急诊冠状动脉介入术后纤维蛋白原和C反应蛋白水平联合预测患者预后

Prognostic value of combining postprocedural fibrinogen with C-reactive protein levels in acute myocardial infarction patient underwent primary percutaneous coronary intervention

目的探讨冠状动脉介入治疗(PCI)后纤维蛋白原(fibrinogen,FIB)和超敏C反应蛋白(high-sensitivity C-reactive protein,hs-CRP)联合应用预测急性ST段抬高型心肌梗死(ST elevated myocardial infarction,STEMI)患者近、远期预后的价值。方法183例发病12h内接受成功PCI治疗的初发急性STEMI患者被入选。PCI术后12h内进行FIB和hs-CRP检测。对患者进行长期随访,一级终点为全因死亡,二级终点为心脏事件联合终点,包括非致死性心肌梗死、心力衰竭(NYHA Ⅲ～Ⅳ)、心肌缺血(负荷试验证实)、再次血管重建及死亡。结果PCI术后FIB和hs-CRP呈线性相关(r=0.452,P<0.0001),ROC曲线确定诊断界值分别为510mg/L(灵敏度69.2%,特异度81.6%)和14mg/L(灵敏度84.6%,特异度73.1%)。将患者分为3组:第1组,FIB<510mg/L+hs-CRP<14mg/L;第2组,FIB<510mg/L+hs-CRP≥14mg/L或FIB≥510mg/L+hs-CRP<14mg/L;第3组,FIB≥510mg/L+hs-CRP≥14mg/L。三组相比近期和远期死亡(30天:χ2=11.74,P=0.003;2年:χ2=27.04,P<0.0001)及心脏事件发生率(30天:χ2=14.34,P=0.001;2年:χ2=13.55,P=0.001)明显不同;30天累积生存率(97.9%比98.0%比83.9%,P=0.002)和2年累积生存率(97.8%比95.8%比69.0%,P<0.0001)差异有统计学意义,其中第3组患者近、远期死亡及心脏事件发生率最高,累积生存率最低。多因素COX回归分析显示,PCI术后FIB≥510mg/L且hs-CRP≥14mg/L的患者与FIB<510mg/L或hs-CRP<14mg/L的患者相比,30天(HR7.95,P=0.018)和2年内(HR12.59,P=0.002)发生死亡的风险分别增加7.95倍和12.59倍。结论急性STEMI患者成功PCI治疗后FIB≥510mg/L且hs-CRP≥14mg/L的患者近期和远期预后不良。

Objective To evaluate the prognostic value of combining postprocedural fibrinogen with high-sensitivity C-reactive protein （hs-CRP） in first time ST elevated myocardial infarction （STEMI） patients who had underwent successful primary percutaneous coronary intervention （PCI）. Methods A total of 183 consecutive patients who had their first acute STEMI attack and underwent successful primary PCI were enrolled. Fibrinogen and hs-CRP levels were measured within 12 hours after PCI. All patients were followed up for 2 years. The primary end point was death of any cause. The secondary end point was a combined end point of death, non-fatal MI, heart failure （ NYHA Ⅲ-Ⅳ ）, myocardial ischemia confirmed by stress test and revascularization. Results Postprocedural fibrinogen level correlated with hs-CRP level linearly （r = 0.452, P 〈 0. 0001 ）. ROC analysis showed that the best cut-off values were 510 mg/L （ sensitivity 69. 2%, specificity 81.6% ） and 14 mg/L （ sensitivity 84.6%, specificity 73.1% ） respectively. The patients were divided into 3 groups according to the cut-off values. Group 1, fibrinogen 〈 510 mg/L ＋ hs-CRP 〈 14 mg/L （ n = 102） ; Group 2, fibrinogen 〈 510 mg/L ＋ hs-CRP t〉 14 mg/L or fibrinogen≥510 mg/L ＋ hs-CRP 〈 14 mg/L （ n = 50） ; Group 3, fibrinogen t〉 510 mg/L ＋ hs-CRP ≥ 14 mg/L （ n = 31 ）. Incidences of 30-day death （X2 = 11.74 ,P = 0. 003）, 30-day cardiac events （X2 = 14. 34, P =0. 001 ）, 2-year death （X2 = 27. 04, P 〈 0. 0001 ） and 2-year cardiac events （Xz = 13.55, P = 0. 001 ） were significantly different among the three groups with Group 3 showing the highest incidences. Furthermore, Group 3 had the lowest 30-day cumulative survival rate （97. 9% vs 98. 0% vs 83. 9% ,P = 0. 002） and 2-year cumulative survival rate （97.8% vs 95.8% vs 69.0%, P 〈 0. 0001 ）. Multivariable COX regression showed the risk of death during 30 days （HR 7. 95 ,P =0. 018） and 2 years （HR 12. 59 ,P --0. 002） increased 7.95 and 12. 59 folds respectively in the patients with fibrinogen 〉I 510 mg/L ＋ hs-CRP I〉14 mg/L compared with the patients with fibrinogen 〈 510 mg/L or hs-CRP 〈 14 mg/L. Conclusion Postprocedural fibrinogen ≥510 mg/L ＋ hs-CRP≥14 mg/L indicates poor prognosis in patients after their first experience of STEMI even they had successful primary PCI.