血小板高反应性、Lp-PLA2及GRACE评分联合评估对AMI患者急诊PCI术后的预后价值

发布时间：2018-03-10 01:23

  本文选题：血小板高反应性　切入点：Lp-PLA2水平　出处：《天津医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究目的:探究血小板高反应性(high platelet reactivity,HPR)、血浆脂蛋白相关磷脂酶A2(lipoprotein-associated phospholipase A2,Lp-PLA2)及GRACE评分联合应用对急性心肌梗死患者接受急诊皮冠状动脉介入治疗术(Percutaneous Coronary Intervention,PCI)后1年主要不良心血管事件(Major Adverse Cardiac Events,MACE)的预测价值。研究方法:入选2015年9月至2016年1月之间因急性心肌梗死就诊于天津市泰达国际心血管病医院,并接受急诊PCI治疗的患者共150例。所有符合入选及排除标准的患者入院时均检测Lp-PLA2及其他生化检查和影检查,行急诊PCI治疗,PCI术后12-24 h行血小板聚集率检测。将ADP诱导的聚集率50%为血小板高反应性组,即HPR组,将ADP诱导的血小板聚集率≤50%为非血小板高反应性组,即非HPR组。将Lp-PLA2水平分组:Lp-PLA2浓度223μg/L定义为高危组,200-223μg/L定义为中危组,200μg/L定义为低危组。根据患者临床资料计算GRACE评分。住院及出院后按照指南常规治疗。门诊及电话随访患者出院后1年内的MACE事件,MACE定义为:非致死性心肌梗死、非计划性靶血管血运重建、再发胸痛、因心绞痛或心力衰竭非计划性住院治疗、非致死性卒中及心源性死亡。采用单因素及多因素Logistic回归分析随访期间MACE事件的预测因子,绘制受试者工作特征曲线(Receiver operating characteristic curve,ROC),通过计算曲线下面积进行比较。分析HPR、Lp-PLA2、GRACE评分及三者联合应用对急性心肌梗死(acute myocardial infarction,AMI)患者急诊PCI治疗术后远期预后的预测价值。研究结果:入选患者150例,其中男性106例(70.67%)、女性44例(29.33%),年龄39~81[60.82±10.68]岁,HPR组46例(30.67%)、NPR组104例(69.33%),ST段抬高型心肌梗死组108例(72.00%)、非ST抬高型心肌梗死组42例(28.00%)。合并高血压98例(65.30%),糖尿病22例(14.70%),血脂异常10例(6.70%),吸烟史90例(60.00%)。其中皮冠脉支架置入患者106例(70.70%),皮冠脉球囊扩张术患者44例(29.30%)。单支或双支冠脉病变87例(58.00%),复杂病变63例(42.00%)。出院后复查冠状动脉造影51例(34.00%)。随访时间11.35±3月。随访内共发生MACE事件20例(13.33%),其中非致死性心肌梗死1例(0.67%)、非计划性靶血管血运重建4例(2.67%)、因不稳定型心绞痛或心力衰竭非计划性住院治疗6例(4.00%)、心源性死亡1例(0.67%)、再发胸痛7例(4.67%)、非致死性卒中1例(0.67%)。HPR组和非HPR组比较,ST段抬高型心肌梗死、GRACE评分、Lp-PLA2、入院时心率、晨起空腹血糖、TNI、甘油三酯、LEVF有统计学差异,P0.05。非参数Pearson分析,HPR和GRACE评分之间有明显相关性(r=0.220,p=0.007)。HPR和Lp-PLA2之间有明显相关性(r=0.486,p=0.000)。Lp-PLA2高危组MACE事件发生率明显高于中危组和低危组,Lp-PLA2中危组MACE事件发生率高于低危组MACE事件发生率,P均0.05。HPR组患者MACE事件发生率高于非HPR组,P0.05。MACE事件的单因素分析显示,两组之间在年龄、Lp-PLA2、血小板聚集率、GRACE评分、复杂病变、陈旧性心梗、入院时收缩压、血小板计数方面有统计学差异,P均0.05。MACE事件的多因素Logistic回归分析显示,Lp-PLA2、HPR和GRACE评分是AMI患者发生MACE的危险因素。Lp-PLA2水平预测MACE事件的ROC曲线下面积为0.649(95%CI:0.5~0.798,P=0.032),敏感性和特异性分别为80.0%和52.3%。GRACE评分预测MACE事件的ROC曲线下面积0.710(95%CI:0.575~0.820,P=0.004),敏感性和特异性分别为60.0%和74.6%。HPR预测MACE事件的ROC曲线下面积0.749(95%CI:0.636~0.863,P=0.000),敏感性和特异性分别为85.0%和71.5%。三者联合因子预测MACE事件的ROC曲线下面积0.807(95%CI:0.729~0.885,P=0.000),敏感性和特异性分别为90.0%和67.7%。三者联合评估对MACE事件发生具有更好的预测价值。研究结论:1、HPR与GRACE评分之间有明显相关性。2、HPR和Lp-PLA2水平之间有明显相关性。3、HPR、血浆Lp-PLA2水平、GRACE评分可以作为急性ST段抬高型心肌梗死患者急诊PCI治疗术后远期MACE的预测因素。这提示我们不仅要关注冠状动脉斑块不稳定性的治疗,也要了解机体对抗血小板药物反应性情况,进行针对性个体化治疗。4、HPR、Lp-PLA2水平、GRACE评分联合评估可以提高AMI患者PCI术后发生MACE的预测能力,提示三者联合评分对急性心肌梗死急诊PCI治疗的患者术后管理有一定的帮助。
[Abstract]:Objective: To explore high platelet reactivity (high platelet, reactivity, HPR), plasma lipoprotein associated phospholipase A2 (lipoprotein-associated phospholipase A2, Lp-PLA2) and GRACE score combined in patients with acute myocardial infarction undergoing emergency percutaneous coronary intervention (Percutaneous Coronary, Intervention, PCI) after 1 years of major adverse cardiovascular events (Major Adverse Cardiac Events, MACE) predictive value. Methods: selected from September 2015 to January 2016 for treatment of acute myocardial infarction in Tianjin Taida International Cardiovascular Disease Hospital, and received emergency treatment of PCI patients with a total of 150 cases. All were detected in Lp-PLA2 and other biochemical tests and examined in accordance with the inclusion and exclusion criteria of patients, treated with PCI. PCI 12-24 h after operation. The detection rate of platelet aggregation induced by ADP 50% for high platelet aggregation reaction Group, HPR group, ADP induced platelet aggregation rate is less than or equal to 50% for non high platelet reactivity group, non HPR group. The level of Lp-PLA2 group: Lp-PLA2 concentration of 223 g/L is defined as the high-risk group, 200-223 g/L is defined as the risk group, 200 g/L defined as low risk group according to the clinical. Patients with GRACE score. The material information in hospital and after discharge in accordance with the guidelines for routine treatment. The MACE event within 1 years of hospital outpatient and telephone follow-up, MACE is defined as: non fatal myocardial infarction, non planned target vessel revascularization, recurrent chest pain, angina or heart failure due to unplanned hospitalization. Non fatal stroke and cardiac death. By univariate and multivariate Logistic regression analysis of predictors of MACE events during the follow-up period, the receiver operating characteristic curve (Receiver operating characteristic curve, ROC), were compared by calculating the area under the curve of H. PR,Lp-PLA2,GRACE璇勫垎鍙婁笁鑰呰仈鍚堝簲鐢ㄥ�规�ユ，

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