郜 攀，宋雙雙，司良毅

·論著·

踝臂指數(shù)、臂踝脈搏波傳導(dǎo)速度及血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值研究

郜 攀，宋雙雙，司良毅

目的 探討踝臂指數(shù)(ABI)、臂踝脈搏波傳導(dǎo)速度(baPWV)及血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值。方法 選取2010—2013年中國人民解放軍第三軍醫(yī)大學(xué)西南醫(yī)院老年病科收治的單純2型糖尿病患者92例(T2DM組)，單純冠心病患者153例(CHD組)，2型糖尿病合并冠心病患者68例(T2DM-CHD組)；另選取同期體檢健康者150例作為對(duì)照組。檢測各組受試者ABI、baPWV及血清Meprin-α水平，并分析ABI、baPWV及血清Meprin-α水平對(duì)冠心病及2型糖尿病合并冠心病的診斷價(jià)值。結(jié)果 T2DM組和T2DM-CHD組患者ABI低于對(duì)照組(P<0.05)；T2DM組、CHD組及T2DM-CHD組患者baPWV高于對(duì)照組，T2DM-CHD組患者baPWV高于CHD組(P<0.05)；T2DM組、CHD組及T2DM-CHD組患者血清Meprin-α水平高于對(duì)照組，T2DM組和T2DM-CHD組患者血清Meprin-α水平高于CHD組(P<0.05)。受試者工作特征曲線(ROC)曲線顯示，ABI對(duì)冠心病無診斷價(jià)值(P>0.05)，baPWV對(duì)冠心病的診斷價(jià)值較高(AUC=0.973)，血清Meprin-α水平對(duì)冠心病的診斷價(jià)值為中等(AUC=0.720)。baPWV對(duì)2型糖尿病合并冠心病的診斷價(jià)值較高(AUC=0.940)，當(dāng)baPWV≥1 936 cm/s時(shí)其診斷2型糖尿病合并冠心病的靈敏度為82.4%、特異度為96.7%；血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值為中等(AUC=0.875)，當(dāng)血清Meprin-α水平≥2 314 ng/L時(shí)其診斷2型糖尿病合并冠心病的靈敏度為80.9%、特異度為92.4%。以冠狀動(dòng)脈造影作為診斷冠心病的金標(biāo)準(zhǔn)，baPWV≥1 936 cm/s聯(lián)合血清Meprin-α水平≥2 314 ng/L對(duì)2型糖尿病合并冠心病的診斷符合率為98.1%。結(jié)論 ABI與冠狀動(dòng)脈病變無明顯相關(guān)性，baPWV對(duì)2型糖尿病合并冠心病的診斷價(jià)值較高，血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值為中等，baPWV聯(lián)合血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值更高。

糖尿病，2型；冠心?。货妆壑笖?shù)；臂踝脈搏波傳導(dǎo)速度；Meprin-α；診斷

郜攀，宋雙雙，司良毅.踝臂指數(shù)、臂踝脈搏波傳導(dǎo)速度及血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值研究[J].實(shí)用心腦肺血管病雜志，2015，23(11)：1-4.[www.syxnf.net]

Gao P，Song SS，Si LY.Diagnostic value of ABI，baPWV and serum Meprin-α level in diagnosis of type 2 diabetes mellitus complicated with coronary heart disease[J].Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease，2015，23(11)：1-4.

臨床研究顯示，糖尿病患者合并冠心病的風(fēng)險(xiǎn)較高，且預(yù)后較差，分析原因可能為糖尿病自身病理變化能夠影響冠狀動(dòng)脈粥樣硬化的發(fā)生、發(fā)展，且冠狀動(dòng)脈粥樣硬化和糖代謝紊亂相互作用、相互影響，導(dǎo)致患者血清炎性因子及蛋白等表達(dá)異常[1-3]。早期診斷冠心病并及時(shí)有效治療能夠明顯減少心肌梗死、心力衰竭、腦卒中等心腦血管事件發(fā)生率。Meprin-α是一種主要由腎臟分泌的蛋白酶，近年來筆者研究了血清Meprin-α水平與炎癥、動(dòng)脈粥樣硬化等的關(guān)系及其作用機(jī)制，結(jié)果發(fā)現(xiàn)Meprin-α有介導(dǎo)細(xì)胞炎性因子、氧化應(yīng)激反應(yīng)進(jìn)而促動(dòng)脈粥樣硬化的作用[4-5]。踝臂指數(shù)(ABI)、臂踝脈搏波傳導(dǎo)速度(baPWV)是反映動(dòng)脈粥樣硬化的主要指標(biāo)，且其可以通過動(dòng)脈血管硬化儀進(jìn)行檢測，具有方便、易操作等特點(diǎn)。本研究擬探討ABI、baPWV聯(lián)合血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值，旨在為臨床早期診斷及及時(shí)干預(yù)2型糖尿病合并冠心病提供依據(jù)。

1 資料與方法

1.1 一般資料 選取2010—2013年中國人民解放軍第三軍醫(yī)大學(xué)西南醫(yī)院老年病科收治的單純2型糖尿病患者92例(T2DM組)，單純冠心病患者153例(CHD組)，2型糖尿病合并冠心病患者68例(T2DM-CHD組)；另選取同期體檢健康者150例作為對(duì)照組。經(jīng)冠狀動(dòng)脈造影證實(shí)至少1處主要冠狀動(dòng)脈狹窄率≥50%則診斷為冠心病，均排除繼發(fā)性高血壓、腎功能不全及其并發(fā)癥、惡性腫瘤患者。T2DM組中男57例，女35例；平均年齡(61.3±7.6)歲。CHD組中男88例，女65例；平均年齡(53.2±6.4)歲。T2DM-CHD組中男42例，女26例；平均年齡(60.2±6.9)歲。對(duì)照組中男87例，女63例；平均年齡(53.4±3.7)歲。各組受試者性別(χ2=0.038)、年齡(F=0.065)比較，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，具有可比性。本研究獲得醫(yī)院倫理委員會(huì)批準(zhǔn)，所有受試者簽署知情同意書。

1.2 研究方法 采集各組受試者臨床資料，包括性別、年齡，入院第2天空腹?fàn)顟B(tài)下檢測血脂、血糖等。記錄各組受試者ABI、baPWV及血清Meprin-α水平。

1.2.1 ABI和baPWV 采用日本歐姆龍動(dòng)脈硬化檢測儀(型號(hào)：BP-203RPEⅢ)檢測baPWV和ABI，每位受檢者均重復(fù)測量2次，并取其平均值。ABI取兩側(cè)低值，baPWV取兩側(cè)高值，其中ABI<0.9考慮為外周血管閉塞癥，但該類患者已被剔除。

1.2.2 血清Meprin-α水平 入院后立即采集受試者靜脈血3 ml，2 h內(nèi)12 000 r/min離心20 min，取上清液，采用酶聯(lián)免疫吸附試驗(yàn)(ELISA)檢測Meprin-α水平。

2 結(jié)果

2.1 各組受試者ABI、baPWV及血清Meprin-α水平比較 各組受試者ABI、baPWV及血清Meprin-α水平比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；T2DM組和T2DM-CHD組患者ABI低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；T2DM組、CHD組及T2DM-CHD組患者baPWV高于對(duì)照組，T2DM-CHD組患者baPWV高于CHD組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；T2DM組、CHD組及T2DM-CHD組患者血清Meprin-α水平高于對(duì)照組，T2DM組和T2DM-CHD組患者血清Meprin-α水平高于CHD組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見表1)。

Table 1 Comparison of ABI，baPWV and serum Meprin-α level among the four groups

組別例數(shù)ABIbaPWV(cm/s)Meprin-α(ng/L)對(duì)照組1501.2±0.31201.89±262.33654.33±91.25T2DM組920.7±0.3a1765.88±125.00a2143.81±123.92abCHD組1531.1±0.21667.22±242.33a1835.96±211.34aT2DM-CHD組680.6±0.3a2245.85±308.98ab2444.40±210.23abF值2.0843.5263.751P值0.0240.0120.010

注：ABI=踝臂指數(shù)，baPWV=臂踝脈搏波傳導(dǎo)速度；與對(duì)照組比較，aP<0.05；與CHD組比較，bP<0.05

2.2 ABI、baPWV及血清Meprin-α水平診斷冠心病的ROC曲線 以對(duì)照組和CHD組受試者作為研究對(duì)象，繪制ABI、baPWV、血清Meprin-α水平診斷冠心病的ROC曲線，結(jié)果顯示ABI診斷冠心病的AUC為0.579，ABI對(duì)冠心病無診斷價(jià)值；baPWV診斷冠心病的AUC為0.973，提示baPWV對(duì)冠心病的診斷價(jià)值較高；血清Meprin-α水平診斷冠心病的AUC為0.720，提示血清Meprin-α水平對(duì)冠心病的診斷價(jià)值為中等，見圖1。

2.3 baPWV及血清Meprin-α水平診斷2型糖尿病合并冠心病的ROC曲線 以T2DM組和T2DM-CHD組患者作為研究對(duì)象，繪制baPWV及血清Meprin-α水平診斷2型糖尿病合并冠心病的ROC曲線。結(jié)果顯示baPWV診斷2型糖尿病合并冠心病的AUC為0.940，提示baPWV對(duì)2型糖尿病合并冠心病的診斷價(jià)值較高；選擇約登指數(shù)最大點(diǎn)作為截?cái)帱c(diǎn)，當(dāng)baPWV≥1 936 cm/s時(shí)其診斷2型糖尿病合并冠心病的靈敏度為82.4%、特異度為96.7%。血清Meprin-α水平診斷2型糖尿病合并冠心病的AUC為0.875，提示血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值為中等；選擇約登指數(shù)最大點(diǎn)作為截?cái)帱c(diǎn)，當(dāng)血清Meprin-α水平≥2 314 ng/L時(shí)其診斷2型糖尿病合并冠心病的靈敏度為80.9%、特異度為92.4%，見圖2。

注：A為baPWV診斷2型糖尿病合并冠心病的ROC曲線，B為血清Meprin-α水平診斷2型糖尿病合并冠心病的ROC曲線

圖2 baPWV及血清Meprin-α水平診斷2型糖尿病合并冠心病的ROC曲線

Figure 2 ROC curve for baPWV and serum Meprin-α level in diagnosis of type 2 diabetes mellitus complicated with coronary heart disease

注：A為ABI診斷冠心病的ROC曲線，B為baPWV診斷冠心病的ROC曲線，C為血清Meprin-α水平診斷冠心病的ROC曲線

圖1 ABI、baPWV及血清Meprin-α水平診斷冠心病的ROC曲線

Figure 1 ROC curve for ABI，baPWV and serum Meprin-α level in diagnosis of coronary heart disease

2.4 baPWV聯(lián)合血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值 以冠狀動(dòng)脈造影作為診斷冠心病的金標(biāo)準(zhǔn)，以baPWV≥1 936 cm/s且血清Meprin-α水平≥2 314 ng/L作為2型糖尿病合并冠心病的診斷標(biāo)準(zhǔn)，本研究中baPWV≥1 936 cm/s且血清Meprin-α水平≥2 314 ng/L的2型糖尿病患者共53例，其中冠心病52例，非冠心病1例，診斷符合率為98.1%。

3 討論

ABI是踝部收縮壓與肱動(dòng)脈收縮壓的比值，是一種可重復(fù)測量和易于獲得的客觀反映肢體缺血嚴(yán)重程度的檢測指標(biāo)。目前循證醫(yī)學(xué)已證實(shí)ABI是診斷外周動(dòng)脈血管性疾病的最佳無創(chuàng)檢測指標(biāo)[6]。有研究顯示，ABI降低與冠心病的發(fā)生相關(guān)，ABI<1.0是預(yù)測冠心病和冠狀動(dòng)脈病變嚴(yán)重程度的獨(dú)立風(fēng)險(xiǎn)因子，美國ATPⅢ指出對(duì)外周動(dòng)脈ABI異常的冠心病患者應(yīng)降低密度脂蛋白(LDL)降至2.6 mmol/L以下[7]。本研究結(jié)果顯示，對(duì)照組和CHD組受試者ABI間無差異，結(jié)合ABI診斷冠心病的ROC曲線，顯示ABI對(duì)冠心病無診斷價(jià)值。究其原因，ABI是踝部收縮壓與肱動(dòng)脈收縮壓的比值，部分高齡患者可能存在嚴(yán)重血管硬化(如血管鈣化)，因此，ABI對(duì)動(dòng)脈粥樣硬化的診斷無特異性；此外，有研究發(fā)現(xiàn)ABI與年齡密切相關(guān)，且高齡人群ABI明顯降低[8]。另有研究顯示，<65歲的冠心病患者與同年齡段非冠心病患者ABI相似[9]。本研究結(jié)果顯示，T2DM組及T2DM-CHD組患者ABI低于對(duì)照組和CHD組，提示2型糖尿病對(duì)血管狹窄程度有影響。

糖尿病易導(dǎo)致動(dòng)脈粥樣硬化，且隨著動(dòng)脈粥樣硬化發(fā)展，粥樣斑塊堵塞管腔而發(fā)展為心腦血管疾病。脈搏波傳導(dǎo)速度(PWV) 是指脈搏波由動(dòng)脈的一特定位置沿管壁傳播至另一特定位置的速率，其可以反映動(dòng)脈彈性，PWV越高提示血管壁越硬[10-12]。但baPWV易受其他因素影響，單純使用baPWV診斷冠心病易發(fā)生偏差。為此，本研究引進(jìn)血清Meprin-α水平作為協(xié)同判定冠狀動(dòng)脈病變的指標(biāo)。既往關(guān)于血清Meprin-α水平與動(dòng)脈粥樣硬化關(guān)系的研究多集中在基礎(chǔ)實(shí)驗(yàn)，并發(fā)現(xiàn)血清Meprin-α水平與細(xì)胞內(nèi)炎性因子分泌過程密切相關(guān)[13-14]。本研究擬初步探討血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值，結(jié)果顯示，血清Meprin-α水平對(duì)冠心病的診斷價(jià)值為中等；進(jìn)一步研究顯示，血清Meprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值亦為中等，而baPWV聯(lián)合血清 Meprin-α水平診斷2型糖尿病合并冠心病的符合率為98.1%。

綜上所述，baPWV聯(lián)合血清Meprin-α水平診斷2型糖尿病合并冠心病時(shí)，能夠克服兩者單獨(dú)使用易受其他因素影響的缺點(diǎn)，且baPWV聯(lián)合血清Meprin-α水平對(duì)2型糖尿病患者合并冠心病的診斷價(jià)值較高。

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(本文編輯：謝武英)

Diagnostic Value of ABI，baPWV and Serum Meprin-α Level in Diagnosis of Type 2 Diabetes Mellitus Complicated with Coronary Heart Disease

GAOPan，SONGShuang-shuang，SILiang-yi.DepartmentofGeriatrics，SouthwestHospitaloftheThirdMilitaryMedicalUniversityofChinesePeople′sLiberationArmy，Chongqing400038，China

Objective To analyze the diagnostic value of ABI，baPWV and serum Meprin-α level in diagnosis of type 2 diabetes mellitus complicated with coronary heart disease.Methods From 2010 to 2013 in the Department of Geriatrics，Southwest Hospital of the Third Military Medical University of Chinese People′s Liberation Army，92 patients with isolated type 2 diabetes mellitus were served as A group，153 patients with isolated coronary heart disease were served as B group，68 type 2 diabetes mellitus patients complicated with coronary heart disease were served as C group，150 healthy cases were served as D group.ABI，baPWV and serum Meprin-α level were detected，and their diagnostic value on coronary heart disease and type 2 diabetes mellitus complicated with coronary heart disease was analyzed，respestively.Results ABI of A group，C group was statistically significantly lower than that of D group，respectively(P<0.05)；baPWV of A group，B group，C group was statistically significantly higher than that of D group，respectively，and baPWV of C group was statistically significantly higher than that of B group(P<0.05)；serum Meprin-α level of A group，B group，C group was statistically significantly higher than that of D group，respectively，and serum Meprin-α level of A group，C group was statistically significantly higher than that of B group，respectively(P<0.05)。ROC curve showed that，ABI had no diagnostic value on coronary heart disease(P>0.05)，while baPWV had relatively high diagnostic value on coronary heart disease(AUC=0.973)，serum Meprin-α level had medium diagnostic value on coronary heart disease(AUC=0.720).baPWV had relatively high diagnostic value on type 2 diabetes mellitus complicated with coronary heart disease(AUC=0.940)，when it was equal or over 1 936 cm/s，the sensitivity was 82.4%，the specificity was 96.7%；serum Meprin-α level had medium diagnostic value on type 2 diabetes mellitus complicated with coronary heart disease(AUC=0.875)，when it was equal or over 2 314 ng/L，the sensitivity was 80.9%，the specificity was 92.4%.Take coronary angiography as the gold standard for coronary heart disease，the diagnostic accordance rate of combination of baPWV equal or over 1 936 cm/s and serum Meprin-α level equal or over 2 314 ng/L was 98.1% on type 2 diabetes mellitus complicated with coronary heart disease.Conclusion ABI is not significantly correlated with coronary artery lesion，baPWV has relatively high diagnostic value on type 2 diabetes mellitus complicated with coronary heart disease，and serum Meprin-α level has medium diagnostic value on type 2 diabetes mellitus complicated with coronary heart disease，combination of baPWV and serum Meprin-α level has higher diagnostic value on type 2 diabetes mellitus complicated with coronary heart disease.

Diabetes mellitus，type 2；Coronary disease；Ankle-brachial index；Brachial-ankle pulse wave velocity；Meprin-α；Diagnosis

國家自然科學(xué)基金(81000132，81370007)

400038重慶市，中國人民解放軍第三軍醫(yī)大學(xué)西南醫(yī)院老年病科

司良毅，400038重慶市，中國人民解放軍第三軍醫(yī)大學(xué)西南醫(yī)院老年病科；E-mail：doctorsly@126.ccom

R 587.1 R 541.4

A

10.3969/j.issn.1008-5971.2015.11.001

2015-08-05，

2015-11-05)

【編者按】 研究表明，2型糖尿病是冠心病的等危癥，>70%的2型糖尿病患者會(huì)并發(fā)冠心病，且其冠狀動(dòng)脈病變范圍較非糖尿病患者更廣，因此早期明確診斷2型糖尿病合并冠心病具有重要臨床意義。本研究探討了踝臂指數(shù)、臂踝脈搏波傳導(dǎo)速度及血清Merprin-α水平對(duì)2型糖尿病合并冠心病的診斷價(jià)值，引入了血清Merprin-α水平這一新指標(biāo)，研究結(jié)果顯示聯(lián)合檢測臂踝脈搏波傳導(dǎo)速度及血清Merprin-α水平對(duì)2型糖尿合并冠心病具有較高的診斷價(jià)值，且有利于克服單獨(dú)使用踝臂指數(shù)、臂踝脈搏波傳導(dǎo)速度或血清Merprin-α水平診斷冠心病易受其他因素影響的缺點(diǎn)，具有一定參考價(jià)值。