ST段抬高型心肌梗死患者微血管阻塞对左室功能及预后的影响

doi:10.3969/j.issn.1674-8115.2021.02.008

摘要/Abstract

摘要：

目的·应用心脏磁共振（cardiac magnetic resonance，CMR）技术，探究ST段抬高型心肌梗死（ST-segment elevation myocardial infarction，STEMI）患者微血管阻塞（microvascular obstruction，MVO）对左室功能及预后的影响。方法·纳入2016年1月—2017年12月于上海交通大学医学院附属仁济医院心内科就诊的STEMI患者124例，应用CMR技术评估患者再灌注后心肌梗死百分比、心肌MVO百分比及左室功能。依据心肌MVO百分比，将患者分为MVO（+）组和MVO（-）组，比较2组的基线特征、血生化指标和CMR指标。MVO（+）组依据心肌梗死百分比的四分位数进一步分为4个亚组，利用Pearson相关分析探究各亚组患者心肌MVO百分比与左室射血分数（left ventricular ejection fraction，LVEF）的相关性。随访所有患者30 d内不良事件的发生情况，采用受试者操作特征曲线（receiver operating characteristic curve，ROC曲线）分析心肌MVO百分比对不良事件的预测价值。结果·在基线特征无明显差异的情况下，MVO（+）组的白细胞计数、血清磷酸肌酸激酶、肌酸激酶同工酶、心肌肌钙蛋白I、总胆固醇水平均高于MVO（-）组（均P<0.05）。MVO（+）组的LVEF低于MVO（-）组（P=0.000）。Pearson相关分析显示，心肌MVO百分比与LVEF呈负相关（均P<0.05）。ROC曲线显示，心肌MVO百分比预测患者30 d内不良事件的曲线下面积为0.889（95%CI 0.823~0.975），其敏感度和特异度均高于心肌梗死百分比。结论·合并MVO的STEMI患者的左室功能及预后更差，提示需更加重视对于此类患者的临床干预。

关键词: 心脏磁共振, ST段抬高型心肌梗死, 微血管阻塞, 左室功能, 预后

Abstract:

Objective·To investigate the effect of microvascular obstruction (MVO) on left ventricle function and prognosis in patients with ST-segment elevation myocardial infarction (STEMI) by using cardiac magnetic resonance (CMR) technique.

Methods·A total of 124 patients with STEMI in the Department of Cardiology of Renji Hospital, Shanghai Jiao Tong University School of Medicine from January 2016 to December 2017 were enrolled. The percentage of myocardial infarction size, the percentage of myocardial MVO size and left ventricle function after reperfusion were evaluated by CMR technique. According to the percentage of myocardial MVO size, the patients were divided into MVO (+) group and MVO (-) group. The baseline characteristics, blood biochemical indexes and CMR indexes of the two groups were compared. The MVO (+) group was further divided into 4 subgroups according to the quartiles of the percentage of myocardial infarction size. Pearson correlation analysis was used to explore the correlation between the percentage of myocardial MVO size and left ventricular ejection fractions (LVEF) in each subgroup. The incidence of adverse events within 30 days was observed. Receiver operating characteristic curve (ROC curve) was used to analyze the predictive value of the percentage of myocardial MVO size for adverse events.

Results·The white blood cell count, creatine phosphokinase, creatine kinase MB, cardiac troponin I and total cholesterol in the MVO (+) group were significantly higher than those in the MVO (-) group (all P<0.05), while baseline characteristics showed no significant difference. LVEF in the MVO (+) group was lower than that in the MVO (-) group (P=0.000). Pearson correlation analysis showed that the percentage of myocardial MVO size was negatively correlated with LVEF (all P<0.05). ROC curve showed that the area under the curve of the percentage of myocardial MVO size in the prediction of adverse events within 30 days was 0.889 (95%CI 0.823?0.975), and the sensitivity and specificity of the percentage of myocardial MVO size were more higher than that of the percentage of myocardial infarction size.

Conclusion·The left ventricle function and prognosis in STEMI patients with MVO are worse, suggesting that more attention should be paid to the clinical intervention for such patients.

Key words: cardiac magnetic resonance (CMR), ST-segment elevation myocardial infarction (STEMI), microvascular obstruction (MVO), left ventricle function, prognosis

中图分类号:

R543.3

胡培堃, 何杰, 吴连明, 葛恒, 许建荣, 卜军. ST段抬高型心肌梗死患者微血管阻塞对左室功能及预后的影响[J]. 上海交通大学学报(医学版), 2021, 41(2): 173-179.

Pei-kun HU, Jie HE, Lian-ming WU, Heng GE, Jian-rong XU, Jun PU. Effect of microvascular obstruction on left ventricle function and prognosis in patients with ST-segment elevation myocardial infarction[J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2021, 41(2): 173-179.

图/表 7

参考文献 25

1	Nabel EG, Braunwald E. A tale of coronary artery disease and myocardial infarction[J]. N Engl J Med, 2012, 366(1): 54-63.
2	Çağdaş M, Karakoyun S, Rencüzoğulları İ, et al. Assessment of the relationship between reperfusion success and T-peak to T-end interval in patients with ST elevation myocardial infarction treated with percutaneous coronary intervention[J]. Anatol J Cardiol, 2018, 19(1): 50-57.
3	Fajar JK, Heriansyah T, Rohman MS. The predictors of no reflow phenomenon after percutaneous coronary intervention in patients with ST elevation myocardial infarction: a meta-analysis[J]. Indian Heart J, 2018, 70 (): S406-S418.
4	Niccoli G, Burzotta F, Galiuto L, et al. Myocardial no-reflow in humans[J]. J Am Coll Cardiol, 2009, 54(4): 281-292.
5	Pu J, Ding S, Ge H, et al. Efficacy and safety of a pharmaco-invasive strategy with half-dose alteplase versus primary angioplasty in ST-segment-elevation myocardial infarction: EARLY-MYO trial (early routine catheterization after alteplase fibrinolysis versus primary PCI in acute ST-segment-elevation myocardial infarction)[J]. Circulation, 2017, 136(16): 1462-1473.
6	He J, Kong LC, Zeng JT, et al. Comparison of direct stenting with conventional strategy on myocardial impairments in ST-segment elevation myocardial infarction: a cardiac magnetic resonance imaging study[J]. Int J Cardiovasc Imaging, 2020, 36(6): 1167-1175.
7	de Waha S, Desch S, Eitel I, et al. Impact of early vs. late microvascular obstruction assessed by magnetic resonance imaging on long-term outcome after ST-elevation myocardial infarction: a comparison with traditional prognostic markers[J]. Eur Heart J, 2010, 31(21): 2660-2668.
8	Cochet AA, Lorgis L, Lalande A, et al. Major prognostic impact of persistent microvascular obstruction as assessed by contrast-enhanced cardiac magnetic resonance in reperfused acute myocardial infarction[J]. Eur Radiol, 2009, 19(9): 2117-2126.
9	Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018)[J]. J Am Coll Cardiol, 2018, 72(18): 2231-2264.
10	Ezekowitz JA, Kaul P, Bakal JA, et al. Declining in-hospital mortality and increasing heart failure incidence in elderly patients with first myocardial infarction[J]. J Am Coll Cardiol, 2009, 53(1): 13-20.
11	Weir RA, Murphy CA, Petrie CJ, et al. Microvascular obstruction remains a portent of adverse remodeling in optimally treated patients with left ventricular systolic dysfunction after acute myocardial infarction[J]. Circ Cardiovasc Imaging, 2010, 3(4): 360-367.
12	Hammer-Hansen S, Leung SW, Hsu LY, et al. Early gadolinium enhancement for determination of area at risk: a preclinical validation study[J]. JACC Cardiovasc Imaging, 2017, 10(2): 130-139.
13	Wu KC, Weiss RG, Thiemann DR, et al. Late gadolinium enhancement by cardiovascular magnetic resonance heralds an adverse prognosis in nonischemic cardiomyopathy[J]. J Am Coll Cardiol, 2008, 51(25): 2414-2421.
14	Hamirani YS, Wong A, Kramer CM, et al. Effect of microvascular obstruction and intramyocardial hemorrhage by CMR on LV remodeling and outcomes after myocardial infarction: a systematic review and meta-analysis[J]. JACC Cardiovasc Imaging, 2014, 7(9): 940-952.
15	Abbas A, Matthews GH, Brown IW, et al. Cardiac MR assessment of microvascular obstruction[J]. Br J Radiol, 2015, 88(1047): 20140470.
16	Yellon DM, Hausenloy DJ. Myocardial reperfusion injury[J]. N Engl J Med, 2007, 357(11): 1121-1135.
17	Mangold A, Alias S, Scherz T, et al. Coronary neutrophil extracellular trap burden and deoxyribonuclease activity in ST-elevation acute coronary syndrome are predictors of ST-segment resolution and infarct size[J]. Circ Res, 2015, 116(7): 1182-1192.
18	Lombardo A, Niccoli G, Natale L, et al. Impact of microvascular obstruction and infarct size on left ventricular remodeling in reperfused myocardial infarction: a contrast-enhanced cardiac magnetic resonance imaging study[J]. Int J Cardiovasc Imaging, 2012, 28(4): 835-842.
19	Mori H, Isobe S, Sakai S, et al. Microvascular obstruction on delayed enhancement cardiac magnetic resonance imaging after acute myocardial infarction, compared with myocardial (201)Tl and (123)I-BMIPP dual SPECT findings[J]. Eur J Radiol, 2015, 84(8): 1516-1524.
20	Wong DT, Leung MC, Richardson JD, et al. Cardiac magnetic resonance derived late microvascular obstruction assessment post ST-segment elevation myocardial infarction is the best predictor of left ventricular function: a comparison of angiographic and cardiac magnetic resonance derived measurements[J]. Int J Cardiovasc Imaging, 2012, 28(8): 1971-1981.
21	Roger VL. Epidemiology of heart failure[J]. Circ Res, 2013, 113(6): 646-659.
22	Durante A, Laricchia A, Benedetti G, et al. Identification of high-risk patients after ST-segment-elevation myocardial infarction: comparison between angiographic and magnetic resonance parameters[J]. Circ Cardiovasc Imaging, 2017, 10(6): e005841.
23	Zhang L, Mandry D, Chen B, et al. Impact of microvascular obstruction on left ventricular local remodeling after reperfused myocardial infarction[J]. J Magn Reson Imaging, 2018, 47(2): 499-510.
24	Ørn S, Manhenke C, Greve OJ, et al. Microvascular obstruction is a major determinant of infarct healing and subsequent left ventricular remodelling following primary percutaneous coronary intervention[J]. Eur Heart J, 2009, 30(16): 1978-1985.
25	Borlaug BA, Lam CS, Roger VL, et al. Contractility and ventricular systolic stiffening in hypertensive heart disease insights into the pathogenesis of heart failure with preserved ejection fraction[J]. J Am Coll Cardiol, 2009, 54(5): 410-418.

Characteristic	MVO (+) group (N=82)	MVO (-) group (N=42)	P value
Age/year	58.6±7.9	58.7±8.4	0.958
Gender/n (%)			0.098
Male	76 (92.7)	34 (81.0)
Female	6 (7.3)	8 (19.0)
Smoking history/n (%)	65 (79.3)	30 (71.4)	0.329
Drinking history/n (%)	22 (26.8)	13 (31.0)	0.629
Hypertension/n (%)	48 (58.5)	19 (45.2)	0.160
Diabetes mellitus/n (%)	30 (36.6)	12 (28.6)	0.372
Hypercholesterolemia/n (%)	46 (56.1)	19 (45.2)	0.252
Previous angina/n (%)	42 (51.2)	25 (59.5)	0.380
Renal dysfunction/n (%)	3 (3.7)	0 (0)	0.524
Previous stroke/n (%)	0 (0)	1 (2.4)	0.732
Pain-to-balloon time/h	5.5±3.2	4.9±1.6	0.166
Reperfusion therapy/n (%)			1.000
PPCI	41 (50.0)	21 (50.0)
PCI after thrombolysis	41 (50.0)	21 (50.0)
Culprit vessel/n (%)			0.398
LAD	47 (57.3)	25 (59.5)
LCX	10 (12.2)	2 (4.8)
RCA	25 (30.5)	15 (35.7)
Killip class/n (%)			1.000
Ⅰ	74 (90.2)	38 (90.5)
Ⅱ	7 (8.5)	3 (7.1)
Ⅲ	1 (1.2)	1 (2.4)
Time delay from the onset of chest pain to CMR/d	5.2±2.2	5.3±1.8	0.863

Characteristic	MVO (+) group (N=82)	MVO (-) group (N=42)	P value
Age/year	58.6±7.9	58.7±8.4	0.958
Gender/n (%)			0.098
Male	76 (92.7)	34 (81.0)
Female	6 (7.3)	8 (19.0)
Smoking history/n (%)	65 (79.3)	30 (71.4)	0.329
Drinking history/n (%)	22 (26.8)	13 (31.0)	0.629
Hypertension/n (%)	48 (58.5)	19 (45.2)	0.160
Diabetes mellitus/n (%)	30 (36.6)	12 (28.6)	0.372
Hypercholesterolemia/n (%)	46 (56.1)	19 (45.2)	0.252
Previous angina/n (%)	42 (51.2)	25 (59.5)	0.380
Renal dysfunction/n (%)	3 (3.7)	0 (0)	0.524
Previous stroke/n (%)	0 (0)	1 (2.4)	0.732
Pain-to-balloon time/h	5.5±3.2	4.9±1.6	0.166
Reperfusion therapy/n (%)			1.000
PPCI	41 (50.0)	21 (50.0)
PCI after thrombolysis	41 (50.0)	21 (50.0)
Culprit vessel/n (%)			0.398
LAD	47 (57.3)	25 (59.5)
LCX	10 (12.2)	2 (4.8)
RCA	25 (30.5)	15 (35.7)
Killip class/n (%)			1.000
Ⅰ	74 (90.2)	38 (90.5)
Ⅱ	7 (8.5)	3 (7.1)
Ⅲ	1 (1.2)	1 (2.4)
Time delay from the onset of chest pain to CMR/d	5.2±2.2	5.3±1.8	0.863

Index	MVO (+) group (N=82)	MVO (-) group (N=42)	P value
Blood biochemical index
CRP/(mg·L^-1)	5.92 (1.52, 22.03)	3.95 (2.42, 12.53)	0.720
WBC/(×10⁹·L^-1)	11.95 (10.01, 13.95)	10.21 (7.92, 12.85)	0.016
Hb/(g·L^-1)	145.23±16.16	140.31±14.37	0.109
PLT/(×10⁹·L^-1)	195.85±48.77	211.36±49.15	0.097
FBG/(g·L^-1)	2.81±0.71	2.88±0.58	0.588
PT/s	10.70 (10.00, 11.83)	10.60 (10.10, 11.70)	0.755
APTT/s	32.10 (28.70, 36.30)	33.65 (29.15, 36.18)	0.748
INR	0.94 (0.88, 0.99)	0.93 (0.88, 1.01)	0.919
Scr/(μmol·L^-1)	71.70±19.35	70.11±14.27	0.640
BUN/(mmol·L^-1)	5.60±1.65	5.32±1.76	0.375
Glu/(mmol·L^-1)	5.72 (5.09, 6.61)	5.29 (4.80, 6.16)	0.093
TAG/(mmol·L^-1)	1.37 (0.96, 2.51)	1.31 (0.95, 1.63)	0.240
TC/(mmol·L^-1)	5.21±1.10	4.77±1.05	0.039
HDL-Ch/(mmol·L^-1)	1.17±0.26	1.16±0.27	0.920
LDL-Ch/(mmol·L^-1)	3.21±0.86	3.09±0.88	0.450
CPK/(U·L^-1)	3 632.00 (2 547.00, 5 151.25)	1 565.00 (1 074.50, 3 228.00)	0.000
CK-MB/(U·L^-1)	370.75 (241.43, 480.45)	201.60 (120.95, 288.25)	0.000
cTnI/(ng·mL^-1)	26.34 (1.54, 80.85)	10.33 (0.93, 28.40)	0.022
BNP/(pg·mL^-1)	101.50 (37.95, 275.00)	93.80 (17.38, 203.00)	0.202
CMR index
LVEF/%	47.07±8.94	53.95±5.79	0.000
Percentage of myocardial infarction/%	23.09 (17.41, 30.46)	11.25 (6.40, 18.14)	0.000

Index	MVO (+) group (N=82)	MVO (-) group (N=42)	P value
Blood biochemical index
CRP/(mg·L^-1)	5.92 (1.52, 22.03)	3.95 (2.42, 12.53)	0.720
WBC/(×10⁹·L^-1)	11.95 (10.01, 13.95)	10.21 (7.92, 12.85)	0.016
Hb/(g·L^-1)	145.23±16.16	140.31±14.37	0.109
PLT/(×10⁹·L^-1)	195.85±48.77	211.36±49.15	0.097
FBG/(g·L^-1)	2.81±0.71	2.88±0.58	0.588
PT/s	10.70 (10.00, 11.83)	10.60 (10.10, 11.70)	0.755
APTT/s	32.10 (28.70, 36.30)	33.65 (29.15, 36.18)	0.748
INR	0.94 (0.88, 0.99)	0.93 (0.88, 1.01)	0.919
Scr/(μmol·L^-1)	71.70±19.35	70.11±14.27	0.640
BUN/(mmol·L^-1)	5.60±1.65	5.32±1.76	0.375
Glu/(mmol·L^-1)	5.72 (5.09, 6.61)	5.29 (4.80, 6.16)	0.093
TAG/(mmol·L^-1)	1.37 (0.96, 2.51)	1.31 (0.95, 1.63)	0.240
TC/(mmol·L^-1)	5.21±1.10	4.77±1.05	0.039
HDL-Ch/(mmol·L^-1)	1.17±0.26	1.16±0.27	0.920
LDL-Ch/(mmol·L^-1)	3.21±0.86	3.09±0.88	0.450
CPK/(U·L^-1)	3 632.00 (2 547.00, 5 151.25)	1 565.00 (1 074.50, 3 228.00)	0.000
CK-MB/(U·L^-1)	370.75 (241.43, 480.45)	201.60 (120.95, 288.25)	0.000
cTnI/(ng·mL^-1)	26.34 (1.54, 80.85)	10.33 (0.93, 28.40)	0.022
BNP/(pg·mL^-1)	101.50 (37.95, 275.00)	93.80 (17.38, 203.00)	0.202
CMR index
LVEF/%	47.07±8.94	53.95±5.79	0.000
Percentage of myocardial infarction/%	23.09 (17.41, 30.46)	11.25 (6.40, 18.14)	0.000

Adverse event	MVO (+) group (N=82)	MVO (-) group (N=42)	P value
All-cause mortality/n (%)	1 (1.2)	0 (0)	1.000
Myocardial reinfarction/n (%)	2 (2.4)	0 (0)	0.548
Recurrent angina/n (%)	8 (9.8)	3 (7.1)	0.880
Heart failure/n (%)	14 (17.1)	1 (2.4)	0.018