miR-133a对PCI相关心肌损伤的诊断价值

发布时间：2018-05-29 23:06

本文选题：经皮冠状动脉介入治疗 + 心肌损伤　；参考：《第二军医大学》2015年硕士论文

【摘要】：研究背景冠状动脉介入治疗已成为冠状动脉粥样硬化性心脏病主要的治疗手段之一,随着技术水平的提高,越来越多的复杂、多支病变选择行PCI治疗。在行PCI治疗的患者中有约30%发生PCI相关的心肌损伤。其中冠状动脉分叉病变的患者,因其病变部位解剖结构特殊,处理该类病变时操作复杂,引起PCI相关心肌损伤的风险相应增加。对于此类患者,心肌损伤主要由PCI手术引起的分支血管受累及末梢血管栓塞所致。目前可以通过检测由坏死心肌释放的标志物来评价是否发生了心肌损伤,标志物升高的水平可反映心肌受损的范围大小,并有助于判断患者的预后。研究目的本研究通过检测PCI相关心肌损伤患者循环血中miR-133a的表达量,并将其与肌钙蛋白、心型脂肪酸结合蛋白的检测结果相比较,探索miR-133a对心肌损伤的诊断价值。研究方法(一)本研究收集自2014年1月至2014年12月在第二军医大学附属长海医院心内科行经皮冠状动脉介入治疗的患者,将冠状动脉分叉病变列为研究对象,排除其中无分叉病变及此次介入治疗前已经对分叉病变进行过介入治疗的患者。根据术中冠状动脉造影结果和肌钙蛋白浓度≥99%参考值上限的3倍,将入组患者分为观察组和对照组,观察组为对分叉病变行PCI术后引起心肌损伤的患者,进一步分为分支血管损伤和末梢血管栓塞两个亚组；对照组为对分叉病变行PCI治疗但未发生PCI相关心肌损伤的患者。(二)分别收集并比较PCI相关心肌损伤组和对照组患者的基本临床资料和手术相关情况。(三)1、检测PCI相关心肌损伤组和对照组患者术后循环血中miRNAs的表达量和肌钙蛋白浓度以及心型脂肪酸结合蛋白的阳性率,比较这三种标志物的表达情况在两组间是否存在差异。2、分别比较分支损伤组和末梢栓塞组与对照组间循环血中miRNAs的表达量、肌钙蛋白浓度以及心型脂肪酸结合蛋白的阳性率是否存在差异。(四)1、分析全部患者循环血中miRNAs表达量与肌钙蛋白浓度和心型脂肪酸结合蛋白阳性率的相关性。2、分析PCI相关心肌损伤患者循环血中miRNAs表达量与肌钙蛋白浓度和心型脂肪酸结合蛋白阳性率的相关性。3、分析分支损伤组患者miR-133a表达量与诊断金标准冠状动脉造影结果的相关性。4、分析末梢栓塞组患者miR-133a表达量与诊断金标准肌钙蛋白浓度的相关性。(五)绘制ROC曲线评价miR-133a对分叉病变PCI相关心肌损伤的诊断价值,以及对分支损伤组和末梢栓塞组的诊断价值,并分别与肌钙蛋白、心型脂肪酸结合蛋白的诊断价值相比较。(六)术后对患者进行3-12月的电话和门诊随访,记录主要不良心血管事件发生情况(Major adverse cardiovascular events, MACEs),包括心源性死亡、非致死性心肌梗死、再发心绞痛、血运重建等。研究结果(一)本研究共纳入符合研究标准的分叉病变患者225例,其中PCI相关心肌损伤组128例,包括分支损伤组患者26例和末梢栓塞组患者102例；对照组患者97例。(二)PCI相关心肌损伤组和对照组相比,以及分支损伤组和末梢栓塞组分别和对照组相比基本临床资料和手术相关情况组间差异无统计学意义(P0.05)。(三)1、循环血中miR-133a的表达量和肌钙蛋白浓度、心型脂肪酸结合蛋白阳性率在PCI相关心肌损伤组中明显升高,与对照组相比差异具有统计学意义(P0.001)。2、分支损伤组和末梢栓塞组的miR-133a表达量和肌钙蛋白浓度、心型脂肪酸结合蛋白阳性率分别,与对照组相比,有明显升高且差异具有统计学意义(P0.01)。(四)1、在全部患者中循环血miR-133a水平与肌钙蛋白浓度和心型脂肪酸结合蛋白阳性率具有正相关性(P0.001)。2、在PCI相关心肌损伤组患者中循环血miR-133a的表达量与肌钙蛋白浓度和心型脂肪酸结合蛋白阳性率具有正相关性(P0.001,P0.05)。3、在分支损伤组患者中循环血miR-133a的表达量与诊断金标准冠脉造影结果具有正相关性(P0.001)。4、在末梢栓塞组患者循环血中miR-133a的表达量与诊断金标准肌钙蛋白水平具有正相关性(P0.05)。(五)1、评价miR-133a对分叉病变PCI相关心肌损伤诊断价值的ROC曲线显示,曲线下面积(Area Under the Curve, AUC)为0.860(95%CI：0.810-0.910),与肌钙蛋白的0.993(95%CI：0-1)相比,诊断价值略低,但差异无统计学意义(P0.05)。与心型脂肪酸结合蛋白的0.594(95%CI：0.521-0.668)相比,诊断价值较高,差异无统计学意义(P0.05)。2、分支损伤组miR-133a的AUC为0.912(95%CI：0.847-0.955),肌钙蛋白绘制的AUC为0.967(95%CI：0.918-0.991),心型脂肪酸结合蛋白的AUC为0.818(95%CI：0.738-0.881),三者之间相比差异无统计学意义(P0.05)。3、在末梢栓塞组中miR-133a的AUC为0.846(95%CI：0.788-0.893),肌钙蛋白的AUC为1.0(95%CI：0.981-1.0),心型脂肪酸结合蛋白的AUC为0.536(95%CI：0.464-0.607),两两比较差异具有统计学意义(P0.001)。(六)住院期间分支损伤组与末梢栓塞组术后均未发生MACEs,出院后3-12月随访期间内,所有入组患者中共有12例(5.33%)发生MACEs,其中观察组10例(7.81%),对照组2例(2.06%)。观察组中分支损伤组发生MACEs者5例(19.23%),末梢栓塞组发生MACEs者5例(4.90%)。PCI相关心肌损伤患者MACEs发生率较对照组高,差异具有统计学意义(P0.05)。进一步分析miR-133a表达量的升高程度与MACEs发生率的相关性,结果表明两者呈正相关关系(P0.001)。结论1、循环血miR-133a在冠状动脉分叉病变PCI相关心肌损伤的患者中表达量明显升高,并且在分支损伤和末梢栓塞两个亚组的患者中均升高。提示miR-133a能够区分分叉病变行PCI术后是否发生了心肌损伤。2、miR-133a的表达量与经典指标肌钙蛋白浓度和心型脂肪酸结合蛋白阳性率具有正相关性,提示miR-133a对PCI相关心肌损伤具有诊断价值。3、miR-133a在PCI相关心肌损伤中的诊断价值不劣于肌钙蛋白的诊断价值,且优于心型脂肪酸结合蛋白；miR-133a对分支血管损伤的诊断价值,与肌钙蛋白及心型脂肪酸结合蛋白的相似；对末梢血管栓塞的诊断价值,优于心型脂肪酸结合蛋白,但较肌钙蛋白低。4、PCI相关心肌损伤患者的MACEs发生率较高,miR-133a表达量升高程度与MACE发生率呈正相关,提示miR-133a可能对评价PCI相关心肌损伤患者的预后具有一定价值。
[Abstract]:Background coronary intervention has become one of the main treatments for coronary atherosclerotic heart disease. With the improvement of the technical level, more and more complex and multi branch lesions are selected for PCI treatment. About 30% of the patients who have been treated with PCI have PCI related cardiac muscle injury. Because of the special anatomical structure of the lesion, the operation of this kind of lesion is complicated and the risk of PCI related myocardial injury is increased accordingly. For this kind of patient, the injury of the myocardium is mainly caused by the involvement of the branch vessels and the peripheral vascular embolism caused by the PCI operation. The level of the elevation of the markers can reflect the extent of myocardial damage and help to determine the prognosis of the patients. The purpose of this study was to explore the expression of miR-133a in circulating blood in patients with PCI related myocardial injury and to compare it with the results of the detection of troponin and heart type fatty acid binding protein, and explore miR-133a The diagnostic value of myocardial injury. (1) this study was collected from January 2014 to December 2014 at the Department of Cardiology, Changhai Hospital, Second Military Medical University, who underwent percutaneous coronary intervention. The coronary bifurcation lesion was listed as the study object, excluding the bifurcation lesions and the bifurcation disease before the intervention treatment. Patients who had undergone interventional therapy were divided into observation group and control group according to the results of coronary arteriography and the upper limit of the concentration of troponin 99% (99%). The observation group was divided into two subgroups of branch vascular injury and peripheral vascular embolization. The control group was treated with PCI treatment but did not have PCI related myocardial injury. (two) the basic clinical data and operation related conditions were collected and compared respectively with the PCI related myocardial injury group and the control group. (three) 1, the expression of miRNAs in the circulation blood and the troponin in the postoperative circulatory blood of the PCI related myocardial injury group and the control group were detected. The positive rate of concentration and heart type fatty acid binding protein was compared to whether the expression of the three markers was different between the two groups, and the expression of miRNAs in the circulating blood of the branch injury group and the end embolic group and the control group was compared, and the difference in the positive rate of the troponin concentration and the heart type lipoic acid binding protein was compared. Four) 1. The correlation between the expression of miRNAs in circulating blood and the positive rate of cardiac troponin and cardiac fatty acid binding protein in circulating blood of all patients was.2. The correlation between the expression of miRNAs in circulating blood and the correlation between the concentration of troponin and the positive rate of cardiac fatty acid binding protein in the circulating blood of patients with PCI related myocardial injury was analyzed, and the analysis of the miR-133a table in the patients with the branch injury group was analyzed. The correlation between the dose and the results of the diagnostic gold standard coronary angiography (.4), the correlation between miR-133a expression and the concentration of the diagnostic gold standard was analyzed. (five) to draw a ROC curve to evaluate the diagnostic value of miR-133a on PCI related myocardial injury in bifurcated lesions, as well as the diagnostic value of the branch injury group and the end embolic group. And compared with the diagnostic value of troponin and heart type fatty acid binding protein respectively. (six) after 3-12 months of telephone and outpatient follow-up, the major adverse cardiovascular events (Major adverse cardiovascular events, MACEs) were recorded, including cardiac death, non fatal myocardial infarction, recurrent angina, and heavy blood transport. 225 cases of PCI related myocardial injury were included in this study, including 128 cases of PCI related myocardial injury group, including 26 cases of branch injury group and 102 cases of end embolic group, 97 cases in control group. (two) compared with the control group, the PCI related myocardial injury group and the control group, and the branch injury group and the end embolic group. Compared with the control group, there was no significant difference between the basic clinical data and the operation related groups (P0.05). (three) 1. The expression of miR-133a in the circulating blood and the concentration of troponin, the positive rate of the cardiac fatty acid binding protein in the PCI related myocardial injury groups were significantly higher, and the difference was statistically significant (P0.001).2, as compared with the control group. The expression of miR-133a, the concentration of troponin and the positive rate of cardiac fatty acid binding protein in the branch injury group and the end embolic group were significantly higher than those in the control group (P0.01). (four) 1, the level of circulating blood miR-133a and the positive rate of cardiac troponin and heart type fatty acid binding protein in all patients were in all patients. With positive correlation (P0.001).2, the expression of circulating blood miR-133a in the patients with PCI related myocardial injury has a positive correlation with the concentration of troponin and the positive rate of the heart type fatty acid binding protein (P0.001, P0.05).3. The amount of circulating blood miR-133a in the patients with branch injury has a positive correlation with the results of the diagnostic gold standard coronary angiography. (P0.001).4, there was a positive correlation between the expression of miR-133a in circulating blood and the level of diagnostic gold standard troponin (P0.05). (five) 1. The ROC curve of the diagnostic value of miR-133a for PCI related myocardial injury in bifurcation lesions showed that the area under the curve (Area Under the Curve, AUC) was 0.860, and muscle calcium. The diagnostic value of protein 0.993 (95%CI:0-1) was slightly lower, but the difference was not statistically significant (P0.05). Compared with 0.594 (95%CI:0.521-0.668) of the heart type fatty acid binding protein (95%CI:0.521-0.668), the diagnostic value was higher, the difference was not statistically significant (P0.05).2, the AUC of miR-133a in the branch injury group was 0.912 (95%CI:0.847-0.955), and the AUC of troponin was 0.967. 95%CI:0.918-0.991), the AUC of the heart type fatty acid binding protein was 0.818 (95%CI:0.738-0.881), and there was no statistically significant difference between the three (P0.05).3. The AUC of miR-133a was 0.846 (95%CI:0.788-0.893) in the end embolic group, and the AUC of troponin was 1 (95%CI: 0.981-1.0), and the AUC of the heart type fatty acid binding protein was 0.536. 4-0.607), 22 the difference was statistically significant (P0.001). (six) there was no MACEs in the branch injury group and the end embolic group during the hospitalization. During the follow-up period of 3-12 months after discharge, 12 cases (5.33%) of all the patients in the group were MACEs, including 10 in the observation group (7.81%) and 2 in the control group (2.06%). The branch injury group in the observation group occurred MAC. There were 5 cases (19.23%) of Es, 5 cases of MACEs in peripheral embolism group (4.90%) the incidence of MACEs in.PCI related myocardial injury patients was higher than that of the control group, the difference was statistically significant (P0.05). Further analysis of the correlation between the degree of miR-133a expression and the incidence of MACEs was further analyzed. The results showed that the positive correlation between the two groups was positive correlation (P0.001). Conclusion 1, circulating miR-133a. The expression level of PCI related myocardial injury in the coronary bifurcation lesions was significantly elevated and increased in the two subgroups of branch injury and distal embolism. It was suggested that miR-133a could distinguish the myocardial injury.2 after PCI, the expression of miR-133a and the cardiac troponin concentration and heart type. The positive correlation of fatty acid binding protein has positive correlation, suggesting that miR-133a has a diagnostic value of.3 for PCI related myocardial injury. The diagnostic value of miR-133a in PCI related myocardial injury is not inferior to the diagnostic value of troponin, and is superior to the heart type fatty acid binding protein; the value of miR-133a in the diagnosis of branch vascular injury and troponin and cardiac troponin and heart The diagnostic value of type fatty acid binding protein is better than that of heart type fatty acid binding protein, but the incidence of MACEs in patients with PCI related myocardial injury is higher than that of cardiac troponin.4, and the level of miR-133a expression is positively correlated with the incidence of MACE. It is suggested that miR-133a may be used to evaluate the patients with myocardial injury associated with PCI The prognosis is of certain value.
【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R542.2

【共引文献】