【作者】 董福明；

【导师】 李廷富；

【作者基本信息】 中国医科大学 ， 老年医学， 2002， 硕士

【摘要】 前言 冠状动脉粥样硬化性心脏病和冠状动脉功能性改变一起统称为冠状动脉性心脏病(Coronary heart disease，CHD)，简称冠心病。冠心病的危险因素除了传统的危险因素如性别，年龄，吸烟，糖尿病，高血压，高脂血症等，在粥样硬化形成和发展过程中，代谢紊乱综合症起到不可忽视的作用，其中外周胰岛素抵抗(Insulin resistance，IR)是关键因素。IR是亚细胞、细胞、组织或机体的一种病理生理状态，是指正常浓度的胰岛素的生理效应低于正常，为了调节血糖在正常水平，机体代偿性分泌过多的胰岛素，即高胰岛素血症，从而引起机体一系列的病理生理的变化，最终导致多种代谢疾病的发生和发展。但现在IR的概念则泛指胰岛素在周围组织摄取和清除葡萄糖的作用减低。大多数研究证实，IR及其密切相关的代谢紊乱，如高血压、2型糖尿病、脂代谢异常一起成为CHD的主要致病因素，但IR可能起着主导作用。在IR的检测方法中，胰岛素敏感性的金标准是高胰岛素正常血糖钳技术，其次是Bergman微小模型法，但这些测定方法比较复杂，有采样多，病人耐受性差，费用昂贵等缺点，而不能应用于流行病学研究，多种以经验公式表示的胰岛素敏感性指数常用的有HOMA Model 20×FIns/(FPG-3.5)及1/Fins×FPG简单易行，适用于临床和大样本研究。 随着医学模式的转变，许多研究提出心理因素与CHD的发生发展有关。心理社会因素通过不良的生活习惯和行为方式激活神经内分泌机制，激活交感和血小板的活性，引起冠脉内皮功能损伤，粥样斑块，冠脉痉挛，促使冠脉狭窄，心肌缺血，引发严重的心血管疾病。对于患者的心理状态测评有许多量表，90项症状校核表uymptom Checklist 90，SCL－90厂主要用于反映精神病人和有躯体疾病病人的心理状态，适合于神经症、适应障碍及其它非精神病性疾病的心理障碍测评，同时反映心理因素对病人躯体症状的影响及心理健康程度。 但IR与心理社会因素之间的相互作用还未有明确的评估。本实验研究了IR及心理因素对CHD的作用，并分析了IR与心理因素之间的相互影响。 研究方法 对象为冠心病组50例，符合1979年WHO制定的缺血性心脏病的命名和诊断标准，平均年龄60．70 t 9．67岁。正常对照组50例，均系健康体检者，排除心血管疾病、糖尿病等，平均年龄 60．06。7．08岁。所有对象禁食 12小时后，采晨起空腹肘静脉血 srnl。用全自动生化分析仪测定血清甘油三脂门G人胆固醇＊h厂载脂蛋白AI（aPoAI八载脂蛋白B（aPoB厂葡萄糖（FBG）含量。采用放射免疫分析法测定胰岛素厂Ins）的含量。并计算 胰岛素敏感性指数（ISI）二 1／（Flus X FBG） 胰岛素抵抗（HOMA－IR）＝FIns x FBG／22．5 p细胞功能（HOMA－pced）＝20 X FIns／（FBG－3·5） 对所有对象采用SCL－90量表进行心理测评。所有数据以均值上标准差表示，利用SPSS软件进行统计学分析，两组间比较用 Student Ne删an－Keuls t检验及相关分析。当 P＜0．05时认为有统计学意义。 研究结果 与正常对照组比较，CHD组的TGJ、apoB显著增高，FBG无差异。CHD组的Fins、ISI．HOMA－JR、HOMA－pced与正常对照组相比有显著差异。CHD组躯体化、抑郁、焦虑、恐怖、饮 ·二·食睡眠障碍均显著高于正常对照组。相关分析的研究表明＊R与TGJ 尽poB名体化、抑郁、焦虑、恐怖、饮食睡眠障碍呈弱相关。 讨 论 IR时胰岛素的生理效应低于正常，主要表现在胰岛素抑制肝脏释放葡萄糖的能力及促进周围组织（主要是骨骼肌）摄取和利用葡萄糖的能力下降，导致代偿性高胰岛素血症，从而引起一系列病理生理变化。本研究结果显示，CHD存在IR，而且存在有血脂。载脂蛋白异常。并通过相关分析，显示出CHD血脂、载脂蛋白异常与IR密切相关。IR导致CHD可与下列机制有关：1．胰岛素可激活胰岛素样生长因子门GF一八，进而诱导动脉壁平滑肌细胞增生和变性，引起动脉壁内膜和中层增殖，管腔狭窄并促进动脉硬化。2．使血浆纤溶酶原激活剂抑制八（PAI一门增加，使纤溶活性降低，从而促进血栓形成。3．IR刺激膜转运系统，使血管平滑肌细胞的钙浓度增高，使小动脉平滑肌对缩血管物质的反应性增强，血管收缩。4．IR引起脂代谢异常也是CHD的重要致病因素。IR引起脂质代谢异常包括高的甘油三脂门G）血症、高的极低密度脂蛋白（VLDL）和低的高密度脂蛋白（HDL）血症。IR引起脂质代谢异常的机制与肝脏发生IR关系密切。IR是导致脂肪代谢紊乱的中心环节，且常先于脂质代谢异常发生。5．IR与CHD危险因素：糖尿病、高血压密切相关，加速动脉硬化形成。综上所述JR是CHD的重要致病因素，而且是CHD的独立危险因素。 心理因素是指影响疾病过程的认知与价值系统、个性、情感。态度以及行为方式等。情绪因素既是一应激原，又可影响个体对应激性刺激的认知评价和应付反应的程度。SCLapo，即疾?更多还原

【Abstract】 Coronary atherosclerotic heart disease and the coronary artery function changes are known together as Coronary heart disease, to be abbreviated as CHD. The dangerous factor of CHD apart from the tradition ’s dangerous factors, during the formation and development process of atheromatous, the metabolism disorder syndrome rise a can t be neglect role, among them insulin resistance(IR) is a key factor . IR is the physiology effect of normal concentration insulin is lower than normal, for regulating the blood sugar in the normal level, organic secrete the excessive insulin for compensation, so cause a series of pathologic physiology changes , which cause occurrence and development of various metabolism disease. IR and its closely - related metabolism disorder, such as the high blood pressure, 2 - diabetes, abnormality of lipid metabolism all become the main cause of CHD, but IR may rise the predominant function. In the IR examination methods the sensitive gold standard is a normal blood sugar clamp technique of high insulin, the next in order is a small model method of Bergman, but these measurement methods are more complicacy, and cant be applied in the epidemiology study, the variety insulin sensitivity that is indicated as the empirical formula, which is in common use are HOMA Model 20 FIns/( FPG -3.5) and I/ Fins x FPG is in brief easy line, so can be applied in clinical and big sample research.Along with the change of medical model, many research suggest that the mental state factor is relatived to the development and occurrence of CHD. The mental social factors activate the mechanism of nervours_endocrine with bad behavior method and living habit, activate sympathetic and blood platelets activity, cause the function damage of coronary endothelium , atheromatous plaque, coronary spasm, urge the coronary narrow, myocardial isocheimal, cause heart vascular disease. For evaluation of mental state the 90 item of symptom checklist ( SCL - 90) , used to reflect the mental disorder and body disease patients mental state, suitable for evaluation of mental state of psycho-neurosis , adjustment disorder and other non mental illness, reflect the influence of mental factor to patients body symptom.But the interaction effect between IR and mental social factor has not been definite valuated. This experiment studied the effect of IR and mental state factor to CHD, and analyzed the affect mutually between IR and mental state factor.Investigate methodsThe object is CHD group 50 pou, matching the standard of diagnosis and assigning name of isocheims heart disease established by WHO , average age 60. 70 ±9. 67Y. Normal matched control group 50 pou, all are healthy checkers, apart from heart - vascular disease, diabetes et al, average age 60. 06±7. 08Y. All the objects are fasting for 12 hours, and adopt the morning fasting elbow vein blood 5 ml. Use full - automatic biochemical analysis machine to measurement the serum glyceryl trioleate ( TG) , cholesterol ( Ch) , apoprotein A1 (apoA1) , apoproteinB ( apoB ) , glucose content ( FBG) . Adopting the radio - immunity analysis method to measurement the insulin con-tent (Fins). And calculate: Insulin sensitivity index number( ISI) = I/(Fins x FBG); The insulin resists (HOMA - IR) = Fins x FBG/22.5; B cell function (HOMA- B cell) =20 x FIns/( FBG -3.5).All objects are evaluated the mental state factor with the SCL -90. All data were expressed as mean value standard deviation. Statistics analysis was done using SPSS software. Comparison between two groups was tested by Student Newman - Keuls t test. When P <0. 05 were considered to be significant.Investigate resultCompare with normal matched control group, and the CHD group increased markedly in TG, apoA1, apoB; FBG make no difference, marked discrepancy in Fins, ISI, HOMA - IR, HOMA - B cell compare with the normal matched control group. In CHD group the symptoms of the somatization dimension, the depression dimension, the anxiety dimension, the phobic anxiety dimension, the diet and sleep dimens更多还原