【作者】 冯莹；

【导师】 杨波；

【作者基本信息】 武汉大学 ， 临床医学， 2012， 博士

【摘要】 冠心病是人类健康的主要杀手之一。冠心病患者极易伴发焦虑、抑郁等情感障碍,影响其生存及预后。广泛收集基线资料、临床资料,开展社会调查,分析与社会支持、生活质量、焦虑或抑郁等情感障碍、人格分型等息息相关的因素,为冠心病的一级预防及治疗提供有效指导,改善冠心病患者的生存及预后。随着治疗手段的进步,冠心病死亡率逐渐下降。对死亡结局进行相关因素logistic回归分析,结合临床实践,用于判断高危冠心病患者,为进一步降低死亡率、提升患者生存质量、改善患者预后提供可能。冠心病是造成心脏性猝死的首因,通常表现为各种类型的心律失常,故而分析冠心病患者临死前心电图或心律失常类型有助于了解、识别高SCD风险患者,防患于未然。基于生物-心理-社会医学模式,在冠心病的一级预防及治疗中,综合考虑,重点控制相关因素,必将有利于冠心病患者的生存及预后。第一部分目的：旨在探讨冠心病急性心梗患者基线及临床资料对生活质量、社会支持、焦虑、抑郁等情感障碍及人格分型的影响及其相关性。方法：收集急性心梗患者资料,运用量表进行社会调查,分层比较各项因素并分析相关性。结果：显著影响社会支持的因素有：年龄、性别、职业、居住地、文化程度、AST、CKMB、伴肺部感染、伴胸腔积液；显著影响生活质量的因素有：年龄、性别、职业、文化程度、心肌梗死部位、冠心病史、Cr、空腹血糖、伴心律失常、伴肺部感染；显著影响焦虑状态的因素有：职业、文化程度、心肌梗死部位、脑卒中病史、空腹血糖、BNP、心脏大小、伴心律失常；显著影响抑郁状态的因素有：性别、职业、文化程度、心肌梗死部位、脑卒中病史、BNP、伴心律失常。社会支持及生活质量评分呈正相关；焦虑及抑郁评分呈强正相关。不同的人格分型社会支持、生活质量、焦虑及抑郁评分均有显著差异。结论：缺乏社会支持,生活质量下降,不同的人格分型,焦虑及抑郁等情感障碍均能影响冠心病的发生、发展及预后,我们需从生物-心理-社会医学模式出发,综合控制各因素,改善患者生存及预后。第二部分目的：旨在探讨导致冠心病急性心梗患者心脏破裂死亡的危险预测因素。方法：收集急性心梗患者的基线及临床资料,分为存活组及死亡组,依次进行单因素及多因素二元logistic回归分析,并结合临床实际,确定具有心脏破裂预测价值的相关因素。结果：高龄,女性,ST段抬高心肌梗死,心肌酶升高,AST值升高,心率异常及脑卒中病史是急性心肌梗死后心脏破裂的高危因素；而既往冠心病史降低急性心肌梗死后心脏破裂发生的风险。结论：在冠心病急性心梗治疗中重点关注伴有高危因素的患者,将有助于降低心脏破裂死亡发生率,改善患者生存及预后。第三部分目的：旨在分析冠心病急性心梗后心脏性猝死患者临死前主要心律失常类型。方法：收集冠心病急性心梗后死亡患者的临死前心电图资料,分析直接致死原因并进行死亡分类,探讨心脏性猝死患者临死前心律失常类型及其机制。结果：急性心梗后死亡超过半数为心脏性猝死,首要原因为快速型室性心律失常(60.61%),其次为心脏破裂(30.30%)；缓慢型心律失常(9.09%)仅见于非心脏性猝死。结论：对高危人群及早应用置入型心律转复除颤器或导管消融术,预防恶性心律失常的发生,将有效降低冠心病急性心梗后心脏性猝死的发生率。更多还原

【Abstract】 Coronary heart disease (CHD) is the main killer to human health. CHD patients always have emotion disorder like anxiety or depression, which may have impact on their survival and prognosis. Collect baseline and clinical information, do some social research, analyze the most relevant factors to social support, quality of life, emotion disorder like anxiety or depression, and personality type, provide guidance to primary prevention and treatment of CHD, and improve patients’survival and prognosis. With the advance of treatment, the mortality of CHD is declining, Do logistic regression analysis to the factors about death, then combine with clinical practice, which can be useful to judge the CHD patients with high risk, so make it possible for further reducing mortality, improving quality of life and prognosis of patients. CHD is the most cause of sudden cardiac death (SCD), it often shows like any type of arrhythmias, so analyzing the before-death ECG or the type of arrhythmias of CHD patients can help understanding and identification of patients with high risk of SCD before some irreversible event happening. Base on the biology-psychology-society medicine model, during the primary prevention and treatment of CHD, considering all, focusing on relevant factors, will do good to the survival and prognosis of CHD patients.Part One OBJECTIVES:Aiming to discuss the impact of CHD acute myocardial infarction (AMI) patients’ baseline and clinical information on social support, quality of life, emotion disorder like anxiety or depression, and personality type, and analyze the correlation. METHODS:collect the information of AMI patients, do social research by scoring scales, compare every factor stratified, and analyze the correlation. RESULTS: Age, sex, profession, residence, education, AST, CKMB, lung infection and pleural effusion have significant impact on social support. Age, sex, profession, education, the site of myocardial infarction, the history of CHD, Cr, FBS, arrhythmias and lung infection have significant impact on quality of life. Profession, education, the site of myocardial infarction, the history of stroke, FBS, BNP, the size of heart and arrhythmias have significant impact on anxiety status. Sex, profession, education, the site of myocardial infarction, the history of stroke, BNP and arrhythmias have significant impact on depression status. There is positive correlation between social support and quality of life score, and there is strong positive correlation between anxiety and depression score. There exists significant difference among every type of personality. CONCLUSION:Lacking of social support, declining of quality of life, different personality type and emotion disorder like anxiety or depression all can influence the occurrence, development and prognosis of CHD. We must base on the biology-psychology-society medicine model, integrated control various factor, improve the survival and prognosis of CHD patients.Part Two OBJECTIVES:Aiming to discuss the predicting risk factors of death for cardiac rupture of AMI patients. METHODS:Collect the baseline and clinical information of AMI patients, group them into survival and death, do single-factor and multi-factors binary logistic regression and combine with clinical practice, then confirm the predicting factors to cardiac rupture. RESULTS:old age, female, STEMI, elevation of myocardial enzymes, elevation of AST, abnormal heart rate and history of stroke are high risk of cardiac rupture after AMI; history of CHD can lower the cardiac rupture risk. CONCLUSIONS:Focusing on the patients with high risk factors during the treatment of AMI will help reducing the incidence of cardiac rupture and improving the survival and prognosis.Part Three OBJECTIVES:Aiming to analyze the main types of arrhythmias of patients with SCD after AMI. METHODS:Collect the AMI patients’before-death ECG information, analyze the direct cause of death and give classification of death, then discuss the main types and mechanism of before-death arrhythmias of SCD patients. RESULTS:More than half of deaths after AMI are classified into SCD, the primary cause is rapid ventricular arrhythmias (60.61%), the second cause is cardiac rupture (30.30%); Brady-arrhythmia (9.09%) is found only in non-sudden cardiac death (NSCD). CONCLUTIONS:Using implantable cardioverter defibrillator (ICD) or radiofrequency catheter ablation (RFCA) to prevent malignant arrhythmias will reduce the incidence of SCD after AMI effectively.更多还原