【作者】 牛海芳；

【导师】 车京津；

【作者基本信息】 天津医科大学 ， 内科学， 2011， 硕士

【摘要】 目的：近年来,冠心病(CHD)在我国的发病率呈迅速上升趋势,已成为威胁我国公众健康的重要疾病。现代生活方式的转变使CHD患者的发病年龄越来越早,冠脉病变程度越来越重。严重冠脉三支病变是导致终末期心力衰竭的主要原因,为个人和社会带来巨大的经济负担。目前关于早发严重冠脉三支病变危险因素的流行病学特点研究尚较少。本研究旨在探讨早发严重冠脉三支病变患者CHD危险因素的分布及聚集情况,对比不同性别CHD危险因素的差异并分析影响早发严重冠脉三支病变左室射血分数(LVEF)降低的因素,为年轻人防治冠脉严重病变提供依据。方法：连续筛选2009年3月-2011年3月天津医科大学第二医院心内科以CHD收入院并行冠脉造影检查的住院患者。根据冠脉造影结果筛选早发严重冠脉三支病变组(男性<55岁,女性<65岁；严重冠脉三支病变指按照定量冠脉造影法左前降支、左回旋支、右冠脉或左主干病变及右冠脉均有面积狭窄≥75%,病变组)339例和冠脉正常组(三支冠脉光滑、无狭窄或扩张,对照组)181例。对所有入选患者均记录性别、年龄,询问吸烟史、饮酒史、高血压史及病程、糖尿病(DM)史及病程、早发CHD家族史等。并计算体质量指数(BMI)=体重／身高2(kg/m2)。记录患者入院即刻抽血测定的血常规、凝血常规及肾功能。记录入选者空腹8小时次日清晨采取外周肘静脉血测定的肝功能、血脂、C反应蛋白(CRP)、肾素-血管紧张素-醛固酮等。常规行超声心动图检查评价心功能。采用SPSS11.5软件对数据进行统计处理。结果：1、两组间男性、吸烟史、高血压、DM、早发CHD家族史、代谢综合症比例及三酰甘油(TG)、高密度脂蛋白胆固醇(HDL-C)、BMI、尿酸(UA)、血小板(PLT)计数、白细胞(WBC)计数、纤维蛋白原(Fbg)、CRP水平差异有统计学意义(p<0.05)。多因素Logistic回归分析显示早发严重冠脉三支病变的危险因素有男性、早发CHD家族史、DM、肥胖、高TG血症、低HDL-C血症及高低密度脂蛋白胆固醇(LDL-C)血症。2、病变组与对照组相比危险因素分布存在差异,病变组危险因素个数>3的患者比例高于对照组(78.8%>25.4%,p<0.01),危险因素个数<3的患者比例低于对照组(2.6%<49.2%,p<0.01)。3、按性别行亚组分析显示男性病变与对照两组吸烟史、早发CHD家族史、BMI、HDL-C、LDL-C差异显著(p<0.05),女性病变与对照两组间早发CHD家族史、BMI、DM、高血压、TG、HDL-C差异显著(P<0.05)。病变组不同性别CHD危险因素比较时,男性组吸烟史、早发CHD家族史比例高于女性组(P<0.01),女性组DM、高TC血症及高TG血症比例高于男性组(p<0.05)。病变组男性危险因素个数>3的比例高于病变组女性(90.8%>38.5%)。4、病变组合并高血压、DM、吸烟或肥胖的患者TG水平高于对照组合并高血压、DM、吸烟或肥胖的患者,HDL-C水平低于对照组患者(P<0.01)。5、本研究亚组分析显示早发严重冠脉三支病变LVEF降低组(LVEF<50%) DM病程、BMI、CRP、PLT、肌酐(Scr)水平高于LVEF正常组(LVEF≥50%) (P<0.05),多因素logistic回归分析显示DM病程、肥胖及Scr是LVEF降低的影响因素。结论：1、早发严重冠脉三支病变的危险因素有男性、早发CHD家族史、DM、肥胖、高TG血症、低HDL-C血症及高LDL-C血症；2、早发严重冠脉三支病变患者存在多种CHD危险因素聚集现象,且3个以上危险因素聚集程度明显增加；3、不同性别早发严重冠脉三支病变患者CHD危险因素的分布及聚集存在差异。DM、高TG及高TC比例在女性早发严重冠脉三支病变患者中高,而吸烟史、早发CHD家族史比例在男性患者中高。男性早发严重冠脉三支病变危险因素聚集程度较女性强；4、无论合并高血压、DM、肥胖或吸烟,早发严重冠脉三支病变患者的TG水平较高而HDL-C水平较低；5、早发严重冠脉三支病变患者LVEF降低的相关因素有DM病程、肥胖及Scr水平。更多还原

【Abstract】 Objective:In recent years, incidence of coronary heart disease (CHD) tends increasing trend. It has been a main disease threatening the public health. The onset of CHD is earlier and the extent of coronary artery lesions is severer with the changing of modern life style. Severe three-vessel coronary artery lesion is the main cause for the end-stage heart failure, which brings tremendous economic burden for the society and the individual. Studies about epidemiologic features of risk factors of premature severe three-vessel coronary artery lesions were fewer.This study is to analyze the contribution and clustering of the risk facors for the premature severe three-vessel coronary artery lesions, and to provide the evidence for prevention of the premature CHD patients.Methods:Consecutive cases of hospitalized patients for CHD were collected at the Second Hospital of Tianjin Medical University during March 2009 to March 2011. All cases accepted coronary angiography. The criteria for premature severe three-vessel coronary artery lesions group included:(1) the onset age of CHD for male is less than 55 years old and for female is less than 65 years old; (2) severe three-vessel coronary artery lesions indicates the area stenosis of LAD, LCX, RCA or LM, RCA is more than 75 percent according to quantitative coronary angiography; The criteria for normal coronarography is that three coronary arteries are smooth without narrow or expansion; 339 cases for premature severe three-vessel coronary artery lesions and 181 cases for normal coronarography were included in the study. For all selected patients, medical history including gender, age, smoking, drinking alcohol, hypertention, diabetes mellitus (DM), positive family history (PFH) of CHD and so on were taken and body mass index (BMI) was measured. Routine blood cell test, blood coagulation and renal functions were measured at the moment of admission. At the next morning of admission peripheral venous blood was taken for the measurement of blood lipids, C reactive protein (CRP) and liver function. Routine examination of the echocardiography was performed. SPSS11.5 was used for statistical processing of data.Results:(1) There were significant difference in ratios of male, smoking, hypertension, DM, PFH of CHD, metabolic syndrome and the value of triglyceride, high-density-lipoprotein-cholesterol(HDL-C), BMI, uric acid, PLT, WBC, fibrinogen and CRP between groups(P< 0.05). Multiple logistic regression analysis showed that male, PFH, DM, obesity, low HDL-C level, high levels of low-density-lipoprotein-cholesterol (LDL-C) and triglyceride were risk factors for premature severe three-vessel coronary lesions. (2) The distribution of risk factors was different between disease group and control group. The ratio of patients with more than 3 risk factors was higher(78.8% vs 25.4%), and the ratio of patients with less than 3 risk factors was lower(2.6% vs 49.2%) in disease group than that in control group(P<0.01).(3) Subgroup analysis indicated that smoking, PFH, BMI, HDL-C, LDL-C were significantly different between male patients in disease group and male subjects in normal group. However, PFH, BMI, HDL-C, DM, hypertention, triglyceride were significantly different between female patients in disease group and female subjects in normal group(P< 0.05).Comparion of risk factors for two genders in the disease group showed that the ratios of smoking and PFH were higher in male disease group and the ratios of DM, hypercholesterolemia and hypertriglyceridemia were higher in female disease group(P<0.05).The proportion of risk factor number above three in male disease group was higher than female disease group(90.8% vs 38.5%).(4) Triglyceride level was higher and HDL-C level was lower in disease group with hypertention or DM or obesity or smoking than in control group with hypertention or DM or obesity or smoking(P<0.01).(5)Subgroup analysis showed that duration of diabetes, BMI, CRP, PLT and serum creatinine level was higher in LVEF reduction group(LVEF<50%) than LVEF normal group(LVEF≥50%) in patients of premature severe three-vessel coronary artery lesions(P<0.05). Multiple logistic regression analysis showed that duration of diabetes, obesity and serum creatinine level were predictors for LVEF reduction.Conclusion:(1) Male, PFH, DM, obesity, high LDL-C, low HDL-C and hypertriglyceridemia were independent risk factors for premature severe three-vessel coronary artery lesions. (2) Clustering of the main risk factors of CHD existed in the premature severe three-vessel coronary artery lesions and clustering extent of any three risk factors or more was significantly higher.(3) Risk factors were significantly different between two genders. DM, hypertriglyceridemia and hypercholesterolemia was significantly associated to female, while smoking and PFH was significantly associated to male. The clustering extent of risk factors was higher in male group.(4) The level of triglyceride was higher and the level of HDL-C was lower in patients with hypertention or DM or obesity or smoking of disease group than those subjects of normal group. (5) The risk factors associated with LVEF reduction in patients of premature severe three-vessel coronary artery lesions were duration of diabetes, obesity and high-creatinine.更多还原