本文選題：血小板高反應性　切入點：Lp-PLA2水平　出處：《天津醫(yī)科大學》2017年碩士論文　論文類型：學位論文

【摘要】：研究目的:探究血小板高反應性(high platelet reactivity,HPR)、血漿脂蛋白相關磷脂酶A2(lipoprotein-associated phospholipase A2,Lp-PLA2)及GRACE評分聯合應用對急性心肌梗死患者接受急診皮冠狀動脈介入治療術(Percutaneous Coronary Intervention,PCI)后1年主要不良心血管事件(Major Adverse Cardiac Events,MACE)的預測價值。研究方法:入選2015年9月至2016年1月之間因急性心肌梗死就診于天津市泰達國際心血管病醫(yī)院,并接受急診PCI治療的患者共150例。所有符合入選及排除標準的患者入院時均檢測Lp-PLA2及其他生化檢查和影檢查,行急診PCI治療,PCI術后12-24 h行血小板聚集率檢測。將ADP誘導的聚集率50%為血小板高反應性組,即HPR組,將ADP誘導的血小板聚集率≤50%為非血小板高反應性組,即非HPR組。將Lp-PLA2水平分組:Lp-PLA2濃度223μg/L定義為高危組,200-223μg/L定義為中危組,200μg/L定義為低危組。根據患者臨床資料計算GRACE評分。住院及出院后按照指南常規(guī)治療。門診及電話隨訪患者出院后1年內的MACE事件,MACE定義為:非致死性心肌梗死、非計劃性靶血管血運重建、再發(fā)胸痛、因心絞痛或心力衰竭非計劃性住院治療、非致死性卒中及心源性死亡。采用單因素及多因素Logistic回歸分析隨訪期間MACE事件的預測因子,繪制受試者工作特征曲線(Receiver operating characteristic curve,ROC),通過計算曲線下面積進行比較。分析HPR、Lp-PLA2、GRACE評分及三者聯合應用對急性心肌梗死(acute myocardial infarction,AMI)患者急診PCI治療術后遠期預后的預測價值。研究結果:入選患者150例,其中男性106例(70.67%)、女性44例(29.33%),年齡39~81[60.82±10.68]歲,HPR組46例(30.67%)、NPR組104例(69.33%),ST段抬高型心肌梗死組108例(72.00%)、非ST抬高型心肌梗死組42例(28.00%)。合并高血壓98例(65.30%),糖尿病22例(14.70%),血脂異常10例(6.70%),吸煙史90例(60.00%)。其中皮冠脈支架置入患者106例(70.70%),皮冠脈球囊擴張術患者44例(29.30%)。單支或雙支冠脈病變87例(58.00%),復雜病變63例(42.00%)。出院后復查冠狀動脈造影51例(34.00%)。隨訪時間11.35±3月。隨訪內共發(fā)生MACE事件20例(13.33%),其中非致死性心肌梗死1例(0.67%)、非計劃性靶血管血運重建4例(2.67%)、因不穩(wěn)定型心絞痛或心力衰竭非計劃性住院治療6例(4.00%)、心源性死亡1例(0.67%)、再發(fā)胸痛7例(4.67%)、非致死性卒中1例(0.67%)。HPR組和非HPR組比較,ST段抬高型心肌梗死、GRACE評分、Lp-PLA2、入院時心率、晨起空腹血糖、TNI、甘油三酯、LEVF有統計學差異,P0.05。非參數Pearson分析,HPR和GRACE評分之間有明顯相關性(r=0.220,p=0.007)。HPR和Lp-PLA2之間有明顯相關性(r=0.486,p=0.000)。Lp-PLA2高危組MACE事件發(fā)生率明顯高于中危組和低危組,Lp-PLA2中危組MACE事件發(fā)生率高于低危組MACE事件發(fā)生率,P均0.05。HPR組患者MACE事件發(fā)生率高于非HPR組,P0.05。MACE事件的單因素分析顯示,兩組之間在年齡、Lp-PLA2、血小板聚集率、GRACE評分、復雜病變、陳舊性心梗、入院時收縮壓、血小板計數方面有統計學差異,P均0.05。MACE事件的多因素Logistic回歸分析顯示,Lp-PLA2、HPR和GRACE評分是AMI患者發(fā)生MACE的危險因素。Lp-PLA2水平預測MACE事件的ROC曲線下面積為0.649(95%CI:0.5~0.798,P=0.032),敏感性和特異性分別為80.0%和52.3%。GRACE評分預測MACE事件的ROC曲線下面積0.710(95%CI:0.575~0.820,P=0.004),敏感性和特異性分別為60.0%和74.6%。HPR預測MACE事件的ROC曲線下面積0.749(95%CI:0.636~0.863,P=0.000),敏感性和特異性分別為85.0%和71.5%。三者聯合因子預測MACE事件的ROC曲線下面積0.807(95%CI:0.729~0.885,P=0.000),敏感性和特異性分別為90.0%和67.7%。三者聯合評估對MACE事件發(fā)生具有更好的預測價值。研究結論:1、HPR與GRACE評分之間有明顯相關性。2、HPR和Lp-PLA2水平之間有明顯相關性。3、HPR、血漿Lp-PLA2水平、GRACE評分可以作為急性ST段抬高型心肌梗死患者急診PCI治療術后遠期MACE的預測因素。這提示我們不僅要關注冠狀動脈斑塊不穩(wěn)定性的治療,也要了解機體對抗血小板藥物反應性情況,進行針對性個體化治療。4、HPR、Lp-PLA2水平、GRACE評分聯合評估可以提高AMI患者PCI術后發(fā)生MACE的預測能力,提示三者聯合評分對急性心肌梗死急診PCI治療的患者術后管理有一定的幫助。
[Abstract]:Objective: To explore high platelet reactivity (high platelet, reactivity, HPR), plasma lipoprotein associated phospholipase A2 (lipoprotein-associated phospholipase A2, Lp-PLA2) and GRACE score combined in patients with acute myocardial infarction undergoing emergency percutaneous coronary intervention (Percutaneous Coronary, Intervention, PCI) after 1 years of major adverse cardiovascular events (Major Adverse Cardiac Events, MACE) predictive value. Methods: selected from September 2015 to January 2016 for treatment of acute myocardial infarction in Tianjin Taida International Cardiovascular Disease Hospital, and received emergency treatment of PCI patients with a total of 150 cases. All were detected in Lp-PLA2 and other biochemical tests and examined in accordance with the inclusion and exclusion criteria of patients, treated with PCI. PCI 12-24 h after operation. The detection rate of platelet aggregation induced by ADP 50% for high platelet aggregation reaction Group, HPR group, ADP induced platelet aggregation rate is less than or equal to 50% for non high platelet reactivity group, non HPR group. The level of Lp-PLA2 group: Lp-PLA2 concentration of 223 g/L is defined as the high-risk group, 200-223 g/L is defined as the risk group, 200 g/L defined as low risk group according to the clinical. Patients with GRACE score. The material information in hospital and after discharge in accordance with the guidelines for routine treatment. The MACE event within 1 years of hospital outpatient and telephone follow-up, MACE is defined as: non fatal myocardial infarction, non planned target vessel revascularization, recurrent chest pain, angina or heart failure due to unplanned hospitalization. Non fatal stroke and cardiac death. By univariate and multivariate Logistic regression analysis of predictors of MACE events during the follow-up period, the receiver operating characteristic curve (Receiver operating characteristic curve, ROC), were compared by calculating the area under the curve of H. PR,Lp-PLA2,GRACE璇勫垎鍙婁笁鑰呰仈鍚堝簲鐢ㄥ鎬ユ，

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