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北京大学学报（医学版） ›› 2024, Vol. 56 ›› Issue (1): 150-156. doi: 10.19723/j.issn.1671-167X.2024.01.023

• 论著 • 上一篇    下一篇

急性前壁ST段抬高型心肌梗死患者直接冠状动脉介入术后微循环阻力指数与左心室不良重构的相关性

王方芳1,梁芙萌2,李楠3,王晓晓3,韩江莉1,*(),郭丽君1,*()   

  1. 1. 北京大学第三医院心内科、血管医学研究所，血管稳态与重构全国重点实验室，国家卫生健康委员会心血管分子生物学与调节肽重点实验室，心血管受体研究北京市重点实验室，北京 100191
    2. 北京大学第三医院北方院区综合内科，北京 100089
    3. 北京大学第三医院临床流行病学研究中心，北京 100191
  • 收稿日期:2023-08-06 出版日期:2024-02-18 发布日期:2024-02-06
  • 通讯作者: 韩江莉,郭丽君 E-mail:dr_hanjiangli@126.com;guo_li_jun@sohu.com
  • 基金资助:
    首都卫生发展科研专项(2014-2-4093);中国医师协会阳光心血管研究基金(SCRFCMDA201321)

Index of microcirculatory resistance is associated with left ventricular remodeling in patients with acute anterior ST-segment elevation myocardial infarction undergoing emergency primary percutaneous coronary intervention

Fangfang WANG1,Fumeng LIANG2,Nan LI3,Xiaoxiao WANG3,Jiangli HAN1,*(),Lijun GUO1,*()   

  1. 1. Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University; NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Peking University; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing 100191, China
    2. Department of General Medicine, Peking University Third Hospital, Beifang Branch, Beijing 100089, China
    3. Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing 100191, China
  • Received:2023-08-06 Online:2024-02-18 Published:2024-02-06
  • Contact: Jiangli HAN,Lijun GUO E-mail:dr_hanjiangli@126.com;guo_li_jun@sohu.com
  • Supported by:
    Capital Health Development Scientific Research Fund(2014-2-4093);Sunshine Cardiovascular Research Fund of Chinese Medical Doctor Association(SCRFCMDA201321)

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摘要：

目的: 评估急性前壁ST段抬高心肌梗死(acute anterior ST elevation myocardial infarction，STEMI)患者直接经皮冠状动脉介入术(primary percutaneous coronary intervention，PPCI)后微循环阻力指数(index of microcirculatory resistance，IMR)与1年后左心室不良重构(left ventricular adverse remodeling，LVAR)之间的关系。方法: 采用单中心回顾性队列研究，连续选择2014年1月至2017年8月在北京大学第三医院住院的前壁STEMI并行PPCI患者，术后即刻通过压力/温度导丝测量IMR。利用血清肌酸激酶(creatine kinase，CK)峰值评估梗死面积，心肌梗死(myocardial infarction，MI)后1 d和1年时评估超声心动图，将左心室舒张末期容积(left ventricular end-diastolic volume，LVEDV)较基线增加≥20%定义为LVAR。结果: 共入选43例患者，平均年龄(58.7±12.4)岁。根据IMR正常参考值将患者分为两组，IMR>25(n=23)组较IMR≤25组(n=20)患者冠状动脉造影显示梗死相关血管完全闭塞率(95.7% vs. 65.0%, P=0.029)更高，血清CK峰值水平更高[4 090(383, 15 833)vs. 1 580(396, 5 583), P=0.004]，室壁瘤发生率更高(30.4% vs. 5.0%，P=0.021)。MI后1 d两组LVEDV差异无统计学意义[(111.0±18.8) mL vs. (115.0±23.6) mL，P=0.503]，而1年后IMR>25组LVEDV明显高于IMR≤25组[(141.5±33.7) mL vs. (115.9±27.9) mL, P=0.018]。IMR>25组LVAR发生比例更高(47.4% vs. 11.8%, P=0.024)。二元Logistics回归显示IMR[B=0.079，exp(B) (95%CI) 为1.082 (1.018~1.149), P=0.011]和血清甘油三酯(triglyceride，TG)水平[B=1.610，exp(B) (95%CI)为5.005 (1.380~18.152), P=0.014]是患者MI后1年发生LVAR的预测因素，IMR对1年后发生LVAR具有良好的预测价值(曲线下面积=0.749, P=0.019)，IMR>29为良好的临界点，敏感性81.8%，特异性68.0%。结论: STEMI患者PPCI术后即刻测定IMR可以反映微血管功能，而微血管功能障碍是STEMI后1年左心室不良重构的有力预测指标。

关键词: 急性心肌梗死, 微循环阻力指数, 左心室不良重构, 甘油三酯

Abstract:

Objective: To evaluate whether index of microcirculatory resistance (IMR) is associated with left ventricular (LV) remodeling in acute anterior ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). Methods: This was a single-center retrospective cohort study. The patients with first anterior STEMI who received PPCI from January 2014 to August 2017 in Peking University Third Hospital was enrolled. After PPCI, IMR was measured immediately by using pressure/temperature guidewire. The success rate of IMR measurement was 100%. Also we collected some related clinical data from the medical records and laboratory results. Infarct size [assessed as creatine kinase (CK) peak], echocardiography at baseline and 1 year follow-up were assessed. LV adverse remodeling (LVAR) was defined as ≥20% increase in LV end-diastolic volume (LVEDV). Results: A total of forty-three patients were enrolled, with an average age of (58.7±12.4) years.The patients were divided into two groups as IMR ≤25 and IMR>25 by normal values recommended by previous literature. Compared with IMR ≤25 group, IMR>25 group had a higher percentage of initial thrombolysis in myocardial infraction (TIMI) grade 0 (95.7% vs. 65.0%, P=0.029), higher serum CK peak value [4 090 (383, 15 833)vs. 1 580 (396, 5 583), P=0.004]. The IMR>25 group suffered higher rates of ventricular aneurysm (30.4% vs. 5.0%, P=0.021). There was no difference in LVEDV [(111.0±18.8) mL vs. (115.0±23.6) mL, P=0.503] between the two groups 1 day after MI, but after 1 year, LVEDV in IMR>25 group was significantly higher than in IMR≤25 group [(141.5±33.7) mL vs. (115.9±27.9) mL, P=0.018]. The incidence of LVAR was more significant in IMR>25 group (47.4% vs. 11.8%, P=0.024). Binary Logistics regression showed that IMR [B=0.079, exp(B) (95%CI)=1.082 (1.018－1.149), P=0.011] and serum triglyceride level [B=1.610, exp(B) (95%CI)=5.005 (1.380－18.152), P=0.014] were the predictors of LVAR 1 year after MI. IMR had a good predictive value for LVAR 1 year after MI [area under the curve (AUC)=0.749, P=0.019], IMR>29 was a good cutoff value with sensitivity 81.8% and specificity 68.0%. Conclusion: Our study elaborates that immediate measurement of IMR after PPCI in patients with STEMI can reflect the microvascular function.And IMR could be used as a quantitative biomarker to predict LVAR after STEMI.

Key words: Acute myocardial infarction, Index of microcirculatory resistance, LV adverse remodeling, Triglyceride

中图分类号: 

  • R542.22

表1

两组患者基线一般临床资料与实验室指标比较"

Parameters IMR ≤25 (n=20) IMR>25 (n=23) P value
Age/years, ˉx±s 55.9±14.7 61.1±9.8 0.205
Male, n (%) 17 (85.0) 18 (78.3) 0.862
Hypertension, n (%) 6 (27.3) 9 (39.1) 0.324
Diabetes mellitus, n (%) 7 (35.0) 6 (26.1) 0.526
Dyslipidemia, n (%) 10 (50.0) 6 (26.1) 0.106
Current smoking, n (%) 15 (75.0) 16 (69.6) 0.692
WBC/(×109/L), ˉx±s 11.20±3.89 11.00±4.22 0.584
Neut/%, M (min, max) 78.4 (64.9, 92.0) 82.8 (54.0, 90.4) 0.279
hs-CRP/(mg/L), M (min, max) 4.53 (2.18, 9.42) 4.02 (2.27, 7.74) 0.543
eGFR/(mL/min), ˉx±s 93.6±22.1 81.8±20.6 0.079
Cholesterol/(mmol/L), ˉx±s 4.80±0.86 4.80±1.38 0.995
LDL-C/(mmol/L), ˉx±s 3.08±0.64 2.99±0.92 0.726
HDL-C/(mmol/L), M (min, max) 0.96 (0.61, 1.59) 0.96 (0.74, 1.45) 0.779
TG/(mmol/L), M (min, max) 1.33 (0.61, 4.68) 1.44 (0.65, 3.08) 0.706
Glu/(mmol/L), M (min, max) 5.6 (4.2, 18.1) 6.4 (4.5, 9.2) 0.886
HbA1C/%, M (min, max) 6.05 (5.00, 11.40) 5.70 (4.90, 7.90) 0.057
NT-proBNP/(ng/mL), M (min, max) 815 (20, 3 357) 1030 (70, 4 264) 0.762
Peak CK/(IU/L), M (min, max) 1 580 (396, 5 583) 4090 (383, 15 833) 0.004
Killip≥Ⅱ, n (%) 1 (5.0) 4 (17.4) 0.431

表2

两组患者手术及用药情况比较"

Parameters IMR ≤25(n=20) IMR>25(n=23) P value
Procedural characteristics
    TIMI flow grade 0(initial), n (%) 13 (65.0) 22 (95.7) 0.029
    Coronary infused tirofiban, n (%) 5 (25.0) 12 (52.2) 0.069
    Thrombus aspiration, n (%) 1 (5.0) 6 (26.1) 0.146
    TIMI flow grade 3 (final) proximal LAD, n (%) 20 (100.0) 20 (87.0) 0.491
    Multivessel disease, n (%) 14 (70.0) 13 (56.5) 0.270
    IMR, M (min, max) 17.90 (8.96, 23.31) 44.20 (25.08, 87.00) < 0.001
    CFR, M (min, max) 1.85 (0.70, 5.30) 1.30 (0.80, 2.30) 0.027
    FFR, M (min, max) 0.85 (0.72, 0.96) 0.87 (0.70, 1.03) 0.378
Discharge treatment
    ACE inhibitor, n (%) 11 (55.0) 10 (43.5) 0.887
    β-blocker, n (%) 10 (50.0) 11 (47.8) 0.451

表3

两组患者心脏超声基线及1年后比较"

Parameters IMR≤25 IMR>25 P
Baseline
    n 20 23
    LVEF/%, ˉx±s 47.6±3.7 44.3±4.9 0.02
    Sm/(cm/s), ˉx±s 7.2±0.8 9.6±2.4 0.01
    LVEDD/mm, ˉx±s 49.2±4.4 48.5±3.6 0.54
    LVEDV/mL, ˉx±s 115.0±23.6 111.0±18.8 0.503
    Ventricular aneurysm, n (%) 1 (5.0) 7 (30.4) 0.021
1 year follow-up
    n 17 19
    LVEF/%, ˉx±s 57.0±9.0 50.0±7.0 0.01
    Sm/(cm/s), ˉx±s 9.7±2.8 8.3±1.8 0.087
    LVEDD/mm, ˉx±s 49.3±5.0 53.7±5.3 0.014
    LVEDV/mL, ˉx±s 115.9±27.9 141.5±33.7 0.018
    ΔLVEF/%, ˉx±s 10.0±9.0 6.0±8.0 0.16
    ΔLVEDV/%, ˉx±s -2.0±21.0 27.0±29.0 0.001
    LVAR, n (%) 2 (11.8) 9 (47.4) 0.024

图1

两组患者LVEF(A)、ΔLVEF (B)基线与1年后情况比较"

图2

两组患者LVEDV(A)、△LVEDV(B)基线与1年后情况比较"

图3

两组患者LVAR基线与1年后情况比较"

图4

IMR预测LVAR的ROC曲线"

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ISSN 1671-167X
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