非ST段抬高型心肌梗死患者非体外循环冠状动脉旁路移植术后的D-二聚体测定

Measurement of D-dimer after the off-pump coronary artery bypass grafting in the patients with non-ST-segment elevation myocardial infarction

目的 研究非体外循环冠状动脉旁路移植（OPCAB）手术后D-二聚体水平的变化特点,探讨其在术后心血管缺血事件风险评估中的价值.方法 回顾性队列分析.随机选择天津医科大学总医院于2010年至2012年间收治的非ST段抬高型心肌梗死（NSTEMI）患者203例进行回顾性队列分析,男151例,女52例,平均年龄（66.9±8.4）岁.采用法国梅里埃VIDAS荧光免疫分析仪测定血浆D-二聚体水平.采用ROC曲线评价D-二聚体的诊断敏感度和特异度;利用x2检验评估D-二聚体与临床病理因素的关系,对预后因素进行Cox回归模型分析.结果 恢复不良组术后第14天D-二聚体水平显著高于稳定组（U=75.09,P＜0.01）.患者组术后第14天的D-二聚体诊断术后第31 ～90天缺血事件的临界值为2 590 μg/L时,曲线下面积为0.867（95％ CI：0.791 ～0.943）,Logistic回归分析显示D-二聚体水平受性别、年龄、左心室射血分数、左主干病变、旁路移植血管数量、使用乳内动脉和高血压等因素的影响,OR值分别为0.495（95％CI：0.327～0.694）、0.527（95％CI：0.370 ～0.812）、0.564（95％ CI：0.419～0.638）、0.331（95％ CI：0.278 ～0.426）、0.592（95％ CI：0.440 ～0.785）、2.093（95％CI：1.533 ～ 2.856）、0.580（95％CI：0.451～0.709）（均P＜0.01）.Cox比例回归模型显示,第14天的血浆D-二聚体不是远期预后的独立评价指标.结论 OPCAB术后血浆D-二聚体受到多种病理因素影响,术后第14天的血浆D-二聚体水平可作为OPCAB术后第31 ～90天内不良事件有效的评价指标.

Objective To study the variation of D-dimer after the off-pump coronary artery bypass grafting（OPCAB）,and to evaluate its value for the assessment of postoperative cardiovascular ischemia events.Methods This is a retrospective cohort study.203 patients with non-ST-segment elevation myocardial infarction（NSTEMI） were random selected from the Tianjin medical university general hospital from 2010 to 2012,including 151 males and 52 females with a mean age of （66.9 ±8.4） years.The level of D-dimer was analysed by using the Biomerieux VIDAS fluor-euzymelinked immunoassay Analyzer assay.Receiver operating characteristic curve （ROC） was used to evaluate the sensitivity and specificity,the relevance between D-dimer and clinical pathological factors was analysed by x2 test,the effect on prognosis was evaluated by using cox regression analysis model.Results Compared the group with stable disease,the level of D-dimer was increased remarkable in the group with poor recovery on the 14th day after surgery,（U =75.09,P 〈0.01）.The optimum cut-off point with D-dimer（the 14th day after surgery） for the diagnosis of ischemic events within the 31th-90th day after surgery was 2 590μg/L,the area under ROC curve was 0.867（95% confidence interval：0.791-0.943）.The logistic analysis showed that the D-dimer was influenced by the sex,age,left ventricular ejection fraction,left main coronary artery disease,the number of vascular with bypass grafts,using internal mammary artery,hypertension and other factors,OR value was 0.495（95% CI：0.327-0.694）,0.527（95% CI：0.370-0.812）,0.564（95% CI：0.419-0.638）,0.331（95% CI：0.278-0.426）,0.592（95% CI：0.440-0.785）,2.093（95% CI：1.533-2.856）,0.580 （95 % CI：O.451-0.709） respectively （P 〈 0.01）.The Cox analysis showed that the level of Ddimer on the 14th day after surgery was not the independent assessment parameter for long-term prognosis.Conclusion The serum D-dimer was influenced by multiple pathological factors after the OPCAB,the level of serum D-dimer（on the 14th day after surgery） could be used as effective estimate parameter for the adverse events within the 31 th-90th after OPCAB.