Analysis of clinical features and coronary artery lesion characteristics in patients with myocardial infarction with non-obstructive coronary artery
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摘要: 目的 探讨冠状动脉非阻塞性心肌梗死(MINOCA)患者的临床特征、冠状动脉(冠脉)病变特点及危险因素。方法 回顾性分析2016年1月—2017年12月于上海交通大学医学院附属第九人民医院住院的AMI患者共476例，根据冠脉造影的结果分为MINOCA组(56例)和MICAD组(420例)。比较2组患者的临床特点、心脏结构、冠脉病变特征、危险因素等。结果 与MICAD组患者比较，MINOCA组患者的年龄较大(P< 0.05)、男性较少(P< 0.05)，吸烟患者较少(P< 0.05)，非ST段抬高急性心肌梗死比例较低(P< 0.05)；空腹血糖、肌酸激酶、肌钙蛋白、白细胞计数、谷草转氨酶值、LDL-C值更低(P< 0.05)；β受体阻滞剂、他汀类药物的应用比例更低(P< 0.05)。MINOCA组患者的多支病变比例显著低于MICAD组(P< 0.05)。在心脏结构方面，MINOCA组和MICAD组差异无统计学意义。多因素logistic回归分析结果表明，吸烟和糖尿病是MINOCA的相关危险因素(P< 0.05)。结论 与MICAD患者相比，MINOCA年龄偏大，女性较多，肌钙蛋白、LDL-C及白细胞计数明显更低。MINOCA的相关危险因素主要为糖尿病和吸烟。
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关键词:
- 心肌梗死 /
- 冠状动脉造影术 /
- 冠状动脉非阻塞性心肌梗死
Abstract: Objective To analyze the clinical characteristics, coronary artery lesion characteristics and risk factors in patients with myocardial infarction with non-obstructive(MINOCA).Methods A total of 476 AMI patients were hospitalized in the Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine from January 2016 to December 2017. They were divided into the MINOCA group (56 cases) and MICAD group (420 cases) according to the results of coronary angiography. The clinical characteristics, heart structure, coronary artery lesion characteristics, and risk factors of the two groups of patients were compared.Results Compared with patients in the MICAD group, MINOCA group patients were older(P< 0.05). Fewer men(P< 0.05) and smokers(P< 0.05) were found in the MINOCA group. The proportion of NSTEMI was lower(P< 0.05);blood glucose, creatine kinase, troponin, white blood cell count, aspartate aminotransferase value, and LDL-C were lower(P< 0.05). The proportion of beta-blockers and statins in the MICAD group was lower than that in the MICAD group(P< 0.05). The number of coronary artery lesions in the MINOCA group was significantly lower than that in the MICAD group(P< 0.05). There was no significant difference in cardiac structure between the MINOCA group and MICAD group. Multivariate logistic regression analysis showed that smoking and diabetes were related risk factors for MINOCA (P< 0.05).Conclusion Patients with MINOCA are older, more female, and had significantly lower troponin, LDL-C, and white blood cell counts. The main risk factors associated with MINOCA are diabetes and smoking. -
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表 1 MINOCA组与MICAD组患者基线特征
Table 1. Baseline features of patients in MINOCA and MICAD groups
例(%), X±S, M(P25, P75) 项目 MINOCA组(56例) MICAD组(420例) t/χ2/Z P 男性 29(51.8) 306(72.9) 10.524 0.001 年龄/岁 72±10 68±12 2.331 0.020 高血压 44(78.6) 297(70.7) 1.501 0.220 糖尿病 13(23.2) 153(36.4) 3.799 0.053 吸烟史 15(26.8) 221(52.6) 13.758 0.001 BMI/(kg·m-2) 23.42±4.21 24.63±4.24 4.617 0.329 心肌梗死类型 11.796 0.001 STEMI 5(3.7) 130(96.3) NSTEMI 51(15.0) 290(85.0) 房颤 6(10.7) 18(4.3) 3.028 0.082 心血管病家族史 31(55.4) 244(58.1) 0.152 0.697 心脏瓣膜病史 3(5.4) 10(2.4) 0.700 0.403 肾功能不全史 7(12.5) 37(8.8) 0.802 0.370 糖尿病家族史 13(23.2) 153(36.4) 3.799 0.051 空腹血糖/(mmol·L-1) 6.7±3.0 7.1±3.1 0.739 0.046 糖化血红蛋白/% 6.5±1.6 6.9±1.7 1.349 0.178 D-二聚体/(μg·mL-1) 0.73(0.26，1.13) 0.42(0.23，0.78) -2.313 0.021 BNP/(pg·mL-1) 342(86，706) 258(94，634) -0.705 0.481 肌钙蛋白/(ng·mL-1) 0.22(0.08，0.63) 1.33(0.15，7.58) -5.002 < 0.001 血清肌酐/(μmol·L-1) 100(79，115) 97(83，115) -0.297 0.766 血清肌酸激酶/(U·L-1) 113(72，505) 174(83，585) -2.792 0.005 药物治疗 β受体阻滞剂 29(51.8) 292(69.7) 7.227 0.007 ACEI/ARB类 30(46.4) 264(62.9) 1.804 0.179 他汀类 50(89.3) 407(96.9) 5.629 0.018 阿司匹林 48(85.7) 385(91.7) 2.130 0.144 P2Y12受体拮抗剂 52(92.9) 363(86.4) 1.828 0.176 白细胞计数/(×109·L-1) 6.70(5.30，8.15) 7.75(6.20，10.18) 2.387 0.017 谷草转氨酶/(U·L-1) 21(17，44) 37(22，79) 8.051 < 0.001 谷丙转氨酶/(U·L-1) 15(11，19) 24(15，37) 1.910 0.057 TC/(mmol·L-1) 4.18±0.78 4.34±1.06 0.977 0.329 TG/(mmol·L-1) 1.69±1.27 1.73±0.91 0.325 0.745 LDL-C/(mmol·L-1) 2.74±0.67 3.01±0.05 2.479 0.015 HDL-C/(mmol·L-1) 1.06±0.34 0.94±0.44 4.705 0.030 Lp(a)/(g·L-1) 0.16±0.14 0.20±0.23 1.634 0.106 载脂蛋白A1/(g·L-1) 1.09±0.24 1.00±0.19 2.84 0.005 载脂蛋白A1/B 1.45±0.42 1.22±0.39 3.47 0.001 载脂蛋白B/(g·L-1) 0.81±0.16 0.91±0.25 2.47 0.014 载脂蛋白E/(g·L-1) 4.46±1.47 4.30±1.35 0.71 0.479 
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表 2 2组患者心脏结构比较
Table 2. Comparison of cardiac structure in 2 groups
例(%) 项目 MINOCA组
(50例)MICAD组
(369例)χ2 P 左房内径增大 19(38.0) 123(33.3) 0.428 0.513 左室内径增大 13(26.0) 82(22.2) 0.358 0.549 室间隔厚度增厚 15(30.0) 100(27.1) 0.186 0.666 左室射血分数≤50% 12(24.0) 124(34.0) 1.853 0.173
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表 3 2组患者冠脉病变支数比较
Table 3. Comparison of the number of coronary artery lesions in 2 groups
例(%) 项目 MINOCA组
(56例)MICAD组
(420例)χ2 P 冠脉病变支数 185.154 < 0.001 无病变 27(48.2) 5(1.2) 174.240 < 0.001 单支病变 14(25.0) 81(19.3) 1.010 0.373 双支病变 8(14.3) 74(17.6) 0.385 0.706 多支病变 7(12.5) 260(61.9) 48.969 0.001
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表 4 2组患者MINOCA的单因素logistic回归分析
Table 4. Univariate logistic regression analysis of risk factors in 2 groups of patients
变量 β S.E. Wald χ2 P OR(95%CI) 性别 0.916 0.289 10.040 < 0.001 2.499(1.418~4.404) 年龄≥65岁 0.550 0.312 3.111 0.078 1.734(0.941~3.196) 高血压史 -0.418 0.343 1.484 0.223 0.659(0.336~1.290) 高脂血症史 -0.223 0.324 0.473 0.491 0.800(0.424~1.511) 糖尿病史 -0.639 0.332 3.702 0.054 1.895(0.988~3.636) 心血管病家族史 -0.112 0.286 0.152 0.697 0.894(0.510~1.568) 吸烟史 -1.120 0.317 12.473 < 0.001 0.326(0.175~0.607)
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表 5 2组患者MINOCA的多因素logistic回归分析
Table 5. Multivariate logistic regression analysis of risk factors in 2 groups of patients
变量 β S.E. Wald χ2 P OR(95%CI) 性别 -0.551 0.351 2.463 0.117 1.736(0.872~3.455) 年龄≥65岁 -0.073 0.353 0.043 0.836 1.076(0.538~2.150) 高血压史 -0.365 0.362 1.018 0.313 0.694(0.341~1.411) 高脂血症史 -0.131 0.343 0.146 0.702 0.877(0.448~1.718) 糖尿病史 0.950 0.353 7.226 0.007 2.585(1.293~5.167) 心血管病家族史 -0.108 0.301 0.129 0.720 0.897(0.497~1.620) 吸烟史 -0.798 0.398 4.023 0.045 0.450(0.206~0.982)
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[1] Gehrie ER, Reynolds HR, Chen AY, et al. Characterization and outcomes of women and men with non-ST-segment elevation myocardial infarction and nonobstructive coronary artery disease: results from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines(CRUSADE)quality improvement initiative[J]. Am Heart J, 2009, 158(4): 688-694. doi: 10.1016/j.ahj.2009.08.004
[2] Agewall S, Beltrame JF, Reynolds HR, et al. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries[J]. Eur Heart J, 2017, 38(3): 143-153.
[3] Kang WY, Jeong MH, Ahn YK, et al. Are patients with angiographically near-normal coronary arteries who present as acute myocardial infarction actually safe?[J]. Int J Cardiol, 2011, 146(2): 207-212. doi: 10.1016/j.ijcard.2009.07.001
[4] Tamis-Holland JE, Jneid H, Reynolds HR, et al. Contemporary Diagnosis and Management of Patients With Myocardial Infarction in the Absence of Obstructive Coronary Artery Disease: A Scientific Statement From the American Heart Association[J]. Circulation, 2019, 139(18): e891-e908.
[5] Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction(2018)[J]. J Am Coll Cardiol, 2018, 72(18): 2231-2264. doi: 10.1016/j.jacc.2018.08.1038
[6] 李为民, 赵红岩, 李俭强. ESC工作组关于冠状动脉非阻塞性心肌梗死诊疗建议解读[J]. 中国循环杂志, 2016, 31(2): 121-124.
[7] Agewall S, Beltrame JF, Reynolds HR, et al. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries[J]. Eur Heart J, 2017, 38(3): 143-153.
[8] Pasupathy S, Air T, Dreyer RP, et al. Systematic review of patients presenting with suspected myocardial infarction and nonobstructive coronary arteries[J]. Circulation, 2015, 131(10): 861-870. doi: 10.1161/CIRCULATIONAHA.114.011201
[9] Daniel M, Agewall S, Caidahl K, et al. Effect of Myocardial Infarction With Nonobstructive Coronary Arteries on Physical Capacity and Quality-of-Life[J]. Am J Cardiol, 2017, 120(3): 341-346. doi: 10.1016/j.amjcard.2017.05.001
[10] 秦涛, 欧阳茂, 彭彩霞. 左前降支冠状动脉持续痉挛引起急性广泛前壁心肌梗死1例[J]. 临床心血管病杂志, 2020, 36(5): 488-492. https://www.cnki.com.cn/Article/CJFDTOTAL-LCXB202005020.htm
[11] 夏彬凤, 崔明月, 王鹤儒. 冠状动脉痉挛致急性心肌梗死及恶性心律失常猝死1例[J]. 临床心血管病杂志, 2020, 36(1): 93-96. https://www.cnki.com.cn/Article/CJFDTOTAL-LCXB202001022.htm
[12] 邹艳, 张波. 冠状动脉非阻塞型心肌梗死的临床特点及预后分析[J]. 中华内科杂志, 2020, 59(7): 546-549. doi: 10.3760/cma.j.cn112138-20190726-00521
[13] Kang WY, Jeong MH, Ahn YK, et al. Are patients with angiographically near-normal coronary arteries who present as acute myocardial infarction actually safe?[J]. Int J Cardiol, 2011, 146(2): 207-212. doi: 10.1016/j.ijcard.2009.07.001
[14] 周博达, 缪国斌. 冠状动脉非阻塞性心肌梗死的原因及治疗进展[J]. 中国临床医生杂志, 2019, 47(4): 390-393. doi: 10.3969/j.issn.2095-8552.2019.04.004
[15] Opolski MP, Spiewak M, Marczak M, et al. Mechanisms of Myocardial Infarction in Patients With Nonobstructive Coronary Artery Disease: Results From the Optical Coherence Tomography Study[J]. JACC Cardiovasc Imaging, 2019, 12(11 Pt 1): 2210-2221.
[16] 王金鑫, 段鹏, 朱庆磊. 冠状动脉非阻塞性急性ST段抬高型心肌梗死的临床特征和预测因素[J]. 中国心血管病研究, 2018, 16(4): 307-310. doi: 10.3969/j.issn.1672-5301.2018.04.006
[17] 李末寒, 陆士奇, 肖卓韬, 等. 白细胞/血小板平均体积联合Gensini积分评估急性心肌梗死患者住院期间预后的研究[J]. 临床急诊杂志, 2020, 21(4): 282-286. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC202004005.htm
[18] 李小林, 杨思进, 赵立志, 等. 简易血栓炎症预后评分对急性ST段抬高型心肌梗死患者预后的评估价值[J]. 临床急诊杂志, 2021, 22(5): 313-318. https://www.cnki.com.cn/Article/CJFDTOTAL-ZZLC202105005.htm
[19] Lindahl B, Baron T, Erlinge D, et al. Response by Lindahl et al to Letter Regarding Article, "Medical Therapy for Secondary Prevention and Long-Term Outcome in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease"[J]. Circulation, 2017, 136(11): 1082-1083. doi: 10.1161/CIRCULATIONAHA.117.029938
[20] Hausvater A, Pasupathy S, Tornvall P, et al. ST-segment elevation and cardiac magnetic resonance imaging findings in myocardial infarction with non-obstructive coronary arteries[J]. Int J Cardiol, 2019, 287: 128-131. doi: 10.1016/j.ijcard.2019.04.028
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