江立生　邵琴　卜軍　何奔

?

·臨床研究·

冠狀動脈造影檢查疑似冠心病患者6040例合并傳統(tǒng)心血管病危險因素的臨床分析

江立生邵琴卜軍何奔

目的對臨床上冠心病患者合并傳統(tǒng)心血管病危險因素進行分析。方法納入本中心2013年1月至2015年2月因冠心病或疑似冠心病行冠狀動脈造影(CAG)檢查的住院患者，將存在嚴重冠心病并接受經(jīng)皮冠狀動脈介入治療(PCI)的患者歸為PCI組(2808例)，不存在嚴重冠心病且未行PCI/冠狀動脈旁路移植術(shù)(CABG)的患者歸為No-PCI/CABG組(3232例)。PCI組再分為急性ST段抬高心肌梗死(STEMI)組、非ST段抬高急性心肌梗死/不穩(wěn)定型心絞痛(NSTEMI/UA)組和穩(wěn)定型心絞痛(SA)組。對臨床上合并的傳統(tǒng)心血管病危險因素進行回顧性分析。結(jié)果(1)PCI組患者男性比例(75.4%比53.1%，P<0.0001)、平均年齡[(64.83±0.20)歲比(63.39±0.18)歲，P<0.0001]、高血壓病(66.7%比54.7%，P<0.0001)、糖尿病/糖耐量異常(37.0%比20.8%，P<0.0001)、卒中(7.0%比5.4%，P=0.0098)和慢性腎病(4.3%比2.8%，P=0.001)比例顯著高于No-PCI/CABG組；而兩組間高脂血癥的比例，差異無統(tǒng)計學(xué)意義(P>0.05)。(2)PCI組中女性高血壓病(74.1%比64.3%,P<0.0001)、糖尿病/糖耐量異常(42.5%比35.3%，P=0.0007)和卒中(9.4%比6.2%，P=0.0054)比例均顯著高于男性，差異均有統(tǒng)計學(xué)意義；無論PCI組還是No-PCI/CABG組，女性高脂血癥比例均顯著高于男性。(3)對PCI組進行亞組分析發(fā)現(xiàn)，STEMI組男性比例顯著高于NSTEMI/UA組和SA組(83.9%比72.9%比72.3%，P<0.0001)，而發(fā)病年齡顯著小于NSTEMI/UA組和SA組[(62.54±0.45)歲比(65.15±0.28)歲比(66.17±0.34)歲，P<0.0001]。SA組高血壓病(71.9%比66.9%比60.0%，P<0.0001)和既往靶血管血運重建(PCI/CABG)(33.9%比18.7%比7.2%，P<0.0001)比例顯著高于STEMI組和NSTEMI/UA組；NSTEMI/UA組糖尿病/糖耐量異常比例顯著高于STEMI組和SA組(39.7%比35.1%比34.4%，P<0.0001)，差異均有統(tǒng)計學(xué)意義；而高脂血癥、慢性腎病和卒中的比例三亞組間差異無統(tǒng)計學(xué)意義(P>0.05)。結(jié)論高血壓病和糖尿病是冠心病最重要的危險因素，既往靶血管血運重建是SA和NSTEMI/UA患者靶血管再次血運重建的重要原因；行PCI的嚴重冠心病患者中，男性比例高于女性，但女性合并高血壓病、糖尿病/糖耐量異常和卒中的比例高于男性。

冠心病；介入治療；危險因素；回顧性分析

冠狀動脈粥樣硬化性心臟病(冠心病)仍然是全球范圍內(nèi)首屈一指的公共衛(wèi)生問題。近年來，歐美等發(fā)達國家冠心病死亡率呈逐年下降趨勢[1-2], 然而這種令人鼓舞的趨勢在中國卻并未出現(xiàn)，反而出現(xiàn)了更加嚴重的情況。根據(jù)《中國心血管病報告2014》數(shù)據(jù)，從2002年到2013年，中國冠心病和心肌梗死的死亡率仍逐年上升，2013年同2002年相比，中國農(nóng)村和城市冠心病的死亡率分別增加了3.6倍和2.5倍，急性心肌梗死的死亡率分別增加了4倍和4.3倍，而且預(yù)測未來10年中國冠心病的發(fā)病率和死亡率仍然上升[3]。

影響冠心病發(fā)病和死亡的因素有很多種，除與經(jīng)濟狀況、治療方式、生活習慣及種族等有關(guān)外，也與高血壓病、糖尿病、高脂血癥等傳統(tǒng)心血管病危險因素密切相關(guān)[4-6]。近年來，有研究報道顯示，冠心病患者合并傳統(tǒng)心血管病危險因素在部分東亞國家與歐美等西方國家相比存在一定差異[7-12]。在PLATO-ACS研究[7]中，亞裔患者并發(fā)糖尿病的比率高于非亞裔患者，而并發(fā)高脂血癥的比率則低于非亞裔患者。換言之，與歐美等發(fā)達國家相比，近年來中國逐年升高的冠心病死亡率也可能與中國人合并心血管病危險因素情況及治療水平與歐美等發(fā)達國家不同有關(guān)。

本研究針對本中心經(jīng)冠狀動脈造影(coronary angiography，CAG)證實存在嚴重阻塞性冠狀動脈病變并接受經(jīng)皮冠狀動脈介入治療(percutaneous coronary intervention，PCI)的冠心病患者和CAG檢查結(jié)果正?；騼H提示輕度病變的住院患者合并傳統(tǒng)心血管病危險因素的狀況進行回顧性分析，以明確不同嚴重程度的冠心病合并傳統(tǒng)心血管病危險因素的狀況，為科學(xué)管理冠心病危險因素和降低冠心病發(fā)病率、死亡率提供依據(jù)。

1　對象與方法

1.1研究對象

本研究以上海交通大學(xué)醫(yī)學(xué)院附屬仁濟醫(yī)院2013年1月至2015年2月住院行CAG檢查的冠心病和疑似冠心病患者為研究對象。在總共6862例行CAG檢查的患者中，2808例存在嚴重冠心病(冠狀動脈狹窄≥75% 或50%<狹窄<75%但介入醫(yī)師認為有PCI適應(yīng)證)并接受PCI的患者作為PCI組；3232例CAG結(jié)果正?；虿淮嬖趪乐毓谛牟冠狀動脈正常，或存在狹窄<70%非左主干病變，或存在狹窄<50%左主干病變]且不需要行PCI或冠狀動脈旁路移植術(shù)(coronary artery bypass grafting，CABG)的患者作為非PCI/CABG組(No-PCI/CABG組)；不需要行PCI的822例患者因既往曾接受PCI或CABG，或存在嚴重冠狀動脈病變接受CABG或藥物保守治療未納入本研究。PCI組患者再根據(jù)臨床類型分為急性ST段抬高心肌梗死(ST-segment elevation myocardial infarction，STEMI)組、非ST段抬高心肌梗死(non-ST-segment elevation myocardial infarction，NSTEMI)/不穩(wěn)定型心絞痛(unstable angina，UA)組和穩(wěn)定型心絞痛(stable angina, SA)組。研究中使用的傳統(tǒng)心血管病危險因素和伴發(fā)疾病的診斷標準如下：(1)存在既往病史并正在接受相應(yīng)藥物治療；(2)住院期間新發(fā)現(xiàn)的心血管病危險因素和伴發(fā)疾病根據(jù)我國現(xiàn)行診療指南進行診斷[13]。

1.2研究方法

對各組/亞組患者的年齡、性別等人口學(xué)數(shù)據(jù)，伴發(fā)的高血壓病、糖尿病/糖耐量異常、高脂血癥、慢性腎病、卒中等傳統(tǒng)心血管病危險因素情況，以及PCI各亞組的住院期間死亡率、住院時間和住院費用進行回顧性分析和比較。

1.3統(tǒng)計學(xué)分析

2　結(jié)果

2.1PCI組和No-PCI/CABG組人口學(xué)資料和心血管病危險因素分析(表1)

PCI組患者男性比例[75.4%(2116/2808)比53.1%(1716/3232),P<0.0001]、平均年齡[(64.83±0.20)歲 比(63.39±0.18)歲，P<0.0001]均顯著高于No-PCI/CABG組，差異均有統(tǒng)計學(xué)意義。無論PCI組還是No-PCI/CABG組，女性平均年齡均高于男性，分別為PCI組[(68.6±0.37)歲比(63.6±0.23)歲，P<0.0001]和No-PCI/CABG組[(64.5±0.26)歲比(62.4±0.26)歲,P=0.0144]，差異均有統(tǒng)計學(xué)意義。

PCI組患者合并高血壓病(66.7%比54.7%，P<0.0001)、糖尿病/糖耐量異常(37.0%比20.8%，P<0.0001)、卒中(7.0%比5.4%，P=0.0098)和慢性腎病(4.3%比2.8%，P=0.001)的比例均顯著高于No-PCI/CABG組，差異均有統(tǒng)計學(xué)意義；而兩組間高脂血癥比較(7.2%比8.3%，P=0.2206)，差異無統(tǒng)計學(xué)意義。在PCI組中，女性合并高血壓病(74.1%比64.3%,P<0.0001)、糖尿病/糖耐量異常(42.5%比35.3%，P=0.0007)、高脂血癥(9.5%比6.4%，P=0.0077)和卒中(9.4%比6.2%，P=0.0054)的比例均顯著高于男性，差異均有統(tǒng)計學(xué)意義；在No-PCI/CABG組中女性高脂血癥比例顯著高于男性(9.8%比6.9%，P=0.0036)，而慢性腎病比例顯著低于男性(1.3%比4.0%，P<0.0001)，差異均有統(tǒng)計學(xué)意義。

2.2PCI組中各亞組人口學(xué)資料和心血管病危險因素分析(表2)

亞組分析發(fā)現(xiàn)，STEMI組患者男性比例顯著高于NSTEMI/UA組和SA組(83.9%比72.9%比72.3%,P<0.0001)，而發(fā)病年齡則顯著低于后兩組[(62.54±0.45)歲比(65.15±0.28)歲比(66.17±0.34)歲，P<0.0001)]，差異均有統(tǒng)計學(xué)意義；但NSTEMI/UA組和SA組兩組間性別和發(fā)病年齡比較，差異均無統(tǒng)計學(xué)意義(均P>0.05)。在合并傳統(tǒng)心血管病危險因素方面，SA組高血壓病(71.9%比66.9%比60.0%，P<0.0001)和既往靶血管血運重建(PCI/CABG)(33.9%比18.7%比7.2%，P<0.0001)比例顯著高于NSTEMI/UA組和STEMI組，NSTEMI/UA組也顯著高于STEMI組(18.7%比7.2%，P<0.0001)，差異均有統(tǒng)計學(xué)意義。NSTEMI/UA組糖尿病/糖耐量異常比例顯著高于STEMI組和SA組(39.7%比35.1%比34.4%，P<0.0001)，而STEMI組和SA組差異無統(tǒng)計學(xué)意義(35.1%比34.4%，P>0.05)。三亞組間合并高脂血癥、慢性腎病和卒中的比例比較，差異均無統(tǒng)計學(xué)意義(均P>0.05)。STEMI患者平均住院時間[(11.14±0.22)d比(7.68±0.14)d比(6.65±0.14)d，P<0.0001]、住院費用[(60 812±980)元比(53 743±615)元比(50 461±788)元，P<0.0001]和住院期間死亡率(3.1%比0.2%比0，P<0.0001)均顯著高于NSTEMI/UA組和SA組；NSTEMI/UA組平均住院時間[(7.68±0.14)d比(6.65±0.14)d，P<0.0001]、住院費用[(53 743±615)元比(50 461±788)元，P<0.001]也均顯著高于SA組，差異均有統(tǒng)計學(xué)意義；但NSTEMI/UA組與SA組住院期間死亡率則差異無統(tǒng)計學(xué)意義。

表1　介入治療患者同非介入治療患者間傳統(tǒng)心血管病危險因素的差別

注：PCI，經(jīng)皮冠狀動脈介入治療；No-PCI，非經(jīng)皮冠狀動脈介入治療；CABG，冠狀動脈旁路移植

表2　PCI組患者亞組分析

注：STEMI，ST段抬高心肌梗死；NSTEMI，非ST段抬高心肌梗死；UA，不穩(wěn)定型心絞痛；SA，穩(wěn)定型心絞痛；PCI，經(jīng)皮冠狀動脈介入治療；CABG，冠狀動脈旁路移植術(shù)

3　討論

本中心的臨床結(jié)果分析顯示，PCI組患者合并高血壓病、糖尿病/糖耐量異常、卒中和慢性腎病的比例顯著高于No-PCI/CABG組患者，這與國外研究結(jié)果相一致[7-9]。此外，本研究結(jié)果還顯示，PCI組患者合并糖尿病/糖耐量異常的比例高于歐美等西方國家，而合并高脂血癥的比例卻顯著低于歐美等西方國家，與No-PCI/CABG組患者相當[7-9]。日本及中國臺灣等東亞國家和地區(qū)的研究結(jié)果與本研究也基本相一致[14-15]，進一步表明東亞國家和地區(qū)的冠心病患者在合并傳統(tǒng)心血管病危險因素方面與歐美國家存在一定差別。

對PCI組患者進行亞組分析發(fā)現(xiàn)，STEMI患者發(fā)病年齡低于NSTEMI/UA組和SA組患者，而住院時間、住院費用和住院期間死亡率均顯著高于NSTEMI/UA組和SA組患者。本研究中住院期間死亡率與歐美發(fā)達國家相近甚至更低[16-17]。此外，本研究數(shù)據(jù)還顯示，接受PCI的SA患者合并高血壓病和既往靶血管血運重建(PCI/CABG)史的比例最高，而NSTEMI/UA患者合并糖尿病/糖耐量異常比例最高。然而，STEMI組、NSTEMI/UA組和SA組三亞組間在合并高脂血癥、慢性腎病和卒中方面卻差異無統(tǒng)計學(xué)意義。國外PL-ACS研究[18]和GRACE研究[9]也顯示，NSTEMI/UA患者合并高血壓病、糖尿病和既往靶血管血運重建的比例高于STEMI患者，這與本研究結(jié)果相一致。

近年來有較多研究顯示，男、女性冠心病患者在合并傳統(tǒng)心血管病危險因素和預(yù)后方面存在一定差異，女性患者合并高血壓病、糖尿病、慢性腎病及高脂血癥的比例高于男性[19-22]，這可能是女性患者在預(yù)后方面比男性差的重要原因[23]。本研究結(jié)果也顯示，接受PCI/CABG的冠心病患者中，女性合并高血壓病、糖尿病/糖耐量異常和卒中的比例均高于男性，而未接受PCI/CABG的患者男、女間則差異無統(tǒng)計學(xué)意義，這與國外報道基本一致[24-25]。然而，兩組患者中，女性合并高脂血癥的比例均高于男性。

總之，高血壓病和糖尿病是冠心病最重要的危險因素；由于PCI/CABG在冠心病治療中的廣泛應(yīng)用，既往靶血管血運重建也成為SA和NSTEMI/UA患者靶血管再次血運重建的重要原因。需要接受PCI的嚴重冠心病患者在卒中發(fā)生率和傳統(tǒng)心血管病危險因素方面存在性別差異，男性發(fā)生需要行PCI的嚴重冠心病比例高于女性，而女性合并高血壓病、糖尿病/糖耐量異常和卒中的比例則高于男性。

[1] Ivanovic J. Heart Disease and Stroke Statistics-2008 Update. Circulation, 2008, 117(4): e25-e146.

[2] National Institutes for Health, National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2007 Chartbook on Cardiovascular, Lung, and Blood Disease. Available at http://www.nhlbi.nih.gov/resources/docs/07-chtbk.pdf

[3] 陳偉偉，高潤霖，劉力生，等.《中國心血管病報告2014》概要.中國循環(huán)雜志，2015，30(7)：617-622.

[4] Canto JG, Kiefe CI, Rogers WJ, et al. Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction. JAMA，2011，306(19):2120-2127.

[5] 姚遠，梁峰，沈珠軍.經(jīng)皮冠狀動脈介入治療后冠心病心絞痛患者生存質(zhì)量影響因素的分析.中國介入心臟病學(xué)雜志，2015，23(9)：508-511.

[6] Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet, 2004,364(9438):937-952.

[7] Kang HJ, Clare RM, Gao R, et al. Ticagrelor versus clopidogrel in Asian patients with acute coronary syndrome: A retrospective analysis from the Platelet Inhibition and Patient Outcomes (PLATO) trial. Am Heart J, 2015,169(6): 899-905.e1.

[8] Owsiak M, Pelc-Nowicka A, Badacz L, et al. Increased prevalence of cardiovascular risk factors in patients with acute coronarysyndrome and indications for treatment with oral anticoagulation. Kardiologia Polska, 2011, 69(9): 907-912.

[9] Avezum A, Makdisse M, Spencer F, et al. Impact of age on management and outcome of acute coronary syndrome: observations from the global registry of acute coronary events (GRACE). Am Heart J, 2005, 149(1): 67-73.

[10] 劉軍，趙冬，劉群，等.中國多省市急性冠狀動脈綜合征住院患者高膽固醇血癥患病現(xiàn)況.中華心血管病雜志，2009，37(5)：449-453.

[11] Hao K, Yasuda S, Takii T, et al.Urbanization, life style changes and the incidence/in-hospital mortality of acute myocardial infarction in Japan:report from the MIYAGI-AMI Registry Study. Circ J, 2012,76(5): 1136-1144.

[12] Yang HY, Huang JH, Hsu CY, et al. Gender differences and the trend in the acute myocardial infarction: a 10-year nationwide population-based analysis. SCI WORLD J, 2011, 2012(8):184075.

[13] 中華醫(yī)學(xué)會心血管病學(xué)分會，中華心血管病雜志編輯委員會. 中國心血管病預(yù)防指南. 中華心血管病雜志, 2011, 39(1): 263-279.

[14] Nishiyama S, Watanabe T, Arimoto T, et al. Trends in coronary risk factors among patients with acute myocardial infarction over the last decade: the Yamagata AMI registry.J Atheroscler Thromb, 2010,17(9):989-998.

[15] Yayan J. Association of traditional risk factors with coronary artery disease in nonagenarians: the primary role of hypertension. Clin Interv Aging, 2014,9(9):2003-2012.

[16] Nallamothu BK, Normand SLT, Wang Y, et al. Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study. Lancet, 2015, 385(9973):1114-1122.

[17] Sugiyama T, Hasegawa K, Kobayashi Y, et al. Differential time trends of outcomes and costs of care for acute myocardial infarction hospitalizations by ST elevation and type of intervention in the United States, 2001-2011. J Am Heart Assoc, 2015, 4(3):e001445.

[18] Owsiak M, Pelc-Nowicka A, Badacz L, et al. Increased prevalence of cardiovascular risk factors in patients with acute coronary syndrome and indications for treatment with oral anticoagulation. Kardiol Pol, 2011,69(9):907-912.

[19] Nguyen HL, Ha DA, Phan DT, et al. Sex differences in clinical characteristics, hospital management practices, and in-hospital outcomes in patients hospitalized in a Vietnamese hospital with a first Aacute myocardial infarction. PLoS One, 2014,9(4): e95631.

[20] Roffi M, Radovanovic D, Erne P, et al. Gender-related mortality trends among diabetic patients with ST-segment elevation myocardial infarction: insights from a nationwide registry 1997-2010. Euro Heart J, 2013,2(4):342-349.

[21] Papakonstantinou NA, Stamou MI, Baikoussis NG, et al. Sex differentiation with regard to coronary artery disease. J Cardiol,2013,62(1):4-11.

[22] Kyt? V, Sipil? J, Rautava P. Gender and in-hospital mortality of ST-segment elevation myocardial infarction (from a multihospital nationwide registry study of 31,689 patients).Am J Cardiol, 2015,115(3):303-306.

[23] Pancholy SB, Shantha GP, Patel T,et al. Sex differences in short-term and long-term all-cause mortality among patients with ST-segment elevation myocardial infarction treated by primary percutaneous intervention: a meta-analysis. JAMA Intern Med,2014,174(11):1822-1830.

[24] Mega JL, Hochman JS, Scirica BM,et al. Clinical features and outcomes of women with unstable ischemic heart disease: observations from metabolic efficiency with ranolazine for less ischemia in non-ST-elevation acute coronary syndromes-thrombolysis in myocardial infarction 36 (MERLIN-TIMI 36). Circulation, 2010,121(16):1809-1817.

[25] Kambara H, Yamazaki T, Hayashi D, et al. Gender differences in patients with coronary artery disease in Japan: the Japanese Coronary Artery Disease Study (the JCAD study). Circ J, 2009, 73(5):912-917.

Real world analysis of traditional cardiovascular risk factors in 6040 patients with suspected coronary heart disease undergoing angiography

JIANGLi-sheng，SHAOQin，BUJun，HEBen.

DepartmentofCardiology,RenjiHospital,SchoolofMedicine,ShanghaiJiaotongUniversity，Shanghai200127，China

ObjectiveTo analyze the real world status of traditional known cardiovascular risk factors in patients with coronary heart disease (CHD). Methods6040 in-hospital patients with CHD or suspected CHD undergoing angiography from 01/01/2013 to 02/28/2015 were retrospectively analyzed. According to angiography result, patients with severe coronary artery lesion and undergoing percutaneous coronary intervention (PCI) were enrolled in the PCI group(n=2808) and patients without severe coronary artery lesion and not undergoing PCI or CABG were enrolled in the No-PCI/CABG group (n=3232). Patients in the PCI group were further divided into 3 subgroups which were STEMI group, NSTEMI/UA group and stable angina (SA) group. Results(1) Compared with the No-PCI/CABG group, patients in the PCI group have higher ratio of male patients (75.4%vs. 53.1%,P<0.0001), older average age (64.83±0.20vs. 63.39±0.18 years old,P<0.0001), and higher existing rates of traditional risk factors including hypertension (66.7%vs. 54.7%,P<0.0001), diabetes/impaired glucose tolerance (IGT)(37.0%vs. 20.8%,P<0.0001), stroke(7.0%vs. 5.4%，P=0.0098)and chronic kidney disease (CKD) (4.3%vs. 2.8%,P=0.001), but there was no statistic difference in existing rates of dyslipidemia between the two groups. (2)In the PCI group，female patients had higher prevalence of hypertension (74.1%vs. 64.3%，P<0.001), diabetes/IGT (42.5%vs. 35.3%,P=0.0007) and stroke (9.4%vs. 6.2%,P=0.0054) than the male patients. There were no significant sex difference in these comorbidities as above in No-PCI/CABG group. Female patients had higher prevalence of dyslipidemia than male patients in both PCI and No-PCI/CABG groups. (3) Among all the 3 PCI subgroups, STEMI patients presented with youngest average age(62.54±0.45vs. 65.15±0.28vs. 66.17±0.34 years old,P<0.0001) and highest male patient ratio (83.9%vs. 72.9%vs. 72.3%,P<0.0001). Patients in the SA subgroup had the highest prevalence of hypertension and prior revascularization including PCI and CABG. Patients in the NSTEMI/UA subgroup had the highest rates of diabetes/IGT. No significant differences were observed in the prevalence of dyslipidemia, CKD and stroke among all the subgroups.ConclusionsHypertension and diabetes are the leading risk factors of coronary artery disease, and prior revascularization is also an important cause of stable angina and NSTEMI/UA undergoing PCI. Patients requiring PCI were found to be more of male gendor, but female patients has higher prevalence of traditional cardiovascular risk factors including hypertension, diabetes/IGT or stroke than male patients.

Coronary heart disease;Percutaneous coronary intervention;Risk factors; Retrospective analysis

10.3969/j.issn.1004-8812.2016.09.004

200127上海，上海交通大學(xué)醫(yī)學(xué)院附屬仁濟醫(yī)院心內(nèi)科

R541.4

2016-05-29)