【作者】 范焕青；

【导师】 张金涛；

【作者基本信息】 泰山医学院 ， 老年医学， 2010， 硕士

【摘要】 研究目的1.通过对大样本、多中心的临床资料分析,探讨急性缺血性脑卒中和出血性脑卒中患者入院时的血压水平与神经功能缺损的关系。2.通过对符合条件的缺血性脑卒中急性期患者进行血压干预,观察缺血性脑卒中急性期血压变化现象,探讨程序性血压控制与临床预后的关系。研究方法1.采用回顾性病例对照研究的方法,以2000年1月1日至2008年11月30日在山东省泰安市、潍坊市和淄博市3个城市4家医院神经内科住院的3231例急性脑卒中患者作为研究对象。根据影像学检查结果分为缺血性脑卒中和出血性脑卒中,采用统一设计的病例调查表,收集患者在入院后24小时(h)内的个人基本信息、生活方式信息、病史相关资料、实验室检查结果、入院时血压水平、影像学资料及神经功能评分(NIHSS)。用EpiDate软件建立数据库,采用SPSS13.0软件进行统计分析。两组均数的比较用t检验,率的比较用x2检验。将NIHSS分为两个水平,即NIHSS<5(轻度)和NIHSS>5(中重度)。采用多因素的非条件Logistic回归分析,计算不同收缩压(SBP)和舒张压(DBP)水平下NIHSS>5的比值比(OR)和95%可信区间(95%Cl)。2.采用临床随机对照研究的方法,以2009年5月1日至2009年11月30日在解放军八十八医院神经内科住院符合入选标准的49例缺血性脑卒中作为研究对象。随机分为实验组和对照组,实验组采取程序性降血压治疗,对照组采取常规治疗(原则上不予降压)；间断测量并记录研究对象入院后14天(出院)血压;收集患者的人口统计学信息、入院时血压水平、入院时实验室检查资料、病史相关资料以及临床预后(NIHSS、MRs)相关资料。用EpiDate软件建立数据库,采用SPSS13.0软件进行统计分析。两组均数的比较用t检验,率的比较用x2检验；分别计算并比较实施降血压治疗对预后(14天、1个月、3个月病死率、NIHSS、MRs)影响。研究结果1.通过对脑卒中患者一般特征的比较,缺血性脑卒中组的年龄和男性所占的比例均高于出血性脑卒中组,缺血性脑卒中组的高甘油三酯(TG)率、低高密度脂蛋白胆固醇(HDL-C)率、高低密度脂蛋白胆固醇(LDL-C)率、糖尿病史率、冠心病史率和心房纤颤史率均高于出血性脑卒中组;出血性脑卒中的高血糖率(BG)、入院收缩压、舒张压和入院NIHSS评分均高于缺血性脑卒中组：两组差异均有统计学意义(P<0.05)。(1)缺血性脑卒中患者的不同入院血压水平下,NIHSS≥5的OR值和95%Cl：以入院SBP<140mmHg作为参照,在调整性别、年龄情况下SBP≥180mmHg者NIHSS≥5的OR值具有统计学意义(P<0.05),NIHSS≥5的危险性是SBP<140mmHg的1.64倍;经多因素调整后,OR值(1.59)仍然具有统计学意义。以入院DBP<90mmHg作为参照,在调整性别、年龄情况下,DBP在90-99mmHg和100-109mmHg者,其NIHSS≥5的OR值分别为1.25和1.51,均具有统计学意义(P<0.05)；经多因素调整后,DBP在100-109mmHg者NIHSS≥5的OR值(1.34)仍具有统计学意义(P<0.05)。(2)出血性脑卒中患者不同入院血压水平下,NIHSS≥5的OR值和95%CI:以入院SBP<140mmHg作为参照,在调整性别、年龄的情况下,SBP在160-179mmHg和≥180mmHg者NIHSS≥5的OR值分别为2.46和2.32,均有统计学意义(P均<0.01)；经多因素调整后,各层次血压水平NIHSS≥5的OR值均无统计学意义(P均>0.05)。以入院DBP<90mmHg作为参照,在调整性别、年龄情况下,DBP在100-109mmHg和≥110mmHg者NIHSS≥5的OR值分别为2.26和3.04,均具有统计学意义(P均<0.01)；经多因素调整后,DBP≥110mmHg者NIHSS≥5的OR值(3.01)仍具有统计学意义(P<0.05),存在着随DBP升高NIHSS≥5的危险性增加的趋势(P<0.05)。2.实验组和对照组不同时间段血压的比较：入院后72h内SBP、DBP均波动明显,但总体呈下降趋势,这种现象在实验组及对照组同时存在,实验组比对照组波动幅度略小,但统计学分析无显著性差异(P>0.05)；4-7天两组比较有统计学意义(P<0.05),实验组血压下降幅度较对照组大,以SBP更为明显；7天后血压趋于稳定,14天(出院)两组比较无统计学意义(P>0.05)。14天(出院)、1个月两组NIHSS评分、MRs评分、病死率的比较均无统计学意义(P>0.05);3个月两组NIHSS评分、MRs评分的比较有统计学意义(P<0.05),两组病死率比较无明显差异(P>0.05)。研究结论1.(1)入院时SBP≥180mmHg和DBP在100-109mmHg与缺血性脑卒中的NIHSS评分相关联。(2)入院时DBP≥110mmHg与出血性脑卒中的NIHSS评分相关联。2.(1)缺血性脑卒中急性期程序性降压对患者14天(出院)及1个月时的NIHSS评分、MRs评分、病死率无明显影响。(2)缺血性脑卒中急性期程序性降压能够改善3个月时的NIHSS评分、MRs评分；对3个月时的病死率无明显影响。研究意义：该研究为缺血性脑卒中血压控制与临床预后的相关性分析方面提供了大量的、详实的临床资料,对于制定缺血性脑卒中急性期血压治疗策略,提供了理论依据和循证医学证据。更多还原

【Abstract】 Objective1.To investigate the relationship admission blood pressure levels and neurological function degree of acute ischemic and hemorrhagic apoplexy patients, through collect a large sample and multi-center clinical information analysis.2.By taking measures on blood pressure that met the criteria of acut cerebral infarction,To observe acute phase blood pressure variation rule. To investigate the relationship between procedural pressure control and the prognosis of ischemic apoplexyMethods1.A retrospective case-control study of epidemiological methods, the 3231 cases of acute stroke patients for the study form Tai’an,Weifang, Zibo,four hospitals of Neurology, that located three different cities,during January 1st,2000 to November 30th,2008. Acute ischemic and hemorrhagic stroke can be defined from imaging.On specialized training for investigators, the case of a uniform questionnaire designed to collect stroke patients hospitalized within 24 hours of basic personal information, lifestyle information, medical history information, laboratory results on admission blood pressure levels, imaging data and neurological score (NIHSS). Establish a database with EpiDate software, using SPSS13.0 software for statistical analysis. Mean were compared by t test and rate compared by X2 test, the both groups. The NIHSS score is divided into two levels, namely NIHSS<5 (mild), and NIHSS≥5 (severe). Multi Factors in Logistic regression analysis to calculate systolic and diastolic blood pressure levels of different NIHSS≥5 of the odds ratio(OR) and 95%confidence interval(95%CI).2. Using randomized control study of hospitalized,Selected from May 1st, to November 30th,2009 at the Hospital of the PLA 88 hospitalization of 49 patients that met the inclusion criteria of cerebral infarction for the study. Randomly divided into experimental and control groups, the experimental group to take procedural antihypertensive treatment; the control group to take conventional treatment (in principle, take no measure); continuous measure and record blood pressure within 14 days after admission. Collection of patient demographic information, admission blood pressure, admission laboratory data, medical history information and the clinical outcome (NIHSS, MRs) information. Establish a database with EpiDate software, using SPSS13.0 software for statistical analysis. Mean were compared by t test and rate compared byχ2 test, the both groups. The difference were compared between the implementation of antihypertensive therapy on prognosis (14 days,1 month and 3 months when the mortality, NIHSS, MRs) and long-term prognosis effects.Results1. By comparison of the general characteristics of patients with stroke, Both the age and the rate of the male are higher than Ischemic stroke, and patients with high triglycerides(TG), low high-density lipoprotein cholesterol (HDL-C), high density lipoprotein cholesterol ratio(LDL-C), diabetes history rates, coronary heart disease rates and atrial fibrillation history was higher than hemorrhagic stroke group; Hemorrhagic stroke rate of high blood sugar, admission systolic blood pressure(SBP), diastolic blood pressure(DBP) and NIHSS score were higher than ischemic stroke group. And the difference was statistically significant.(1)Ischemic stroke patients admitted to hospital with different blood pressure levels, NIHSS≥5 of the OR values and 95%CI. Adjusting for gender, age circumstances, and the admission SBP<140mmHg were compared, SBP≥180mmHg were NIHSS≥5 of the OR values were statistically significant (P<0.05), NIHSS score≥5 is the risk of SBP<140mmHg of 1.64 times. After adjustment by multiple factors, OR value (1.59) remains statistically signific-ant.With admission DBP<90mmHg as a reference, adjusting for gender, age circumstances, DBP 90-99mmHg and 100-109mmHg in those, the NIHSS≥5 of the OR values were 1.25 and 1.51, outcome were statistically significant (P<0.05). After multivariate adjustment, diastolic blood pressure of 100-109 mmHg who NIHSS> 5 of the OR value (1.34) still has a significant difference (P<0.05).(2) Hemorrhagic stroke patients admitted to hospital with different blood pressure levels, NIHSS> 5 of the OR values and 95%CI. Adjusting for gender, age circumstances, and the admission SBP<140mmHg were compared, SBP≥180mmHg in the 160-179mmHg and the OR were NIHSS≥5 were 2.46 and 2.32, outcome were statistically significant (allP<0.01). And by multi-adjusted, blood pressure levels of all those NIHSS≥5 of the OR values were not statistically significant (all P> 0.05).With admission DBP<90mmHg as a reference, adjusting for gender, age circumstances, DBP≥110mmHg were in the 100-109mmHg and NIHSS≥5 of the OR values were 2.26 and 3.04, outcome were significant differences (all P<0.01). After adjustment by multiple factors, DBP≥110mmHg were NIHSS≥5 of the OR value (3.01) still has a significant difference (P<0.05), there is increasing on NIHSS≥5 with DBP increased risk of a trend (P<0.05).2. Experimental and control group comparison of blood pressure in different time periods:within 72h after admission SBP, DBP fluctuations are obvious, but the overall downward trend, the phenomenon exists in the both group, the control group volatility slightly smaller and no statistically significant difference (P>0.05); acute ischemic and hemorrhagic The variation were significantly different (P<0.05) during 4-7 day groups. especially the systolic blood pressure; The blood pressure were stabilized after 7 days 14 days or at discharge showed no significant difference (P>0.05). The outcome no significant difference on 14 days and one month, MRs, mortality showed (P>0.05); The comparison two groups of 3 monthsNIHSS, MRs were signify-cant differences (P<0.05), and the mortality was no significant difference (P> 0.05).Conclusions1. (1)SBP≥180mmHg and DBP 100-109mmHg at admission were significantly associated with neurological function impairment among acute ischemic stroke patients.(2)DBP>110mmHg at admission was significantly associated with neurological function impairment among acute hemorrhagic stroke patients.2. (1)Antihypertensive therapy of acut cerebral infarction can not improve the prognosis of patients about 14 days and 1 month NIHSS, MRs, mortality. (2)Antihypertensive therapy of acut cerebral infarction can improve the prognosis of patients about 3 month NIHSS, MRs, but not make influnce on 3 months mortality significantlyResearch SignificanceThe research takes ischemic stroke lots of real clinical date on the blood control and prognosis, and applies the acue blood pressure therapy with theoretical basis and evidence-based medical evidence.更多还原