应激性血糖升高的急性冠状动脉综合征患者经皮冠状动脉介入治疗四年预后分析

Impact of stress hyperglycemia on acute coronary syndrome after primary percutaneous coronary intervention for four years

目的探讨合并应激性血糖升高(SH)的急性冠状动脉综合征(ACS)患者经皮冠状动脉介入(PCI)治疗后住院期间及四年预后。方法入选327例ACS患者于入院即刻测定静脉血糖,依血糖水平及病史将入选病例分为两组,试验组151例,空腹血糖≥7.0mmol/L,随机血糖≥11.1mmol/L,既往无糖尿病史,住院期间及随访期间未诊为糖尿病及糖代谢异常。对照组176例,为血糖水平空腹<6.1mmol/L,随机血糖<7.8mmol/L,既往无明确糖尿病史,住院期间及随访期间未诊为糖尿病及糖代谢异常。分析两组患者一般临床资料、冠状动脉造影提示的冠状动脉病变特点及PCI治疗成功率、并发症、住院期间及出院后四年内心血管事件发病率、病死率。结果患者资料中的一般临床情况在年龄、性别、吸烟、病史方面无差异,试验组较对照组血甘油三酯升高[(1.90±0.19)mmol/Lvs.(1.70±0.37)mmol/L,t=5.60,P=0.00],左心室射血分数降低[(53.44±9.44)%vs.(55.68±8.41)%,t=2.26,P=0.02]。两组患者均行冠状动脉造影检查,行PCI治疗成功率试验组与对照组(97.35%vs.98.30%,χ2=0.34,P=0.56)比较无统计学差异,B2型病变数试验组高于对照组(49.01%vs.26.70%,χ2=17.34,P=0.00),A型病变数对照组高于试验组(17.61%vs.4.64%,χ2=13.33,P=0.00)。冠状动脉病变置入支架相对比试验组高于对照组(73.46%vs.65.05%,χ2=6.48,P=0.01)。随访两组患者四年,住院期间两组心脏事件发生概率(3.31%vs.2.27%,χ2=0.05,P=0.82)无统计学差异,在出院后至12个月时,试验组心脏事件发生的区间概率明显升高[16.11%vs.5.75%,RR=2.80(95%CI:1.32～5.93),χ2=7.23,P=0.00]。在12个月后至48个月的中、长期随访中,两组心脏事件发生的区间概率无统计学差异。至随访结束时,试验组累积心血管事件发生概率增多[26.12%vs.11.66%,RR=2.24(95%CI:1.28～3.91),χ2=8.02,P=0.00]。试验组较对照组再发心肌梗死及缺血性靶血管血运重建率增加,对照组患者的心血管事件以不稳定型心绞痛及心力衰竭多见。两组心因性病死率无显著差异。校正血脂因素后SH导致心血管事件发生的OR为2.019,95%CI:1.059～3.850,P=0.033。各区间病死率比较无统计学差异,总病死率比较(9.27%vs.3.98%,χ2=3.79,P=0.052)差异无统计学意义。结论 SH的ACS患者行PCI治疗后12个月内心脏不良事件的发生率增加,SH对中、长期预后无影响。SH是导致心血管事件发生的独立危险因素。

Objective To investigate the impact of stress hyperglycemia （SH） on acute coronary syndrome （ACS） who underwent primary percutaneous coronary intervention （PCI） for four years. Methods There were 327 patients with ACS who underwent primary PCI, according to the levels of the admission blood suga and the history, these patients were divided into two groups： experimental group： 151 patients fasting blood suger ≥7.0 mmol/L, nomal blood suger 11.1 mmol/L, non-diabetic, control group： 176 patients, fasting blood suga 〈 6. 1 mmol/L, nomal blood suga 〈 7. 8 mmol/L, non-diabetic. The general clinical setting, adverse cardiac events and mortality rate in the two groups for four years were analyzed by statistics. Results There were no significant difference in general clinical （age, male, history, smoking） setting in this data. TG was higher in experimental group （ 1.90 ± 0. 19,1.70± 0. 37, t = 5.60, P = 0. 00） LVEF% was lower in experimental group （53. 44 ± 9. 44,55. 68±8.41, t = 2. 26, P = 0. 02 ）. The success rate of primary percutaneous coronary intervention were similar between he two groups （97.35% ,98. 30%, χ2= 0.34, P=0.56）. B2 vessel lesion were significantly higher in experimental group （49.01%, 26.70% ,χ2 = 17.34, P=0. 00）, A vessel lesion were significantly higher in control group （17.61%, 4. 64% ,χ2 = 13.33, P = 0. 00）. The relative ratio using stents were significantly higher in experimental group （73.46% ,65.05 %, χ2 = 6. 48, P = 0.00）, the in-hospital adverse cardiac events incidence probability （IP） were similar in two groups（3. 31% ,2. 27% ,χ2=0. 05, P=0. 82）. The adverse cardiac events IP in out-hospital to 12 months were significantly higher in experimental group （ 16. 11%, 5.75%, RR = 2. 80, X2 =7. 23, P =0. 00, 95% CI： 1.32-5. 93）, the adverse cardiac events IP in 12 ± to 48 months were similar between the two groups. In the end, the accumulate incidence probability of the adverse cardiac events were significantly higher in experimental group（26. 12% ,11.66% ,RR =2. 24, χ2 =8.02, P =0.00, 95% C[： I. 28-3.91 ）, the patients repeated AMI and coronary revascularization in experimental group were more than those in control group. Proofing TG, the SH lead to the adverse cardiac events （P = 0. 033, OR = 2. 019,95% CI： 1. 059-3. 850）. The total mortality rate were similar between the two groups （ 9. 27% , 3.98%, χ2 = 3.79, P = 0. 052）. Conclusions The adverse cardiac events rate was higher in out-hospital- 12 months in stress hyperglycemia patients with ACS who underwent PCI, there was no influence in 12 -48 months; stress hyperglycemia is an independent risk factor for ACS.