Predictive value of homocysteine combined with CRP/Alb ratio on the no-reflow phenomenon after emergency PCI in ST-segment elevation myocardial infarction patients with metabolic syndrome
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摘要: 目的 探究同型半胱氨酸(Hcy)联合C反应蛋白/白蛋白比值(CAR)对急性ST段抬高型心肌梗死(STEMI)合并代谢综合征(MS)患者急诊行经皮冠状动脉介入(PCI)术后无复流(NRP)的预测价值。方法 连续收集2017年12月—2019年10月于宁夏医科大学总医院行急诊PCI术的STEMI合并MS患者187例，根据冠脉造影结果分为正常血流组(152例)和NRP组(35例)，比较2组一般资料及临床特征。采用单因素和多因素logistic回归分析NRP的影响因素，绘制ROC曲线评估Hcy、CAR及两者联合对NRP的预测效能。结果 纳入患者187例，NRP发生率为18.71%。通过调整混杂因素后，二元Logistic回归显示术前Hcy(OR=1.053，95%CI：1.027~1.081，P< 0.001)，CAR(OR=2.745，95%CI：1.029~7.322，P=0.044)，舒张压(OR=0.959，95%CI：0.926~0.993，P=0.018)及梗死血管RCA(OR=0.378，95%CI：0.148~0.963，P=0.042)是NRP发生的危险因素。在NRP预测中，Hcy在ROC曲线下面积为0.761(95%CI：0.676~0.845)，灵敏度为80%，特异度为65.2%，最佳临界值为18.86μmol/L；CAR在ROC曲线下面积为0.652(95%CI：0.549~0.755)，灵敏度为77.1%，特异度为50%，最佳临界值为0.167。Hcy联合CAR(联合预测因子)在ROC曲线下面积为0.799(95%CI：0.719~0.878)，灵敏度为71.4%，特异度为80.6%。结论 Hcy、CAR是STEMI合并MS患者发生NRP的危险因素，二者联合检测有助于NRP的早期识别。
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关键词:
- 同型半胱氨酸 /
- C反应蛋白/白蛋白 /
- 无复流 /
- 代谢综合征 /
- ST段抬高型心肌梗死
Abstract: Objective To investigate the predictive value of homocysteine(Hcy) combined with C-reactive protein/albumin ratio(CAR) on the no-reflow phenomenon(NRP) after emergency percutaneous coronary intervention in acute ST-segment elevation myocardial infarction with metabolic syndrome(MS).Methods One hundred and eighty-seven STEMI patients with MS treated with emergency PCI at Ningxia Medical University General Hospital from December 2017 to October 2019 were consecutively selected. According to coronary angiography results, they were divided into two groups: the normal flow group(n=152) and the no-reflow group(n=35). The general dates and clinical characteristics of the two groups were compared. Binary-way logistic regression was used to analyze the independent factors of NRP, and ROC curves were performed to assess the predictive efficacy of HCY, CAR, and the combined factors on NRP.Results The incidence of NRP was 18.71% in 187 included patients. After adjusting for confounding factors, binary-logistic regression showed that Hcy(OR=1.053, 95%CI: 1.027~1.081,P< 0.001), CAR(OR=2.745, 95%CI: 1.029~7.322,P=0.044), diastolic blood pressure level(OR=0.959, 95%CI: 0.926~0.993,P=0.018) and infarct vessel RCA(OR=0.378, 95%CI: 0.148~0.963,P=0.042) were independent predictors of no-reflow. In the predictive value of no-reflow, the area under the ROC curve(AUC) of Hcy was 0.761(95%CI: 0.676~0.845), its sensitivity was 80% and specificity was 65.2%, and the best critical value was 18.86μmol/L. The AUC of CAR was 0.652(95%CI: 0.549~0.755), its sensitivity was 77.1% and specificity was 50%, and the critical value was 0.167. The AUC of Hcy combined with CAR was 0.799(95%CI: 0.719~0.878), its sensitivity was 71.4% and specificity was 80.6%.Conclusion Hcy and CRP/Alb are independent predictors of the no-reflow phenomenon.Hcy combined CAR is a better factor to predict the NRP in acute ST-elevation myocardial infarction with metabolic syndrome after PCI, and can help in the early identification of NRP. -
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图 1 Hcy、CAR和Hcy+CAR联合预测NRP的ROC曲线分析
Figure 1. ROC curves of Hcy, CAR, and combined Hcy and CAR for predicting no-reflow
表 1 2组基线资料比较
Table 1. Comparison of baseline characteristics between two groups
例(%), X±S 项目 血流正常组(152例) NRP组(35例) χ2/t P 年龄/岁 69.61±12.21 63.57±12.89 1.712 0.089 男性 119(78.28) 24(68.57) 1.493 0.222 高血压病 120(78.94) 32(91.43) 2.913 0.088 糖尿病 88(57.89) 19(54.28) 0.151 0.697 高脂血症 74(48.68) 15(42.86) 4.486 0.534 吸烟史 95(62.50) 20(57.14) 0.387 0.557 冠心病家族史 38(25.00) 3(8.57) 4.486 0.034 BMI/(kg·m-2) 26.00±3.31 25.48±3.52 -0.835 0.405 入院心率/(次·min-1) 79.70±12.56 83.14±18.63 1.325 0.187 入院SBP/mmHg 126.58±21.54 109.29±20.15 -4.296 < 0.001 入院DBP/mmHg 79.07±13.77 69.11±13.92 -3.848 < 0.001 入院Killip分级 4.272 0.234 Ⅰ级 127(83.55) 25(71.43) Ⅱ~Ⅳ级 25(16.45) 10(28.57) 
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表 2 2组血液生化及心脏彩超相关资料比较
Table 2. Comparison of laboratory and echocardiography results between two groups
X±S 项目 血流正常组(152例) NRP组(35例) t P值 Hcy/(μmol·L-1) 20.38±12.41 33.19±19.65 4.872 0.000 CRP/(mg·dL-1) 13.24±5.21 15.91±4.67 2.179 0.031 Alb/(g·L-1) 39.45±4.17 36.57±8.46 -2.942 0.004 CAR 0.26±0.03 0.50±0.10 3.129 0.002 TG/(mmol·L-1) 2.82±1.50 2.69±1.80 -0.465 0.643 TC/(mmol·L-1) 4.22±0.87 4.37±0.79 0.898 0.370 LDL/(mmol·L-1) 1.99±0.61 2.06±0.61 0.600 0.550 HDL/(mmol·L-1) 0.79±0.14 0.84±0.17 1.556 0.121 入院血糖//(mmol·L-1) 9.53±4.48 10.25±5.10 0.831 0.407 白细胞总数/(×109·L-1) 11.31±3.35 11.85±3.65 0.838 0.643 中性粒细胞计数/(×109·L-1) 9.22±3.28 9.85±3.69 0.987 0.325 淋巴细胞计数/(×109·L-1) 1.46±0.67 1.36±0.67 -0.793 0.429 血红蛋白/(g·dL-1) 147.45±18.90 140.75±19.17 -1.887 0.061 血小板计数/(×109·L-1) 233.93±67.79 230.40±54.46 -0.288 0.774 血肌酐/(μmol·L-1) 69.71±18.55 75.25±24.64 1.491 0.138 D-二聚体/(ng·mL-1) 0.58±0.45 0.52±0.45 0.670 0.504 LVEF/% 52.16±7.61 50.48±7.41 -1.063 0.289
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表 3 2组介入相关数据比较
Table 3. Comparison of Intervention related data between two groups
例(%), X±S 项目 血流正常组(152例) NRP组(35例) χ2/t P 病变血管数量 0.902 0.342 1支 44(28.95) 13(37.14) >1支 108(71.05) 22(62.86) 术前TIMI血流 1.527 0.408 0~1级 143(94.08) 33(94.28) 2~3级 9(9.21) 2(11.43) 梗死相关动脉 LAD 68(44.74) 10(28.57) 0.058 0.080 LCX 19(12.50) 2(5.71) 1.514 0.252 RCA 65(42.76) 23(65.71) 6.015 0.014 IABP 35(23.03) 9(25.71) 0.981 0.401 血栓抽吸 32(21.05) 7(20.00) 0.837 0.272 支架数量/个 1.49±0.76 1.43±0.66 2.973 0.643 支架直径/mm 3.22±0.46 3.38±0.45 1.954 0.052 支架长度/mm 25.85±7.83 26.34±8.45 0.332 0.741
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表 4 NRP现象的单因素logistic回归分析
Table 4. Univariate logistic analysis of no-reflow phenomenon
变量 B S.E. Wald OR 95%CI P SBP -0.039 0.010 15.380 0.962 0.943~0.981 0.001 DBP -0.057 0.016 12.864 0.945 0.916~0.975 < 0.001 CRP 0.023 0.012 3.917 1.024 1.002~1.048 0.048 Alb -0.089 0.036 6.253 0.915 0.853~0.981 0.012 CAR 1.088 0.422 6.651 2.967 1.298~6.781 0.010 Hcy 0.047 0.012 16.272 1.048 1.024~1.072 < 0.001 RCA -0.942 0.392 5.775 0.390 0.181~0.841 0.016 冠心病家族史 -1.269 0.632 4.029 0.281 0.081~0.971 0.045
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表 5 NRP现象的多因素logistic回归分析
Table 5. Multivariate logistic analysis of no-reflow phenomenon
变量 B S.E. Wald OR 95%CI P DBP -0.042 0.018 5.580 0.959 0.926~0.993 0.018 CAR 1.010 0.501 4.069 2.745 1.029~7.322 0.044 Hcy 0.052 0.013 15.532 1.053 1.027~1.081 < 0.001 RCA -0.973 0.477 4.153 0.378 0.148~0.963 0.042
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