發(fā)布時(shí)間：2018-04-06 20:24

  本文選題：急性心肌梗死　切入點(diǎn)：超敏C反應(yīng)蛋白　出處：《廣西醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的急性心肌梗死(AMI)是臨床上的急危重癥,是冠心病常見(jiàn)且危重的類(lèi)型,有著高住院率、高死亡率的特點(diǎn),嚴(yán)重危害著人類(lèi)的健康。急性心肌梗死后心室重構(gòu)是導(dǎo)致病情進(jìn)行性發(fā)展,引起心力衰竭、惡性心律失常甚至心源性猝死等的重要因素。目前很多研究已經(jīng)表明炎癥反應(yīng)在AMI的發(fā)病過(guò)程中起著重要作用,但在AMI后心室重構(gòu)的具體作用和機(jī)制仍不甚明確。本研究通過(guò)檢測(cè)AMI患者入院時(shí)血清超敏C反應(yīng)蛋白(Hs-CRP)和胱抑素C(CysC)的水平,結(jié)合入院后1周及隨訪(fǎng)末(12個(gè)月)的超聲心動(dòng)圖指標(biāo)。探討血清Hs-CRP和CysC的水平與首發(fā)AMI后心室重構(gòu)程度的相關(guān)性,為臨床AMI的治療、病情評(píng)估和預(yù)后的預(yù)測(cè)提供科學(xué)依據(jù)。方法納入2013年10月-2015年10月期間,在廣西醫(yī)科大學(xué)第八附屬醫(yī)院心血管內(nèi)科住院治療的發(fā)病24h以?xún)?nèi)的首次確診急性ST段抬高型心肌梗死患者80例,包括前壁32例,廣泛前壁13例,下壁24例,正后壁11例;入選者均符合2012年美國(guó)心臟病協(xié)會(huì)(AHA)、美國(guó)心臟病學(xué)會(huì)(ACC)、歐洲心臟病學(xué)會(huì)(ESC)及世界心臟聯(lián)盟(WHF)共同制定并發(fā)表的AMI的診斷標(biāo)準(zhǔn)。排除陳舊心梗、周?chē)�血管或血栓性疾病、腦卒中、風(fēng)心病、甲狀腺疾病、結(jié)核、惡性腫瘤、急慢性感染等患者;對(duì)入選患者入院后24小時(shí)內(nèi)抽靜脈血測(cè)定血清Hs-CRP、CysC及其他生化指標(biāo),于入院后1周行心臟超聲測(cè)定左心室舒張末期內(nèi)徑(LVEDD)、左心室舒張末期容積(LVEDV)、左心室射血分?jǐn)?shù)(LVEF)等指標(biāo),另選同期門(mén)診健康體檢者80例為對(duì)照組,分析兩組間各參數(shù)的差異。所入選AMI患者于隨訪(fǎng)末(12個(gè)月)復(fù)查超聲心動(dòng)圖,并詳細(xì)記錄以上指標(biāo),設(shè)定發(fā)病后1周LVEDV為L(zhǎng)VEDV0,隨訪(fǎng)末(12個(gè)月)時(shí)lvedv為lvedv1,lvedv增長(zhǎng)率△lvedv%=(lvedv1-lvedv0)/lvedv0×100%。并根據(jù)△lvedv%的大小將ami組患者劃分為心室重構(gòu)組(△lvedv≥20%,n=19)和非重構(gòu)組(△lvedv20%,n=61),比較兩組之間各參數(shù)的差異。用統(tǒng)計(jì)學(xué)軟件spss16.0對(duì)數(shù)據(jù)進(jìn)行分析,計(jì)量資料用均數(shù)±標(biāo)準(zhǔn)差表示,計(jì)量資料組間差異的比較采用非配對(duì)t檢驗(yàn),計(jì)數(shù)資料采用卡方檢驗(yàn)。分析血清hs-crp及cysc水平與左室重構(gòu)各指標(biāo)進(jìn)行相關(guān)性,采用spearman法。將性別、年齡、hs-crp、cysc、ck-mb、tc、tg、高血壓、糖尿病等臨床指標(biāo)與與心室重構(gòu)進(jìn)行l(wèi)ogistic回歸分析。結(jié)果采用雙側(cè)檢驗(yàn),p0.05為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果(1)ami組患者血清hs-crp水平為7.41±1.85mg/l,血清cysc水平為1.68±0.35mg/l;對(duì)照組的血清hs-crp水平為1.46±0.23mg/l,血清cysc水平為0.44±0.12mg/l;ami組患者血清hs-crp及cysc均顯著高于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(p0.05,見(jiàn)表1、圖1);(2)ami組患者發(fā)病后1周lvef57.3±7.8%,lvedv96.7±15.4ml,lvedd46.3±6.2mm;對(duì)照組lvef68.2±9.4%,lvedv78.4±13.2ml,lvedd40.5±3.7mm;兩組間各參數(shù)比較,差異均有統(tǒng)計(jì)學(xué)意義(p均0.05,見(jiàn)表1、圖1)。(3)ami組患者隨訪(fǎng)末(12個(gè)月)復(fù)查超聲心動(dòng)圖,lvef48.69±6.53%,lvedv108.4±14.8ml,lvedd52.74±8.28mm;根據(jù)隨訪(fǎng)末(12個(gè)月)△lvedv%的大小將ami組患者分為心室重構(gòu)組(△lvedv≥20%)和非重構(gòu)組(△lvedv20%):心室重構(gòu)組:19例,男性12例,女性7例,年齡62.58±8.31(41~78)歲。非重構(gòu)組:61例,男性39例,女性22例,年齡64.92±9.16(45~78)歲(見(jiàn)表2)。兩組間年齡、性別、體重、血脂、糖尿病、梗死部位、治療方法(保守治療、溶栓治療、pci治療)差異均無(wú)統(tǒng)計(jì)學(xué)意義(p0.05,見(jiàn)表2)。心室重構(gòu)組患者血清hs-crp水平為9.46±1.72mg/l,血清cysc水平為1.98±0.33mg/l;非重構(gòu)組患者血清hs-crp水平為4.15±1.25mg/l,血清cysc水平為1.32±0.21mg/l;心室重構(gòu)組患者血清hs-crp及CysC均顯著高于非重構(gòu)組,差異有統(tǒng)計(jì)學(xué)意義(P0.05,見(jiàn)表2、圖2);心室重構(gòu)組患者LVEF 44.7±6.4%,LVEDV128.4±13.2ml,LVEDD60.5±7.1mm;非重構(gòu)組患者LVEF 59.3±7.8%,LVEDV90.7±15.4ml,LVEDD42.3±5.8mm;兩組間各參數(shù)比較,差異均有統(tǒng)計(jì)學(xué)意義(P均0.05,見(jiàn)表2、圖2)。(4)血清Hs-CRP與LVEDD(r=0.75,P0.05)、LVEDV(r=0.58,P0.05)呈顯著正相關(guān);與LVEF(r=-0.73,P0.05)呈顯著負(fù)相關(guān)(表3、圖3-5)。血清CysC與LVEDD(r=0.48,P0.05)、LVEDV(r=0.75,P0.05)呈顯著正相關(guān);與LVEF(r=-0.52,P0.05)呈顯著負(fù)相關(guān)(表4、圖6-8)。(5)將性別、年齡、Hs-CRP、CysC、CK-MB、血脂、高血壓、糖尿病等臨床指標(biāo)與心室重構(gòu)做Logistic回歸分析,結(jié)果顯示Hs-CRP和CysC進(jìn)入回歸方程,其他指標(biāo)被剔除,說(shuō)明在本研究中Hs-CRP和CysC與心室重構(gòu)獨(dú)立相關(guān),是預(yù)示心室重構(gòu)的可靠指標(biāo)。結(jié)論1、在心肌梗死急性期,血清Hs-CPR、CysC濃度有不同程度的升高,在心肌梗死早期及晚期均發(fā)生心室重構(gòu);2、急性心肌梗死后第一天血清Hs-CPR、CysC含量水平與心室重構(gòu)程度呈顯著的、獨(dú)立的相關(guān)性,提示血清Hs-CPR、CysC含量水平是預(yù)測(cè)AMI后心室重構(gòu)程度的可靠指標(biāo),對(duì)病情評(píng)估、預(yù)測(cè)預(yù)后有一定的臨床指導(dǎo)意義。
[Abstract]:Objective to acute myocardial infarction (AMI) is a severe clinical type, is a common and severe coronary heart disease, with high hospitalization rates, high mortality and serious harm to human health. Ventricular remodeling after acute myocardial infarction is the result of the development of disease, caused by heart failure, an important factor of malignant arrhythmia even suddencardiac death. At present, many studies have shown that inflammation plays an important role in the pathogenesis of AMI, but in AMI the specific role of ventricular remodeling and the mechanism is still unclear. In this study, through the detection of AMI patients in the hospital when the serum high-sensitivity C reactive protein (Hs-CRP) and cystatin C (CysC) level, with 1 weeks after admission and at the end of follow-up (12 months) of the echocardiography. The correlation of ventricular remodeling on serum Hs-CRP level and the first AMI and CysC after the treatment of AMI in clinical practice, the assessment of disease severity and prognosis To provide a scientific basis for prediction. Methods included in October 2013 -2015 year in October, in the hospital within 24h treatment for the first time in the diagnosis of disease in patients with acute ST segment elevation myocardial infarction in 80 cases of cardiovascular department of the eighth Affiliated Hospital of Guangxi Medical University, including 32 cases of anterior wall, anterior wall in 13 cases, inferior 24 cases, 11 cases were selected after the wall; are in line with the 2012 American Heart Association (AHA), American Heart Association (ACC), the European Society of Cardiology (ESC) and the World Heart Federation (WHF) jointly formulated and published diagnostic criteria of AMI. The history of old myocardial infarction, vascular and thrombotic diseases, stroke, rheumatic heart disease, thyroid disease, tuberculosis, malignant tumor, acute and chronic infection of patients; patients within 24 hours after admission. Venous blood serum Hs-CRP, CysC and other biochemical indicators in hospital 1 weeks after echocardiographic determination of left ventricular end diastolic diameter (LVEDD), left Left ventricular end diastolic volume (LVEDV), left ventricular ejection fraction (LVEF) and other indicators, choose healthy subjects served as a control group of 80 cases, analysis of the differences between the two groups of parameters. The AMI patients were enrolled in follow-up (12 months) in echocardiography, and detailed records to index. Set the 1 week after the onset of LVEDV is LVEDV0, at the end of follow-up (12 months) when LVEDV was lvedv1, the growth rate of LVEDV lvedv%= (lvedv1-lvedv0) /lvedv0 * 100%. and lvedv% according to the delta size of AMI group were divided into left ventricular remodeling group (LVEDV = 20%, n=19) and non remodeling group (lvedv20%, n=61), compare the differences between the two groups of parameters. The data were analyzed using statistical software SPSS16.0, measurement data with the mean standard deviation of that measurement data between groups were compared using the unpaired t test, count data using chi square test. Analysis of serum hs-CRP and CysC levels and the left ventricular remodeling The correlation index, using the Spearman method. The gender, age, hs-CRP, CysC, CK-MB, TC, TG, hypertension, diabetes and other clinical indicators and ventricular remodeling were analyzed by logistic regression analysis. Results using two-sided test, P0.05 difference was statistically significant. Results (1) hs-CRP level of serum AMI was 7.41 + 1.85mg/l, the level of serum CysC was 1.68 + 0.35mg/l; serum hs-CRP level in control group was 1.46 + 0.23mg/l, the level of serum CysC was 0.44 + 0.12mg/l; hs-CRP and CysC in the patients with AMI were significantly higher than the control group, the difference was statistically significant (P0.05, see Table 1, figure 1); (2) AMI patients after onset 1 weeks lvef57.3 + 7.8%, lvedv96.7 + 15.4ml, lvedd46.3 + 6.2mm; control group lvef68.2 + 9.4%, lvedv78.4 + 13.2ml, lvedd40.5 + 3.7mm; comparing the parameters between the two groups, the differences were statistically significant (P < 0.05, see Table 1, figure 1). (3) patients in the AMI group at the end of follow-up (12 months Super Review) 澹板績(jī)鍔ㄥ浘,lvef48.69鹵6.53%,lvedv108.4鹵14.8ml,lvedd52.74鹵8.28mm;鏍規(guī)嵁闅忚�挎�，

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