【作者】 李雨薇；

【导师】 葛均波；

【作者基本信息】 复旦大学 ， 内科学， 2010， 硕士

【摘要】 机体循环中血细胞形态和体积的变化与一些疾病如血液系统疾病或心血管疾病的发生、发展甚至预后有一定的关系,而血细胞分布宽度的改变则可能对疾病的转归具有一定的评估价值。本文希望通过回顾性分析探讨血细胞分布宽度包括红细胞体积分布宽度(Red cell distribution width,RDW)及血小板体积分布宽度(Platelet distribution width or Platelet size deviation width, PDW)与心力衰竭及冠心病之间的关系,初步了解二者在临床上预测和评估心力衰竭及冠心病的应用价值,同时分析RDW及PDW能否用作对患者进行危险分层的指标为临床治疗提供参考。目的：红细胞体积分布宽度升高可能对冠心病及慢性心力衰竭的发生和预后有一定的预测和评估作用,本为拟通过回顾性分析探讨RDW与冠心病及心力衰竭之间的关系,并进一步了解红细胞体积分布宽度作为一个参考指标对冠心病或心力衰竭的预测价值及所能为临床医生提供的相关信息。方法：对250例2008年11月至2009年12月份因各种适应症在我院行冠脉造影的患者进行回顾性分析,根据冠脉造影结果将患者分为CAG(-)及CAG(+)两组,通过t检验比较两组患者间RDW是否存在差异。结合临床、实验室评价和心脏超声心动图检查,参照纽约心功能分级,将患者进一步根据有无心功能不全分为CAG(-)/NYHAI、CAG(-)/NYHAII-IV、CAG(+)/NYHAI、CAG(+)/NYHAII-IV四组,再通过单因素方差分析判断各组间RDW是否有统计学差异。其后,应用单因素分析、相关分析和多因素线性回归分析等了解它们之间的相关性,同时比较各组之间左室射血分数、左室舒张末期内径、血液学参数及生化等指标。结果：CAG(-)及CAG(+)组的RDW分别为13.16±0.91及13.13±1.10,两组之间RDW并没有统计学差异(P=0.845),但是在包括由心肌缺血及其他原因引起的慢性心功能不全NYHAII-IV级的患者与NYHAI级的患者间存在统计学差异,CAG(-)/NYHAII-IV及CAG(+)/NYHAII-IV组的RDW依次为13.55±1.08及13.36±1.27明显高于CAG(-)/NYHAI及CAG(+)/NYHAI组12.76±0.43及12.84±0.72,差异具有显著统计学意义(P<0.01)。其中同为心功能不全患者的CAG(-)/NYHAII-IV与CAG(+)/NYHAII-IV两组间RDW差异并没有统计学意义(P=0.916),而同为非心功能不全的CAG(-)/NYHAI及CAG(+)/NYHAI两组间RDW也没有统计学差异(P=0.985)。而在控制了年龄、血红蛋白、左室射血分数、左房内径、白蛋白和尿素等与心功能不全相关的预后和预测因子后,RDW的升高仍然与慢性心力衰竭呈独立正相关(回归系数=0.879,OR=2.408,P<0.01)。结论：红细胞体积分布宽度改变对冠心病的发生发展并没有预测能力,但是RDW升高与慢性心力衰竭的关系密切且独立正相关,进一步对该指标如何且为何与慢性心力衰竭有关及二者相关机制进行研究或者可以让我们更深入了解慢性心力衰竭的病理生理机制。目的：血小板体积的变化和功能与冠心病的发生发展密不可分,本研究希望通过对冠心病患者血小板体积分布宽度的回顾性分析,探讨作为反映血小板异质性的指标,PDW对冠心病的预测及其在临床上应用的价值。方法：资料为173例2008年11月至2009年12月份因各种适应症在我院心内科病房住院临床上排除了房颤及扩心、瓣膜病、风心等其他器质性心脏病的患者,对他们的临床资料进行回顾性分析。NCHD组即对照组为冠脉造影排除了冠心病的患者,SCHD组即病例组1为冠脉造影确诊有冠心病且非反复接受介入治疗或曾经接受外科搭桥手术治疗的稳定型冠心病患者,ACS组即病例组2为所有急性冠脉综合症(包括急性心肌梗塞、不稳定心绞痛)发作接受冠脉造影检查和介入治疗的不稳定型冠心病患者,以单因素方差分析比较三组间PDW的差异,同时比较各组的其他血液参数及生化指标,再进一步通过单因素分析,相关分析和多因素线性回归分析了解各组之间PDW与其他指标的相关性,分析PDW和冠心病之间的关系。结果：SCHD及ACS两组PDW的均值分别为13.83±2.63及13.84±2.13,皆为冠心病组之间没有差异(P=1.00),而两组的PDW明显高于NCHD组12.55±2.07(P<0.01)。此外,SCHD组的平均血小板体积(Mean platelet volume,MPV)和大血小板比率(Platelet large cell ratio,P-LCR)也较NCHD组明显升高为11.11±1.20 vs 10.48±0.88和32.74±9.96 vs 28.39±7.66(皆为P<0.01)；而SCHD组与ACS组没有明显差异(P>0.05)。在控制了年龄、性别等与冠心病相关的预测和危险分层因子后,PDW仍然与冠心病独立正相关(SCHD组OR=1.338, ACS组OR=1.352,P<0.01)。结论：血小板体积分布宽度、平均血小板体积及大血小板比率都是反映循环中血小板体积变化的指标,它们的升高与冠心病的发生呈正相关,对冠心病的预测具有一定价值,可以作为冠心病患者危险分层的指标。进一步研究大血小板的形态和功能,及大血小板与冠心病相关的机制或者可以让我们更深入了解冠心病发生发展的病理生理机制且在预防与治疗上有所突破。更多还原

【Abstract】 The changes of the morphology and size of blood cells are associated with the occurrence, development or the prognosis of related diseases for example hematologic diseases or cardiovascular diseases. Thus, the raise of blood cell distribution width may be an indicator of risk evaluation or stratification of the diseases. Our study sought to understand the relationship between blood cell distribution width, that is red cell distribution width (RDW) and platelet distribution width or platelet size deviation width (PDW) with coronary heart disease and heart failure through retrospective study. And to preliminary study and assess the value of both indicators in predicting cardiovascular diseases and the prognosis. In the other hand, to analysis whether the indicators can provide a reference for clinical treatment in prediction and stratification of high risk patients.Objective:The change of red cell distribution width might be valuable in predicting the occurrence, development and prognosis of coronary heart disease and chronic heart failure. Our study aimed to understand is there any existence of the relationship between coronary heart disease or heart failure and red cell distribution width. Thus further explore of the possibility of red cell distribution width to serve as a reference indicator for clinical doctors to provide relevant information of in stratify high risk patients.Methods:We performed a retrospective study on 250 cases that were included due to a variety of indications for coronary angiography in our hospital start from November 2008 to December 2009. The patients were defined into 2 groups according to coronary angiography results as group CAG(-) and group CAG(+), t-test comparison were used to compare whether differences of RDW exist in between the groups. Then, the two groups were further separated according to clinical manifestations, laboratory evaluation and cardiac echocardiography, and refer to the New York Heart functional class (NYHA), patients were divided into 4 groups which are CAG(-)/NYHA I, CAG(-)/NYHA II-IV, CAG(+)/NYHA I and CAG(+)/NYHA II-IV. We used One-way analysis of variance (ANOVA) inter-group comparison to examine the association between RDW and heart failure. Furthermore, single factor analysis and multivariate linear regression analysis were use to understand the co-relationship and relationship of RDW, heart failure and other markers such as left ventricular ejection fraction, hematology parameters, biochemical parameters.Results:There has no significant difference of RDW found between CAG(-)group and CAG(+) group, which were 13.16±0.91 and 13.13±1.10 respectively (P=0.845). However higher RDW in patients with heart failure in all-cause was detected,13.55±1.08 of group CAG(-)/NYHAII-IV and 13.36±1.27 of group CAG(+)/NYHAII-IV and there are significantly statistical difference compare to group CAG(-)/NYHAI and group CAG(+)/NYHAI which were 12.76±0.43 and 12.84±0.72 respectively (P＜0.01). In addition, there have no difference between the heart failure group CAG(-)/NYHA II-IV and CAG(+)/NYHA II-IV group (P=0.916), and no difference between groups without heart failure (P=0.985). For instant, RDW remains an independent factor that associated with chronic heart failure (regression coefficient=0.879, OR=2.408, P＜0.01) after adjustment of other predictor and prognostic factor of heart failure such as age, hemoglobin, left ventricular ejection fraction, left atrial diameter, albumin and urea.Conclusion:Red cell distribution width has no predictive ability of coronary heart disease, but the elevation of RDW was highly and independently associated with chronic heart failure. Thus, RDW can be clinically used as a parameter in risk stratification of patients with heart failure. On the other hand, further investigation of how and why this indicator relates to chronic heart failure and study of related mechanism will allow us to better understand the pathophysiology of chronic heart failureObjective:The occurrence and development of coronary heart disease are ultimately associated with the size and function of platelet. Our study aimed to determine the clinical value of platelet distribution width (or platelet size deviation width, PDW) as an indicator for prediction or risk stratification of coronary heart disease by retrospective analysis of particular population.Methods:Our retrospective study had included 173 cases which admitted to our cardiologic department started from November 2008 to December 2009, coronary angiography were performed in all cases and clinical atrial fibrillation, dilated cardiomyopathy, rheumatic heart disease or any other organic heart diseases were ruled out. The control group NCHD were the patients without coronary heart disease confirmed by coronary angiographic examination, group SCHD were patients with stable type coronary heart disease confirmed diagnosis by coronary angiography, repeated coronary angiography examination or post-CABG were excluded; study group 2 defined as group ACS were the patents who suffering acute coronary syndrome episode (both myocardial infarction and unstable angina) at admission and received coronary angiography and interventional treatment thereafter. We used one way ANOWA to test the different of PDW between the groups. Further analysis of variance (ANOVA), single factor analysis and multivariate linear regression analysis were use to understand their co-relationship and relationship with other blood parameters and biochemical parameters.Results:The mean of PDW of group SCHD and ACS were 13.83±2.63 and 13.84±2.13 respectively, there have no difference found between the groups as both of them were associated with coronary heart disease (P=1.000), but their PDW were significantly higher than group NCHD which PDW was 12.55±2.07 (P＜0.01). We also found that the mean platelet volume (MPV) and platelet large cell ratio (P-LCR) were associated with coronary heart disease, they are higher in group SCHD than group NCHD 11.11±1.20 vs 10.48±0.88 and 32.74±9.96 vs 28.39±7.66 (P＜0.01), and there had no statistic difference between group SCHD and group ACS (P＞0.05). In addition, after adjustment for coronary heart disease-related risk factors such as age and gender, PDW remained independently associated with coronary heart disease (OR=1.338 for group SCHD and OR=1.352 for group ACS, P＜0.01).Conclusion:Platelet distribution width, mean platelet volume and the platelet large cell ratio are the platelet volume indicator that can reflex the variability of circulation platelet, their raise was highly and positively associated with coronary heart disease. Therefore they may be the valuable independent indicators for risk stratification and prediction of coronary heart disease and can be useful in clinical practice. Further investigation of the mechanisms associated with coronary heart disease and large platelet will allow us to better understand the mechanisms, the development and the pathophysiology of coronary heart disease. Last but not least, to seek for the best strategy for coronary heart disease prevention and treatment.更多还原