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        動脈僵硬度和骨保護素對穩(wěn)定型冠狀動脈疾病患者的預后評估

        2019-10-18 07:25:11延喜悅黃永華
        心腦血管病防治 2019年4期

        延喜悅 黃永華

        [摘 要] 目的 探討動脈僵硬度和骨保護素對穩(wěn)定型冠狀動脈疾?。╯table coronary artery disease,SCAD)患者預后的預測價值。方法 回顧性選擇在我院接受冠狀動脈介入治療的SCAD患者160例作為研究對象。根據隨訪期間有無主要不良心血管事件(major adverse cardiovascular events,MACE)發(fā)生分為MACE發(fā)生組(n=70)和MACE未發(fā)生組(n=90)。比較兩組患者在臨床特征方面的差異。通過繪制受試者工作特征曲線(receiver operating characteristic curve,ROC),篩選切點,計算曲線下面積評估不同參數預測SCAD患者MACE發(fā)生效力。應用多因素非條件Logistic回歸分析影響SCAD患者MACE發(fā)生的危險性因素。結果 MACE未發(fā)生組左心室射血分數高于MACE發(fā)生組,Gensini評分、脈搏波速度(pulse wave velocity,PWV)、骨保護素水平低于MACE發(fā)生組,差異有統(tǒng)計學意義(均P<0.05)。左心室射血分數、Gensini評分、PWV、骨保護素預測SCAD患者MACE發(fā)生的診斷界值分別為50.00%、32.35分、8.85m/s、3.78pmol/L(均P<0.05)。多因素Logistic回歸分析結果顯示,Gensini評分≥32.35分、PWV≥8.85m/s、骨保護素≥3.78pmol/L增加SCAD患者MACE發(fā)生風險(OR=3.72~3.85,均P<0.05)。結論 Gensini評分、PWV、骨保護素水平與SCAD患者MACE發(fā)生密切相關。PWV和骨保護素水平偏高不利于SCAD患者預后。

        [關鍵詞] 動脈僵硬度;骨保護素;穩(wěn)定型冠狀動脈疾病;主要不良心血管事件

        中圖分類號:R541.4? 文獻標識碼:A? 文章編號:1009-816X(2019)04-0311-04

        [Abstract] Objective To investigate the prognostic role of arterial stiffness and osteoprotegerin in patients with stable coronary artery disease (SCAD). Methods 160 patients with SCAD received coronary intervention therapy in our hospital were selected.The patients were divided into MACE group (n=70) and non-MACE group (n=90) according to whether MACE happened or not during the follow-up period. The differences in clinical characteristics between the two groups were compared. The ROC curve was drawn, the cut points were selected, the area under the curve was calculated, and the different parameters were used to predict the effectiveness of MACE in SCAD patients. Multivariate logistic regression analysis was used to analyze the risk factors of MACE in SCAD patients. Results The left ventricular ejection fraction in non-MACE group was higher than that in MACE group, while Gensini score, PWV, and osteoprotegerin were lower than those in MACE group, the difference were statistically significant (P<0.05). The diagnostic values of left ventricular ejection fraction, Gensini score, PWV and osteoprotegerin in predicting the occurrence of MACE in SCAD patients were 50.00%, 32.35points, 8.85m/s and 3.78pmol/L, respectively (P<0.05). The results of multiple factor logistic regression analysis showed that the Gensini score≥32.35 points, PWV≥8.85m/s, and osteoprotegerin≥3.78pmol/L increased the risk of MACE occur in SCAD patients (OR=3.72~3.85, P<0.05).Conclusions Gensini score, PWV and osteoprotegerin are closely related to MACE in SCAD patients. The high level of PWV and osteoprotegerin is bad for the prognosis of SCAD patients.

        2.2 相關參數預測SCAD患者MACE發(fā)生的ROC參數的特異度和靈敏度:見表2。

        2.3 SCAD患者MACE發(fā)生的多因素Logistic回歸分析:以隨訪期間有無MACE發(fā)生為因變量(賦值:未發(fā)生=0,發(fā)生=1),以左心室射血分數、Gensini評分、PWV、骨保護素為自變量,構建Logistic回歸模型。模型似然比檢驗,有統(tǒng)計學意義(均P<0.05)。多因素Logistic回歸分析結果顯示,Gensini評分≥32.35分、PWV≥8.85m/s、骨保護素≥3.78pmol/L會增加SCAD患者MACE發(fā)生風險(OR=3.72~3.85,均P<0.05),見表3。

        3 討論

        根據歐洲心臟病學會《穩(wěn)定性冠心病診治指南》標準,急性冠狀動脈綜合征(ACS)穩(wěn)定后無癥狀或癥狀穩(wěn)定、穩(wěn)定型心絞痛、痙攣導致的靜息發(fā)作心絞痛均屬于SCAD[9]。既往研究證實,SCAD的發(fā)病機制包括微血管功能障礙、心外膜冠狀動脈狹窄、局灶性或彌漫性痙攣、既往急性缺血、冠狀動脈粥樣硬化、左心室功能不全等[11]。因此,尋找能預測SCAD患者MACE發(fā)生的危險性因素,對于提高患者生活質量至關重要。目前,SCAD患者常規(guī)的血清學、冠狀動脈造影、心電圖檢測多為陰性,且缺乏相關預測SCAD患者MACE發(fā)生的特異性分子標志物及指標。

        本研究160例SCAD患者中,MACE發(fā)生率為43.75%(70/160),高于既往研究結果。這或許是由于入組的患者臨床病理資料差異導致。本研究發(fā)現,MACE未發(fā)生組與發(fā)生組在左心室射血分數、Gensini評分、PWV、骨保護素方面差異有統(tǒng)計學意義。上述指標或許與SCAD患者MACE發(fā)生密切相關。進一步多因素Logistic回歸分析發(fā)現,Gensini評分≥32.35分、PWV≥8.85m/s、骨保護素≥3.78pmol/L會增加SCAD患者MACE發(fā)生風險。研究結果表明Gensini評分、PWV及骨保護素參與了SCAD患者冠狀動脈介入治療后MACE發(fā)生過程。Gensini評分可反映每支冠狀動脈血管病變的狹窄程度,并能客觀評估冠狀動脈病變的進展情況[12]。本研究證實了Gensini評分是SCAD患者MACE發(fā)生的危險性因素。先前研究已經證實,骨保護素在骨代謝、惡性腫瘤、冠心病、糖尿病等疾病方面發(fā)揮重要作用[13,14]。骨保護素影響SCAD患者MACE發(fā)生的機制或許為:(1)骨保護素可通過抑制細胞毒性配體-腫瘤壞死因子相關凋亡誘導配體介導的血管細胞的凋亡影響SCAD患者血管系統(tǒng);(2)SCAD患者MACE發(fā)生組中骨保護素水平升高,可能是對動脈粥樣硬化進程的一種自我防御性代償反應。PWV是一種反映SCAD患者動脈僵硬度的非侵入性手段,是評價血管結構及功能的重要指標。PWV升高預示動脈彈性減退,造成動脈所受的牽拉力增加、血管壁壓力增大,可導致血管壁彈性成分斷裂,進一步造成血管內膜損傷及動脈粥樣硬化,當動脈粥樣硬化發(fā)展到一定程度便可導致MACE發(fā)生[13]。本研究與Siasos等[15]研究結果一致,均明確骨保護素和PWV在預測SCAD患者預后中具有重要價值。相關機制研究還需后期進一步探討。

        本研究為回顧性研究,容易造成選擇偏倚;且為單中心研究,樣本量少,制約研究結論準確性;加之,患者發(fā)病及入院時間不一致,可能對PWV、骨保護素等臨床指標的測定產生影響。但本文顯示Gensini評分、PWV、骨保護素與SCAD患者MACE發(fā)生密切相關,PWV和骨保護素水平偏高不利于SCAD患者預后,應引起臨床醫(yī)師密切關注。

        參考文獻

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        [2]王朝暉.冠狀動脈斑塊與微血管病變—2013 ESC-SCAD指南的啟示[J].臨床心血管病雜志,2014,30(7):557-559.

        [3]Adams H, Paratz E, Somaratne J, et al. Different patients, different outcomes: A case-control study of spontaneous coronary artery dissection versus acute coronary syndrome[J]. J Interv Cardiol,2018,31(1):41-47.

        [4]Lin MJ, Chen CY, Lin HD, et al. Impact of diabetes and hypertension on cardiovascular outcomes in patients with coronary artery disease receiving percutaneous coronary intervention[J]. BMC Cardiovasc Disord,2017,17(1):12-21.

        [5]Rusnak J, Fastner C, Behnes M, et al. Biomarkers in stable coronary artery disease[J]. Curr Pharm Biotechnol,2017,18(6):456-471.

        [6]Mccarthy CP, Mcevoy JW, Januzzi JL. Biomarkers in stable coronary artery disease[J]. Am Heart J,2018,196(1):82-96.

        [7]耿學峰,宋麗萍,朱宏旭,等.BaPWV聯(lián)合超聲心動圖檢測在冠心病心功能異常和心臟重構研究中的意義[J].中國醫(yī)藥導刊,2016,18(7):653-654.

        [8]Nugroho J, Widorini W. Correlation between osteoprotegerin serum level and coronary calcification using coronary artery calcium score in patient with moderate-severe cardiovascular risk factor[J]. Int J Angiol,2017,26(4):234-237.

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        [11]Rah S, Colquhoun DM, Marschner SL, et al. Persistent psychological distress and mortality in patients with stable coronary artery disease[J]. Heart,2017,103(23):1860-1866.

        [12]Ueland T, Akerblom A, Ghukasyan T, et al. Osteoprotegerin is associated with major bleeding but not with cardiovascular outcomes in patients with acute coronary syndromes: insights from the PLATO (platelet inhibition and patient outcomes) trial[J]. J Am Heart Assoc,2018,7(2):e007009.

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        [15]Siasos G, Oikonomou E, Maniatis K, et al. Prognostic significance of arterial stiffness and osteoprotegerin in patients with stable coronary artery disease[J]. Eur J Clin Invest,2018,48(3):e12890.

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