首诊非瓣膜性心房颤动患者E/e'及颈动脉粥样硬化斑块与缺血性脑卒中的关系

E/e′and Carotid Atherosclerotic Plaques are Associated with Ischemic Stroke in Patients with Non-valvular Atrial Fibrillation

目的探讨首诊非瓣膜性心房颤动患者E/e'及颈动脉粥样硬化斑块与缺血性脑卒中的关系。方法选择2013年1月~2015年12月在湖北省恩施州中心医院首次诊断为非瓣膜性心房颤动、心功能Ⅰ~Ⅱ级的患者466例。所有患者均经超声心动图检查,测量E/e'。按E/e'三分位数分为E/e'<8.8、8.8≤E/e'<13.5、E/e'≥13.5三组,对患者进行随访研究,分析E/e'及颈动脉粥样硬化斑块与发生缺血性脑卒中的关系。结果BMI、CHADS2、CHA2DS2-VASc、左房前后径(LAD)、左室舒张末期内径、射血分数、持续性房颤、既往合并高血压病(HBP)、糖尿病(DM)、既往缺血性脑卒中/短暂脑缺血发作(IS/TIA)、慢性肾功能不全、颈动脉斑块的比例在三组间差异具有统计学意义(均P<0.05)。进一步将CHA2DS2-VASc评分根据分值分为0~1分、2~4分、5~7分、8~9分4组。随着CHA2DS2-VASc评分的增高,E/e'呈明显上升趋势,E/e'与CHA2DS2-VASc评分呈明显正相关(r=0.213,P<0.01)。在平均36.6个月的随访时间内,共有17例患者出现新发IS/TIA。IS/TIA组E/e'、LAD、CHA2DS2-VASc、既往合并IS/TIA病史和颈动脉斑块的比例明显高于非IS/TIA组,差异均具有统计学意义(均P<0.05)。Kaplan-Meier生存分析示:E/e'≥13.5组缺血性脑卒中(P=0.041)、心衰(P=0.036)的累计发病率均明显高于另外两组。单因素COX回归分析结果提示:8.8≤E/e'<13.5、E/e'≥13.5、年龄≥75岁、吸烟、BMI、HBP、DM、既往IS/TIA、颈动脉斑块,抗血小板、抗凝、他汀类药物使用,及LAD为房颤患者并发缺血性脑卒中的危险因素。多因素COX回归分析示:E/e'≥13.5(HR:2.103,95%CI:1.721~3.059,P=0.011)、颈动脉斑块(HR:1.591,95%CI:1.041~3.125,P=0.008)、年龄≥75岁(HR:1.621,95%CI:1.351~2.868,P=0.035)、LAD(HR:2.057,95%CI:1.896~3.400,P=0.003)均为房颤患者发生缺血性脑卒中的危险因素。ROC曲线分析示:E/e'诊断缺血性脑卒中的ROC曲线下面积为0.658(95%CI:0.537~0.779),最佳截断值为13.85,敏感度和特异度分别为70.6%和74.6%。结论房颤患者E/e'升高及颈动脉斑块是发生缺血性脑卒中的独立危险因素。在房颤的临床管理中,除了常规行CHA2DS2-VASc评分外,系统评估房颤患者心室舒张功能及颈动脉硬化斑块对减少栓塞事件具有重要意义。

Objective To investigate the relationship between E/e′and carotid atherosclerotic plaque and ischemic stroke in non-valvular atrial fibrillation(NVAF)patients.Methods A total of 466 patients with NYHAⅠtoⅡ,who were diagnosed as NVAF for the first time in Enshi Central Hospital from January 2013 to December 2015,were included in this study.All the patients were examined by echocardiography and E/e′was measured.The patients were divided into three groups according to the quartile of E/e′:E/e′<8.8、8.8≤E/e′<13.5、E/e′≥13.5.A follow-up study was conducted to analyze the relationship between E/e′,carotid atherosclerotic plaque and ischemic stroke.Results BMI,CHADS2,CHA2 DS2-VASc,LAD,LVDd,EF,persistent atrial fibrillation,and a history of hypertension,diabetes,ischemic stroke/transient ischemic attack(IS/TIA),chronic kidney disease(CKD),carotid plaque were statistically different among the three groups(all P<0.05).According to CHA2 DS2-VASc,the patients were divided into four groups:0-1,2-4,5-7 and 8-9.We found that with the increase of CHA2 DS2-VASc score,E/e′also gradually increased,and there was a significantly positive correlation between E/e′and CHA2 DS2-VASc score(r=0.213,P<0.01).During an average follow-up of 36.6 months,17 subjects developed newly diagnosed IS/TIA.E/e′,LAD,CHA2 DS2-VASc,proportion of patients with previous history of IS/TIA and carotid plaque in the IS/TIA group were significantly higher than those in the non IS/TIA group(all P<0.05).Kaplan-Meier analysis showed that the cumulative incidence of cerebral infarction(P=0.041),heart failure(P=0.036)in the group with E/e′≥13.5 were significantly higher than those in the other two groups.The univariate COX regression analysis showed that 8.8≤E/e′<13.5,E/e′≥13.5,age≥75 years,smoking,BMI,HBP,DM,previous IS/TIA,carotid plaque,antiplatelet,anticoagulation,statin and LAD were risk factors for ischemic stroke in patients with NVAF.Multivariate COX regression analysis showed that E/e′≥13.5(HR 2.103,95%CI:1.721-3.059,P=0.011),carotid plaque(HR 1.591,95%CI:1.041-3.125,P=0.008),age≥75 years(HR 1.621,95%CI:1.351-2.868,P=0.035),LAD(HR 2.057,95%CI:1.896-3.400,P=0.003)were risk factors of ischemic stroke in NVAF.The area under the ROC curve was 0.658(95%CI 0.537-0.779)with the best cutoff value was 13.85 to diagnose ischemic stroke and the sensitivity and specificity were 70.6%and 74.6%,respectively.Conclusion E/e′elevation and carotid plaque in NVAF patients are independent risk factors for ischemic stroke.In addition to the routine CHA2 DS2-VASc score,systematic assessment of ventricular diastolic function and carotid plaque is of great importantance for reducing embolism in the clinical practice.