頸—股脈搏波速度與冠狀動(dòng)脈病變嚴(yán)重程度關(guān)系的研究*

陳炳偉，王志廣，黨愛民，柳青，呂納強(qiáng)，楊躍進(jìn)

頸—股脈搏波速度與冠狀動(dòng)脈病變嚴(yán)重程度關(guān)系的研究*

陳炳偉，王志廣，黨愛民，柳青，呂納強(qiáng)，楊躍進(jìn)

目的：探討頸—股脈搏波速度（cfPWV）與冠狀動(dòng)脈病變嚴(yán)重程度之間的關(guān)系。

方法：共入選接受首次冠狀動(dòng)脈（冠脈）造影檢查的患者319例。對(duì)所有患者的冠脈造影結(jié)果進(jìn)行SYNTAX評(píng)分，評(píng)價(jià)其冠脈病變程度。118例冠脈造影顯示未見≥ 50%狹窄作為對(duì)照組，其余201例患者依據(jù)SYNTAX評(píng)分分為低SYNTAX組（1～17.5分，n=96）和高SYNTAX組（18～72分，n=105）。測(cè)量入選患者的cfPWV。采用等級(jí)Logistic回歸方法，分析SYNTAX評(píng)分與cfPWV的關(guān)系。采用ROC曲線分析cfPWV預(yù)測(cè)SYNTAX評(píng)分結(jié)果的準(zhǔn)確性。

結(jié)果：在校正了年齡、性別、肥胖、吸煙、冠心病家族史、平均血壓、總膽固醇、高密度脂蛋白膽固醇、踝臂指數(shù)、高血壓、高脂血癥、糖尿病等因素后，SYNTAX評(píng)分與cfPWV顯著相關(guān)（OR=1.24，P=0.006）。進(jìn)一步分析顯示，cfPWV與SYNTAX評(píng)分的關(guān)系在男性、非肥胖、吸煙、糖尿病以及非高血壓患者中更為密切。cfPWV預(yù)測(cè)SYNTAX評(píng)分≥33分具有較高準(zhǔn)確性（ROC曲線下面積0.703）。

結(jié)論：作為評(píng)估主動(dòng)脈僵硬度的“金標(biāo)準(zhǔn)”，cfPWV與冠脈病變程度有相關(guān)性。

主動(dòng)脈僵硬度；動(dòng)脈脈搏波速度；冠狀動(dòng)脈粥樣硬化性心臟??；SYNTAX評(píng)分

Methods: A total of 319 patients who received the first time coronary angiography were studied. SYNTAX score evaluation was conducted to assess the severity of coronary lesions and the patients were divided into 3 groups: Control group, the subjects without coronary stenosis ≥ 50%, n=118, the rest 201 patients were divided as Low SYNTAX score (1-17.5) group, n=96 and High SYNTAX score (18-72) group, n=105. The cfPWV was measured in all patients, the relationship between SYNTAX score and cfPWV was studied by Ordinal logistic regression analysis, the accuracy for cfPWV predicting SYNTAX scoring was assessed by ROC analysis.

Results: With the adjusted factors of age, gender, obesity, smoking, family history of CAD, mean blood pressure, TC, HDL-C, ankle-brachial index (ABI), hypertension, hyperlipidaemia and diabetes, SYNTAX score was obviously related to cfPWV (OR=1.24, P=0.006). Further analysis for both High and Low SYNTAX score groups, the relationship between cfPWV and SYNTAX score was more close in patients with male gender, non-obesity, smoking, diabetes and non-hypertension. The accuracy for cfPWV predicting SYNTAX scoring had the higher sensitivity in patients with SYNTAX ≥ 33 (ROC=0.703).

Conclusion: As golden standard for measuring aortic stiffness, cfPWV is related to the severity of coronary artery lesions in relevant patients.

(Chinese Circulation Journal, 2015,30:326.)

頸—股脈搏波速度（cfPWV）是評(píng)估主動(dòng)脈僵硬度的金標(biāo)準(zhǔn)[1,2]，cfPWV升高是多種心血管事件的獨(dú)立危險(xiǎn)因素[3-6]。SYNTAX評(píng)分是一種評(píng)估冠狀動(dòng)脈（冠脈）病變的半定量工具，與既往的冠脈狹窄評(píng)分相比，它能更精確的反映冠脈狹窄的解剖學(xué)特征[7]。研究顯示，SYNTAX評(píng)分可以預(yù)測(cè)冠脈血運(yùn)重建患者的預(yù)后[8-10]。既往有研究證實(shí)，臂—踝脈搏波速度（baPWV）與SYNTAX評(píng)分相關(guān)[11]。雖然baPWV與cfPWV之間存在一定的相關(guān)性[12]，但是后者作為評(píng)估主動(dòng)脈僵硬度的“金標(biāo)準(zhǔn)”，其與SYNTAX評(píng)分之間的相關(guān)性少見報(bào)道。本研究探討了cfPWV與SYNTAX評(píng)分之間的關(guān)系，并探討cfPWV預(yù)測(cè)冠脈狹窄程度的價(jià)值。

1 資料與方法

研究對(duì)象：入選2012-07至2013-08期間在阜外心血管病醫(yī)院11病區(qū)就診并行冠脈造影檢查的319例患者，平均年齡（55.4±10.6）歲，257例（80.6%）為男性。118例冠脈造影顯示未見冠脈≥50%狹窄作為對(duì)照組，其余201例患者依據(jù)SYNTAX評(píng)分分為低SYNTAX組（1～17.5分，n=96）和高SYNTAX組（18～72分，n=105）。排除標(biāo)準(zhǔn)：已行冠脈介入治療或者冠脈旁路移植術(shù)治療、心肌炎、嚴(yán)重瓣膜病、先天性心臟病、結(jié)締組織病、心功能不全（左心室射血分?jǐn)?shù)＜50%）、急慢性感染性疾病、自身免疫病以及嚴(yán)重的腎功能不全。

入選患者均采集其基本信息，并檢測(cè)其血漿高密度脂蛋白膽固醇、低密度脂蛋白膽固醇等指標(biāo)。按《中國(guó)2型糖尿病防治指南（2010年版）》診斷糖尿?。嚎崭寡恰?.0 mmol/L，或隨機(jī)血糖≥11.1 mmol/L，或正在服用降糖藥[13]。按《中國(guó)高血壓防治指南2010》診斷標(biāo)準(zhǔn)診斷高血壓：收縮壓≥140 mmHg和（或）舒張壓≥90 mmHg（1 mmHg=0.133 kPa），或血壓正常但正在服用降壓藥者[14]。肥胖定義[14]：體重指數(shù)（BMI）≥28 kg/m2。本研究經(jīng)阜外心血管病醫(yī)院倫理委員會(huì)通過(guò)，所有患者均簽署知情同意書。

SYNTAX評(píng)分：SYNTAX評(píng)分由兩位有經(jīng)驗(yàn)的冠脈介入醫(yī)生進(jìn)行。兩位醫(yī)生所做SYNTAX結(jié)果具有較高的一致性（采用Bland-Altman分析）。評(píng)分時(shí)采用SYNTAX網(wǎng)站（www.syntaxscore.com）所提供的工具進(jìn)行。在直徑≥ 1.5 mm的冠脈中，每個(gè)狹窄≥50%的冠脈病變將依照評(píng)分標(biāo)準(zhǔn)給予打分，其總和即為SYNTAX評(píng)分。SYNTAX評(píng)分的臨床意義在于能用于指導(dǎo)冠心病尤其是復(fù)雜冠脈病變患者接受血運(yùn)重建治療方法的選擇。在冠心病介入治療指南中將SYNTAX≥33分作為血運(yùn)重建高?；颊叩臉?biāo)準(zhǔn)[15]。

cfPWV及踝臂指數(shù)的測(cè)量：采用SphygmoCor儀器（AtCor Medical， Sydney，Australia）測(cè)量cfPWV。檢測(cè)時(shí)，將壓力記錄探頭放置于患者右頸動(dòng)脈及股動(dòng)脈，同時(shí)連接心電圖。記錄心電圖波形校正的頸動(dòng)脈及股動(dòng)脈波形并計(jì)算兩者之間的時(shí)間差，計(jì)算時(shí)采用連續(xù)10次波形記錄的平均時(shí)間差。采樣點(diǎn)之間的距離采用皮尺手動(dòng)測(cè)量。cfPWV的數(shù)值即是將此距離用上述時(shí)間差相除得到的結(jié)果。測(cè)量獲得四肢收縮壓，即左肱動(dòng)脈、右肱動(dòng)脈、左踝動(dòng)脈、右踝動(dòng)脈的收縮壓。肱動(dòng)脈收縮壓取兩側(cè)測(cè)量值的高值，并分別以左踝及右踝動(dòng)脈的收縮壓計(jì)算相應(yīng)的左右兩側(cè)踝臂指數(shù)（ABI）。最后取左右兩側(cè)ABI的低值作為該患者的ABI納入統(tǒng)計(jì)學(xué)分析。ABI是下肢動(dòng)脈疾病診斷的重要指標(biāo)。根據(jù)《歐洲心臟學(xué)會(huì)外周動(dòng)脈疾病診療指南2011》，將ABI＜0.9作為提示下肢動(dòng)脈疾病的標(biāo)準(zhǔn)[16]。cfPWV及ABI均由同一名有經(jīng)驗(yàn)的醫(yī)生進(jìn)行測(cè)量，該醫(yī)生不知曉患者的臨床情況及SYNTAX評(píng)分結(jié)果。

統(tǒng)計(jì)學(xué)處理：所有數(shù)據(jù)均采用SPSS 19.0軟件進(jìn)行分析。連續(xù)變量以均數(shù)±標(biāo)準(zhǔn)差表示，分類變量以頻率及百分比表示。采用χ2檢驗(yàn)比較分類數(shù)據(jù)，采用方差分析比較多組間連續(xù)變量。采用等級(jí)Logistic回歸模型評(píng)估SYNTAXA評(píng)分與多個(gè)臨床因素以及cfPWV之間的關(guān)系。采用試者工作特征曲線（ROC）曲線分析cfPWV對(duì)于SYNTAX評(píng)分≥33分預(yù)測(cè)的準(zhǔn)確度，cfPWV預(yù)測(cè)SYNTAX評(píng)分≥33分的最佳界值是通過(guò)Youden指數(shù)來(lái)確定[17]。以P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 患者基本情況

三組患者的基本情況見表1。

表1 三組患者的基本資料比較（

表1 三組患者的基本資料比較（

注：1 mmHg=0.133 kPa

?

2.2 頸—股脈搏波速度與SYNTAX的關(guān)系分析

對(duì)SYNTAX分組行等級(jí)Logistic回歸分析。三組間年齡、性別、肥胖、吸煙、冠心病家族史、低密度脂蛋白膽固醇、高密度脂蛋白膽固醇、ABI、高血壓、高脂血癥、糖尿病等因素存在統(tǒng)計(jì)學(xué)差異，校正了上述因素后，cfPWV與SYNTAX評(píng)分明顯相關(guān)[比值比（OR）=1.24，95%可信區(qū)間：1.06～1.44，P=0.006，表2]。進(jìn)一步分析顯示，cfPWV與SYNTAX評(píng)分的關(guān)系僅在男性、非肥胖、吸煙者、糖尿病及非高血壓患者中存在相關(guān)關(guān)系。圖1

表2 319例患者頸—股脈搏波速度與SYNTAX評(píng)分多因素等級(jí)Logistic回歸分析結(jié)果

2.3 頸—股脈搏波速度預(yù)測(cè)SYNTAX評(píng)分的評(píng)估

鑒于SYNTAX評(píng)分的界值33分對(duì)于評(píng)估冠心病血運(yùn)重建風(fēng)險(xiǎn)的指導(dǎo)意義，將cfPWV對(duì)SYNTAX評(píng)分≥33分做ROC曲線（圖2）。ROC曲線下面積為0.703（95%可信區(qū)間0.635～0.765）。通過(guò)Youden指數(shù)確定cfPWV的最佳界值為10.25 m/s （敏感度為44.4%，特異度為87.3%）。圖3

圖1 頸—股脈搏波速度與SYNTAX評(píng)分關(guān)系分析

圖2 頸—股脈搏波速度預(yù)測(cè)SYNTAX評(píng)分≥33分的ROC曲線

圖3 通過(guò)Youden指數(shù)判斷頸—股脈搏波速度預(yù)測(cè)SYNTAX≥33分的最佳界值

3 討論

多個(gè)臨床指南推薦cfPWV作為評(píng)估主動(dòng)脈僵硬度的“金標(biāo)準(zhǔn)”。研究顯示，cfPWV不但可以作為冠心病、高血壓以及卒中等心腦血管疾病發(fā)病的獨(dú)立預(yù)測(cè)因素[4,5]，同時(shí)還可以作為心血管事件以及全因死亡率等臨床預(yù)后的獨(dú)立危險(xiǎn)因素[3]。在2013年《歐洲心臟病學(xué)會(huì)高血壓診療指南》中，推薦將cfPWV＞10 m/s作為高血壓靶器官損害的重要指標(biāo)[18]。

SYNTAX評(píng)分最初是作為SYNTAX研究的一部分，用于冠心病患者冠脈病變嚴(yán)重程度的量化評(píng)估[7]。之后越來(lái)越多的研究發(fā)現(xiàn)SYNTAX評(píng)分可以用于冠脈介入治療后患者不良事件的預(yù)測(cè)[8,9]。許多學(xué)者還嘗試將各種臨床指標(biāo)與SYNTAX評(píng)分進(jìn)行結(jié)合，從而進(jìn)一步提高了SYNTAX評(píng)分風(fēng)險(xiǎn)評(píng)估的臨床應(yīng)用價(jià)值[19]。

年齡和高血壓等因素是冠脈粥樣硬化和主動(dòng)脈僵硬度增加的共同危險(xiǎn)因素。在主動(dòng)脈硬化病理發(fā)展中的一些基本過(guò)程如膠原纖維聚集、纖維化、炎癥、中層平滑肌細(xì)胞凋亡以及鈣化等，在冠狀動(dòng)脈粥樣硬化中同樣存在，可以說(shuō)兩者有著類似的病理生理機(jī)制[2]。既往研究利用冠狀動(dòng)脈鈣化[20-22]、病變累及冠脈支數(shù)[23,24]以及冠脈狹窄總數(shù)[25]等指標(biāo)作為評(píng)估冠脈粥樣硬化嚴(yán)重程度的指標(biāo)，發(fā)現(xiàn)其與主動(dòng)脈僵硬度之間存在相關(guān)性。SYNTAX評(píng)分為量化評(píng)估冠狀動(dòng)脈粥樣硬化提供了更為精確的指標(biāo)。既往有研究證實(shí)baPWV與SYNTAX評(píng)分相關(guān)[10]，然而baPWV明顯受到外周動(dòng)脈硬化的影響，主動(dòng)脈僵硬度僅能解釋其60%的結(jié)果[26]。與主動(dòng)脈僵硬度相比，外周動(dòng)脈僵硬度與Framingham 危險(xiǎn)評(píng)分[27]、冠脈鈣化[28]、冠心病發(fā)病率[29]以及心血管死亡率之間的相關(guān)性較差[30]。因此，各個(gè)指南中均將cfPWV作為評(píng)估主動(dòng)脈僵硬度的金標(biāo)準(zhǔn)[1,2]。

本研究顯示，在調(diào)整了其他動(dòng)脈粥樣硬化危險(xiǎn)因素之后，SYNTAX評(píng)分所反映的冠脈狹窄嚴(yán)重程度與cfPWV所反映的主動(dòng)脈僵硬度之間存在明顯相關(guān)性。在預(yù)測(cè)冠心病血運(yùn)重建高?；颊邥r(shí)，cfPWV表現(xiàn)出一定的準(zhǔn)確性，而得到的最佳切點(diǎn)值（10.25 m/s）非常接近目前指南中所推薦的用于判斷主動(dòng)脈僵硬度顯著增高的界值（10 m/s）。利用cfPWV預(yù)測(cè)高SYNTAX評(píng)分，具有較高的特異度（87.3%），提示主動(dòng)脈僵硬度顯著增高的患者中，近90%合并嚴(yán)重冠脈狹窄，因此對(duì)于cfPWV大于10 m/s者，臨床心血管病風(fēng)險(xiǎn)較高，應(yīng)給予更為積極的干預(yù)。利用cfPWV預(yù)測(cè)高SYNTAX評(píng)分，敏感度較低，可能與各種危險(xiǎn)因素對(duì)于冠脈粥樣硬化和動(dòng)脈硬化的影響程度不同有關(guān)，如主動(dòng)脈僵硬度與年齡以及高血壓等的關(guān)系更為密切[31-33]。同時(shí)本研究還發(fā)現(xiàn)，在具有男性、吸煙以及糖尿病等冠心病危險(xiǎn)因素的患者中，cfPWV與SYNTAX評(píng)分的關(guān)系更為密切，提示對(duì)于此類患者，主動(dòng)脈硬化與冠脈粥樣硬化的關(guān)系更為密切。

本研究首次發(fā)現(xiàn)了cfPWV與SYNTAX評(píng)分之間的相關(guān)性，cfPWV可以作為高SYNTAX評(píng)分的預(yù)測(cè)因素。但作為橫斷面研究，本研究無(wú)法明確cfPWV在SYNTAX評(píng)分基礎(chǔ)上能否增加其預(yù)測(cè)冠脈血運(yùn)重建治療后風(fēng)險(xiǎn)的能力等問(wèn)題。未來(lái)需要更多的前瞻性研究對(duì)于動(dòng)脈硬化與SYNTAX評(píng)分之間是否存在交互作用等問(wèn)題進(jìn)行更深入的探討。

總之，作為評(píng)估主動(dòng)脈僵硬度的“金標(biāo)準(zhǔn)”，cfPWV與冠脈狹窄嚴(yán)重程度有明確的相關(guān)性，其對(duì)于預(yù)測(cè)冠脈病變嚴(yán)重程度具有一定價(jià)值。

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Relationship Between Carotid-femoral Pulse Wave Velocity and Severity of Coronary Artery Lesions Measured by SYNTAX Score

CHEN Bing-wei, WANG Zhi-guang, DANG Ai-min, LIU Qing, LV Na-qiang, YANG Yue-jin.
Department of Cardiology, Cardiovascular Institute and Fu Wai Hospital, CAMS and PUMC, Beijing (100037), China

Objective: To explore the relationship between carotid-femoral pulse wave velocity (cfPWV) and the severity of coronary artery lesions measured by SYNTAX score.

Arterial stiffness; Pulse wave velocity; Coronary artery disease; SYNTAX score

2014-07-24）

（編輯：許 菁）

首都衛(wèi)生發(fā)展科研專項(xiàng)項(xiàng)目（首發(fā)2011-4003-04）

100037 北京市， 中國(guó)醫(yī)學(xué)科學(xué)院 北京協(xié)和醫(yī)學(xué)院 國(guó)家心血管病中心 阜外心血管病醫(yī)院 心內(nèi)科

陳炳偉 主治醫(yī)生 博士 主從事冠心病學(xué)研究 Email: cbwmail@163.com 通訊作者：黨愛民 Email: amdang@fuwaihospital.org

R54

A

1000-3614（2015）04-0326-05

10.3969/j.issn.1000-3614.2015.04.006