發(fā)布時間：2018-05-26 17:34

  本文選題：冠心病 + 冠狀動脈介入治療　； 參考：《中國人民解放軍醫(yī)學院》2015年博士論文

【摘要】：研究背景及目的研究背景盡管隨著醫(yī)學的飛速發(fā)展以及診療技術的進步,心血管疾病和大部分腫瘤的死亡率明顯下降,但是2013年最新人群死亡原因數據分析仍然顯示缺血性心臟病和腫瘤為全球死亡原因前兩位。冠心病和腫瘤已經成為嚴重威脅我國人群健康的多發(fā)病和常見病,特別是兩者還具有相同的發(fā)病人群(老年人)和重疊的危險因素(如吸煙、不均衡飲食、缺少鍛煉等),因此常常合并存在。隨著我國人口老齡化的進程,在臨床上冠心病合并腫瘤的患者也越來越多,針對這部分患者的診斷和治療尤其是手術策略,越來越成為心血管醫(yī)生和腫瘤�？漆t(yī)生不能忽視和不可回避的重要臨床問題。在合并冠心病的腫瘤患者中,如果需要外科手術切除腫瘤病灶,一定會首先評估心臟情況,如果發(fā)現心臟處于嚴重的不穩(wěn)定的缺血狀態(tài),會大大增加外科手術圍術期的急性心臟事件發(fā)生的風險,或者不能耐受外科手術。對于這些患者,必須首先對心臟行再血管化治療,才有機會行外科手術切除腫瘤病灶,并且心臟本身也需要盡快再血管化治療,降低嚴重冠狀動脈狹窄給心臟本身帶來的風險。因此術前準確評估患者心臟缺血程度和風險,做好再血管化治療,并在最短時間內進行腫瘤的外科限期手術,將會對這類患者產生巨大獲益,具有重要的臨床意義。由于治療上存在有一定的矛盾,如何對冠心病合并腫瘤患者做好預防性的再血管化治療,一直是困擾著心臟科和外科醫(yī)生的難題,其中最核心的問題就是：如何平衡好患者的缺血出血風險和手術獲益。AHA/ACC已經有明確指南,建議在非心臟手術前,對一些嚴重的心肌缺血患者應該進行預防性的再血管化治療；而腫瘤病灶切除則屬于外科限期手術,在各方面情況允許時應盡快手術。所以,目前爭論的焦點主要集中在：一、冠狀動脈介入手術后最快多長時間可以進行腫瘤手術?二、圍術期抗血小板、抗栓藥物如何應用?本研究回顧了解放軍總醫(yī)院近6年的冠心病合并腫瘤患者,分析了先冠狀動脈介入治療(PCI)后再行外科手術患者的臨床資料、圍術期用藥及預后,對患者死亡原因的風險進行析因分析,探討了PCI術后腫瘤切除最佳時機和圍術期合理應用抗血小板、抗栓藥物的問題�？偨Y治療經驗以及對預后的影響,旨在為提高腫瘤合并冠心病患者的治療療效、延長患者壽命提供臨床依據和指導。目的闡明冠狀動脈介入治療對腫瘤合并冠心病患者限期外科手術的安全性的影響,明確不同類型支架對腫瘤患者預后的影響是否不同。方法2006年03月-2012年03月在我科住院的冠心病合并腫瘤患者共209例,根據AHA/ACC對冠心病行非心臟手術前是否需要再血管化的指南,其中122例行先行冠狀動脈支架植入術,4周后再行腫瘤病灶切除術,為支架+腫瘤切除組；另外87例行單純冠狀動脈造影后次日轉外科行腫瘤病灶切除術,為造影+腫瘤切除組。比較分析兩組患者的基本資料、外科圍術期安全性。隨訪支架+腫瘤切除組患者的生存情況、科圍術期心血管事件發(fā)生情況。采用單因素、多因素生存分析的方法分析影響PCI術后短期內行腫瘤切除手術患者預后的影響因素。結果1、122位冠心病合并腫瘤患者行冠脈介入治療,共植入220枚支架,其中196(89.1%)枚為藥物洗脫支架,24(10.9%)枚金屬裸支架。手術即刻成功率為100%,支架后擴張率為100%。2、1例消化道腫瘤患者在冠狀動脈支架術后3天出現消化道出血,立即給與輸血,調整抗血小板、抗凝藥物的使用,急診行外科手術。75(61.5%)例患者在冠狀動脈支架術后第4至6周在我院完成了腫瘤病灶切除術,26(21.3%)例患者在第6至10周內完成了腫瘤病灶切除術,20(16.4%)例患者在第10周之后完成了腫瘤病灶切除術。3、冠狀動脈介入治療術后,在外科圍術期應用低分子肝素替代抗血小板藥物治療,患者術中出血量、術后引流量、手術時間、術后住院時間和應用抗血小板、抗凝藥物的患者比較,無統(tǒng)計學差異；支架+腫瘤切除組患者在圍術期沒有支架內血栓發(fā)生。4、支架+腫瘤切除組患者中位隨訪時間31個月,2年生存率為82.79%,3年生存率為68.85%。單因素及多因素分析發(fā)現PCI至手術間隔時間、CEA水平和心率對PCI術后行腫瘤切除患者生存時間有影響,而植入支架類型、植入支架冠狀動脈支數等因素對其生存時間無影響。結論1、對PCI術后短期內行外科腫瘤切除術的患者,圍術期應用低分子肝素替代抗血小板藥物治療是安全的；2、PCI術后6周內行腫瘤切除、心率控制在90次/分以下,是影響該組患者預后的保護因素；3、植入藥物洗脫支架和金屬裸支架組患者相比,圍術期安全性及遠期預后均無統(tǒng)計學差異。
[Abstract]:Background and objective research background, although with the rapid development of medicine and the progress of diagnosis and treatment technology, the mortality of cardiovascular disease and most tumors has declined significantly, but the analysis of the cause of death of the latest population in 2013 still shows that two of the leading causes of global death are ischemic heart disease and tumor. In order to seriously threaten the prevalence and common diseases of the health of the population in our country, especially in the same population (old people) and the risk factors of overlapping (such as smoking, unbalanced diet, lack of exercise, etc.), it is often combined. With the aging process of our population, patients with coronary heart disease combined with tumors are becoming more and more in the clinic. More and more, the diagnosis and treatment of this part of the patients, especially the surgical strategy, are becoming more and more important and important clinical problems that can not be ignored and unavoidable. In the patients with coronary heart disease, if surgical resection of the tumor is needed, the heart condition will be evaluated first, if the heart is found. Severe and unstable ischemic state can greatly increase the risk of acute cardiac events during surgical perioperative period, or can not tolerate surgery. For these patients, it is necessary to revascularization of the heart first to have the opportunity to surgical resection of the tumor, and the heart itself needs to be revascularized as soon as possible. Treatment, reducing the risk of serious coronary artery stenosis to the heart itself. Therefore, accurate assessment of the degree and risk of heart ischemia, revascularization, and surgical limited surgery within the shortest time will be of great benefit to these patients and have important clinical significance. A certain contradiction, how to do preventive revascularization for patients with coronary heart disease and cancer has been a difficult problem for the cardiology department and surgeons. The most important problem is: how to balance the risk of ischemia and bleeding in patients and the benefit of operation.AHA/ACC has a clear guide, it is suggested that before the non cardiac surgery, some Patients with severe myocardial ischemia should be treated with prophylactic revascularization; tumor resection is a surgical limit operation and should be operated as soon as possible in all aspects. Therefore, the focus of the current debate is: (1) how soon after coronary intervention is the fastest time for tumor surgery? Two, perioperative period How to use antiplatelet and antithrombotic drugs? This study reviewed the recent 6 years of coronary heart disease combined with tumor patients in the General Hospital of PLA, analyzed the clinical data of patients undergoing coronary intervention (PCI), the perioperative medication and prognosis, analysis of the risk of death of the patients, and discussed the tumor resection after PCI. In order to improve the therapeutic efficacy of the patients with coronary heart disease and prolong the life span of the patients with coronary heart disease, the aim of this study is to provide the clinical basis and guidance to improve the therapeutic effect and prolong the life span of the patients with coronary heart disease. The effect of the safety of the operation is to determine whether different types of stents have different effects on the prognosis of cancer patients. Methods 209 cases of coronary heart disease combined with tumors were hospitalized in our department in 2006, -2012, 03 months, according to the guidelines for revascularization for coronary heart disease before non cardiac surgery, and 122 of them were first coronary artery branch. 4 weeks later, the tumor resection was performed for the stent plus tumor resection group, and the other 87 cases were treated with the tumor resection group after the simple coronary angiography. The basic data of the two groups were compared and analyzed. The safety of surgical perioperative period was compared and the survival of the patients in the stent and tumor resection group was followed up. A single factor and multifactor survival analysis were used to analyze the factors affecting the prognosis of patients undergoing PCI resection in the short term. Results 1122 patients with CAD and tumor were treated with coronary intervention, and 220 stents were implanted, of which 196 (89.1%) were drug-eluting stents and 24 (10.9%). A bare metal stent. The immediate success rate of the operation was 100%. The poststent dilatation rate was 3 days after the coronary stent implantation in 100%.2,1 patients with digestive tract tumors. The blood transfusion was given immediately, the antiplatelet and anticoagulants were adjusted, and the emergency operation was performed in.75 (61.5%) patients fourth to 6 weeks after coronary artery stenting. Tumor excision was performed in the hospital. 26 (21.3%) patients completed tumor resection in sixth to 10 weeks. 20 (16.4%) patients completed tumor resection.3 after tenth weeks. After coronary intervention, low molecular weight heparin was used to replace antiplatelet drugs in surgical perioperative period. The amount of intraoperative bleeding and postoperative bleeding were observed. There was no statistical difference in the flow rate, the time of operation, the time of postoperative hospitalization and the use of antiplatelet and anticoagulant drugs. There was no stent thrombosis in the perioperative period of the stent plus tumor resection group.4, the median follow-up time of the stent + tumor resection group was 31 months, the 2 year survival rate was 82.79%, and the 3 year survival rate was 68.85%. single factor and more. Factor analysis found that PCI to operation interval time, CEA level and heart rate have an influence on the survival time of the patients undergoing tumor resection after PCI, and the type of stent implantation and the number of coronary artery support implantation have no influence on the survival time. Conclusion 1, low molecular weight heparin (LMWH) was used in the perioperative period of postoperative intraoperative surgical swollen tumor resection for PCI. The replacement of antiplatelet drugs was safe; 2, the tumor resection was performed within 6 weeks after PCI and the heart rate control was below 90 times per cent. It was a protective factor affecting the prognosis of the patients in this group. 3, there was no statistical difference between the perioperative safety and the long term after implantation of drug eluting stents and bare metal stents.
【學位授予單位】：中國人民解放軍醫(yī)學院
【學位級別】：博士
【學位授予年份】：2015
【分類號】：R541.4;R730.5

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