Combining Oculus Fundus Vascular Characteristics to Study the Risk of Two-Year Recurrence in Patients with Ischemic Stroke of Two Traditional Chinese Medical Syndromes
-
摘要: 目的 构建结合眼底血管特征的不同中医证型的缺血性中风复发风险评估模型。方法 采用前瞻性观察研究, 共纳入425例符合纳入标准的缺血性中风患者并随访2 a, 采集与中风相关的临床风险因素、中医证型及眼底血管特征参数信息, 采用生存分析法比较气虚血瘀证和风痰阻络证缺血性中风患者的复发风险, 运用单因素分析辨识中风复发的核心危险因素和眼底血管特征, 分别建立2个证型的多因素Logistic复发风险评估模型。结果 2个证型的复发风险比较, 风痰阻络证较气虚血瘀证高(P<0.05)。气虚血瘀证缺血性中风复发风险评估模型受试者ROC曲线下面积值为0.799 6, 风痰阻络证缺血性中风复发风险评估模型值为0.719 3。结论 风痰阻络证缺血性中风患者复发风险较气虚血瘀证高, 建立识别不同证型缺血性中风复发的风险因素模型可以为临床提供有针对性的预防策略。Abstract: OBJECTIVE To establish a model for risk assessment of recurrent ischemic stroke by combining different traditional Chinese medicine (TCM) syndromes with oculus fundus vascular characteristics.METHODS In a prospective observational study, a total of 425 ischemic stroke patients who met the inclusion criteria were enrolled and followed up for two years. In addition, the information on clinical risk factors, TCM syndromes, and oculus fundus vascular characteristics related to stroke were collected. Survival analysis was used to compare the risk of recurrence in patients with ischemic stroke with qi deficiency and blood stasis and wind-phlegm obstructing collaterals. A multifactorial Logistic risk assessment model was developed for each of the two evidence types using single-factor analysis to identify the core risk factors for stroke recurrence and oculus fundus vascular characteristics.RESULTS Through comparing the recurrence risk between the two syndromes, we found that the recurrence risk was higher in the wind-phlegm obstructing collaterals syndrome than that in the qi deficiency and blood stasis syndrome (P < 0.05). The area under curve value of the ischemic stroke risk assessment model of qi deficiency and blood stasis syndrome was 0.799 6, while the value of the ischemic stroke risk assessment model of wind-phlegm obstructing collaterals syndrome was 0.719 3.CONCLUSION The risk of recurrence in patients with ischemic stroke of wind-phlegm obstructing collaterals syndrome is higher than that of qi deficiency and blood stasis syndrome, and the establishment of a risk factor model to identify recurrence in different syndromes of ischemic stroke can provide targeted prevention strategies for clinical practice.
-
表 1 2组患者复发风险的单因素分析(x±s)
组别 年龄/岁 性别 体质量指数 中风部位(1) 男 女 左侧大脑 右侧大脑 双侧大脑 气虚血瘀组 未复发组(n=113) 55.61±12.43 76 37 23.22±2.66 47 36 30 复发组(n=27) 55.33±9.26 22 5 23.42±2.77 8 7 12 风痰阻络证 未复发组(n=187) 56.25±12.13 143 61 23.31±2.53 88 61 38 复发组(n=74) 57.30±12.45 44 13 23.44±2.83 23 26 25* 组别 中风部位(2) 颈动脉狭窄或闭塞 椎动脉狭窄或闭塞 脑内血管硬化 脑内血管狭窄或闭塞 幕上 幕下 上下均有 气虚血瘀组 未复发组(n=113) 91 11 11 29 13 49 29 复发组(n=27) 16 5 6 13* 6 19* 13* 风痰阻络证 未复发组(n=187) 154 19 0 31 21 90 52 复发组(n=74) 61 4 0 17 9 48* 26 组别 脑白质病变 家族史 睡眠障碍 血压控制不佳 血糖控制不佳 高甘油三酯血症 高胆固醇血症 高尿酸血症 气虚血瘀组 未复发组(n=113) 34 4 29 75 50 13 3 19 复发组(n=27) 14* 2 12 19 27 1 1 2 风痰阻络证 未复发组(n=187) 65 4 58 72 50 18 1 42 复发组(n=74) 29 7* 27 38 27 5 1 12 组别 高同型半胱氨酸血症 凝血酶原活动度/% 国际标准化比值 凝血酶原比率/% 部分凝血活酶时间/s 纤维蛋白原/(g·L-1) 凝血酶时间/s 气虚血瘀组 未复发组(n=113) 29 108.84±24.98 1.00±0.28 0.99±0.21 36.19±4.86 3.27±0.91 18.13±6.52 复发组(n=27) 4 117.15±17.79 0.93±0.08 0.94±0.07 35.40±4.03 3.39±1.00 17.53±0.99 风痰阻络证 未复发组(n=187) 63 111.50±20.63 0.98±0.96 0.98±0.19 35.37±4.51 3.57±1.04 17.68±3.50 复发组(n=74) 21 112.15±18.91 0.27±0.13 0.96±0.10 35.69±4.50 3.58±0.93 17.87±5.93 组别 左视网膜中央静脉当量 左视网膜中央动脉当量 左视网膜中央动静脉比值 左小静脉/大静脉不对称指数 左小动脉/大动脉不对称指数 左小静脉分支角度 左小动脉分支角度 左静脉分支系数 气虚血瘀组 未复发组(n=113) 14.26±1.04 20.87±1.00 0.68±0.02 0.77±0.02 0.83±0.01 68.76±2.32 70.96±1.90 1.29±0.03 复发组(n=27) 14.22±0.70 20.89±0.65 0.68±0.01 0.77±0.01 0.83±0.01 68.26±2.01 70.44±2.43 1.29±0.02 风痰阻络证 未复发组(n=187) 14.29±0.84 20.86±0.82 0.69±0.02 0.77±0.02 0.83±0.01 68.84±2.14 70.95±1.94 1.29±0.03 复发组(n=74) 14.21±0.93 20.74±0.83 0.68±0.02 0.77±0.02 0.83±0.01 68.64±2.06 70.55±2.63 1.28±0.02 组别 左动脉分支系数 左血管弯曲度指数 左眼动静脉交叉压迹指数 左小动脉阻塞指数 右视网膜中央静脉当量 右视网膜中央动脉当量 右视网膜中央动静脉比值 气虚血瘀组 未复发组(n=113) 1.64±0.06 0.37±0.06 0.30±0.08 0.10±0.05 13.97±0.69 20.69±0.74 0.67±0.02 复发组(n=27) 1.66±0.06 0.40±0.06 0.31±0.07 0.11±0.07 14.22±0.87 20.92±0.76 0.68±0.02 风痰阻络证 未复发组(n=187) 1.64±0.06 0.37±0.06 0.31±0.08 0.10±0.05 13.99±0.84 20.69±0.85 0.67±0.02 复发组(n=74) 1.63±0.06 0.39±0.06 0.31±0.07 0.12±0.07 14.03±0.87 20.59±0.92 0.68±0.02 组别 右小静脉/大静脉不对称指数 右小动脉/大动脉不对称指数 右小静脉分支角度 右小动脉分支角度 右静脉分支系数 右动脉分支系数 右血管弯曲度指数 右眼动静脉交叉压迹指数 右小动脉阻塞指数 气虚血瘀组 未复发组(n=113) 0.77±0.02 0.83±0.01 68.87±2.31 70.49±1.90 1.29±0.03 1.65±0.06 0.35±0.06 0.28±0.08 0.10±0.06 复发组(n=27) 0.77±0.03 0.83±0.01 69.06±2.24 70.65±1.98 1.29±0.02 1.62±0.05* 0.37±0.06 0.28±0.09 0.10±0.05 风痰阻络证 未复发组(n=187) 0.77±0.03 0.83±0.02 69.04±2.15 70.53±1.94 1.28±0.02 1.64±0.05 0.37±0.06 0.29±0.08 0.11±0.06 复发组(n=74) 0.77±0.02 0.83±0.02 68.66±2.04 69.98±2.05* 1.28±0.03 1.64±0.07 0.37±0.07 0.28±0.08 0.10±0.05 注: 气虚血瘀证组间经χ2检验,χ颈动脉狭窄或闭塞2=5.25,*P < 0.05;χ脑内血管硬化2=6.36,*P < 0.05;χ脑内血管狭窄或闭塞2=5.25,*P < 0.05;χ脑白质病变2=4.58,*P < 0.05;组间经t检验,右动脉分支系数,*P < 0.05。
风痰阻络证组间经χ2检验,χ中风部位(1)2=7.26,*P < 0.05;χ脑内血管硬化2=5.96,*P < 0.05;χ家族史2=7.04,*P < 0.05;组间经t检验,右小动脉分支角度,*P < 0.05。表 2 气虚血瘀证缺血性中风患者复发风险的Logistic回归分析
项目 风险比 标准误 Z值 P值 95%CI 下限 上限 左血管弯曲度 23 087.54 103 886.90 2.23 0.03* 3.41 1.56E+08 右动脉分支系数 0.00 0.00 -1.80 0.07 3.69E-08 2.06 颈动脉闭塞或狭窄 1.98 1.19 1.14 0.25 0.61 6.43 脑内血管硬化 1.54 0.93 0.72 0.47 0.47 5.03 脑内血管狭窄或闭塞 2.11 1.20 1.32 0.19 0.70 6.41 脑白质病变 2.14 1.14 1.43 0.15 0.75 6.10 血压控制不佳 1.75 0.99 1.00 0.32 0.58 5.28 中风部位(2) 1.28 0.42 0.75 0.46 0.67 2.43 睡眠障碍 2.79 1.45 1.98 0.05* 1.01 7.70 常数 148.34 1 135.57 0.65 0.51 0.00 4.87E+08 表 3 风痰阻络证缺血性中风患者复发风险的Logistic回归分析
项目 风险比 标准误 Z值 P值 95%CI 下限 上限 左静脉分支系数 6.43E-07 4.01E-06 -2.29 0.02* 3.17E-12 0.13 左血管弯曲度 14.56 39.01 1 0.32 0.08 2 777.28 左小动脉阻塞 10.82 27.77 0.93 0.35 0.07 1 655.95 右小动脉分支角度 0.89 0.07 -1.58 0.11 0.77 1.03 右视网膜中央动静脉比值 4 967.53 43 506.58 0.97 0.33 0 1.42E+11 右侧大脑中风 23 087.54 103 886.9 2.23 0.03* 3.41 1.56E+08 双侧大脑中风 0 0 -1.8 0.07 3.69E-08 2.06 脑内血管硬化 11.47 0.47 1.22 0.22 0.79 2.74 中风家族史 32.53 3.42 2.30 0.02* 1.27 19.22 纤维蛋白原 1.15 0.18 0.93 0.35 0.85 1.56 血压控制不佳 1.70 0.22 -1.15 0.25 0.38 1.28 血糖控制不佳 0.63 0.21 -1.42 0.15 0.33 1.19 常数 6.29E+07 7.00E+08 1.61 0.11 0.02 1.84E+17 -
[1] 王陇德, 刘建民, 杨弋, 等. 我国脑卒中防治仍面临巨大挑战: 《中国脑卒中防治报告2018》概要[J]. 中国循环杂志, 2019, 34(2): 105-119. doi: 10.3969/j.issn.1000-3614.2019.02.001 [2] GRAU AJ, WEIMAR C, BUGGLE F, et al. Risk factors, outcome, and treatment in subtypes of ischemic stroke: The German stroke data bank[J]. Stroke, 2001, 32(11): 2559-2566. doi: 10.1161/hs1101.098524 [3] WANG Y, XU J, ZHAO X, et al. Association of hypertension with stroke recurrence depends on ischemic stroke subtype[J]. Stroke, 2013, 44(5): 1232-1237. doi: 10.1161/STROKEAHA.111.000302 [4] YANG J, FU JH, CHEN XY, et al. Validation of the ABCD2 score to identify the patients with high risk of late stroke after a transient ischemic attack or minor ischemic stroke[J]. Stroke, 2010, 41(6): 1298-1300. doi: 10.1161/STROKEAHA.110.578757 [5] ZHUO Y, YU H, YANG Z, et al. Prediction factors of recurrent stroke among Chinese adults using retinal vasculature characteristics[J]. J Stroke Cerebrovasc Dis, 2017, 26(4): 679-685. doi: 10.1016/j.jstrokecerebrovasdis.2017.01.020 [6] 中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2014[J]. 中华神经科杂志, 2015, 48(4): 246-257. doi: 10.3760/cma.j.issn.1006-7876.2015.04.002 [7] 周仲瑛. 中医内科学[M]. 2版. 北京: 中国中医药出版社, 2007: 311. [8] ZEE B, LEE J, LI Q. Method and device for retinal image analysis: US8787638B2[P]. 2014-09-22. [9] ZEE BCY, LEE J, MOK VCT, et al. Stroke risk assessment for the community by automatic retinal image analysis using fundus photograph[J]. Qual Prim Care, 2016, 24(3): 114-124. http://primarycare.imedpub.com/stroke-risk-assessment-for-the-community-by-automatic-retinal-image-analysis-using-fundus-photograph.pdf [10] APPELROS P, NYDEVIK I, VⅡTANEN M. Poor outcome after first-ever stroke: Predictors for death, dependency, and recurrent stroke within the first year[J]. Stroke, 2003, 34(1): 122-126. doi: 10.1161/01.STR.0000047852.05842.3C [11] WOLF PA, D'AGOSTINO RB, BELANGER AJ, et al. Probability of stroke: A risk profile from the Framingham Study[J]. Stroke, 1991, 22(3): 312-318. doi: 10.1161/01.STR.22.3.312 [12] ROTHWELL PM, GILES MF, FLOSSMANN E, et al. A simple score (ABCD) to identify individuals at high early risk of stroke after transient ischaemic attack[J]. Lancet, 2005, 366(9479): 29-36. doi: 10.1016/S0140-6736(05)66702-5 [13] JOHNSTON SC, ROTHWELL PM, NGUYEN-HUYNH MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack[J]. Lancet, 2007, 369(9558): 283-292. doi: 10.1016/S0140-6736(07)60150-0 [14] 杨勇. 中风危险因素的证候分布特点及比较干预后变化趋势[D]. 北京: 北京中医药大学, 2010. [15] 戚婉, 吴成翰, 许亚晔, 等. 缺血性中风磁共振波谱分析与中医证型关系的初步研究[J]. 福建中医药大学学报, 2011, 21(6): 7-9. doi: 10.3969/j.issn.1004-5627.2011.06.003 [16] 杨春霞, 杜会山, 李玉清, 等. 缺血性中风患者中医辨证分型与脑血管造影结果相关性研究[J]. 世界中西医结合杂志, 2012, 7(8): 700-702, 716. doi: 10.3969/j.issn.1673-6613.2012.08.020 [17] LEE J, ZEE BC, LI Q. Detection of neovascularization based on fractal and texture analysis with interaction effects in diabetic retinopathy[J]. PLoS ONE, 2013, 8(12): e75699. doi: 10.1371/journal.pone.0075699 [18] 卓缘圆, 于海波, 杨卓欣, 等. 影响脑梗死复发的眼底血管特征及脑梗死复发预测模型的建立[J]. 广西医学, 2016, 38(5): 635-638. https://www.cnki.com.cn/Article/CJFDTOTAL-GYYX201605010.htm [19] 灵枢经[M]. 田代华, 刘更生, 整理. 北京: 人民卫生出版社, 2005: 11. [20] 金明. 眼与心脑血管相关性及气血痰湿诊治思维[J]. 中国中医眼科杂志, 2021, 31(6): 390-394. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGKZ202106002.htm