【作者】 王喆；

【导师】 董建增；

【作者基本信息】 郑州大学 ， 内科学（心血管病学）（专业学位）， 2021， 硕士

【摘要】 背景房颤(atrial fibrillation,简称房颤)是临床上最常见的心血管疾病之一,房颤的发生可以使患者心力衰竭、肾功能损害等风险明显增加。目前导管射频消融术(radiofrequency catheter ablation,RFCA)是房颤的主要治疗方式。然而房颤患者消融术后的复发率不低。阵发性房颤患者在环肺静脉电隔离(circumpulmonary venous electrical isolation,CPVI)消融术后随访1年手术成功率保持在70%～90%,持续性房颤更低为65%～75%。房颤具有许多危险因素使其消融术后复发率增加,比如合并高血压、代谢综合征、睡眠呼吸暂停综合征等疾病。胰岛素抵抗是胰岛素反应下降的一种状态,其表现出的体征包括肥胖,血糖升高,血脂异常和血压升高等,胰岛素抵抗认为是代谢综合征的构成部分,也是2型糖尿病的前兆。胰岛素抵抗是糖尿病和代谢综合征的共同特性,是异常葡萄糖代谢发生发展的潜在机制。空腹血糖受损和葡萄糖耐量受损,可导致心房内电传导延迟和低电压区域的形成,使得房颤的发生机率加大。研究发现胰岛素抵抗的患者发生房颤的易感性增加。目前房颤患者导管消融术后复发率与胰岛素抵抗之间关系尚不明确,胰岛素抵抗是否会影响房颤患者导管消融术后的复发仍需要进一步的研究来证实。目的分析影响房颤患者导管射频消融术后复发的危险因素,探讨胰岛素抵抗对房颤导管射频消融术后复发的影响。方法选取2018年1月至2019年6月期间在郑州大学第一附属医院心内科住院的222例首次进行导管射频消融的房颤患者为研究对象,进行回顾性研究。将胰岛素抵抗定义为稳态模型胰岛素抵抗指数(homeostasis model assessment of insulin resistance,HOMA-IR)≥2.69,根据房颤患者有无胰岛素抵抗,分为胰岛素抵抗组(n=66)和无胰岛素抵抗组(n=156),并比较两组房颤患者基线临床资料的差异。房颤患者消融术后第3、6、9、12月行门诊和电话随访,检查患者的体表心电图和(或)动态心电图,患者院外期间出现临床症状时及时到就近医院就诊有无复发房颤。依据房颤消融术后随访12个月是否复发,分为房颤复发组(n=58)和未复发组(n=164)。将两组患者的指标采用logistic回归分析房颤复发的危险因素。并用Kaplan-Meier方法分析无房颤复发事件的生存率,Log-Rank检验比较组间的生存差异。以P<0.05为差异具有统计学意义。结果(1)胰岛素抵抗组(n=66)与无胰岛素抵抗组患者(n=156)的基线临床资料比较显示,两组患者在高敏C反应蛋白、血沉、左心房内径等指标无明显差异,均无统计学意义(P>0.05)。胰岛素抵抗组患者空腹血糖、空腹胰岛素、HOMA-IR值相比无胰岛素抵抗组患者显著增高,差异均具有统计学意义(P<0.01)。(2)房颤消融术后随访12个月,Kaplan-Meier分析显示胰岛素抵抗组的房颤消融术后复发患者26例(39.39%)显著高于无胰岛素抵抗组的患者32例(20.51%),两组的无房颤复发事件存率存在统计学意义(Log-Rank检验:χ2=8.394,P=0.004)。(3)依据消融术后随访12个月为终点,术后复发58例患者(26.13%),术后未复发组患者164例(73.87%)。单因素logistic回归分析显示两组患者在房颤类型、BMI、线性消融等参数差异无统计学意义(P均>0.05),左心房内径(OR=1.053,95%CI1.005～1.102,P=0.029)和HOMA-IR值(OR=1.390,95%CI 1.096～1.762,P=0.007)是术后复发的危险因素,术后复发组患者的左心房内径和HOMA-IR值明显大于未复发组的患者,有统计学意义。(4)将单因素分析中P<0.1的变量和具有重要临床意义的变量房颤类型、房颤病程(>5年)、高敏C反应蛋白、左心房内径、BMI、HOMA-IR纳入多因素Cox回归分析,显示左房内径(OR=1.052,95%CI 1.003～1.104 P=0.038)和HOMA-IR值(OR=1.344,95%CI 1.052～1.718,P=0.018)是术后复发的独立危险因素,高的HOMA-IR水平及大的左房内径值与术后复发率高显著相关。结论房颤患者的HOMA-IR水平和左心房内径大小是导管射频消融术后复发的独立危险因素,HOMA-IR和左心房内径值越大,消融术后房颤复发的风险增加。房颤患者具有胰岛素抵抗与消融术后房颤复发率高具有相关性,胰岛素抵抗对消融术后房颤的复发有较高的预测价值。更多还原

【Abstract】 BackgroundAtrial fibrillation(AF)is one of the most common arrhythmic cardiovascular diseases in clinical practice,.AF can significantly increases the risk of heart failure、renal impairment and so on.Radiofrequency catheter ablation(RFCA)has become the major treatment for AF.However,there is a high recurrence rate after catheter ablation of AF.In patients with paroxysmal atrial fibrillation,the success rate remained at 70%～90%at 1 year follow-up after circumferential pulmonary vein isolation(CPVI)ablation,and the success rate was even lower at 65%～75%for persistent atrial fibrillation.Recurrence after catheter ablation of AF has many risk factors,such as hypertension、metabolic syndrome、sleep apnea syndrome and other diseases.Insulin resistanceis a state of decreased insulin response,which shows signs including obesity,elevated blood glucose,dyslipidemia and elevated blood pressure,insulin resistance is generally a component of metabolic syndrome and a precursor of type 2 diabetes mellitus.Insulin resistance is a common feature of metabolic syndrome and diabetes mellitus and it is a potential mechanism for the development of abnormal glucose metabolism.Studies have shown that impaired fasting glucose and impaired glucose tolerance can lead to delayed electrical conduction in the atria and the formation of low-voltage areas,thereby increasing incidence of AF.Reasearches have shown that insulin resistance can increase the susceptibility to atrial fibrillation.However,the relationship between recurrence rate after catheter ablation of AF and insulin resistance is not clear,and whether insulin resistance can affect recurrence after catheter ablation in patients with AF still needs further studies to confirm.ObjectiveTo search the risk factors of recurrence after RFCA in patients with AF and to investigate the effect of insulin resistance on recurrence after RFCA of AF patients.MethodsA total of 222 AF patients who received RFCA for the first time in the First Affiliated Hospital of Zhengzhou University from January 2018 to June 2019 were selected as the study subjects and it was z retrospectively study.Homeostasis model assessment of insulin resistance(HOMA-IR)≥2.69 was defined as insulin resistance,and the subjects were divided into insulin resistance group(n=66)and no insulin resistance group(n=156)according to whether they had insulin resistance or not,and to compare the differences in baseline clinical data between the two groups of AF patients.Outpatient and telephone follow-up was performed at 3,6,9,and 12 months after ablation in patients with AF to examine the surface electrocardiogram and(or)dynamic electrocardiogram.When the patient had clinical symptoms outside the hospital,he/she promptly visited the nearest hospital for examination to determine whether the AF had recurrence.According to the ablation of AF after 12 months follow-up whether recurrence,they were divided into recurrence group(n=58)and non-recurrence group(n=164)according to whether AF recurred after RFCA.The logistic regression analyses were applied to analyze the risk factors for AF recurrence in the two groups.Kaplan-Meier method was used to analyze the event-free survival rate of AF recurrence,and the Log-Rank test was used to compare whether the survival difference was statistically significant.P<0.05 was considered statistically significant.Results(1)The comparison of clinical data showed that there were no significant differences between the two groups in high-sensitivity C-reactive protein(HS-CRP),erythrocyte sedimentation rate(ESR),left atrial diameter and other factors(P>0.05).Fasting blood glucose,fasting insulin and HOMA-IR in IR group were significantly higher than those in non-insulin resistance group(P<0.01).(2)The patients were followed up for 12 months.Kaplan-Meier analysis revealed that the recurrence rate of AF in the insulin resistance group 26 cases(39.39%)was significantly higher than without insulin resistance group 32 cases(20.51%).There was a statistically significant difference in the survival rate of AF recurrence events(Log-Rank test:χ2=8.394,P=0.004).(3)According to the endpoint of 12-month follow-up after ablation in patients with AF,58 patients(26.13%)in recurrence group and 164 patients(73.87%)in the non-recurrence group had recurrence after ablation.Univariate logistic regression analysis showed that there was no statistical significance in the duration of AF(>5 years)、BMI、linear ablation and other indexes between the two groups(P>0.05)..Left atrial diameter(OR=1.053,95%CI 1.005～1.102,P=0.029)and HOMA-IR value(OR=1.390,95%CI 1.096～1.762,P=0.007)were risk factors for recurrence after AF ablation,LAD and HOMA-IR values were significantly higher in patients with recurrence after AF ablation than in those without recurrence after ablation,they were statistically significant.(4)Indicators with P<0.1 in univariate logistic regression analysis and variables with important clinical significance AF type、duration of AF(>5 years)、high-sensitivity C-reactive protein、left atrial diameter、BMI and HOMA-IR were included in multivariate logistic regression analysis.Analysis showed that left atrial diameter(OR=1.052,95%CI 1.003～1.104,P=0.038)and HOMA-IR value(OR=1.344,95%CI 1.052～1.718,P=0.018)were independent risk factors for recurrence after AF ablation,.high HOMA-IR level and large left atrial diameter were significantly associated with higher postoperative recurrence rate.ConclusionHOMA-IR levels and left atrial diameter are independent risk factors for AF recurrence,the greater HOMA-IR and left atrial diameter values,the greater risk of recurrence.Moreover,insulin resistance in patients with AF is associated with a high recurrence rate,and insulin resistance has a high predictive value for recurrence of AF.更多还原