老年急性心肌梗死病人血清sST2、NT-proBNP、胰岛素抵抗水平与疾病严重程度及心功能的关系探讨

目的探讨老年急性心肌梗死(AMI)病人血清可溶性生长刺激表达因子2(sST2)、N-末端脑钠肽前体(NT-proBNP)、胰岛素抵抗水平与疾病严重程度及心功能的关系。方法选取珠海市中西医结合医院2018年1月—2019年4月收治的AMI病人128例作为AMI组,根据Killip心功能分级分为Ⅰ级组(52例)、Ⅱ级组(35例)、Ⅲ级组(25例)、Ⅳ级组(16例);收集同期、同年龄段、知情同意并自愿配合相关检查的健康体检人群50名作为对照组。受试人群均检测空腹血胰岛素(FINS)、血脂、肿瘤坏死因子-α(TNF-α)及超敏C反应蛋白(hs-CRP)、sST2、NT-proBNP、左心室射血分数(LVEF)、左心室收缩末期容积(LVESV)、左心室舒张末期容积(LVEDV),采用自我平衡模型分析法计算胰岛素抵抗指数(IRI),分析AMI病人血清sST2、NT-proBNP水平与疾病严重程度的相关性。结果与对照组比较,AMI组各心功能分级亚组病人总胆固醇(TC)、三酰甘油(TG)、低高密度脂蛋白胆固醇(LDL-C)明显升高(P0.05),高密度脂蛋白胆固醇(HDL-C)明显降低(P0.05);AMI组病人随着心功能分级上升血清TC、TG、LDL-C水平呈递增趋势(P0.05),HDL-C水平呈递减趋势(P0.05)。与对照组比较,AMI组各心功能分级亚组病人hs-CRP、TNF-α、白介素-6(IL-6)、sST2、NT-proBNP、FINS、IRI、LVESV、LVEDV明显升高(P0.05),LVEF明显降低(P0.05);AMI组病人随着心功能分级上升血清IL-6、hs-CRP、TNF-α、sST2、NT-proBNP、FINS、IRI、LVESV、LVEDV值呈递增趋势(P0.05),LVEF值呈递减趋势(P0.05)。Pearson相关性分析显示sST2、NT-proBNP、IRI、LVESV、LVEDV与Killip心功能分级呈正相关(P0.05),LVEF与Killip心功能分级呈负相关(P0.05);相关性分析显示血清sST2、NT-proBNP、IRI水平与LVEF呈负相关(P0.05),与LVESV、LVEDV呈正相关(P0.05)。结论老年急性心肌梗死病人Killip心功能分级越高,血清sST2、NT-proBNP、IRI水平越高,且血清sST2、NT-proBNP、IRI水平与左心室功能存在一定相关性。     

肾功能损伤对N末端B型利钠肽原应用于心力衰竭诊断的影响

目的:探讨不同肾功能损伤程度下N末端B型利钠肽原(NT-pro BNP)诊断心力衰竭的价值。方法:选取50~75岁的420例心血管疾病患者,根据超声心动图检查测定的左心室射血分数(LVEF)将患者分为心力衰竭组(LVEF40%,n=188)和心功能正常组(LVEF≥40%,n=232),再按估测肾小球滤过率(e GFR)将两组均进一步分为肾功能正常亚组[e GFR≥90 ml/(min·1.73m2)]、肾功能轻度损伤亚组[90e GFR≥60 ml/(min·1.73m2)]、肾功能中度损伤亚组[60e GFR≥30 ml/(min·1.73m2)]及肾功能重度损伤亚组[e GFR30 ml/(min·1.73m2)4个亚组。观察不同亚组血清NT-pro BNP水平的变化及诊断心力衰竭的最佳截断值。结果:心力衰竭组患者NT-pro BNP水平明显高于心功能正常组(P0.05);NT-pro BNP与e GFR呈显著负相关(总样本r=-0.664;心功能正常组r=-0.686;心力衰竭组r=-0.721,P0.05);心功能正常组中,与肾功能正常亚组比较,肾功能轻度损伤亚组的NT-pro BNP水平无明显升高(P0.05),肾功能中度损伤亚组和肾功能重度损伤亚组的NTpro BNP水平均明显升高(P0.05);心力衰竭组中,仅肾功能重度损伤亚组的NT-pro BNP水平较其他亚组显著升高(P0.05)。肾功能正常或轻度损伤时NT-pro BNP诊断心力衰竭的最佳截断值为1 070 pg/ml(敏感性为91.8%,特异性为72.6%),肾功能中度损伤时最佳截断值为7 121 pg/ml(敏感性为80.2%,特异性为89.7%),肾功能重度损伤时最佳截断值为33 344 pg/ml(敏感性为83.3%,特异性为80.0%)。结论:肾功能中、重度损伤会影响循环中NT-pro BNP水平,心力衰竭患者合并肾功能损伤时,NT-pro BNP水平明显升高,且与肾功能损伤程度呈正相关;在肾功能损伤情况下,应用血清NT-pro BNP诊断心力衰竭的截断值应相应提高。     

G蛋白偶联受体激酶2与血清可溶性ST2对老年心肌梗死后心力衰竭预警的意义

目的分析75岁以上老年急性非ST段抬高型心肌梗死(NSTEMI)患者外周血淋巴细胞G蛋白偶联受体激酶2(GRK2)与血清可溶性ST2(sST2)水平在心力衰竭(心衰)预警中的意义。方法选取75岁以上老年男性急性NSTEMI患者80例作为急性心肌梗死(AMI)组,平均年龄(85.4±3.2)岁;选取同期体检的健康老年男性30例作为对照组,平均年龄(84.8±2.9)岁。测定2组患者GRK2、血清sST2水平,并行超声心动图检测LVEF、左心室收缩末期容积(LVESV)、左心室舒张末期容积(LVEDV)。AMI组患者在发病后3、6、12、24个月时进行随访。结果AMI组患者GRK2的表达、血清sST2水平均高于对照组[3.60 vs 0.72,(30.63±1.36)μg/L vs (26.87±0.55)μg/L,P0.01],LVEF低于对照组[(50.87±4.58)%vs (55.15±5.87)%,P0.01]。AMI组GRK2在发病后3、6、12、24个月随访时逐渐增高(P0.05,P0.01),sST2水平在发病后6、12、24个月随访时显著增高(P0.05),LVEF在发病后6、12、24个月随访时显著降低(P0.01)。结论 75岁以上老年男性急性NSTEMI患者GRK2对AMI后心衰的预警作用优于sST2。     

择期经皮冠状动脉介入治疗对心肌梗死恢复期患者左室收缩功能及血浆脑钠肽水平的影响

目的评价急性心肌梗死(AMI)恢复期经皮冠状动脉介入治疗(PCI)对左心室收缩功能的影响和血浆脑钠肽(BNP)水平的变化。方法将成功PCI 77例患者分为2组,AMI组36例,非AMI组41例。结果(1)非AMI组PCI前、后BNP水平和左心室收缩功能参数和左心室大小无显著变化。(2)AMI组PCI前左心室舒张末容积(LVEDV)及指数(LVEDVI)、收缩末容积(LVESD)及指数(LVESDI)比非AMI组均已显著增大、BNP水平显著升高(P均<0.01),左心室射血分数(LVEF)显著降低(P<0.01);PCI后LVESV、LVESVI及BNP水平均比治疗前显著降低(P均<0.05),LVEF显著提高(P<0.05);LVESVI降低和LVEF升高的程度比非AMI组更显著(P<0.01)。(3)AMI组BNP水平与LVEF呈负相关(r=-0.49,P<0.01)。结论AMI患者恢复期已发生左心室重构伴收缩功能减低,择期PCI可有效逆转左心室重构,提高左心室收缩功能,同时降低BNP水平,且血浆BNP水平可作为治疗AMI的一个灵敏观察指标。     

老年射血分数保留及舒张性心力衰竭患者基质金属蛋白酶9、可溶性人基质裂解素2检测对心功能评估的价值

目的探讨基质金属蛋白酶(MMP)-9和可溶性人基质裂解素(sST)2在老年射血分数保留及舒张性心力衰竭患者中的表达水平及与B型脑钠肽(BNP)的相互关系,同时分析两者对老年射血分数保留及舒张性心力衰竭患者心功能评估的价值。方法老年慢性心力衰竭患者共96例,分为射血分数保留心力衰竭组(HF-PEF组,50例)和舒张性心力衰竭(DHF)组(46例),同期临床诊断为单纯高血压或冠心病患者48例为对照组。收集整理各组一般临床资料及实验室检查结果。MMP-9、sST2水平分别采用双抗夹心免疫比浊法及酶联免疫吸附实验(ELISA)进行检测。结果 HF-PEF组及DHF组的NYHAⅣ级亚组与对照组比较,平均动脉压、谷丙转氨酶、总胆固醇及肌酐水平差异有统计学意义(P0.05)。HF-PEF组及DHF组与对照组比较,MMP-9、sST2、BNP水平有统计学差异(P0.05)。HF-PEF组及DHF组比较,相同心功能Ⅱ、Ⅲ级亚组间MMP-9、sST2水平比较无有统计学意义(P0.05),但随着心功能的增加,血MMP-9、sST2水平升高,相同心功能Ⅳ级亚组间MMP-9、sST2水平比较有统计学意义(P0.05)。相关性分析:在HF-PEF组中,MMP-9与BNP水平呈正相关(r=0.917,P=0.000),sST2与BNP水平呈正相关(r=0.828,P=0.000),MMP-9与sST2呈正相关(r=0.930,P=0.000);在DHF组中,MMP-9与BNP水平呈正相关(r=0.867,P=0.000),sST2与BNP水平呈正相关(r=0.833,P=0.000),MMP-9与sST2呈正相关(r=0.983,P=0.000)。受试者工作特征(ROC)曲线分析:血清MMP-9、sST2和BNP区分HF-PEF组NYHAⅡ级与NYHAⅢ级的曲线下面积(AUC)分别是0.873、0.836、0.955(P0.05);血清MMP-9、sST2和BNP区分HF-PEF组NYHAⅢ级与NYHAⅣ级的AUC分别是0.698、0.764、0.757(P0.05),血清MMP-9、sST2和BNP区分DHF组NYHAⅡ级与NYHAⅢ级的AUC分别是0.739、0.795、0.960(P0.05),血清MMP-9、sST2和BNP区分DHF组NYHAⅢ级与NYHAⅣ级的AUC分别是0.754、0.732、0.746(P0.05)。结论血清MMP-9、sST2水平均与老年射血分数保留及舒张性心力衰竭患者心功能状态紧密相关,且可反映患者病情严重程度,为两种疾病的评估提供可靠的依据。     

高龄急性心肌梗死合并心力衰竭患者G蛋白耦联受体激酶2和可溶性ST2表达水平的变化

目的检测高龄急性心肌梗死(AMI)患者外周血G蛋白耦联受体激酶2(GRK2)和可溶性ST2(sST2)表达水平,分析其对心力衰竭的预测价值。方法选择2015年1月—2019年9月于广西壮族自治区南溪山医院心内科诊治的年龄80岁的高龄AMI患者246例,获取患者入院时基线资料、心功能状态指标[左心室射血分数(LVEF)、室壁运动积分、脑利尿钠肽(BNP)、氨基末端脑利尿钠肽前体(NT-proBNP)]和GRK2、sST2水平,统计心力衰竭发生例数,采用相关统计学方法分析心力衰竭发生的高危因素和GRK2、sST2水平预测心力衰竭发生的敏感度和特异度。结果最终确定发生心力衰竭75例,发生率30.5%。心力衰竭组年龄、BNP、NT-proBNP、室壁运动积分、sST2高于无心力衰竭组(P0.05),GRK2、LVEF低于无心力衰竭组(P0.05)。sST2与BNP、室壁运动积分呈正相关,与LVEF呈负相关(P0.05),GRK2与室壁运动积分呈负相关,与LVEF呈正相关(P0.05)。年龄、BNP、NT-proBNP、室壁运动积分、sST2为心力衰竭发生的独立危险因素(P0.05),GRK2为心力衰竭发生的保护因素(P0.05)。sST2、GRK2对心力衰竭的诊断均有一定准确性(P0.05);sST2、GRK2联合检测对心力衰竭诊断效能高于单独检测(P0.05)。结论外周血GRK2、sST2与高龄AMI患者心力衰竭发生相关,预测价值较高。     

急性心肌梗死患者血浆脑尿钠肽与心功能的相关性

目的:探讨急性心肌梗死(AMI)患者血浆脑钠尿肽(BNP)与左心室射血分数(LVEF)、左心室舒张末容积(LVEDV)、Killip分级及心肌梗死部位的关系,评价BNP对AMI患者心功能和危险分层的预测价值。方法:检测120例AMI患者和120例对照组血浆BNP水平,同时行心脏彩色多普勒检测LVEF、LVEDV,比较AMI组与对照组以及不同LVEF、Killip分级和不同梗死部位亚组间的血浆BNP水平差异。结果:与对照组相比,AMI组BNP和LVEDV显著升高,LVEF显著降低(均P<0.01)。与LVEF>50%组比较,LVEF<40%组BNP、LVEDV显著升高(P<0.05);与Killip I、II级比较,Killip III、IV级组BNP显著升高(P<0.05),Killip IV级组LVEDV显著增大(P<0.05)。与下壁心肌梗死患者相比,下后壁、前壁梗死患者BNP显著升高(P<0.05)。BNP与Killip分级成正相关(r=0.97,P<0.05),与LVEF成负相关(r=-0.33,P<0.05)。结论:AMI患者血浆BNP显著增高,尤以LVEF<40%、Killip IV级、前壁心肌梗死者为甚。     

实时三维超声心动图测量老年慢性心力衰竭患者左心室血流动力学的价值

目的探讨实时三维超声心动图(RT-3DE)在评定老年慢性心力衰竭(CHF)患者左心室功能的疗效。方法行RT-3DE检查的老年CHF患者64例临床资料为观察组,同期老年健康体检者30例为对照组。观察组根据生化B型脑钠肽(BNP)水平分为:BNP≤400 pg/ml和BNP400 pg/ml组。观察并比较各组左心室舒张末期容积(LVEDV)、左心室收缩末期容积(LVESV)、左心室每搏输出量(LVSV)、左心室射血分数(LVEF)、射血-充盈血流速转间期(FRI)、射血-充盈血流速转率(FRR)和左心室射血期峰值流率(FRPE)组间差异。结果观察组LVEDV、LVESV、FRI参数均显著高于对照组,FRR、FRPE和心指数(CI)均显著低于对照组(P0.05)。随着心力衰竭程度增高RT-3DE测量CHF患者左心室功能及血流动力学参数LVEF、CI、FRR、FRPE显著减低,LVEDV、LVESV、FRI显著增高(P0.05)。结论 RT-3DE在测量老年CHF患者左心室血流动力学的准确度较高,且可为诊断老年CHF程度提供可靠的依据。     

AMI患者血浆脑钠肽水平测定及其与左室重构的关系

测定对68例急性心肌梗死(AM I)患者发病后48 h内(早期)血浆脑钠肽(BNP)水平;于发病后28~30 d行超声心动图检查,测量左心室收缩末期容积(LVESV)、左心室舒张末期容积(LVEDV)和左心室射血分数(LVEF)。对血浆BNP水平与LVESV、LVEDV、LVEF进行相关性分析。结果LVEF≤40%者血浆BNP水平显著高于LVEF>40%者,P<0.05;血浆BNP水平与LVESV、LVEDV呈正相关,与LVEF呈负相关。认为AM I早期血浆BNP水平升高与其28~30 d左室重构程度密切相关,应积极进行干预治疗。     

血清可溶性致癌抑制因子2水平与急性ST段抬高型心肌梗死患者近期临床预后的相关性研究

目的:本研究初步探讨基线可溶性致癌抑制因子2(sST2)水平与急性ST段抬高型心肌梗死(STEMI)患者30 d主要不良心血管事件(MACE)发生的关系。方法:连续入组2015-05-01至2015-07-30期间就诊我院并明确诊断STEMI患者121例。依据基线sST2中位数水平分为sST2低值组(sST2≤56.68 ng/ml,n=61)、sST2高值组(sST256.68 ng/ml,n=60)。比较两组患者的临床资料及30 d的MACE(定义为死亡、新发慢性心力衰竭)发生率。结果:(1)两组在收缩压、Killip心功能分级≥Ⅱ级、血清肌钙蛋白I峰值、N末端B型利钠肽原(NT-pro BNP)、超敏C反应蛋白(hs-CRP)、左心室射血分数(LVEF)等方面差异均有统计学意义(P均0.05)。(2)基线sST2水平与心率(r=0.271,P=0.003)、hs-CRP(r=0.359,P=0.000)、肌钙蛋白I(r=0.324,P=0.000)及NT-pro BNP(r=0.425,P=0.000)均呈正相关;与收缩压(r=-0.226,P=0.013)及LVEF(r=-0.406,P=0.000)均呈负相关。(3)sST2低值组MACE发生率(8.2%)低于sST2高值组(30%),差异有统计学意义(P=0.002)。(4)多因素Cox回归分析显示sST256.68 ng/ml是STEMI患者30 d出现MACE的危险因素(危险比=1.152,95%可信区间:1.078~1.231,P=0.000)。结论:STEMI患者基线sST2水平升高提示近期死亡及新发心力衰竭风险增加。     

Anaerobic myocardial abscess following myocardial infarction

An anaerobic myocardial abscess due to Bacteroides fragilis developed in a 60-year-old man when he had an acute myocardial infarction while recuperating from surgery for a paracolonic abscess. Anaerobic bacteremia is a common event and may lead to infection in areas of low oxygen tension far removed from the original portal of entry.     

曲尼司特对心肌梗死后心肌间质纤维化的影响

目的探讨曲尼司特对兔心肌梗死后心肌间质纤维化干预作用。方法结扎左前降支制作兔心肌梗死模型,分实验组和对照组。3周后经胃管分别给予曲尼司特及安慰剂1月,心脏彩超评价心功能并检测血清转化生长因子（transform ing growth factor,TGF-β1）,I、III型胶原浓度及组织羟脯胺酸含量。结果实验组治疗前后心功能、心腔内径、室壁厚度明显改善,血清TGF-β1,I、III型胶原浓度及羟脯胺酸含量较对照组明显下降。结论曲尼司特可有效拮抗心肌梗死后心肌间质纤维化,预防心室重构。     

Transient myocardial ischaemia after acute myocardial infarction

The prevalence and characteristics of transient myocardial ischaemia were studied in 203 patients with recent acute myocardial infarction by both early (6.4 days) and late (38 days) ambulatory monitoring of the ST segment. Transient ST segment depression was much commoner during late (32% patients) than early (14%) monitoring. Most transient ischaemia (greater than 85% episodes) was silent and 80% of patients had only silent episodes. During late monitoring painful ST depression was accompanied by greater ST depression and tended to occur at a higher heart rate. Late transient ischaemia showed a diurnal distribution, occurred at a higher initial heart rate, and was more often accompanied by a further increase in heart rate than early ischaemia. Thus in the first 2 months after myocardial infarction transient ischaemia became increasingly common and more closely associated with increased myocardial oxygen demand. Because transient ischaemic episodes during early and late ambulatory monitoring have dissimilar characteristics they may also have different pathophysiologies and prognostic implications.     

Assessment of myocardial viability using myocardial contrast echocardiography

Myocardial contrast echocardiography (MCE) is a technique that uses microbubbles as a tracer during simultaneous ultrasound of the heart. The microbubbles can be used to provide quantitative information regarding the adequacy of myocardial blood flow (MBF), as well as the spatial extent of microvascular integrity. In acute myocardial infarction, MCE can identify the presence of collateral flow within the risk area, and can therefore predict preservation of myocardial viability and ultimate infarct size even prior to reperfusion. After reperfusion, the extent of microvascular no-reflow can be determined, and has significant implications for recovery of left ventricular function. In chronic ischemic heart disease, MCE has also been shown to successfully differentiate viable from necrotic myocardium. This technique can accurately predict recovery of function after revascularization. More importantly, MCE can be used to identify viable segments that may help to prevent infarct expansion and remodeling, and thus improve patient outcomes.     

Assessment of myocardial viability with myocardial contrast echocardiography

The application of noninvasive imaging techniques to assess myocardial viability has become an important part of routine management of patients with acute myocardial infarction and chronic coronary artery disease. Information regarding the presence and extent of viability may help identify patients likely to benefit from revascularization or therapy directed at attenuating left ventricular remodeling. Myocardial contrast echocardiography (MCE) is capable of defining the presence and extent of viability by providing an accurate assessment of microvascular integrity needed to maintain myocellular viability. It is especially suited for the spatial assessment of perfusion, even when myocardial blood flow is reduced substantially in the presence of severe epicardial stenoses or in a bed dependent on collateral perfusion. The routine use of MCE to evaluate viability in patients with acute and chronic coronary artery disease is now feasible with the advent of new imaging technologies and microbubble agents capable of myocardial opacification from venous injections. The utility of this technique for determining treatment strategies has not been established but is forthcoming.     

经静脉心肌声学造影评价心肌梗死后存活心肌的价值

目的　探讨经静脉心肌声学造影 (MCE)对心肌梗死后存活心肌的诊断价值。方法　 2 4例心肌梗死患者用二维超声评价室壁运动情况 ,同时经静脉进行MCE ,以 3个月后静态超声心动图左室心肌节段性运动改善为依据评价MCE对心肌梗死后存活心肌的诊断价值。结果　在 2 4例病人的 384个心肌节段中 ,运动异常节段 184个。在运动异常的 184个节段中 ,MCE1分 39段 ,0 5分 5 0段 ,0分 95段。 3个月复查 79个节段有运动改善 ,其中 39段来自MCE1分的心肌 ,4 0段来自MCE0 5分的心肌。MCE对预测心肌梗死后室壁运动改善的敏感性、特异性、阳性预测值、阴性预测值及准确率分别为 :10 0 %、89 7%、84 8%、10 0 %和 94 6 %。结论　MCE能比较准确地预测心肌梗死后心肌的存活性     

Transient myocardial ischaemia after acute myocardial infarction.

The prevalence and characteristics of transient myocardial ischaemia were studied in 203 patients with recent acute myocardial infarction by both early (6.4 days) and late (38 days) ambulatory monitoring of the ST segment. Transient ST segment depression was much commoner during late (32% patients) than early (14%) monitoring. Most transient ischaemia (greater than 85% episodes) was silent and 80% of patients had only silent episodes. During late monitoring painful ST depression was accompanied by greater ST depression and tended to occur at a higher heart rate. Late transient ischaemia showed a diurnal distribution, occurred at a higher initial heart rate, and was more often accompanied by a further increase in heart rate than early ischaemia. Thus in the first 2 months after myocardial infarction transient ischaemia became increasingly common and more closely associated with increased myocardial oxygen demand. Because transient ischaemic episodes during early and late ambulatory monitoring have dissimilar characteristics they may also have different pathophysiologies and prognostic implications.