【作者】 党群；

【导师】 黄体钢；

【作者基本信息】 天津医科大学 ， 心血管内科， 2004， 博士

【摘要】 目的 以血管内超声(IVUS)为研究手段，在介入治疗前对急性冠状动脉综合征(包括急性心肌梗死和不稳定性心绞痛)患者和稳定性心绞痛患者的罪犯病变及近端、远端参考段进行观测，测量各部位的EEM面积、斑块面积、管腔面积，计算斑块负担、重塑指数，确定重塑方向(正性重塑，负性重塑，无重塑)，观察病变性质和特征，并分组进行对比研究，以探讨斑块大小、斑块性质、重塑方向和斑块的形态特征等在动脉粥样硬化发展与消退和急性冠状动脉综合征发生中的作用、与各种临床表现之间的关系和对临床治疗的指导意义。 研究对象与方法 1、在冠状动脉介入治疗前对73例冠心病患者进行血管内超声检查，男55例，女18例，年龄57.37±10.59岁(范围：23～73岁)。根据临床表现将入选病人分为三组：包括急性心肌梗死(AMI)组，共27例；不稳定型心绞痛(UAP)组，共22例；稳定型心绞痛(SAP)组，共24例。急性冠状动脉综合征(ACS)组共49例，为急性心肌梗死患者27例+不稳定型心绞痛患者22例。收集病人的临床资料，测定血糖、血清磷酸肌酸激酶(CK)、血清磷酸肌酸激酶同功酶(CKMB)、血清胆固醇(TC)、高密度脂蛋白胆固醇(HDL)、低密度脂蛋白胆固醇(LDL)、极低密度脂蛋白胆固醇(VLDL)、血清甘油三酯(TG)、载脂蛋白A1(APOA1)、载脂蛋白B(APOB)、脂蛋白a(Lpa)水平。血清胆固醇水平＞5.7mmol／l为高胆固醇血症，血清甘油三酯水平＞1.69mmol／l为高甘油三酯血症。稳定性心绞痛定义为6周内心绞痛频率、持续时间和强度无改变，不稳定性心绞痛定义为新发生的严重心绞痛、加重的心绞痛和休息时心绞痛，急性心肌梗死为3周内发生的心肌梗死。 2、按Judkins法将造影导管分别送到左、右冠状动脉开口，依次行选择性左冠状动脉和右冠状动脉造影，并同步电影记录造影影像，供以后测量分户 天津医科人学博_卜学位论文析。常规多体位投照，根据多个投照体位中显示狭窄最严重的造影图像，协助确定罪犯病变。 3、使用Boston Seientifie Ceivis血管内超声仪，采用3.2Fr 30 MHz超声导管，应用标准的冠状动脉内介入导管操作技术。在肝素抗凝和冠状动脉内注射硝酸甘油200陀后，将血管内超声导管通过导引钢丝越过靶病变，放至靶病变远端，采用自动回撤装置，以lmm/秒的恒定速度自动回撤至病变近端，并连续录像。再结合手动方式，将IVUS探头放至罪犯病变处，对罪犯病变及其附近血管段进行反复观测，并将WUS探头固定于罪犯病变处，注射造影剂，观察造影剂与斑块的关系，观测有无造影剂进入到斑块内。通过手工描记外膜和内膜的内边缘测量外弹力膜(EEM)面积和管腔面积，斑块面积为EEM面积减去管腔面积，斑块负担为斑块面积除以EEM面积。对患者的罪犯病变及近端、远端参考段进行IVUS检查，测量各部位的EEM面积、管腔面积，计算斑块面积、斑块负担、重塑指数，确定重塑方向，观察病变性质和特点，并在各组间进行对比研究。 4、IVUS图像分析①、各项定量指标的测量及定义 (l)、EEM面积:是指血管外弹力膜的横断面积，是手工描记外膜内边缘，通过计算机自动边缘测量系统测得的。 (2)、管腔面积:是指血管腔的横断面积，是手工描记内膜的内边缘，通过计算机自动边缘测量系统测得的。 ③、斑块面积:为EEM面积减去管腔面积。 (4)、斑块负担(pl叫ue bUrden):为斑块面积+EEM面积X 1 00%。 (5)、罪犯病变:为病变处有最小的管腔直径(MLD)，由冠状动脉造影协助确定。 (6)、近端参考段:为罪犯病变近端含有最少量斑块且没有分支的部位。 (7)、远端参考段:为罪犯病变远端含有最少量斑块且没有分支的部位。 (8)、动脉重塑计算:重塑指数为病变部位EEM面积与近端参段EEM面天津医科大学博卜学位论文积之比，重塑指数>l .05为正性重塑;重塑指数<0.95为负性重塑;重塑指数在0.95与1.05之间为无重塑。②、斑块性质的测定:斑块性质是通过目侧病变斑块成分而定的。 (1)、软斑块和硬斑块:软斑块的回声比血管壁外膜的回声弱，硬斑块与血管壁外膜的回声一致或比血管壁外膜的回声强。软斑块定义为斑块内密度低于外膜密度的成分占整个斑块的75%或以上，否则为硬斑块。 (2)、钙化斑块:钙化斑块的回声比血管壁外膜的回声强，其后方伴有声影。浅表钙化:钙化分布在靠近病变的管腔与内膜交界侧，趴离管腔较近，管腔与钙化之间看不到斑块。深部钙化:钙化分布在斑块的深层，靠近中层与外膜交界侧，距离外膜较近。墓 (3)、偏心斑块:斑块的最厚处与最薄处的厚度比值大于2:1。 (4)、破裂斑块:斑块内有腔洞，表面有撕裂的纤维帽，以注射造影剂时可见造影剂通过撕裂的纤维帽进入斑块内的腔洞确认。 5、统计学分析 应用SPSS10.0软件进行统计学检验与处理，计量资料川均数士标准差(x士s)表示。i{，量资料两组间比较采用非配对的t检验:计晕资料多组介lJ比较采用方差分析(。ne一way ANovA法);计数资料组间比较采川卜力一检验(xZ检验)。P<0.05为有统计学显著性差异。 结果 1、ACS、AMI、UAP和SAP四组?更多还原

【Abstract】 ObjectiveWe studied the culprit lesions,proximal and distal reference segments in patients with acute coronary syndromes(included acute myocardial infarctions and unstable angina pectoris) and in patients with stable angina pectoris before interventional therapy,measured the external elastic membrane cross-sectional area and lumen cross-sectional area,and calculated the plaque area, plaque burden, remodeling index and the direction of remodeling of each site, and compared the characteristics of each group to investigate the morphological and remodeling characteristics of coronary lesions in vivo with intravascular ultrasound, and to explore the relationship between plaque size,arterial remodeling ,lesion characteristics and clinical presentations.Methods1 73 cases of patients with coronary artery disease were studied using intravascular ultrasound before coronary intervention,55 cases were male, 18 cases were female,aged as 57.37+ 10.59 years(ranged 23 to 73 years).The patients were divided into three groups according to the clinical presentations:including the group of acute myocardial infarction, 27 cases; the group of unstable angina pectoris,22 cases; the group of stable angina pectoris,24 cases. The lesion site and a proximal reference site were analyzed .The external elastic membrane cross-sectional area and lumen cross-sectional area were measured,and the plaque area, plaque burden, remodeling index were calculated , and the direction of remodeling were determined. The characteristics of each group were compared.2 The selective coronary angiographys were performed according to theJudkins method,multiple projection views were taken.3 All IVUS studies were performed before any intervention and after the intracoronary administration of nitroglycerin 200 ug using a commercially available system (Boston Scientific Corp Ceivis ). The IVUS catheter was advanced distally to the lesion, and retrograde imaging was performed back to the proximally to the lesion (motorized pullback speed of 1 mm/s). The external elastic membrane and minimum lumen cross-sectional area (the minimum lumen area site) of the lesion sites and the proximal and distal reference sites were identified and measured. Plaque area was external elastic membrane cross-sectional area minus lumen cross-sectional area, plaque burden was plaque area divided by the external elastic membrane cross-sectional area.4 The calculation of remodeling index: The remodeling index was lesion external elastic membrane area divided by the proximal reference external elastic membrane cross-sectional area. We defined positive remodeling as a remodeling index of >1.05,negative remodeling as a remodeling index of <0.95, and neutral remodeling as a remodeling index between 0.95 and 1.05.5 The characterization of plaque: The characterization of plaque was qualitatively analysed according to the plaque composition. Hypoechoic plaque was less bright than the adventitia. Hyperechoic, noncalcified plaque was as bright or brighter than the adventitia without shadowing. Hyperechoic, calcified plaque was as bright or brighter than the adventitia with shadowing. Hypoechoic lesion within a plaque was >75% of the plaque , the plaque was considered "soft",otherwise, the plaque was considered "hard".Results1 There was no significantly differences among plaque area in ACS AMI UAP and SAPgroups.The plaque burden was significantly greater at culprit lesions in patients with acute coronary syndromes than in patients with stableangina pectoris2 The remodeling index was significantly greater in patients with acute coronary syndromes than in patients with stable angina pectoris(0.97 + 0.23 versus 0.79+0.13; P=0.003).The distribution of remodeling index in these two groups was different, Positive remodeling was more frequent in patients with acute coronary syndromes than in patients with stable angina pectoris (34.69% versus 4.17%,P=0.038), whereas negative remodeling was more frequent in stable angina pectoris (91.67% versus 46.94 % ,P=0.000).3 The remodeling更多还原