光学相干断层成像观察冠状动脉支架置入术后新生动脉粥样硬化相关因素分析

Analysis of related factors of neoatherosclerosis after coronary stent implantation by optical coherence tomography

目的本研究旨在通过光学相干断层成像(optical coherence tomography,OCT)观察,探究药物洗脱支架经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)术后发生的新生动脉粥样硬化(neoatherosclerosis,NA)相关危险因素的评估以及他汀类药物降脂治疗的作用。方法回顾性分析从2013年6月至2016年6月在北京大学第一医院进行冠状动脉支架置入术后复查OCT的40例患者。根据患者低密度脂蛋白胆固醇(LDL-C)控制水平是否达标分为达标组(19例,LDL-C<1.8 mmol/L)和非达标组(21例,LDL-C≥1.8 mmol/L)。比较两组患者病史、生化指标及服药情况,通过OCT进行NA定性及定量分析。结果非达标组LDL-C水平[(2.42±0.79)mmol/L比(1.30±0.35)mmol/L,P<0.001]及胆固醇水平[(4.38±1.01)mmol/L比(3.07±0.87)mmol/L,P<0.001]均高于达标组,差异均有统计学意义;非达标组他汀类药物口服剂量[(15.26±2.30)mg/d比(22.38±2.10)mg/d,P=0.032]低于达标组,差异有统计学意义。两组患者OCT图像特征定量分析比较,非达标组管腔面积[(6.14±0.16)mm^2比(5.68±0.14)mm^2,P=0.038]及新生内膜再狭窄率[(25.12±1.10)%比(19.70±1.10)%,P=0.001]高于达标组,差异均有统计学意义。两组患者冠状动脉造影结果定量分析比较,非达标组参照血管直径[(2.62±0.18)mm比(3.08±0.15)mm,P=0.049]及最小管腔内径(MLD)[(1.88±0.15)mm比(2.55±0.15)mm,P=0.002]低于达标组,差异均有统计学意义;非达标组血管直径狭窄率(diameter stenosis,DS)[(27.22±3.95)%比(17.42±2.52)%,P=0.040]高于达标组,差异有统计学意义。两组患者OCT图像定性分析比较,非达标组NA(78.9%比38.1%,P=0.009),异质性新生内膜(78.9%比38.1%,P=0.009),脂质斑块(73.7%比38.1%,P=0.024),钙化斑块(26.3%比4.8%,P=0.049)发生率高于达标组,差异均有统计学意义。多因素回归分析显示,低密度脂蛋白水平(P=0.009),他汀类药物剂量(P=0.040)、男性(P=0.042)及血清肌酸酐水平(P=0.012)为NA影响因素,且低密度脂蛋白水平及他汀药物剂量,为其独立影响因素。低密度脂蛋白水平与支架内新生动脉硬化呈正相关性,口服他汀类药物剂量与之呈负相关性(均P<0.05)。结论 PCI术后支架内再狭窄(in-stent restenosis,ISR)和NA密切相关,LDL-C达标可以显著减少NA发生风险,相对强化的他汀类药物治疗策略可以预防NA发生。

Objective To evaluate the risk factors of neoatherosclerosis af ter coronary stent implantation through the study of optical coherence tomography（OCT） observation, and the effect of statin lipid-lowering therapy. Methods The clinical data of 40 patients with coronary heart disease（CHD） after coronary stent implantation（OCT） in Peking University First Hospital from June 2013 to June 2016 were analyzed retrospectively. The patients were divided into the target-achieved group（19 cases, LDL-C〈1.8 mmol/L） and the above-target group（21 cases LDL-C ≥ 1.8 mmol/L） according to whether their low density lipoprotein（LDL） levels reached the treatment target. The medical history, biochemical parameters, medication and the qualitative and quantitative analysis of the neoatherosclerosis in the two groups were reviewed and compared. Results There were no statistical differences between the two groups in age, sex, smoking, comorbidities of hypertension, diabetes mellitus, kidney disease, history of myocardial infarction and time of stent implantation. Patients in the above-target group had higher LDL-C levels [（2.42 ± 0.79） mmol/L vs.（1.30 ± 0.35） mmol/L, P〈0.001],higher cholesterol levels [（4.38 ±1.01） mmol/L vs.（3.07± 0.87） mmol/L, P〈0.001],but lower statin used dosage [（15.26 ±2.30） mg/d vs.（22.38 ± 2.10） mg/d,P=0.032] as compared to patients in the target-achieved group. There was no statistical difference between the other parameter and medication prof ile. Qualitative analysis showed higher rates of neoatherosclerosis in the abovetarget group as compared to the target-achieved group（78.9% vs. 38.1%, P=0.009）,plus higher rates of endothelial heterogeneity（78.9% vs. 38.1%,P=0.009）,lipid plaque（73.7% vs. 38.1%, P=0.024）and calcif ied plaque（26.3% vs. 4.8%,P=0.049）. The rate of neointima restenosis in the abovetarget group was higher than that of the target-achieved group [（25.12 ±1.10）% vs.（19.70±1.10）%,P=0.001]. Logistic analysis showed that the level of low density lipoprotein（P=0.009）, dosage of statin prescribed（P=0.040）, male gender（P=0.042） and serum creatinine（P=0.012） were associated with the present of neonatal arteriosclerosis.Multivariate regression analysis showed levels of lipoprotein and low presence of statin dosage were the independent wish factors. Low density lipoprotein levels were positively correlated with neoatherosclerosis formation and the dosage of statin was negatively correlated（P〈0.05）.Conclusions In-stent restenosis after PCI is closely related to neonatal atherosclerosis. Controlling LDL-C to target levels can signif icantly reduce the risk of neoatherosclerosis. Intensif ied statin therapy strategy can prevent neoatherosclerosis in by certain extent.