血管健康指標(biāo)對(duì)新發(fā)心腦血管事件的預(yù)測(cè)價(jià)值:北京血管健康分級(jí)標(biāo)準(zhǔn)的初步驗(yàn)證
Predictive value of vascular health indicators on newly cardiovascular events: Preliminary validation of Beijing vascular health stratification system
LIU Huan1,2,*, HE Ying-dong3,*, LIU Jin-bo1,2, HUANG Wei1, ZHAO Na1, ZHAO Hong-wei1, ZHOU Xiao-hua ,2,3,△, WANG Hong-yu ,1,2,△
摘要
目的 探索血管健康指標(biāo)(包括頸-股動(dòng)脈脈搏波傳導(dǎo)速度、頸-橈動(dòng)脈脈搏波傳導(dǎo)速度、心踝血管指數(shù)和踝臂指數(shù))與冠狀動(dòng)脈粥樣硬化性心臟病(簡(jiǎn)稱冠心病)和腦梗塞的關(guān)系,初步評(píng)估北京血管健康分級(jí)的預(yù)測(cè)價(jià)值。方法 研究納入2010—2017年首鋼醫(yī)院血管醫(yī)學(xué)科至少有2次住院記錄的受試者,排除基線時(shí)血管指標(biāo)數(shù)據(jù)缺失且患有冠心病或腦梗塞的患者。建立兩個(gè)隊(duì)列,隊(duì)列1(冠心病)入組467例受試者[平均年齡(63.4±12.3)歲,女性42.2%],隊(duì)列2(腦梗塞)入組658例受試者[平均年齡(64.3±12.2)歲,女性48.7%],分別應(yīng)用Cox比例風(fēng)險(xiǎn)回歸建立冠心病或腦梗塞的預(yù)測(cè)模型。結(jié)果 隊(duì)列1和隊(duì)列2的中位隨訪時(shí)間分別為1.9年和2.1年,隨訪期間,隊(duì)列1中有164例首發(fā)冠心病事件發(fā)生,隊(duì)列2中有117例首發(fā)腦梗塞事件發(fā)生。將4種血管健康指標(biāo)同時(shí)作為連續(xù)變量進(jìn)行多變量調(diào)整分析,隊(duì)列1中,4種指標(biāo)均有統(tǒng)計(jì)學(xué)意義(P均<0.05);隊(duì)列2中,僅心踝血管指數(shù)有統(tǒng)計(jì)學(xué)意義(P<0.05)。未調(diào)整模型中,北京血管健康分級(jí)對(duì)于冠心病和腦梗塞的預(yù)測(cè)價(jià)值均有統(tǒng)計(jì)學(xué)意義(P均<0.05),而在多變量調(diào)整模型中,北京血管健康分級(jí)僅對(duì)冠心病具有預(yù)測(cè)價(jià)值(P<0.05)。結(jié)論 不同的血管健康指標(biāo)對(duì)于冠心病和腦梗塞的預(yù)測(cè)價(jià)值不同,其中心踝血管指數(shù)可能是一種較為穩(wěn)定的指標(biāo)。北京血管健康分級(jí)對(duì)于冠心病具有預(yù)測(cè)價(jià)值,而對(duì)于腦梗塞的預(yù)測(cè)價(jià)值還需進(jìn)一步研究。
關(guān)鍵詞：心血管疾病;危險(xiǎn)因素;隊(duì)列研究;北京血管健康分級(jí)
Abstract
Objective: To explore the predictive value of carotid femoral artery pulse wave velocity (CF-PWV), carotid radial artery pulse wave velocity (CR-PWV), cardio-ankle vascular index (CAVI), and ankle brachial index (ABI) on coronary heart disease (CHD) and cerebral infarction (CI), and the preliminary validation of Beijing vascular health stratification (BVHS).Methods: Subjects with at least 2 in-patient records were included into the study between 2010 and 2017 from Vascular Medicine Center of Peking University Shougang Hospital. Subjects with CHD or CI, and without data of vascular function at baseline were excluded. Eventually, 467 subjects free of CHD [cohort 1, mean age: (63.4±12.3) years, female 42.2%] and 658 subjects free of CI [cohort 2, mean age: (64.3±12.2) years, female 48.7%] at baseline were included. The first in-patient records were as the baseline data, the second in-patient records were as a following-up data. Cox proportional hazard regression was used to establish the predictive models of CHD or CI derived from BVHS by multivariable-adjusted analysis.Results: The median follow-up time of cohort 1 and cohort 2 was 1.9 years and 2.1 years, respectively. During the follow-up, 164 first CHD events occurred in cohort 1 and 117 first CI events occurred in cohort 2. Four indicators were assessed as continuous variables simultaneously by multivariable-adjusted analysis. In cohort 1, CF-PWV, CR-PWV, ABI, and CAVI reached statistical significance in the multivariable-adjusted models (P<0.05). In cohort 2, only CAVI (P<0.05) was of statistical significance. In addition, the higher CF-PWV became a protector of CHD or CI (P<0.05). The prediction value of BVHS reached the statistical significance for CHD and CI in the unadjusted models (all P<0.05), however, BVHS could only predict the incidence of CHD (P<0.05), but not the incidence of CI (P>0.05) in the multivariable-adjusted models. CF-PWV, CR-PWV, ABI, and CAVI were associated factors of CHD independent of each other (P<0.05), only CAVI (P<0.05) was the risk factor of CI independent of the other three.Conclusion: The different vascular indicators might have different effect on CHD or CI. CAVI might be a stable predictor of both CHD and CI. Higher baseline CF-PWV was not necessarily a risk factor of CHD or CI because of proper vascular health management. BVHS was a potential factor for the prediction of CHD, and further research is needed to explore the prediction value for CI.
Keywords：Cardiovascular disease;Risk factors;Cohort studies;Beijing vascular health stratification
本文引用格式
劉歡, 何映東, 劉金波, 黃薇, 趙娜, 趙紅薇, 周曉華, 王宏宇.
LIU Huan, HE Ying-dong, LIU Jin-bo, HUANG Wei, ZHAO Na, ZHAO Hong-wei, ZHOU Xiao-hua, WANG Hong-yu. Predictive value of vascular health indicators on newly cardiovascular events: Preliminary validation of Beijing vascular health stratification system. Journal of Peking University(Health Sciences)[J], 2020, 52(3): 514-520 doi:10.19723/j.issn.1671-167X.2020.03.018
目前血管結(jié)構(gòu)病變(如管腔狹窄或閉塞)被常規(guī)用于心血管疾病的風(fēng)險(xiǎn)評(píng)估,盡管以往研究已發(fā)現(xiàn)動(dòng)脈功能障礙與心血管疾病的關(guān)系,但尚未引起臨床重視。一些無(wú)創(chuàng)指標(biāo)已被用來(lái)量化評(píng)估血管健康,包括踝臂指數(shù)(ankle brachial index,ABI)、頸-股動(dòng)脈脈搏波傳導(dǎo)速度(carotid-femoral artery pulse wave velocity,CF-PWV)、頸-橈動(dòng)脈脈搏波傳導(dǎo)速度(carotid-radial artery pulse wave velocity,CR-PWV)、心踝血管指數(shù)(cardio-ankle vascular index,CAVI)。ABI是踝部動(dòng)脈與肱動(dòng)脈收縮壓之比,常作為下肢動(dòng)脈粥樣硬化閉塞的診斷標(biāo)準(zhǔn)之一[1],還是其他血管床發(fā)生動(dòng)脈粥樣硬化的提示指標(biāo),低的ABI還被認(rèn)為是西方和亞洲人群心血管疾病的獨(dú)立預(yù)測(cè)因子[2,3]。CF-PWV作為動(dòng)脈硬化評(píng)估指標(biāo)的研究較多,其增高是患病人群和一般人群的心血管疾病危險(xiǎn)因子[4,5],目前尚未發(fā)現(xiàn)CR-PWV與心血管疾病有關(guān)[6,7,8]。CAVI也是動(dòng)脈硬化的指標(biāo)之一,但其在檢測(cè)時(shí)不受即刻血壓的影響[9],有研究發(fā)現(xiàn)CAVI與心血管疾病的危險(xiǎn)因素有關(guān)[10,11,12,13]。
關(guān)于上述指標(biāo)的研究尚存在以下不足:(1)ABI和CF-PWV的相關(guān)研究眾多,但是關(guān)于CR-PWV和CAVI的研究以及多種指標(biāo)聯(lián)合評(píng)估的研究較少;(2)大多數(shù)研究的是西方人群,關(guān)于亞洲人群的研究多是日本人群,關(guān)于中國(guó)人群的隊(duì)列研究尚缺乏。一些血管健康指標(biāo)已被證實(shí)為心血管疾病的獨(dú)立危險(xiǎn)因素,用于心血管事件的預(yù)測(cè),且血管健康指標(biāo)聯(lián)合傳統(tǒng)的危險(xiǎn)因素能夠提高心血管事件的預(yù)測(cè)能力[14,15,16]。本研究團(tuán)隊(duì)在總結(jié)了多年的臨床及科研經(jīng)驗(yàn)后,提出了血管健康綜合評(píng)估系統(tǒng)的概念,并提出了以血管為評(píng)估靶點(diǎn)的北京血管健康分級(jí)標(biāo)準(zhǔn)(Beijing vascular health stratification, BVHS)[17,18],然而此分級(jí)系統(tǒng)尚未被驗(yàn)證其應(yīng)用價(jià)值。
因此,本研究基于醫(yī)院內(nèi)數(shù)據(jù)設(shè)計(jì)回顧性隊(duì)列研究,目的在于在中國(guó)人群中,探索不同血管健康指標(biāo)對(duì)兩種主要心血管疾病——冠狀動(dòng)脈粥樣硬化性心臟病(簡(jiǎn)稱冠心病)和腦梗塞(cerebral infarction,CI)預(yù)測(cè)的聯(lián)合效應(yīng)以及相對(duì)權(quán)重,初步評(píng)估BVHS的預(yù)測(cè)價(jià)值。
1 資料與方法
1.1 研究人群
本研究設(shè)計(jì)為基于醫(yī)院內(nèi)數(shù)據(jù)的回顧性隊(duì)列研究,使用北京血管疾病人群評(píng)估研究(Beijing Vascular Disease Patients Evaluation Study,BEST Study)的部分?jǐn)?shù)據(jù)。BEST研究(Clinical Trials.gov Identifier: NCT02569268)是一項(xiàng)自2010年在北京大學(xué)首鋼醫(yī)院血管醫(yī)學(xué)中心開展的前瞻性隊(duì)列研究[19]。
收集2010—2017年在首鋼醫(yī)院血管醫(yī)學(xué)科住院就診人群(涵蓋各種血管相關(guān)疾病,主要包括高血壓、糖尿病、冠心病、腦梗塞和外周動(dòng)脈疾病等)的醫(yī)療數(shù)據(jù)。
建立兩個(gè)隊(duì)列,隊(duì)列1(冠心病隊(duì)列),隊(duì)列2(腦梗塞隊(duì)列),兩個(gè)隊(duì)列的入選標(biāo)準(zhǔn)為:(1)年齡、性別不限;(2)至少有一次住院記錄(作為基線數(shù)據(jù)資料),且在其當(dāng)次住院后至少有一次住院記錄(作為隨訪記錄數(shù)據(jù))。
隊(duì)列1和隊(duì)列2的排除標(biāo)準(zhǔn):(1)基線時(shí)血管健康指標(biāo)數(shù)據(jù)缺失;(2)基線時(shí)患有冠心病者(隊(duì)列1)、患有腦梗塞者(隊(duì)列2)。
隊(duì)列1入選467例無(wú)冠心病受試者,隊(duì)列2入選658例無(wú)腦梗塞受試者,入選流程圖見圖1。
圖1
圖1 受試者入選流程圖
Figure 1 Flow diagram of subject inclusion process
CHD, coronary heart disease; CI, cerebral infarction.
BEST研究方案符合1975年《赫爾辛基宣言》,且通過北京大學(xué)首鋼醫(yī)院倫理委員會(huì)批準(zhǔn)(批件號(hào)IRBK-2017-017-01),入選受試者均簽署書面知情同意書。
1.2 血管健康指標(biāo)檢查
血管健康指標(biāo)測(cè)量前囑受檢者休息、保持安靜并平臥位5~10 min,如運(yùn)動(dòng)后需靜息20 min,受檢者去枕仰臥體位,雙手手心向上置于身體兩側(cè)。
CF-PWV和CR-PWV使用自動(dòng)血管功能檢查設(shè)備(Artech Medical, Pantin, 法國(guó))檢測(cè),其原理為脈搏波在動(dòng)脈系統(tǒng)的兩個(gè)既定點(diǎn)之間的傳播速度通過測(cè)量?jī)牲c(diǎn)之間的傳導(dǎo)時(shí)間(t)和距離(L)求得,計(jì)算公式為PWV(m/s)=L/t。
CAVI和ABI使用血管篩查系統(tǒng)(VS-1000,Fukuda Denshi,日本)檢測(cè),將四肢血壓袖帶縛于被檢測(cè)者上臂及下肢踝部,將2個(gè)心電電極分別置于雙腕部以采集心電信號(hào),將心音傳感器放置在胸骨上第二肋間的位置,儀器自動(dòng)檢測(cè)雙側(cè)CAVI和ABI。本研究中,ABI取平均值(因ABI數(shù)值反映動(dòng)脈狹窄閉塞的病變程度,本研究中取雙側(cè)平均值用于評(píng)估下肢動(dòng)脈的病變負(fù)荷),CAVI取兩側(cè)中較大值。
1.3 心血管危險(xiǎn)因素的臨床評(píng)估和定義
收集記錄基線時(shí)吸煙、飲酒數(shù)據(jù),高血壓、糖尿病和高脂血癥的診斷數(shù)據(jù)來(lái)自于首次住院時(shí)醫(yī)療文件記錄,身高、體質(zhì)量、心率、收縮壓和舒張壓由CAVI設(shè)備同時(shí)獲得,體重指數(shù)(body mass index,BMI)=體質(zhì)量/身高2,平均動(dòng)脈壓(mean arterial pressure,MAP)=2/3舒張壓+1/3收縮壓。
1.4 簡(jiǎn)化的BVHS
BVHS是一種基于血管結(jié)構(gòu)和功能(如動(dòng)脈內(nèi)皮功能、動(dòng)脈僵硬度和動(dòng)脈狹窄)進(jìn)行綜合評(píng)估的新的血管健康評(píng)估系統(tǒng)。本研究中,僅用動(dòng)脈僵硬度和動(dòng)脈狹窄指標(biāo),將BVHS簡(jiǎn)化為七級(jí)評(píng)分系統(tǒng),定義及賦值為: 1: 動(dòng)脈硬化,右側(cè)CF-PWV>9 m/s或任意一側(cè)CAVI>9; 0: 無(wú)動(dòng)脈硬化,右側(cè)CF-PWV<9 m/s且雙側(cè)CAVI<9。
動(dòng)脈狹窄程度的評(píng)估基于影像學(xué)檢查,包括顱腦磁共振成像血管造影、外周動(dòng)脈和冠狀動(dòng)脈的X線血管造影、計(jì)算機(jī)斷層掃描血管造影(computed tomography angiography,CTA)或血管超聲(頸動(dòng)脈、鎖骨下動(dòng)脈、下肢動(dòng)脈、腹主動(dòng)脈)。如無(wú)影像學(xué)診斷報(bào)告,則被認(rèn)定為動(dòng)脈狹窄程度為1,即無(wú)血管管腔狹窄,賦值如下:1:無(wú)血管管腔狹窄;2:血管管腔狹窄<50%;3:血管管腔狹窄50%~75%;4:血管管腔狹窄>75%。最終簡(jiǎn)化的BVHS詳見表1。
表1 簡(jiǎn)化的北京血管健康分級(jí)賦值
Table 1
Artery stenosis including peripheral artery and coronary artery detected by vascular ultrasound or computed tomography angiography or angiography. 1, 2, 3, 4, correspond to no vascular lumen stenosis, vascular lumen stenosis<50%, vascular lumen stenosis 50%-75%, vascular lumen stenosis>75%. Arterial stiffness=1, corresponds to CF-PWV>9 m/s or CAVI>9 in either side, and otherwise=0. BVHS, Beijing vascular health stratification.
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1.5 結(jié)局
隊(duì)列1中主要的結(jié)局變量是冠心病,隊(duì)列2中主要的結(jié)局變量是腦梗塞。對(duì)于隨訪的醫(yī)療記錄,再次核實(shí)冠心病及腦梗塞的診斷。冠心病定義為有心肌梗死、明確的心絞痛、復(fù)蘇的心臟驟停、冠狀動(dòng)脈旁路移植術(shù)或血管成形術(shù)的病史。腦梗塞的診斷來(lái)自于顱腦磁共振檢查結(jié)果。
1.6 統(tǒng)計(jì)學(xué)分析
隊(duì)列1和隊(duì)列2中應(yīng)用同樣的統(tǒng)計(jì)分析方法,所有受試者按照年齡被分為6組:年齡<40歲、40~49歲、50~59歲、60~69歲、70~79歲和≥80歲。以性別和年齡組特定的中位數(shù)作為界定值來(lái)定義高或低的血管健康指標(biāo),包括CF-PWV、CR-PWV、ABI和CAVI。采用兩獨(dú)立樣本t檢驗(yàn)和卡方檢驗(yàn)比較兩組之間的差異,以Cox比例風(fēng)險(xiǎn)模型檢驗(yàn)4種血管健康指標(biāo)以及BVHS綜合評(píng)估系統(tǒng)與冠心病或腦梗塞之間的關(guān)系。本研究以單一血管健康指標(biāo)或4個(gè)血管健康指標(biāo)同時(shí)作為自變量,冠心病或腦梗塞為因變量,調(diào)整其他混雜因素,建立如下模型:(1)單一血管健康指標(biāo)作為二分類變量(高或低)建立多變量調(diào)整模型;(2)單一血管健康指標(biāo)作為連續(xù)變量建立多變量調(diào)整模型;(3)4個(gè)血管健康指標(biāo)同時(shí)作為連續(xù)變量建立多變量調(diào)整模型;(4)以BVHS建立模型。本研究為將年齡、性別、吸煙、飲酒、BMI、心率、平均動(dòng)脈壓、高血壓、糖尿病、高脂血癥、基線時(shí)腦梗塞(隊(duì)列1)或基線時(shí)冠心病(隊(duì)列2)進(jìn)行調(diào)整的多變量分析,雙側(cè)P<0.05為差異有統(tǒng)計(jì)學(xué)意義,所有分析均使用R軟件(版本3.5.1,奧地利,維也納,R統(tǒng)計(jì)計(jì)算基金會(huì))進(jìn)行。
2 結(jié)果
2.1 隊(duì)列1和隊(duì)列2的一般臨床特點(diǎn)
隊(duì)列1和隊(duì)列2的中位隨訪時(shí)間分別為1.9年和2.1年,隨訪期間,隊(duì)列1中有164例首發(fā)冠心病事件發(fā)生,隊(duì)列2中有117例首發(fā)腦梗塞事件發(fā)生(表2)。
表2 隊(duì)列1人群和隊(duì)列2人群的基線特點(diǎn)
Table 2
(n=467)Cohort 2
(n=658)Age/years63.4±12.364.3±12.2Female/%42.248.7Body mass index/(kg/m2)25.2±3.825.6±6.1Heart rate/(beats/min)70.3±11.671.7±42.6Mean artery pressure/mmHg101.8±11.9101.6±14.5Smoking/%30.026.6Drinking/%27.023.1Diabetes/%23.329.7Hypertension/%62.764.6Hyperlipidemia/%57.864.2Coronary heart disease
(baseline/endpoint)/%52.1/66.1Cerebral infarction
(baseline/endpoint)/%32.8/41.8CF-PWV/(m/s)11.6±2.911.6±2.7CR-PWV/(m/s)9.2±1.79.1±1.8CAVI8.7±1.98.6±1.9ABI1.02±0.201.01±0.21Median follow-up time/years1.92.1Number of events164117
Values are ?x±s for continuous variables or % for categorical variables. CF-PWV, carotid-femoral artery pulse wave velocity; CR-PWV, carotid-radial artery pulse wave velocity; ABI, ankle brachial index; CAVI, cardio-ankle vascular index.
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2.2 4種血管健康指標(biāo)對(duì)于冠心病和腦梗塞事件的預(yù)測(cè)
由表3~6可見,隊(duì)列1中,將4種血管健康指標(biāo)分別作為二分類變量進(jìn)行多變量調(diào)整的Cox分析發(fā)現(xiàn),CF-PWV、CR-PWV和CAVI有統(tǒng)計(jì)學(xué)意義,而ABI并無(wú)統(tǒng)計(jì)學(xué)意義。將4種血管健康指標(biāo)分別作為連續(xù)變量進(jìn)行多變量調(diào)整的Cox分析發(fā)現(xiàn),CF-PWV、CR-PWV和ABI均具有統(tǒng)計(jì)學(xué)意義,而CAVI無(wú)統(tǒng)計(jì)學(xué)意義。將4種血管健康指標(biāo)同時(shí)作為連續(xù)變量進(jìn)行多變量調(diào)整分析,4種指標(biāo)均具有統(tǒng)計(jì)學(xué)意義。
表3 隊(duì)列1中4種血管健康指標(biāo)分別對(duì)于冠心病風(fēng)險(xiǎn)的預(yù)測(cè)
Table 3
Multivariable-adjusted model is adjusted for age, gender, smoking, alcohol use, body mass index, heart rate, mean arterial pressure, hypertension, diabetes mellitus, cerebral infarction at baseline and hyperlipoidemia. CF-PWV, carotid-femoral artery pulse wave velocity; CR-PWV, carotid-radial artery pulse wave velocity; ABI, ankle brachial index; CAVI, cardio-ankle vascular index; SD, standard deviation; CI, confidence interval; HR, hazard ratio.
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表4 隊(duì)列2中4種血管健康指標(biāo)分別對(duì)于腦梗塞風(fēng)險(xiǎn)的預(yù)測(cè)
Table 4
Multivariable-adjusted model is adjusted for age, gender, smoking, alcohol use, body mass index, heart rate, mean arterial pressure, hypertension, diabetes mellitus, coronary heart disease at baseline and hyperlipoidemia. Abbreviations as in Table 3.
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表5 隊(duì)列1中4種血管健康指標(biāo)同時(shí)對(duì)于冠心病風(fēng)險(xiǎn)的預(yù)測(cè)
Table 5
Abbreviations and footnotes as in Table 3.
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表6 隊(duì)列2中4種血管健康指標(biāo)同時(shí)對(duì)于腦梗塞風(fēng)險(xiǎn)的預(yù)測(cè)
Table 6
Abbreviations as in Table 3. Footnotes as in Table 4.
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隊(duì)列2中,將4種血管健康指標(biāo)分別作為二分類變量和連續(xù)變量進(jìn)行多變量調(diào)整的Cox分析發(fā)現(xiàn),只有CF-PWV和CAVI有統(tǒng)計(jì)學(xué)意義。將4種血管指標(biāo)同時(shí)作為連續(xù)變量進(jìn)行多變量調(diào)整分析,只有CAVI具有統(tǒng)計(jì)學(xué)意義。
2.3 簡(jiǎn)化的BVHS對(duì)于冠心病和腦梗塞的預(yù)測(cè)價(jià)值
未調(diào)整的Cox分析發(fā)現(xiàn),簡(jiǎn)化的BVHS對(duì)于冠心病和腦梗塞的預(yù)測(cè)均有統(tǒng)計(jì)學(xué)意義,而在多變量調(diào)整的Cox分析中,簡(jiǎn)化的BVHS僅對(duì)冠心病的預(yù)測(cè)有統(tǒng)計(jì)學(xué)意義,而對(duì)腦梗塞的預(yù)測(cè)沒有統(tǒng)計(jì)學(xué)意義(表7)。
表7 簡(jiǎn)化的BVHS對(duì)于冠心病和腦梗塞的預(yù)測(cè)價(jià)值
Table 7
heart diseaseUnadjusted1.20 (1.13-1.27)<0.001Multivariable-adjusted1.17 (1.10-1.25)<0.001Cerebral
infarctionUnadjusted1.20 (1.00-1.45)0.048Multivariable-adjusted1.07 (0.87-1.32)0.518
Coronary heart disease cohort: multivariable-adjusted model is adjusted for age, gender, smoking, alcohol use, body mass index, heart rate, mean arterial pressure, hypertension, diabetes mellitus, cerebral infarction at baseline and hyperlipoidemia. Cerebral infarction cohort: multivariable-adjusted model is adjusted for age, gender, smoking, alcohol use, body mass index, heart rate, mean arterial pressure, hypertension, diabetes mellitus, coronary heart disease at baseline and hyperlipoidemia. BVHS, Beijing vascular health stratification; CI, confidence interval; HR, hazard ratio.
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3 討論
本研究發(fā)現(xiàn)4種血管健康指標(biāo)CF-PWV、CR-PWV、ABI和CAVI同時(shí)是冠心病的獨(dú)立相關(guān)因素,且相互之間獨(dú)立,而只有CAVI升高是腦梗塞的獨(dú)立危險(xiǎn)因素,且不受其他3種指標(biāo)的影響。這些結(jié)果提示,不同的血管健康指標(biāo)對(duì)于冠心病和腦梗塞的預(yù)測(cè)價(jià)值不同,而且CAVI可能是冠心病和腦梗塞比較穩(wěn)定的預(yù)測(cè)指標(biāo)。此外,本研究分析了BVHS的價(jià)值,發(fā)現(xiàn)其對(duì)于冠心病具有預(yù)測(cè)價(jià)值,而對(duì)于腦梗塞的預(yù)測(cè)價(jià)值還需要進(jìn)一步的研究。
關(guān)于血管健康指標(biāo)的研究較多,但大多數(shù)研究?jī)H圍繞某一指標(biāo)進(jìn)行單獨(dú)研究,很少研究多種血管健康指標(biāo)在同一隊(duì)列中的價(jià)值。目前為止,較高的CF-PWV一直被認(rèn)為是心血管事件的危險(xiǎn)因素。一項(xiàng)包括19項(xiàng)研究的薈萃分析估計(jì)CF-PWV的風(fēng)險(xiǎn)比(hazard risk, HR)為1.25(每增加1個(gè)標(biāo)準(zhǔn)差,95%CI為1.19~1.31),且這些研究均提示較高的CF-PWV是顯著的危險(xiǎn)因子[5]。然而,本研究中較高的CF-PWV在一些研究分析中并不是危險(xiǎn)因素,而表現(xiàn)為冠心病或腦梗塞的保護(hù)因子。究其原因,可能是本研究在基線時(shí)具有較高CF-PWV的人群被給予了更多的系統(tǒng)性治療和管理,延緩了CF-PWV的進(jìn)展,甚至使CF-PWV水平降低,從而導(dǎo)致基線時(shí)較高的CF-PWV成為了冠心病或腦梗塞事件的保護(hù)因素。由此可見,基線時(shí)即使具有較高的CF-PWV水平,但是通過系統(tǒng)管理和治療,較高的CF-PWV可延緩年齡相關(guān)的動(dòng)脈硬化進(jìn)展,甚或是逆轉(zhuǎn),從而導(dǎo)致這部分人群的心腦血管事件發(fā)生率較低,也初步說(shuō)明,僅一次血管健康狀況評(píng)估并不能反映未來(lái)心血管事件的風(fēng)險(xiǎn),而是要終身評(píng)估和維護(hù)血管健康,從而降低心腦血管事件的發(fā)生。此外,CF-PWV指標(biāo)在檢測(cè)時(shí)容易受到檢測(cè)時(shí)即刻血壓變化的影響,本研究結(jié)果也初步證實(shí)CAVI是一種更加穩(wěn)定的指標(biāo),本研究中對(duì)ABI和CAVI的研究結(jié)果與既往其他研究結(jié)果一致,通常情況下,截點(diǎn)值0.9被用來(lái)評(píng)估ABI的高低。Ohkuma等[2]通過分析個(gè)體數(shù)據(jù)的薈萃分析研究發(fā)現(xiàn),與ABI為1.10~1.19相比,ABI≤0.9對(duì)于心血管事件的HR為1.60,Hong等[20]的薈萃分析中發(fā)現(xiàn)了更大的HR為2.22。本研究中,血管健康指標(biāo)用年齡和性別校正的中位數(shù)來(lái)作為截點(diǎn)值,而不是用特定的截點(diǎn)數(shù)值,這樣不同的指標(biāo)分析結(jié)果都以類似的方式展示。不論是作為二分類變量還是連續(xù)變量,較低的ABI都是冠心病的顯著危險(xiǎn)因子,而其對(duì)于腦梗塞并無(wú)統(tǒng)計(jì)學(xué)意義。本研究中CAVI對(duì)于冠心病和腦梗塞的HR估測(cè)值與Satoh-Asahara等[13](HR=1.44,每增加一個(gè)標(biāo)準(zhǔn)差,95%CI:1.02~2.02)和Sato等[12](HR=1.126,每增加一個(gè)標(biāo)準(zhǔn)差,95%CI:1.006~1.259)的研究結(jié)果類似。
本研究團(tuán)隊(duì)在2015年提出了新的血管健康分級(jí)——BVHS標(biāo)準(zhǔn)[18],本研究中簡(jiǎn)化了BVHS,初步分析結(jié)果發(fā)現(xiàn),其對(duì)于冠心病的預(yù)測(cè)是一個(gè)有效的風(fēng)險(xiǎn)評(píng)估系統(tǒng),而對(duì)于腦梗塞的預(yù)測(cè)價(jià)值還需要進(jìn)一步研究確定。
本研究發(fā)現(xiàn),4種血管健康指標(biāo)同時(shí)是冠心病和腦梗塞的預(yù)測(cè)因子,且相互之間獨(dú)立,承擔(dān)不同的權(quán)重,其中CAVI是一種更為穩(wěn)定的指標(biāo),此外,通過有效的血管健康管理和干預(yù),即使基線時(shí)較高的CF-PWV水平也并不一定是心腦血管事件的危險(xiǎn)因素。BVHS在中國(guó)人群中對(duì)于冠心病具有預(yù)測(cè)價(jià)值,而對(duì)于腦梗塞的預(yù)測(cè)價(jià)值尚需研究。今后將進(jìn)行進(jìn)一步的前瞻性隊(duì)列研究,以驗(yàn)證本研究結(jié)果,并不斷完善BVHS分級(jí)系統(tǒng)。
本研究有以下局限性:首先,數(shù)據(jù)收集并未按照標(biāo)準(zhǔn)的隊(duì)列研究設(shè)計(jì)標(biāo)準(zhǔn)收集,而是利用醫(yī)院現(xiàn)有數(shù)據(jù)進(jìn)行分析,本研究的事件發(fā)生率較高,原因主要是由回顧性構(gòu)建隊(duì)列所造成,與隊(duì)列構(gòu)建方法和入組標(biāo)準(zhǔn)有關(guān)。本研究入組標(biāo)準(zhǔn)主要是患者需要有至少2次住院記錄,第一次作為基線,第二次作為隨訪,這樣就導(dǎo)致了隊(duì)列人群事件發(fā)生率過高的問題,因?yàn)槟切┎话l(fā)病的患者未回來(lái)住院,也就不在隊(duì)列里,這是本研究的一個(gè)重要不足。其次,隨訪并未經(jīng)過嚴(yán)格的研究設(shè)計(jì),基線后,將每位受試者的每次住院就診記錄作為隨訪數(shù)據(jù),因此有可能此人的心血管事件在患者此次來(lái)醫(yī)院前就已經(jīng)發(fā)生,或者選擇了其他醫(yī)院就診。第三,本研究?jī)H入選心血管疾病高危人群(主動(dòng)就診患者),因此研究結(jié)果可能并不適用于一般人群。
盡管本研究并未經(jīng)嚴(yán)格的方案設(shè)計(jì)和實(shí)施,但對(duì)于無(wú)創(chuàng)血管健康評(píng)估指標(biāo)建立的綜合評(píng)估系統(tǒng)和分級(jí)標(biāo)準(zhǔn)的臨床應(yīng)用價(jià)值進(jìn)行了初步探索,并得到了較好的結(jié)果,因此,本結(jié)果對(duì)于后續(xù)進(jìn)行嚴(yán)謹(jǐn)方案設(shè)計(jì)的研究開展,提供了研究?jī)r(jià)值。
參考文獻(xiàn)
[1]
Winsor T.
Influence of arterial disease on the systolic blood pressure gradients of the extremity
[J]. Am J Med Sci, 1950,220(2):117-126.[本文引用: 1]
[2]
Ohkuma T, Ninomiya T, Tomiyama H, et al.
Ankle-brachial index measured by oscillometry is predictive for cardiovascular disease and premature death in the Japanese population: An individual participant data meta-analysis
[J]. Atherosclerosis, 2018,275:141-148.URL PMID:29902702 [本文引用: 2]
[3]
Heald CL, Fowkes FG, Murray GD, et al.
Risk of mortality and cardiovascular disease associated with the ankle-brachial index: Systematic review
[J]. Atherosclerosis, 2006,189(1):61-69.[本文引用: 1]
[4]
Zhong Q, Hu MJ, Cui YJ, et al.
Carotid-femoral pulse wave velocity in the prediction of cardiovascular events and mortality: an updated systematic review and meta-analysis
[J]. Angiology, 2018,69(7):617-629.[本文引用: 1]
[5]
Willum-Hansen T, Staessen JA, Torp-Pedersen C, et al.
Prognostic value of aortic pulse wave velocity as index of arterial stiffness in the general population
[J]. Circulation, 2006,113(5):664-670.[本文引用: 2]
[6]
Niiranen TJ, Kalesan B, Larson MG, et al.
Aortic-brachial arte-rial stiffness gradient and cardiovascular risk in the community: the Framingham Heart Study
[J]. Hypertension, 2017,69(6):1022-1028.URL PMID:28396534 [本文引用: 1]
[7]
Mitchell GF, Hwang SJ, Vasan RS, et al.
Arterial stiffness and cardiovascular events: the Framingham Heart Study
[J]. Circulation, 2010,121(4):505-511.[本文引用: 1]
[8]
Tillin T, Chambers J, Malik I, et al.
Measurement of pulse wave velocity: site matters
[J]. J Hypertens, 2007,25(2):383-389.URL PMID:17211245 [本文引用: 1]
[9]
Shirai K, Utino J, Otsuka K, et al.
A novel blood pressure-independent arterial wall stiffness parameter; cardio-ankle vascular index (CAVI)
[J]. J Atheroscler Thromb, 2006,13(2):101-107.[本文引用: 1]
[10]
Laucevi?ius A, Ryli?kytè L, Balsytè J, et al.
Association of cardio-ankle vascular index with cardiovascular risk factors and cardiovascular events in metabolic syndrome patients
[J]. Medicina (Kaunas), 2015,51(3):152-158.[本文引用: 1]
[11]
Matsushita K, Ding N, Kim ED, et al.
Cardio-ankle vascular index and cardiovascular disease: Systematic review and meta-analysis of prospective and cross-sectional studies
[J]. J Clin Hypertens (Greenwich), 2019,21(1):16-24.[本文引用: 1]
[12]
Sato Y, Nagayama D, Saiki A, et al.
Cardio-ankle vascular index is independently associated with future cardiovascular events in outpatients with metabolic disorders
[J]. J Atheroscler Thromb, 2016,23(5):596-605.[本文引用: 2]
[13]
Satoh-Asahara N, Kotani K, Yamakage H, et al.
Cardio-ankle vascular index predicts for the incidence of cardiovascular events in obese patients: a multicenter prospective cohort study (Japan Obesity and Metabolic Syndrome Study: JOMS)
[J]. Atherosclerosis, 2015,242(2):461-468.[本文引用: 2]
[14]
Vallée A, Petruescu L, Kretz S, et al.
Added value of aortic pulse wave velocity index in a predictive diagnosis decision tree of coronary heart disease
[J]. Am J Hypertens, 2019,32(4):375-383.URL PMID:30624553 [本文引用: 1]
[15]
Velescu A, Clara A, Pe?afiel J, et al.
Adding low ankle brachial index to classical risk factors improves the prediction of major cardiovascular events. The REGICOR study
[J]. Atherosclerosis, 2015,241(2):357-363.URL PMID:26071658 [本文引用: 1]
[16]
Gronewold J, Hermann DM, Lehmann N, et al.
Ankle-brachial index predicts stroke in the general population in addition to classical risk factors
[J]. Atherosclerosis, 2014,233(2):545-550.URL PMID:24530962 [本文引用: 1]
[17]
中國(guó)醫(yī)藥教育協(xié)會(huì)血管醫(yī)學(xué)專業(yè)委員會(huì), 中華醫(yī)學(xué)會(huì)北京心血管病學(xué)分會(huì)血管專業(yè)學(xué)組, 北京大學(xué)醫(yī)學(xué)部血管疾病社區(qū)防治中心.中國(guó)血管健康評(píng)估系統(tǒng)應(yīng)用指南
[J]. 中華醫(yī)學(xué)雜志, 2018,98(37):2955-2967.[本文引用: 1]
[18]
王宏宇, 劉歡.
新的血管健康分級(jí)標(biāo)準(zhǔn)與血管醫(yī)學(xué)
[J]. 心血管病學(xué)進(jìn)展, 2015,36(4):365-368.[本文引用: 2]
[19]
Liu H, Liu J, Zhao H, et al.
The design and rationale of the Beijing Vascular Disease Patients Evaluation Study (BEST study)
[J]. Contemp Clin Trials Commun, 2017,7:18-22.[本文引用: 1]
[20]
Hong JB, Leonards CO, Endres M, et al.
Ankle-brachial index and recurrent stroke risk: meta-analysis
[J]. Stroke, 2016,47(2):317-322.DOI:10.1161/STROKEAHA.115.011321 URL PMID:26658450 [本文引用: 1]
BACKGROUND AND PURPOSE: The ankle-brachial index (ABI) is a fast, cheap, noninvasive indicator of atherosclerotic burden that may also be a predictor of stroke recurrence. In this systematic review and meta-analysis, we sought to explore ABI's merit as a marker for stroke recurrence and vascular risk by synthesizing the data currently available in stroke literature. METHODS: We searched Embase, MEDLINE, and Pubmed databases for prospective cohort studies that included consecutive patients with stroke and transient ischemic attack, measured ABI at baseline, and performed a follow-up assessment at least 12 months after initial stroke or transient ischemic attack. The following end points were chosen for our analysis: recurrent stroke and combined vascular end point (recurrent vascular event or vascular death). Crude risk ratios and adjusted Cox proportional hazard ratios were combined separately using the random-effects model. Study-level characteristics (eg, percent of cohort with a history of hypertension, average cohort age, level of adjustment, and mean follow-up duration) were included as covariates in a metaregression analysis. RESULTS: We identified 11 studies (5374 patients) that were not significantly heterogeneous. Pooling adjusted hazard ratios showed that low ABI was associated with both an increased hazard of recurrent stroke (hazard ratio, 1.70; 95% confidence interval, 1.10-2.64) and an increased risk of vascular events or vascular death (hazard ratio, 2.22; 95% confidence interval, 1.67-2.97). CONCLUSION: Our results confirm the positive association between ABI and stroke recurrence. Further studies are needed to see whether inclusion of ABI will help improve the accuracy of prediction models and management of stroke patients.
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