【作者】 张鹏飞；

【导师】 安毅；

【作者基本信息】 青岛大学 ， 内科学（心血管系病）（专业学位）， 2018， 硕士

【摘要】 研究目的目前,全球急性冠脉综合征(ACS)的防治形势严峻,统计显示,ACS患者每年发生的数量在美国是140万,而我国高达250万,其心血管病事件的发生率1年内为15-20%,6个月内的死亡率高达5-8%。而急性心肌梗死(AMI)作为ASC的一种类型,其致残、致死率极高。因此,对AMI早期识别和诊断,降低其风险具有重要临床意义。AMI患者的共同病理特点是冠状动脉粥样硬化斑块的破裂、血栓形成,也包括斑块侵蚀、血管痉挛等。人们针对这一发病机制,曾探索更多的临床指标及手段对AMI进行早期识别和干预。近年来我们研究发现尿酸(UA)与代谢综合征、多种肾脏疾病相关,UA可能通过脂质代谢紊乱等途径影响动脉粥样硬化斑块的形成,而既往研究发现颈动脉内膜中膜厚度(CIMT)与颈动脉动脉粥样硬化相关。本文旨在通过对临床病例数据的分析研究,探讨UA水平升高是否可以通过促使脂质代谢紊乱和炎症反应的途径,加速AMI的发病进展过程,了解AMI患者中尿酸及颈动脉内膜中膜厚度对于冠脉血管病变程度评价的临床意义,从而探索一种对于AMI更好的预测指标,作为在人群中AMI的风险识别因子。研究方法研究共入选102例临床诊断为AMI并成功行冠状动脉造影术的患者,将102例(平均年龄58±11.75岁)AMI患者按照高尿酸血症评判标准分为高尿酸组24例和对照组(尿酸正常组)78例。采集纳入研究患者的一般健康状况资料,包括现病史、既往病史、吸烟状况、饮酒情况,入院时的生化指标检查:血清尿酸(UA)、总胆红素(TB)、血清肌酐(SCr)、总胆固醇(TC)、甘油三脂(TG)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、空腹血糖(FBG)、超敏C反应蛋白(Hs-CRP);血浆内皮素(ET);颈动脉内膜中膜厚度(CIMT)及CAG的检查结果。纳入研究对象的AMI患者或其家属均签署与其相关的知情同意书,符合医学伦理学基本规范的要求。研究结果(1)从高血尿酸组与其对照组的分析结果可以看出:高尿酸组的甘油三酯(TG)、超敏C反应蛋白(Hs-CRP)及血浆内皮素(ET)水平显著升高,其差异有统计学意义(P=0.028,0.001,0.001);(2)从高血尿酸组与其对照组的数据分析可以看出:两组的CIMT存在明显差异(P=0.001)。(3)通过对CAG检查结果的数据进行对比分析,可以得到如下结论:UA与Gensini评分正相关(r=0.249,P=0.012)。(4)按照国际通用Gensini评分高低将AMI患者分为两组后分析,研究结论提示CIMT与Gensini评分正相关(r=0.703,P=0.000)。研究结论这项研究基于我国AMI人群,以样本对比研究的方式,首次分析评估了UA和CIMT的临床诊疗价值。本课题研究的意义在于探索UA通过促使脂质代谢紊乱、炎症反应的机制致使颈动脉及冠状动脉粥样硬化,UA和CIMT应当成为临床上评判冠状动脉血管病变进展的优先考虑指标,从而优化、简化AMI的诊断,最终目的是对AMI高危患者进行早期干预,降低AMI高危患者的发病率及其经济负担。更多还原

【Abstract】 objectiveAt present,the global acute coronary syndrome(ACS)prevention and control situa tion is severe.Statistics show that the number of patients in ACS is 1,400 thousa nd in the United States,and in our country is up to 2,500 thousand.The incidenc e of cardiovascular events is 15-20% within 1 year,and the death rate of 6 mont hs is up to 5-8%.Acute myocardial infarction(AMI),as a type of ASC,has high er disability and mortality.Therefore,it is of great clinical significance to identify and diagnose AMI early and reduce its risk.The common pathological characteristi cs of AMI patients are the rupture and thrombosis of coronary atherosclerotic plaq ues,including plaque erosion and vasospasm.In view of this pathogenesis,we are trying to explore more testing indicators and technical means,so that we can ident ify and intervene early in AMI.In recent years,we have found that uric acid(U A)is associated with metabolic syndrome and a variety of renal diseases.UA ma y affect the formation of atherosclerotic plaques through lipid metabolic disorders,and previous studies have found that carotid intima membrane thickness(CIMT)is associated with carotid atherosclerosis.The purpose of this study is to explore w hether the elevated level of UA can accelerate the progression of AMI by means of promoting lipid metabolism disorder and inflammatory response through the ana lysis of clinical case data.To investigate the clinical significance of uric acid and carotid intima media thickness to the degree of coronary angiopathy in AMI patie nts,and to explore a better predictor of AMI as a risk identification factor for A MI in the population.MethodLooking back the 102 cases of AMI patients with successful coronary angiograph y.The average age was(58 + 11.75)years.They were divided into 24 cases of high uric acid group and 78 cases in the control group(normal uric acid group)a ccording to hyperuricemia.The general health status of the patients was collected,including current medical history,past medical history,smoking status,drinking co nditions,and biochemical tests at admission: serum uric acid(UA),hypersensitive C-reactive protein(Hs-CRP),total bilirubin(TB),Serum creatinine(SCr),total choles terol(TC),triglyceride(TG),high density lipoprotein cholesterol(HDL-C),low de nsity lipoprotein cholesterol(LDL-C),fasting blood-glucose(FBG);plasma endoth elin(ET);carotid intima-media thickness(CIMT);the examination results of coron ary angiography.The selected subjects all signed the relevant informed consent,w hich conformed to the requirements of the basic norms of medical ethics.Result(1)From the analysis of the high uric acid group and the control group,the level s of triglyceride(TG),hypersensitive C reactive protein(Hs-CRP)and plasma end othelin(ET)in the high uric acid group were significantly increased,and the diffe rence was statistically significant(P=0.028,0.001,0.001).(2)From the data analysis of hyperuricemia group and control group,it can be se en that there is a significant difference between the two groups of CIMT(P=0.001).(3)By comparing and analyzing the data of CAG examination,we can get the fol lowing conclusion: UA is positively correlated with Gensini score(r=0.249,P=0.012).(4)According to the international general Gensini score,the AMI patients were di vided into two groups and the results showed that CIMT was positively correlated with the Gensini score(r=0.703,P=0.000).ConclusionThis study is based on the AMI population in our country.This study analyzed a nd evaluated the clinical diagnosis and treatment value of UA and CIMT for the f irst time.The significance of this study is to explore the pathogenesis of carotid a nd coronary atherosclerosis by inducing the mechanism of lipid metabolism disorde r and inflammatory response.UA and CIMT should be a priority index to evaluat e the progress of coronary artery disease in clinic,so as to optimize and simplify the diagnosis of AMI.The ultimate aim is to make early intervention for high-risk patients with AMI to reduce the morbidity and economic burden更多还原