伴有卵圆孔未闭隐源性缺血性脑血管病不同治疗方式的长期疗效及其影响因素分析  

Cryptogenic ischemic cerebral vascular disease with patent foramen ovale: analysis of the long-term efficacy of treatments and prognostic factors

作　　者：董静[1] 郄静媛 马欣[1] Dong Jing;Qie Jingyuan;Ma Xin(Department of Neurology,Xuanwu Hospital,Capital Medical University,Beijing 100053,China)

机构地区：[1]首都医科大学宣武医院神经内科,北京100053

出　　处：《中华医学杂志》2022年第45期3604-3610,共7页National Medical Journal of China

摘　　要：目的观察伴有卵圆孔未闭(PFO)隐源性缺血性脑血管病(CICVD)不同治疗方式的长期疗效并分析其影响因素,为PFO相关脑血管病的治疗和二级预防提供参考。方法连续收集2012年5月1日至2021年12月31日于首都医科大学宣武医院神经内科住院的CICVD患者,均行经食管超声或经颅彩色多普勒超声发泡试验明确存在PFO相关右向左分流。所有患者均行高凝相关因素筛查及综合分级评分,并对PFO根据解剖特征分为高危型和低危型,按治疗方式将患者分为药物治疗组(包括抗血小板聚集和抗凝治疗)和PFO封堵术组,通过随访观察,采用Kaplan-Meier法比较两组患者脑缺血事件的复发情况,采用多因素Cox生存分析探索影响复发的因素。结果共纳入117例患者,失访10例,最终107例患者纳入分析,其中男66例,女41例,年龄14~67岁,随访[M(Q1,Q3)]1229(45,3508)d。药物治疗组(66例)与PFO封堵术组(41例)脑缺血事件的复发率分别为6%(4/66)和7%(3/41),其中封堵术组复发患者均存在残余分流。累积复发风险曲线显示,PFO封堵术组脑缺血事件的累积复发率(17.9%)与药物治疗组(7.1%)比较,差异无统计学意义(χ^(2)=0.368,P=0.544),进一步对伴有高危PFO和低危PFO的CICVD患者进行亚组分析,两组间脑缺血事件的累积复发风险差异仍无统计学意义(高危PFO亚组分析:χ^(2)=0.685,P=0.408;低危PFO亚组分析:χ^(2)=0.072,P=0.789)。多因素Cox生存分析提示,经校正高危PFO、封堵术等影响因素后,高凝相关因素评分是复发脑缺血事件的预测因素(HR=2.079,95%CI 1.069~4.045,P=0.031),且随着高凝相关因素评分升高,患者的累积复发率有升高趋势(P=0.046)。结论对伴有高危PFO或低危PFO的CICVD患者,不应忽视首选药物治疗对此类患者的重要价值。高凝相关因素异常增加了该类患者复发脑缺血事件的风险,对此需加以重视并进行相应筛查和兼顾性药物治疗。Objective To evaluate the long-term efficacy of treatments on cryptogenic ischemic cerebral vascular disease(CICVD)with patent foramen ovale(PFO)and analyze prognostic factors,so as to provide the references for the treatment and secondary prevention of PFO related cerebral vascular disease.Methods Consecutive patients with CICVD and PFO related right-to-left shunting confirmed by transesophageal echocardiography or transcranial doppler bubble test,who admitted to the Department of Neurology in Xuanwu Hospital from May 1,2012 to December 312021 were enrolled.All the patients underwent hypercoagulability screening,and the degree of hypercoagulability was evaluated by a scoring scale.Each PFO was classified as either high-risk or low-risk according to its anatomic features.Patients were divided into the drug treatment group(including antiplatelet and anticoagulation therapies)and transcatheter PFO closure group.After follow-up,the recurrence of cerebral ischemic events were compared between the two groups by Kaplan-Meier method,the prognostic factors were analyzed by multifactorial Cox′s regression model.Results A total of 117 patients were recruited,10 patients were lost to follow-up,and 107 patients were included in the final analysis,consisting of 66 males and 41 females,with age ranging from 14 to 67 years and the follow-up period of 1229(45,3508)d.The recurrence rate of cerebral ischemic events was 6%(4/66)and 7%(3/41)for the drug treatment group(66 cases)and closure group(41 cases),respectively,and residual shunting was detected in all patients with recurrent events in the closure group.Cumulative hazard curve indicated that there was no significant difference of recurrence risk of cerebral ischemic events between the two groups(cumulative recurrence rate:17.9%in the closure group vs 7.1%in the drug treatment group,χ^(2)=0.368,P=0.544),and the insignificance persisted even in subgroup analysis of CICVD patients with either high-risk(χ2=0.685,P=0.408)or low-risk PFO(χ^(2)=0.072,P=0.789).Cox′s regression

关 键 词：卵圆孔 未闭 隐源性 脑血管病 复发 高凝 队列研究 

分 类 号：R743[医药卫生—神经病学与精神病学]