【作者】 徐勇；

【导师】 陈如坤；

【作者基本信息】 浙江大学 ， 外科学， 2003， 博士

【摘要】 背景： 1．糖尿病与冠心病关系密切，糖尿病病人冠状动脉粥样硬化性心脏病的发病率较非糖尿病患者增加2-4倍，合并糖尿病的冠心病人无论内科治疗、介入治疗还是外科治疗，其预后均比非糖尿病组差。糖尿病和非糖尿病冠心病人冠状动脉病变的严重程度和弥漫性是否不同仍有争论。早期的冠状动脉造影分析显示合并糖尿病或糖耐量减低的冠心病患者更多地发生三支血管病变，较少发生单支病变。一些尸检报告也认为：合并糖尿病的冠心病患者动脉粥样硬化的病变范围更加广泛，病变呈弥漫性，而且更多累及左主干。近年来有一些研究对此提出了疑问。Waller等的尸检研究发现糖尿病和非糖尿病之间冠心病的严重性无明显差别。Hochman JS等的尸检研究认为糖尿病和非糖尿病冠心病患者冠状动脉狭窄在血管近、中和远端的分布无明显差异。一些学者通过一些评分系统比较了糖尿病和非糖尿病冠心病患者冠状动脉造影的特点，得出了相似的结论，Pia Pajunen等认为：冠心病不论是否合并糖尿病，在特定的年龄，临床症状相似的病人，其血管病变的严重程度和病变范围相似。Francois等按照1997年美国糖尿病协会(ADA)专家组制定的糖尿病的新标准，认为空腹血糖为7mM／L到7.7mM／L的轻度糖尿病的动脉粥样硬化情况与非糖尿病相似，仅仅狭窄程度＜50％的非严重病变的情况 浙江大学博士学位论文与传统的糖尿病相似。大多数研究多着重于分析病变的血管数，即一支病变、二支病变或三支病变，狭窄的严重程度和分布情况。通常只考虑严重病变（狭窄程度大于70％或75％以及梗阻性病变人这可能对总体评价冠状动脉粥样硬化造成偏差，并且低估了那些无血流动力学重要意义的非严重病变对判断预后的重要性。另外，对狭窄远端血管的弥漫性病变的分析描述少见报道。 2．冠状动脉搭桥术后心脏事件的常见预测因素包括：年龄、术前左心室功能、槽尿病、术后是否戒烟、病变的血管数目和性别（女性）。另外，在某些研究中，还列出了其他的一些预测因素如：心绞痛的分级、高血压、既往心肌梗塞史、肾功能不全、充血性心力衰竭、肥胖和没有使用胸廓内动脉。从解剖学的角度来讲，狭窄远端弥漫性病变或直径过细会限制冠状动脉搭桥术后移植血管和吻合口远端自身血管血流，容易发生血液滞留和血栓形成，从而导致移植血管失败和吻合口远端血管堵塞，尽管有时移植血管或吻合口远端自身血管维持通畅，由于血流受限而导致的缺血也会使再发心绞痛、新发严重心律失常、因充血性心力衰竭再次入院、再次介入治疗或冠状动脉搭桥术、急性心肌梗死、心脏性死亡等冠状动脉搭桥术后心脏事件容易发生。但是冠状动脉远端弥漫性病变不易量化描述，国内外文献未见有关远端弥漫性病变对冠状动脉搭桥术后心脏事件的预测价值的报道。目的： 设计一个半定量的评分系统，描述冠心病的冠状动脉造影特点，包括远端弥漫性病变。评价该评分系统的可靠性和可重复性。并且利用该评分系统比较接受冠状动脉搭桥病人中合并糖尿病和非糖尿病患者冠状动脉病变的特点，评价远端弥漫性病变评分对冠状动脉搭桥术后心脏事件的预测价值。方法： 一、病人选择： 2000年1月1日至2000年12月31日连续在沙特阿拉伯王国国家卫队医院心脏中心接受冠状动脉造影术和冠状动脉搭桥术的病人。合并糖尿病患者67例， 2 浙江大学博士学位论文非糖尿病患者40例。入选标准如下： 1．国籍为沙特阿拉伯国籍； 2．冠状动脉造影在手术前1月内施行： 3．单纯冠状动脉搭桥术。首次冠状动脉搭桥术； 4．冠状动脉搭桥术均在体外循环下进行； 5．使用至少一侧胸廓内动脉。 二、资料收集： 1．入院时病人一般情况、冠心病危险因素和疾病特点： 国籍、性别、年龄、吸烟、肥胖、高脂血症、糖尿病、高血压、心绞痛卜心功能、急性心梗史。 2．终点评价： 病人行冠状动脉搭桥术后均在沙特阿拉伯国家卫队医院心脏中心接受随访，随访时间 27士 3．4月u2卡3月入终点事件如下： （1）再发心绞痛； o）．新发严重心律失常； （3）．再次介入治疗或冠状动脉招桥术： （4）．因充血性心力衰竭再次入院； ⑤．急性心肌梗死； 历）．心脏性死亡。 以上终点事件如出现二项以上则记为一项。 三、冠状动脉评分方法： 1．评分对象： 冠状动脉树分为15个段，即左主干、近段左前降支／穿隔支、中段左前降支、心尖部左前降支、第一对角支、第二对角支、近段回旋支、中间支、第一钝缘支、第二钝缘支、后外侧支ln段回旋封第三钝缘支、后降支／第四钝缘支、远段右冠、中段右冠、近段右冠。 2．冠状动脉狭窄的记分方法： 狭窄程度0．24％记为0分；狭窄程度25－49％记为1分；狭窄程度50－74％记为更多还原

【Abstract】 BACKGROUND:Type 2 diabetes mellitus (DM) is associated with a two to four fold increased incidence of coronary artery disease(CAD). The prognosis is worse in CAD patients with type 2 DM than in those without after whatever treatments including medical, percutaneous transluminal coronary angioplasty (PTCA) or bypass surgery. The question of whether the severity, extent or diffuseness of CAD is different in diabetic patients compared with non-diabetic subjects is controversial. Some early angiographic comparisons have suggested that patients with diabetes or impaired glucose tolerance have more triple-vessel CAD and less single-vessel CAD than those with normal glucose tolerance. Some autopsy studies reported that diabetic patients had a greater incidence of left main coronary artery stenosis and more extensive and diffuse disease compared with nondiabetic subjects. But it has been questioned in more recent studies. Waller found that the severity of CAD was the same between diabetic and non-diabetic patients. Hochman JS et al’s autopsy study also demonstrated that CAD patients with DM had the same stenosis distribution in proximal, middle or distal vessels. Pia Pajunen suggested that CAD patients, with and without DM , who had similar symptoms at a given age, had similar severity and extent of CAD. Francois think that the situation ofCAD in mild DM patients (fasting glucose between 7nM/L and 7.7mM/L) is similar to non-diabetic patients. Most of these angiographic studies emphasized on the number of diseased vessels, like one-vessel disease, two-vessel disease and triple-vessel disease. Concerning the stenosis, generally only stenosis>70% was considered. This may bias the assessment of CAD, for it may underestimate the importance of those non-significant stenosis without rheology significance. Furthermore, many concepts are confused, especially the definition of diffuseness. Someone defined it as multi-vessel disease, someone defined it as a lesion >2cm, others also defined it as multi-lesions in one segment.The predictive factors of cardiac events after bypass surgery include age, preoperative left ventricular function, DM, cessation of smoking after bypass surgery, the number of diseased vessels, the classification of angina, hypertension, myocardial infarction history, renal failure, congestive heart failure, obesity and lack of using internal mammary artery. But anatomically, distal diffuse lesions or small vessel may theoretically restrict the blood flow, which predispose to stasis and thrombosis, resulting in both graft failure and vessel occlusion distal to the point of graft insertion. Even when the graft and the native artery remain patent, the ischemia caused by inadequate blood flow may predispose to recurrent angina, arrhythmia, congestive heart failure, re-intervention, myocardial infarction and cardiac death. The prognostic value of distal diftuseness score on cardiac event after bypass surgery has not been reported.OBJECTIVE:The present study seeks to show that the angiographic features of CAD with type 2 DM can be assessed by a structured quantificational reading of the coronary angiogram, especially distal difiuseness lesions, and that the distal difiuseness score predicts cardiac events after bypass surgery.METHODS:1. Patient selection:107 consecutive Isolated, non-emergency bypass surgery patients performed in Cardiac Science, National Guard Hospital, Saudi Arabia were included. 40 were non-diabetic, 67 were diabetic.Including criteria: Saudi nationality; Angiography were performed within 1 month before bypass surgery; isolated bypass surgery; first time bypass surgery; bypass surgery were performed under cardio-pulmonary bypass; at least one internal mammary artery was used.2. Data collection:(1)All demographic, CAD risk factors and clinical features of CAD were obtained from the database in Cardiac Science, which include nationality, gender, age, smoking, obesity, hyperlipidemia, DM, hypertention, classification of angina, heart function(NYHA) an更多还原