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

上海交通大学学报(医学版) ›› 2021, Vol. 41 ›› Issue (2): 173-179.doi: 10.3969/j.issn.1674-8115.2021.02.008

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

胡培堃(), 何杰, 吴连明, 葛恒, 许建荣, 卜军()

上海交通大学医学院附属仁济医院心内科，上海 200127

收稿日期:2020-06-01 出版日期:2021-02-28 发布日期:2021-02-28
通讯作者: 卜军 E-mail:hupei-kun@foxmail.com;pujun310@hotmail.com
作者简介:胡培堃（1993—），男，住院医师，博士生；电子信箱：hupei-kun@foxmail.com。
基金资助:
国家杰出青年科学基金(81625002);上海市优秀学术带头人计划(18XD1402400);上海交通大学医学院高水平地方高校创新团队(SSMU-ZDCX20180200);上海申康医院发展中心促进市级医院临床技能与临床创新三年行动计划(16CR3034A);上海市教育委员会高峰高原学科建设计划(20152209)

Effect of microvascular obstruction on left ventricle function and prognosis in patients with ST-segment elevation myocardial infarction

Pei-kun HU(), Jie HE, Lian-ming WU, Heng GE, Jian-rong XU, Jun PU()

Department of Cardiology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China

Received:2020-06-01 Online:2021-02-28 Published:2021-02-28
Contact: Jun PU E-mail:hupei-kun@foxmail.com;pujun310@hotmail.com
Supported by:
National Science Fund for Distinguished Young Scholars(81625002);Shanghai Outstanding Academic Leaders Program(18XD1402400);Innovative Research Team of High-Level Local Universities in Shanghai(SSMU-ZDCX20180200);Clinical Research Plan of Shanghai Hospital Development Center(16CR3034A);Shanghai Municipal Education Commission—Gaofeng Clinical Medicine Grant Support(20152209)

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

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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

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

Effect of microvascular obstruction on left ventricle function and prognosis in patients with ST-segment elevation myocardial infarction

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参考文献 25

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Metrics

Index	AUC	95%CI	Youden index	Cut-off value	Sensitivity/%	Specificity/%	P value
Percentage of myocardial MVO size	0.899	0.823?0.975	0.730	2.99	83.3	89.7	0.000
Percentage of myocardial infarction size	0.785	0.660?0.911	0.512	29.70	66.7	84.5	0.000

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