肺炎鏈球菌感染增加急性冠心症的風險

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题名:	肺炎鏈球菌感染增加急性冠心症的風險 Pneumococcal Pneumonia and the Risk of Acute Coronary Syndrome
作者:	王駿丞;Chun-Cheng Wang
贡献者:	臨床醫學研究所碩士班
关键词:	肺炎鏈球菌;肺炎;急性冠心症;Streptococcal Pneumonia;Pneumonia;Acute coronary syndrome
日期:	2013-08-02
上传时间:	2013-10-02 11:22:21 (UTC+8)
出版者:	中國醫藥大學
摘要:	簡介: 臨床上感染與急性冠心症之間的關聯過去的研究已被提及。感染會造成急性冠心症的病理機轉包含發炎反應，血液容積濃縮，與氧氣供需的失衡。在所有感染中，肺炎感染與急性冠心症之間最為相關肺炎鏈球菌是社區性肺炎最好發的致病菌，且往往造成臨床上表現較嚴重的社區性肺炎。然而,肺炎鏈球菌的感染與急性冠心症的關聯則較少被提及。我們的研究主要目的是探討肺炎鏈球菌的感染與急性冠心症的關聯。我們的研究可以提供一個想法，就是肺炎鏈球菌疫苗可能減少未來得到急性冠心症的風險。研究方法: 我們利用台灣健保資料庫作一個回溯性世代研究。我們搜索從民國86年至民國99年共20111位病人初次診斷為肺炎鏈球菌感染，且之前未曾患有急性冠心症的病人。對照組則是80444位過去未曾診斷有任何形式肺炎或是急性冠心症的病人。肺炎鏈球菌組與對照組的樣本是依1:4的比例且分別依年齡與性別去配對。兩組的基本資料我們用卡方分析作比較，我們考慮高血壓、糖尿病、高血脂及慢性呼吸道阻塞疾病當作共變項。我們使用Cox-Proportional Hazard model來評估經過多變項分析，肺炎鏈球菌感染是否是得到急性冠心症的一個危險因子。我們用Kaplan-Meier curve與log-rank test來探討肺炎鏈球菌組與對照組長期得到急性冠心症的風險是否有所不同。研究結果: 在肺炎鏈球菌組中得到急性冠心症的發生率是43.1/10000人年，在對照組中得到急性冠心症的發生率是22.4/10000人年。(發生率比例為1.92,95%信賴區間為1.70-2.17) 經過年紀、性別與其它共變項的校正後，肺炎鏈球菌組長期得到急性冠心症的風險仍比對照組增加47%，且其風險的增加呈統計上有意義相關。(95%信賴區間為1.24-1.73) 我們把臨床上從感染肺炎鏈球菌到得到急性冠心症的時間分為三個時段(小於3個月, 3個月至1年,及大於一年)，我們發現肺炎鏈球菌組在感染的前三個月得到急性冠心症的相對風險與對照組比較起來增加最多。(發生率比例為3.9, 95%信賴區間為2.46-6.18) 我們用Kaplan-Meier curve比較兩組發生急性冠心症,肺炎鏈球菌組得到急性冠心症的風險仍顯著的比對照組高。（Log-rank test, P<0.0001）結論: 肺炎鏈球菌感染會增加得到急性冠心症的風險。病人在得到肺炎鏈球菌感染的前三個月得到急性冠心症的相對風險最高。我們的研究也建議未來發展合適的疫苗可能可以減少得到急性冠心症的風險。 Introduction A link between infection and the incidence of acute coronary syndrome (ACS) has been suggested. The reason of infection leading to ACS maybe explained by increased inflammation, hemoconcentration, imbalance between oxygen demand and supply. Of all bacterial infections, pneumonia is mostly associated with the development of ACS.Streptococcus pneumonia is the most common causative pathogen of community acquired pneumonia, and Streptococcus pneumonia infection is asscociated with clinically severe form of pneumonia. However, relatively few studies have specifically discussed the association between pneumococcal pneumonia and ACS. This study focuses on investigating the association between pneumococcal pneumonia and the development of ACS. This is an important research topic, because it may provide a rationale for implementing pneumococcal vaccination in preventing ACS, especially in Asian populations. Materials and methods We conducted a longitudinal cohort study from the Taiwan National Health Institute Research Database (NHIRD). The study sample consisted of 20111 patients who received the first diagnoses of pneumococcal pneumonia between 1997 and 2010. We age and sex-matched these participants with 80444 control patients without a previous diagnosis of either pneumococcal pneumonia or ACS. We first compared the differences of baseline demographics between the two groups with chi-square test.We consider hypertension, diabetes, hyperlipidemia, and chronic obstructive pulmonary disease as potential covariates. We used the follow-up person-years to assess the incidence density rates until ACS was either identified or censored.We used Poisson regression models to evaluate the ratios of the pneumococcal pneumonia cohort to the controls (relative risk) and 95% confidence intervals (CI). We used the Cox proportional-hazards model to investigate whether pneumococcal pneumonia is independently associated with ACS after adjusting for all potential risk factors. We then used Kaplan-Meier analysis and the log-rank test to compare the cumulative risk of developing ACS between the 2 groups. Results The incidence of ACS was 43.1 per 10000 person-years in the pneumococcal pneumonia and 22.4 per 10000 person-years in the control group.(Incidence rate ratio: 1.92; 95% confidence interval: 1.70-2.17). Higher proportions of hypertension, diabetes, hyperlipidemia and chronic obstructive pulmonary disease are noted in the pneumococcal pneumonia group. After adjusting for age, sex, and comorbidities, we found that the risk of ACS was 47% higher in the pneumococcal pneumonia group than in the control group (95% confidence interval: 1.24-1.73). We divided the time lag into 3 periods, (≤ 3 mo, 3 mo to 1 y and >1 y), and found that the highest relative risk of incidence of ACS between the 2 groups was within the first 3 months after infection with pneumococcal pneumonia (Incidence rate ratio: 3.90; 95% confidence interval: 2.46-6.18). The Kaplan-Meier survival curve showed that the risk of ACS was higher in the pneumococcal pneumonia group than in the control group (Log-rank test, P<0.0001). Conclusion Pneumococcal pneumonia is associated with an increased incidence of ACS, and the relative risk of incidence of ACS between the two groups is highest within the first three months. Our study implied that pneumococcal vaccination may be considered as an option for prevention of incidence of ACS.
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