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急性心肌梗死后再发脑梗死的危险因素分析

作者 / Author:袁书刚 黄晓远 郭英选

摘要 / Abstract:

目的 分析急性心肌梗死(AMI)再发脑梗死的危险因素。方法 从2009-02—2016-08许昌市中心医院南区医院AMI病例中选取AMI后6个月内再发脑梗死40例为观察组,另筛选同期收治的280例单纯AMI患者为对照组,对比2组临床资料,筛选单因素分析有差异指标行多因素Logistic回归分析,探讨AMI后再发脑梗死的危险因素。结果 年龄、吸烟、心房颤动、高脂血症、高血压、糖尿病、HDL-C、收缩压均为引发AMI后再发脑梗死的独立危险因素(P<0.05),以高脂血症相关性最强。结论 在AMI治疗过程中应严密关注高龄、长期吸烟、心房颤动、高脂血症、高血压、糖尿病、HDL-C异常、收缩压异常患者病情变化,做到早预防、早治疗,最大限度降低AMI患者再发脑梗死风险。

关键词 / KeyWords:

脑梗死,急性心肌梗死,高脂血症,心房颤动,危险因素
急性心肌梗死后再发脑梗死的危险因素分析
袁书刚 黄晓远 郭英选
许昌市中心医院南区医院,河南许昌 461000
作者简介:袁书刚,Email:13949833173@163.com
 
摘要 目的 分析急性心肌梗死(AMI)再发脑梗死的危险因素。方法 从2009-02—2016-08许昌市中心医院南区医院AMI病例中选取AMI后6个月内再发脑梗死40例为观察组,另筛选同期收治的280例单纯AMI患者为对照组,对比2组临床资料,筛选单因素分析有差异指标行多因素Logistic回归分析,探讨AMI后再发脑梗死的危险因素。结果 年龄、吸烟、心房颤动、高脂血症、高血压、糖尿病、HDL-C、收缩压均为引发AMI后再发脑梗死的独立危险因素(P<0.05),以高脂血症相关性最强。结论 在AMI治疗过程中应严密关注高龄、长期吸烟、心房颤动、高脂血症、高血压、糖尿病、HDL-C异常、收缩压异常患者病情变化,做到早预防、早治疗,最大限度降低AMI患者再发脑梗死风险。
关键词】 脑梗死;急性心肌梗死;高脂血症;心房颤动;危险因素
中图分类号】  R743.33    【文献标识码】  A    【文章编号】  1673-5110(2019)03-0303-06
 
Risk factors of recurrent cerebral infarction after acute myocardial infarction
YUAN ShugangHUANG XiaoyuanGUO Yingxuan
Xuchang Central HospitalXuchang 461000,China
Abstract  Objective  To analyze the risk factors of recurrent cerebral infarction after acute myocardial infarction (AMI).Methods  40 patients with recurrent cerebral infarction within 6 months after AMI were selected from patients with AMI who were admitted to the hospital from February 2009 to August 2016 and they were included in the observation group.Another 280 patients with simple AMI were selected as the control group.The general clinical data and pathological data were compared between the two groups.Indexes with differences afterunivariate analysis were analyzed by Logistic regression analysis to identify the risk factors of recurrent cerebral infarction after AMI.Results  Age,smoking,atrial fibrillation,hyperlipidemia,hypertension,diabetes,HDL-C and systolic blood pressure were independent risk factors for recurrent cerebral infarction after AMI (P<0.05),and the correlation with hyperlipidemia was the strongest.Conclusion  Close attention should be paid to the elderly,long-term smoking patients,patients with atrial fibrillation,hyperlipidemia,hypertension,diabetes,abnormal HDL-C or systolic blood pressure disorders in the clinical treatment of AMI.Strengthening the control of the disease in such patients,early prevention and treatment,can minimize the risk of recurrent cerebral infarction in patients with AMI.
Key words】  Cerebral infarction;Acute myocardial infarction;Hyperlipidemia;Atrial fibrillation;Risk factor
 
        急性心肌梗死(AMI)和脑梗死均为致死、致残率较高的心脑血管疾病,两者发病机制具有较强的关联性,临床治疗难度极大,AMI后再发脑梗死更对患者病情造成双重恶化作用,致死、致残率也较单纯AMI更高[1-8]。研究报道,对AMI患者进行早期干预可有效降低再发脑梗死的风险,提高患者生存率[9-13]。本次研究通过对2009-02—2016-08的40例AMI后再发脑梗死患者进行回顾性分析,进一步明确AMI后再发脑梗死的危险因素,以便对AMI患者进行早期干预,减少再发脑梗死风险。
 
1  资料与方法
1.1  一般资料 从2009-02—2016-08在许昌市中心医院确诊为AMI患者中筛选AMI后6个月内再发脑梗死患者40例为观察组,选取同期收治的280例单纯AMI患者为对照组。分析2组患者年龄、性别、高血压史、糖尿病史、吸烟史、饮酒史以及血糖(FBG)、尿酸(UA)、胆总固醇(TC)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C)、收缩压、舒张压等资料。
1.2  诊断标准  急性心肌梗死诊断标准:依据2012年心肌梗死与心电图诊断新标准中制定的急性心肌梗死诊断标准[14]。脑梗死诊断标准:《2013年AHA/ASA卒中新定义》中制定的脑梗死诊断标准[15]。高血压诊断标准:依据中国高血压防治指南修订委员会修订的2004年中国高血压防治指南(实用本)中制定的高血压诊断标准[16]。糖尿病诊断:依据糖尿病医学诊治标准-2011(概要)[17]制定的糖尿病诊断标准。高脂血症诊断标准:依据2016年修订的中国成人血脂异常防治指南中的高脂血症诊断标准[18]。吸烟史判定标准:每日吸烟10或以上支,持续12个月以上。饮酒史判定标准:每日饮酒150 mL,持续12个月以上。其他:采用分光光度法、比浊法分别测定UA、TC、TG、LDL-C、HDL-C、FBG水平;采用超声心动图诊断收缩压、舒张压及心房颤动等指标。
1.3  统计学方法 采用SPSS 19.0统计软件,数据用均数±标准差(x±s)或百分比表示,组间比较行t检验或卡方检验;筛选单因素有差异的选项进行多因素Logistic回归分析,P<0.05为差异有统计学意义。
 
2  结果
2.1  AMI后再发脑梗死的危险因素单因素分析  2组性别、饮酒史、UA、TC、TG、LDL-C、舒张压、血糖对比差异无统计学意义(P>0.05);观察组平均年龄高于对照组,吸烟、心房颤动、高脂血症、高血压、糖尿病患者占比高于对照组,HDL-C、收缩压较对照组均有明显差异(P<0.05)。见表1。
2.2  AMI后再发脑梗死危险因素的Logistic回归性分析 多因素Logistic回归性分析显示,年龄、吸烟、心房颤动、高脂血症、高血压、糖尿病、HDL-C、收缩压均为AMI后再发脑梗死的独立危险因素(P<0.05),其中高脂血症相关性最高,其次为心房颤动。见表2。
表1  AMI后再发脑梗死的危险因素单因素分析  (x±s)
Table 1  Univariate analysis of risk factors for recurrent cerebral infarction after AMI  (x±s)
因素 观察组(n40) 对照组(n280) 统计值 P
年龄/ 67.18±4.98 56.13±4.61 27.247 0
性别(n)     1.32 0.187
   28 204    
   12 76    
吸烟[n(%)] 36(90.00) 201(71.79) 10.181 0
饮酒[n(%)] 19(47.50) 128(45.71) 0.721 0.471
心房颤动[n(%)] 22(55.00) 28(11.20) 7.555 0
高脂血症[n(%)] 16(40.00) 84(30.00) 6.153 0.013
高血压[n(%)] 16(40.00) 64(22.86) 3.071 0.002
糖尿病[n(%)] 14(35.00) 41(14.64) 3.174 0.001
UA 394.37±141.64 393.51±139.61 0.072 0.942
TC(mmol/L) 4.33±0.77 4.25±0.78 1.221 0.222
TG(mmol/L) 1.39±0.52 1.41±0.49 0.468 0.639
LDL-C(mmol/L) 2.88±0.77 2.81±0.69 1.133 0.258
HDL-C(mmol/L) 0.87±0.13 1.12±0.26 14.391 0
收缩压(mmHg) 156.03±11.03 139.97±9.01 18.869 0
舒张压(mmHg) 94.89±8.12 94.21±8.23 0.984 0.326
血糖(mmol/L) 7.01±2.17 6.98±2.25 0.161 0.872
表2  AMI后再发脑梗死的危险因素分析
Table 2  Analysis of risk factors for recurrent cerebral infarction after AMI
因素 回归系数 标准误 统计值 P OR(95% CI)
年龄 1.536 0.228 4.109 0.05 1.788(1.2372.957)
吸烟 0.523 0.174 8.897 0.05 1.680(1.1892.584)
心房颤动 1.518 0.217 4.178 0.05 1.803(1.3223.012)
高脂血症 1.419 0.184 5.121 0.05 2.131(1.5674.114)
高血压 0.537 0.212 6.449 0.05 1.713(1.1922.659)
糖尿病 0.639 0.228 8.384 0.05 1.197(1.5523.073)
HDL-C 1.509 0.163 4.588 0.05 0.799(0.5181.493)
收缩压 1.368 0.209 4.616 0.05 1.799(1.1314.358)
 3  讨论
        AMI是心脏部位因供血供氧不足导致的缺血性病变,与脑梗死发病机制相似,由动脉循环功能异常引起器官组织缺血缺氧症状后导致的一系列心脑血管并发症[19-26]。AMI及脑梗死不仅发病机制相似,其发病因素也较为相似,过度劳累、不良饮食习惯、吸烟、饮酒、情绪过分紧张或激动、高脂血症、糖尿病等均可诱发AMI或脑梗死[27-32]。该病发病突然,病情发展较快,患者伴不同程度的动脉粥样硬化,易重复性发作恶性心律失常、血栓等。研究报道,AMI和脑梗死患者多伴其他不同程度的心脑血管功能障碍,并直接参与病情发展导致病情加速恶化[33-40]。随着社会的发展,人们日常生活及饮食的日益丰富,吸烟、饮酒、暴饮暴食等不良生活习惯导致高脂血症、糖尿病等日益增加,加大了AMI和脑梗死的发病风险,且患者预后极差,多数患者治疗后均伴不同程度的偏瘫、失语或痴呆,给社会及个人造成严重的经济、生活负担[41-47]
        报道指出,AMI后再发脑梗死的发生率在AMI患者中占2%~3%[48-55],死亡风险极高。心脏与脑部均为机体的重要器官组织,心脏主导整个机体的血液循环,是机体正常工作必备的基础条件。脑部是主导机体行为、心理、运动、语言等的神经中枢系统,两者关系紧密,具有相互作用。AMI患者心肌功能异常,心肌无法维持正常舒张功能,导致血流速度异常,对血管壁造成冲击,导致血液流动性变差从而形成血栓,继而导致脑部组织缺血缺氧诱发脑梗死;同时因心律失常等引起栓子脱落,脱落的栓子随血液循环至脑部血管组织,导致血液流动性变差继而造成再发脑梗死,对AMI患者造成不可逆转的伤害[56-60]。因此,如何区分AMI后再发脑梗死的高危患者,采取积极有效的预防措施,对减少AMI后再发脑梗死风险,降低AMI病死率,改善预后尤为重要。
        本研究显示,年龄、吸烟、心房颤动、高脂血症、高血压、糖尿病、HDL-C、收缩压均为AMI后再发脑梗死的独立危险因素。其中,AMI后再发脑梗死患者年龄较单纯AMI患者更大,这可能是因高龄患者机体免疫力、生理新陈代谢、血管壁韧性、收缩力衰退,与相关研究[61]一致;而长期吸烟患者体内焦油、尼古丁成分日益累积易导致血栓或脑细胞死亡,增加心脑血管事件的发生率[62];高血压、糖尿病患者因血液中糖原沉积导致血管基底膜肥厚、脂肪样变性等引发血管级联反应,紊乱血管细胞的调节功能,导致血管细胞代谢异常继而形成一系列血管微小病变,是动脉血管粥样硬化的催化剂[63];心房颤动是AMI后再发脑梗死的独立危险因素可能与心房颤动患者出现体循环动脉栓塞风险较高有关;HDL-C降低、收缩压增高均为心脑血管事件发生的独立危险因素,可能与AMI患者HDL-C水平较低有关,HDL-C降低则会导致其对LDL-C的抑制效果降低,增加了动脉粥样硬化的风险,继而引起AMI再发脑梗死[64-67];收缩压增高说明患者心率增快,心脏负荷加重,也是脑梗死的诱发因素[65]。高脂血症与AMI后再发脑梗死的相关性最高,可能与高脂血症患者血液内总胆固醇和LDL胆固醇过高有关,血脂水平异常增加了心脑血管事件的发生率[68-71]
 
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(收稿 2018-08-15)
本文责编:夏保军
本文引用信息:袁书刚,黄晓远,郭英选.急性心肌梗死后再发脑梗死的危险因素分析[J].中国实用神经疾病杂志,2019,22(3):303-308.DOI:10.12083/SYSJ.2019.03.056

Reference informationYUAN ShugangHUANG XiaoyuanGUO Yingxuan.Risk factors of recurrent cerebral infarction after acute myocardial infarction[J]Chinese Journal of Practical Nervous Diseases201922(3)303-308.DOI10.12083/SYSJ.2019.03.056

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