前白蛋白在急性ST段抬高型心肌梗死中的临床意义

发布时间：2018-08-08 14:54

【摘要】：急性ST段抬高型心肌梗死(acute ST-segment elevation myocardial infarction,STEMI)是严重威胁人类健康的重要疾病之一,目前其基本病因主要认为是在冠状动脉粥样硬化的基础上,不稳定斑块破溃导致出血、血小板聚集和继发血栓形成,使冠状动脉脉完全闭塞,导致心肌缺血缺氧造成相应心肌损伤和不可逆性坏死,进一步可引发乳头肌功能失调、急性心力衰竭、心脏破裂、栓塞、梗死后综合征等并发症,严重影响临床医生治疗策略和患者及患者家属治疗积极性。目前研究表明,STEMI急性发作时局部和全身的炎症反应对疾病发展和预后起着重要的作用。与局部和全身性炎症反应相关的多种血清学标志物的变化水平,如C反应蛋白(CRP)、肌钙蛋白T(cTnT)、脑钠肽(BNP)等和STEMI患者预后之间的关系正受到越来越多的关注。前白蛋白(prealbumin,PA)是由肝脏合成的同源四聚体,PA作为快速周转的内脏蛋白,认为其不仅能反应全身的氮代谢,被当作是反映患者营养状态的较好指标,而且血清PA也被为是一种非特异性的防御性蛋白,在炎症反应期能其游离的亚基能结合病原分子及机体毒性代谢产物,导致自身被消耗,使血清浓度降低。最近几年来国外有研究显示PA能作为判断外周动脉血管造影术后1年内发生主要不良事件的预测因子,较低水平的PA同样与心力衰竭的不良预后有着明显相关性,国内研究已有学者将PA变化与川崎病患者、冠心病患者冠状动脉病变严重程度和急性心肌梗死近期预后做了相关研究,表明了PA作为反应炎症及急性应激反应的指标在评估急性心肌梗死中对血管病变程度,炎症范围及病情预后中有重要价值。然而STEMI作为透壁性心肌梗死,相较于稳定型心绞痛(stable angina pectoris,SAP)、不稳定型心绞痛(unstable angina pectoris,UAP)、非ST段抬高型心肌梗死(non-ST-segment elevation myocardial infarction,NSTEMI)有着不同的治疗方案和预后结局,目前关于STEMI患者近期预后与PA水平的关系研究较少,因此本研究通过比较STEMI患者近期预后与PA水平的关系,为临床药物干预PA水平作为治疗靶点提供理论参考。本研究采用回顾性调查方法,连续性入选2013年1月至2015年6月张家口市第一医院心内科160名STEMI患者,记录患者的性别、年龄、心率、收缩压、既往高血压病史、糖尿病病史、吸烟史、血脂、肝功能、心功能等资料。所有患者入科时即刻抽肘静脉血送我院检验科室行生化检测。所有患者均于入院后接受了经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI),PCI术均由我院两名高年资心内科介入医师完成,患者术前均给予负荷量拜阿司匹林肠溶片300mg,硫酸氢氯吡格雷片600mg,支架置入标准为冠状动脉狭窄程度大于75%以上,统计三者病变血管支数。根据STEMI患者在住院期间是否发生心脏事件将患者分为事件组和非事件组。其中事件组58例;非事件102例。采用SPSS17.0进行处理,符合正态分布的计量资料数据组间比较采用独立样本t检验,3组或3组以上数据采用单因素方差分析;非正态分布数据资料采用秩和检验,计数资料比较采用χ_2检验或Fisher精确检验;运用单变量和多变量Logistic回归模型分析对心血管事件发生有影响的独立预测因子,绘制受试者工作曲线(ROC曲线)计算发生心脏事件的最佳阈值。所有数据检验均行双侧检验,P0.05表示差异具有统计学意义。STEMI患者中3支冠状动脉狭窄较2支、1支冠状动脉狭窄PA水平降低,差异有统计学意义,2支冠状动脉狭窄患者较1支冠状动脉狭窄PA水平较低有统计学意义。Spearman相关分析分析显示,血清前白蛋白水平与冠状动脉病变程度呈负相关,PA在病变较重、病情较急的STEMI患者中低表达。随后将STEMI患者分为事件组和非事件组,两组患者在基线资料比较时可见年龄、糖尿病病史的比例上事件组均高于非事件组,而事件组在男性比例、收缩压、前白蛋白、左室射血分数(left ventricular ejection fraction,LVEF)低于非事件组,两组在心率、高血压病史、吸烟、左室舒张末期内径、前壁心肌梗死比例、血脂、肌钙蛋白T及支架放置个数上差异无统计学意义。证明了PA对STEMI患者预后相关;谷草转氨酶(aspertate aminotransferase,AST)、谷丙转氨酶(alanine transaminase,ALT)比较上有差异,可能是急性心肌梗死是导致了肝脏的可逆性损失。随后本研究对可能与患者预后有关的因素进行了单因素Logistic分析,结果显示性别、年龄、糖尿病病史、收缩压、LVEF、PA是影响患者预后的相关因素;但多因素分析示只有糖尿病病史、收缩压、LVEF、PA是影响患者预后的相关因素。随后本研究通过绘制受试者工作曲线得出PA预测患者发生心血管事件的曲线下面积为0.709,差异有统计学意义,最佳阈值为20.85mg/dl。根据得ROC测得的阈值将患者分成前白蛋白20.85mg/dl和≥20.85mg/dl两组,与≥20.85mg/dl组相比,20.85mg/dl组在心室颤动、高度房室传导阻滞、心源性休克、心力衰竭、心脏总不良事件中发生率增高,而新发房颤或房扑、术后再发心梗、死亡两组患者差异无统计学意义。结果提示PA对预测STEMI患者预后有重要意义。上述研究表明,PA可能与传统预测因子一样可以作为评估STEMI患者在院期间发生心脏事件的独立预测因子,因此常规检测STEMI患者血清PA,对患者及早做出病情及预后评估可能具有重要的临床意义。
[Abstract]:Acute ST segment elevation myocardial infarction (acute ST-segment elevation myocardial infarction, STEMI) is one of the important diseases that seriously threaten human health. At present, the basic etiology is mainly based on coronary atherosclerosis. Unstable plaque rupture leads to blood, platelet aggregation and secondary thrombosis, and causes coronary artery to cause coronary artery disease. Complete occlusion of the veins causes myocardial ischemia and hypoxia to cause corresponding myocardial damage and irreversible necrosis, which can further trigger the dysfunction of the papillary muscles, acute heart failure, cardiac rupture, embolism, and post infarction syndrome, which seriously affect the treatment strategy of the clinicians and the treatment of the patients and their families. The present study shows that STEMI is urgent. Local and systemic inflammatory responses play an important role in the development and prognosis of the disease. The changes in the level of the variety of serological markers related to local and systemic inflammatory responses, such as C reactive protein (CRP), troponin T (cTnT), brain natriuretic peptide (BNP), and the prognosis of patients with STEMI are being paid more and more attention. Prealbumin (PA) is a homologous four polymer synthesized by the liver. As a fast turnover viscera, PA is considered not only to react to the nitrogen metabolism of the whole body, but also as a better indicator of the nutritional status of the patient, and the serum PA is also a nonspecific defensive protein that can free the subunit of the subunit in the inflammatory response period. The combination of the pathogenic molecules and the toxic metabolites of the body leads to its own consumption and the decrease in serum concentration. In recent years, studies have shown that PA can be used as a predictor of the major adverse events within 1 years after peripheral artery angiography, and the lower level of PA is also associated with the poor prognosis of the heart failure. Some scholars have studied the changes of PA with the severity of coronary artery disease and the short-term prognosis of acute myocardial infarction in patients with Kawasaki disease, coronary heart disease and acute myocardial infarction. It is shown that the index of PA as a response to inflammation and acute stress response is important in assessing the degree of vascular disease, the range of inflammation and the prognosis of the patients in acute myocardial infarction. However, STEMI as a transmural myocardial infarction, compared to stable angina pectoris (stable angina pectoris, SAP), unstable angina pectoris (unstable angina pectoris, UAP), and non ST segment elevation myocardial infarction (non-ST-segment elevation) has different therapeutic options and prognostic outcomes. The relationship between the short-term prognosis of the patients and the PA level is less. Therefore, this study provides a theoretical reference for the clinical drug intervention PA level as a therapeutic target by comparing the relationship between the short-term prognosis and the level of PA in the patients with STEMI. This study adopts a retrospective survey method and continues to be selected from the Department of Cardiology of the first hospital of Zhangjiakou from January 2013 to June 2015, 1 60 STEMI patients, recorded the patient's sex, age, heart rate, systolic blood pressure, past history of hypertension, history of diabetes, smoking history, blood lipid, liver function, heart function and so on. All patients were immediately given elbow vein blood to our hospital for biochemical test. All patients received percutaneous coronary intervention after admission (percut Aneous coronary intervention, PCI), PCI operation was performed by two senior Department of Cardiology interventional physicians in our hospital. The patients were given a load of Aspirin Enteric-coated Tablets 300mg and Clopidogrel Bisulfate Tablets 600mg before operation. The stent implantation standard was the degree of coronary artery stenosis more than 75%, and the number of vascular branches of the three patients was counted. According to STEMI patients, Cardiac events during hospitalization were divided into event group and non event group. 58 cases of event group and 102 cases of non events were treated with SPSS17.0. Independent sample t test was used for the comparison of data groups conforming to normal distribution. The data of 3 or more than 3 groups were analyzed by single factor analysis of variance; non normal distribution data were collected. Using the rank sum test, the count data were compared by the chi square _2 test or the Fisher accurate test; the independent predictors of the cardiovascular events were analyzed by the single variable and multivariable Logistic regression model, and the best threshold for the cardiac events was calculated by the ROC curve of the subjects. All the data tests were both bilateral test, P0.0 5 the difference was statistically significant in 3.STEMI patients with 2 coronary artery stenosis and 1 coronary stenosis, the difference was statistically significant. 2 coronary stenosis patients had lower level of PA than 1 coronary artery stenosis. The.Spearman correlation analysis showed that the level of serum prealbumin and coronary artery were compared with that of coronary artery. The degree of pathological changes was negatively correlated, PA was low in the more severe and acute STEMI patients. Then STEMI patients were divided into event group and non event group. The age of the two groups was compared to the baseline data, and the proportion of the diabetic history was higher than that in the non event group, while the event group was in the male proportion, systolic pressure, prealbumin, left ventricle. The ejection fraction (left ventricular ejection fraction, LVEF) was lower than the non event group. There was no statistical difference between the two groups in heart rate, hypertension history, smoking, left ventricular end diastolic diameter, the ratio of anterior wall myocardial infarction, blood lipid, troponin T and the number of stent placement. It is clear that PA is related to the prognosis of STEMI patients; aspertate amino (aspertate amino). Transferase, AST), the alanine transaminase (ALT) is different. It may be that acute myocardial infarction is the reversible loss of the liver. Subsequently, this study conducted a single factor Logistic analysis of factors that may be associated with the prognosis of the patient. The results showed that sex, age, diabetes history, systolic pressure, LVEF, PA were affected. The factors related to the prognosis of the patients were analyzed. However, multivariate analysis showed that only the history of diabetes, systolic blood pressure, LVEF, and PA were related factors affecting the prognosis of the patients. Then, the results of this study showed that the area under the curve under the curve of PA was 0.709, the difference was statistically significant, and the best threshold was 20.85mg/dl. based on R The threshold values measured by OC were divided into two groups of prealbumin 20.85mg/dl and more than 20.85mg/dl. Compared with group more than 20.85mg/dl, the incidence of ventricular fibrillation, high atrioventricular block, cardiogenic shock, heart failure, heart total adverse events increased in 20.85mg/dl group, while new atrial fibrillation or atrial flutter, postoperative recurrence of heart infarction, and death of two groups were no difference. The results suggest that PA is of great significance for predicting the prognosis of patients with STEMI. The above study suggests that PA may be the same as the traditional predictor as an independent predictor of cardiac events in patients with STEMI during the hospital. Therefore, the routine detection of serum PA in patients with STEMI may be of the possibility of early making and evaluating the prognosis of the patients. Important clinical significance.
【学位授予单位】：河北北方学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R542.22

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