刘道莹,刘 笛
·论著·
血清脂蛋白(a)和N末端脑钠肽前体水平对65岁以上冠心病患者冠状动脉病变程度的评估价值研究
刘道莹,刘 笛
目的探讨血清脂蛋白(a)〔Lp(a)〕和N末端脑钠肽前体(NT-proBNP)水平对65岁以上冠心病患者冠状动脉病变程度的评估价值。方法选取2011年2月—2014年3月在肥城市矿业中心医院心内科住院治疗的伴有心前区不适的65岁以上老年患者342例,根据冠状动脉造影检查结果分为冠心病组246例和非冠心病组96例,再根据冠状动脉病变支数将冠心病患者分为单支组67例、双支组77例和三支组102例。根据Gensini积分定量评估冠状动脉病变程度,并分析血清Lp(a)和NT-proBNP水平与Gensini积分的相关性。结果冠心病组与非冠心病组患者性别、年龄、体质指数、腰臀比、收缩压、舒张压、血糖、总胆固醇、三酰甘油、低密度脂蛋白及高密度脂蛋白比较,差异均无统计学意义(P>0.05);冠心病组患者血清Lp(a)和NT-proBNP水平高于非冠心病组(P<0.05)。三支组和双支组患者血清Lp(a)、NT-proBNP水平及Gensini积分高于单支组,三支组患者血清Lp(a)、NT-proBNP水平及Gensini积分高于双支组(P<0.05)。Pearson相关性分析结果显示,血清Lp(a)、NT-proBNP水平与Gensini积分呈正相关(r值分别为0.389、0.585,P<0.05);多元线性回归分析结果显示,冠状动脉病变支数、血清Lp(a)和NT-proBNP水平与Gensini积分呈正相关,且Gensini积分变异的39.1%可以由冠状动脉病变支数、血清Lp(a)和NT-proBNP水平变化解释。结论血清Lp(a)和NT-proBNP水平与65岁以上冠心病患者冠状动脉病变程度呈正相关,联合检测血清Lp(a)和NT-proBNP水平可用于评估患者冠状动脉病变程度。
冠心病;老年人,65岁以上;脂蛋白(A);N端脑钠肽前体
刘道莹,刘笛.血清脂蛋白(a)和N末端脑钠肽前体水平对65岁以上冠心病患者冠状动脉病变程度的评估价值研究[J].实用心脑肺血管病杂志,2016,24(9):33-36.[www.syxnf.net]
LIU D Y,LIU D.Assessment value of serum levels of lipoprotein(a)and NT-proBNP on severity of coronary artery lesion in aged patients(over 65 years old)with coronary heart disease[J].Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease,2016,24(9):33-36.
冠状动脉粥样硬化性心脏病简称冠心病,是临床上常见的心脏病类型。该病是因冠状动脉发生粥样硬化而导致管腔狭窄或阻塞、心肌供血不足而引发心肌缺氧或坏死,其也是导致心力衰竭的主要原因[1]。近年来,随着我国人口老龄化进程加剧及人们生活方式的改变,65岁以上老年人冠心病发病率呈明显上升趋势,严重影响老年人的身体健康,且成为老年人死亡的主要原因[2]。因此,积极寻找有效评估冠状动脉病变程度的敏感指标对冠心病患者的科学预防、治疗及预后具有重要的临床意义。脂蛋白(a)〔Lp(a)〕是一种大分子脂蛋白,结构类似于低密度脂蛋白,由肝脏合成,在血栓形成及动脉粥样硬化发生过程中发挥着重要作用,是脉粥样硬化的独立危险因素[3]。N末端脑钠肽前体(NT-proBNP)是脑钠肽前体物质分解为脑钠肽的中间产物,其水平高于脑钠肽,具有分子量大、易检测、t1/2长、浓度相对稳定、受药物等其他因素影响较小等优点,且当心脏功能减弱时其水平明显升高[4]。本研究通过联合检测65岁以上冠心病患者Lp(a)和NT-proBNP水平,旨在探讨二者对65岁以上冠心病患者冠状动脉病变程度的评估价值。
1.1一般资料选取2011年2月—2014年3月在肥城市矿业中心医院心内科住院治疗的伴有心前区不适的65岁以上老年患者342例,其中男143例,女199例;平均年龄(69.7±5.4)岁。所有患者行冠状动脉造影检查,根据检查结果分为冠心病组246例和非冠心病组96例,再根据冠状动脉病变支数将冠心病患者分为单支组67例、双支组77例和三支组102例。排除心力衰竭、肝肾等重要脏器严重功能不全、原发性醛固酮增多症、肿瘤、甲状腺功能亢进、先天性心脏病、自身免疫性疾病患者。
1.2方法
1.2.1冠状动脉造影检查方法采用美国GE公司生产的大型C臂数字减影血管造影X线机,按照Judkins法行选择性冠状动脉造影,由两位经验丰富的主任医师采用目测法评估冠状动脉狭窄程度及病变性质。至少有一支主要冠状动脉及其分支狭窄程度>50%定义为冠心病;根据血管病变支数分为单支病变、双支病变和三支病变,但需要注意的是当左主干出现病变时,无论回旋支或前降支是否存在病变均定义为双支病变。
1.2.2实验室指标检测方法采集所有患者晨起空腹12 h以上肘静脉血10 ml,采用日本日立公司7100全自动生化分析仪检测血糖、血脂指标(包括总胆固醇、三酰甘油、低密度脂蛋白及高密度脂蛋白)及血清Lp(a)水平,采用德国罗氏cobase411型全自动电化学发光免疫分析仪及配套试剂检测血清NT-proBNP水平。
1.2.3Gensini积分采用Gensini积分[5]定量评估冠状动脉病变程度:(1)基本评分:按照狭窄程度不同,32分:100%;16分:91%~99%;8分:76%~90%;4分:51%~75%;2分:26%~50%;1分:≤25%。(2)按照病变部位进行评分系数确定:左主干:×5.0;左前降支:远端×1.0、中段×1.5、近端×2.5;对角支:第一对角支×1.0,第二对角支×0.5;左回旋支:后侧支×0.5,远端和后降支均×1.0,近段×2.5;右冠状动脉:后降支及近中远支均×1.0。(3)积分计算方法:基本评分×评分系数,各分支积分总和作为最终的Gensini积分。
2.1两组患者临床资料比较两组患者性别、年龄、体质指数、腰臀比、收缩压、舒张压、血糖、总胆固醇、三酰甘油、低密度脂蛋白及高密度脂蛋白比较,差异均无统计学意义(P>0.05);冠心病组患者血清Lp(a)和NT-proBNP水平高于非冠心病组,差异有统计学意义(P<0.05,见表1)。
2.2不同冠状动脉病变支数冠心病患者血清Lp(a)、NT-proBNP水平及Gensini积分比较不同冠状动脉病变支数冠心病患者血清Lp(a)、NT-proBNP水平及Gensini积分比较,差异有统计学意义(P<0.05);三支组和双支组患者血清Lp(a)、NT-proBNP水平及Gensini积分高于单支组,三支组患者血清Lp(a)、NT-proBNP水平及Gensini积分高于双支组,差异均有统计学意义(P<0.05,见表2)。
Table 2Comparison of serum levels of Lp(a)and NT-proBNP,and Gensini score in CHD patients with different number of stenosed coronary arteries
组别例数Lp(a)(mg/L)NT-proBNP(ng/L)Gensini积分(分)单支组67228.63±97.57526.81±248.5827.4±9.5双支组77304.31±139.74a648.37±256.94a36.9±11.2a三支组102358.95±166.71ab769.51±328.72ab48.8±10.4abF值17.51615.65424.839P值0.0000.0000.000
注:与单支组比较,aP<0.05;与双支组比较,bP<0.05
2.3相关性分析Pearson相关性分析结果显示,血清Lp(a)、NT-proBNP水平与Gensini积分呈正相关(r值分别为0.389、0.585,P<0.05,见图1)。
2.4多元线性回归分析将Gensini积分作为因变量,将性别、年龄、体质指数、腰臀比、收缩压、舒张压、血糖、总胆固醇、冠状动脉病变支数、血清Lp(a)和NT-proBNP水平作为自变量进行多元线性回归分析,结果显示,冠状动脉病变支数、血清Lp(a)和NT-proBNP水平与Gensini积分呈正相关,且Gensini积分变异的39.1%可以由冠状动脉病变支数、血清Lp(a)和NT-proBNP水平的变化解释。
表3Gensini积分相关因素的多元线性回归分析
Table 3Multivariate linear regression analysis on related factors of Gensini score
变量bSbb'P值R2冠状动脉病变支数5.6121.0840.325<0.0010.391Lp(a)2.8290.3740.193<0.05-NT-proBNP3.8130.6810.237<0.001-
注:“-”表示无相关数据
表1 冠心病组和非冠心病组患者临床资料比较
注:a为χ2值;Lp(a)=脂蛋白(a),NT-proBNP=N末端脑钠肽前体;1 mm Hg=0.133 kPa
注:Lp(a)=脂蛋白(a),NT-proBNP=N末端脑钠肽前体
图1血清Lp(a)和NT-proBNP水平与Gensini积分相关性的散点图
Figure 1Scatter plots for correlations between serum level of Lp(a),of NT-proBNP and Gensini score
冠心病是致残率和病死率极高的常见疾病之一,是导致老年人死亡的主要原因,其主要病理改变为冠状动脉粥样硬化斑块破裂及继发血栓形成[6]。及早确诊、科学评估病情及合理治疗对降低冠心病患者的病死率具有重要意义[7]。Lp(a)是由肝脏合成的富含胆固醇的大分子脂蛋白,WU等[8]研究指出,Lp(a)在动脉粥样硬化及血栓形成过程中具有促进作用。TSIMIKAS等[9]研究指出,Lp(a)能与有促炎作用的脂蛋白及与氧化磷脂有关的磷脂酶A2相结合,产生氧化游离脂肪酸及溶血卵磷脂,进而促发炎性反应及动脉粥样硬化形成。除此之外,Lp(a)还能竞争性抑制纤溶酶原产生,使纤溶及凝血功能失调,从而促进血栓形成[10]。脑钠肽是一种重要的心脏疾病标志物,而NT-proBNP是脑钠肽生成过程中的中间产物,其水平高于脑钠肽,且稳定、分子量大、存在时间长、不易受其他因素影响[11]。临床研究显示,NT-proBNP与心肌缺血的发生密切相关,且其水平与心脏缺血范围呈正相关[12-13]。为此,本研究探讨了血清Lp(a)和NT-proBNP水平对65岁以上冠心病患者冠状动脉病变程度的评估价值,旨在为冠心病的防治提供科学依据。
本研究结果显示,冠心病组患者血清Lp(a)和NT-proBNP水平均高于非冠心病组,提示血清Lp(a)和NT-proBNP水平升高与冠心病相关。本研究结果还显示,三支组和双支组患者血清Lp(a)、NT-proBNP水平及Gensini积分高于单支组,三支组患者血清Lp(a)、NT-proBNP水平及Gensini积分高于双支组,提示冠状动脉病变支数越多,患者冠状动脉病变程度越严重、血清Lp(a)和NT-proBNP水平越高。本研究进一步进行Pearson相关性分析及多元线性回归分析显示,血清Lp(a)和NT-proBNP水平与Gensini积分呈正相关,且Gensini积分变异的39.1%可以由冠状动脉病变支数、血清Lp(a)和NT-proBNP水平的变化解释。提示血清Lp(a)和NT-proBNP水平升高可反映65岁以上冠心病患者冠状动脉病变的严重程度,故临床上应对血清Lp(a)和NT-proBNP水平较高的冠心病患者予以重视。
综上所述,血清Lp(a)和NT-proBNP水平均随冠状动脉病变支数增加而升高,且其升高程度与冠状动脉病变严重程度呈正相关。因此,联合检测血清Lp(a)和NT-proBNP水平有助于评估65岁以上冠心病患者的冠状动脉病变程度,这对指导临床早期采取治疗措施以减缓病情发展及改善患者预后具有重要意义。
作者贡献:刘道莹进行实验设计与实施、资料收集整理、撰写论文、成文并对文章负责;刘笛进行实验实施、评估、资料收集;刘道莹进行质量控制及审校。
本文无利益冲突。
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(本文编辑:谢武英)
Assessment Value of Serum Levels of Lipoprotein(a)and NT-proBNP on Severity of Coronary Artery Lesion in Aged Patients(over 65 Years Old)with Coronary Heart Disease
LIUDao-ying,LIUDi.
ICU,MiningCentralHospitalofFeicheng,Feicheng271608,China
ObjectiveTo investigate the assessment value of serum levels of lipoprotein(a)〔Lp(a)〕and NT-proBNP on severity of coronary artery lesion in aged patients(over 65 years old)with coronary heart disease.MethodsA total of 342 aged patients(over 65 years old)with discomfort of precordial region were selected in Mining Central Hospital of Feicheng from February 211 to March 2014,and they were divided into A group(with coronary heart disease,n=246)and B group(without coronary heart disease,n=96)according to the coronary angiography examination results;according to the number of stenosed coronary arteries,patients of A group were divided into three subgroups:A1 group(with single vessel lesion,n=67),A2 group(with double-vessel lesions,n=77)and A3 group(with triple-vessel lesions,n=102).The severity of coronary artery lesion was quantitatively evaluated by Gensini score,and correlations between serum level of Lp(a),of NT-proBNP and Gensini score were analyzed.ResultsNo statistically significant differences of gender,age,BMI,WHR,SBP,DBP,FPG,TC,TG,LDL or HDL was found between A group and B group(P>0.05),while serum levels of Lp(a) and NT-proBNP of A group were statistically significantly higher than those of B group(P<0.05).Serum levels of Lp(a)and NT-proBNP,and Gensini score of A2 group and A3 group were statistically significantly higher than those of A1 group,meanwhile serum levels of Lp(a)and NT-proBNP,and Gensini score of A3 group were statistically significantly higher than those of A2 group(P<0.05).Pearson correlation analysis results showed that,serum level of Lp(a),of NT-proBNP was positively correlated with Gensini score,respectively(r=0.389,0.585;P<0.05);multivariate linear regression analysis results showed that,number of stenosed coronary arteries,serum level of Lp(a),of NT-proBNP was positively correlated with Gensini score,respectively,39.1% variation of Gensini score can be explained by the changes of number of stenosed coronary arteries,serum levels of Lp(a)and NT-proBNP.ConclusionSerum levels of Lp(a)and NT-proBNP are positively correlated with the severity of coronary artery lesion in aged patients(over 65 years old)with coronary heart disease,joint detection of serum levels of Lp(a)and NT-proBNP can be used to evaluate the severity of coronary artery lesion.
Coronary disease;Aged,65 and over;Lipoprotein(a);N-terminal pro-brain natriuretic peptide
271608山东省肥城市,肥城矿业中心医院ICU(刘道莹),儿科(刘笛)
R 541.4
A
10.3969/j.issn.1008-5971.2016.09.008
2016-06-05;
2016-09-18)