本文選題：經(jīng)皮冠狀動脈介入治療 + 心肌損傷　； 參考：《第二軍醫(yī)大學(xué)》2015年碩士論文

【摘要】：研究背景冠狀動脈介入治療已成為冠狀動脈粥樣硬化性心臟病主要的治療手段之一,隨著技術(shù)水平的提高,越來越多的復(fù)雜、多支病變選擇行PCI治療。在行PCI治療的患者中有約30%發(fā)生PCI相關(guān)的心肌損傷。其中冠狀動脈分叉病變的患者,因其病變部位解剖結(jié)構(gòu)特殊,處理該類病變時操作復(fù)雜,引起PCI相關(guān)心肌損傷的風(fēng)險相應(yīng)增加。對于此類患者,心肌損傷主要由PCI手術(shù)引起的分支血管受累及末梢血管栓塞所致。目前可以通過檢測由壞死心肌釋放的標(biāo)志物來評價是否發(fā)生了心肌損傷,標(biāo)志物升高的水平可反映心肌受損的范圍大小,并有助于判斷患者的預(yù)后。研究目的本研究通過檢測PCI相關(guān)心肌損傷患者循環(huán)血中miR-133a的表達量,并將其與肌鈣蛋白、心型脂肪酸結(jié)合蛋白的檢測結(jié)果相比較,探索miR-133a對心肌損傷的診斷價值。研究方法(一)本研究收集自2014年1月至2014年12月在第二軍醫(yī)大學(xué)附屬長海醫(yī)院心內(nèi)科行經(jīng)皮冠狀動脈介入治療的患者,將冠狀動脈分叉病變列為研究對象,排除其中無分叉病變及此次介入治療前已經(jīng)對分叉病變進行過介入治療的患者。根據(jù)術(shù)中冠狀動脈造影結(jié)果和肌鈣蛋白濃度≥99%參考值上限的3倍,將入組患者分為觀察組和對照組,觀察組為對分叉病變行PCI術(shù)后引起心肌損傷的患者,進一步分為分支血管損傷和末梢血管栓塞兩個亞組；對照組為對分叉病變行PCI治療但未發(fā)生PCI相關(guān)心肌損傷的患者。(二)分別收集并比較PCI相關(guān)心肌損傷組和對照組患者的基本臨床資料和手術(shù)相關(guān)情況。(三)1、檢測PCI相關(guān)心肌損傷組和對照組患者術(shù)后循環(huán)血中miRNAs的表達量和肌鈣蛋白濃度以及心型脂肪酸結(jié)合蛋白的陽性率,比較這三種標(biāo)志物的表達情況在兩組間是否存在差異。2、分別比較分支損傷組和末梢栓塞組與對照組間循環(huán)血中miRNAs的表達量、肌鈣蛋白濃度以及心型脂肪酸結(jié)合蛋白的陽性率是否存在差異。(四)1、分析全部患者循環(huán)血中miRNAs表達量與肌鈣蛋白濃度和心型脂肪酸結(jié)合蛋白陽性率的相關(guān)性。2、分析PCI相關(guān)心肌損傷患者循環(huán)血中miRNAs表達量與肌鈣蛋白濃度和心型脂肪酸結(jié)合蛋白陽性率的相關(guān)性。3、分析分支損傷組患者miR-133a表達量與診斷金標(biāo)準(zhǔn)冠狀動脈造影結(jié)果的相關(guān)性。4、分析末梢栓塞組患者miR-133a表達量與診斷金標(biāo)準(zhǔn)肌鈣蛋白濃度的相關(guān)性。(五)繪制ROC曲線評價miR-133a對分叉病變PCI相關(guān)心肌損傷的診斷價值,以及對分支損傷組和末梢栓塞組的診斷價值,并分別與肌鈣蛋白、心型脂肪酸結(jié)合蛋白的診斷價值相比較。(六)術(shù)后對患者進行3-12月的電話和門診隨訪,記錄主要不良心血管事件發(fā)生情況(Major adverse cardiovascular events, MACEs),包括心源性死亡、非致死性心肌梗死、再發(fā)心絞痛、血運重建等。研究結(jié)果(一)本研究共納入符合研究標(biāo)準(zhǔn)的分叉病變患者225例,其中PCI相關(guān)心肌損傷組128例,包括分支損傷組患者26例和末梢栓塞組患者102例；對照組患者97例。(二)PCI相關(guān)心肌損傷組和對照組相比,以及分支損傷組和末梢栓塞組分別和對照組相比基本臨床資料和手術(shù)相關(guān)情況組間差異無統(tǒng)計學(xué)意義(P0.05)。(三)1、循環(huán)血中miR-133a的表達量和肌鈣蛋白濃度、心型脂肪酸結(jié)合蛋白陽性率在PCI相關(guān)心肌損傷組中明顯升高,與對照組相比差異具有統(tǒng)計學(xué)意義(P0.001)。2、分支損傷組和末梢栓塞組的miR-133a表達量和肌鈣蛋白濃度、心型脂肪酸結(jié)合蛋白陽性率分別,與對照組相比,有明顯升高且差異具有統(tǒng)計學(xué)意義(P0.01)。(四)1、在全部患者中循環(huán)血miR-133a水平與肌鈣蛋白濃度和心型脂肪酸結(jié)合蛋白陽性率具有正相關(guān)性(P0.001)。2、在PCI相關(guān)心肌損傷組患者中循環(huán)血miR-133a的表達量與肌鈣蛋白濃度和心型脂肪酸結(jié)合蛋白陽性率具有正相關(guān)性(P0.001,P0.05)。3、在分支損傷組患者中循環(huán)血miR-133a的表達量與診斷金標(biāo)準(zhǔn)冠脈造影結(jié)果具有正相關(guān)性(P0.001)。4、在末梢栓塞組患者循環(huán)血中miR-133a的表達量與診斷金標(biāo)準(zhǔn)肌鈣蛋白水平具有正相關(guān)性(P0.05)。(五)1、評價miR-133a對分叉病變PCI相關(guān)心肌損傷診斷價值的ROC曲線顯示,曲線下面積(Area Under the Curve, AUC)為0.860(95%CI：0.810-0.910),與肌鈣蛋白的0.993(95%CI：0-1)相比,診斷價值略低,但差異無統(tǒng)計學(xué)意義(P0.05)。與心型脂肪酸結(jié)合蛋白的0.594(95%CI：0.521-0.668)相比,診斷價值較高,差異無統(tǒng)計學(xué)意義(P0.05)。2、分支損傷組miR-133a的AUC為0.912(95%CI：0.847-0.955),肌鈣蛋白繪制的AUC為0.967(95%CI：0.918-0.991),心型脂肪酸結(jié)合蛋白的AUC為0.818(95%CI：0.738-0.881),三者之間相比差異無統(tǒng)計學(xué)意義(P0.05)。3、在末梢栓塞組中miR-133a的AUC為0.846(95%CI：0.788-0.893),肌鈣蛋白的AUC為1.0(95%CI：0.981-1.0),心型脂肪酸結(jié)合蛋白的AUC為0.536(95%CI：0.464-0.607),兩兩比較差異具有統(tǒng)計學(xué)意義(P0.001)。(六)住院期間分支損傷組與末梢栓塞組術(shù)后均未發(fā)生MACEs,出院后3-12月隨訪期間內(nèi),所有入組患者中共有12例(5.33%)發(fā)生MACEs,其中觀察組10例(7.81%),對照組2例(2.06%)。觀察組中分支損傷組發(fā)生MACEs者5例(19.23%),末梢栓塞組發(fā)生MACEs者5例(4.90%)。PCI相關(guān)心肌損傷患者MACEs發(fā)生率較對照組高,差異具有統(tǒng)計學(xué)意義(P0.05)。進一步分析miR-133a表達量的升高程度與MACEs發(fā)生率的相關(guān)性,結(jié)果表明兩者呈正相關(guān)關(guān)系(P0.001)。結(jié)論1、循環(huán)血miR-133a在冠狀動脈分叉病變PCI相關(guān)心肌損傷的患者中表達量明顯升高,并且在分支損傷和末梢栓塞兩個亞組的患者中均升高。提示miR-133a能夠區(qū)分分叉病變行PCI術(shù)后是否發(fā)生了心肌損傷。2、miR-133a的表達量與經(jīng)典指標(biāo)肌鈣蛋白濃度和心型脂肪酸結(jié)合蛋白陽性率具有正相關(guān)性,提示miR-133a對PCI相關(guān)心肌損傷具有診斷價值。3、miR-133a在PCI相關(guān)心肌損傷中的診斷價值不劣于肌鈣蛋白的診斷價值,且優(yōu)于心型脂肪酸結(jié)合蛋白；miR-133a對分支血管損傷的診斷價值,與肌鈣蛋白及心型脂肪酸結(jié)合蛋白的相似；對末梢血管栓塞的診斷價值,優(yōu)于心型脂肪酸結(jié)合蛋白,但較肌鈣蛋白低。4、PCI相關(guān)心肌損傷患者的MACEs發(fā)生率較高,miR-133a表達量升高程度與MACE發(fā)生率呈正相關(guān),提示miR-133a可能對評價PCI相關(guān)心肌損傷患者的預(yù)后具有一定價值。
[Abstract]:Background coronary intervention has become one of the main treatments for coronary atherosclerotic heart disease. With the improvement of the technical level, more and more complex and multi branch lesions are selected for PCI treatment. About 30% of the patients who have been treated with PCI have PCI related cardiac muscle injury. Because of the special anatomical structure of the lesion, the operation of this kind of lesion is complicated and the risk of PCI related myocardial injury is increased accordingly. For this kind of patient, the injury of the myocardium is mainly caused by the involvement of the branch vessels and the peripheral vascular embolism caused by the PCI operation. The level of the elevation of the markers can reflect the extent of myocardial damage and help to determine the prognosis of the patients. The purpose of this study was to explore the expression of miR-133a in circulating blood in patients with PCI related myocardial injury and to compare it with the results of the detection of troponin and heart type fatty acid binding protein, and explore miR-133a The diagnostic value of myocardial injury. (1) this study was collected from January 2014 to December 2014 at the Department of Cardiology, Changhai Hospital, Second Military Medical University, who underwent percutaneous coronary intervention. The coronary bifurcation lesion was listed as the study object, excluding the bifurcation lesions and the bifurcation disease before the intervention treatment. Patients who had undergone interventional therapy were divided into observation group and control group according to the results of coronary arteriography and the upper limit of the concentration of troponin 99% (99%). The observation group was divided into two subgroups of branch vascular injury and peripheral vascular embolization. The control group was treated with PCI treatment but did not have PCI related myocardial injury. (two) the basic clinical data and operation related conditions were collected and compared respectively with the PCI related myocardial injury group and the control group. (three) 1, the expression of miRNAs in the circulation blood and the troponin in the postoperative circulatory blood of the PCI related myocardial injury group and the control group were detected. The positive rate of concentration and heart type fatty acid binding protein was compared to whether the expression of the three markers was different between the two groups, and the expression of miRNAs in the circulating blood of the branch injury group and the end embolic group and the control group was compared, and the difference in the positive rate of the troponin concentration and the heart type lipoic acid binding protein was compared. Four) 1. The correlation between the expression of miRNAs in circulating blood and the positive rate of cardiac troponin and cardiac fatty acid binding protein in circulating blood of all patients was.2. The correlation between the expression of miRNAs in circulating blood and the correlation between the concentration of troponin and the positive rate of cardiac fatty acid binding protein in the circulating blood of patients with PCI related myocardial injury was analyzed, and the analysis of the miR-133a table in the patients with the branch injury group was analyzed. The correlation between the dose and the results of the diagnostic gold standard coronary angiography (.4), the correlation between miR-133a expression and the concentration of the diagnostic gold standard was analyzed. (five) to draw a ROC curve to evaluate the diagnostic value of miR-133a on PCI related myocardial injury in bifurcated lesions, as well as the diagnostic value of the branch injury group and the end embolic group. And compared with the diagnostic value of troponin and heart type fatty acid binding protein respectively. (six) after 3-12 months of telephone and outpatient follow-up, the major adverse cardiovascular events (Major adverse cardiovascular events, MACEs) were recorded, including cardiac death, non fatal myocardial infarction, recurrent angina, and heavy blood transport. 225 cases of PCI related myocardial injury were included in this study, including 128 cases of PCI related myocardial injury group, including 26 cases of branch injury group and 102 cases of end embolic group, 97 cases in control group. (two) compared with the control group, the PCI related myocardial injury group and the control group, and the branch injury group and the end embolic group. Compared with the control group, there was no significant difference between the basic clinical data and the operation related groups (P0.05). (three) 1. The expression of miR-133a in the circulating blood and the concentration of troponin, the positive rate of the cardiac fatty acid binding protein in the PCI related myocardial injury groups were significantly higher, and the difference was statistically significant (P0.001).2, as compared with the control group. The expression of miR-133a, the concentration of troponin and the positive rate of cardiac fatty acid binding protein in the branch injury group and the end embolic group were significantly higher than those in the control group (P0.01). (four) 1, the level of circulating blood miR-133a and the positive rate of cardiac troponin and heart type fatty acid binding protein in all patients were in all patients. With positive correlation (P0.001).2, the expression of circulating blood miR-133a in the patients with PCI related myocardial injury has a positive correlation with the concentration of troponin and the positive rate of the heart type fatty acid binding protein (P0.001, P0.05).3. The amount of circulating blood miR-133a in the patients with branch injury has a positive correlation with the results of the diagnostic gold standard coronary angiography. (P0.001).4, there was a positive correlation between the expression of miR-133a in circulating blood and the level of diagnostic gold standard troponin (P0.05). (five) 1. The ROC curve of the diagnostic value of miR-133a for PCI related myocardial injury in bifurcation lesions showed that the area under the curve (Area Under the Curve, AUC) was 0.860, and muscle calcium. The diagnostic value of protein 0.993 (95%CI:0-1) was slightly lower, but the difference was not statistically significant (P0.05). Compared with 0.594 (95%CI:0.521-0.668) of the heart type fatty acid binding protein (95%CI:0.521-0.668), the diagnostic value was higher, the difference was not statistically significant (P0.05).2, the AUC of miR-133a in the branch injury group was 0.912 (95%CI:0.847-0.955), and the AUC of troponin was 0.967. 95%CI:0.918-0.991), the AUC of the heart type fatty acid binding protein was 0.818 (95%CI:0.738-0.881), and there was no statistically significant difference between the three (P0.05).3. The AUC of miR-133a was 0.846 (95%CI:0.788-0.893) in the end embolic group, and the AUC of troponin was 1 (95%CI: 0.981-1.0), and the AUC of the heart type fatty acid binding protein was 0.536. 4-0.607), 22 the difference was statistically significant (P0.001). (six) there was no MACEs in the branch injury group and the end embolic group during the hospitalization. During the follow-up period of 3-12 months after discharge, 12 cases (5.33%) of all the patients in the group were MACEs, including 10 in the observation group (7.81%) and 2 in the control group (2.06%). The branch injury group in the observation group occurred MAC. There were 5 cases (19.23%) of Es, 5 cases of MACEs in peripheral embolism group (4.90%) the incidence of MACEs in.PCI related myocardial injury patients was higher than that of the control group, the difference was statistically significant (P0.05). Further analysis of the correlation between the degree of miR-133a expression and the incidence of MACEs was further analyzed. The results showed that the positive correlation between the two groups was positive correlation (P0.001). Conclusion 1, circulating miR-133a. The expression level of PCI related myocardial injury in the coronary bifurcation lesions was significantly elevated and increased in the two subgroups of branch injury and distal embolism. It was suggested that miR-133a could distinguish the myocardial injury.2 after PCI, the expression of miR-133a and the cardiac troponin concentration and heart type. The positive correlation of fatty acid binding protein has positive correlation, suggesting that miR-133a has a diagnostic value of.3 for PCI related myocardial injury. The diagnostic value of miR-133a in PCI related myocardial injury is not inferior to the diagnostic value of troponin, and is superior to the heart type fatty acid binding protein; the value of miR-133a in the diagnosis of branch vascular injury and troponin and cardiac troponin and heart The diagnostic value of type fatty acid binding protein is better than that of heart type fatty acid binding protein, but the incidence of MACEs in patients with PCI related myocardial injury is higher than that of cardiac troponin.4, and the level of miR-133a expression is positively correlated with the incidence of MACE. It is suggested that miR-133a may be used to evaluate the patients with myocardial injury associated with PCI The prognosis is of certain value.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R542.2

【共引文獻】

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