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        急性冠脈綜合征患者B型利鈉肽與全球急性冠狀動脈事件注冊評分的相關(guān)性

        2017-08-26 12:53:26李晶瑋王鴻杜鳳和徐秀英
        中國醫(yī)藥導報 2017年20期
        關(guān)鍵詞:危組B型意義

        李晶瑋++王鴻++杜鳳和++徐秀英++田俊萍

        [摘要] 目的 探討急性冠脈綜合征(ACS)患者B型利鈉肽(BNP)與全球急性冠狀動脈事件注冊(GRACE)評分間的關(guān)系。 方法 選取首都醫(yī)科大學附屬北京天壇醫(yī)院2015年6月~2016年8月收治的104例ACS患者,根據(jù)GRACE評分將ACS患者分為低危(≤108分)、中危(109~140分)和高危(>140分)三組,分別檢測各亞組BNP。將BNP水平從低到高按四分位數(shù)分成Q1~4組,計算各組GRACE評分及高危百分比。分析BNP與GRACE評分的相關(guān)性。使用受試者操作特征曲線(ROC)分析BNP水平及GRACE評分對ACS患者住院期間發(fā)生主要不良心臟事件(MACE)的曲線下面積,評估其預(yù)測價值。 結(jié)果 ACS三個亞組中,高危組BNP高于中危組(P < 0.05)和低危組(P < 0.01),差異有統(tǒng)計學意義。Q4組GRACE評分及高危百分比高于Q4以下組(P < 0.05)。相關(guān)性分析顯示,BNP結(jié)果與GRACE評分呈正相關(guān)(r = 0.448,P < 0.01)?;€BNP水平及GRACE評分對ACS患者住院期間發(fā)生MACE的曲線下面積分別為0.677和0.745,差異有統(tǒng)計學意義(P < 0.05)。 結(jié)論 BNP水平和GRACE評分對ACS患者住院期間發(fā)生MACE有預(yù)測價值,可能成為ACS患者預(yù)后判斷的重要指標。

        [關(guān)鍵詞] 急性冠脈綜合征;B型利鈉肽;全球急性冠狀動脈事件注冊;主要不良心臟事件

        [中圖分類號] R541.4 [文獻標識碼] A [文章編號] 1673-7210(2017)07(b)-0054-04

        Association between interleukin-6 and global registry of acute coronary events score in patients with acute coronary syndrome

        LI Jingwei1▲ WANG Hong2 DU Fenghe1 XU Xiuying1 TIAN Junping1▲

        1.Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China; 2.Department of Endocrinology, Aerospace Center Hospital, Beijing 100049, China

        [Abstract] Objective To investigate the correlation between brain natriuretic peptide (BNP) level and global registry of acute coronary events (GRACE) risk score in patients with acute coronary syndrome (ACS). Methods One hundred and four patients with ACS admitted to Beijing Tiantan Hospital, Capital Medical University from June 2015 to August 2016 were selected. According to GRACE risk score, the patients with ACS were divided into low risk (GRACE: ≤108 points), intermediate (GRACE: 109-140 points) and high (GRACE: >140 points) 3 groups, the levels of BNP in each subgroup were detected. According to the BNP level, the patients were divided into 4 groups from Q1 to Q4, and the GRACE scores and high-risk percentages were calculated. The correlation between BNP and GRACE score was analyzed. Receiver operating characteristic (ROC) was used to analyze the area under the curve of BNP level and GRACE risk score for major adverse cardiac events (MACE) in patients with ACS during hospitalization, and to evaluate its predictive value. Results Among the 3 subgroups of ACS, the BNP in high risk group was higher than the middle risk group (P < 0.05) and the low risk group (P < 0.01), the differences were statistically significant. The GRACE score and high-risk percentage in group Q4 were higher than those in groups under Q4 (P < 0.05). Correlation analysis showed that BNP results were positively correlated with GRACE score (r = 0.448, P < 0.01). The area under the curve of baseline BNP level and GRACE score for ACS patients during hospitalization was 0.677 and 0.745, respectively, the difference was statistically significant (P < 0.05). Conclusion Both BNP level and GRACE score can predict the occurrence of MACE in ACS patients during hospitalization, which may be an important prognostic indicator for ACS patients.

        [Key words] Acute coronary syndrome; Brain natriuretic peptide; Global registry of acute coronary events; Major adverse cardiac events

        急性冠脈綜合征(ACS)患者早期風險評估對于高?;颊叩念A(yù)后與治療有重要的臨床價值[1-2]。全球急性冠狀動脈事件注冊(GRACE)評分是目前最有效的預(yù)測ACS患者預(yù)后及危險程度的評價系統(tǒng)[3-6],不僅可預(yù)測患者心血管事件發(fā)生率及住院期間病死率,還可預(yù)測患者遠期病死率[7-8]。B型利鈉肽(BNP)可用于心力衰竭的診斷及預(yù)后評估、穩(wěn)定型心絞痛及ACS患者的危險分層[9-11]。本研究旨在探討B(tài)NP水平與GRACE評分在ACS患者中的相關(guān)性。

        1 資料與方法

        1.1 一般資料

        選擇首都醫(yī)科大學附屬北京天壇醫(yī)院重癥監(jiān)護病房2015年6月~2016年8月收治的104例首診ACS患者。其中,男69例,女35例,年齡33~89歲,平均(62.38±12.12)歲。

        入選標準:患者首診ACS,并經(jīng)冠狀動脈造影證實;獲得患者本人知情同意。排除標準:既往明確診斷冠心病、先天性心臟病、心肌病、瓣膜病變者均排除在外;并發(fā)腦卒中、全身大動脈疾病、周圍血管疾病或周圍血管栓塞性疾病者、嚴重肝腎疾病、腫瘤、血液系統(tǒng)疾病、惡性腫瘤、急性感染、慢性感染急性發(fā)作、自身免疫病。

        1.2 方法

        1.2.1 儀器設(shè)備及血液標本采集 日本日立LABOSPECT008型全自動生化分析儀。患者禁食至少8 h后,入院第2天清晨8:00之前空腹采血。

        1.2.2 冠狀動脈造影結(jié)果分析及風險評分方法 冠心病診斷標準是冠狀動脈造影結(jié)果顯示至少1支冠狀動脈狹窄程度≥50%。風險評估用GRACE評分[2],分3組:低危組≤108分;中危組109~140分;高危組>140分。

        1.2.3 隨訪 計算主要不良心臟事件(MACE)的發(fā)生率。院內(nèi)終點事件包括心血管死亡、心力衰竭、心源性休克、室性心動過速及心室顫動等高危心律失常、心跳驟停、心絞痛、再次心梗、再次血運重建、腦卒中等。

        1.3 統(tǒng)計學方法

        所有數(shù)據(jù)用SPSS 17.0統(tǒng)計軟件包處理。計量資料以均數(shù)±標準差(x±s)表示,采用單因素方差分析;計數(shù)資料以百分比或率表示,采用χ2檢驗。正態(tài)分布資料間的相關(guān)性采用Pearson直線相關(guān)分析。非正態(tài)分布資料間的相關(guān)性采用Spearman直線相關(guān)分析。非正態(tài)分布時,采用秩和檢驗。使用受試者操作特征曲線(ROC)分析基線BNP水平及GRACE評分對ACS發(fā)生MACE的預(yù)測價值。以P < 0.05為差異有統(tǒng)計學意義。

        2 結(jié)果

        研究過程中,2例患者因不明原因未抽血檢測BNP。

        2.1 GRACE不同危險分層的ACS患者基線資料比較

        ACS三個亞組中,中危組、高危組GRACE評分、年齡、三酰甘油與低危組比較,差異均有高度統(tǒng)計學意義(P < 0.01),高危組BNP、舒張壓、C反應(yīng)蛋白、肌酐與低危組比較,差異有統(tǒng)計學意義(P < 0.05或P < 0.01)。高危組BNP、GRACE評分、年齡、肌酐與中危組比較,差異有統(tǒng)計學意義(P < 0.05或P < 0.01)。見表1。

        2.2 GRACE評分高危組與ACS患者血漿BNP水平四分位數(shù)分組的關(guān)系

        按照BNP水平,將ACS患者進行四分位數(shù)分組(Q1~4組)。Q4組GRACE評分與Q1~3組GRACE評分進行比較,差異均有統(tǒng)計學意義(P < 0.05)。見表2。Q1~4組的GRACE低中高危構(gòu)成比較,Pearson Chi-square=22.58,P = 0.001,差異有統(tǒng)計學意義。其中,GRACE低危組與中危組,Pearson Chi-square=5.625,P = 0.131;GRACE低危組與高危組,Pearson Chi-square=23.050,P = 0.000;GRACE中危組與高危組,Pearson Chi-square=10.056,P = 0.018。GRACE高危組與低危及中危組比較,差異均有統(tǒng)計學意義。見表3。

        注:與Q1組比較,**P < 0.01;與Q2組比較,△△P < 0.01;與Q3組比較,▲P < 0.05;BNP:B型利鈉肽;ACS:急性冠脈綜合征;GRACE:全球急性冠狀動脈事件注冊

        2.3 ACS患者血漿BNP水平與GRACE評分相關(guān)性

        將BNP與GRACE作雙變量相關(guān)分析,結(jié)果顯示:二者呈正相關(guān),差異有統(tǒng)計學意義。相關(guān)系數(shù)r = 0.448,P = 0.000,即GRACE與BNP高度相關(guān)。見圖1。

        2.4 ACS患者BNP水平對院內(nèi)MACE的預(yù)測

        使用ROC曲線分析,BNP對ACS患者發(fā)生院內(nèi)MACE的曲線下面積(AUC)為0.677,差異有統(tǒng)計學意義(SE = 0.080,P = 0.017,95%CI:0.520~0.834)。GRACE對ACS患者住院期間發(fā)生MACE的AUC為0.745,差異有統(tǒng)計學意義(SE = 0.070,P = 0.001,95%CI:0.608~0.882)。見圖2。104例ACS患者有20例(19.23%)發(fā)生院內(nèi)MACE,院內(nèi)死亡1例(0.96%)。在預(yù)測ACS患者近期(住院期間)發(fā)生MACE的價值上,兩項指標差異有統(tǒng)計學意義(P < 0.05)。

        3 討論

        ACS致病機制主要包括不穩(wěn)定斑塊內(nèi)膜的淺表糜爛和穩(wěn)定斑塊的纖維帽破裂[12]。炎性反應(yīng)在易損斑塊的形成及不穩(wěn)定斑塊的破潰中都發(fā)揮著重要作用[13-14]。GRACE評分在預(yù)測心肌梗死死亡、評估冠狀動脈血管病變嚴重程度等方面具有重要的臨床價值[15],優(yōu)于PURSUIT評分和TIMI評分[16]。

        本研究GRACE評分高危組的BNP水平,與低、中危組比較差異均有統(tǒng)計學意義。將ACS患者按照BNP水平從低到高進行四分位數(shù)分組,Q4組GRACE分值及高危百分比與Q1~3組比較均有統(tǒng)計學差異,表明BNP數(shù)值與ACS病情嚴重性呈正相關(guān)。本研究BNP水平與GRACE評分呈正相關(guān)。ROC曲線分析顯示BNP與GRACE評分在預(yù)測ACS患者發(fā)生MACE的價值上差異有統(tǒng)計學意義(P < 0.05)。結(jié)果提示:BNP與GRACE評分對ACS患者預(yù)后均有預(yù)測價值;GRACE評分預(yù)測價值優(yōu)于BNP。

        腦鈉肽前體(NT-proBNP)水平與GRACE評分是強大的MACE的預(yù)測因子[17]。血漿BNP水平可以提高GRACE評分的準確性,可能在臨床實踐中提高ACS的危險分層準確性[18],支持本研究結(jié)論。另外一些研究認為,BNP附加判斷價值高于GRACE評分[19]。超敏肌鈣蛋白或BNP沒有提高GRACE評分的風險預(yù)測價值[20]。

        本研究提示BNP與GRACE評分具有相關(guān)性,BNP可預(yù)測ACS預(yù)后,但預(yù)測價值并不優(yōu)于GRACE評分,二者協(xié)同可對ACS患者進行更有效的早期風險評估。本研究總樣本量偏少,觀察時間偏短,需進一步在多中心、大規(guī)模人群中進一步研究。

        [參考文獻]

        [1] Raposeiras-Roubín S,Abu-Assi E,Cabanas-Grandío P,et al. Walking beyond the GRACE model in the death risk stratification during hospitalization in patients with acutecoronary syndrome:what do the AR-G Registry and GWTG,NCDR,and EuroHeart Risk Scores Provide? [J]. JACC Cardiovasc Interv,2012,5(11):1117-1125.

        [2] Bajaj RR,Goodman SG,Yan RT,et al. Treatment and outcomes of patients with suspected acute coronary syndromes in relation to initial diagnostic impressions(Insights from the Canadian GRACE and CANRACE)[J]. Am J Cardiol,2013, 111(2):202-207.

        [3] Widera C,Pencina MJ,Meisuer A,et al. Adjustment of the GRACE score by growth differentiation factor 15enables a more accurate appreelation of risk in non.ST-elevation acute coronary syndrome [J]. Eur Heart J,2012,33(9):1095-1104.

        [4] Zhou BD,Zu LY,Mi L,et al. An analysis of patients receiving emergency CAG without PCI and the value of GRACE score in predicting PCI possibilities in NSTE-ACS patient [J]. J Geriatr Cardiol,2015,12(3):246-250.

        [5] Chew DP,Astley CM,Luker H,et al. A cluster randomized trial of objective risk assessment versus standard care for acute coronary syndromes:Rationale and design of the Australian GRACE Risk score Intervention Study(AGRIS)[J]. Am Heart J,2015,170(5):995-1004.

        [6] McAllister DA,Halbesma N,Carruthers K,et al. GRACE score predicts heart failure admission following acute coronary syndrome [J]. Eur Heart J Acute Cardiovasc Care,2015,4(2):165-171.

        [7] Wan ZF,Zhou D,Xue JH,et al. Combination of mean platelel volume and the GRACE risk score better predicts future cardiovascu1ar events in patients with acute coronary syndrome [J]. Platelets,2014,25(6):447-451.

        [8] Oncel RC,Ucar M,Karakas MS,et al. Relation of neutrophil-to-lymphocyte ratio with grace risk score to inhospital cardiac events in patients with ST-segment elevated myocardial infarction [J]. Clin Appl Thromb Hemost,2015, 21(4):383-388.

        [9] Mueller C,Laule-Kilian K,F(xiàn)rana B,et al. Use of B-type natriuretic peptide in the management of acute dyspnea in patients with pulmonary disease [J]. Am Heart J,2006,151(2):471-477.

        [10] Bibbins-Domingo K,Gupta R,Na B,et al. N-terminal fragment of the prohormone brain-type natriuretic peptide(NT-proBNP),cardiovascular events,and mortality in patients with stable coronary heart disease [J]. JAMA,2007,297(2):169-176.

        [11] Lindahl B,Lindback J,Jemberg T,et al. Serial analyses of N-terminal pro-B-type natriuretic peptide in patients with non-ST segment elevation acute coronary syndromes:a Fragmin and fast Revascularisation during In Stability in Coronary artery disease(FRISC)-Ⅱ substudy [J]. J Am Coll Cardiol,2005,45(4):533-541.

        [12] Libby P. Mechanisms of acute coronary syndromes and their implications for therapy [J]. N Engl J Med,2013,368(21):2004-2013.

        [13] Bentzon JF,Otsuka F,Virmani R,et al. Mechanisms of pla?鄄que formationand rupture [J]. Circ Res,2014,114(12):1852-1866.

        [14] Liang Y,Hou Y,Niu H,et al. Correlation of high-sensitivity C-reactive protein and carotid plaques with coronary artery disease in elderly patients [J]. Exp Ther Med,2015,10(1):275-278.

        [15] Martins A,Ribeiro S,Goncalves P,et al. Role of central obesity in risk stratification after an acute oronary event:does central obesity add prognostic value to the Global Registry of Acute Coronary Events(GRACE)risk score in patients with acute coronary syndrome? [J]. Rev Port Cardiol,2013,32(10):769-776.

        [16] Cakar MA,Sahinkus S,Aydin E,et al. Relation between the GRACE score and severity of atherosclerosis in acute coronary syndrome [J]. J Cardial,2014,63(1):24-28.

        [17] Onda T,Inoue K,Suwa S,et al. Reevaluation of cardiac risk scores and multiple biomarkers for the prediction of first major cardiovascular events and death in the drug-eluting stent era [J]. Int J Cardiol,2016,219:180-185.

        [18] Guidez T,Maréchaux S,Pin?觭on C,et al. Addition of B-type natriuretic peptide to the GRACE score to predict outcome in acute coronary syndrome:a retrospective(development)and prospective(validation)cohort-based study [J]. Emerg Med J,2012,29(4):274-279.

        [19] García-Alvarez A,Regueiro A,Hernández J,et al. Additional value of B-type natriuretic peptide on discrimination of patients at risk for mortality after a non-ST- segment elevation acute coronary syndrome [J]. Eur Heart J Acute Cardiovasc Care,2014,3(2):132-140.

        [20] Meune C,Drexler B,Haaf P,et al. The GRACE score's performance in predicting in-hospital and 1-year outcome in the era of high-sensitivity cardiac troponin assays and B-type natriuretic peptide [J]. Heart,2011,97(18):1479-1483.

        (收稿日期:2017-03-20 本文編輯:張瑜杰)

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