缺血性脑卒中复发的相关因素的探讨
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摘要
目的:探讨缺血性脑卒中复发的相关影响因素,为改善缺血性脑卒中不良预后提供依据。
方法:选择自大连市友谊医院神经内科2006年4月～2007年4月入院的初发缺血性脑卒中患者150例,随访一年,记录其一年内是否复发及具体复发时间间隔,并填写调查问卷及记录相应的辅助检查结果。诊断标准依据第四届脑血管学会制定的缺血性脑卒中诊断标准;纳入标准:初发的明确诊断为缺血性脑卒中患者,无其他疾病(其他神经系统疾病、尿毒症)史,意识清楚,认知功能正常,能够配合完成调查问卷的患者;排除标准:患有出血性卒中和混合性卒中的脑卒中患者。由经培训的神经内科医生对研究对象进行问卷调查,问卷内容包括调查对象一般情况(姓名、年龄、性别、民族、职业、学历、婚姻、性格)、脑卒中复发的主要危险因素(脑血管病家族史、高血压、糖尿病、高脂血症、心脏病、TIA、脑卒中、吸烟、饮酒、体重指数、饮食、肥胖、其他因素)、治疗措施(是否接受过正规治疗,是否进行脑血管检查,就诊医院的级别和科室情况,是否坚持治疗,是否随访,是否接受过健康教育)等。辅助检查包括血常规、血糖、血脂、肾功、血离子、血白蛋白、血纤维蛋白、尿蛋白、心电图、颈部血管超声等。分别由大连市友谊医院化验室提供相关血液,尿液检查结果及循环专科医生提供心电图报告,彩超专业人员提供颈部血管的超声报告来协助完成。统计分析:采用SPSS13.0统计软件进行统计分析。计量资料以x±s表示,组间比较用t检验;计数资料用率、百分比表示,组间比较用χ2检验;多因素分析采用Cox回归模型。
结果:不同性别复发率具有统计学差异(P=0.003),表现为男性复发率显著高于女性。家族有脑卒中史组脑卒中复发率为33.33%,无家族史组复发率为15.55%,经过统计分析得出两组差异有统计学意义(P=0.001)。脑卒中并高脂血症(P=0.000)或糖尿病(P=0.04)患者脑卒中的复发率明显升高,尤其是高脂血症患者脑卒中复发率显著高于血脂正常者。随着尿蛋白(P=0.02)及尿酮体(P=0.04)的增加脑卒中的复发率也增加。心电图异常结果(左室肥厚、心肌梗死、窦性心动过速、房颤、快速心室率)与脑卒中的复发关系显著(P=0.005)。将性别、年龄、家族史、高血压、高脂血症史、糖尿病史、心脏病、尿蛋白、体重指数、高盐饮食等因素带入Cox回归模型进行多因素分析,结果发现:性别、糖尿病史及尿蛋白与脑卒中的复发有关,即男性及有糖尿病史者和尿蛋白阳性可能为脑卒中复发的危险因素。
结论:男性、家族史、高脂血症、糖尿病、尿蛋白、尿酮体及心电图异常是缺血性脑卒中复发的主要因素,提示预防脑卒中复发应从控制患者的血糖、血脂等可干预的因素入手。
Objective: To study the associated factors of recurrence ischemic stroke and to provide scientific basis for improve prognosis of ischemic stroke.
Methods: To choice 150 inpatients with ischemic stroke during April 2006 to April 2007 in our hospital. Then they were followed up one year. All subjects were asked if recur ischemic stroke and the time gap from first diagnosed ischemic stroke to recur ischemic stroke, then examined by neurologists. The standard of subjects were initial ischemic stroke patients and had no other history of neural disease or uraemia. Also subjects must had clearly consciousness and normally cognize. But if the subjects had hemorrhagic stroke or had not only ischemic stroke but also hemorrhagic stroke must be excluded. All the subjects asked by neurologists. The main contents of questionnaire include that demography like name, age, sex, nationality, occupation, diploma, marriage, character; risk factors like family history of disease, hypertension, diabetes, hyperlipidemia, coronary heart disease, TIA, stroke, smoking, drinking, BMI,dietetic factors, obesity; therapy like if take regularity therapy, if take cerebrovascular examine, the level of hospital, if follow up and so on. The items of examine include that blood sugar blood lipidsetc, urinary albumin, cardiogram and so on. We compared and analyzed the risk factors between the recurrence group and the non-recurrence group using spss13.0 statistic analysis software. The statistic methods which used include that Chi-square test, t test and the Cox regression.
Result: There were six independent risk factors of ischemic stroke by t test and Chi-square test which were male (P=0.003), family history of stroke (P=0.001), hyperlipidemia (P=0), diabetes(P=0.04), urinary albumin positive (P=0.02), urine acetone bodies ( P=0.04 ), abnormal ECG (P=0.005). Cox regression analysis showed that male, diabetes and urinary albumin were the risk factors of recurrence ischemic stroke.
Conclusion: Sex, family history of stroke, hyperlipoproteinemian, diabetes, urinary albumin, urine acetone bodies and abnormal ECG may be the risk factors in recurrent ischemic stroke. So it is very important to control blood sugar and blood lipidemia in order to prevent the recurrence.
方法:选择自大连市友谊医院神经内科2006年4月～2007年4月入院的初发缺血性脑卒中患者150例,随访一年,记录其一年内是否复发及具体复发时间间隔,并填写调查问卷及记录相应的辅助检查结果。诊断标准依据第四届脑血管学会制定的缺血性脑卒中诊断标准;纳入标准:初发的明确诊断为缺血性脑卒中患者,无其他疾病(其他神经系统疾病、尿毒症)史,意识清楚,认知功能正常,能够配合完成调查问卷的患者;排除标准:患有出血性卒中和混合性卒中的脑卒中患者。由经培训的神经内科医生对研究对象进行问卷调查,问卷内容包括调查对象一般情况(姓名、年龄、性别、民族、职业、学历、婚姻、性格)、脑卒中复发的主要危险因素(脑血管病家族史、高血压、糖尿病、高脂血症、心脏病、TIA、脑卒中、吸烟、饮酒、体重指数、饮食、肥胖、其他因素)、治疗措施(是否接受过正规治疗,是否进行脑血管检查,就诊医院的级别和科室情况,是否坚持治疗,是否随访,是否接受过健康教育)等。辅助检查包括血常规、血糖、血脂、肾功、血离子、血白蛋白、血纤维蛋白、尿蛋白、心电图、颈部血管超声等。分别由大连市友谊医院化验室提供相关血液,尿液检查结果及循环专科医生提供心电图报告,彩超专业人员提供颈部血管的超声报告来协助完成。统计分析:采用SPSS13.0统计软件进行统计分析。计量资料以x±s表示,组间比较用t检验;计数资料用率、百分比表示,组间比较用χ2检验;多因素分析采用Cox回归模型。
结果:不同性别复发率具有统计学差异(P=0.003),表现为男性复发率显著高于女性。家族有脑卒中史组脑卒中复发率为33.33%,无家族史组复发率为15.55%,经过统计分析得出两组差异有统计学意义(P=0.001)。脑卒中并高脂血症(P=0.000)或糖尿病(P=0.04)患者脑卒中的复发率明显升高,尤其是高脂血症患者脑卒中复发率显著高于血脂正常者。随着尿蛋白(P=0.02)及尿酮体(P=0.04)的增加脑卒中的复发率也增加。心电图异常结果(左室肥厚、心肌梗死、窦性心动过速、房颤、快速心室率)与脑卒中的复发关系显著(P=0.005)。将性别、年龄、家族史、高血压、高脂血症史、糖尿病史、心脏病、尿蛋白、体重指数、高盐饮食等因素带入Cox回归模型进行多因素分析,结果发现:性别、糖尿病史及尿蛋白与脑卒中的复发有关,即男性及有糖尿病史者和尿蛋白阳性可能为脑卒中复发的危险因素。
结论:男性、家族史、高脂血症、糖尿病、尿蛋白、尿酮体及心电图异常是缺血性脑卒中复发的主要因素,提示预防脑卒中复发应从控制患者的血糖、血脂等可干预的因素入手。
Objective: To study the associated factors of recurrence ischemic stroke and to provide scientific basis for improve prognosis of ischemic stroke.
Methods: To choice 150 inpatients with ischemic stroke during April 2006 to April 2007 in our hospital. Then they were followed up one year. All subjects were asked if recur ischemic stroke and the time gap from first diagnosed ischemic stroke to recur ischemic stroke, then examined by neurologists. The standard of subjects were initial ischemic stroke patients and had no other history of neural disease or uraemia. Also subjects must had clearly consciousness and normally cognize. But if the subjects had hemorrhagic stroke or had not only ischemic stroke but also hemorrhagic stroke must be excluded. All the subjects asked by neurologists. The main contents of questionnaire include that demography like name, age, sex, nationality, occupation, diploma, marriage, character; risk factors like family history of disease, hypertension, diabetes, hyperlipidemia, coronary heart disease, TIA, stroke, smoking, drinking, BMI,dietetic factors, obesity; therapy like if take regularity therapy, if take cerebrovascular examine, the level of hospital, if follow up and so on. The items of examine include that blood sugar blood lipidsetc, urinary albumin, cardiogram and so on. We compared and analyzed the risk factors between the recurrence group and the non-recurrence group using spss13.0 statistic analysis software. The statistic methods which used include that Chi-square test, t test and the Cox regression.
Result: There were six independent risk factors of ischemic stroke by t test and Chi-square test which were male (P=0.003), family history of stroke (P=0.001), hyperlipidemia (P=0), diabetes(P=0.04), urinary albumin positive (P=0.02), urine acetone bodies ( P=0.04 ), abnormal ECG (P=0.005). Cox regression analysis showed that male, diabetes and urinary albumin were the risk factors of recurrence ischemic stroke.
Conclusion: Sex, family history of stroke, hyperlipoproteinemian, diabetes, urinary albumin, urine acetone bodies and abnormal ECG may be the risk factors in recurrent ischemic stroke. So it is very important to control blood sugar and blood lipidemia in order to prevent the recurrence.
引文
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1程学铭.脑血管病的流行病学.见程学铭,王文志,等.神经系统疾病流行病学.第六版.北京人民卫生出版社,2000.72-87
2王文志.卒中流行病学学与人群防治.张国谨,赵增容主编。国外脑血管疾病研究进展.第五版.北京:中国医药科技出版社,2007.177-197
3王忠诚,程学铭.等.中国六城市居民神经系统疾病的流行病学调查[J] .中华神经外科杂志,1985;1:2-8
4李振三,杨期东,苏启庚.等.中国农村脑血管病流行病学调查[J] .中华神经外科杂志,1989;5(增刊):7-11
5吴升平,王文志,等。中国城乡四社区人群脑卒中类型分布[J]。中华预防医学杂志,1998;32(增刊):27-29
6杨期东,周艳红,王文志,等。中国三个城市社区人群脑卒中死亡及其类型分布特征[J]。中华老年心脑血管病杂志,2003;5:39-42.
7王文志,吴升平,等。社区综合性预防对脑卒中发病力率和死亡率的影响[J]。中华预防医学杂志,1998;32(增刊):8-11.
8周孝达.各类脑血管病诊断要点[J] .中华神经科杂志,1996,29(6):379-380.
9 S SalehTM,Connell BJ, Legge C, et al. Estrogen attenuates neuronalexcitability in the insular cortex following middle cerebral artery oc-clusion[J] . Brain Res, 2004,1018:119 -129。
10 Zhuang H,Kim YS,Koehler RC, et al. Potential mechanism bywhich resveratrol,a red wine constituent,protects neurons[J]. Ann NY Acad Sci,2003, 993:276-288.
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12 Modan B,Wagener DK.Some eqidemiological aspects of stroke:mortality and morbidity trends, age, sex, race, socioeconomic status[J] . Steoke,1992,23: 1230-1236
13 Wolf PA,Abbott RD,Kannel WB,et al.Secular trends in stroke incidence and mortality.The Framingham study[J] .Stroke,1992;23:1551-1555
14 Chang CC,Chen CJ.Secular trend of mortality from cerebral infarction and cerebral hemorrhage hemorrhage in Taiwan,1974-1988[J] .Stroke, 1993; 24:212-218
15 Grobbee DE,Koudstaal PJ,Bots ML,et al.Incidence and risk factors of ischaemicand haemorrhagic stroke in Europe[J] .Neuroepidemiologp,1996;15:291-300
16 Khaw KT.Epidemiology of stroke[J] .J Neurol Neurosurg Psychiatr,1996; 61:333-338
17 Sudlow CL,Bch BM,Warlow CP.Comparing stroke incidence worldwide.What makes studies comparable[J]? Stroke,1996;27:550-558
18 Bonita R.Epidemiology of stroke[J] .Lancet,1992;339:342-344
19 Pilar GC,Fernando RA,Jose RB,et al.Cerebrovascular disease mortality in Spain, 1955-1992:An age-period-cohort analysis[J] .Neuroepidemiology, 1997; 16: 116-123
20 Stegmayr B,Asplund K,Kunlasmaa K,et al.Stroke incidence and mortality correlated to stroke risk factors in the WHO MONICA project[J] .Stroke, 1997;28:1367-1374
21 Thorvaldsen P,Asplund K,Kuulasmaa K,et al.Stroke incidence,case fatality,and mortality in the WHO MONICA project[J] .Stroke,1995;26:361-367
22 Bonita R,Stewart A,Beaglehole R.International trends in stroke mortality:1970- 1985[J] .Stroke,1990;21:989-992
23 Cheng XM,Ziegler DK,Li SC,et al.Stroke in china,1986 through 199[J] 0.Stroke,1995;26:1990-1994
24 Thorvaldsen P,Kuulasmss K,Rsjakangas AM,et al.Stroke trends in the WHO MONICA Project[J] .Stroke,1997;28:500-506
25 World Health Organization. World health statistics annuals[J] .Geneva: WHO, 1982-1994
26 Bonita R,Beaglehole R.Explaining stroke mortality trends[J] .Lancet, 1993; 341:1510-1511
27 Thomas T,Ruth B.Advance in ischemic stroke epidemiology.Ischemic stroke: advances in Neurology,Vol.92.Edited by H.J.M.Barnett,Julien Bogouss-lavsky, and Heather Meldrum[J] .Lippincott Williams& wilkins, Philadelpia. 2003
28 Sart C,Rastenyte D,Cepailis Z,et al.International trends in mortality from stroke,1968 to 1994[J] .Stroke,2000;31:1588-1601
29 Sarti C,Stegmayr B,Tolonen H,et al.Changes in mortality from stroke caused by changes in stroke event rates or case fatality?Results from the WHO MONICA Project[J] .Stroke,2003;34:1833-1841
30 World Health Organization. The World Health Report 2000.Geneva:WHO,2000
31 Asian Acute Stroke Advisory Panel[J]. Stroke epidemiological data of nineAsian countries.J Med Assoc Thai,2000;83:1-7
32 Suh-Hang HJ,Sacco RL.Genetic and molecular epidemiologic methods for stroke.Ischemic stroke:Advances in Neurology,Vol.92.Edited by H.J.M. Barnet, Julien Bogousslavsky,and Heather Meldrnm[J].Lippincott Williams&Wilkins, Phiadelphia.2003
33李莉,姜玉新,乌正赉.等.高血压病及心脑血管疾病与颈动脉粥样硬化[J] .中华心血管病杂志,1996,24(2):126.
34张临洪,闻立斗.复发性缺血性卒中的预防[J].国外医学:脑血管疾病分册,2000,8(6):372-374.
35张颖冬,石静萍,李作流.等.脑再梗塞的危险因素分析[J].中风与神经疾病杂志,1998,15(4):233-235.
36吴兆苏,姚崇华.我国多省市心血管病趋势及决定因素的人群监测[J].中华心血管病杂志,1997,25(1):6-11.
37智光,主编.冠心病超声诊断.北京:人民军医出版社,2001.131.
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33李莉,姜玉新,乌正赉.等.高血压病及心脑血管疾病与颈动脉粥样硬化[J] .中华心血管病杂志,1996,24(2):126.
34张临洪,闻立斗.复发性缺血性卒中的预防[J].国外医学:脑血管疾病分册,2000,8(6):372-374.
35张颖冬,石静萍,李作流.等.脑再梗塞的危险因素分析[J].中风与神经疾病杂志,1998,15(4):233-235.
36吴兆苏,姚崇华.我国多省市心血管病趋势及决定因素的人群监测[J].中华心血管病杂志,1997,25(1):6-11.
37智光,主编.冠心病超声诊断.北京:人民军医出版社,2001.131.
38钱荣立.关于糖尿病的新诊断标准与分型[J].中国糖尿病杂志,2000,8(1):5-6.
39董怡,华秀云.颈动脉斑块的超声表现与神经血管症状[J].中国临床神经科学,2002,10(2):205.
40 Jin K,Mao XO,Eshoo MW,et al.Microarray analysis of hippocampal gene expression in global cerebral ischemia[J].Ann Neurol,2001;50:93-103
41 Poungvarin N,Stroke in the developing world[J].Lancet 1998;352:(SⅢ)19-22
42 Kolominsky-Rabas PL.Weber Gefeller O,et al.Epidemiology of ischemic stroke subtypes according to TOAST criteria:incidence,recurrence,and long-term survival in ischemic stroke subtypes:a population-based study[J].Stroke,2001; 32(12):2735-2740
43 Kleindorfer D,Panagos P,Pancioli A,et al.Incidence and short-term prognosis of transient ischemic attack in a population-based study[J].Stroke,2005; 36(4): 720-723
44 White H,Boden-Albala B,Wang C,et al.Ischemic strokr subtype incidence among whites,blacks,and Hispanics:the Northern Manhattan Study[J].Circulation, 2005;111(10):1327-1331
45 Woo D,Gebel J,Miller R,et al.Incidence rates of first-ever ischemic stroke subtypes among blacks:a population-based study[J].Strokr,1999; 30(12): 2517-2522