急性冠脉综合征患者生活事件与冠状动脉粥样硬化斑块稳定性的相关性研究：抑郁的中介作用

背景　急性冠脉综合征（ACS）主要由不稳定斑块形成及破裂所致。研究表明，生活事件可增加ACS的发生风险，然而生活事件是否可通过影响斑块稳定性导致ACS的发生，目前尚不清楚。同时研究证实，生活事件可引起个体抑郁的负性情绪，且抑郁与斑块稳定性密切相关，然而抑郁是否在生活事件与斑块稳定性间发挥中介作用尚未明确。目的　探究ACS患者发病前1年内生活事件与冠状动脉粥样硬化斑块稳定性的关系，以及抑郁在其中的中介作用。方法　选取2018年9月-2019年4月于哈尔滨市某三级甲等医院心血管内科行冠状动脉造影首次确诊为ACS的患者311例为研究对象。采用生活事件量表（LES）、抑郁自评量表（SDS）调查其发病前1年内生活事件及抑郁的发生情况。同时采用光学相干断层成像技术（OCT）测量患者冠状动脉粥样硬化斑块稳定性，OCT指标包括薄纤维帽粥样硬化斑块（TCFA）（TCFA以纤维帽厚度、脂质核心角度衡量）、斑块破裂、富脂质斑块、血栓、巨噬细胞及胆固醇结晶。结果　165例（53.1%）患者发病前1年内发生生活事件，67例（21.5%）患者存在抑郁。多因素Logistic 回归分析结果显示，生活事件是TCFA〔OR=1.029，95%CI（1.016，1.043），P<0.001〕、斑块破裂〔OR=1.022，95%CI（1.010，1.034），P<0.001〕、富脂质斑块〔OR=1.018，95%CI（1.005，1.031），P=0.005〕、血栓〔OR=1.032，95%CI（1.014，1.050），P=0.001〕、胆固醇结晶〔OR=1.013，95%CI（1.002，1.024），P=0.025〕的独立影响因素。Spearman秩相关分析显示，生活事件与SDS评分（rs=0.461，P<0.01）、脂质核心角度（rs=0.385，P<0.01）呈正相关，与纤维帽厚度呈负相关（rs=-0.465，P<0.01）；SDS评分与脂质核心角度呈正相关（rs=0.406，P<0.01），与纤维帽厚度呈负相关（rs=-0.494，P<0.01）。路径分析及Bootstrap检验中介效应显示，抑郁在生活事件与斑块纤维帽厚度〔β=-0.117，95%CI（-0.157，-0.089），P<0.01〕及脂质核心角度〔β=0.114，95%CI（0.070，0.173），P<0.01〕之间起中介作用。结论　发病前1年内生活事件与冠状动脉粥样硬化斑块稳定性密切相关，且抑郁在其中发挥中介作用。因此，早期筛查经历生活事件及发生抑郁的个体，有助于识别斑块不稳定的高危人群，及时实施心理干预有利于减缓不稳定斑块的发生进程，将ACS的防治关口前移。

Stressful Life Events and Coronary Atherosclerotic Plaque Vulnerability in Patients with Acute Coronary Syndrome: the Mediating Effect of Depression

Background　Acute coronary syndrome （ACS） is mainly caused by the formation and rupture of vulnerable plaques.Some studies have demonstrated that stressful life events can increase the risk of ACS.However，it is still unclear whether stressful life events can cause ACS through influencing plaque vulnerability.At the same time，studies have confirmed that stressful life events can induce depression in individuals，which is closely related to plaque vulnerability.However，whether depression plays a mediating role between stressful life events and plaque vulnerability is also unknown.Objective　To explore the relationship between stressful life events and coronary atherosclerotic plaque vulnerability within one year before the onset of ACS，and analyze the mediating effect of depression.Methods　A total of 311 patients with ACS diagnosed by coronary angiography for the first time were selected as the research objects from the Department of Cardiology in a tertiary Class A hospital in Harbin from September 2018 to April 2019.The Life Events Scale（LES） and Self-Rating Depression Scale（SDS） were used to investigate the occurrence of stressful life events and depression in the year before the onset of ACS.Meanwhile，optical coherence tomography （OCT） was used to measure the vulnerability of coronary atherosclerotic plaques in patients，including thin-cap fibroatheroma（TCFA，measured by fibrous cap thickness and lipid arc），plaque rupture，lipid-rich plaque，thrombosis，macrophage and cholesterol crystallization.Results　Stressful life events occurred in 165（53.1%） patients with ACS within one year before the onset of the disease，and 67（21.5%） patients had depression.Multivariate Logistic regression analysis showed that stressful life events were the independent influencing factors of TCFA〔OR=1.029，95%CI（1.016，1.043），P<0.001〕，plaque rupture〔OR=1.022，95%CI（1.010，1.034），P<0.001〕，lipid-rich plaque〔OR=1.018，95%CI（1.005，1.031），P=0.005〕，thrombosis〔OR=1.032，95%CI（1.014，1.050），P=0.001〕，and cholesterol crystallization〔OR=1.013，95%CI（1.002，1.024），P=0.025〕.Spearman correlation analysis showed that stressful life events were positively correlated with depression（rs=0.461，P<0.01），lipid arc（rs=0.385，P<0.01），and negatively correlated with fibrous cap thickness（rs=-0.465，P<0.01）.Depression was positively correlated with lipid arc （rs=0.406，P<0.01） and negatively correlated with fibrous cap thickness（rs=-0.494，P<0.01）.Pathway analysis and Bootstrap test showed that depression had the mediating effect in the relationship between stressful life events and fibrous cap thickness 〔β=-0.117，95%CI（-0.157，-0.089），P<0.01〕 and lipid arc〔β=0.114，95%CI（0.070，0.173），P<0.01〕.Conclusion　The stressful life events within one year before the onset of ACS are closely related to the coronary atherosclerotic plaque vulnerability，and depression plays a mediating role between them.Hence，the early screening of stressful life events and depression among individuals would contribute to the identification of high-risk groups with vulnerable plaques.The timely psychological intervention is beneficial to slowing down the occurrence of vulnerable plaques and carrying out the prevention and treatment of ACS in advance.