青年冠心病危險因素的探討

全勇俊，朱 航，蘇小俊，王昊天，何 凱，張子云，孫金燕

青年冠心病危險因素的探討

全勇俊1，朱 航2，蘇小俊1，王昊天3，何 凱4，張子云5，孫金燕1

目的探討青年冠心病的危險因素。方法選擇2008-06至2013-03在解放軍總醫院門診及住院期間收治的青年(年齡≤40歲)疑似冠心病患者855例，其中確診為青年冠心病455例(冠心病組)和非冠心病400例(對照組)。詳細采集病史，用高效液相色譜法檢測血清同型半胱氨酸(homocysteine，Hcy)水平。采用單因素與多因素非條件Logistic 回歸分析青年冠心病患者病因及危險因素。結果冠心病組和對照組在冠心病家族史、HDL-C、APOA1、血Hcy指標的差異均有統計學意義(P<0.01 或P<0.05)。多因素非條件Logistic 回歸分析顯示：冠心病家族史(OR=3.556，P=0.002)、Hcy(OR=1.380，P=0.001)是青年冠心病患者的獨立危險因素。結論血漿Hcy水平和冠心病家族史是青年冠心病患者的危險因素。

冠心病；同型半胱氨酸；青年；危險因素

冠心病是脂代謝紊亂而引起的冠狀動脈粥樣硬化性病變，具有高發病率和高病死率，且發病趨勢越來越年輕化。青年冠心病預后評估取決于對危險因素的干預和對病情的診斷。多項研究證實，同型半胱氨酸(homocysteine，Hcy)是心肺血管疾病的獨立危險因素[1,2]。血漿Hcy水平與青年冠心病的關系，尚缺乏充分的研究。本研究將通過對大量青年冠心病患者有效指標的評估，旨在探討Hcy及其他傳統冠心病危險因素與青年冠心病的關系，為中國人群中青年冠心病的危險因素的評估及早期診斷提供依據。

1 對象與方法

1.1 對象 選擇2011-06至2013-03在解放軍總醫院門診及住院期間收治的，年齡≤40歲的疑似冠心病患者855例，排除不符合WHO缺血性心臟病標準或臨床資料不完整的患者，排除患有腦梗死病史，嚴重的肝腎疾病、惡性腫瘤、自身免疫性疾病、應用葉酸或利尿藥等影響Hcy水平藥物的疾病者。其中，根據冠狀動脈造影、心電圖及血壓等診斷為青年冠心病455例(青年冠心病組)，非冠心病400例(對照組)。

1.2 病史采集 通過臨床資料及問診調查患者性別、年齡、高血壓、糖尿病和冠心病病史及家族史、2型糖尿病病史等。

1.3 血漿標本收集方法 入選者采用Judkins法行冠狀動脈造影后,Seldinger法穿刺抽取靜脈血，加入抗凝藥后, 于3000 r/min，離心10 min, 取血清于-80 ℃冰箱中保存待測。

1.4 血漿Hcy含量測定 血漿Hcy水平用高效液相色譜法(日本Shimadzu公司)進行檢測。

1.5 相關觀察指標 所有患者于入院后取隔夜空腹12 h 靜脈血，按中華醫學會檢驗學會推薦的方法測定總膽固醇(TC)、三酰甘油(TG)、高密度脂蛋白膽固醇(HDL-C)、低密度脂蛋白膽固醇(LDL-C)等指標。

2 結 果

2.1 單因素分析 青年冠心病組和對照組在性別、年齡、高血壓病史、收縮壓、2型糖尿病病史、TG、TC、LDL-C、APOB值等方面比較，差異均無統計學意義，但在冠心病家族史、HDL-C、APOA1、Hcy上比較，差異均有統計學意義(P<0.05，表1、2)。

2.2 多因素分析 多因素非條件Logistic 回歸分析結果顯示，冠心病家族史、Hcy是青年冠心病患者的獨立危險因素(表3)。

表1 青年冠心病組和對照組患者的計數資料比較 (n；%)

比較指標青年CHD組(n=455)對照組(n=400)tP年齡(歲)36．5±0．334．6±3．6 0．2010．841收縮壓(mmHg)94±592±7 0．1320．895TG(mmol/L)2．09±1．521．63±0．690．0430．482TC(mmol/L)4．93±1．214．82±2．061．3250．185LDL?C(mmol/L)2．72±1．232．55±1．311．8450．065HDL?C(mmol/L)0．90±0．241．21±1．472．3010．022APOA1(mmol/L)1．04±0．521．24±0．812．0000．045APOB(mmol/L)217±98 220±1071．1150．265Hcy(μmol/L)19．23±8．43 15．72±6．32 5．2840．000

表3 青年冠心病危險因素的非條件Logistic 回歸分析

3 討 論

近期研究表明，青年冠心病患者由于其特殊人群、不同的生活及飲食習慣，在臨床表現及冠脈病變上有著自身特點[3-5]。因此，不能僅依據傳統冠心病的危險因素及指標來評估青年冠心病，需要更加精確的符合青年冠心病特點的評估手段。本次研究目的是通過采集大量青年冠心病患者，在大樣本(>400例)的情況下探討青年冠心病患者與血漿Hcy水平及其他危險因素的關系，更加準確地評估青年冠心病危險因素。

本研究發現，青年冠心病組與對照組的比較中，冠心病家族史、HDL-C、APOA1、HCY差異均具有統計學意義(P<0.05)。進一步對青年冠心病危險因素進行多因素非條件Logistic 回歸分析發現，冠心病家族史、Hcy又是青年冠心病患者的獨立危險因素。

青年冠心病患者血漿Hcy水平可能與青年患者的遺傳因素有關[7,8]，基因多態性主要是參與Hcy代謝的酶的突變或缺陷，主要包括3種：亞甲基四氫葉酸還原酶(MTHFR)基因多態性[9-13]、蛋氨酸合成酶基因多態性[14,15]，以及CBS基因多態性[16,17]。另外，隨著生活水平的提高，青年人的生活習慣也影響著血Hcy水平。研究表明，長期嗜酒可引起肝細胞的蛋氨酸合成酶活性下降，造成高Hcy血癥[18]。吸煙、飲食中攝入過多蛋氨酸、飲用高糖咖啡飲品等，均可導致血漿Hcy濃度升高，而且幾種因素聯合作用明顯大于各因素的單獨作用[19，21]。研究發現，不受冠心病已知危險因素的影響，Hcy水平每增加5 μmol/L，發生冠心病的危險性將增高約20%[22]。高Hcy血癥可通過血管內皮及平滑肌細胞、炎性作用、凝血因子及血小板等多因素共同作用，在短期內發展成動脈粥樣硬化。

本研究結果示，Hcy是青年冠心病獨立的危險因素，可作為青年冠心病發病的預測分子。根據青年的血漿Hcy水平及對遺傳因素對冠心病早期發病風險進行分層，有助于對青年冠心病的早期干預。隨著生活條件的提升，高脂飲食，長期吸煙嗜酒等常見的不良習慣也影響著青年冠心病的發病率。通過預防這些不良因素可有效控制青年冠心病發病率。

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(2013-12-24收稿 2014-03-25修回)

(責任編輯 武建虎)

Astudyonriskfactorsinyoungpatientswithcoronaryheartdisease

QUAN Yongjun1, ZHU Hang2, SU Xiaojun1, WANG Haotian3, HE kai4, ZHANG Ziyun5, and SUN Jinyan1.

1. Medical College of Nankai University, Tianjin 300071, China; 2. Department of Cardiology, Chinese PLA General Hospital, Beijing 100853, China; 3. Medical Center of Tsinghua University, Beijing 100084, China; 4. Department of Cardiology, People’s Hospital of Chongqing Municipality,Chongqing 400053, China; 5. Department of Cardiology, Henan Honli Hospital, Changyuan 453400, China

ObjectiveTo study the risk factors in young patients with coronary heart disease.MethodsA total of 855 patients (age≤40 years) hospitalized in this department between June 2011 and March 2013 were included in this study. Patients with definite diagnosis were as young coronary heart disease group (n=455) and other patients were as control group (n=400). Their serum homocysteine was measured by high performance liquid chromatography. The single factor analysis and multivariate logistic regression analysis were used for risk factors of young coronary heart disease.ResultsThe serum Hcy, family history of coronary heart disease in young coronary heart disease group were all higher than those in control group(P<0.01 orP<0.05). The logistic regression analysis demonstrated that Hcy(OR=1.380，P=0.001)and history of coronary heart disease(OR=3.556，P=0.002)were all independent risk factors for young coronary heart disease patients.ConclusionsHigh serum homocysteine and family history of CHD are independent risk factors for young CHD patients.

coronary heart disease; homocystein; young; risk factors

全勇俊，碩士研究生，E-mail:qyongjun@yeah.net

1.300071天津，南開大學醫學院；2. 100853北京，解放軍總醫院心內科；3. 100084北京，清華大學醫學中心；4.400053，重慶市第十三人民醫院心內科；5.453400長垣，河南宏力醫院心血管內科

朱 航，E-mail: zhuhang301@126.com

R541.4