无糖尿病病史患者胰岛素抵抗水平与急性ST段抬高型心肌梗死后左室重构的相关性

doi:10.3969/j.issn.1674-8115.2025.03.005

上海交通大学学报（医学版） ›› 2025, Vol. 45 ›› Issue (3): 292-300.doi: 10.3969/j.issn.1674-8115.2025.03.005

无糖尿病病史患者胰岛素抵抗水平与急性ST段抬高型心肌梗死后左室重构的相关性

杨晨蝶¹(), 胡长青²(), 袁贺³, TAY Guan Poh³, 阿布力克木·阿木提³, 张瑞岩¹, 王晓群¹^,³()

^1.上海交通大学医学院附属瑞金医院心内科，上海 200025
^2.山西省人民医院心内科，太原 030012
^3.上海交通大学医学院心血管病研究所，上海 200025

收稿日期:2024-08-26 接受日期:2024-11-04 出版日期:2025-03-28 发布日期:2025-03-18
通讯作者: 王晓群，副教授，副主任医师，副研究员，博士；电子信箱：wangxq@shsmu.edu.cn。
作者简介:杨晨蝶（1989—），女，主治医师，博士；电子信箱：yangcd1029@163.com
胡长青（1982—），男，副主任医师，硕士；电子信箱：690068686@qq.com
基金资助:
国家重点研发计划(2022YFC2503502);国家自然科学基金(82170423);上海交通大学医学院高峰学科-临床医学“研究型医师”(20240801);国家转化医学中心（上海）开放课题项目(NRCTM(SH)-2023-13);上海交通大学医学院附属瑞金医院广慈-金光创新技术启航计划

Association between insulin resistance and left ventricular remodeling after STEMI in patients without a history of diabetes mellitus

YANG Chendie¹(), HU Changqing²(), YUAN He³, TAY Guan Poh³, AMUTI Abulikemu³, ZHANG Ruiyan¹, WANG Xiaoqun¹^,³()

^1.Department of Cardiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025
^2.Department of Cardiology, Shanxi Provincial People's Hospital, Taiyuan 030012
^3.Institute of Cardiovascular Disease, Shanghai Jiao Tong University School of Medicine, Shanghai 200025

Received:2024-08-26 Accepted:2024-11-04 Online:2025-03-28 Published:2025-03-18
Contact: WANG Xiaoqun, E-mail: wangxq@shsmu.edu.cn.
Supported by:
National Key Research and Development Program of China(2022YFC2503502);National Natural Science Foundation of China(82170423);Shanghai Jiao Tong University School of Medicine-Gaofeng Clinical Medicine Grant Support(20240801);Opening Project Program of the National Research Center for Translational Medicine at Shanghai(NRCTM(SH)-2023-13);Guangci Innovative Technology Sailing Plan of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine

摘要/Abstract

摘要：

目的·探索无糖尿病病史患者胰岛素抵抗水平与ST段抬高型心肌梗死（ST-segment elevation myocardial infarction，STEMI）后左室重构的相关性。方法·连续入组自2014年1月—2022年12月收治于上海交通大学医学院附属瑞金医院心内科因STEMI行急诊经皮冠状动脉介入治疗的无糖尿病病史患者，随访6个月。收集患者的年龄、性别、吸烟情况、体格检查（血压、体质量指数等）、生化指标（肝肾功能、血脂、血糖、心肌肌钙蛋白峰值等）、用药情况等资料。采用稳态模型评估胰岛素抵抗指数（homeostasis model assessment of insulin resistance，HOMA-IR）作为反映胰岛素抵抗水平的指标。根据随访期间测定的平均HOMA-IR的四分位数，将患者分为4组：低水平组、中低水平组、中高水平组、高水平组。分别于基线和随访结束时行超声心动图检查，分析胰岛素抵抗水平与STEMI后左室重构的相关性。结果·共纳入219例患者，平均年龄（62.7±11.9）岁，男性占85.4%（187例）。平均随访时间为（6.4±1.8）个月。随访期间平均测定HOMA-IR（4.32±2.18）次，HOMA-IR中位数为2.41（1.58，3.98），高于正常人群水平。随着HOMA-IR水平的升高，心肌梗死后的左室舒张末内径（P=0.027）及左室舒张末容积指数（P=0.013）从整体上呈扩张趋势。Pearson相关性分析显示，随访期间的平均HOMA-IR水平（log变换后）与左室舒张末容积指数变化值（r=0.20，P=0.003）和左室舒张末内径变化值（r=0.21，P=0.002）呈正相关。多元回归分析进一步表明，在校正了年龄、性别、传统危险因素（高血压病史、体质量指数、吸烟史、肾功能、血脂等）、药物治疗情况及基线左室射血分数和心肌肌钙蛋白峰值后，高水平HOMA-IR仍然是STEMI后左室重构的独立危险因素。与低水平HOMA-IR组相比，高水平组患者的左室舒张末容积指数增加7.727 mL/m²（P<0.001）。结论·无糖尿病病史的STEMI患者普遍存在胰岛素抵抗，且胰岛素抵抗水平是心肌梗死后左室不良重构的独立预测因子。

关键词: 胰岛素抵抗, 心肌梗死, 左室扩张, 重构

Abstract:

Objective ·To investigate the association of insulin resistance with left ventricular (LV) remodeling after ST-segment elevation myocardial infarction (STEMI) in patients without a history of diabetes mellitus. Methods ·This study consecutively enrolled STEMI patients without a history of diabetes mellitus who underwent percutaneous coronary intervention in the Department of Cardiology of Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, from January 2014 to December 2022. The patients were followed up for 6 months. Age, gender, smoking status, blood pressure, body mass index, biochemical indexes (liver function, kidney function, lipid profiles, glycemic levels and peak troponin levels, etc.) and pharmacological treatment were recorded. Homeostasis model assessment of insulin resistance (HOMA-IR) was used to evaluate insulin resistance and mean values of visit-to-visit HOMA-IR were calculated. Patients were divided into 4 groups (low-level group, low-to-medium-level group, medium-to-high-level group, and high-level group) according to the quartiles of mean HOMA-IR levels. Echocardiography was performed at baseline and during follow-up. Then the association between mean values of insulin resistance and post-infarction LV remodeling was analyzed. Results ·A total of 219 patients were finally included, with an average age of (62.7±11.9) years, and male patients accounted for 85.4% (187 cases). The average follow-up time was (6.4±1.8) months. During follow-up, the average number of HOMA-IR measurements was (4.32±2.18), and the mean value of visit-to-visit HOMA-IR was 2.41 (1.58, 3.98), which was higher than normal range. The results showed that post-infarction LV end-diastolic diameter (P=0.027) and LV end-diastolic volume index (P=0.013) generally showed a trend for dilation with increasing mean HOMA-IR levels. Pearson correlation analysis revealed the mean values of visit-to-visit HOMA-IR were positively correlated to changes in LV dimensions (Δ LV end-diastolic volume index: r=0.20, P=0.003; Δ LV end-diastolic diameter: r=0.21, P=0.002). Multivariate regression analysis demonstrated that higher HOMA-IR was independently associated with greater LV dilation after STEMI, even after adjusting for age, gender, traditional risk factors (history of hypertension, body mass index, smoking status, renal function and lipid profiles), pharmacological treatment, baseline LV ejection fraction and peak troponin levels. Compared with patients with the lowest quartile of HOMA-IR, those with the highest HOMA-IR quartile exhibited a 7.727 mL/m² increase in LV end-diastolic volume index (P<0.001). Conclusion ·This study reveals that insulin resistance is prevalent in STEMI patients without a history of diabetes mellitus. Insulin resistance is an independent predictor of adverse LV remodeling in this population.

Key words: insulin resistance, myocardial infarction, left ventricular dilation, remodeling

中图分类号:

R543.3

杨晨蝶, 胡长青, 袁贺, TAY Guan Poh, 阿布力克木·阿木提, 张瑞岩, 王晓群. 无糖尿病病史患者胰岛素抵抗水平与急性ST段抬高型心肌梗死后左室重构的相关性[J]. 上海交通大学学报（医学版）, 2025, 45(3): 292-300.

YANG Chendie, HU Changqing, YUAN He, TAY Guan Poh, AMUTI Abulikemu, ZHANG Ruiyan, WANG Xiaoqun. Association between insulin resistance and left ventricular remodeling after STEMI in patients without a history of diabetes mellitus[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2025, 45(3): 292-300.

图/表 6

参考文献 24

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Item	Mean HOMA-IR level				P value
Item	Low (≤1.58) (n=55)	Low-medium (>1.58 and ≤2.41) (n=56)	Medium-high (>2.41 and ≤3.98) (n=54)	High (>3.98) (n=54)	P value
Demographic characteristics and clinical assessment
Gender (male)/n (%)	48 (87.3)	46 (82.1)	47 (87.0)	46 (85.2)	0.862
Age/year	63.40±12.28	66.04±10.56	60.39±10.45	60.70±13.47	0.042
Hypertension/%	27 (49.1)	25 (44.6)	28 (51.9)	39 (72.2)	0.020
Current smoker/%	27 (49.1)	22 (39.3)	27 (50.0)	30 (55.6)	0.386
BMI/(kg·m^-2)	23.24±3.48	23.67±3.27	25.80±2.74	27.27±6.61	<0.001
Systolic blood pressure/mmHg	121.89±22.83	121.36±16.63	121.72±20.59	127.48±17.38	0.305
Diastolic blood pressure/mmHg	73.78±13.63	76.68±12.50	74.61±14.66	77.39±13.11	0.460
Laboratory measurement
HbA1c/%	5.61±0.32	5.66±0.38	5.87±0.84	6.19±1.22	0.001
Fasting glucose/(mmol·L^-1)	5.60 (4.96‒7.53)	6.68 (5.34‒8.48)	5.84 (4.78‒7.50)	6.54 (5.62‒9.00)	0.073
2 h Postprandial blood glucose/(mmol·L^-1)	8.61 (7.46‒12.40)	8.72 (7.37‒10.40)	8.30 (7.01‒10.59)	8.61 (7.46‒12.40)	0.587
Fasting insulin/(μIU·mL^-1)	6.69(5.02‒9.12)	9.27 (7.22‒12.45)	14.29 (11.31‒17.47)	16.67 (12.83‒21.80)	<0.001
Alanine transaminase/(IU·L^-1)	34.80±26.54	42.71±39.29	37.28±22.18	46.44±31.00	0.188
Triglyceride/(mmol·L^-1)	1.08 (0.77‒1.60)	1.43 (1.00‒1.80)	1.82 (1.31‒2.41)	1.90 (1.35‒2.45)	<0.001
Total cholesterol/(mmol·L^-1)	4.68±1.39	4.60±1.29	4.77±1.05	4.86±1.05	0.700
LDL-C/(mmol·L^-1)	3.04±1.36	2.91±1.01	3.01±1.00	3.01±0.85	0.928
HDL-C/(mmol·L^-1)	1.14±0.28	1.09±0.24	1.03±0.20	1.02±0.20	0.030
Serum creatine/(μmol·L^-1)	79.42±17.26	82.36±16.11	84.83±22.32	84.24±25.95	0.521
Blood urea nitrogen/(mmol·L^-1)	5.81±1.58	5.74±1.52	5.52±1.63	5.61±1.60	0.775
eGFR/[mL·min^-1·(1.732 m)^-2]	97.50±21.38	91.00±12.33	98.45±25.65	97.94±22.95	0.208
NT-proBNP/(pg·mL^-1)	355.50 (148.40‒1 525.00)	493.25 (192.78‒1 364.50)	602.15 (135.18‒1 861.00)	253.20 (110.62‒1 069.00)	0.285
Peak cTnI level/(ng·mL^-1)	41.20 (5.47‒87.67)	54.70 (15.42‒104.85)	44.64 (9.69‒110.19)	31.40 (25.61‒95.52)	0.389
Medication use
Aspirin/n (%)	50 (90.9)	56 (100.0)	54 (100.0)	51 (94.4)	0.025
P2Y12 inhibitor/n (%)	55 (100.0)	52 (92.9)	54 (100.0)	50 (92.6)	0.041
β blocker/n (%)	53 (96.4)	40 (71.4)	47 (87.0)	50 (92.6)	0.001
ACEI/ARB/n (%)	36 (65.5)	39 (69.6)	39 (72.2)	47 (87.0)	0.061
ARNI/n (%)	15 (27.3)	12 (21.4)	16 (29.6)	17 (31.5)	0.661
SGLT2 inhibitor/n (%)	2 (3.6)	2 (3.6)	2 (3.7)	7 (13.0)	0.096
MRA/n (%)	4 (7.3)	6 (10.7)	7 (13.0)	6 (11.1)	0.806
Diuretics/n (%)	1 (1.8)	6 (10.7)	7 (13.0)	4 (7.4)	0.164

Item	Mean HOMA-IR level				P value
Item	Low (≤1.58) (n=55)	Low-medium (>1.58 and ≤2.41) (n=56)	Medium-high (>2.41 and ≤3.98) (n=54)	High (>3.98) (n=54)	P value
Demographic characteristics and clinical assessment
Gender (male)/n (%)	48 (87.3)	46 (82.1)	47 (87.0)	46 (85.2)	0.862
Age/year	63.40±12.28	66.04±10.56	60.39±10.45	60.70±13.47	0.042
Hypertension/%	27 (49.1)	25 (44.6)	28 (51.9)	39 (72.2)	0.020
Current smoker/%	27 (49.1)	22 (39.3)	27 (50.0)	30 (55.6)	0.386
BMI/(kg·m^-2)	23.24±3.48	23.67±3.27	25.80±2.74	27.27±6.61	<0.001
Systolic blood pressure/mmHg	121.89±22.83	121.36±16.63	121.72±20.59	127.48±17.38	0.305
Diastolic blood pressure/mmHg	73.78±13.63	76.68±12.50	74.61±14.66	77.39±13.11	0.460
Laboratory measurement
HbA1c/%	5.61±0.32	5.66±0.38	5.87±0.84	6.19±1.22	0.001
Fasting glucose/(mmol·L^-1)	5.60 (4.96‒7.53)	6.68 (5.34‒8.48)	5.84 (4.78‒7.50)	6.54 (5.62‒9.00)	0.073
2 h Postprandial blood glucose/(mmol·L^-1)	8.61 (7.46‒12.40)	8.72 (7.37‒10.40)	8.30 (7.01‒10.59)	8.61 (7.46‒12.40)	0.587
Fasting insulin/(μIU·mL^-1)	6.69(5.02‒9.12)	9.27 (7.22‒12.45)	14.29 (11.31‒17.47)	16.67 (12.83‒21.80)	<0.001
Alanine transaminase/(IU·L^-1)	34.80±26.54	42.71±39.29	37.28±22.18	46.44±31.00	0.188
Triglyceride/(mmol·L^-1)	1.08 (0.77‒1.60)	1.43 (1.00‒1.80)	1.82 (1.31‒2.41)	1.90 (1.35‒2.45)	<0.001
Total cholesterol/(mmol·L^-1)	4.68±1.39	4.60±1.29	4.77±1.05	4.86±1.05	0.700
LDL-C/(mmol·L^-1)	3.04±1.36	2.91±1.01	3.01±1.00	3.01±0.85	0.928
HDL-C/(mmol·L^-1)	1.14±0.28	1.09±0.24	1.03±0.20	1.02±0.20	0.030
Serum creatine/(μmol·L^-1)	79.42±17.26	82.36±16.11	84.83±22.32	84.24±25.95	0.521
Blood urea nitrogen/(mmol·L^-1)	5.81±1.58	5.74±1.52	5.52±1.63	5.61±1.60	0.775
eGFR/[mL·min^-1·(1.732 m)^-2]	97.50±21.38	91.00±12.33	98.45±25.65	97.94±22.95	0.208
NT-proBNP/(pg·mL^-1)	355.50 (148.40‒1 525.00)	493.25 (192.78‒1 364.50)	602.15 (135.18‒1 861.00)	253.20 (110.62‒1 069.00)	0.285
Peak cTnI level/(ng·mL^-1)	41.20 (5.47‒87.67)	54.70 (15.42‒104.85)	44.64 (9.69‒110.19)	31.40 (25.61‒95.52)	0.389
Medication use
Aspirin/n (%)	50 (90.9)	56 (100.0)	54 (100.0)	51 (94.4)	0.025
P2Y12 inhibitor/n (%)	55 (100.0)	52 (92.9)	54 (100.0)	50 (92.6)	0.041
β blocker/n (%)	53 (96.4)	40 (71.4)	47 (87.0)	50 (92.6)	0.001
ACEI/ARB/n (%)	36 (65.5)	39 (69.6)	39 (72.2)	47 (87.0)	0.061
ARNI/n (%)	15 (27.3)	12 (21.4)	16 (29.6)	17 (31.5)	0.661
SGLT2 inhibitor/n (%)	2 (3.6)	2 (3.6)	2 (3.7)	7 (13.0)	0.096
MRA/n (%)	4 (7.3)	6 (10.7)	7 (13.0)	6 (11.1)	0.806
Diuretics/n (%)	1 (1.8)	6 (10.7)	7 (13.0)	4 (7.4)	0.164

Item	Mean HOMA-IR level				P value
Item	Low(≤1.58)	Low-medium (>1.58 and ≤2.41)	Medium-high (>2.41 and ≤3.98)	High (>3.98)	P value
LVEDV index/(mL·m^-2)
Baseline	71.41±20.42	68.22±15.72	73.52±18.68	63.09±11.13	0.009
Follow-up	68.69±21.54	69.11±16.91	71.99±14.54	66.85±12.42	0.455
Δ	-2.73±12.30	0.88±9.58	-1.52±12.01	3.77±9.93	0.013
LVESV index/(mL·m^-2)
Baseline	30.01±15.62	27.96±12.03	31.20±14.04	24.48±6.23	0.032
Follow-up	28.45±16.11	28.33±12.47	28.74±10.16	25.67±8.75	0.528
Δ	-1.56±6.22	0.37±5.87	-2.46±9.57	1.19±8.10	0.047
LVEDD/mm
Baseline	50.56±6.50	49.84±6.06	52.46±5.45	49.87±4.01	0.051
Follow-up	49.76±6.99	50.00±5.93	52.07±4.41	50.91±4.13	0.118
Δ	-0.80±3.46	0.16±3.03	-0.39±3.49	1.04±3.31	0.027
LVESD/mm
Baseline	34.44±7.14	33.88±6.55	35.91±6.33	33.39±4.15	0.168
Follow-up	33.64±7.40	33.91±6.31	35.00±4.67	33.72±4.64	0.599
Δ	-0.80±2.59	0.04±2.91	-0.91±3.67	0.33±4.11	0.147
IVST/mm
Baseline	9.36±1.01	9.32±1.16	9.93±1.53	9.46±1.30	0.050
Follow-up	9.33±1.02	9.11±1.14	9.54±1.22	9.46±1.19	0.216
Δ	-0.04±0.90	-0.21±0.99	-0.39±1.17	0±1.17	0.204
LVPWT/mm
Baseline	8.93±0.63	8.66±0.84	9.33±0.95	9.00±1.18	0.002
Follow-up	8.87±0.75	8.79±0.85	9.13±0.97	8.91±0.96	0.216
Δ	-0.05±0.65	0.12±0.72	-0.20±0.88	-0.09±1.15	0.255
LVMI/(g·mm^-2)
Baseline	96.11±24.27	90.16±18.38	103.38±28.52	86.74±18.06	0.001
Follow-up	92.94±24.73	90.57±21.50	97.43±22.24	89.89±20.66	0.288
Δ	-3.17±15.22	0.42±12.82	-5.95±14.79	3.15±15.28	0.008
LVEF/%
Baseline	57.85±8.97	58.20±8.85	56.69±9.80	59.31±8.09	0.500
Follow-up	58.44±9.98	57.91±9.55	58.33±8.33	60.24±7.33	0.531
Δ	0.58±4.89	-0.29±4.77	1.65±3.89	0.93±7.08	0.285

Item	Mean HOMA-IR level				P value
Item	Low(≤1.58)	Low-medium (>1.58 and ≤2.41)	Medium-high (>2.41 and ≤3.98)	High (>3.98)	P value
LVEDV index/(mL·m^-2)
Baseline	71.41±20.42	68.22±15.72	73.52±18.68	63.09±11.13	0.009
Follow-up	68.69±21.54	69.11±16.91	71.99±14.54	66.85±12.42	0.455
Δ	-2.73±12.30	0.88±9.58	-1.52±12.01	3.77±9.93	0.013
LVESV index/(mL·m^-2)
Baseline	30.01±15.62	27.96±12.03	31.20±14.04	24.48±6.23	0.032
Follow-up	28.45±16.11	28.33±12.47	28.74±10.16	25.67±8.75	0.528
Δ	-1.56±6.22	0.37±5.87	-2.46±9.57	1.19±8.10	0.047
LVEDD/mm
Baseline	50.56±6.50	49.84±6.06	52.46±5.45	49.87±4.01	0.051
Follow-up	49.76±6.99	50.00±5.93	52.07±4.41	50.91±4.13	0.118
Δ	-0.80±3.46	0.16±3.03	-0.39±3.49	1.04±3.31	0.027
LVESD/mm
Baseline	34.44±7.14	33.88±6.55	35.91±6.33	33.39±4.15	0.168
Follow-up	33.64±7.40	33.91±6.31	35.00±4.67	33.72±4.64	0.599
Δ	-0.80±2.59	0.04±2.91	-0.91±3.67	0.33±4.11	0.147
IVST/mm
Baseline	9.36±1.01	9.32±1.16	9.93±1.53	9.46±1.30	0.050
Follow-up	9.33±1.02	9.11±1.14	9.54±1.22	9.46±1.19	0.216
Δ	-0.04±0.90	-0.21±0.99	-0.39±1.17	0±1.17	0.204
LVPWT/mm
Baseline	8.93±0.63	8.66±0.84	9.33±0.95	9.00±1.18	0.002
Follow-up	8.87±0.75	8.79±0.85	9.13±0.97	8.91±0.96	0.216
Δ	-0.05±0.65	0.12±0.72	-0.20±0.88	-0.09±1.15	0.255
LVMI/(g·mm^-2)
Baseline	96.11±24.27	90.16±18.38	103.38±28.52	86.74±18.06	0.001
Follow-up	92.94±24.73	90.57±21.50	97.43±22.24	89.89±20.66	0.288
Δ	-3.17±15.22	0.42±12.82	-5.95±14.79	3.15±15.28	0.008
LVEF/%
Baseline	57.85±8.97	58.20±8.85	56.69±9.80	59.31±8.09	0.500
Follow-up	58.44±9.98	57.91±9.55	58.33±8.33	60.24±7.33	0.531
Δ	0.58±4.89	-0.29±4.77	1.65±3.89	0.93±7.08	0.285

Mean HOMA-IR level	Model 1	Model 2	Model 3	Model 4	Model 5
Low (≤1.58)	Reference	Reference	Reference	Reference	Reference
Low-medium (>1.58 and ≤2.41)
Coefficient (95%CI)	3.608 (-0.515‒7.730)	3.506 (-0.645‒7.657)	4.036 (-0.206‒8.279)	5.541 (1.169‒9.914)	3.036 (-1.373‒7.445)
Standardized β	0.141	0.137	0.157	0.216	0.118
P value	0.086	0.097	0.062	0.013	0.176
Medium-high (>2.41 and ≤3.98)
Coefficient (95%CI)	1.201 (-2.959‒5.361)	1.199 (-2.990‒5.388)	1.918 (-2.434‒6.270)	2.386 (-1.915‒6.688)	2.674 (-1.492‒6.839)
Standardized β	0.046	0.046	0.074	0.092	0.103
P value	0.570	0.573	0.386	0.275	0.207
High (>3.98)
Coefficient (95%CI)	6.492 (2.332‒10.652)	6.453 (2.266‒10.641)	7.348 (2.786‒11.910)	8.028 (3.530‒12.526)	7.727 (3.317‒12.136)
Standardized β	0.250	0.248	0.283	0.309	0.298
P value	0.002	0.003	0.002	<0.001	<0.001

无糖尿病病史患者胰岛素抵抗水平与急性ST段抬高型心肌梗死后左室重构的相关性

Association between insulin resistance and left ventricular remodeling after STEMI in patients without a history of diabetes mellitus

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