胰岛素抵抗与冠状动脉性心脏病严重程度的相关性

Study on relationship between insulin resistance and severity of coronary heart disease

目的探讨胰岛素抵抗(IR)与冠状动脉性心脏病(CHD)患者冠状动脉病变严重程度及院内预后的关系。方法共入选355例行冠状动脉造影检查的患者,根据冠状动脉的情况分为正常对照组(106例)、单支病变组(79例)、双支病变组(80例)和多支病变组(90例),测定各组的空腹血糖(FPG)及空腹血胰岛素(FINS)水平,计算其稳态模型IR指数(HOMA-IR)和Gensini积分,分析IR对冠状动脉严重程度及心功能的影响。结果 Gensini积分随着冠状动脉病变支数的增加而增高,各组间的差异均有统计学意义(P值均<0.01)。左心室射血分数(LVEF)随着冠状动脉病变支数的增加而降低,CHD各组与正常对照组以及双支病变和多支病变组与单支病变组间的差异均有统计学意义(P值分别<0.05、0.01)。HOMA-IR与体质指数(BMI,r=0.114,P=0.032)、三酰甘油(TG,r=0.223,P<0.01)、总胆固醇(TC,r=0.152,P=0.004)、低密度脂蛋白胆固醇(LDL-C,r=0.244,P<0.01)、FPG(r=0.473,P<0.01)、FINS(r=0.920,P<0.01)、Gensini积分(r=0.401,P<0.01)、左心室舒张末内径(LVEDD,r=0.162,P=0.002)、左心室收缩末内径(LVESD,r=0.140,P=0.008)均呈正相关,与LVEF呈负相关(r=-0.145,P=0.006)。校正年龄、血压、血糖、血脂等的影响后,HOMA-IR仍与Gensini积分呈正相关(r=0.349,P<0.01)。多元逐步回归分析显示,FPG、Gensini积分、LVEDD、TG是影响HOMA-IR的独立因素(P值均<0.01),FINS、TC、LVEF、LVESD是影响Gensini积分的独立因素(P值分别<0.01、0.05)。将HOMA-IR≥5的CHD患者(66例)作为IR组,HOMA-IR<5的CHD患者(183例)作为非IR组,IR组的院内心力衰竭发生率(12.12%)和全因病死率(10.61%)显著高于非IR组(均为2.73%,P值分别<0.01、0.05)。结论有IR的CHD患者中,其IR状态与冠状动脉病变程度密切相关,且在院内发生心力衰竭和死亡的风险增加。

Objective To explore the relationship between insulin resistance （IR） and severity of coronary heart disease （CHD） and in-hospital prognoses of patients. Methods Totally 355 patients confirmed by coronary angiography were enrolled in the present study. They were divided into four groups according to the number of vessels involved;one-vessel group, two-vessel group, multi-vessel group and normal control group. Homeostasis model assessment of insulin resistance index （HOMA-IR） and Gensini＇s score of coronary stenosis were calculated. We analyzed the influence of IR on severity of coronary artery stenosis and heart function. Results Gensini＇s score was significantly increased with the number of vessels involved, while left ventricular ejection fraction （LVEF） was significantly different decreased with the number of vessels involved （P〈0.01）. And the LVEF values were also significantly between one-vessel group, two vessel group and multi-vessel group （P〈0.05, 0.01）. We also found that the HOMA-IR values were positively correlated with the body mass index （BMI, r=0. 114,P=0.032）, triglycercide （TG, r=0.223, P〈0.01）, total cholesterol （TO, r=0. 152, P=0.004）, low density lipoprotein cholesterol （LDL-C, r=0.244, P〈0.01）, fasting plasma glucose （FPG, r=0.473, P〈0.01）, fasting insulin （FINS, r=0.920, P〈0.01）, Gensini＇s score （r=0.401, P〈0.01）, left ventricular enddiastolic diameter （LVEDD, r = 0. 162, P = 0. 002）, and left ventricular end-systolic diameter （LVESD, r = 0,140, P = 0,008）;and were negatively correlated with LVEF （ r = - 0. 145, P = 0. 006）. After adjusting age, blood pressure, blood glucose, and blood lipids, HOMA-IR values were still positively correlated with Gensini＇s score （ r = 0. 349, P〈0.01 ）. Multivariate linear regression model showed that FPG, Gensini ＇ s score, LVEDD and TG were independent factors of HOMA-IR, while FINS, TO, LVEF and LVESD were independent factors of Gensini＇ s score. The CHD patients were divided into the following 2 groups; 66 patients with higher HOMA-IR （group IR, HOMA-IR^5） and 183 patients with lower HOMA-IR （group NIR, HOMA-IR〈5）. The incidence of heart failure （12.12%） and mortality （10. 61%） in group IR were significantly higher than those in group NIR （2. 73%, 2.73%, P〈0.01, 0.05）. Conclusions Insulin resistance in patients with CHD is closely correlated with the severity of coronary artery stenosis and a high risk of in-hospital heart failure and death. （Shanghai Med J, 2011, 34, 351-355）