【作者】 王秀华；

【导师】 何国平；

【作者基本信息】 中南大学 ， 护理学， 2009， 博士

【摘要】 目的:①探讨老年冠心病抑郁状态患病情况及危险因素。②探讨炎症细胞因子白细胞介素-17(IL-17)及炎性标志物C反应蛋白(CRP)与老年冠心病抑郁状态的相关性。③了解综合干预对老年冠心病抑郁状态患者抑郁状况、生活质量及心肌缺血的影响。方法:①利用自制调查表、汉密顿量表、日常生活能力量表及社会支持评定表,采用面对面访谈方式收集资料,随机抽取长沙市望月湖、陈家湖、广济桥三个社区,调查了332例老年冠心病患者。②随机抽取38例老年冠心病抑郁状态患者及30例老年冠心病非抑郁状态患者作为研究对象,用夹心酶联免疫吸附法检测血浆白细胞介素-17和C反应蛋白浓度,用逆转录聚合酶链反应(RT-PCR)技术检测单核细胞白细胞介素-17表达情况。③随机抽取96例老年冠心病抑郁状态患者,分别进行综合干预(n=50)及药物治疗(n=46),,观察综合干预对老年冠心病抑郁状态的影响。结果:①老年冠心病患者332例,其中男性183例,女性149例。332例中抑郁状态患者152例,抑郁状态发生率为45.8%,女性发生率为48.9%,高于男性43.2%(P<0.05)。女性、年龄、文化程度低、日常生活不能完全自理增加患者抑郁风险,相应OR值分别为1.48、1.69、2.154、8.92(P均<0.05)。抑郁组主观支持评分及对支持利用度评分均低于对照组(P均<0.05)。②老年冠心病抑郁状态患者血浆IL-17、CRP浓度及单核细胞IL-17表达明显高于对照组(P均<0.01),老年冠心病抑郁状态患者血浆IL-17、CRP浓度随抑郁程度的加重而升高(P均<0.05)。老年冠心病抑郁状态患者血浆CRP浓度与IL-17浓度呈正相关(P<0.05):老年冠心病抑郁状态患者中,急性冠脉综合征合并抑郁组CRP、IL-17浓度及单核细胞IL-17mRNA均高于稳定型心绞痛合并抑郁组(P<0-01)。③综合干预与药物治疗组在HAMD评分、SAQ评分及ST段压低次数和持续时间方面较治疗前均明显改善(P均<0.05),综合干预组与药物治疗组疗效相当。结论:①对长沙市社区进行调查发现,老年冠心病患者抑郁状态发生率为45.8%,女性患病率高于男性;女性、年龄、文化程度低、生活不能完全自理及社会支持降低等与抑郁状态的发生有关。②白细胞介素-17及C反应蛋白在老年冠心病抑郁状态患者的炎性发病机理中可能起一定的作用,但其因果关系尚不能完全明了。③综合干预能减轻老年冠心病患者抑郁症状,提高患者生活质量,改善心绞痛症状。第一章老年冠心病抑郁状态与社会心理因素相关性分析目的:探讨老年冠心病抑郁的患病情况及危险因素方法:采用横断面调查的方法,于2006年7月至2008年2月对长沙市望月湖、陈家湖、广济桥三个社区的老年人进行调查,随机抽取冠心病患者332例,由经过培训的调查员使用统一的调查表进行入户面对面调查,调查表包括汉密顿量表’(HAMD)、日常生活能力量表、社会支持评定量表及自制调查表进行测评。结果:①332例对象中抑郁状态患者152例(45.8%),其中轻至中度抑郁状态者115例(34.6%),重度抑郁状态者37例(11.2%)。②70岁年龄组抑郁状态发生率高于60岁年龄组(分别为55.8%、36.9%,P<0.05)。③老年女性抑郁状态发生率高于老年男性(分别为48.9%、43.2%,P<0.05)。④女性、年龄、文化程度低、日常生活不能完全自理增加患者抑郁风险性,相应OR值分别为1.48、1.69、2.154、8.92。P均<0.05⑤抑郁状态组主观支持评分(15.0±3.9)及对支持利用度评分(6.4±2.0)均低于非抑郁状态组(分别为22.6±4.0 8.0±2.9,P均<0.05)。⑥客观支持评分、主观支持评分对及支持利用度评分与HAMD总分不相关(r分别为0.125、0.132、0.218,P均>0.05)。结论:老年冠心病患者抑郁状态发生率高;年龄增加,发生率增高;女性患病率高于男性;文化程度低、日常生活不能完全自理、社会支持降低与抑郁状态的发生有关。第二章老年冠心病抑郁状态患者白细胞介素-17和C反应蛋白的变化目的:探讨老年冠心病抑郁状态患者血浆白细胞介素-17浓度及单核细胞白细胞介素-17表达的变化和血浆C反应蛋白浓度的变化。方法:随机抽取38例老年冠心病抑郁状态患者做为研究对象,30例老年冠心病非抑郁状态患者为对照组,采用夹心酶联免疫吸附法(ELISA)检测血浆中白细胞介素-17及C反应蛋白浓度,采用逆转录聚合酶链反应(RT-PCR)技术观察单核细胞IL-17表达。结果:①老年冠心病抑郁状态组患者血浆IL-17、CRP浓度明显高于对照组(323.96±97.15 pg/ml、214.30±58.08 pg/ml,P<0.01)、(4.86±1.32ng/ml、2.16±0.69ng/ml,P<0.01);老年冠心病抑郁状态患者单核细胞IL-17表达明显高于对照组(0.55±0.14,0.26±0.08,P<0.01)②老年冠心病抑郁状态患者中,急性冠脉综合征合并抑郁状态组血浆IL-17、CRP浓度及单核细胞IL-17mRNA表达均明显高于稳定型心绞痛合并抑郁状态组(分别为372.67±91.39 pg/ml、284.57±84.45pg/ml;5.51±1.36ng/ml、4.28±1.01ng/ml;0.62±0.19、0.49±0.13。P均<0.01)。③老年冠心病抑郁状态组中,重度抑郁状态患者血浆IL-17明显高于轻-中度抑郁状态患者组(395.42±128.75pg/ml,310.27±96.35pg/ml,p<0.01)。重度抑郁状态患者血浆CRP浓度明显高于轻-中度抑郁状态组(4.90±1.38ng/ml,4.10±1.25ng/ml,p<0.01),重度抑郁状态患者单核细胞IL-17mRNA的表达明显高于轻-中度抑郁状态患者(0.61±0.22,0.48±0.13,p<0.01)。④老年冠心病抑郁状态组中,急性冠脉综合征患者重度抑郁比例高于稳定型心绞痛患者重度抑郁比例(P<0.05)。⑤老年冠心病抑郁状态组血浆CRP浓度与血浆IL-17浓度呈显著正相关(r=0.802,p<0.05),血浆IL-17及CRP浓度与抑郁评分呈正相关(r=0.672,P<0.05;r=0.421,P<0.05)。结论:白细胞介素-17及C反应蛋白在老年冠心病抑郁状态的发病机理中可能起重要的作用。第三章综合干预对老年冠心病抑郁状态患者生活质量的影响目的:对老年冠心病抑郁状态患者进行综合干预,观察综合干预对老年冠心病抑郁状态患者抑郁状况、生活质量的改善情况以及心肌缺血改善的效果。方法:选择老年冠心病抑郁患者96例,随机分为综合干预组(n=50)、药物治疗组(n=46)。二组患者均给予常规治疗,如硝酸盐类、β受体阻滞剂、钙离子拮抗剂、抗凝、抗血小板、调脂等治疗。药物治疗组在常规药物治疗基础上加用盐酸舍曲林(左洛复50mg Qd,辉瑞制药有限公司)。综合干预组采用综合干预措施进行干预。结果:①综合干预组及药物治疗组干预后HAMD、SAQ评分及ST段改变方面均有改善。综合干预组及药物治疗组HAMD评分较干预前明显改善(分别为17.87±5.38 VS 28.72±7.54,18.72±6.19 VS27.85±8.27,P均<0.01);活动受限程度评分较干预前均明显改善(32.32±8.67 VS 26.58±5.30,33.28±7.95 VS 27.32±5.47,P均<0.01)。治疗满意程度评分较干预前均明显改善(16.39±4.83 VS14.20±2.64,16.31±5.07 VS 13.98±4.02,P均<0.01);SAQ总分较干预前明显改善(80.25±25.32 VS 62.1 9±12.35,83.27±27.12 VS 63.07±13.54,P均<0.01);心绞痛发作情况评分较干预前明显改善(8.19±2.45 VS 7.05±2.35,8.06±2.63 VS 6.97±2.18,P均<0.05);疾病认识程度评分较干预前明显改善(12.28±4.03 VS 10.07±2.85,12.01±3.96 VS 9.98±2.91,P均<0.05);ST段压低次数较干预前明显改善(32.5±12.7 VS 84.3±13.8,31.9±13.9 VS 82.2±15.7,P均<0.05);ST段压低持续时间较干预前明显减少(88.4±28.7 VS 172.5±32.8,89.5±32.7 VS176.3±36.4,P均<0.01)。心绞痛稳定状态评分较干预前无统计学意义(3.52±0.87 VS 3.02±1.27 3.47±0.95 VS 2.95±1.15.P均>0.05)。②干预后,综合干预组及药物治疗组HAMD评分差值比较无统计学意义(9.03±3.15,9.35±3.01,P>0.05);疾病认识程度评分、活动受限程度评分、心绞痛发作情况评分、治疗满意程度评分、心绞痛稳定状态评分及SAQ总分差值比较均无统计学意义(分别为2.32±0.67 VS 2.28±0.65,6.32±1.81 VS 6.10±2.05,1.17±0.38 VS 1.08±0.29,2.13±0.68 VS 2.09±0.63,0.52±0.17 VS 0.49±0.16,19.98±6.56 VS 19.75±6.72,P均>0.05);ST段压低次数及ST段压低持续时间差值比较无统计学(50.08±16.75 VS 50.75±17.36,92.75±31.26 VS 88.75±30.92,P均>0.05)。结论:综合干预能减轻老年冠心病抑郁状态患者抑郁症状,提高患者生活质量,改善心绞痛症状。更多还原

【Abstract】 Objectives:①To explore the risk factors and morbility of depression in aging patients with coronary heart disease.②To evalute changes of the level of IL-17 and CRP in plasma of aging coronary heart disease with depression and expression of IL-17 in monocytes of these patients.③To know the role of comprehensive intervention to aging coronary heart disease with depression in depressive systom,quality of life and ischemia of myocardium.Methods:①A cross-sectional study was conducted in three communities of Wangyuehu,Chengjiahu,Guangjiqiao.322 aging CHD patients were selected.Face to face interview was used in data collection together with the HAMD,social support rating scales and self-made scales.The data were analysis in spss 15.0.②We analyzed the levels of IL-17 and CRP in plasma using enzyme-linked immunosorbent assay and expression of IL-17 in monocytes using RT-PCR in 68 patients divided into two groups. Depression group(n＝38)and un-depression group(n＝30).③The 96 depressive aging patients with coronary heart disease were alloted into comprehensive intervention group(n＝50),Drug therapy group(n＝46).We observed the effect of comprehensive intervention on depressive system,quality of life and ischemia of myocardium.Results:①The prevalence of depression in aging coronary heart disease was 45.8%in 332 patients.The prevalence of female patients is higher than that of male patients(48.9%vs 43.2%).Female,aging,lower degree culture and non-ambulatory patients had higher risk of depression with OR at 1.48,1.69,2.154,8.92.(all P＜0.05).Subjective support scores and utilized degree to support scores of depression groups were all higher than that of the control group(all P＜0.05).②Concentrations of IL-17 and CRP and expression of IL-17 in monocytes of aging coronary heart disease with depressive status were significantly higher than that of the control group(all P＜0.01).Concentrations of IL-17 and CRP were positively related to scores of HAMD(P＜0.05).Concentrations of IL-17 were positively related to CRP in plasma in aging coronary heart disease patients with depressive status(P＜0.05).Leves of CRP and IL-17 and expression of IL-17 in monocytes in acute coronary syndrom acccompanied depressive status were higher than those of stable angina acompanied depression(all P＜0.01).③Comprehensive intervention and drug therapy could improve scores of HAMD,scores of SAQ,frequency of ST depression and time of ST depression compared to treatment before(all P＜0.05).the effect of comprehensive intervention was the same as drug therapy.Conclusions:①we investigated conditions of aging coronary artery disease patients with depression in changsha for the first time.The results indicated that the prevalence of depression in aging patients with coronary heart disease was high.The prevalence of female patients was higherthan that of male patients.Female,aging,lower degree of culture, non-ambulatory and lower social support were correlation with depressive status.②For the first time we found that interleukin-17 and C-reactive protein may play an important role in the mechanism of aging coronary heart diseasewith depression.③Comprehensive intervention can lighten depressive systoms, elevate quality of life and improve symptoms of angina Chapter 1 Analysis of relationship between depressivestatus and psychosocial factors in aging coronary heartdiseaseObjective:To explore the risk factors and morbility of depression in aging patients with coronary heart disease(CHD)。Methods:A cross-sectional study was conducted in communities of wang yuehu,Chenjiahu and Guangjiqiao in changsha from June in 2006 to Feburary in 2008.332 CHD patients were selected randomly.Face to face interview was used in data collection together with the HAMD,social support rating scales and investigate scales self-made.Multinomial Logistic Model was adopted in date analysis.Results:①Among 332 patients,152 patients suffered from depression (45.8%).115 patients(34.6%) were minor to middle depressive disorders and 37 patients(11.2%) were major depression.②The prevalence,of depressive status in 70-year group was higher than that of 60-year group(55.8%VS 36.9%,P＜0.05).③The prevalence of depressive status in female aging patients was higher than that of male aging patients(48.9%VS 43.2%,P＜0.05). ④Female,age,lower culture degree and non-ambulatory patients had a statistically higher risk of depression with the OR at 1.48,1.69, 2.154,8.92,(all P＜0.05)⑤Subjective support scores and utilized degree to support scores of depressive stares groups were all higher than that of non-depressive status groups(15.0±3.9 VS 22.6±4.0,6.4±2.0 VS 8.0±2.0,respectively,all P＜0.05).⑥Objective support scores,subjective support scores and utilized degree to support scores were not correlation with HAMD scores.Conclusion:It was noticeable that the prevalence of depressive status in patients of aging coronary heart disease was high.With aging increasing,the prevalence increased,The prevalence of depressive status in female patients were higher than that of men patients.Low culture level, non-ambulatory patients and low social support were associated with depressive status. Chapter 2 Changes of interleukin-17 and C-reactive proteinin aging coronary heart disease patients with depressivestatusObjective:The aim was to evaluate levels of IL-17 and CRP in plasma of aging coronary heart disease patients with depressive status and expression of IL-17 in monocytes of these patients.Methods:We analyzed the concentrations of IL-17 and CRP in plasma using enzym-linked immunosorbent assay and expression of IL-17 in monocytes using RT-PCR in 68 selected patient randomly divided into two groups,depressive status group(n＝38)and un-depressive status group(n＝30).Results:①Concentrations of IL-17 and CRP were significantly higher in aging depressive status patient with coronary heart disease than those of the control group(323.96±97.15 pg/ml VS 214.30±58.08 pg/ml,4.86±1.32 ng/ml VS 2.16±0.69ng/ml,all P＜0.01).Expression of IL-17 in monocytes of aging depressive status with coronary heart disease were higher than that of the control group(0.55±0.14,0.26±0.08,P＜0.01).②In aging coronary heart disease patients with depressive status group,levels of IL-17 and CRP and expressions of IL-17 in monocytes in acute coronary syndrome accompanied depressive status group were higher than those of stable angina accompanied depressive status group. (372.67±91.39 pg/ml VS 284.57±84.45 pg/ml,5.51±1.36ng/ml VS 4.28±1.01 ng/ml,0.62±0.19 VS 0.49±0.13,all P＜0.01)③In aging coronary heart disease patients depressive status group concentrations of IL-17 major depressive status patients were significantly higher than those of minor to moderate depressive status patients(395.42±128.75pg/ml,310.27±96.35pg/ml p＜0.01).The plasma levels of CRP in aging coronary heart disease patients with major depression status were increased as compared,with minor to moderate depressive status patients(4.90±1.38ng/ml,4.10±1.25ng/ml,P＜0.01). Expression of IL-17 in monocyte of aging coronary heart disease with major depressive status were elevated as compared with minor to moderate depressive status patients(0.61±0.22,0.48±0.13, P＜0.01).Expression of IL-17 in the major depression patients were higher than that of the minor to moderate depression patients,(P＜0.05).④The prevalence of major depressive status in acute coronary syndrome was higher than that in stable angina in aging coronary heart disease patients with depressive status(P＜0.05).⑤The levels of CRP were positively related with IL-17 in aging coronary heart disease patients with depressive status (r＝0.802,P＜0.05).The concentration of IL-17 and CRP were positively associated with the scores of HAMD(r＝0.672,P＜0.05,r＝0.421,P＜0.05).Conclusion:Interleukin-17 and C-reactive protein are play an important role in the mechanism of aging coronary heart disease with depressive status. Chapter 3 The effect of comprehensive intervention onquality of life of aging coronary heart disease patientswith depressive statusObjective:To study whether comprehensive intervention for depression in aging patients with coronary heart disease(CHD) can or not lead to some improvement in depressive symptoms,quality of life and ischemia of myocardium.Methods:96 depressive status aging patients with coronary heart disease were alloted into comprehensive intervention group(n＝50),drug treatment group(n＝46)randomly.Patients received comprehensive intervention and anti-depressant serotonin HCIz(zoloft,Pfizer50mg qd) on the basis of conventional cardiac medicine therapy for 12 weeks in the comprehensive intervention group and drug therapy,respectively.Results:①After treatment scores of HAMD and SAQ and change of ST were improvement in comprehensive intervention group and drug treatment group.Scores of HAMD were lower than treatment before(17.85±5.38 VS 28.72±7.54,18.72±6.17 VS 27.85±8.27,respectively,all P＜0.01)in the two groups.Scores of activate restriction were higher than treatment before(32.32±8.67 VS 26.58±5.30,33.28±7.95 VS 27.32±5.47,all P＜0.01)in the two groups,Scores of contest degree were higher than treatment before(16.39±4.83 VS 14.20±2.64,16.31±5.07 VS 13.98±4.02,all P＜0.01)in the two groups.Total scores of SAQ were higher than treatment before(80.25±25.32 VS 62.19±12.35,83.27±27.12 VS 63.07±13.54,all P＜0.01),Score of angina attack were higher than treatment before(8.19±2.45 VS 7.05±2.35,8.06±2.63 VS 6.97±2.18,all P＜0.05).Frequency of ST depression were lower than treatment before(32.5±12.7 VS 84.3±13.8, 31.9±13.9 VS 82.2±15.7,all P＜0.05).Times of ST depression were lower than treatment before(88.4±28.7 VS 172.5±32.8,89.5±32.7 VS 176.3±36.4,all P＜0.01).There were no difference in the scores of angina stability between treatment before and.after treatment in two. group(3.52±0.87 VS 3.02±1.27,3.47±0.95 VS 2.95±1.15,all P＞0.05).②There were no difference in scores difference of HAMD among the two groups after treatment(9.03±3.15,9.35±3.01,P＞0.05).There were no difference in scores difference of degree to recognizing disease,activate restriction,angina attack,content degree,angina stability and total SAQ among the two groups(2.32±0.67 VS 2.28±0.65,6.32±1.81 VS 6.10±2.05,1.17±0.38 VS 1.08±0.29,2.13±0.68 VS 2.09±0.63,0.52±0.17 VS 0.49±0.16,19.98±6.56 VS 19.75±6.72 respectively,all P＞0.05).There were no difference in difference of frequency and times of ST depression among the two groups(50.08±16.75 VS 50.75±17.36, 92.75±31.26 VS 88.75±30.92,respectively,all P＞0.05).Conclusion:Comprehensive intervention can relieve depressive symptoms,improve quality of life and improve anginal symptoms.更多还原