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Advances in Clinical Medicine
Vol. 13  No. 11 ( 2023 ), Article ID: 74670 , 5 pages
10.12677/ACM.2023.13112389

缺血伴非阻塞下冠脉疾病患者发生不良心血管事件的危险因素分析

木沙·阿布都力1，雷建新2*

1新疆医科大学研究生院，新疆 乌鲁木齐

2新疆维吾尔自治区人民医院心内科，新疆 乌鲁木齐

收稿日期：2023年9月30日；录用日期：2023年10月26日；发布日期：2023年11月2日

摘要

冠状动脉粥样硬化性心脏病是人类死亡的最主要原因之一，也是对公众健康威胁最大的疾病。目前对冠心病的诊断、治疗及预防等工作，往往局限于与阻塞性冠脉疾病(狭窄>50%)，非阻塞性冠脉疾病表现出的胸疼等症状，既往被认为与心脏无关，是良性病变，未引起公众关注。但近几年来研究提示缺血伴非阻塞性冠脉疾病并非良性，因管理的缺乏性，导致发生不良心血管事件。此文探讨缺血伴非阻塞性冠脉疾病患者发生不良心血管事件的危险因素。

关键词

冠状动脉粥样硬化性心脏病，非阻塞性冠脉疾病，不良心血管事件

Analysis of Risk Factors for Adverse Cardiovascular Events in Ischemia Patients with Non-Obstructive Coronary Arteries

Musha Abuduli1, Jianxin Lei2*

1Graduate School of Xinjiang Medical University, Urumqi Xinjiang

2Department of Cardiology, People’s Hospital of Xinjiang Uygur Autonomous Region, Urumqi Xinjiang

Received: Sep. 30th, 2023; accepted: Oct. 26th, 2023; published: Nov. 2nd, 2023

ABSTRACT

Coronary atherogenic heart disease is one of the most leading causes of human death and represents the greatest threat to public health. At present, the diagnosis, treatment and prevention of coronary heart disease are often limited to obstructive coronary disease (stenosis > 50%), chest pain shown by non-obstructive coronary disease, which was considered to be unrelated to the heart, are benign, and have not attracted public attention. However, in recent years, studies have suggested that ischemia with non-obstructive coronary disease is not benign, due to the lack of management, leading to adverse cardiovascular events. This article explores the risk factors for adverse cardiovascular events in patients with ischemia and non-obstructive coronary disease.

Keywords:Coronary Atherosclerotic Heart Disease, Non-Obstructive Coronary Artery Disease, Adverse Cardiovascular Events

Copyright © 2023 by author(s) and Hans Publishers Inc.

This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).

http://creativecommons.org/licenses/by/4.0/

1. 前言

根据2017年全球疾病负担显示，冠状动脉粥样硬化性疾病(coronary artery disease, CAD)占据国内居民死亡原因的第二位 [1] ，冠脉疾病的诊断金标准为：冠状动脉造影检查。据报道，由于心绞痛和心肌缺血证据而接受冠状动脉造影检查的患者，有60%~70%的患者无阻塞性冠状动脉疾病 [2] [3] [4] 。此类患者临床上被定义为缺血伴非阻塞性冠状动脉疾病(ischemia with non-obstructive coronary arteries, INOCA)，ACC公布了INOCA的统一定义如下：1) 持续(数周或更长)的症状提示缺血性心脏病；2) 心电图或其他心脏成像测试(如超声心动图、磁共振成像、核成像或光谱学)中心肌缺血的客观证据；3) 根据心外膜冠状动脉狭窄的定义，冠状动脉造影无血流限制性阻塞 ≥ 50%或部分流量储备 < 0.8 [4] 。临床上，对冠脉疾病患者的治疗及预防方案仅限于阻塞性冠脉疾病患者，缺血伴非阻塞性冠脉疾病往往被认为是良性病变，系列研究表明，缺血伴非阻塞性冠状动脉疾病(INOCA)是更严重病变的前兆，以及随后出现的动脉粥样硬化血栓并发症和相关临床症状 [5] 。

目前对INOCA患者的预后等相关研究少，迄今为止，尚未制定针对这一人群的最佳管理策略 [6] 。对此类患者的管理仍是难题。INOCA患者存在典型的症状和体征，但这些症状经常误诊为非心源性，患者未能得到个体化治疗及健康宣教，导致此类患者不良心血管事件发病率增加、生活质量下降、医疗保健费用的增加。国内外相关研究多以单个因素为中心进行INOCA患者远期预后研究。INOCA患者5年内发生不良心血管事件(不良心血管事件定义为心源性死亡、急性心肌梗死、恶性心律失常和再次冠脉紧急血运重建)中，关于多个危险因素影响作用大小比较的研究较少。

缺血伴非阻塞性冠脉疾病拟机制如下：① 冠状动脉微循环功能障碍：微循环异常原因中内皮功能障碍患者约占非阻塞性CAD患者的三分之二，并显示出聚集性心血管事件的风险增加 [7] [8] [9] [10] 。② 冠状动脉痉挛 [11] ；③ 氧化应激 [12] ：氧化应激可导致血管收缩和内皮损伤，导致冠状动脉微血管功能障碍和冠状动脉血管痉挛，进而导致INOCA。

最新研究INOCA患者五年内发生不良心血管事件的危险因素如下：

① 斑块位置：近端血管供应心肌的大部分，斑块破裂和血栓闭塞倾向于聚集在冠状动脉近三分之一处。多数认为发生不良心血管事件与冠脉狭窄的严重程度相关，但部分不良心血管事件与非阻塞冠脉疾病相关。早期血管造影研究结果表明，位于近端的动脉粥样硬化斑块因急性冠状动脉事件而发生侵蚀或破裂的风险较高 [13] ，在一项2065位INOCA患者参与的随访研究中，当INOCA患者按近端受累进一步分层时，无近端受累和近端受累的INOCA患者的5年内发生不良心血管事件发生率分别为1.3%和2.2%。与无近端受累的患者相比，近端受累患者的不良心血管事件发生率更高(P = 0.033)，因此INOCA患者近端冠状动脉受累与不良心血管事件发生风险增加相关，与冠状动脉斑块的程度无关 [14] 。冠脉板块位置可为INOCA患者发生MACE的预测提供额外的价值。

② 低密度脂蛋白胆固醇(LDL-C)变异性：LDL-C变异性是指根据每位患者连续测量LDL-C的平均值计算个体内平均值(LDL-C-mean)。连续LDL-C测量的标准偏差(LDL-C-sd)为LDL-C变异性。可能由于脂质流出机制的变异性(即损害斑块稳定的胆固醇依赖性机制)而导致血管壁的不稳定。一项2012名非阻塞性CAD患者在5年随访中，用LDL-C变异系数(LDL-C-cv)校正平均值。由于缺乏现有的LDL-C变异性指数的截止点，我们根据每个LDL-C变异性指数的中位数将受试者分为高、低两组，共观察到99例(4.92%)死亡病例和154例(7.65%)复合终点病例。LDL-C变异性越高，在长期随访中全因死亡率或复合终点越高 [15] 。结果表明，即使在调整了可能的混杂因素(包括该人群的LDL-C平均水平)后，访间LDL-C变异性是全因死亡率或复合终点的强大且独立的预测因子。

③ D-二聚体：D-二聚体是交联纤维蛋白的降解产物，被广泛认为是血栓形成的标志物。D-二聚体升高对健康人和CAD患者的不良心血管事件具有预测价值 [16] [17] ，研究表明，D-二聚体水平升高与微血管血栓形成 [18] 、炎症 [19] 和内皮损伤 [20] 有关，在充分调整了其他潜在的临床危险因素，包括年龄、性别、高血压、糖尿病、吸烟、饮酒和血小板后，高d-二聚体(>500 ng/ml)患者发生冠脉微循功障碍的风险是低d-二聚体患者的1.86倍(95% CI: 1.09~3.19) (P < 0.05) [21] 。冠脉微循环功能障碍增加INOCA患者5年内发生不良心血管事件发生率。

④ 高敏感性C-反应蛋白：hs-CRP水平较高的患者中，BMI较高，糖尿病患者比例较高，总胆固醇、甘油三酯、葡萄糖和胰岛素水平较高。Hs-CRP是异常冠状动脉血管反应性的独立预测因子。在未使用降脂治疗的患者中，hs-CRP较高的患者心外膜和微血管内皮功能较差。这种关系似乎与其他心血管危险因素和潜在混杂因素无关 [22] 。

2. 结语

尽管最初有人提出，INOCA可能构成良好心血管预后良好，近年来，有充分证据表明，INOCA患者的心血管发病率和死亡率有所增加。与无CAD的预后相比，INOCA的存在会导致不良预后 [23] 。基于证据的INOCA患者个性化管理指南仍然缺失 [4] 。目前国内外研究均以单个因素为中心进行研究，但关于多个危险因素在不良心血管事件为终点的INOCA患者中的影响作用大小比较的研究较少。未来需要在INOCA患者5年内发生不良心血管事件的危险因素影响作用进行统计分析，构建危险因素预测模型，进行分层。能够以上述危险分层预测不良心血管事件发生率，让患者及家属理解疾病危险，通过饮食、运动、药物等干预措施，减少不良心血管事件发生，改善INOCA患者预后及生活质量。

文章引用

木沙·阿布都力. 缺血伴非阻塞下冠脉疾病患者发生不良心血管事件的危险因素分析
Analysis of Risk Factors for Adverse Cardiovascular Events in Ischemia Patients with Non-Obstructive CoronaryArteries[J]. 临床医学进展, 2023, 13(11): 17057-17061. https://doi.org/10.12677/ACM.2023.13112389

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    24. NOTES

    *通讯作者。

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