發(fā)布時(shí)間：2018-09-12 14:19

【摘要】：目的:伴隨著人們生活水平提高,我國冠心病的發(fā)病率以及死亡率也隨之逐漸上升,并且趨于年輕化,需要冠脈旁路移植術(shù)治療的患者數(shù)量也在不斷增加。近年來,非體外循環(huán)下冠脈旁路移植術(shù)日益成熟。圍手術(shù)期心肌梗死(PMI)是較為常見的冠脈旁路移植術(shù)術(shù)后并發(fā)癥。當(dāng)前來講,臨床上只是依托患者癥狀、心肌酶學(xué)以及心電圖檢查,在PMI發(fā)生早期做出準(zhǔn)確的診斷依然較為困難。國內(nèi)外已有研究證明,在評(píng)價(jià)手術(shù)過程與心肌保護(hù)措施、判斷預(yù)后方面,c Tn I檢測(cè)具有廣泛的臨床應(yīng)用價(jià)值。因此,探討冠脈旁路移植術(shù)術(shù)后c Tn I的動(dòng)態(tài)變化及其評(píng)價(jià)預(yù)后的作用將具有重要的指導(dǎo)意義。本臨床實(shí)驗(yàn)擬研究非體外循環(huán)下冠脈旁路移植術(shù)術(shù)后不同時(shí)間段c Tn I與預(yù)后的相關(guān)性及預(yù)測(cè)價(jià)值。方法:選取2013年12月~2014年12月期間在河北醫(yī)科大學(xué)第二醫(yī)院心臟外科擇期行單純非體外循環(huán)下冠脈旁路移植術(shù)的患者98例,年齡43~78歲,平均年齡為60.19±6.84歲,其中男性56例,女性42例,既往心梗病史患者26例,合并高血壓患者54例,合并高血脂癥患者41例,合并糖尿病患者33例,合并神經(jīng)系統(tǒng)疾病患者10例,合并其他疾病患者33例�；颊咝g(shù)前均停服阿司匹林、氯吡格雷,給予肝素鈣4100萬IU皮下注射2/日,繼續(xù)口服他汀類、β受體阻滯劑、ACEI等藥物。全部患者均于術(shù)后3~5h(TNI0)、18~24h(TNI1)、36~48h(TNI2)分次抽取靜脈血,以測(cè)定c Tn I的水平。應(yīng)用SPSS17.0統(tǒng)計(jì)軟件分析比較此3個(gè)不同時(shí)間段的肌鈣蛋白I與預(yù)后的相關(guān)性及預(yù)測(cè)價(jià)值,其中P0.05被認(rèn)為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果:1手術(shù)情況、手術(shù)前后c Tn I檢測(cè)結(jié)果及預(yù)后情況及早期預(yù)后情況:術(shù)前所有患者c Tn I值均在正常值范圍之內(nèi),c Tn I值(0.07±0.11)ng/ml,最低0.00ng/ml,最高0.04ng/ml。所有患者均在非體外循環(huán)下順利完成冠脈旁路移植術(shù),術(shù)后安返心外ICU,給予呼吸機(jī)輔助呼吸、心電監(jiān)護(hù)、抗感染、營養(yǎng)心肌等綜合治療。術(shù)后3~5小時(shí)c Tn I值(TNI0)(0.66±0.45)ng/ml,最低為0.07ng/ml,最高為9.19ng/ml,術(shù)后18~24小時(shí)c Tn I值(TNI1)(3.54±0.62)ng/ml,最低為0.31ng/ml,最高為182.43ng/ml,術(shù)后36~48小時(shí)c Tn I值(TNI2)(1.12±0.55)ng/ml,最低為0.06ng/ml,最高為24.25ng/ml。經(jīng)統(tǒng)計(jì)學(xué)處理,TNI0、TNI1、TNI2與術(shù)前c Tn I值相比z值均為:8.595(P0.01),差異具有統(tǒng)計(jì)學(xué)意義。TNI0、TNI1、TNI2分布散點(diǎn)圖見Fig.1術(shù)后早期預(yù)后情況:術(shù)后呼吸機(jī)輔助(15±20.02)小時(shí),中位數(shù)11.43h,ICU滯留時(shí)間(72.02±33.71)小時(shí),中位數(shù)65.5h,術(shù)后住院時(shí)間(11.67±4.37)天,中位數(shù)9天,術(shù)后應(yīng)用升壓藥物26例(26.53%),應(yīng)用IABP者3例(3.06%),術(shù)后心電圖異常改變者27例(27.55%)。2 TNI0、TNI1、TNI2與早期預(yù)后的相關(guān)性:以c Tn I中位數(shù)為切點(diǎn),分析術(shù)后心肌肌鈣蛋白I(TNI0、TNI1、TNI2)與預(yù)后各指標(biāo)之間的相關(guān)性,TNI0、TNI1、TNI2與術(shù)后呼吸機(jī)輔助時(shí)間相關(guān)系數(shù)分別為0.081(P=0.177)、0.670(P=0.000)、0.168(P=0.099),與ICU滯留時(shí)間相關(guān)系數(shù)分別為0.236(P=0.114)、0.434(P=0.000)、0.206(P=0.042),與術(shù)后住院時(shí)間相關(guān)系數(shù)分別為0.174(P=0.087)、0.830(P=0.000)、0.332(P=0.001),與術(shù)后應(yīng)用升壓藥物情況相關(guān)系數(shù)分別為0.195(P=0.055)、0.601(P=0.000)、0.231(P=0.022),與術(shù)后應(yīng)用IABP情況相關(guān)系數(shù)分別為0.052(P=0.611)、0.178(P=0.080)、0.178(P=0.080),與術(shù)后心電圖異常改變的相關(guān)系數(shù)分別為0.181(P=0.075)、0.571(P=0.000)、0.206(P=0.042)。結(jié)果提示術(shù)后18~24 h的c Tn I值與預(yù)后顯著相關(guān)(P值均0.05),且相關(guān)關(guān)系系數(shù)也較大(0.178相關(guān)系數(shù)0.830)。3應(yīng)用SPSS17.0軟件進(jìn)行分析,TNI0、TNI1、TNI2預(yù)測(cè)升壓藥使用情況的AUC分別為0.672(P=0.059)、0.991(P=0.007)、0.701(P=0.065),TNI0、TNI1、TNI2預(yù)測(cè)IABP使用情況的AUC分別為0.847(P=0.086)、0.966(P=0.029)、0.935(P=0.036),TNI0、TNI1、TNI2預(yù)測(cè)ICU滯留時(shí)間的AUC分別為0.534(P=0.075)、0.791(P=0.047)、0.692(P=0.062),TNI0、TNI1、TNI2預(yù)測(cè)術(shù)后住院時(shí)間的AUC分別為0.661(P=0.057)、0.959(P=0.022)、0.735(P=0.051),TNI0、TNI1、TNI2預(yù)測(cè)呼吸機(jī)輔助時(shí)間的AUC分別為0.643(P=0.058)、0.937(P=0.026)、0.682(P=0.054)。TNI0、TNI1、TNI2預(yù)測(cè)心電圖異常改變情況的AUC分別為0.667(P=0.058)、0.980(P=0.014)、0.689(P=0.064)。術(shù)后18~24小時(shí)c Tn I值對(duì)患者預(yù)后的預(yù)測(cè)價(jià)值更大(P值均0.05),TNI1對(duì)升壓藥使用情況、IABP使用情況、術(shù)后住院時(shí)間、呼吸機(jī)輔助時(shí)間、心電圖異常改變情況有較高預(yù)測(cè)價(jià)值,AUC0.9;對(duì)ICU滯留時(shí)間有一定的預(yù)測(cè)價(jià)值,AUC0.7。4術(shù)后18~24h c Tn I值與預(yù)后情況各自的預(yù)測(cè)價(jià)值:以c Tn I正常上限的5、10、50、100倍數(shù)值為切點(diǎn),即0.20、0.40、2.0、4.0ng/ml,和TNI1分布中25%、50%、75%、90%百分位數(shù)為切點(diǎn),即0.29ng/ml、0.63ng/ml、1.78ng/ml、6.99ng/ml,分別估計(jì)其對(duì)升壓藥使用情況、IABP使用情況、術(shù)后住院時(shí)間、呼吸機(jī)輔助時(shí)間及心電圖異常改變情況的預(yù)測(cè)價(jià)值,見Table 3。當(dāng)術(shù)后18~24h c Tn I值1.78ng/ml時(shí),其對(duì)升壓藥使用情況、IABP使用情況、術(shù)后住院時(shí)間、呼吸機(jī)輔助時(shí)間及心電圖異常改變情況具有較好的預(yù)測(cè)價(jià)值。結(jié)論:1非體外循環(huán)下冠脈旁路移植術(shù)后患者心肌肌鈣蛋白I較術(shù)前均有不同程度升高。2 c Tn I值在術(shù)后3~5h開始升高,18~24h達(dá)到高峰,36~48h逐漸下降。3術(shù)后18~24 h c Tn I值與早期預(yù)后有相關(guān)性并且有較高的預(yù)測(cè)價(jià)值。對(duì)升壓藥使用情況、IABP使用情況、術(shù)后住院時(shí)間、呼吸機(jī)輔助時(shí)間、心電圖異常改變情況有較高預(yù)測(cè)價(jià)值,對(duì)ICU滯留時(shí)間有一定的預(yù)測(cè)價(jià)值。4結(jié)合心電圖及心臟彩超,對(duì)早期診斷PMI具有非常重要的意義。
[Abstract]:OBJECTIVE: With the improvement of people's living standards, the incidence and mortality of coronary heart disease (CHD) in China are gradually increasing, and tends to be younger. The number of patients who need coronary artery bypass grafting is also increasing. In recent years, off-pump coronary artery bypass grafting is becoming more and more mature. Perioperative myocardial infarction (PMI) is more common. Currently, it is still difficult to make an accurate diagnosis in the early stage of PMI by relying on symptoms, myocardial enzymology and electrocardiogram. Therefore, it is of great significance to study the dynamic changes of C Tn I after coronary artery bypass grafting and its role in evaluating prognosis. This clinical trial is to study the correlation between C Tn I and prognosis at different time after off-pump coronary artery bypass grafting. Ninety-eight patients, aged 43-78 years, with an average age of 60.19 (+ 6.84), underwent selective off-pump coronary artery bypass grafting in the second hospital of Hebei Medical University during February. Among them, 56 were males, 42 were females, 26 had a history of myocardial infarction, 54 had hypertension, 41 had hyperlipidemia, and 41 had glycosuria. 33 patients, 10 patients with nervous system diseases, 33 patients with other diseases. All patients stopped taking aspirin, clopidogrel, heparin calcium 41 million IU subcutaneous injection for 2 days, and continued to take statins, beta-blockers, ACEI and other drugs. All patients were selected at 3 to 5 hours (TNI0), 18 to 24 hours (TNI1), 36 to 48 hours (TNI2) after surgery. The correlation and predictive value between troponin I and prognosis were analyzed by SPSS17.0 statistical software. Among them, P 0.05 was considered to be statistically significant. All patients successfully completed coronary artery bypass grafting without cardiopulmonary bypass. All patients returned to the ICU safely after operation. They were given ventilator-assisted breathing, ECG monitoring, anti-infection, cardiac nutrition and other comprehensive treatment. The lowest is 0.45 ng/ml, the lowest is 0.07 ng/ml, the highest is 9.19 ng/ml. The lowest is 0.31 ng/ml and the highest is 182.43 ng/ml. The lowest is 0.06 ng/ml and the highest is 24.25 ng/ml. Compared with preoperative Tn I, I 0, I 1 and I2, the highest is 182.43 ng/ml. The early prognosis of Fig. 1 was as follows: ventilator-assisted (15 The correlation between postoperative cardiac troponin I (TNI 0, TNI 1, TNI 2) and prognosis was analyzed with the median of C Tn I as the cut point. The correlation coefficients between postoperative cardiac troponin I (TNI 0, TNI 1, TNI 2) and prognosis were 0.081 (P = 0.17), respectively. 7, 0.670 (P = 0.000), 0.670 (P = 0.000), 0.168 (P = 0.099), 0.236 (P = 0.114), 0.434 (P = 0.000), 0.206 (P = 0.042), 0.174 (P = 0.087), 0.830 (P = 0.000), 0.000 (P = 0.000), 0.332 (P = 0.001), 0.195 (P = 0.055), 0.601 (P = 0.601), 0.601 (P = 0.601, P = 0.231 (P = 0.000), 0.830 0 830 0 0 0 0 0 0 0 0 0 0 0 0 000 (P = 0.000), 0.332 (P = 0.001) and 0. The correlation coefficients with postoperative application of IABP were 0.052 (P = 0.611), 0.178 (P = 0.080), 0.178 (P = 0.080), 0.181 (P = 0.075), 0.571 (P = 0.000) and 0.206 (P = 0.042), respectively. The correlation coefficients between postoperative application of IABP and postoperative abnormal changes of ECG were significant (P = 0.05) and large (0.075) respectively. The AUCfor predictpredictpredictors of the usususususususususususof presprespresserdrugs were 0.672 (P = 0.059), 0.991 (P = 0.007), 0.701 (P = 0.065), TNI0, TNI0, TNI1 1, 1, TNI1, and TNI2 were 0.847 (P = 0.0.086, 0.086, 0.966 (P = 0.0.96 (P = 0.0.0.029 (P = 0.0.935 (P = 0.0.935 (P = 0.0.0.035 (P = 0.0.030.036), 1, III0, 1, 1, 1, 1, 1, IIIII2, 1, 1, Divide AUCwere 0.661 (P = 0.057), 0.959 (P = 0.022), 0.959 (P = 0.022), 0.959 (P = 0.0.022), 0.735 (P = 0.051), 0.791 (P = 0.0.0.057, 0.791 (P = 0.0.0.0.0.0 0.051), 0 0, 0, TNI0, TNI1, TNI1, and TNI1, and TNI2 predictAUCwere 0.643 (P = 0.050.0.053 (P = 0.058, 0.0.937 (P = 0.0.937 (P = 0.0.0.026 (P = 0.0.0.026 (P = 0.TNI1 and TNI2 predict abnormal changes of ECG AUC was 0.667 (P = 0.058), 0.980 (P = 0.014) and 0.689 (P = 0.064). The prognostic value of C Tn I between 18 and 24 hours after operation was greater (P = 0.05). TNI1 had a higher predictive value for the use of antihypertensive drugs, IABP, postoperative hospital stay, ventilator-assisted time and abnormal changes of ECG, AUC 0.9; ICU retention time was longer in ICU. AUC 0.7.4 postoperative 18-24 h C Tn I value and prognosis of the respective predictive value: C Tn I normal upper limit of 5,10,50,100 times as the tangent point, that is, 0.20,0.40,2.0,4.0 ng/ml, and TNI 1 Distribution in 25%, 50%, 75%, 90% percentiles as the tangent point, that is, 0.29ng/ml, 0.63ng/ml, 1.78ng/ml, 6.99ng/ml, respectively, to estimate the effect of hypertension drugs. The predictive value of usage, IABP usage, postoperative hospitalization time, ventilator-assisted time and abnormal changes of ECG was found in Table 3. When the C Tn I value was 1.78 ng/ml 18-24 hours after operation, the predictive value of IABP usage, postoperative hospitalization time, ventilator-assisted time and abnormal changes of ECG were better. Conclusion: 1. After off-pump coronary artery bypass grafting, cardiac troponin I increased in varying degrees. 2 C Tn I increased at 3-5 hours, peaked at 18-24 hours, and decreased gradually at 36-48 hours. 3 18-24 hours after coronary artery bypass grafting had correlation with early prognosis and high predictive value. ABP usage, postoperative hospitalization time, ventilator-assisted time, abnormal changes in electrocardiogram have a higher predictive value for ICU retention time. 4 Combining ECG and color Doppler echocardiography, it is very important for early diagnosis of PMI.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R654.2

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