【摘要】：研究背景:長久以來,臨床上對于不穩(wěn)定型心絞痛(Unstable angina,UA)的診斷多依據(jù)胸痛癥狀及胸痛發(fā)作時心電圖的ST-T改變,但大部分患者無法做到胸痛發(fā)作當(dāng)時及時就醫(yī)檢查心電圖,而來院就診時心電圖已恢復(fù)正常或心電圖變化不具有診斷意義,因此如何早期診斷UA成為了目前臨床上一個亟待解決的問題。近年來研究發(fā)現(xiàn)缺血修飾白蛋白(Ischemia modified albumin,IMA)是早期識別心肌缺血的敏感指標(biāo),但診斷特異性不高;而二維斑點(diǎn)追蹤技術(shù)(Two-dimensional speckle tracking imaging,2D-STI)對于定量識別心肌缺血具有高度特異性,但敏感度較差。目的:利用受試者工作特征曲線(ROC曲線),探究聯(lián)合應(yīng)用缺血修飾白蛋白(IMA)與二維斑點(diǎn)追蹤技術(shù)(2D-STI)參數(shù)——左室整體峰值縱向應(yīng)變(GPLS)早期診斷不穩(wěn)定型心絞痛(UA)的價值。方法:根據(jù)冠狀動脈造影結(jié)果選取123例冠狀動脈左前降支單一病變且狹窄程度≥70%并行PCI治療的不穩(wěn)定型心絞痛(UA)患者(PCI組)以及82例冠狀動脈無狹窄的患者(對照組),兩組于術(shù)中記錄胸痛癥狀及胸痛發(fā)作時的標(biāo)準(zhǔn)12導(dǎo)聯(lián)心電圖,并且分別于術(shù)前及術(shù)后檢測血清IMA、行超聲心動圖檢查。應(yīng)用2D-STI技術(shù)測定左心室17節(jié)段的收縮期峰值縱向應(yīng)變(LS),并計算左室整體峰值縱向應(yīng)變(GPLS)。應(yīng)用ROC曲線確定IMA、GPLS對于UA的診斷臨界值(Cut-off值)。分別采用統(tǒng)計學(xué)上平行診斷試驗(yàn)及系列診斷試驗(yàn)兩種聯(lián)合診斷方法,評價IMA聯(lián)合GPLS(2D-STI)早期診斷UA的診斷價值。結(jié)果:1、PCI組術(shù)前血清IMA為43.56±9.38(U/ml),對照組術(shù)前血清IMA為44.55±8.81(U/ml),兩者比較差異無統(tǒng)計學(xué)意義(P0.001);PCI組術(shù)后血清IMA為82.80±14.28(U/ml),對照組術(shù)后血清IMA為59.91±18.29(U/ml),兩者比較差異有統(tǒng)計學(xué)意義(P0.001)。2、PCI組術(shù)前GPLS為-21.29±1.23(%),對照組術(shù)前GPLS為-21.47±1.53(%),兩者比較差異無統(tǒng)計學(xué)意義(P0.001);PCI組術(shù)后GPLS為-18.20±2.74(%),對照組術(shù)后GPLS為-21.28±2.39(%),兩者比較差異有統(tǒng)計學(xué)意義(P0.001)。3、IMA診斷UA的ROC曲線下面積為0.799[95%CI:0.734,0.864,P0.001],GPLS診斷UA的ROC曲線下面積為0.790[95%CI:0.726,0.853,P0.001];IMA聯(lián)合GPLS診斷UA的ROC曲線下面積為0.900[95%CI:0.859,0.940,P0.001]。4、IMA早期診斷UA的敏感度與特異性分別為83.3%、70.7%,誤診率與漏診率分別為29.3%、16.7%;GPLS早期診斷UA的敏感度與特異性分別為72.5%、82.9%,誤診率與漏診率分別為17.1%、27.5%。5、平行診斷試驗(yàn)時,IMA聯(lián)合GPLS早期診斷UA的敏感度與特異性分別為93.3%、53.7%,誤診率與漏診率分別為46.3%、6.7%。6、系列診斷試驗(yàn)時,IMA聯(lián)合GPLS早期診斷UA的敏感度與特異性分別為59.2%、100%,誤診率與漏診率分別為0%、40.8%。結(jié)論:1、IMA聯(lián)合GPLS(2D-STI)早期診斷UA的診斷準(zhǔn)確度高于IMA、GPLS(2D-STI)分別各自早期診斷UA。2、IMA聯(lián)合GPLS(2D-STI)采用平行診斷試驗(yàn)可以提高早期診斷UA的敏感度,降低漏診率;IMA聯(lián)合GPLS(2D-STI)采用系列診斷試驗(yàn)可以提高早期診斷UA的特異性,降低誤診率。3、臨床上對于UA的早期診斷旨在降低漏診率,可以采用平行診斷試驗(yàn)聯(lián)合IMA與2D-STI以早期診斷UA。
[Abstract]:BACKGROUND: For a long time, clinical diagnosis of unstable angina (UA) has been based on the symptoms of chest pain and ST-T changes of electrocardiogram during chest pain attacks. However, most of the patients can not get timely examination of electrocardiogram at the time of chest pain attacks, and the electrocardiogram has returned to normal at the time of hospitalization. In recent years, it has been found that ischemia modified albumin (IMA) is a sensitive marker for early detection of myocardial ischemia, but its diagnostic specificity is not high; and two-dimensional speckle tracking imagine (two-dimensional speckle tracking imagine) is an important technique for early detection of myocardial ischemia. Objective: To explore the early diagnosis of unstable angina pectoris (UA) by combining ischemic modified albumin (IMA) with two-dimensional speckle tracking technique (2D-STI), i.e. global peak longitudinal strain of the left ventricle (GPLS). Methods: 123 patients with unstable angina pectoris (UA) and 82 patients without coronary artery stenosis (control group) with single lesion of left anterior descending coronary artery (LAD) and more than 70% stenosis were selected according to the results of coronary angiography. The peak systolic longitudinal strain (LS) of 17 segments of the left ventricle was measured by two-dimensional STI technique and the global peak longitudinal strain (GPLS) of the left ventricle was calculated. The diagnostic value of IMA combined with GPLS (2-D-STI) in early diagnosis of UA was evaluated by diagnostic test and serial diagnostic test. Results: 1. The preoperative serum IMA of PCI group was 43.56 (+9.38) U/ml, while that of control group was 44.55 (+8.81) U/ml. There was no significant difference between the two methods (P 0.001); the postoperative serum IMA of PCI group was 82.80 (+14.28) U/ml, respectively. The serum IMA of the control group was 59.91 (+18.29) (U/ml), and the difference was statistically significant (P 0.001). The GPLS of the PCI group was -21.29 (%) and the control group was - 21.47 (%) before operation. The difference was not statistically significant (P 0.001); the GPLS of the PCI group was - 18.20 (%) and the control group was - 21.28 (%) after operation. The area under the ROC curve of IMA was 0.799 [95% CI: 0.734, 0.864, P 0.001], the area under the ROC curve of GPLS was 0.790 [95% CI: 0.726, 0.853, P 0.001], and the area under the ROC curve of IMA combined with GPLS was 0.900 [95% CI: 0.859, 0.940, P 0.001]. 4, the sensitivity and specificity of IMA for early diagnosis of UA were 83.3%, respectively. The sensitivity and specificity of GPLS for early diagnosis of UA were 72.5%, 82.9%, 17.1% and 27.5% respectively. The sensitivity and specificity of IMA combined with GPLS for early diagnosis of UA were 59.2%, 100%, misdiagnosis rate and missed diagnosis rate were 0% and 40.8%, respectively. Conclusion: 1. IMA combined with GPLS (2D-STI) for early diagnosis of UA was more accurate than IMA, GPLS (2D-STI) for early diagnosis of UA was higher than IMA, GPLS (2D-STI) for early diagnosis of UA was higher than IMA combined with GPLS (2D-STI). The sensitivity of early diagnosis of UA and the rate of missed diagnosis can be reduced. The combination of IMA and GPLS (2D-STI) can improve the specificity of early diagnosis of UA and reduce the rate of misdiagnosis.
【學(xué)位授予單位】：山西醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R541.4

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本文編號：2211904