入院24h平均血糖对急性ST段抬高型心肌梗死患者近期预后的影响

Impact of first 24 hours mean blood glucose level on the prognosis of hospitalized patients with STsegment elevation myocardial infarction

目的 探讨人院24 h平均血糖（mean blood glucose,MBG）与急性ST段抬高型心肌梗死（STEMI）患者近期病死率及不良心血管事件的相关性.比较MBG与入院血糖（admission glucose,AG）对顶后影响的顶测价值.方法 人选病例来自2001至2004年间我国274家中心参加CREATE（Clinical trial of reviparin and metabolic modulation in acute myocardial infarction treatment evaluation）研究数据库、症状出现12 h内STEMI的中国患者7446例,将入院即刻、6 h、24 h血糖值计箅均值,以入院第1个24 h的MBG水平分成6组,即MBG＜4.5 mmol/L组、4.5～5.5 mmol/L组、5.6～7.0 mmol/L组、7.1～8.5 mmol/L组、8.6～11.0 mmol/L组和MBG＞11.0 mmol/L组.以MBG 4.5～5.5 mmol/L组作为对照组,其他血糖水平组与之进行比较.分析7 d和30 d病死率及联合终点事件发生情况.比较MBG与AG对上述事件预测价值的影响.结果 单因素分析显示,7 d、30 d病死率、联合终点事件发生率随着MBG水平升高而逐渐升高.MBG 7.1～8.5 mmol/L及以上组与MBG 4.5～5.5 mmol/L组的患者比较,差异均有统计学意义.多因素logistic回归分析显示MBG 7.1～8.5 mmol/L及以上各组是STEMI患者7 d、30 d病死率、联合终点事件的独立危险因素.MBG 7.1～8.5 mmol/L、8.6～11.0 mmol/L和＞11.0 mmol/L的患者7 d死亡危险分别比对照组患者增加56%（P=0.022）、61%（P=0.018）和230%（P＜0.001）,30 d死亡危险分别比对照组患者增加41%（P=0.048）、40%（P=0.032）和185%（P＜0.001）.MBG＜4.5 mmol/L组30 d联合终点事件发生危险无明显增加（P=0.085）.应用Nested模型对AG及24 h MBG对病死率以及联合终点事件预测模型比较显示,24 hMBG较AG预测价值更大（均P＜0.001）.结论 24 h MBG≥7.1 mmol/L与STEMI患者7 d、30 d病死率增高相关.24 h MBG较AG对预后具有更好的预测价值.

Objective To compare the impact of the first 24 hours mean blood glucose （MBG）level and admission glucose （AG） during hospitalization on the short term mortality and combined end point events in patients with ST-segment elevation acute myocardial infarction （STEMI）. Methods A total of 7446 Chinese STEMI patients hospitalized within 12 hours of symptom onset were included. Plasma glucose was measured at admission, 6 and 24 hours after admission, respectively. The MBG level through the first 24 hours for each patient was calculated. Patients were stratified into six groups according to their MBG levels： 〈4.5, 4.5 -5.5, 5.6-7.0, 7.1 -8.5, 8.6-11.0and 〉11.0 mmol/L. The incidence of all cause mortality and combined end point of death, re-infarction, cardiogenic shock, recurrence ischemia, and stroke at 7 days and 30 days post hospitalization were analyzed. Nested models were compared to determine whether logistic regression models that included MBG provided a significantly better fit than logistic regression models included AG. Results Compared with the MBG of 4. 5 - 5.5 mmol/L group, 7-day and 30-day mortality and combined end point events increased in proportion to plasma MBG level increase.Multivariate logistic regression analysis showed that elevated MBG （ equal or greater than 7. 1 - 8. 5 mmol/L） level is an independent predictor of 7-day and 30-day mortality and combined end point events. Nested models analysis showed that the prognostic impact of MBG is superior to AG . P 〈 0. 001 ） on predicting 7-day and 30-day mortality and combined end point events in this patient cohort. Conclusion Elevated MBG （ ≥7. 1 mmol/L） level is an independent predictor of 7-day and 30-day mortality and combined end point events. MBG is superior to AG on predicting short-term prognosis in this patient cohort.