【作者】 杨军；

【导师】 周敬华；

【作者基本信息】 三峡大学 ， 临床医学（专业学位）， 2024， 硕士

【摘要】 研究背景:颅内动脉粥样硬化是我国脑血管病患者中最常见的血管病变,胰岛素抵抗与其发生发展密不可分。甘油三酯-葡萄糖(Triglyceride-Glucose,TyG)指数作为胰岛素抵抗的生物标志物,能否预测急性缺血性卒中(acute ischemic stroke,AIS)患者颅内动脉粥样硬化的发生仍不确定,且其与颅内动脉粥样硬化程度的关系尚存争议。目的:探讨TyG指数与急性缺血性卒中患者颅内动脉粥样硬化的相关性。方法:选取2021年1月到2024年1月于三峡大学第一临床医学院神经内科住院治疗的急性缺血性卒中患者并收集相关资料,根据纳入标准和排除标准共纳入273名。颅内动脉粥样硬化程度根据颅脑CTA或DSA显示的颅内动脉粥样硬化斑块和狭窄程度,使用半定量评分来评估动脉粥样硬化状况(无动脉粥样硬化斑块;1分:1处动脉粥样硬化斑块,无明显管腔狭窄或狭窄<50%;2分:狭窄50%-69%;3分:狭窄70%-99%;4分:闭塞)。将颅内动脉段的动脉粥样硬化评分相加计算颅内动脉粥样硬化负荷,分为0分、1分、2～3分和≥4分共4个等级。(1)根据有无颅内动脉粥样硬化程度将AIS患者分为n ICAS组(0分)和ICAS组(≥1分),探讨TyG指数与AIS患者是否发生颅内动脉粥样硬化的关系;(2)根据颅内动脉粥样硬化半定量评分将AIS患者中ICAS组分为AS1(1分)组、AS2(2～3分)组、AS3(≥4分)组,探讨TyG指数与AIS患者颅内动脉粥样硬化程度的关系;(3)根据有无合并2型糖尿病(Type 2 diabetes,T2DM)将AIS患者分为AIS不合并T2DM组、AIS合并T2DM组,探讨TyG指数与不同患病情况下AIS患者颅内动脉粥样硬化程度的关系;(4)比较不同患病情况下TyG指数与AIS患者颅内动脉粥样硬化程度的相关性。结果:(1)吸烟史(P=0.001)、2型糖尿病史(P<0.001)、高血压病史(P<0.001)、空腹血糖(P<0.001)、糖化血红蛋白(P<0.001)、甘油三酯(P<0.001)、TyG指数(P<0.001)是AIS患者发生颅内动脉粥样硬化的危险因素,高密度脂蛋白(P=0.001)是AIS患者发生颅内动脉粥样硬化的保护因素。其中,吸烟史(β=0.762,95%CI:1.056～4.335,P=0.034)、高血压病史(β=1.034,95%CI:1.230～6.431,P=0.014)、TyG指数(β=1.738,95%CI:1.572～20.570,P=0.008)是AIS患者发生颅内动脉粥样硬化的独立危险因素。ROC曲线分析结果显示:TyG指数预测AIS患者颅内动脉粥样硬化发生的AUC为0.816(95%CI:0.753～0.878,P<0.001),最佳截断值为8.595,灵敏度为71.6%,特异度为78.2%。相较于甘油三酯、空腹血糖、糖化血红蛋白,TyG指数预测AIS患者发生颅内动脉粥样硬化的效能最佳。(2)2型糖尿病史(P=0.042)、高血压病史(P=0.032)、高密度脂蛋白(P=0.026)、空腹血糖(P<0.001)、糖化血红蛋白(P=0.002)、甘油三酯(P<0.001)、TyG指数(P<0.001)与AIS患者颅内动脉粥样硬化程度的有关。有序回归分析结果显示:在调整混杂因素以及吸烟史、饮酒史等潜在危险因素后,TyG指数四分位数的增加与AIS患者颅内动脉粥样硬化程度的增加存在显著关联(Q2:OR=2.382,95%CI:1.065～5.328,P=0.035;Q3:OR=5.601,95%CI:2.289～13.695,P<0.001;Q4:OR=15.456,95%CI:5.238～45.650,P<0.001)。(3)与AIS不合并T2DM的患者相比,AIS合并TD2M的患者低密度脂蛋白[2.89(2.37,3.39)vs 3.13(2.54,3.80),P=0.007]、空腹血糖[5.06(4.58,5.52)vs 8.61(6.89,10.54),P<0.001]、糖化血红蛋白[5.50(5.30,5.72)vs 7.60(6.70,9.32),P<0.001]、甘油三酯[1.12(0.93,1.63)vs 1.51(1.16,2.12),P<0.001]、TyG指数[8.45(8.20,8.61)vs 9.26(8.93,9.55),P<0.001]水平更高,存在颅内动脉粥样硬化占比更大[93(67.39%)vs 125(92.59%),P<0.001]、颅内动脉动脉粥样硬化程度高分组占比更大(P=0.042),而高密度脂蛋白[1.32(1.12,1.52)vs 1.12(0.98,1.30),P<0.001]更低。(4)高血压病史(P=0.003)、空腹血糖(P=0.004)、甘油三酯(P<0.001)、TyG指数(P<0.001)与AIS不合并T2DM患者颅内动脉粥样硬化程度有关,有序回归分析结果显示:在调整混杂因素以及吸烟史、饮酒史等潜在危险因素后,TyG指数仅在第三、第四四分位数的增加与AIS不合并T2DM患者颅内动脉粥样硬化程度的增加存在显著关联(Q3:OR=5.726,95%CI:1.737～18.859,P=0.004;Q4:OR=9.875,95%CI:2.904～33.582,P<0.001)。(5)空腹血糖(P<0.001)、糖化血红蛋白(P=0.029)、甘油三酯(P=0.002)、TyG指数(P<0.001)与AIS合并T2DM患者颅内动脉粥样硬化程度有关,有序回归分析结果显示:在调整混杂因素以及吸烟史、饮酒史、高血压病史等潜在危险因素后,TyG指数四分位数的增加与AIS合并T2DM患者颅内动脉粥样硬化程度的增加存在显著关联(Q2:OR=2.883,95%CI:1.020～8.142,P=0.046;Q3:OR=4.693,95%CI:1.442～15.272,P=0.009;Q4:OR=7.207,95%CI:1.288～40.326,P=0.025)。结论:(1)TyG指数是AIS患者发生颅内动脉粥样硬化的独立危险因素,TyG指数升高与AIS患者颅内动脉粥样硬化程度增加独立相关;(2)TyG指数升高与AIS合并T2DM患者颅内动脉粥样硬化程度增加独立相关;(3)与AIS不合并T2DM患者相比,TyG指数与AIS合并T2DM患者颅内动脉粥样硬化程度的相关性更强。更多还原

【Abstract】 Background Intracranial atherosclerosis is the most common vascular disease in cerebrovascular disease patients in China,and insulin resistance is closely related to its occurrence and development.As a biomarker of insulin resistance,whether the triglyceride-glucose（TyG）index can predict the occurrence of intracranial atherosclerosis in patients with acute ischemic stroke（AIS）is still uncertain,and its relationship with the degree of intracranial atherosclerosis is still controversial.Objective To investigate the correlation between TyG index and intracranial atherosclerosis in patients with acute ischemic stroke.Methods A total of 273 patients with acute ischemic stroke who were hospitalized in the Department of Neurology of the First Clinical Medical College of China Three Gorges University from January 2021 to January 2024 were selected and relevant data were collected.Intracranial atherosclerosis degree is assessed using a semi-quantitative score based on the degree of intracranial atherosclerotic plaque and stenosis shown by cranial CTA or DSA（0score,no atherosclerotic plaque;1 score,atherosclerotic plaque without evident lumen stenosis or stenosis<50%;2 scores,stenosis 50-69%;3 scores,stenosis 70-99%;4 scores,occlusion）.Intracranial atherosclerotic load was calculated by adding the atherosclerotic scores of intracranial artery segments into 4 grades:0,1,2～3 and≥4.（1）AIS Patients were divided into n ICAS group（0 score）and ICAS group（≥1 scores）according to the degree of intracranial atherosclerosis,and the relationship between TyG index and intracranial atherosclerosis in AIS patients was investigated.（2）The ICAS group of AIS patients was divided into AS₁（1 score）group,AS₂（2～3 scores）group and AS₃（≥4 scores）group according to the semi-quantitative score of intracranial atherosclerosis,and the relationship between TyG index and the degree of intracranial atherosclerosis in AIS patients was investigated.（3）AIS patients were divided into AIS group without T2DM and AIS group with T2DM according to whether they were combined with type 2 diabetes（T2DM）,and the relationship between TyG index and the degree of intracranial atherosclerosis in AIS patients under different conditions was investigated;（4）To compare the correlation between TyG index and the degree of intracranial atherosclerosis in AIS patients under different disease conditions.Results（1）History of smoking（P=0.001）,history of type 2 diabetes（P<0.001）,history of hypertension（P<0.001）,fasting blood glucose（P<0.001）,glycosylated hemoglobin（P<0.001）,triglyceride（P<0.001）,TyG index（P<0.001）were AIS risk factors for intracranial atherosclerosis.High density lipoprotein（P=0.001）is a protective factor for intracranial atherosclerosis in AIS patients.Among them,history of smoking（β=0.762,95%CI:1.056～4.335,P=0.034）,history of hypertension（β=1.034,95%CI:1.230～6.431,P=0.014）,TyG index（β=1.738,95%CI:1.572～20.570,P=0.008）is an independent risk factor for intracranial atherosclerosis in AIS patients.ROC curve analysis results showed that the AUC of TyG index for predicting intracranial atherosclerosis in AIS patients was 0.816（95%CI:0.753～0.878,P<0.001）,the optimal cut-off value was 8.595,the sensitivity was 71.6%,and the specificity was 78.2%.Compared with triglyceride,fasting blood glucose and glycated hemoglobin,TyG index was the best predictor of intracranial atherosclerosis in AIS patients.（2）History of type 2 diabetes（P=0.042）,hypertension（P=0.032）,high density lipoprotein（P=0.026）,fasting blood glucose（P<0.001）,glycated hemoglobin（P=0.002）,triglyceride（P<0.001）,TyG index（P<0.001）were associated with the degree of intracranial atherosclerosis in AIS patients.The results of ordered regression analysis showed that after adjusting for confounder factors and potential risk factors such as history of smoking and history of drinking,the increase of TyG index quartile was significantly associated with the increase of intracranial atherosclerosis in AIS patients（Q2:OR=2.382,95%CI:1.065-5.328,P=0.035;Q3:OR=5.601,95%CI:2.289～13.695,P<0.001;Q4:OR=15.456,95%CI:5.238～45.650,P<0.001）.（3）Compared with AIS patients without T2DM,AIS patients with TD2M had low density lipoprotein[2.89（2.37,3.39）vs 3.13（2.54,3.80）,P=0.007],fasting blood glucose[5.06（4.58,5.52）vs 8.61（6.89,10.54）,P<0.001],glycosylated hemoglobin[5.50（5.30,5.72）vs 7.60（6.70,9.32）,P<0.001],triglyceride[1.12（0.93,1.63）vs 1.51（1.16,2.12）,P<0.001],TyG index[8.45（8.20,8.61）vs 9.26（8.93,9.55）,P<0.001]were higher,and the proportion of intracranial atherosclerosis was greater[93（67.39%）vs 125（92.59%）.P<0.001],the proportion of patients with high degree of intracranial atherosclerosis was higher（P=0.042）,and the proportion of high-density lipoprotein[1.32（1.12,1.52）vs1.12（0.98,1.30）,P<0.001]was lower.（4）History of hypertension（P=0.003）,fasting blood glucose（P=0.004）,triglyceride（P<0.001）and TyG index（P<0.001）were correlated with the degree of intracranial atherosclerosis in AIS patients without T2DM.The results of ordered regression analysis showed:After adjusting for confounding factors and potential risk factors such as history of smoking and history of drinking,only the increase of TyG index in the third and fourth quartiles was significantly associated with the increase of intracranial atherosclerosis in AIS patients without T2DM（Q3:OR=5.726,95%CI:1.737-18.859,P=0.004;Q4:OR=9.875,95%CI:2.904～33.582,P<0.001）.（5）Fasting blood glucose（P<0.001）,glycated hemoglobin（P=0.029）,triglyceride（P=0.002）and TyG index（P<0.001）were correlated with the degree of intracranial atherosclerosis in AIS patients with T2DM.The results of ordered regression analysis showed:After adjusting for confounder factors and potential risk factors such as history of smoking,history of drinking,and history of hypertension the increase of TyG index quartile was significantly associated with the increase of intracranial atherosclerosis in AIS patients with T2DM（Q2:OR=2.883,95%CI:1.020-8.142,P=0.046;Q3:OR=4.693,95%CI:1.442-15.272,P=0.009;Q4:OR=7.207,95%CI:1.288-40.326,P=0.025）.Conclusion（1）TyG index is an independent risk factor for intracranial atherosclerosis in AIS patients,and the increase of TyG index is independently correlated with the increase of intracranial atherosclerosis in AIS patients.（2）The increase of TyG index was independently correlated with the increase of intracranial atherosclerosis in AIS patients with T2DM.（3）Compared with AIS patients without T2DM,TyG index was more strongly correlated with the degree of intracranial atherosclerosis in AIS patients with T2DM.更多还原