本文選題：急性心肌梗死 + 谷胱甘肽��； 參考：《成都醫(yī)學(xué)院》2017年碩士論文

【摘要】：目的通過測定急性ST段抬高性心肌梗死患者接受急診冠脈介入治療24h前后血漿中MDA、SOD及GSH氧化還原態(tài)的變化,探究不同分組下的STEMI患者氧化應(yīng)激狀態(tài)的改變,并初步探討血漿GSH氧化還原態(tài)與急性心肌梗死患者預(yù)后之間的關(guān)系。方法(1)選取2015年1月至2016年8月于成都醫(yī)學(xué)院第一附屬醫(yī)院心血管內(nèi)科就診的首次發(fā)病12小時以內(nèi)并接受經(jīng)皮冠狀動脈介入治療(percutaneous coronary intervention,PCI)且成功開通罪犯血管的急性ST段抬高性心肌梗死患者,共計93例。經(jīng)皮冠狀動脈介入治療使用常規(guī)技術(shù)標(biāo)準(zhǔn)執(zhí)行,并除外癌癥、慢性炎癥以及其他在24小時內(nèi)發(fā)生的全身感染。入院后參照中華醫(yī)學(xué)會心血管病學(xué)分會等制訂的《急性心肌梗死診斷和治療指南》對患者進(jìn)行規(guī)范化治療,主要措施包括經(jīng)皮冠狀動脈支架植入術(shù)以及術(shù)后抗凝、抗血小板治療、糾正心律失常、心力衰竭以及對癥支持治療等。(2)術(shù)前和術(shù)后24h分別抽取患者肘靜脈血5ml。采用酶聯(lián)免疫吸附法檢測血漿MDA,SOD含量,采用酶標(biāo)微板法檢測血漿中GSH、GSSG含量,并計算GSH/GSSG比值以及GSH/GSSG氧化還原電勢Eh(GSH/GSSG)。(3)按照患者心梗部位分不同為前壁組和非前壁組,按照血管狹窄數(shù)目不同分為單只病變組、雙支病變組和三支病變組,比較組間患者血漿氧化應(yīng)激水平和GSH氧化還原態(tài)的差異。(4)對93例患者連續(xù)隨訪180天,按照是否發(fā)生心血管不良事件(MACE事件)分為無MACE組72例和MACE組21例。比較兩組患者血漿GSH氧化還原態(tài)的差異。(5)初步評價Eh(GSH/GSSG)對心肌梗死患者近期預(yù)后的診斷價值。探究并尋找心肌梗死患者PCI術(shù)后發(fā)生MACE事件的獨(dú)立危險因素。結(jié)果(1)與PCI術(shù)前相比,PCI術(shù)后24h,血漿MDA水平增加(p0.05)、SOD水平降低(p0.05),GSH、GSH/GSSG水平降低(p0.05),GSSG水平無明顯差異(p0.05),Eh(GSH/GSSG)水平升高(p0.05)。(2)PCI術(shù)前,與非前壁組相比,前壁組血漿MDA、SOD水平無明顯差異(p0.05),GSSG、GSH/GSSG水平無明顯差異(p0.05),GSH水平較低(p0.05),Eh(GSH/GSSG)水平更高(p0.05)。PCI術(shù)后24h,與非前壁組相比,前壁組血漿MDA、SOD水平仍無明顯差異(p0.05),GSH、GSH/GSSG水平較低(p0.05),GSSG無明顯差異(p0.05),Eh(GSH/GSSG)仍然處于更高水平(p0.05)。PCI術(shù)前,單支病變組、雙支病變組和三支病變組兩兩對比,血漿GSH、GSSG、GSH/GSSG和Eh(GSH/GSSG)水平均無明顯差異(p0.05),PCI術(shù)后24h再次對比,血漿MDA、SOD無明顯差異(p0.05),GSH、GSSG、GSH/GSSG水平也無明顯差異(p0.05),但Eh(GSH/GSSG)水平差異顯著(p0.05),且隨病冠脈變數(shù)目的增加,Eh(GSH/GSSG)水平也相應(yīng)升高。(3)與無MACE組相比,MACE組術(shù)前血漿MDA、SOD、GSH、GSSG、GSH/GSSG和Eh(GSH/GSSG)水平均無明顯差異(p0.05)。PCI術(shù)后24h,MACE組較無MACE組GSSG水平仍無明顯差異(p0.05),而GSH、GSH/GSSG水平更低(p0.05),Eh(GSH/GSSG)水平更高(p0.05)。ROC曲線得到預(yù)測MACE事件Eh(GSH/GSSG)的最佳臨界值為-122.5m V,此時靈敏度71%,特異性76%。在Kaplan-Meier生存分析中,高危組與低危組相比,MACE發(fā)生率差異顯著(p0.05),30天內(nèi)的MACE發(fā)生率差異顯著(p0.05),30天后兩組MACE發(fā)生率無明顯差異(p0.05)。多變量Cox比例風(fēng)險分析中,24小時Eh(GSH/GSSG)"g-122.5m V(HR 4.25,p=0.005,95%Cl 1.56-11.55),慢性腎臟疾病(HR 3.70,p=0.008,95%CI 1.40-9.76),左室射血分?jǐn)?shù)(5%HR 0.94,p=0.005,95%CI 0.90-0.98)。結(jié)論(1)STEMI患者PCI術(shù)后24h,外周血漿SOD活力降低,MDA含量和Eh(GSH/GSSG)水平升高,表明心肌缺血再灌注損傷造成了自由基爆發(fā),發(fā)生脂質(zhì)過氧化的同時消耗了SOD、GSH,GSH氧化還原態(tài)向氧化方向偏移,氧化應(yīng)激加重。(2)前壁STEMI患者無論P(yáng)CI術(shù)前還是術(shù)后24h,與非前壁患者相比血漿GSH水平更低,Eh(GSH/GSSG)水平更高。表明梗死部位在前壁會造成更嚴(yán)重的氧化應(yīng)激和缺血再灌注損傷。PCI術(shù)前不同數(shù)目冠脈病變患者GSH氧化還原狀態(tài)無明顯差異,PCI術(shù)后24h隨病冠脈變數(shù)目增加,Eh(GSH/GSSG)水平遞增。表明冠脈病變數(shù)目與缺血再灌注后的氧化應(yīng)激水平呈正相關(guān)。(3)外周血漿Eh(GSH/GSSG)水平可用于接受PCI治療的STEMI患者的危險分層。PCI術(shù)后24h血漿Eh(GSH/GSSG)"g-122.5m V的STEMI患者的MACE風(fēng)險增加,Eh(GSH/GSSG)對STEMI患者PCI術(shù)后MACE具有獨(dú)立預(yù)測價值。
[Abstract]:Objective to investigate the changes of MDA, SOD and GSH redox state in the plasma of acute ST segment elevation myocardial infarction (AMI) patients before and after the emergency coronary intervention therapy (24h), and to explore the relationship between the plasma GSH redox state and the prognosis of patients with acute myocardial infarction. (1) from January 2015 to August 2016, a total of 93 patients with acute ST segment elevation myocardial infarction (percutaneous coronary intervention, PCI) for the first time in the First Affiliated Hospital of Chengdu Medical College were selected for the first 12 hours of medical treatment in the Department of cardiovascular medicine. Interventional therapy is performed with conventional technical standards, excluding cancer, chronic inflammation, and other systemic infections within 24 hours. A guideline for the diagnosis and treatment of acute myocardial infarction, which is formulated by the CMA cardiovascular disease branch, is standardized after admission to patients. The main measures include percutaneous coronary stent implantation. Anticoagulant, antiplatelet therapy, arrhythmia, heart failure, and symptomatic support therapy were used. (2) the plasma 5ml. was detected by enzyme linked immunosorbent assay (ELISA) in the elbow vein blood before and after 24h, and the content of MDA and SOD was detected by enzyme linked immunosorbent assay. The content of GSH and GSSG in blood plasma was detected by the enzyme labeled microplate method, and the GSH/GSSG ratio and GSH/GSSG were calculated. Redox potential Eh (GSH/GSSG). (3) the patients were divided into the anterior wall group and the non anterior wall group according to the location of the patients' myocardial infarction. According to the number of vascular stenosis, they were divided into single lesion group, double branch lesion group and three pathological group. The difference of plasma oxidative stress level and GSH redox state were compared between the two groups. (4) 93 patients were followed up for 180 days, according to the results. No cardiovascular events (MACE events) were divided into 72 cases without MACE and 21 cases in group MACE. The difference between the plasma GSH redox states of the two groups was compared. (5) the diagnostic value of Eh (GSH/GSSG) for the short-term prognosis of myocardial infarction patients was preliminarily evaluated. The independent risk factors of MACE event after PCI operation in patients with myocardial infarction were explored and found (1) Compared with 24h, plasma MDA level increased (P0.05), SOD level decreased (P0.05), GSH, GSH/GSSG level decreased (P0.05), GSSG level had no significant difference (P0.05) and increased level (P0.05). (2) there was no significant difference (2) before the operation, there was no significant difference between the anterior wall group and the anterior wall group. P0.05), the level of GSH was lower (P0.05), and the level of Eh (GSH/GSSG) was higher (P0.05) after.PCI. Compared with the non anterior wall group, there was no significant difference in plasma MDA and SOD levels in the anterior wall group (P0.05). The levels of plasma GSH, GSSG, GSH/GSSG and Eh (GSH/GSSG) were not significantly different in the three group of pathological changes (P0.05). There was no significant difference in plasma MDA and SOD (P0.05) after PCI, but there was no significant difference in the level of SOD, but there was no significant difference in the level of GSH and SOD. (3) compared with the non MACE group, there was no significant difference in plasma MDA, SOD, GSH, GSSG, GSH/GSSG and Eh (GSH/GSSG) before operation in group MACE (P0.05).PCI after operation (P0.05). The best critical value of Eh (GSH/GSSG) was -122.5m V, at this time the sensitivity was 71%, and the specificity 76%. was in the Kaplan-Meier survival analysis. Compared with the low risk group, the incidence of MACE had a significant difference (P0.05), and the occurrence of MACE within 30 days was significant (P0.05), and there was no significant difference between the two groups of MACE (P0.05) in 30 days. 2 4 hours Eh (GSH/GSSG) "g-122.5m V (HR 4.25, p=0.005,95%Cl 1.56-11.55), chronic renal disease (HR 3.70, p=0.008,95%CI 1.40-9.76), left ventricular ejection fraction (5%HR 0.94, p=0.005,95%CI). The injury caused the free radical eruption, and the lipid peroxidation caused SOD, GSH, GSH redox state to shift to the oxidation direction, and the oxidative stress was aggravated. (2) the plasma GSH level was lower and the level of Eh (GSH /GSSG) was higher in the anterior wall STEMI patients, no matter before or after PCI, and the level of Eh (GSH /GSSG) was higher than those of the non anterior wall patients. There was no significant difference in the redox state of GSH in patients with different number of coronary lesions before.PCI with severe oxidative stress and ischemia-reperfusion injury. The number of coronary artery changes and the level of Eh (GSH/GSSG) increased gradually after PCI, indicating that the number of coronary lesions was positively correlated with the level of oxidative stress after ischemia reperfusion. (3) the level of plasma Eh (GSH/GSSG) in peripheral plasma could be found. The risk of 24h plasma Eh (GSH/GSSG) "g-122.5m V's STEMI patient's MACE risk increased after the dangerous stratified.PCI for the STEMI patients receiving PCI treatment, and Eh (GSH/GSSG) had an independent predictive value for the postoperative patients.

【學(xué)位授予單位】：成都醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R542.22

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