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ST段抬高型心肌梗死(ST elevation myocardial infarction,STEMI)为临床常见心脏急性事件,以剧烈而持久的胸骨后疼痛,经休息或硝酸酯类药物无法完全缓解为临床表现,同时伴有心电图ST段抬高[1-3]。平均血小板体积(meam platelet volume, MPV)与血小板活化程度呈负相关,在多种心血管疾病的风险评估、诊断及预后预测方面均得到广泛的应用[1, 4]。虽然近年来随着溶栓、经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)、主动脉球囊反搏等技术的发展,STEMI的病死率有所下降,但全球每年因缺血性心脏病死亡的病人数仍在百万以上,因此对STEMI死亡预测具有重要的意义[5]。目前关于STEMI病人死亡预测指标有高敏C反应蛋白、冠状动脉钙化积分、D-二聚体等,但在基层医院中多不涉及上述指标[6-7]。MPV为血常规检查中常用的指标,具有较高的普及率,研究证实MPV可用于STEMI病人住院期间死亡事件预测[8],但关于MPV对STEMI病人远期预后预测方面研究较少,同时关于MPV及STEMI病人治疗后再灌注损伤预测未见相关报道,心肌缺血再灌注损伤为STEMI病人远期预后的重要影响因素,对心肌缺血再灌注损伤的预测有助于提高预后预测的准确性,因此本研究旨在通过相关分析以期为STEMI病人的远期死亡预测提供新的思路。
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本组193例病人中男99例,女94例;年龄45~71岁,平均(58.19±12.06)岁;体质量指数19.43~28.02 kg/m2,平均(24.10±3.16)kg/m2;有吸烟史84例,高血压103例,糖尿病75例;病变血管:左冠状动脉前降支96例,左回旋支31例,右冠状动脉102例;血管病变单支81例,多支112例。所有病人均在STEMI后随诊至2019年10月8日,平均随诊时间(35.02±7.13)个月,164例完成随访,随访率85.0%,其中心源性死亡35例(18.1%),非心源性死亡3例(1.6%)。
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存活组病人中性粒细胞、嗜碱性粒细胞与MPV水平均低于死亡组病人(P < 0.05~P < 0.01),而嗜酸性粒细胞水平高于死亡组病人(P < 0.01)(见表 1)。
分组 n 红细胞/ (×1012/L) 白细胞/ (×109/L) 中性粒细胞/ (×109/L) 淋巴细胞/ (×109/L) 嗜酸性粒细胞/ (×109/L) 嗜碱性粒细胞/ (×109/L) 红细胞分布宽度 MPV/fL 血小板/ (×103/μL) 存活组 126 5.33±1.61 7.59±2.35 3.72±1.46 2.79±0.83 0.26±0.01 0.07±0.02 35.58±5.39 12.93±3.17 225.84±126.75 死亡组 38 5.38±1.75 7.32±2.61 5.39±1.51 2.57±0.69 0.13±0.01 0.08±0.02 36.27±5.19 14.87±3.42 233.09±127.59 t — 0.16 0.61 6.13 1.49 70.24 2.70 0.70 3.25 0.31 P — >0.05 >0.05 < 0.01 >0.05 < 0.01 < 0.05 >0.05 < 0.05 >0.05 表 1 不同预后情况病人血常规指标的比较(x±s)
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以表 1中具有统计学意义的变量为自变量,STEMI病人远期预后情况为因变量进行多因素logistic回归分析,自变量均为连续型变量,均按实际值进入回归,因变量赋值:死亡=0,存活=1,结果显示:MPV低为STEMI病人存活的保护性因素(P < 0.05)(见表 2)。
变量 B SE Waldχ2 P OR 95%CI 中性粒细胞 -0.274 0.162 2.86 >0.05 0.760 0.553 ~1.044 嗜酸性粒细胞 0.195 0.117 2.78 >0.05 1.215 0.966 ~1.529 嗜碱性粒细胞 -0.203 0.129 2.48 >0.05 0.816 0.634 ~1.051 MPV -0.377 0.162 5.42 < 0.05 0.686 0.499 ~0.942 表 2 血常规指标及MPV对STEMI病人远期预后多因素分析
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MPV对STEMI病人远期死亡预测截断值为13.14 fL,ROC曲线下面积(AUC)为0.741,95%CI:0.658~0.824,灵敏度为78.94%(30/38),特异度为83.33%(105/126),准确度为82.32%(135/164),阳性预测值为58.82%(30/51),阴性预测值为92.92%(105/113)(见图 1、表 3)。
MPV 随访结果 合计 生存 死亡 < 13.14 fL 105 8 113 ≥13.14 fL 21 30 51 合计 126 38 164 表 3 MPV对STEMI病人远期死亡的预测价值(n)
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根据ROC分析结果,将病人分为MPV低水平组(MPV < 13.14 fL)113例,死亡8例;MPV高水平组(MPV≥13.14 fL)51例,死亡30例。以Kaplan-Meier分析法对STEMI病人入院时MPV水平与远期生存关系进行分析,MPV低水平组中位生存时间为33个月(95%CI:31.092~34.263)长于MPV高水平组的25个月(95%CI:22.132~27.291)(χ2=70.27,P < 0.01)(见图 2)。
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MPV低水平组(MPV < 13.14 fL)心脑血管事件共发生28例,其中心源性死亡5例,再发心肌梗死4例,再发心绞痛8例,再次血运重建8例,脑卒中3例;MPV高水平组(MPV≥13.14 fL)出现心脑血管事件39例,其中心源性死亡30例,再发心肌梗死5例,再发心绞痛3例,脑卒中1例。MPV低水平组脑血管事件发生率24.78%(28/113)低于高水平组的76.47%(39/51)(χ2=38.86,P < 0.01)。
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193例STEMI病人中,共有98例(50.78%)出现不同程度的心肌缺血再灌注损伤,心肌缺血再灌注损伤组病人MPV水平为(14.72±3.27)fL,高于无心肌缺血再灌注损伤的(13.06±3.11)fL(t=3.61,P < 0.01)。
ST段抬高型心肌梗死病人远期死亡率与入院首次化验时平均血小板体积的关系
Study on the relationship between long-term mortality and mean platelet volume at the first test in patients with ST-segment elevation myocardial infarction
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摘要:
目的探讨ST段抬高型心肌梗死(STEMI)病人远期死亡率与入院首次化验时平均血小板体积(MPV)的关系。 方法选择STEMI病人193例进行研究,病人均在STEMI后随诊至2019年10月8日,根据随访结果将病人分为存活组及死亡组,对比2组血常规指标水平,采用多元线性回归对血常规指标与STEMI远期预后关系进行分析,以ROC分析MPV对STEMI远期死亡的预测截断值,以Kaplan-Meier曲线进行生存分析,采用Log-Rank检验。 结果血常规指标比较显示,存活组病人中性粒细胞、嗜碱性粒细胞与MPV水平均低于死亡组病人(P < 0.05~P < 0.01),嗜酸性粒细胞高于死亡组病人(P < 0.01)。MPV对STEMI病人远期死亡预测截断值为13.14 fL,AUC为0.741,95%CI:0.658~0.824,灵敏度为78.94%(30/38),特异度为83.33%(105/126),准确度为82.32%(135/164),阳性预测值为58.82%(30/51),阴性预测值为92.92%(105/113)。ROC分析结果显示,MPV低水平组(MPV < 13.14 fL)病人113例,死亡8例;MPV高水平组(MPV ≥ 13.14 fL)51例,死亡30例。Kaplan-Meier分析显示,MPV低水平组中位生存时间为33个月(95%CI:31.09~34.26),高于MPV高水平组的25个月(95%CI:22.13~27.29)(P < 0.01)。MPV低水平组脑血管事件发生率24.78%低于高水平组的76.47%(P < 0.01)。193例STEMI病人中,共有98例(50.78%)出现不同程度的心肌缺血再灌注损伤,心肌缺血再灌注损伤病人MPV水平高于无心肌缺血再灌注损伤病人(P < 0.01)。 结论STEMI病人入院首次化验时MPV水平明显高于健康人群,MPV可作为STEMI病人远期预后的评价指标,当STEMI病人MPV ≥ 13.14 fL时病人的远期死亡风险明显增加,同时MPV水平升高心肌缺血再灌注风险上升。 -
关键词:
- ST段抬高型心肌梗死 /
- 平均血小板体积 /
- 死亡率 /
- 生存分析
Abstract:ObjectiveTo investigate the relationship between long-term mortality and mean platelet volume(MPV) at the first test in patients with ST-segment elevation myocardial infarction(STEMI). MethodsA total of 193 STEMI patients were followed up until October 8, 2019 after STEMI.According to the results of following up, the patients were divided into the survival group and death group.The blood routine indexes between the two groups were compared.The relationship between the blood routine indexes and long-term prognosis of STEMI was analyzed using multiple linear regression analysis, the cut-off value of MPV to long-term mortality of STEMI was analyzed using ROC analysis, the survival analysis was conducted by Kaplan-Meier curve, and the Log-Rank test was used. ResultsThe results of blood routine indicators analysis showed that the levels of neutrophils, eosinophils, basophils and MPV in survival group were significantly lower than those in death group(P < 0.05 to P < 0.01).The cut-off value of MPV predicting long-term death in STEMI patients was 13.14 fL, the AUC was 0.741, the 95%CI was 0.658-0.824, the sensitivity was 78.94%(30/38), the specificity was 83.33%(105/126), the accuracy was 82.32% (135/164), the positive predictive value was 58.82% (30/51), and the negative predictive value was 92.92%(105/113).The results of ROC analysis showed that 8 patients died in the low-level MPV group(113 cases, MPV < 13.14 fL), and 30 patients died in the high level MPV group(51 cases, MPV ≥ 13.14 fL).The results of Kaplan-Meier analysis showed that the median survival time in low-level MPV group was 33 months(95%CI: 31.09-34.26), which was higher than that in high-level MPV group[25 months, (95%CI: 22.13-27.29)] (P < 0.01).The incidence rates of cerebrovascular events in low-level MPV group(24.78%) was lower than that in high-level MPV group(76.47%)(P < 0.01).Among 193 STEMI patients, 98 patients (50.78%) with different degrees of myocardial ischemia reperfusion injury were identified, and the level of MPV in patients with myocardial ischemia reperfusion injury was higher than that in patients without myocardial ischemia reperfusion injury(P < 0.01). ConclusionsThe level of MPV in STEMI patients is significantly higher than that in healthy people at the first test, and the MPV can be used as an indicator for the long-term prognosis of STEMI patients.When the MPV is more than or equal to 13.14 fL, the risk of long-term death in patients with STEMI significantly increases, and the risk of myocardial ischemia reperfusion increases with the increasing of MPV level. -
Key words:
- ST elevation myocardial infarction /
- mean platelet volume /
- mortality /
- survival analysis
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表 1 不同预后情况病人血常规指标的比较(x±s)
分组 n 红细胞/ (×1012/L) 白细胞/ (×109/L) 中性粒细胞/ (×109/L) 淋巴细胞/ (×109/L) 嗜酸性粒细胞/ (×109/L) 嗜碱性粒细胞/ (×109/L) 红细胞分布宽度 MPV/fL 血小板/ (×103/μL) 存活组 126 5.33±1.61 7.59±2.35 3.72±1.46 2.79±0.83 0.26±0.01 0.07±0.02 35.58±5.39 12.93±3.17 225.84±126.75 死亡组 38 5.38±1.75 7.32±2.61 5.39±1.51 2.57±0.69 0.13±0.01 0.08±0.02 36.27±5.19 14.87±3.42 233.09±127.59 t — 0.16 0.61 6.13 1.49 70.24 2.70 0.70 3.25 0.31 P — >0.05 >0.05 < 0.01 >0.05 < 0.01 < 0.05 >0.05 < 0.05 >0.05 表 2 血常规指标及MPV对STEMI病人远期预后多因素分析
变量 B SE Waldχ2 P OR 95%CI 中性粒细胞 -0.274 0.162 2.86 >0.05 0.760 0.553 ~1.044 嗜酸性粒细胞 0.195 0.117 2.78 >0.05 1.215 0.966 ~1.529 嗜碱性粒细胞 -0.203 0.129 2.48 >0.05 0.816 0.634 ~1.051 MPV -0.377 0.162 5.42 < 0.05 0.686 0.499 ~0.942 表 3 MPV对STEMI病人远期死亡的预测价值(n)
MPV 随访结果 合计 生存 死亡 < 13.14 fL 105 8 113 ≥13.14 fL 21 30 51 合计 126 38 164 -
[1] LIU X, WANG S, YUAN L, et al. Increased mean platelet volume is associated with higher in-hospital mortality rate in patients with acute myocardial infarction[J]. Clin Lab, 2017, 63(1): 163. [2] JIANG P, SONG Y, XU JJ, et al. Two-year prognostic value of mean platelet volume in patients with diabetes and stable coronary artery disease undergoing elective percutaneous coronary intervention[J]. Cardiol J, 2019, 26(2): 138. [3] ORAK M, KARAKOÇ Y, VSTVNDAG M, et al. An investigation of the effects of the mean platelet volume, platelet distribution width, platelet/lymphocyte ratio, and platelet counts on mortality in patents with sepsis who applied to the emergency department[J]. Niger J Clin Pract, 2018, 21(5): 667. doi: 10.4103/njcp.njcp_44_17 [4] HUDZIK B, KORZONEK-SZLACHETA I, SZKODZIŃSKI J, et al. Association between multimorbidity and mean platelet volume in diabetic patients with acute myocardial infarction[J]. Acta Diabetol, 2018, 55(2): 175. doi: 10.1007/s00592-017-1079-6 [5] MEERSHOEK AJA, LEUNISSEN TC, VAN WAES JAR, et al. Reticulated platelets as predictor of myocardial injury and 30 day mortality after non-cardiac surgery[J]. Eur J Vasc Endovasc, 2020, 59(2): 309. doi: 10.1016/j.ejvs.2019.06.027 [6] 唐小勇, 钟万芬. D-二聚体水平评价急性心肌梗死危险程度及对预后的预测[J]. 现代医学, 2016(5): 697. [7] PAFILI K, PENLIOGLOU T, MIKHAILIDIS DP, et al. Mean platelet volume and coronary artery disease[J]. Curr Opin Cardiol, 2019, 34(4): 390. doi: 10.1097/HCO.0000000000000624 [8] GUO TM, CHENG B, KE L, et al. Prognostic value of neutrophil to lymphocyte ratio for in-hospital mortality in elderly patients with acute myocardial infarction[J]. Curr Med Sci, 2018, 38(2): 354. doi: 10.1007/s11596-018-1887-0 [9] 袁晋青, 宋莹. 《2015年中国急性ST段抬高型心肌梗死诊断及治疗指南》——更新要点解读[J]. 中国循环杂志, 2016, 31(4): 318. doi: 10.3969/j.issn.1000-3614.2016.04.002 [10] MARTIN-GARCIA AC, ARACHCHILLAGE DRJ, KEMPNY A, et al. Platelet count and mean platelet volume predict outcome in adults with Eisenmenger syndrome[J]. Heart, 2018, 104(1): 45. doi: 10.1136/heartjnl-2016-311144 [11] HAMEED A, RUBAB Z, RIZVI SKA, et al. Levels of platelet-derived microparticles and soluble p-selectin in patients of acute myocardial infarction (Case control study)[J]. J Pak Med Assoc, 2017, 67(7): 998. [12] LI YH, WANG LH, LI Q, et al. Effects of rosuvastatin on pentraxin 3 level and platelet aggregation rate in elderly patients with acute myocardial infarction undergoing elective interventional therapy: a double-blind controlled study[J]. Eur Rev Med Pharmacol Sci, 2017, 21(16): 3730. [13] EL-BATTRAWY I, BORGGREFE M, AKIN I. β-Blockers and outcome after acute myocardial infarction[J]. J Am Coll Cardiol, 2017, 70(13): 1685. [14] 杨华, 陈枝琼. 血小板参数在判断强直性脊柱炎疾病活动中的价值[J]. 蚌埠医学院学报, 2018, 265(1): 52. [15] 许丽娇, 黄东平, 汪云霞. 红细胞分布宽度及血小板参数在急性心肌梗死诊断中的应用研究[J]. 临床医学工程, 2016, 23(11): 1515. doi: 10.3969/j.issn.1674-4659.2016.11.1515 [16] MUBANG R, TERZIAN WH, CIPOLLA J, et al. Acute myocardial infarction following right coronary artery dissection due to blunt trauma[J]. Heart Views, 2016, 17(1): 35. doi: 10.4103/1995-705X.182646 [17] BESLI F, ILTER A, GUNGOREN F. The link between mean platelet volume to lymphocyte ratio and complexity of coronary artery disease[J]. Angiology, 2018, 69(4): 358. doi: 10.1177/0003319717743315 [18] OMAR M, TANRIVERDI O, COKMERT S, et al. Role of increased mean platelet volume (MPV) and decreased MPV/platelet count ratio as poor prognostic factors in lung cancer[J]. Clin Respir J, 2018, 12(3): 922. doi: 10.1111/crj.12605 [19] PENG F, ZHENG W, LI F, et al. Elevated mean platelet volume is associated with poor outcome after mechanical thrombectomy[J]. J Neurointerv Surg, 2018, 10(1): 25. doi: 10.1136/neurintsurg-2016-012849