睡眠障碍性呼吸评分与缺血性卒中患者血小板功能及卒中复发的相关性

Correlation between sleep-disordered breathing score and platelet function and stroke recurrence in patients with ischemic stroke

目的探讨应用四变量评分评估的睡眠障碍性呼吸(sleep-disordered breathing,SDB)患病可能性对急性缺血性卒中患者血小板功能及卒中复发风险的影响。方法前瞻性纳入2020年1月至2021年1月期间威海市立医院神经内科收治的急性缺血性卒中患者。主要纳入标准:在发病24 h内入院;美国国立卫生研究院卒中量表评分≤3分;接受阿司匹林+氯吡格雷双联抗血小板治疗(以下简称"双抗")。依据四变量评分将所有患者分为SDB高可能性组和低可能性组。在双抗治疗后(7±2)d使用PL-12多参数血小板功能分析仪检测血小板最大聚集率(maximum aggregation rate,MAR)。出院后进行为期6个月的随访,观察缺血性卒中复发情况。构建以患SDB高可能性为自变量、MAR为中介变量、卒中复发为因变量的中介效应模型,首先对因变量MAR和自变量SDB高可能性进行线性回归分析,然后进行因变量为缺血性卒中复发对自变量SDB高可能性和MAR的二元logistic回归分析。结果共213例患者纳入研究,患者平均年龄(62.70±10.04)岁,男性146例(68.5%),高可能性组121例(56.8%),随访期间24例(11.3%)出现卒中复发。单变量分析显示,SDB高可能性组花生四烯酸(arachidonic acid,AA)诱导的MAR(MAR-AA)以及二磷酸腺苷(adenosine diphosphate,ADP)诱导的MAR(MAR-ADP)均显著高于低可能性组(P均<0.05);复发组MAR-AA和MAR-ADP均显著高于未复发组(P均<0.05),且复发组患SDB高可能性的比例显著更高(P=0.008)。二元logistic回归分析显示,高半胱氨酸(优势比1.132,95%置信区间1.048~1.223;P=0.002)和患SDB高可能性(优势比6.351,95%置信区间1.134~35.566;P=0.035)是双抗患者卒中复发的独立危险因素。中介效应分析显示,MAR对患SDB高可能性患者的卒中复发风险具有显著的中介效应。结论SDB高可能性组MAR和卒中复发率均显著高于低可能性组,其卒中风险很可能是由血小板高反应性介导的。

Objective To investigate the effect of the possibility of sleep-disordered breathing(SDB)as assessed by the four-variable score on the platelet function and the risk of stroke recurrence in patients with acute ischemic stroke.Methods Patients with acute ischemic stroke admitted to the Department of Neurology,Weihai Municipal Hospital from January 2020 to January 2021 were enrolled prospectively.Main inclusion criteria:admission within 24 h of onset;National Institutes of Health Stroke Scale score≤3;Receiving aspirin+clopidogrel dual antiplatelet therapy.All patients were divided into a high possibility group and a low possibility group of SDB according to the four-variable score.7±2 d after dual antiplatelet therapy,PL-12 multi-parameter platelet function analyzer was used to detect the maximum aggregation rate(MAR).The patients were followed up for 6 months after discharge and the recurrence of ischemic stroke was observed.The mediating effect model was established with the high possibility of SDB as the independent variable,MAR as the intermediary variable and stroke recurrence as the dependent variable.Firstly,MAR as the dependent variable and high probability of SDB as the independent variable were analyzed by linear regression;then,a binary logistic regression analysis was performed with ischemic stroke recurrence as the dependent variable and the high probability of SDB and MAR as independent variables.Results A total of 213 patients were enrolled in the study.The average age of the patients was 62.70±10.04 years old.There were 146 male(68.5%)and 121 patients(56.8%)were in the high possibility group(56.8%).During the follow-up period,24 patients(11.3%)had stroke recurrence.Univariate analysis showed that arachidonic acid(AA)induced MAR(MAR-AA)and adenosine diphosphate(ADP)induced the MAR(MAR-ADP)in the high possibility group of SDB were significantly higher than those in the low possibility group(all P<0.05);MAR-AA and MAR-ADP in the recurrent group were significantly higher than those in the non-recurrent group(all P<0.05),and the proportion of high possibility of SDB in the recurrent group was significantly higher(P=0.008).Binary logistic regression analysis showed that homocysteine(odds ratio 1.132,95%confidence interval 1.048-1.223;P=0.002)and having high possibility of SDB(odds ratio 6.351,95%confidence interval 1.134-35.566;P=0.035)were the independent risk factors for stroke recurrence in patients treated with dual antiplatelet therapy.Intermediary effect analysis showed that MAR had a significant intermediary effect on the risk of stroke recurrence in patients with high probability of SDB.Conclusion The MAR and stroke recurrence rates in the high possibility group of SDB were significantly higher than those in the low possibility group,and its stroke risk was probably mediated by platelet hyperreactivity.