合并心房颤动对急性缺血性卒中患者静脉溶栓治疗后临床结局的影响  

Impact of atrial fibrillation on clinical outcome in patients with acute ischemic stroke undergoing thrombolytic therapy

作　　者：娄一萍 严慎强[1] 张圣[1] 陈智才[1] 万锦平[1] 楼敏[1] 

机构地区：[1]浙江大学医学院附属第二医院神经内科,浙江杭州310009

出　　处：《浙江大学学报（医学版）》2014年第1期28-35,共8页Journal of Zhejiang University(Medical Sciences)

基　　金：浙江省杰出青年科学基金(LR12H09001);浙江省科技厅重大科技专项计划(2013C13G2010032)

摘　　要：目的：分析合并心房颤动对急性缺血性卒中患者静脉溶栓后发生出血转化、再灌注及神经功能结局的影响.方法：回顾性分析在浙江大学医学院附属第二医院神经内科接受静脉重组组织型纤溶酶原激活剂（rt-PA）溶栓治疗的330例急性缺血性卒中患者资料,包括临床、实验室、影像检查结果和溶栓后出血转化及3个月后神经功能评分,出血转化根据ECASSⅡ标准评定,改良Rankin评分≤2分定义为临床结局不良,将心房颤动对溶栓后出血转化风险以及3个月神经功能结局的影响进行单因素和多因素分析.脑血流达峰时间〉6 s区域定义为低灌注区,脑血流达峰时间〉8 s区域定义为严重低灌注区,二元logistic回归分析合并心房颤动与未合并心房颤动患者不同低灌注区的再灌注情况.结果：合并心房颤动者共137例（占41.5%）,心房颤动患者较未合并心房颤动患者年龄大、基线美国国立卫生研究院卒中量表（NIHSS）评分高、出血转化者多、溶栓后3个月神经功能结局差.多因素分析结果显示,合并心房颤动对患者溶栓后3个月神经功能结局（OR=0.920,95%CI：0.533~1.586;P=0.763）和病死率（OR=1.381,95%CI：1 096~1.242;P=0.466）均无显著影响;合并心房颤动不影响出血性脑梗死型出血转化（OR=1.676,95%CI：0.972~3.031;P=0.088）,但增加脑实质血肿型出血转化（OR=3.621,95%CI：1.403~9 344;P=0.008）;心房颤动会增加严重低灌注区的再灌注（OR=10.57,95%CI：1.16~96.50;P=0.037）.结论：合并心房颤动增加严重低灌注区的再灌注,也增加脑实质血肿型出血转化的风险,但心房颤动不是影响急性缺血性卒中患者rt-PA静脉溶栓3个月神经功能结局的独立因素.Objective： To investigate the impact of atrial fibrillation （AF） on clinical outcomes in patients with acute ischemic stroke undergoing thrombolytic therapy. Methods： The clinical data of 330 patients with acute ischemic stroke who received intravenous recombinant tissue plasminogen activator （rt-PA） therapy in the Second Affiliated Hospital, Zhejiang University School of Medicine between June 2009 and August 2013 were reviewed. Clinical outcomes in AF and non-AF groups were evaluated by univariate and multivariate analysis. Favorable outcome was defined as a modified Rankin Scale （mRS） 0-2 on day 90. Hemorrhagic transformation （HT） was classified as hemorrhagic infarction （HI） and parenchymal hematoma （PH） within the first 24h according to ECASS 11 criteria. Hypoperfusion and severe hypoperfusion were defined as Tmax 〉 6 s and 〉 8 s, respectively. The rate of reperfusion was compared between AF and non-AF groups. Results： Among 330 patients, 137 （41.5%） had AF. Compared with non-AF patients, patients with AF were older [ （71.7 ± 11.5）y vs （63.4± 13.2）y, P 〈 0.001 ], had higher baseline National Institutes of Health Stroke Scale [IQR, 13（8-16） vs 9（5-15）, P 〈0.0013, higher rate of HT（HI： 28.5% vs 17.1%, P =0.015; PH： 13.9% vs 4.1% , P =0. 002） , and lower rate of favorable outcome （41.5% vs 58.0% , P =0.005） at d 90. After adjustment, AF was not a risk factor for favorable outcome （ OR = 0. 920, 95% CI：0. 533-1. 586 ; P = 0. 763 ） and mortality （ OR = 1. 381, 95% CI ： 1. 096-1. 242 ; P = 0.466） on day 90. AF was also not associated with HI （OR = 1. 676, 95% CI： 0. 972-3. 031; P =0. 088）, but it increased the rate of PH （ OR = 3. 621, 95% CI ： 1. 403-9. 344 ; P = 0. 008）. Among 94 patients with pre- and post-thrombolytic perfusion-weighted image, AF was not associated with increased rate of reperfusion for hypoperfusion （Tmax 〉 6 s, OR = 1.12, 95% CI ： 0. 35-3.63, P = 0. 849） , but was correlated with increased

关 键 词：心房颤动 急性病 脑缺血 药物疗法 卒中 药物疗法 组织型纤溶酶原激活物 治疗应用 血栓溶解疗法 神经系统 出血 再灌注 体层摄影术 发射型计算机 单光子 磁共振波谱学 统计学(主题) 回顾性研究 

分 类 号：R743.3[医药卫生—神经病学与精神病学]