他汀类药物对冠心病患者冠状动脉病变程度及临床预后的影响

Effect of statins on severity of coronary artery lesion and clinical prognosis in patients with coronary heart disease

目的探讨他汀类药物对冠心病患者冠状动脉病变程度的影响,并分析影响患者临床预后的危险因素。方法采用回顾性队列研究方法,收集2017年1月至2021年12月北京大学人民医院心内科收治并完成冠状动脉CT血管造影(CCTA)二次复查的156例冠心病患者的临床资料。根据首次CCTA确诊冠心病后是否遵医嘱规律服用他汀类药物,将患者分为他汀组和非他汀组,比较分析两组患者的临床特征和CCTA二次复查结果;根据确诊冠心病后3~5年是否发生主要心脑血管不良事件(MACCE),将患者分为MACCE组和非MACCE组,对比分析两组患者的临床特征,采用多因素Logistic回归分析筛选冠心病患者预后不良(即发生MACCE)的危险因素。结果①156例冠心病患者均纳入最终分析,其中他汀组113例(占72.44%),非他汀组43例(占27.56%);两组患者除低密度脂蛋白(LDL)、血肌酐(SCr)存在差异外,性别、年龄、体质量指数(BMI)、基础疾病、吸烟史、首次CCTA冠状动脉病变和斑块特征、两次CCTA间隔时间及其他实验室指标差异均无统计学意义。与非他汀组相比,他汀组患者CCTA二次复查冠状动脉狭窄程度评分(Gensini评分)整体升高率和MACCE发生率均显著下降〔Gensini评分升高率:25.66%(29/113)比46.51%(20/43),MACCE发生率:9.73%(11/113)比30.23%(13/43),均P<0.05〕。②156例冠心病患者中,有24例(占15.38%)在确诊后3~5年发生MACCE,132例(占84.62%)未发生MACCE。MACCE组确诊后规律服用他汀类药物患者比例显著低于非MACCE组〔45.83%(11/24)比77.27%(102/132),P<0.01〕,D-二聚体和糖化血红蛋白(HbA1c)显著高于非MACCE组〔D-二聚体(μg/L):148.50(101.25,314.75)比88.10(59.03,132.12),HbA1c:6.45%(6.20%,7.93%)比6.10%(5.81%,6.92%),均P<0.05〕;与非MACCE组相比,MACCE组患者首次CCTA结果显示总动脉粥样硬化斑块体积百分比(PAV)、纤维脂肪PAV、坏死核心PAV及Gensini评分均显著升高〔总PAV:43.05%(29.19%,60.60%)比24.57%(16.94%,39.09%),纤维脂肪PAV:18.61%(8.48%,26.44%)比6.81%(4.16%,12.57%),坏死核心PAV:5.96%(2.98%,8.71%)比2.29%(1.47%,4.36%),Gensini评分(分):30.25(23.50,38.30)比19.50(13.20,31.10),均P<0.05〕。多因素Logistic回归分析显示,规律服用他汀类药物〔优势比(OR)=0.282,95%可信区间(95%CI)为0.110~0.727,P=0.008〕、D-二聚体(OR=1.011,95%CI为1.005~1.017,P<0.001)、坏死核心PAV(OR=1.323,95%CI为1.120~1.563,P=0.001)和Gensini评分(OR=1.038,95%CI为1.004~1.073,P=0.028)是冠心病患者确诊后3~5年发生MACCE的独立危险因素。结论对于冠心病患者,应密切关注D-二聚体、坏死核心PAV及Gensini评分;他汀类药物可有效缓解冠心病患者冠状动脉病变程度,并减少MACCE的发生。

Objective To investigate the effect of statins on the severity of coronary artery lesion in patients with coronary heart disease,and to analyze the risk factors of clinical prognosis.Methods A retrospective cohort study was conducted.The clinical data of 156 patients with coronary heart disease and completed the second re-examination of coronary CT angiography(CCTA)who were admitted to the department of cardiovascular medicine of Peking University People's Hospital from January 2017 to December 2021 were collected.According to whether they took statins regularly according to the doctor's instructions after being diagnosed with coronary heart disease based on the first CCTA examination,the patients were divided into statin group and non-statin group,and the clinical characteristics of the two groups and the results of the second re-examination of CCTA were compared and analyzed.According to whether the patients had major adverse cardiovascular and cerebrovascular events(MACCE)within 3-5 years after diagnosis of coronary heart disease,the patients were divided into MACCE group and non-MACCE group,and the clinical characteristics of the two groups were compared and analyzed.Multivariate Logistic regression analysis was used to screen the risk factors related to the adverse prognosis(occurrence of MACCE)of patients with coronary heart disease.Results①A total of 156 patients with coronary heart disease were enrolled,including 113 patients(72.44%)in the statin group and 43 patients(27.56%)in the non-statin group.Except for low density lipoprotein(LDL)and serum creatinine(SCr),there was no significant difference in gender,age,body mass index(BMI),basic diseases,smoking history,the first CCTA display of coronary artery lesions and plaque characteristics,the interval between the two CCTA and other laboratory indicators between the two groups.Compared with the non-statin group,the statin group had a significant reduction in the overall increase rate of coronary artery stenosis score(Gensini score)in the CCTA re-examination and the incidence of MACCE[Gensini score increase rate:25.66%(29/113)vs.46.51%(20/43),incidence of MACCE:9.73%(11/113)vs.30.23%(13/43),both P<0.05].②Among 156 patients with coronary heart disease,24 cases(15.38%)experienced MACCE within 3-5 years after diagnosis,while 132 cases(84.62%)did not experience MACCE.The proportion of patients in the MACCE group who regularly took statins after diagnosis was significantly lower than that in the non-MACCE group[45.83%(11/24)vs.77.27%(102/132),P<0.01],and D-dimer and glycosylated hemoglobin(HbA1c)were significantly higher than those in the non-MACCE group[D-dimer(μg/L):148.50(101.25,314.75)vs.88.10(59.03,132.12),HbA1c:6.45%(6.20%,7.93%)vs.6.10%(5.81%,6.92%),both P<0.05].Compared with the non-MACCE group,in the first CCTA examination of patients in the MACCE group,the total percentage of atheroma volume(PAV),fibrous-fat PAV,necrotic core PAV and Gensini score were significantly increased[total PAV:43.05%(29.19%,60.60%)vs.24.57%(16.94%,39.09%),fibrous-fat PAV:18.61%(8.48%,26.44%)vs.6.81%(4.16%,12.57%),necrotic core PAV:5.96%(2.98%,8.71%)vs.2.29%(1.47%,4.36%),Gensini score:30.25(23.50,38.30)vs.19.50(13.20,31.10),all P<0.05].Multivariate Logistic regression analysis showed that regular use of statins[odds ratio(OR)=0.282,95%confidence interval(95%CI)was 0.110-0.727,P=0.008],D-dimer(OR=1.011,95%CI was 1.005-1.017,P<0.001),necrotic core PAV(OR=1.323,95%CI was 1.120-1.563,P=0.001)and Gensini score(OR=1.038,95%CI was 1.004-1.073,P=0.028)were independent risk factors for MACCE within 3-5 years after diagnosis in patients with coronary heart disease.Conclusions For patients with coronary heart disease,D-dimer,necrotic core PAV,and Gensini scores should be closely monitored.Statins can effectively alleviate the severity of coronary artery disease and reduce the occurrence of MACCE in patients with coronary artery disease.