前白蛋白在急性ST段抬高型心肌梗死中的臨床意義
發(fā)布時間：2018-08-08 14:54
【摘要】：急性ST段抬高型心肌梗死(acute ST-segment elevation myocardial infarction,STEMI)是嚴重威脅人類健康的重要疾病之一,目前其基本病因主要認為是在冠狀動脈粥樣硬化的基礎(chǔ)上,不穩(wěn)定斑塊破潰導致出血、血小板聚集和繼發(fā)血栓形成,使冠狀動脈脈完全閉塞,導致心肌缺血缺氧造成相應(yīng)心肌損傷和不可逆性壞死,進一步可引發(fā)乳頭肌功能失調(diào)、急性心力衰竭、心臟破裂、栓塞、梗死后綜合征等并發(fā)癥,嚴重影響臨床醫(yī)生治療策略和患者及患者家屬治療積極性。目前研究表明,STEMI急性發(fā)作時局部和全身的炎癥反應(yīng)對疾病發(fā)展和預(yù)后起著重要的作用。與局部和全身性炎癥反應(yīng)相關(guān)的多種血清學標志物的變化水平,如C反應(yīng)蛋白(CRP)、肌鈣蛋白T(cTnT)、腦鈉肽(BNP)等和STEMI患者預(yù)后之間的關(guān)系正受到越來越多的關(guān)注。前白蛋白(prealbumin,PA)是由肝臟合成的同源四聚體,PA作為快速周轉(zhuǎn)的內(nèi)臟蛋白,認為其不僅能反應(yīng)全身的氮代謝,被當作是反映患者營養(yǎng)狀態(tài)的較好指標,而且血清PA也被為是一種非特異性的防御性蛋白,在炎癥反應(yīng)期能其游離的亞基能結(jié)合病原分子及機體毒性代謝產(chǎn)物,導致自身被消耗,使血清濃度降低。最近幾年來國外有研究顯示PA能作為判斷外周動脈血管造影術(shù)后1年內(nèi)發(fā)生主要不良事件的預(yù)測因子,較低水平的PA同樣與心力衰竭的不良預(yù)后有著明顯相關(guān)性,國內(nèi)研究已有學者將PA變化與川崎病患者、冠心病患者冠狀動脈病變嚴重程度和急性心肌梗死近期預(yù)后做了相關(guān)研究,表明了PA作為反應(yīng)炎癥及急性應(yīng)激反應(yīng)的指標在評估急性心肌梗死中對血管病變程度,炎癥范圍及病情預(yù)后中有重要價值。然而STEMI作為透壁性心肌梗死,相較于穩(wěn)定型心絞痛(stable angina pectoris,SAP)、不穩(wěn)定型心絞痛(unstable angina pectoris,UAP)、非ST段抬高型心肌梗死(non-ST-segment elevation myocardial infarction,NSTEMI)有著不同的治療方案和預(yù)后結(jié)局,目前關(guān)于STEMI患者近期預(yù)后與PA水平的關(guān)系研究較少,因此本研究通過比較STEMI患者近期預(yù)后與PA水平的關(guān)系,為臨床藥物干預(yù)PA水平作為治療靶點提供理論參考。本研究采用回顧性調(diào)查方法,連續(xù)性入選2013年1月至2015年6月張家口市第一醫(yī)院心內(nèi)科160名STEMI患者,記錄患者的性別、年齡、心率、收縮壓、既往高血壓病史、糖尿病病史、吸煙史、血脂、肝功能、心功能等資料。所有患者入科時即刻抽肘靜脈血送我院檢驗科室行生化檢測。所有患者均于入院后接受了經(jīng)皮冠狀動脈介入治療(percutaneous coronary intervention,PCI),PCI術(shù)均由我院兩名高年資心內(nèi)科介入醫(yī)師完成,患者術(shù)前均給予負荷量拜阿司匹林腸溶片300mg,硫酸氫氯吡格雷片600mg,支架置入標準為冠狀動脈狹窄程度大于75%以上,統(tǒng)計三者病變血管支數(shù)。根據(jù)STEMI患者在住院期間是否發(fā)生心臟事件將患者分為事件組和非事件組。其中事件組58例;非事件102例。采用SPSS17.0進行處理,符合正態(tài)分布的計量資料數(shù)據(jù)組間比較采用獨立樣本t檢驗,3組或3組以上數(shù)據(jù)采用單因素方差分析;非正態(tài)分布數(shù)據(jù)資料采用秩和檢驗,計數(shù)資料比較采用χ_2檢驗或Fisher精確檢驗;運用單變量和多變量Logistic回歸模型分析對心血管事件發(fā)生有影響的獨立預(yù)測因子,繪制受試者工作曲線(ROC曲線)計算發(fā)生心臟事件的最佳閾值。所有數(shù)據(jù)檢驗均行雙側(cè)檢驗,P0.05表示差異具有統(tǒng)計學意義。STEMI患者中3支冠狀動脈狹窄較2支、1支冠狀動脈狹窄PA水平降低,差異有統(tǒng)計學意義,2支冠狀動脈狹窄患者較1支冠狀動脈狹窄PA水平較低有統(tǒng)計學意義。Spearman相關(guān)分析分析顯示,血清前白蛋白水平與冠狀動脈病變程度呈負相關(guān),PA在病變較重、病情較急的STEMI患者中低表達。隨后將STEMI患者分為事件組和非事件組,兩組患者在基線資料比較時可見年齡、糖尿病病史的比例上事件組均高于非事件組,而事件組在男性比例、收縮壓、前白蛋白、左室射血分數(shù)(left ventricular ejection fraction,LVEF)低于非事件組,兩組在心率、高血壓病史、吸煙、左室舒張末期內(nèi)徑、前壁心肌梗死比例、血脂、肌鈣蛋白T及支架放置個數(shù)上差異無統(tǒng)計學意義。證明了PA對STEMI患者預(yù)后相關(guān);谷草轉(zhuǎn)氨酶(aspertate aminotransferase,AST)、谷丙轉(zhuǎn)氨酶(alanine transaminase,ALT)比較上有差異,可能是急性心肌梗死是導致了肝臟的可逆性損失。隨后本研究對可能與患者預(yù)后有關(guān)的因素進行了單因素Logistic分析,結(jié)果顯示性別、年齡、糖尿病病史、收縮壓、LVEF、PA是影響患者預(yù)后的相關(guān)因素;但多因素分析示只有糖尿病病史、收縮壓、LVEF、PA是影響患者預(yù)后的相關(guān)因素。隨后本研究通過繪制受試者工作曲線得出PA預(yù)測患者發(fā)生心血管事件的曲線下面積為0.709,差異有統(tǒng)計學意義,最佳閾值為20.85mg/dl。根據(jù)得ROC測得的閾值將患者分成前白蛋白20.85mg/dl和≥20.85mg/dl兩組,與≥20.85mg/dl組相比,20.85mg/dl組在心室顫動、高度房室傳導阻滯、心源性休克、心力衰竭、心臟總不良事件中發(fā)生率增高,而新發(fā)房顫或房撲、術(shù)后再發(fā)心梗、死亡兩組患者差異無統(tǒng)計學意義。結(jié)果提示PA對預(yù)測STEMI患者預(yù)后有重要意義。上述研究表明,PA可能與傳統(tǒng)預(yù)測因子一樣可以作為評估STEMI患者在院期間發(fā)生心臟事件的獨立預(yù)測因子,因此常規(guī)檢測STEMI患者血清PA,對患者及早做出病情及預(yù)后評估可能具有重要的臨床意義。
[Abstract]:Acute ST segment elevation myocardial infarction (acute ST-segment elevation myocardial infarction, STEMI) is one of the important diseases that seriously threaten human health. At present, the basic etiology is mainly based on coronary atherosclerosis. Unstable plaque rupture leads to blood, platelet aggregation and secondary thrombosis, and causes coronary artery to cause coronary artery disease. Complete occlusion of the veins causes myocardial ischemia and hypoxia to cause corresponding myocardial damage and irreversible necrosis, which can further trigger the dysfunction of the papillary muscles, acute heart failure, cardiac rupture, embolism, and post infarction syndrome, which seriously affect the treatment strategy of the clinicians and the treatment of the patients and their families. The present study shows that STEMI is urgent. Local and systemic inflammatory responses play an important role in the development and prognosis of the disease. The changes in the level of the variety of serological markers related to local and systemic inflammatory responses, such as C reactive protein (CRP), troponin T (cTnT), brain natriuretic peptide (BNP), and the prognosis of patients with STEMI are being paid more and more attention. Prealbumin (PA) is a homologous four polymer synthesized by the liver. As a fast turnover viscera, PA is considered not only to react to the nitrogen metabolism of the whole body, but also as a better indicator of the nutritional status of the patient, and the serum PA is also a nonspecific defensive protein that can free the subunit of the subunit in the inflammatory response period. The combination of the pathogenic molecules and the toxic metabolites of the body leads to its own consumption and the decrease in serum concentration. In recent years, studies have shown that PA can be used as a predictor of the major adverse events within 1 years after peripheral artery angiography, and the lower level of PA is also associated with the poor prognosis of the heart failure. Some scholars have studied the changes of PA with the severity of coronary artery disease and the short-term prognosis of acute myocardial infarction in patients with Kawasaki disease, coronary heart disease and acute myocardial infarction. It is shown that the index of PA as a response to inflammation and acute stress response is important in assessing the degree of vascular disease, the range of inflammation and the prognosis of the patients in acute myocardial infarction. However, STEMI as a transmural myocardial infarction, compared to stable angina pectoris (stable angina pectoris, SAP), unstable angina pectoris (unstable angina pectoris, UAP), and non ST segment elevation myocardial infarction (non-ST-segment elevation) has different therapeutic options and prognostic outcomes. The relationship between the short-term prognosis of the patients and the PA level is less. Therefore, this study provides a theoretical reference for the clinical drug intervention PA level as a therapeutic target by comparing the relationship between the short-term prognosis and the level of PA in the patients with STEMI. This study adopts a retrospective survey method and continues to be selected from the Department of Cardiology of the first hospital of Zhangjiakou from January 2013 to June 2015, 1 60 STEMI patients, recorded the patient's sex, age, heart rate, systolic blood pressure, past history of hypertension, history of diabetes, smoking history, blood lipid, liver function, heart function and so on. All patients were immediately given elbow vein blood to our hospital for biochemical test. All patients received percutaneous coronary intervention after admission (percut Aneous coronary intervention, PCI), PCI operation was performed by two senior Department of Cardiology interventional physicians in our hospital. The patients were given a load of Aspirin Enteric-coated Tablets 300mg and Clopidogrel Bisulfate Tablets 600mg before operation. The stent implantation standard was the degree of coronary artery stenosis more than 75%, and the number of vascular branches of the three patients was counted. According to STEMI patients, Cardiac events during hospitalization were divided into event group and non event group. 58 cases of event group and 102 cases of non events were treated with SPSS17.0. Independent sample t test was used for the comparison of data groups conforming to normal distribution. The data of 3 or more than 3 groups were analyzed by single factor analysis of variance; non normal distribution data were collected. Using the rank sum test, the count data were compared by the chi square _2 test or the Fisher accurate test; the independent predictors of the cardiovascular events were analyzed by the single variable and multivariable Logistic regression model, and the best threshold for the cardiac events was calculated by the ROC curve of the subjects. All the data tests were both bilateral test, P0.0 5 the difference was statistically significant in 3.STEMI patients with 2 coronary artery stenosis and 1 coronary stenosis, the difference was statistically significant. 2 coronary stenosis patients had lower level of PA than 1 coronary artery stenosis. The.Spearman correlation analysis showed that the level of serum prealbumin and coronary artery were compared with that of coronary artery. The degree of pathological changes was negatively correlated, PA was low in the more severe and acute STEMI patients. Then STEMI patients were divided into event group and non event group. The age of the two groups was compared to the baseline data, and the proportion of the diabetic history was higher than that in the non event group, while the event group was in the male proportion, systolic pressure, prealbumin, left ventricle. The ejection fraction (left ventricular ejection fraction, LVEF) was lower than the non event group. There was no statistical difference between the two groups in heart rate, hypertension history, smoking, left ventricular end diastolic diameter, the ratio of anterior wall myocardial infarction, blood lipid, troponin T and the number of stent placement. It is clear that PA is related to the prognosis of STEMI patients; aspertate amino (aspertate amino). Transferase, AST), the alanine transaminase (ALT) is different. It may be that acute myocardial infarction is the reversible loss of the liver. Subsequently, this study conducted a single factor Logistic analysis of factors that may be associated with the prognosis of the patient. The results showed that sex, age, diabetes history, systolic pressure, LVEF, PA were affected. The factors related to the prognosis of the patients were analyzed. However, multivariate analysis showed that only the history of diabetes, systolic blood pressure, LVEF, and PA were related factors affecting the prognosis of the patients. Then, the results of this study showed that the area under the curve under the curve of PA was 0.709, the difference was statistically significant, and the best threshold was 20.85mg/dl. based on R The threshold values measured by OC were divided into two groups of prealbumin 20.85mg/dl and more than 20.85mg/dl. Compared with group more than 20.85mg/dl, the incidence of ventricular fibrillation, high atrioventricular block, cardiogenic shock, heart failure, heart total adverse events increased in 20.85mg/dl group, while new atrial fibrillation or atrial flutter, postoperative recurrence of heart infarction, and death of two groups were no difference. The results suggest that PA is of great significance for predicting the prognosis of patients with STEMI. The above study suggests that PA may be the same as the traditional predictor as an independent predictor of cardiac events in patients with STEMI during the hospital. Therefore, the routine detection of serum PA in patients with STEMI may be of the possibility of early making and evaluating the prognosis of the patients. Important clinical significance.
【學位授予單位】：河北北方學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R542.22
本文編號：2172137
[Abstract]:Acute ST segment elevation myocardial infarction (acute ST-segment elevation myocardial infarction, STEMI) is one of the important diseases that seriously threaten human health. At present, the basic etiology is mainly based on coronary atherosclerosis. Unstable plaque rupture leads to blood, platelet aggregation and secondary thrombosis, and causes coronary artery to cause coronary artery disease. Complete occlusion of the veins causes myocardial ischemia and hypoxia to cause corresponding myocardial damage and irreversible necrosis, which can further trigger the dysfunction of the papillary muscles, acute heart failure, cardiac rupture, embolism, and post infarction syndrome, which seriously affect the treatment strategy of the clinicians and the treatment of the patients and their families. The present study shows that STEMI is urgent. Local and systemic inflammatory responses play an important role in the development and prognosis of the disease. The changes in the level of the variety of serological markers related to local and systemic inflammatory responses, such as C reactive protein (CRP), troponin T (cTnT), brain natriuretic peptide (BNP), and the prognosis of patients with STEMI are being paid more and more attention. Prealbumin (PA) is a homologous four polymer synthesized by the liver. As a fast turnover viscera, PA is considered not only to react to the nitrogen metabolism of the whole body, but also as a better indicator of the nutritional status of the patient, and the serum PA is also a nonspecific defensive protein that can free the subunit of the subunit in the inflammatory response period. The combination of the pathogenic molecules and the toxic metabolites of the body leads to its own consumption and the decrease in serum concentration. In recent years, studies have shown that PA can be used as a predictor of the major adverse events within 1 years after peripheral artery angiography, and the lower level of PA is also associated with the poor prognosis of the heart failure. Some scholars have studied the changes of PA with the severity of coronary artery disease and the short-term prognosis of acute myocardial infarction in patients with Kawasaki disease, coronary heart disease and acute myocardial infarction. It is shown that the index of PA as a response to inflammation and acute stress response is important in assessing the degree of vascular disease, the range of inflammation and the prognosis of the patients in acute myocardial infarction. However, STEMI as a transmural myocardial infarction, compared to stable angina pectoris (stable angina pectoris, SAP), unstable angina pectoris (unstable angina pectoris, UAP), and non ST segment elevation myocardial infarction (non-ST-segment elevation) has different therapeutic options and prognostic outcomes. The relationship between the short-term prognosis of the patients and the PA level is less. Therefore, this study provides a theoretical reference for the clinical drug intervention PA level as a therapeutic target by comparing the relationship between the short-term prognosis and the level of PA in the patients with STEMI. This study adopts a retrospective survey method and continues to be selected from the Department of Cardiology of the first hospital of Zhangjiakou from January 2013 to June 2015, 1 60 STEMI patients, recorded the patient's sex, age, heart rate, systolic blood pressure, past history of hypertension, history of diabetes, smoking history, blood lipid, liver function, heart function and so on. All patients were immediately given elbow vein blood to our hospital for biochemical test. All patients received percutaneous coronary intervention after admission (percut Aneous coronary intervention, PCI), PCI operation was performed by two senior Department of Cardiology interventional physicians in our hospital. The patients were given a load of Aspirin Enteric-coated Tablets 300mg and Clopidogrel Bisulfate Tablets 600mg before operation. The stent implantation standard was the degree of coronary artery stenosis more than 75%, and the number of vascular branches of the three patients was counted. According to STEMI patients, Cardiac events during hospitalization were divided into event group and non event group. 58 cases of event group and 102 cases of non events were treated with SPSS17.0. Independent sample t test was used for the comparison of data groups conforming to normal distribution. The data of 3 or more than 3 groups were analyzed by single factor analysis of variance; non normal distribution data were collected. Using the rank sum test, the count data were compared by the chi square _2 test or the Fisher accurate test; the independent predictors of the cardiovascular events were analyzed by the single variable and multivariable Logistic regression model, and the best threshold for the cardiac events was calculated by the ROC curve of the subjects. All the data tests were both bilateral test, P0.0 5 the difference was statistically significant in 3.STEMI patients with 2 coronary artery stenosis and 1 coronary stenosis, the difference was statistically significant. 2 coronary stenosis patients had lower level of PA than 1 coronary artery stenosis. The.Spearman correlation analysis showed that the level of serum prealbumin and coronary artery were compared with that of coronary artery. The degree of pathological changes was negatively correlated, PA was low in the more severe and acute STEMI patients. Then STEMI patients were divided into event group and non event group. The age of the two groups was compared to the baseline data, and the proportion of the diabetic history was higher than that in the non event group, while the event group was in the male proportion, systolic pressure, prealbumin, left ventricle. The ejection fraction (left ventricular ejection fraction, LVEF) was lower than the non event group. There was no statistical difference between the two groups in heart rate, hypertension history, smoking, left ventricular end diastolic diameter, the ratio of anterior wall myocardial infarction, blood lipid, troponin T and the number of stent placement. It is clear that PA is related to the prognosis of STEMI patients; aspertate amino (aspertate amino). Transferase, AST), the alanine transaminase (ALT) is different. It may be that acute myocardial infarction is the reversible loss of the liver. Subsequently, this study conducted a single factor Logistic analysis of factors that may be associated with the prognosis of the patient. The results showed that sex, age, diabetes history, systolic pressure, LVEF, PA were affected. The factors related to the prognosis of the patients were analyzed. However, multivariate analysis showed that only the history of diabetes, systolic blood pressure, LVEF, and PA were related factors affecting the prognosis of the patients. Then, the results of this study showed that the area under the curve under the curve of PA was 0.709, the difference was statistically significant, and the best threshold was 20.85mg/dl. based on R The threshold values measured by OC were divided into two groups of prealbumin 20.85mg/dl and more than 20.85mg/dl. Compared with group more than 20.85mg/dl, the incidence of ventricular fibrillation, high atrioventricular block, cardiogenic shock, heart failure, heart total adverse events increased in 20.85mg/dl group, while new atrial fibrillation or atrial flutter, postoperative recurrence of heart infarction, and death of two groups were no difference. The results suggest that PA is of great significance for predicting the prognosis of patients with STEMI. The above study suggests that PA may be the same as the traditional predictor as an independent predictor of cardiac events in patients with STEMI during the hospital. Therefore, the routine detection of serum PA in patients with STEMI may be of the possibility of early making and evaluating the prognosis of the patients. Important clinical significance.
【學位授予單位】：河北北方學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R542.22
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