胰岛素抵抗与急性心梗患者预后的关系

发布时间：2018-07-14 11:12

【摘要】：目的:探讨胰岛素抵抗在接受直接皮冠状动脉介入治疗的急性心梗患者中的临床分布特征,了解胰岛素抵抗与急性心梗患者冠状动脉病变的关系,通过随访1年内MACCE事件发生率了解胰岛素抵抗与心梗患者院内、院外预后的相关性。方法:收集年月至年月在天津市泰达国际心血管病医院急诊就诊的符合入选标准的接受直接皮冠脉介入治疗的急性心梗患者202例作为入选对象。采用稳态模型胰岛素抵抗指数(Homeostasis model assessment of insulin resistance HOMA-IR)评价胰岛素抵抗,即IRI=[空腹血糖(mmol/L)×空腹胰岛素(U/L)]÷22.5,以IRI≥2.69定义为胰岛素抵抗,IRI2.69为胰岛素敏感。按照胰岛素抵抗指数将观察对象分为胰岛素抵抗组和敏感组,应用四分位数法将胰岛素抵抗患者分为轻、中、重、极重度四组。记录所有患者的性别、年龄、体重、身高、高血压史、糖尿病史、吸烟史,并检测其甘油三酯(triglyceride TG)、总胆固醇(total cholesterol TC)、低密度脂蛋白(low-density lipoprotein LDL)、高密度脂蛋白(high density lipoprotein HDL)、超敏C-反应蛋白(High-sensitivity C-reactive protein hs-CRP)、同型半胱氨酸(homocysteinemia HCY)、空腹血糖(fasting plasma glucose FPG)、空腹胰岛素(Fasting serum insulin FINS)、肌酐(creatinite CR)、尿酸(uric acid UC)水平。根据冠脉造影,通过SYNTAX积分评价冠脉病变严重程度;罪犯血管及冠脉病变支数了解冠脉病变范围;支架长度及直径推断冠脉病变类型,分析胰岛素抵抗与以上冠脉病变因素的相关性。记录急性心梗患者左心室(left ventricle LV)内径大小及左室射血分数(left ventricle ejection fraction LVEF)进而评估心功能情况。随访心梗患者介入治疗术后1年内MACCE(全因死亡、再发心梗、需住院治疗的心衰、心绞痛、卒中、支架血栓等)事件发生率,应用ROC曲线评价胰岛素抵抗对MACCE事件的预测价值。结果:.胰岛素抵抗组例,男例,年龄岁,平均()岁,敏感组96例,男74例,年龄35-83岁,平均(61±12)岁;胰岛素抵抗亚组中,轻度抵抗组26例,男性16例,年龄35-80岁,平均(63±10)岁,中度抵抗组27例,男性例,年龄岁,平均()岁,重度抵抗组例,男性例,年龄岁,平均()岁,极重度抵抗组例,男性例,年龄43-82岁,平均(63±7)岁。2.胰岛素抵抗组高血压患病率(66.98%)、糖尿病患病率(33.02%)、BMI(25.37±2.44/kg/m2)、TG(2.31±3.42/mmol/L)、CR(75.87±23.53/umol/L)、CRP(23.33±31.00/mg/L)、FPG(8.70±3.55/mmol/L)、FINS(17.37±11.89/U/L)明显高于敏感患者,且差异具有统计学意义(p0.05)。胰岛素抵抗亚组分析中,极重度抵抗组BMI(26.46±2.01/kg/m2)、CRP(36.62±41.88/mg/L)较轻度、中度组明显升高,TG(4.11±6.33/mmol/L)、FPG(11.20±5.25/mmol/L)、FINS(31.17±16.36/U/L)较轻、中、重度抵抗组亦明显升高,差异均具有统计学意义(p0.05)。胰岛素抵抗组与敏感组、胰岛素抵抗亚组中患者的年龄、性别、吸烟史、TC、LDL、HDL、HCY、UC水平均无统计学差异(p0.05)。3.胰岛素抵抗组SYNTAX积分(19.00±8.65)、支架长度(36.18±19.62/mm)、多支病变比例(75.47%)明显高于敏感组,支架直径(2.98±0.45/mm)明显小于敏感(3.45±2.29/mm)组,差异具有统计学意义(p0.05)。SYNTAX积分在极重度抵抗组(23.56±8.27)较轻度(16.48±8.23)、中度(17.15±7.42)、重度(18.89±9.24)组明显升高,且具有统计学差异(p0.05)。在胰岛素抵抗亚组分析中支架长度、直径、冠脉病变支数、冠脉病变部位均无统计学差异(p0.05)。4.胰岛素抵抗组左室射血分数(51.21±8.47%)明显低于敏感组(55.25±7.10%),且极重度抵抗组(47.27±8.21/%)较轻度(53.31±6.88%)、中度(52.15±10.63%)、重度(52.04±6.69%)组明显降低,差异具有统计学意义(p0.05)。5.胰岛素抵抗组再发心绞痛(33.96%)、心力衰竭(23.58%)发生率均高于敏感组,差异具有统计学意义(p0.05),全因死亡(9.43%)、再发心肌梗死(8.49%)、卒中(8.49%)及支架内血栓(4.72%)发生率虽高于敏感组,但无统计学差异(p0.05)。6.急性心梗患者发生MACCE事件的危险因素为HOMA-IR、LVEF。所建立的回归方程为Y(MACCE)=3.013+0.039×HOMA-IR-0.100×LVEF。7.应用ROC曲线评价HOMA-IR指数对急性心梗患者MACCE事件的早期预测价值,所得AUC为0.611,95%可信区间(confidence interval,CI)为0.531~0.691(P0.01)。结论:1.胰岛素抵抗患者高血压、糖尿病患病率明显增加,表明胰岛素抵抗与高血压、糖尿病具有相关性。2.胰岛素抵抗患者体质指数、血脂、空腹血糖、空腹胰岛素及炎症反应水平明显升高,提示胰岛素抵抗与肥胖、高脂血症、炎症反应相关。3.胰岛素抵抗患者冠脉病变严重,冠脉病变范围广泛,且冠脉病变类型以弥漫性小病变为主。4.HOMA-IR、LVEF是急性心梗患者MACCE事件发生的独立危险因素,胰岛素抵抗对心梗患者预后产生不良影响。5.胰岛素抵抗对急性心梗患者MACCE事件具有一定的预测价值。
[Abstract]:Objective: To investigate the clinical distribution of insulin resistance in patients with acute myocardial infarction receiving direct percutaneous coronary intervention, and to understand the relationship between insulin resistance and coronary artery disease in patients with acute myocardial infarction. The correlation between insulin resistance and the prognosis of patients with myocardial infarction in hospital and in patients with myocardial infarction was investigated through the follow-up of the incidence of MACCE events within 1 years. 202 patients with acute myocardial infarction receiving direct percutaneous coronary intervention in Tianjin Taida International Cardiovascular Disease Hospital from year to year to the year were selected as the subjects of acute myocardial infarction. The insulin resistance was evaluated by the homeostasis model insulin resistance index (Homeostasis model assessment of insulin resistance HOMA-IR). IRI=[empty fasting blood glucose (mmol/L) * empty stomach insulin (U/L)] 22.5, defined as insulin resistance with IRI > 2.69, and IRI2.69 as insulin sensitive. According to the insulin resistance index, the subjects were divided into insulin resistance group and sensitive group, and the patients were divided into four groups of light, medium, heavy and extremely severe with four quantiles. All patients were recorded. Sex, age, weight, height, history of hypertension, diabetes, smoking history, and detection of triglyceride TG, total cholesterol (total cholesterol TC), low density lipoprotein (low-density lipoprotein LDL), high density lipoprotein (high density lipoprotein HDL), and hypersensitive reactive protein. S-CRP), homocysteine (homocysteinemia HCY), fasting blood glucose (fasting plasma glucose FPG), fasting insulin (Fasting serum insulin FINS), creatinine (creatinite), uric acid level. Change range, stent length and diameter to deduce the type of coronary lesion, analyze the correlation between insulin resistance and the factors of coronary lesions above. Record the internal diameter of left ventricle (left ventricle LV) and left ventricular ejection fraction (left ventricle ejection fraction LVEF) in patients with acute myocardial infarction (left ventricle ejection fraction LVEF) and evaluate cardiac function. Follow up intervention therapy for patients with myocardial infarction The incidence of MACCE (all deaths, re infarction, myocardial infarction, hospitalized heart failure, angina, stroke, stent thrombosis) within 1 years after the operation was used to evaluate the predictive value of insulin resistance on MACCE events. Results: insulin resistance, male, age, age, age, age, age, age, age, age, age, age, age, age, age, and age of 35-83 years, mean (61 + 12). In the insulin resistance subgroup, there were 26 cases of mild resistance, 16 males, 35-80 years old, average age (63 + 10), 27 cases of moderate resistance, age, average age, age, age, age, age, extreme resistance, age, age, age 43-82, average (63 + 7) years old.2. insulin resistance group. Rate (66.98%), the prevalence of diabetes (33.02%), BMI (25.37 + 2.44/kg/m2), TG (2.31 + 3.42/mmol/L), CR (75.87 + 23.53/umol/L), CRP (23.33 + 31.00/mg/L), FPG (8.70 + 3.55/mmol/L), FINS (17.37 + 11.89/U/L) significantly higher than those of the sensitive patients. 2.01/kg/m2), CRP (36.62 + 41.88/mg/L) was mild, moderate group was significantly higher, TG (4.11 + 6.33/mmol/L), FPG (11.20 + 5.25/mmol/L), FINS (31.17 + 16.36/U/L) was lighter, and severe resistance group was also significantly higher, the difference was statistically significant (P0.05). Age, sex, smoking in insulin resistance group and insulin resistance group. History, TC, LDL, HDL, HCY, UC levels were not statistically significant (P0.05) SYNTAX integral of.3. insulin resistance group (19 + 8.65), the length of the stent was (36.18 + 19.62/mm), the proportion of multibranch lesions (75.47%) was significantly higher than that of the sensitive group, and the diameter of the stent was significantly lower than that of the sensitive group (3.45 + 2.29/mm), and the difference was statistically significant (P0.05) was in the extreme. Severe resistance group (23.56 + 8.27) was mild (16.48 + 8.23), moderate (17.15 + 7.42), severe (18.89 + 9.24), and significant difference (P0.05). In the analysis of insulin resistance subgroup, the length of the stent, diameter, the number of coronary lesions and the left ventricular ejection fraction in the.4. insulin resistance group were not statistically significant (51. (P0.05) (51.). 21 + 8.47%) was significantly lower than that of the sensitive group (55.25 + 7.10%), and the extreme severe resistance group (47.27 + 8.21/%) was mild (53.31 + 6.88%), moderate (52.15 + 10.63%), and severe (52.04 + 6.69%) group significantly decreased, the difference was statistically significant (P0.05).5. insulin resistance group, recurrent angina (33.96%), heart failure (23.58%) incidence was higher than the sensitive group, the difference Statistically significant (P0.05), total death (9.43%), recurrent myocardial infarction (8.49%), stroke (8.49%) and stent thrombosis (4.72%) were higher than those in the sensitive group, but there was no statistically significant difference (P0.05) the risk factor of MACCE in.6. acute myocardial infarction patients was HOMA-IR, and the regression equation established by LVEF. was Y (MACCE) =3.013+0.039 x HOMA-IR-0.10. 0 x LVEF.7. used the ROC curve to evaluate the early predictive value of HOMA-IR index to the MACCE event in patients with acute myocardial infarction. The results showed that AUC was 0.611,95% confidence interval (confidence interval, CI) was 0.531~0.691 (P0.01). Conclusion: 1. insulin resistance patients with hypertension, the prevalence of diabetes is significantly increased, indicating that insulin resistance and hypertension, diabetes have The level of body mass index, blood lipid, fasting blood glucose, fasting insulin and inflammatory response in patients with.2. insulin resistance increased significantly, suggesting that insulin resistance is related to obesity, hyperlipidemia, and inflammatory response in patients with.3. insulin resistance, the coronary lesions are serious, the coronary lesion range is wide, and the type of coronary lesion is mainly diffuse small lesions.4.HOM A-IR and LVEF are independent risk factors for the occurrence of MACCE events in patients with acute myocardial infarction. Insulin resistance has a bad effect on the prognosis of patients with myocardial infarction..5. insulin resistance is of certain predictive value for the MACCE event in patients with acute myocardial infarction.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R542.22

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