老年急性冠脉综合征患者胰岛素抵抗与冠状动脉钙化积分及预后的关系

Correlation of insulin resistance with coronary calcium score and prognosis in elderly patients with acute coronary syndrome

目的探讨老年非ST段抬高型急性冠脉综合征（ACS）患者胰岛素抵抗（IR）与冠状动脉钙化严重程度的关系及对患者临床预后的影响。方法入选2013年6月至2014年6月广州市第一人民医院心内科收治的非ST段抬高型ACS的老年患者（年龄／〉60岁）150例。采用稳态模型方法（HOMA）计算IR指数（HOMA—IR），并根据HOMA-IR，将所有患者分为两组：IR组（HOMA—IR〉5．0；n=80）和非IR组（HOMA-IR≤5．0；n=70）。入选患者行经皮冠状动脉介入治疗（PCI）前均接受螺旋CT心脏冠脉成像检查，计算冠状动脉钙化积分（CCS）。PCI术后对两组患者进行12个月的随访，记录主要心脏不良事件（MACE）的发生情况。结果两组患者的空腹血糖、空腹胰岛素、低密度脂蛋白胆固醇（LDL—C）、高敏C-反应蛋白（hs—CRP）和同型半胱氨酸（Hcy）间均具有显著性差异（P〈0．05）。Spearman相关分析显示老年ACS患者HOMA—IR和CCS呈正相关（r=0．393，P〈0．01）。随访12个月，多因素logistic回归分析显示HOMA—IR〉5．0，CCS〉400、纽约心脏病协会（NYHA）分级Ⅲ-Ⅳ级和糖尿病是老年ACS患者PCI术后MACE发生的独立危险因素；Kaplan-Meier生存分析显示IR组患者累积生存率显著低于非IR组（Log-rank=4．755，P=0．029）。结论存在IR的老年非ST段抬高型ACS患者冠状动脉钙化更为严重，IR及CCS对接受PCI术的老年非ST段抬高型ACS患者临床预后有预测价值。

Objective To investigate the relationship of insulin resistance （IR） with the severity of coronary calcification and determine the effect of IR on prognosis in the elderly patients with non-ST segment elevation acute coronary syndrome （NSTACS）. Methods A total of 150 consecutive elderly patients （ I〉60 years old） with NSTACS admitted in our department from June 2013 to June 2014 were enrolled in this study. Based on their IR index measured by homeostasis model assessment （ HOMA）, they were divided into the IR group （ HOMA-IR 〉 5.0, n = 80） and non-IR group （ HOMA-IR ≤ 5.0, n = 70）. All patients received 320-detector row computed tomography scanning to calculate coronary calcium score （CCS） before percutaneous coronary intervention （PCI）. These patients were followed up for 12 months, and the occurrence of major adverse cardiac events （MACE） were recorded. Results The levels of fasting plasma glucose （ FPG）, fasting insulin （ FINS ）, low density lipoprotein-cholesterol （ LDL-C ）, high sensitivity C-reactive protein （hs-CRP） and homocysteine （Hcy） had significant discrepancies between the patients of IR and non-IR groups （P 〈0.05）. Spearman correlation analysis showed that HOMA-IR was positively correlated with CCS in the elderly NSTACS patients （ r = 0. 393, P 〈 0. 01 ）. In 12 months of follow-up, muhivariate logistic regression analysis showed that HOMA-IR 〉 5.0, CCS 〉 400, New York Heart Association （NYHA） classification grade Ⅲ - Ⅳ and diabetes were independent risk factors for MACE in the elderly NSTACS patients after PC[ （P 〈 0.05 ）. Kaplan-Meier survival analysis indicated that the cumulative survival rates was significantly lower in the IR group than in the non-IR group （ Log rank = 4. 755, P = 0. 029）. Conclusion The elderly ACS patients with IR have more serious coronary calcification. IR and CCS are of predictive value for the prognosis in the elderly NSTACS patients undergoing PCI.