【作者】 李健；

【导师】 丛洪良；

【作者基本信息】 天津医科大学 ， 内科学， 2011， 硕士

【摘要】 目的：通过研究不同体脂测量指标与冠心病发病、类型以及病变严重程度的关系,探讨脂肪分布对冠心病的影响。观察术前联用不同剂量阿托伐他汀与普罗布考对择期接受经皮冠状动脉介入治疗(percutaneous coronary intervention, PCI)患者围手术期心肌损伤的保护作用,并探讨其可能机制。方法：选择拟诊为冠心病并进行冠状动脉造影的患者197例,其中男性118例,女性79例。其中确诊为急性心肌梗死患者52例；心绞痛患者100例；对照组(非冠心病组)45例。所有入选患者中无病变、单支病变、双支病变、三支病变的患者分别为45例,48例,51例和53例。入选其中101例接受择期PCI的冠心病心绞痛患者,随机分为标准联合剂量组24例,阿托伐他汀每晚顿服20 mg及普罗布考500 mg,2次/d：强化联合组38例,阿托伐他汀每晚顿服40 mg及普罗布考500 mg,2次/d,术前2h顿服阿托伐他汀40 mg普罗布考500 mg；强化剂量组39例,阿托伐他汀每晚顿服40 mg,术前2h顿服阿托伐他汀40 mg。入选病例抽血完成生化检查,应用酶联免疫法(ELISA)测定用药前及术后24小时血清基质金属蛋白酶-9(MMP-9)、髓过氧化物酶(MPO)及氧化性低密度脂蛋白(ox-LDL)水平。测量观察对象的身高、体质量、颈围(NC)及腰围(WC),计算体重指数(BMI)=体质量(kg)·身高(m)-2。对所选病例进行分组,结合临床及冠状动脉造影结果分为急性心肌梗死组、心绞痛组及对照组；按冠状动脉病变分为无病变组、单支病变组、双支病变组和三支病变组。对各体脂测量指标与血脂及冠心病程度进行相关分析,用Logistic回归评估各种危险因素与冠心病危险性的关系。结果：1.男性与女性脂肪的分布特点不同,冠心病的发病及严重程度亦存在差异(p<0.05)。2急性心肌梗死组与对照组及心绞痛组比较,体质量、腰围差异有统计学意义(p<0.05)；心绞痛组和急性心肌梗死组颈围大于对照组,p值分别为0.009和0.000。3.以冠状动脉病变支数不同所分的四组患者间颈围有统计学差异(p=0.014),无冠脉病变组颈围测量值小于双支病变组并显著小于三支病变组,p值分别为0.011和0.002。4. NC、WC及BMI与其他指标的多元相关分析：三者与TG及vLDLc正相关p<0.05),WC亦与CHO正相关、与HDLc负相关(均p<0.05)；颈围与冠心病类型和冠状动脉病变支数均显著相关(p值分别为0.000和0.002)。5多因素Logistic回归分析结果显示：BMI (beta=0.162, p=0.003);颈围(beta=0.222,p=0.000),糖尿病(beta=1.154,p=0.047)与冠心病的发生的关系最为密切,为冠心病的独立危险因素。6强化联合剂量组术后与术前CK-MB的差值小于标准联合剂量组(p=0.032),其术前与术后TnI的差值小于其他两组(p值分别为0.048和0.023)；7不同用药组患者术后血脂均较术前减低,但血脂差值在三组无统计学差异(p>0.05)。8强化剂量组术后MMP-9水平较术前升高(p=0.026),其他两组PCI术后MMP-9无显著升高；强化联合剂量组术后ox-LDL水平较术前显著降低(p=0.008)；MPO水平较术前减低(p=0.04),PCI术后与术前MPO差值小于标准联合剂量组和强化剂量组,p值分别为0.023和0.033。结论：1.腰围与血脂的关系较BMI和颈围更为密切；2.颈围对于预测冠心病的诊断较腰围和BMI更为灵敏,且与冠状动脉病变程度具有相关性；3.回归分析表明BMI和颈围是冠心病的独立危险因素；4.脂肪分布及含量须由各项体脂测量指标综合评价,从而对冠心病作出准确的风险评估。5.阿托伐他汀与普罗布考强化联合治疗能够减少PCI术后心肌损伤；这种对PCI术后心肌的保护作用不单纯依赖于血脂降低,其可能机制是抑制PCI术后炎症及氧化应激反应,改善微循环更多还原

【Abstract】 Objective:To investigate the association between distribution of body fat and coronary heart disease (CHD) by analysing the correlation between body fat distribution measures and incidence, type and severity of coronary heart disease. To investigate the association between distribution of body fat and coronary heart disease (CHD) by analysing the correlation between body fat distribution measures and incidence, type and severity of coronary heart disease.Methods:One hundred and ninety-seven patients(male 118 and female 79) with suspected coronary heart disease were studied by the case-contral method, who were divided into acute infarction (AMI) group (n=52)、angina group (n=100) and non-CHD group(n=45); and according to the results of coronary arteriography they were divided into:normal group(n=45),Single-vessel disease group(n=48) double -vessel disease group(n=51) and triple-vessel disease group(n=53). One hundred and one cases were randomly divided into 3 groups,standard combined treatment group(n=24,atorvastatin 20 mg,1 time/d and probucol 500 mg,2 times/d;intensively combined treatment group(n=38,atorvastatin 40 mg,l time/d,and probucol 500 mg,2 times/d,intaking bolus of atorvastatin 40 mg and probucol 500 mg 2 hours before intervention;intensive atorvastatin therapy group(n=39,atorvastatin 40 mg,1 time/d,bolus intaking atorvastatin 40 mg 2hours before procedure.Blood lipids were detected by the standard method, Keep the serum at the same time then matrix metalloproteinases-9(MMP-9)、myeloperoxidase(MPO) and oxidized low density(ox-LDL) were measured by enzyme immunoassay kit. Body surveying index consisting of the patients’ height, weight, neck circumference and waist circumference was measured and body mass index(BMI)were computed. Analysis the correlation between body fat distribution measures and incidence, type and severity of coronary heart disease.CHD risk factors were collected by logistic multivariate regression analysis.Results:1 Male and female have different features in distribution of body fat,and CHD has different characteristic in them (p<0.05)2 Compared with non-CHD group and angina groups, weight and waist circumference were higher in AMI group(p<0.05). Compared with non-CHD group, neck circumference were higher in angina and AMI groups (p=0.009&0.000) 3 In the four groups divided by vessel disease, there were significant difference in neck circumference (p=0.014), compared with double and triple vessel disease groups neck circumference were lower in single-vessel disease group (p=0.011&0.002)4 Multiple correlative analysis showed BMI、NC and WC were positively correlated with TG and vLDLc, WC was also correlated withchd and HDLc(p<0.05), NC was positively correlated with type coronary heart disease and the number of diseased vessels(p=0.000&0.002).5 Logistic multivariate analysis indicated that BMI (beta=0.162, p=0.003); NC (beta=0.222,p=0.000), diabetes (beta=1.154, p=0.047) were closely related to the hazard of CHD.6 Post/pre-PCI remainder of CK-MB in intensively combined treatment group is less than that in standard combined treatment group(p=0.032). There were statistically differences of post/pre-operative remainder of TnI among the three groups, and the difference in intensively combined treatment group is less than that in other two groups (p=0.048&0.023)7 The values of serum lipid profile are lower after PCI in all three groups, but there was no statistically differences of post/pre-PCI remainder of serum lipid profile among the three groups.8 The level of MMP-9 raised after PCI in intensive atorvastatin therapy group(p=0.026); The level of ox-LDL and MPO are lower than pre-PCI in intensively combined treatment group after PCI (p=0.008);post/pre-PCI remainder of MPO in intensively combined treatment group is less than that in the other groups (p=0.023&0.033)Conclusions:1 The associations with lipid were stronger for BMI and waist circumference than it for neck circumference;2 Compared with WC and BMI, neck circumference offered greater sensitivity for the diagnosis in coronary artery disease,and associated with the number of diseased vessels;3 BMI and NC were important risk factors of coronary artery disease; 4 Distribution and Content of fat should be comprehensively evaluated by various body fat distribution measures, so that risk evaluation of CHD can be provided;5 The intensively combined treatment of atorvastatin and probucol before percutaneous coronary intervention significantly reduces procedural myocardial injury in elective PCI, this protective effect is independent of lipid decreasing, the possible mechanism is reducing inflammation and oxidative stress reaction, and improving the microcirculation.更多还原