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心脑血管疾病在我国较为常见,其因发病率高、致残率高、致死率高而广受重视[1]。研究结果表明,冠状动脉病变的程度与头颈动脉病变有着密切的关系,并且可能增加发生缺血性脑卒中的危险[1-5],因此,心脑血管疾病与动脉粥样硬化密切相关。当血管内存在易损斑块时,随时都有可能破裂而形成血栓,导致血流迅速中断,出现心脑血管急性事件,据统计,超过70%的心脑血管急性事件由此类斑块诱发[6]。同时行冠状动脉和头颈部动脉CT血管造影(CT angiography,CTA),即第三代双源低剂量CT心脑血管一体化成像,在保证图像质量的同时,显著降低了辐射剂量,具有较高的学术及应用价值。传统的心脑血管疾病的危险因素包括年龄、性别、超重与肥胖、吸烟史、高血压、总胆固醇水平和糖尿病等[2],然而约20%发生心脑血管急性事件的患者并无这些危险因素[6],Framingham风险评分作为近期发生恶性心脑血管事件预警模型的价值受到争议[3-8],临床上迫切需要更为准确的预警模型来预测发生心脑血管疾病的风险。
传统的多层螺旋CT行冠状动脉、头颈部动脉一体化成像的总辐射剂量高、对比剂用量大、操作费时且局限于低心率患者。如果能突破心率限制行心脑血管联合成像,一次完成3个部位的扫描,则可进一步降低辐射剂量和对比剂用量。随着影像技术的发展,这一问题逐渐被解决,心脑血管联合扫描一体化成像技术日益成熟,其优点显著:无创、操作简单快捷、大大降低了辐射剂量、可以迅速了解病情变化、准确性较高,其临床应用日益广泛。本研究拟通过第三代双源低剂量CT心脑血管一体化成像早期识别易损斑块,结合临床生化指标,建立心脑血管疾病发病风险预警模型,进一步提高早期预测心脑血管疾病发病风险的能力,为临床早期干预、降低心脑血管急性事件的发生率提供依据。
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由表1可知,易损斑块组患者的年龄、体质指数、血糖、同型半胱氨酸、甘油三酯、低密度脂蛋白、载脂蛋白E、脂蛋白、胱抑素C、C反应蛋白、血沉、糖化血红蛋白c水平均明显高于非易损斑块组,且差异均有统计学意义(均P<0.05)。易损斑块组的MACCE、高血压、糖尿病、冠心病发生率均高于非易损斑块组,且差异均有统计学意义(均P<0.05);高密度脂蛋白、乳酸脱氢酶、肌酸激酶水平均明显低于非易损斑块组,且差异均有统计学意义(均P<0.05)。
基线资料 正常组
(n=203)稳定斑块组
(n=97)易损斑块组
(n=200)检验值 P值 年龄( ,岁)$ \bar x \pm s$ 54.0±10.3 60.8±9.5 61.9±10.3 F=60.212 <0.001 男性[例(%)] 89(43.8) 51(52.6) 105(52.5) χ2=3.638 0.162 MACCE [例(%)] 1(0.5) 50(51.5) 122(61.0) χ2=178.272 <0.001 体质指数( ,kg/m2)$ \bar x \pm s$ 24.94±3.72 25.03±3.05 25.70±3.58 F=4.636 0.032 心率( ,次/min)$ \bar x \pm s$ 76.08±12.66 80.36±43.31 74.61±13.84 F=0.422 0.516 高血压[例(%)] 61(30.0) 52(53.6) 116(58.0) χ2=34.662 <0.001 糖尿病[例(%)] 18(8.9) 17(17.5) 60(30.0) χ2=29.405 <0.001 高血脂[例(%)] 4(2.0) 7(7.2) 6(3.0) χ2=5.662 0.059 冠心病[例(%)] 9(4.4) 14(14.4) 34(17.0) χ2=16.847 <0.001 血糖( ,mmol/L)$ \bar x \pm s$ 6.35±1.99 6.87±2.09 7.47±2.41 F=26.354 <0.001 同型半胱氨酸( ,μmol/L)$ \bar x \pm s$ 11.77±3.97 13.45±4.17 14.14±4.15 F=33.891 <0.001 甘油三酯( ,mmol/L)$ \bar x \pm s$ 1.91±0.79 2.34±0.91 2.47±0.99 F=40.249 <0.001 总胆固醇( ,mmol/L)$ \bar x \pm s$ 4.43±0.87 4.34±1.21 4.32±1.05 F=0.807 0.370 高密度脂蛋白( ,mmol/L)$ \bar x \pm s$ 1.18±0.28 1.12±0.25 1.04±0.23 F=18.273 <0.001 低密度脂蛋白( ,mmol/L)$ \bar x \pm s$ 1.97±1.00 2.26±1.07 2.45±1.13 F=20.326 <0.001 载脂蛋白A1( ,g/L)$ \bar x \pm s$ 1.50±0.31 1.34±0.25 1.40±0.22 F=1.697 0.195 载脂蛋白B( ,g/L)$ \bar x \pm s$ 0.87±0.18 0.93±0.20 0.89±0.24 F=0.044 0.834 载脂蛋白E( ,g/L)$ \bar x \pm s$ 56.81±18.49 61.89±17.42 64.72±19.68 F=17.924 <0.001 脂蛋白( ,mmol/L)$ \bar x \pm s$ 244.34±65.25 255.06±67.36 261.96±71.08 F=6.777 0.010 胱抑素C( ,mg/L)$ \bar x \pm s$ 0.81±0.34 0.95±0.36 1.02±0.34 F=35.842 <0.001 C反应蛋白( ,mg/L)$ \bar x \pm s$ 2.00±1.13 11.89±4.67 13.20±5.26 F=678.519 <0.001 血沉( ,mm/h)$ \bar x \pm s$ 6.50±2.86 7.87±4.02 17.23±5.86 F=509.717 <0.001 糖化血红蛋白c( ,%)$ \bar x \pm s$ 6.59±2.02 7.13±2.02 8.94±2.12 F=128.750 <0.001 乳酸脱氢酶( ,U/L)$ \bar x \pm s$ 191.50±55.17 186.50±45.68 154.44±24.40 F=7.825 0.008 CK-MB[M(Q1,Q3),ng/ml] 2.00(0.95,5.40) 2.40(1.05,4.65) 0.90(0.60,1.45) H=3.545 0.170 肌酸激酶[M(Q1,Q3),U/L] 107.00(61.00,283.50) 85.50(61.25,160.00) 56.00(35.50,74.00) H=4.384 0.012 肌红蛋白[M(Q1,Q3),g/ml] 39.80(23.95,89.00) 64.85(34.60,126.00) 20.40(13.30,30.50) H=3.667 0.160 注:CT为计算机体层摄影术;MACCE 为主要心脑血管不良事件;CK-MB为肌酸激酶同工酶 表 1 同时行冠状动脉和头颈部动脉CT血管造影的500例有心脑血管疾病易患因素患者的基线资料
Table 1. Baseline data of 500 patients with cardiovascular and cerebrovascular disease susceptibility factors who received CT angiography of both coronary and head and neck arteries
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由表2可知,易损斑块组患者的年龄、体质指数、血糖、同型半胱氨酸、甘油三酯、低密度脂蛋白、载脂蛋白E、脂蛋白、胱抑素C、C反应蛋白、血沉、糖化血红蛋白c水平均明显高于非易损斑块组,且差异均有统计学意义(均P<0.05)。易损斑块组的MACCE、高血压、糖尿病、冠心病发生率均高于非易损斑块组,且差异均有统计学意义(均P<0.05);易损斑块组的高密度脂蛋白、乳酸脱氢酶、肌酸激酶水平均明显低于非易损斑块组,且差异均有统计学意义(均P<0.05)。
变量 非易损斑块组
(n=300)易损斑块组
(n=200)检验值 P值 年龄( ,岁)$ \bar x \pm s$ 56.2±10.5 61.9±10.3 t=5.989 <0.001 男性[例(%)] 140(46.7) 105(52.5) χ2=1.634 0.201 MACCE[例(%)] 51(17.0) 122(61.0) χ2=102.667 <0.001 体质指数( ,kg/m2)$ \bar x \pm s$ 24.97±3.51 25.70±3.58 t=2.267 0.024 心率( ,次/min)$ \bar x \pm s$ 77.45±26.66 74.61±13.84 t=1.389 0.166 高血压[例(%)] 113(37.7) 116(58.0) χ2=19.986 <0.001 糖尿病[例(%)] 35(11.7) 60(30.0) χ2=26.207 <0.001 高血脂[例(%)] 11(3.7) 6(3.0) χ2=0.162 0.687 冠心病[例(%)] 23(7.7) 34(17.0) χ2=10.349 <0.001 血糖( ,mmol/L)$ \bar x \pm s$ 6.52±2.03 7.47±2.41 t=4.738 <0.001 同型半胱氨酸( ,μmol/L)$ \bar x \pm s$ 12.32±4.11 14.14±4.15 t=4.848 <0.001 甘油三酯( ,mmol/L)$ \bar x \pm s$ 2.05±0.85 2.47±0.99 t=5.148 <0.001 总胆固醇( ,mmol/L)$ \bar x \pm s$ 4.41±0.98 4.32±1.05 t=0.772 0.441 高密度脂蛋白( ,mmol/L)$ \bar x \pm s$ 1.16±0.27 1.04±0.23 t=4.062 <0.001 低密度脂蛋白( ,mmol/L)$ \bar x \pm s$ 2.06±1.03 2.45±1.13 t=3.922 <0.001 载脂蛋白A1( ,g/L)$ \bar x \pm s$ 1.42±0.29 1.40±0.22 t=0.443 0.659 载脂蛋白B( ,g/L)$ \bar x \pm s$ 0.90±0.19 0.89±0.24 t=0.210 0.835 载脂蛋白E( ,g/L)$ \bar x \pm s$ 58.45±18.28 64.72±19.68 t=3.643 <0.001 脂蛋白( ,mmol/L)$ \bar x \pm s$ 247.81±66.02 261.96±71.08 t=2.278 0.023 胱抑素C( ,mg/L)$ \bar x \pm s$ 0.86±0.35 1.02±0.34 t=5.016 <0.001 C反应蛋白( ,mg/L)$ \bar x \pm s$ 5.20±1.41 13.20±5.26 t=16.376 <0.001 血沉( ,mm/h)$ \bar x \pm s$ 6.94±3.34 17.23±5.86 t=24.930 <0.001 糖化血红蛋白c( ,%)$ \bar x \pm s$ 6.77±2.03 8.94±2.12 t=11.498 <0.001 乳酸脱氢酶( ,U/L)$ \bar x \pm s$ 188.64±47.97 154.44±24.40 t=2.965 0.005 CK-MB[M(Q1,Q3),ng/ml] 2.00(1.10,5.40) 0.90(0.60,1.45) Z=1.883 0.060 肌酸激酶[M(Q1,Q3),U/L] 88.00(61.00,173.50) 56.00(35.50,74.00) Z=−2.065 0.039 肌红蛋白[M(Q1,Q3),g/ml] 54.10(30.05,96.95) 20.40(13.30,30.50) Z=−1.742 0.082 注:MACCE 为主要心脑血管不良事件;CK-MB为肌酸激酶同工酶 表 2 2组有心脑血管疾病易患因素患者间各指标的单因素分析
Table 2. Univariate analysis of each index between two groups of patients with cardiovascular and cerebrovascular disease susceptibility factors
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以是否为易损斑块为因变量、上述单因素分析有统计学意义的变量为自变量,多因素Logistic回归分析结果见表3。年龄、高血压、糖尿病、高血糖、同型半胱氨酸、C反应蛋白这6个指标为易损斑块的危险因素。
因素 B S.E Wald P值 OR 95%CI 下限 上限 年龄 0.027 0.012 5.085 0.024 1.027 1.004 1.052 糖尿病 0.911 0.304 8.974 0.003 2.488 1.370 4.517 高血糖 0.204 0.055 13.585 <0.001 1.227 1.100 1.368 C反应蛋白 0.699 0.345 4.091 0.043 2.011 1.022 3.958 高血压 0.503 0.244 4.259 0.039 1.654 1.026 2.667 同型半胱氨酸 0.075 0.029 6.978 0.008 1.078 1.020 1.140 脂蛋白 0.003 0.002 2.895 0.089 1.003 1.000 1.007 注:B为回归系数;S.E为回归系数的标准误;Wald为回归系数的Wald χ2检验;OR为优势比;CI为置信区间 表 3 有心脑血管疾病易患因素患者易损斑块发生的多因素Logistic回归分析
Table 3. Multivariate Logistic regression analysis of vulnerable plaque in patients with cardiovascular and cerebrovascular disease susceptibility factors
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与非易损斑块组患者相比,易损斑块组患者发生MACCE的时间更早[(1.1±0.3)年对(0.8±0.2)年],患者年龄更小[(59.9±13.7)岁对(54.1±8.5)岁],且差异均有统计学意义(t=7.775,P<0.001;t=2.059,P=0.043)。
通过对易损斑块组患者分析发现,发生MACCE的患者有122例,未发生MACCE的患者有78例。发生MACCE的患者多合并多个易损斑块征象,发生与未发生MACCE患者的易损斑块征象情况比较详见表4。
组别 低CT衰减 血管正性重构指数 点状钙化 “餐巾环”征 无 有 无 有 无 有 无 有 发生MACCE的患者(n=122) 22(18.0) 100(82.0) 39(32.0) 83(68.0) 72(59.0) 50(41.0) 42(34.4) 80(65.6) 未发生MACCE的患者(n=78) 64(82.1) 14(17.9) 55(70.5) 23(29.5) 56(71.8) 22(28.2) 54(69.2) 24(30.8) χ2值 4.057 2.789 4.665 3.274 P值 0.025 0.033 0.021 0.044 注:MACCE为主要心脑血管不良事件;CT为计算机体层摄影术 表 4 发生与未发生MACCE患者的易损斑块征象情况比较[例(%)]
Table 4. Comparison of vulnerable plaque signs between patients with and without major adverse cardiovascular and cerebrovascular events (case (%))
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由表5可知,有易损斑块的患者发生MACCE的概率是无易损斑块患者的7.637倍。
因素 B S.E. Wald P值 OR 95%CI 下限 上限 易损斑块 2.033 0.211 92.579 <0.001 7.637 5.047 11.554 注:MACCE为主要心脑血管不良事件;B为回归系数;S.E为回归系数的标准误;Wald为回归系数的Wald χ2检验;OR为优势比;CI为置信区间 表 5 有心脑血管疾病易患因素患者的易损斑块与MACCE的多因素Logistic分析
Table 5. Multivariate Logistic analysis of vulnerable plaques and major adverse cardiovascular and cerebrovascular events in patients with cardiovascular and cerebrovascular disease susceptibility factors
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易损斑块组发生MACCE的122例患者中,发生心血管不良事件的有85例,发生脑血管意外的有37例(表6)。发生心血管不良事件的85例患者中稳定性心绞痛(stable angina pectoris,SAP)患者47例、急性冠状动脉综合征(acute coronary syndrome,ACS)患者38例。由表7可知,点状钙化斑块在ACS患者中出现的更频繁,大钙化斑块在SAP患者中更常见。另外,ACS患者斑块的平均最低密度CT值低于SAP患者,且差异有统计学意义(P<0.05)。
组别 正常 稳定性心绞痛 恶性心律失常 心梗 支架或搭桥 心源性猝死 脑血管意外 非易损斑块组(n=300) 249(83.0) 23(7.7) 3(1.0) 6(2.0) 7(2.3) 0(0.0) 12(4.0) 易损斑块组(n=200) 78(39.0) 47(23.5) 8(4.0) 8(4.0) 20(10.0) 2(1.0) 37(18.5) 合计 327(65.4) 70(14.0) 11(2.2) 14(2.8) 27(5.4) 2(0.4) 49(9.8) 注:MACCE为主要心脑血管不良事件 表 6 2组有心脑血管疾病易患因素患者发生MACCE的类别统计[例(%)]
Table 6. Category statistics of major adverse cardiovascular and cerebrovascular events in two groups of patients with cardiovascular and cerebrovascular disease susceptibility factors (case (%))
组别 点状钙化斑块
(%)大钙化斑块
(%)CT值( ,HU)$ \bar x \pm s$ 斑块负荷( ,mm3)$ \bar x \pm s $ 有 无 有 无 ACS患者(n=38) 19(50.0) 19(50.0) 7(18.4) 31(81.6) 78±39 100.6±43.3 SAP患者(n=47) 8(17.0) 39(83.0) 18(38.3) 29(61.7) 114±55 90.3±42.6 χ2值 10.543 3.999 2.330 0.519 P值 0.002 0.046 0.025 0.084 注:ACS为急性冠状动脉综合征;SAP为稳定性心绞痛 表 7 2组发生心血管不良事件患者的斑块成分及钙化形态特征的比较
Table 7. Comparison of plaque composition and morphological characteristics of calcification between two groups of patients with cardiovascular adverse events
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易损斑块的CTA特征主要表现为低CT衰减、血管正性重构指数、点状钙化、“餐巾环”征。典型CT特征图见图1~2,典型病例图见图3~5。
图 1 有心脑血管疾病易患因素患者的冠状动脉容积再现图(A)、冠状动脉重建最大密度投影图(B)与前降支曲面重建图(C、D)
Figure 1. Coronary artery volume reconstruction (A), maximum intensity projection of coronary artery reconstruction (B) and curved planar reformation of anterior descending branch (C and D) of a patient with cardiovascular and cerebrovascular disease susceptibility factors
图 2 有心脑血管疾病易患因素患者的冠状动脉曲面重建图
Figure 2. Curved planar reformation of coronary artery surface of a patient with cardiovascular and cerebrovascular disease susceptibility factors
图 3 有心脑血管疾病易患因素患者的心脑血管容积再现图(A)、冠状动脉容积再现图(B)及冠状动脉重建最大密度投影图(C)
Figure 3. Cardio-cerebrovascular volume reconstruction (A), coronary artery volume reconstruction (B), and maximum intensity projection of coronary artery reconstruction (C) of a patient with cardiovascular and cerebrovascular disease susceptibility factors
图 4 有心脑血管疾病易患因素患者的脑血管容积再现图(后面观)(A)、脑血管重建最大密度投影图(后面观)(B)、左冠状动脉回旋支曲面重建图(C)及左冠状动脉前降支曲面重建图(D)
Figure 4. Head vascular volume reconstruction (back view) (A), maximum intensity projection of head vascular reconstruction (back view) (B), curved planar reformation of left coronary artery circumflex branch (C) and curved planar reformation of the anterior descending branch of the left coronary artery (D) of a patient with cardiovascular and cerebrovascular disease susceptibility factors
第三代双源低剂量CT心脑血管一体化成像评价斑块易损性及其早期预警价值的研究
Evaluation of plaque vulnerability and early warning value of the third-generation dual-source low-dose CT integrative cardio-cerebrovascular imaging
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摘要:
目的 使用第三代双源低剂量CT心脑血管一体化成像[即同时行冠状动脉和头颈部动脉CT血管造影(CTA)]对有心脑血管危险因素的高危人群进行筛查,通过分析易损斑块发生的危险因素,为临床提供心脑血管疾病的早期预警。 方法 前瞻性选择包头市中心医院2016年1月至2019年1月临床上需要同时进行冠状动脉和头颈部动脉CTA的患者,连续纳入614例。根据纳入排除标准,最终选择500例患者,其中,男性245例、女性255例,年龄(57.8±14.2)岁。根据CTA特征,将500例患者分为易损斑块组200例、稳定斑块组97例和正常组203例,其中稳定斑块组和正常组合称为非易损斑块组。通过对易损斑块患者发生的主要心脑血管不良事件(MACCE)进行随访,构建多因素Logistic模型对易损斑块发生的危险因素进行分析,评价斑块易损性。计数资料组间比较采用卡方检验;符合正态分布的计量资料的多组间比较采用方差分析;呈偏态分布的计量资料的两组间比较采用非参数U检验,多组间比较采用非参数Kruskal-Wallis检验。采用多因素Logistic回归分析,分析易损斑块与危险因素、MACCE的相关性。易损斑块和非易损斑块组间各指标单因素比较分析采用两样本t检验。 结果 (1)易损斑块组患者的年龄、体质指数、血糖、同型半胱氨酸、甘油三酯、低密度脂蛋白、载脂蛋白E、脂蛋白、胱抑素C、C反应蛋白、血沉、糖化血红蛋白c水平均明显高于非易损斑块组,且差异均有统计学意义(t=2.267~24.930,均P<0.05)。易损斑块组的MACCE、高血压、糖尿病、冠心病发生率均高于非易损斑块组,且差异均有统计学意义(χ2=10.349~102.667,均P<0.05);易损斑块组的高密度脂蛋白、乳酸脱氢酶、肌酸激酶水平均明显低于非易损斑块组,且差异均有统计学意义(t=4.062、2.965,Z=−2.065,均P<0.05)。(2)年龄(OR=1.027,95%CI:1.004~1.052)、高血压(OR=1.654,95%CI:1.026~2.667)、糖尿病(OR=2.488,95%CI:1.370~4.517)、高血糖(OR=1.227,95%CI:1.100~1.368)、同型半胱氨酸(OR=1.078,95%CI:1.020~1.140)、C反应蛋白(OR=2.011,95%CI:1.022~3.958)这6个指标为易损斑块发生的危险因素。(3)与非易损斑块组患者相比,易损斑块组患者发生MACCE的时间更早[(1.1±0.3)年对(0.8±0.2)年],患者年龄更小[(59.9±13.7)岁对(54.1±8.5)岁],且差异均有统计学意义(t=7.775,P<0.001;t=2.059,P=0.043)。(4)发生MACCE的患者多合并多个易损斑块征象。(5)有易损斑块的患者发生MACCE的概率是无易损斑块患者的7.637倍,易损斑块是MACCE事件的独立危险因素(OR=7.637,95%CI:5.047~11.554)。 结论 使用第三代双源低剂量CT心脑血管一体化成像评估心脑血管动脉易损斑块对心脑血管疾病早期预警具有重要价值。 -
关键词:
- 计算机体层摄影血管造影术 /
- 危险因素 /
- 心血管疾病 /
- 脑血管障碍 /
- 易损斑块
Abstract:Objective To screen the high-risk population with cardiovascular and cerebrovascular risk factors using third-generation dual-source low-dose computed tomography (CT) integrative cardio-cerebrovascular imaging (i.e., simultaneous coronary artery and head and neck artery computed tomography angiography (CTA)), and to provide early warning of cardiovascular and cerebrovascular diseases by analyzing the risk factors for the occurrence of vulnerable plaques. Methods Patients requiring simultaneous coronary artery and head and neck artery CTA were prospectively selected from the Baotou Central Hospital from January 2016 to January 2019, and 614 cases were consecutively included. According to the inclusion and exclusion criteria, 500 patients were selected, including 245 males and 255 females. The age was (57.8±14.2) years. Based on CTA characteristics, the 500 patients were divided into the vulnerable plaque group (200 cases), the stable plaque group (97 cases), and the normal plaque group (203 cases). The stable plaque group and the normal plaque group were called the non-vulnerable plaque group. Through the follow-up of major cardiovascular and cerebrovascular adverse events (MACCE) in patients with vulnerable plaque, the multivariate logistic model was constructed to analyze the vulnerable plaque risk factors and evaluate the plaque block vulnerability. Chi-square test was used to compare the counting data groups. Analysis of variance was used to compare the measurement data with normal distribution between multiple groups. The comparison between two groups of econometric data with skewed distribution used a non parametric U-test, while the comparison between multiple groups used a non parametric Kruskal-Wallis test. Multivariate Logistic regression analysis was used to examine the correlation between vulnerable plaques, risk factors, and MACCE. Two-sample t test was used for the single-factor comparative analysis of indicators between the vulnerable plaque group and the non-vulnerable plaque group. Results (1) The levels of age, body mass index, blood glucose, homocysteine, triglyceride, low-density lipoprotein, apolipoprotein E, lipoprotein, cystatin C, C-reactive protein, erythrocyte sedimentation rate, and glycosylated hemoglobin c in the vulnerable plaque group were significantly higher than those in the non-vulnerable plaque group, and the differences were statistically significant (t=2.267−24.930, all P<0.05). The incidence of MACCE, hypertension, diabetes, coronary heart disease in the vulnerable plaque group were higher than those in the non-vulnerable plaque group, and the differences were statistically significant (χ2=10.349−102.667, all P<0.05). High-density lipoprotein, lactate dehydrogenase, and the level of creatine kinase were significantly lower in the vulnerable plaque group than those in the non-vulnerable plaque group, and the differences were statistically significant (t=4.062, 2.965, Z=−2.065; all P<0.05). (2) Age (OR=1.027, 95%CI: 1.004–1.052), hypertension (OR=1.654, 95%CI: 1.026–2.667), glycosuria (OR=2.488, 95%CI: 1.370–4.517), hyperglycemia (OR=1.227, 95%CI: 1.100–1.368), homocysteine (OR=1.078, 95%CI: 1.020–1.140), and C-reactive protein (OR=2.011, 95%CI: 1.022–3.958) were risk factors for vulnerable plaques. (3) Compared with the non-vulnerable plaque group, the onset of MACCE in the vulnerable plaque group was earlier ((1.1±0.3) years vs. (0.8±0.2) years), and the patients were younger ((59.9±13.7) years vs. (54.1±8.5) years). All the differences were statistically significant (t=7.775, P<0.001; t=2.059, P=0.043). (4) More patients with MACCE had multiple signs of vulnerable plaques. (5) The probability of MACCE in patients with vulnerable plaque was 7.637 times higher than that in patients without vulnerable plaque. Vulnerable plaque was an independent risk factor for MACCE (OR=7.637, 95%CI: 5.047–11.554). Conclusion The third-generation dual-source low-dose CT integrated cardio-cerebrovascular imaging is of great value for the early warning of cardiovascular and cerebrovascular diseases. -
图 1 有心脑血管疾病易患因素患者的冠状动脉容积再现图(A)、冠状动脉重建最大密度投影图(B)与前降支曲面重建图(C、D)
Figure 1. Coronary artery volume reconstruction (A), maximum intensity projection of coronary artery reconstruction (B) and curved planar reformation of anterior descending branch (C and D) of a patient with cardiovascular and cerebrovascular disease susceptibility factors
图 3 有心脑血管疾病易患因素患者的心脑血管容积再现图(A)、冠状动脉容积再现图(B)及冠状动脉重建最大密度投影图(C)
Figure 3. Cardio-cerebrovascular volume reconstruction (A), coronary artery volume reconstruction (B), and maximum intensity projection of coronary artery reconstruction (C) of a patient with cardiovascular and cerebrovascular disease susceptibility factors
图 4 有心脑血管疾病易患因素患者的脑血管容积再现图(后面观)(A)、脑血管重建最大密度投影图(后面观)(B)、左冠状动脉回旋支曲面重建图(C)及左冠状动脉前降支曲面重建图(D)
Figure 4. Head vascular volume reconstruction (back view) (A), maximum intensity projection of head vascular reconstruction (back view) (B), curved planar reformation of left coronary artery circumflex branch (C) and curved planar reformation of the anterior descending branch of the left coronary artery (D) of a patient with cardiovascular and cerebrovascular disease susceptibility factors
表 1 同时行冠状动脉和头颈部动脉CT血管造影的500例有心脑血管疾病易患因素患者的基线资料
Table 1. Baseline data of 500 patients with cardiovascular and cerebrovascular disease susceptibility factors who received CT angiography of both coronary and head and neck arteries
基线资料 正常组
(n=203)稳定斑块组
(n=97)易损斑块组
(n=200)检验值 P值 年龄( ,岁)$ \bar x \pm s$ 54.0±10.3 60.8±9.5 61.9±10.3 F=60.212 <0.001 男性[例(%)] 89(43.8) 51(52.6) 105(52.5) χ2=3.638 0.162 MACCE [例(%)] 1(0.5) 50(51.5) 122(61.0) χ2=178.272 <0.001 体质指数( ,kg/m2)$ \bar x \pm s$ 24.94±3.72 25.03±3.05 25.70±3.58 F=4.636 0.032 心率( ,次/min)$ \bar x \pm s$ 76.08±12.66 80.36±43.31 74.61±13.84 F=0.422 0.516 高血压[例(%)] 61(30.0) 52(53.6) 116(58.0) χ2=34.662 <0.001 糖尿病[例(%)] 18(8.9) 17(17.5) 60(30.0) χ2=29.405 <0.001 高血脂[例(%)] 4(2.0) 7(7.2) 6(3.0) χ2=5.662 0.059 冠心病[例(%)] 9(4.4) 14(14.4) 34(17.0) χ2=16.847 <0.001 血糖( ,mmol/L)$ \bar x \pm s$ 6.35±1.99 6.87±2.09 7.47±2.41 F=26.354 <0.001 同型半胱氨酸( ,μmol/L)$ \bar x \pm s$ 11.77±3.97 13.45±4.17 14.14±4.15 F=33.891 <0.001 甘油三酯( ,mmol/L)$ \bar x \pm s$ 1.91±0.79 2.34±0.91 2.47±0.99 F=40.249 <0.001 总胆固醇( ,mmol/L)$ \bar x \pm s$ 4.43±0.87 4.34±1.21 4.32±1.05 F=0.807 0.370 高密度脂蛋白( ,mmol/L)$ \bar x \pm s$ 1.18±0.28 1.12±0.25 1.04±0.23 F=18.273 <0.001 低密度脂蛋白( ,mmol/L)$ \bar x \pm s$ 1.97±1.00 2.26±1.07 2.45±1.13 F=20.326 <0.001 载脂蛋白A1( ,g/L)$ \bar x \pm s$ 1.50±0.31 1.34±0.25 1.40±0.22 F=1.697 0.195 载脂蛋白B( ,g/L)$ \bar x \pm s$ 0.87±0.18 0.93±0.20 0.89±0.24 F=0.044 0.834 载脂蛋白E( ,g/L)$ \bar x \pm s$ 56.81±18.49 61.89±17.42 64.72±19.68 F=17.924 <0.001 脂蛋白( ,mmol/L)$ \bar x \pm s$ 244.34±65.25 255.06±67.36 261.96±71.08 F=6.777 0.010 胱抑素C( ,mg/L)$ \bar x \pm s$ 0.81±0.34 0.95±0.36 1.02±0.34 F=35.842 <0.001 C反应蛋白( ,mg/L)$ \bar x \pm s$ 2.00±1.13 11.89±4.67 13.20±5.26 F=678.519 <0.001 血沉( ,mm/h)$ \bar x \pm s$ 6.50±2.86 7.87±4.02 17.23±5.86 F=509.717 <0.001 糖化血红蛋白c( ,%)$ \bar x \pm s$ 6.59±2.02 7.13±2.02 8.94±2.12 F=128.750 <0.001 乳酸脱氢酶( ,U/L)$ \bar x \pm s$ 191.50±55.17 186.50±45.68 154.44±24.40 F=7.825 0.008 CK-MB[M(Q1,Q3),ng/ml] 2.00(0.95,5.40) 2.40(1.05,4.65) 0.90(0.60,1.45) H=3.545 0.170 肌酸激酶[M(Q1,Q3),U/L] 107.00(61.00,283.50) 85.50(61.25,160.00) 56.00(35.50,74.00) H=4.384 0.012 肌红蛋白[M(Q1,Q3),g/ml] 39.80(23.95,89.00) 64.85(34.60,126.00) 20.40(13.30,30.50) H=3.667 0.160 注:CT为计算机体层摄影术;MACCE 为主要心脑血管不良事件;CK-MB为肌酸激酶同工酶 表 2 2组有心脑血管疾病易患因素患者间各指标的单因素分析
Table 2. Univariate analysis of each index between two groups of patients with cardiovascular and cerebrovascular disease susceptibility factors
变量 非易损斑块组
(n=300)易损斑块组
(n=200)检验值 P值 年龄( ,岁)$ \bar x \pm s$ 56.2±10.5 61.9±10.3 t=5.989 <0.001 男性[例(%)] 140(46.7) 105(52.5) χ2=1.634 0.201 MACCE[例(%)] 51(17.0) 122(61.0) χ2=102.667 <0.001 体质指数( ,kg/m2)$ \bar x \pm s$ 24.97±3.51 25.70±3.58 t=2.267 0.024 心率( ,次/min)$ \bar x \pm s$ 77.45±26.66 74.61±13.84 t=1.389 0.166 高血压[例(%)] 113(37.7) 116(58.0) χ2=19.986 <0.001 糖尿病[例(%)] 35(11.7) 60(30.0) χ2=26.207 <0.001 高血脂[例(%)] 11(3.7) 6(3.0) χ2=0.162 0.687 冠心病[例(%)] 23(7.7) 34(17.0) χ2=10.349 <0.001 血糖( ,mmol/L)$ \bar x \pm s$ 6.52±2.03 7.47±2.41 t=4.738 <0.001 同型半胱氨酸( ,μmol/L)$ \bar x \pm s$ 12.32±4.11 14.14±4.15 t=4.848 <0.001 甘油三酯( ,mmol/L)$ \bar x \pm s$ 2.05±0.85 2.47±0.99 t=5.148 <0.001 总胆固醇( ,mmol/L)$ \bar x \pm s$ 4.41±0.98 4.32±1.05 t=0.772 0.441 高密度脂蛋白( ,mmol/L)$ \bar x \pm s$ 1.16±0.27 1.04±0.23 t=4.062 <0.001 低密度脂蛋白( ,mmol/L)$ \bar x \pm s$ 2.06±1.03 2.45±1.13 t=3.922 <0.001 载脂蛋白A1( ,g/L)$ \bar x \pm s$ 1.42±0.29 1.40±0.22 t=0.443 0.659 载脂蛋白B( ,g/L)$ \bar x \pm s$ 0.90±0.19 0.89±0.24 t=0.210 0.835 载脂蛋白E( ,g/L)$ \bar x \pm s$ 58.45±18.28 64.72±19.68 t=3.643 <0.001 脂蛋白( ,mmol/L)$ \bar x \pm s$ 247.81±66.02 261.96±71.08 t=2.278 0.023 胱抑素C( ,mg/L)$ \bar x \pm s$ 0.86±0.35 1.02±0.34 t=5.016 <0.001 C反应蛋白( ,mg/L)$ \bar x \pm s$ 5.20±1.41 13.20±5.26 t=16.376 <0.001 血沉( ,mm/h)$ \bar x \pm s$ 6.94±3.34 17.23±5.86 t=24.930 <0.001 糖化血红蛋白c( ,%)$ \bar x \pm s$ 6.77±2.03 8.94±2.12 t=11.498 <0.001 乳酸脱氢酶( ,U/L)$ \bar x \pm s$ 188.64±47.97 154.44±24.40 t=2.965 0.005 CK-MB[M(Q1,Q3),ng/ml] 2.00(1.10,5.40) 0.90(0.60,1.45) Z=1.883 0.060 肌酸激酶[M(Q1,Q3),U/L] 88.00(61.00,173.50) 56.00(35.50,74.00) Z=−2.065 0.039 肌红蛋白[M(Q1,Q3),g/ml] 54.10(30.05,96.95) 20.40(13.30,30.50) Z=−1.742 0.082 注:MACCE 为主要心脑血管不良事件;CK-MB为肌酸激酶同工酶 表 3 有心脑血管疾病易患因素患者易损斑块发生的多因素Logistic回归分析
Table 3. Multivariate Logistic regression analysis of vulnerable plaque in patients with cardiovascular and cerebrovascular disease susceptibility factors
因素 B S.E Wald P值 OR 95%CI 下限 上限 年龄 0.027 0.012 5.085 0.024 1.027 1.004 1.052 糖尿病 0.911 0.304 8.974 0.003 2.488 1.370 4.517 高血糖 0.204 0.055 13.585 <0.001 1.227 1.100 1.368 C反应蛋白 0.699 0.345 4.091 0.043 2.011 1.022 3.958 高血压 0.503 0.244 4.259 0.039 1.654 1.026 2.667 同型半胱氨酸 0.075 0.029 6.978 0.008 1.078 1.020 1.140 脂蛋白 0.003 0.002 2.895 0.089 1.003 1.000 1.007 注:B为回归系数;S.E为回归系数的标准误;Wald为回归系数的Wald χ2检验;OR为优势比;CI为置信区间 表 4 发生与未发生MACCE患者的易损斑块征象情况比较[例(%)]
Table 4. Comparison of vulnerable plaque signs between patients with and without major adverse cardiovascular and cerebrovascular events (case (%))
组别 低CT衰减 血管正性重构指数 点状钙化 “餐巾环”征 无 有 无 有 无 有 无 有 发生MACCE的患者(n=122) 22(18.0) 100(82.0) 39(32.0) 83(68.0) 72(59.0) 50(41.0) 42(34.4) 80(65.6) 未发生MACCE的患者(n=78) 64(82.1) 14(17.9) 55(70.5) 23(29.5) 56(71.8) 22(28.2) 54(69.2) 24(30.8) χ2值 4.057 2.789 4.665 3.274 P值 0.025 0.033 0.021 0.044 注:MACCE为主要心脑血管不良事件;CT为计算机体层摄影术 表 5 有心脑血管疾病易患因素患者的易损斑块与MACCE的多因素Logistic分析
Table 5. Multivariate Logistic analysis of vulnerable plaques and major adverse cardiovascular and cerebrovascular events in patients with cardiovascular and cerebrovascular disease susceptibility factors
因素 B S.E. Wald P值 OR 95%CI 下限 上限 易损斑块 2.033 0.211 92.579 <0.001 7.637 5.047 11.554 注:MACCE为主要心脑血管不良事件;B为回归系数;S.E为回归系数的标准误;Wald为回归系数的Wald χ2检验;OR为优势比;CI为置信区间 表 6 2组有心脑血管疾病易患因素患者发生MACCE的类别统计[例(%)]
Table 6. Category statistics of major adverse cardiovascular and cerebrovascular events in two groups of patients with cardiovascular and cerebrovascular disease susceptibility factors (case (%))
组别 正常 稳定性心绞痛 恶性心律失常 心梗 支架或搭桥 心源性猝死 脑血管意外 非易损斑块组(n=300) 249(83.0) 23(7.7) 3(1.0) 6(2.0) 7(2.3) 0(0.0) 12(4.0) 易损斑块组(n=200) 78(39.0) 47(23.5) 8(4.0) 8(4.0) 20(10.0) 2(1.0) 37(18.5) 合计 327(65.4) 70(14.0) 11(2.2) 14(2.8) 27(5.4) 2(0.4) 49(9.8) 注:MACCE为主要心脑血管不良事件 表 7 2组发生心血管不良事件患者的斑块成分及钙化形态特征的比较
Table 7. Comparison of plaque composition and morphological characteristics of calcification between two groups of patients with cardiovascular adverse events
组别 点状钙化斑块
(%)大钙化斑块
(%)CT值( ,HU)$ \bar x \pm s$ 斑块负荷( ,mm3)$ \bar x \pm s $ 有 无 有 无 ACS患者(n=38) 19(50.0) 19(50.0) 7(18.4) 31(81.6) 78±39 100.6±43.3 SAP患者(n=47) 8(17.0) 39(83.0) 18(38.3) 29(61.7) 114±55 90.3±42.6 χ2值 10.543 3.999 2.330 0.519 P值 0.002 0.046 0.025 0.084 注:ACS为急性冠状动脉综合征;SAP为稳定性心绞痛 -
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