冠脉旁路移植术后肌钙蛋白Ⅰ的动态变化与早期预后的相关性分析

发布时间：2018-09-12 14:19

【摘要】：目的:伴随着人们生活水平提高,我国冠心病的发病率以及死亡率也随之逐渐上升,并且趋于年轻化,需要冠脉旁路移植术治疗的患者数量也在不断增加。近年来,非体外循环下冠脉旁路移植术日益成熟。围手术期心肌梗死(PMI)是较为常见的冠脉旁路移植术术后并发症。当前来讲,临床上只是依托患者症状、心肌酶学以及心电图检查,在PMI发生早期做出准确的诊断依然较为困难。国内外已有研究证明,在评价手术过程与心肌保护措施、判断预后方面,c Tn I检测具有广泛的临床应用价值。因此,探讨冠脉旁路移植术术后c Tn I的动态变化及其评价预后的作用将具有重要的指导意义。本临床实验拟研究非体外循环下冠脉旁路移植术术后不同时间段c Tn I与预后的相关性及预测价值。方法:选取2013年12月~2014年12月期间在河北医科大学第二医院心脏外科择期行单纯非体外循环下冠脉旁路移植术的患者98例,年龄43~78岁,平均年龄为60.19±6.84岁,其中男性56例,女性42例,既往心梗病史患者26例,合并高血压患者54例,合并高血脂症患者41例,合并糖尿病患者33例,合并神经系统疾病患者10例,合并其他疾病患者33例。患者术前均停服阿司匹林、氯吡格雷,给予肝素钙4100万IU皮下注射2/日,继续口服他汀类、β受体阻滞剂、ACEI等药物。全部患者均于术后3~5h(TNI0)、18~24h(TNI1)、36~48h(TNI2)分次抽取静脉血,以测定c Tn I的水平。应用SPSS17.0统计软件分析比较此3个不同时间段的肌钙蛋白I与预后的相关性及预测价值,其中P0.05被认为差异有统计学意义。结果:1手术情况、手术前后c Tn I检测结果及预后情况及早期预后情况:术前所有患者c Tn I值均在正常值范围之内,c Tn I值(0.07±0.11)ng/ml,最低0.00ng/ml,最高0.04ng/ml。所有患者均在非体外循环下顺利完成冠脉旁路移植术,术后安返心外ICU,给予呼吸机辅助呼吸、心电监护、抗感染、营养心肌等综合治疗。术后3~5小时c Tn I值(TNI0)(0.66±0.45)ng/ml,最低为0.07ng/ml,最高为9.19ng/ml,术后18~24小时c Tn I值(TNI1)(3.54±0.62)ng/ml,最低为0.31ng/ml,最高为182.43ng/ml,术后36~48小时c Tn I值(TNI2)(1.12±0.55)ng/ml,最低为0.06ng/ml,最高为24.25ng/ml。经统计学处理,TNI0、TNI1、TNI2与术前c Tn I值相比z值均为:8.595(P0.01),差异具有统计学意义。TNI0、TNI1、TNI2分布散点图见Fig.1术后早期预后情况:术后呼吸机辅助(15±20.02)小时,中位数11.43h,ICU滞留时间(72.02±33.71)小时,中位数65.5h,术后住院时间(11.67±4.37)天,中位数9天,术后应用升压药物26例(26.53%),应用IABP者3例(3.06%),术后心电图异常改变者27例(27.55%)。2 TNI0、TNI1、TNI2与早期预后的相关性:以c Tn I中位数为切点,分析术后心肌肌钙蛋白I(TNI0、TNI1、TNI2)与预后各指标之间的相关性,TNI0、TNI1、TNI2与术后呼吸机辅助时间相关系数分别为0.081(P=0.177)、0.670(P=0.000)、0.168(P=0.099),与ICU滞留时间相关系数分别为0.236(P=0.114)、0.434(P=0.000)、0.206(P=0.042),与术后住院时间相关系数分别为0.174(P=0.087)、0.830(P=0.000)、0.332(P=0.001),与术后应用升压药物情况相关系数分别为0.195(P=0.055)、0.601(P=0.000)、0.231(P=0.022),与术后应用IABP情况相关系数分别为0.052(P=0.611)、0.178(P=0.080)、0.178(P=0.080),与术后心电图异常改变的相关系数分别为0.181(P=0.075)、0.571(P=0.000)、0.206(P=0.042)。结果提示术后18~24 h的c Tn I值与预后显著相关(P值均0.05),且相关关系系数也较大(0.178相关系数0.830)。3应用SPSS17.0软件进行分析,TNI0、TNI1、TNI2预测升压药使用情况的AUC分别为0.672(P=0.059)、0.991(P=0.007)、0.701(P=0.065),TNI0、TNI1、TNI2预测IABP使用情况的AUC分别为0.847(P=0.086)、0.966(P=0.029)、0.935(P=0.036),TNI0、TNI1、TNI2预测ICU滞留时间的AUC分别为0.534(P=0.075)、0.791(P=0.047)、0.692(P=0.062),TNI0、TNI1、TNI2预测术后住院时间的AUC分别为0.661(P=0.057)、0.959(P=0.022)、0.735(P=0.051),TNI0、TNI1、TNI2预测呼吸机辅助时间的AUC分别为0.643(P=0.058)、0.937(P=0.026)、0.682(P=0.054)。TNI0、TNI1、TNI2预测心电图异常改变情况的AUC分别为0.667(P=0.058)、0.980(P=0.014)、0.689(P=0.064)。术后18~24小时c Tn I值对患者预后的预测价值更大(P值均0.05),TNI1对升压药使用情况、IABP使用情况、术后住院时间、呼吸机辅助时间、心电图异常改变情况有较高预测价值,AUC0.9;对ICU滞留时间有一定的预测价值,AUC0.7。4术后18~24h c Tn I值与预后情况各自的预测价值:以c Tn I正常上限的5、10、50、100倍数值为切点,即0.20、0.40、2.0、4.0ng/ml,和TNI1分布中25%、50%、75%、90%百分位数为切点,即0.29ng/ml、0.63ng/ml、1.78ng/ml、6.99ng/ml,分别估计其对升压药使用情况、IABP使用情况、术后住院时间、呼吸机辅助时间及心电图异常改变情况的预测价值,见Table 3。当术后18~24h c Tn I值1.78ng/ml时,其对升压药使用情况、IABP使用情况、术后住院时间、呼吸机辅助时间及心电图异常改变情况具有较好的预测价值。结论:1非体外循环下冠脉旁路移植术后患者心肌肌钙蛋白I较术前均有不同程度升高。2 c Tn I值在术后3~5h开始升高,18~24h达到高峰,36~48h逐渐下降。3术后18~24 h c Tn I值与早期预后有相关性并且有较高的预测价值。对升压药使用情况、IABP使用情况、术后住院时间、呼吸机辅助时间、心电图异常改变情况有较高预测价值,对ICU滞留时间有一定的预测价值。4结合心电图及心脏彩超,对早期诊断PMI具有非常重要的意义。
[Abstract]:OBJECTIVE: With the improvement of people's living standards, the incidence and mortality of coronary heart disease (CHD) in China are gradually increasing, and tends to be younger. The number of patients who need coronary artery bypass grafting is also increasing. In recent years, off-pump coronary artery bypass grafting is becoming more and more mature. Perioperative myocardial infarction (PMI) is more common. Currently, it is still difficult to make an accurate diagnosis in the early stage of PMI by relying on symptoms, myocardial enzymology and electrocardiogram. Therefore, it is of great significance to study the dynamic changes of C Tn I after coronary artery bypass grafting and its role in evaluating prognosis. This clinical trial is to study the correlation between C Tn I and prognosis at different time after off-pump coronary artery bypass grafting. Ninety-eight patients, aged 43-78 years, with an average age of 60.19 (+ 6.84), underwent selective off-pump coronary artery bypass grafting in the second hospital of Hebei Medical University during February. Among them, 56 were males, 42 were females, 26 had a history of myocardial infarction, 54 had hypertension, 41 had hyperlipidemia, and 41 had glycosuria. 33 patients, 10 patients with nervous system diseases, 33 patients with other diseases. All patients stopped taking aspirin, clopidogrel, heparin calcium 41 million IU subcutaneous injection for 2 days, and continued to take statins, beta-blockers, ACEI and other drugs. All patients were selected at 3 to 5 hours (TNI0), 18 to 24 hours (TNI1), 36 to 48 hours (TNI2) after surgery. The correlation and predictive value between troponin I and prognosis were analyzed by SPSS17.0 statistical software. Among them, P 0.05 was considered to be statistically significant. All patients successfully completed coronary artery bypass grafting without cardiopulmonary bypass. All patients returned to the ICU safely after operation. They were given ventilator-assisted breathing, ECG monitoring, anti-infection, cardiac nutrition and other comprehensive treatment. The lowest is 0.45 ng/ml, the lowest is 0.07 ng/ml, the highest is 9.19 ng/ml. The lowest is 0.31 ng/ml and the highest is 182.43 ng/ml. The lowest is 0.06 ng/ml and the highest is 24.25 ng/ml. Compared with preoperative Tn I, I 0, I 1 and I2, the highest is 182.43 ng/ml. The early prognosis of Fig. 1 was as follows: ventilator-assisted (15 The correlation between postoperative cardiac troponin I (TNI 0, TNI 1, TNI 2) and prognosis was analyzed with the median of C Tn I as the cut point. The correlation coefficients between postoperative cardiac troponin I (TNI 0, TNI 1, TNI 2) and prognosis were 0.081 (P = 0.17), respectively. 7, 0.670 (P = 0.000), 0.670 (P = 0.000), 0.168 (P = 0.099), 0.236 (P = 0.114), 0.434 (P = 0.000), 0.206 (P = 0.042), 0.174 (P = 0.087), 0.830 (P = 0.000), 0.000 (P = 0.000), 0.332 (P = 0.001), 0.195 (P = 0.055), 0.601 (P = 0.601), 0.601 (P = 0.601, P = 0.231 (P = 0.000), 0.830 0 830 0 0 0 0 0 0 0 0 0 0 0 0 000 (P = 0.000), 0.332 (P = 0.001) and 0. The correlation coefficients with postoperative application of IABP were 0.052 (P = 0.611), 0.178 (P = 0.080), 0.178 (P = 0.080), 0.181 (P = 0.075), 0.571 (P = 0.000) and 0.206 (P = 0.042), respectively. The correlation coefficients between postoperative application of IABP and postoperative abnormal changes of ECG were significant (P = 0.05) and large (0.075) respectively. The AUCfor predictpredictpredictors of the usususususususususususof presprespresserdrugs were 0.672 (P = 0.059), 0.991 (P = 0.007), 0.701 (P = 0.065), TNI0, TNI0, TNI1 1, 1, TNI1, and TNI2 were 0.847 (P = 0.0.086, 0.086, 0.966 (P = 0.0.96 (P = 0.0.0.029 (P = 0.0.935 (P = 0.0.935 (P = 0.0.0.035 (P = 0.0.030.036), 1, III0, 1, 1, 1, 1, 1, IIIII2, 1, 1, Divide AUCwere 0.661 (P = 0.057), 0.959 (P = 0.022), 0.959 (P = 0.022), 0.959 (P = 0.0.022), 0.735 (P = 0.051), 0.791 (P = 0.0.0.057, 0.791 (P = 0.0.0.0.0.0 0.051), 0 0, 0, TNI0, TNI1, TNI1, and TNI1, and TNI2 predictAUCwere 0.643 (P = 0.050.0.053 (P = 0.058, 0.0.937 (P = 0.0.937 (P = 0.0.0.026 (P = 0.0.0.026 (P = 0.TNI1 and TNI2 predict abnormal changes of ECG AUC was 0.667 (P = 0.058), 0.980 (P = 0.014) and 0.689 (P = 0.064). The prognostic value of C Tn I between 18 and 24 hours after operation was greater (P = 0.05). TNI1 had a higher predictive value for the use of antihypertensive drugs, IABP, postoperative hospital stay, ventilator-assisted time and abnormal changes of ECG, AUC 0.9; ICU retention time was longer in ICU. AUC 0.7.4 postoperative 18-24 h C Tn I value and prognosis of the respective predictive value: C Tn I normal upper limit of 5,10,50,100 times as the tangent point, that is, 0.20,0.40,2.0,4.0 ng/ml, and TNI 1 Distribution in 25%, 50%, 75%, 90% percentiles as the tangent point, that is, 0.29ng/ml, 0.63ng/ml, 1.78ng/ml, 6.99ng/ml, respectively, to estimate the effect of hypertension drugs. The predictive value of usage, IABP usage, postoperative hospitalization time, ventilator-assisted time and abnormal changes of ECG was found in Table 3. When the C Tn I value was 1.78 ng/ml 18-24 hours after operation, the predictive value of IABP usage, postoperative hospitalization time, ventilator-assisted time and abnormal changes of ECG were better. Conclusion: 1. After off-pump coronary artery bypass grafting, cardiac troponin I increased in varying degrees. 2 C Tn I increased at 3-5 hours, peaked at 18-24 hours, and decreased gradually at 36-48 hours. 3 18-24 hours after coronary artery bypass grafting had correlation with early prognosis and high predictive value. ABP usage, postoperative hospitalization time, ventilator-assisted time, abnormal changes in electrocardiogram have a higher predictive value for ICU retention time. 4 Combining ECG and color Doppler echocardiography, it is very important for early diagnosis of PMI.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R654.2

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