (95%CI:0.687-0.766), the AUC of the CADS score 0 model is 0.753 (95%Cl:0.713-0.789). The above three models can better predict high-risk individuals with severe atherosclerosis load. Conclusion 1. intuitively passes the coronary artery tree pattern. The map shows the distribution of coronary atherosclerotic plaque load in patients with suspected coronary heart disease. The most frequently occurring lesion is the proximal part of the left anterior descending branch of the coronary artery, followed by the right coronary proximal segment, the middle of the left anterior descending branch, the left circumflex proximal segment and the right coronary artery in the middle segment of the.2. three models, which indicate the three models. In the case of no CTA or DSA, the type of patients with suspected coronary heart disease can be noninvasive, simple and preliminary screening, reduce the patient's economic burden and reduce the patient's invasive examination, and reduce the missed diagnosis rate.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R541.4

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