D-二聚体联合半胱氨酸蛋白酶抑制剂C预测急性心肌梗死患者PCI术后的主要不良心血管事件

doi:10.16138/j.1673-6087.2022.03.010

摘要/Abstract

摘要：

目的：探讨D-二聚体联合半胱氨酸蛋白酶抑制剂（胱抑素）C对接受经皮冠脉介入术（percutaneous coronary intervention,PCI）治疗的急性心肌梗死（acute myocardial infarction, AMI）患者发生主要不良心血管事件（major adverse cardiovascular event, MACE）的预测价值。方法：选取我院2014年1月至2017年12月期间,接受PCI治疗并且基线资料完整的AMI住院患者287例,根据患者入院后血清D-二聚体、胱抑素C中位数水平,将患者分为4组,其中组1：D-二聚体<0.33 mg/L、胱抑素C<1.06 mg/L;组2：D-二聚体<0.33 mg/L、胱抑素C≥1.06 mg/L;组3：D-二聚体≥0.33 mg/L、胱抑素C<1.06 mg/L;组4：D-二聚体≥0.33 mg/L、胱抑素C≥1.06 mg/L。采用多因素Cox回归分析评估D-二聚体联合胱抑素C预测MACE发生的价值。结果：中位随访时间2.89年。多因素Cox回归分析显示,校正年龄、性别和传统危险因素后,组4 MACE发生率显著升高[风险比（hazard ratio, HR）=2.71, 95%置信区间（confidence interval,CI）：1.37~5.36, P<0.01]。结论：D-二聚体联合胱抑素C可有效预测接受PCI治疗的AMI患者远期MACE发生。

关键词: 急性心肌梗死, 经皮冠脉介入术, D-二聚体, 胱抑素C, 主要不良心血管事件

Abstract:

Objective To investigate the predictive value of D-dimer combined with cystatin C level in the occurrence of major adverse cardiovascular event(MACE) in the patients with acute myocardial infarction. Methods From January 2014 to December 2017, 287 patients with acute myocardial infarction who received undergoing percutaneous coronary intervention (PCI) were selected. According to the median levels of serum D-dimer and cystatin C after admission, the patients were divided into four groups, group 1: D-dimer<0.33 mg/L, cystatin C<1.06 mg/L; group 2: D-dimer<0.33 mg/L, cystatin C≥1.06 mg/L; group 3: D-dimer≥0.33 mg/L, cystatin C<1.06 mg / L; group 4: D-dimer≥0.33 mg/L, cystatin C≥1.06 mg/L. The multivariate Cox regression analysis was used to analyze the value of D-dimer combined with cystatin C level in predicting the occurrence of MACE. Results The median time of follow up was 2.89 years. The multivariate Cox regression analysis showed that, the incidence of MACE was significantly increased in the group with high D-dimer and cystatin C levels [hazard ratio (HR)=2.71, 95% confidence interval (CI): 1.37-5.36, P<0.01] after adjustment of age, gender and traditional risk factors. Conclusions The D-dimer combined with cystatin C can effectively predict the occurrence of MACE in the patients with acute myocardial infarction undergoing PCI.

Key words: Acute myocardial infarction, Percutaneous coronary intervention, D-dimer, Cystatin C, Major adverse cardiovascular events

中图分类号:

R542.22

席锐, 范骎, 王芳, 陶蓉, 顾刚. D-二聚体联合半胱氨酸蛋白酶抑制剂C预测急性心肌梗死患者PCI术后的主要不良心血管事件[J]. 内科理论与实践, 2022, 17(03): 227-232.

XI Rui, FAN Qin, WANG Fang, TAO Rong, GU Gang. Value of D-dimer combined with cystatin C in predicting the occurrence of major adverse cardiovascular events in patients with acute myocardial infarction undergoing percutaneous coronary intervention[J]. Journal of Internal Medicine Concepts & Practice, 2022, 17(03): 227-232.

图/表 5

表1

根据D-二聚体、胱抑素C水平分组后患者基线临床特征[$\bar{x}\pm s$/n(%)]

项目	D-二聚体		t/χ²	P	胱抑素C		t/χ²	P
项目	<0.33 mg/L（n=143）	≥0.33 mg/L（n=144）	t/χ²	P	<1.06 mg/L（n=144）	≥1.06 mg/L（n=143）	t/χ²	P
年龄(岁)	61.35±10.93	64.16±13.39	-1.95	0.05	58.32±12.26	67.23±10.61	-6.58	<0.01
男性	128 (89.5)	124 (86.1)	0.77	0.38	126 (87.5)	126 (88.1)	0.03	0.87
吸烟史[n(%)]	87 (60.8)	81 (56.3)	0.62	0.43	81 (56.3)	87 (60.8)	0.62	0.43
饮酒史[n(%)]	45 (31.5)	32 (22.2)	3.13	0.08	38 (26.4)	39 (27.3)	0.03	0.87
BMI （kg/m²）	24.58±3.22	24.42±3.34	0.41	0.68	24.71±3.32	24.29±3.23	1.09	0.28
收缩压（mmHg）	123.91±20.72	122.88±21.83	0.41	0.68	124.93±17.76	121.85±22.62	1.23	0.22
舒张压（mmHg）	74.94±13.06	73.27±12.80	1.10	0.27	75.42±13.47	72.78±12.27	1.73	0.09
心率（次/min）	78.41±12.97	79.04±14.55	-0.39	0.70	78.08±12.78	79.38±14.71	-0.80	0.42
既往史[n(%)]
高血压	95 (66.4)	99 (68.8)	0.18	0.68	87 (60.4)	107 (74.8)	6.80	0.01
糖尿病	38 (26.6)	46 (31.9)	1.00	0.32	51 (35.4)	33 (23.1)	5.28	0.02
肾功能不全	8 (5.6)	46 (31.9)	32.61	<0.01	1 (0.7)	53 (37.1)	62.13	<0.01
高脂血症	50 (35.0)	43 (29.9)	0.85	0.36	52 (36.1)	41 (28.7)	1.81	0.18
脑卒中	15 (10.5)	24 (16.7)	2.33	0.13	11 (7.6)	28 (19.6)	8.71	<0.01
超声心动图
LVEF（%）	56.83±9.37	49.11±11.34	6.29	<0.01	53.71±10.85	52.21±11.29	1.14	0.26
左心室舒张末期内径（mm）	52.18±5.52	54.74±5.87	-3.80	<0.01	53.13±5.07	53.80±6.51	-0.99	0.33
左心室收缩末期内径（mm）	36.00±6.12	40.07±7.08	-5.21	<0.01	37.59±6.46	38.50±7.35	-1.11	0.27
左心房内径（mm）	39.10±4.00	41.21±4.47	-4.21	<0.01	39.94±3.83	40.38±4.85	-0.85	0.39
实验室检查
白细胞（×10⁹/L）	8.54±2.79	8.79±3.42	-0.66	0.51	8.72±2.78	8.61±3.43	0.29	0.77
血红蛋白（g/L）	134.04±11.78	126.95±16.80	4.14	<0.01	132.71±12.80	128.24±16.53	2.56	0.01
血小板（×10⁹/L）	197.19±60.90	205.19±69.22	-1.04	0.3	209.59±66.95	192.76±62.53	2.20	0.03
空腹血糖（mmol/L）	5.71±1.56	6.35±3.60	-1.95	0.05	6.01±1.88	6.05±3.48	-0.12	0.90
糖化血红蛋白（%）	6.28±1.16	6.45±1.36	-1.09	0.28	6.60±1.48	6.14±0.97	3.08	<0.01
谷丙转氨酶（U/L）	38.87±26.24	55.97±70.94	-2.71	0.01	46.18±38.44	48.73±66.44	-0.40	0.69
白蛋白（g/L）	36.09±3.57	33.36±4.88	5.41	<0.01	35.72±3.87	33.71±4.83	3.89	<0.01
血肌酐（μmol/L）	81.59±16.24	111.11±118.32	-2.96	<0.01	75.65±12.73	117.29±117.32	-4.22	<0.01
尿酸（μmol/L）	343.43±87.06	338.63±133.60	0.36	0.72	307.86±89.84	374.41±123.29	-5.23	<0.01
eGFR[mL/ (min·1.73m²）]	84.72±18.44	72.07±24.86	4.90	<0.01	91.74±16.70	64.91±19.97	12.35	<0.01
总胆固醇（mmol/L）	4.20±0.99	4.17±1.07	0.31	0.75	4.33±0.99	4.04±1.05	2.40	0.02
三酰甘油（mmol/L）	1.79±1.17	1.42±0.60	3.30	<0.01	1.66±1.00	1.55±0.89	0.93	0.35
低密度脂蛋白（mmol/L）	2.64±0.86	2.58±0.94	0.63	0.53	2.77±0.89	2.45±0.89	3.02	<0.01
高密度脂蛋白（mmo/L）	1.01±0.41	0.91±0.25	2.41	0.02	1.00±0.42	0.93±0.23	1.84	0.07
CRP（mg/L）	16.22±26.39	41.87±65.38	-4.36	<0.01	18.72±31.68	39.55±64.07	-3.49	<0.01
NT-proBNP（ng/L）	1 513.35±1 974.10	3 470.74±4 763.06	-4.55	<0.01	1 469.95±1 889.16	3 528.12±4 790.10	-4.78	<0.01
高敏肌钙蛋白I（μg/L）	21.35±32.03	21.99±33.45	-0.17	0.87	19.85±32.06	23.51±33.34	-0.95	0.34
纤维蛋白原（g/L）	3.04±0.87	3.64±1.51	-4.10	<0.01	3.21±0.99	3.47±1.49	-1.70	0.09
纤维蛋白降解产物（mg/L）	1.20±0.96	4.28±5.02	-7.22	<0.01	2.45±3.94	3.04±3.92	-1.28	0.20
冠脉病变Gensini 评分(分)	54.83±34.01	55.71±35.17	-0.22	0.83	49.96±27.72	60.62±39.64	-2.64	0.01
用药情况[n(%)]
ACEI/ARB	105 (73.4)	99 (68.8)	0.76	0.38	96 (66.7)	108 (75.5)	2.74	0.10
β受体阻滞剂	125 (87.4)	121 (84.0)	0.67	0.41	122 (84.7)	124 (86.7)	0.23	0.63
硝酸酯类	62 (43.4)	64 (44.4)	0.03	0.85	62 (43.1)	64 (44.8)	0.08	0.77
他汀类	131 (91.6)	121 (84.0)	3.85	0.05	128 (88.9)	124 (86.7)	0.32	0.57

表1

图1

表2

图2

表3

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项目	非校正	P	校正模型1	P	校正模型2	P
D-二聚体per SD	1.48 （1.24~1.78）	<0.01	1.46 （1.21~1.77）	<0.01	1.36 （1.11~1.66）	<0.01
D-二聚体<中位数	1（ref）		1（ref）		1（ref）
D-二聚体 ≥中位数	2.46 （1.58~3.83）	<0.01	2.40 （1.54~3.74）	<0.01	2.15 （1.34~3.45）	<0.01
胱抑素C per SD	1.48 （1.29~1.69）	<0.01	1.37 （1.18~1.58）	<0.01	1.34 （1.15~1.57）	<0.01
胱抑素C<中位数	1（ref）		1（ref）		1（ref）
胱抑素C≥中位数	2.00 （1.29~3.10）	<0.01	1.62 （1.03~2.54）	0.04	1.43 （0.88~2.31）	0.12

组别	非校正	P	HR（校正模型1）	P	HR（校正模型2）	P
组1	1（ref）		1（ref）		1（ref）
组2	1.80 （0.87~3.70）	0.11	1.73 （0.83~3.57）	0.14	1.69 （0.81~3.50）	0.16
组3	2.38 （1.19~4.77）	0.01	2.65 （1.32~5.32）	0.01	2.69 （1.33~5.43）	0.01
组4	4.18 （2.22~7.88）	<0.01	3.58 （1.86~6.86）	<0.01	2.71 （1.37~5.36）	<0.01