生长分化因子15预测ST段抬高型心肌梗死患者术后早期心力衰竭风险的价值

Growth differentiation factor-15 as a predictor of postoperative heart failure in ST-elevation myocardial infarction

目的探讨生长分化因子15（GDF-15）预测ST段抬高型心肌梗死（STEMI）患者术后早期心力衰竭风险的价值。方法选取2008年6月至2009年1月在北京大学第三医院就诊的STEMI患者59例，并征募健康志愿者30名。所有患者发病6h内接受急诊经皮冠状动脉介入治疗。在患者诊断STEMI即刻和发病后24h分别检测血清GDF-15、N末端B型脑钠肽前体（NT—proBNP）水平，发病后24h评价心功能Killip分级并超声心动图检查肺动脉收缩压（PASP）。比较STEMI患者和健康志愿者血清GDF-15水平，分析GDF-15与NT—proBNP、心功能Killip分级和PASP的相关性，评价基线血清GDF-15水平预测STEMI发生24h后心功能Killip分级的敏感度和特异度。结果STEMI患者基线血清GDF-15水平明显高于健康志愿者[（1112±543）ng／L比（309±239）ng／L，P〈0．01]。心功能Killip分级Ⅲ、Ⅳ级患者的基线和发病后24h血清GDF-15水平均明显高于Ⅰ、Ⅱ级患者[基线：（1640±483）、（1899±214）ng／L比（781±285）、（902±276）ng／L；发病后24h：（1514±599）、（2081±381）ng／L比（861±221）、（917±243）ng／L]（均P〈0．05）。不同心功能Killip分级患者的基线血清NT-proBNP水平之间差异无统计学意义（P〉0．05），发病后24h，心功能Killip分级Ⅳ级患者的血清NT—proBNP水平明显高于Ⅰ、Ⅱ、Ⅲ级患者（均P〈0．05）。基线及发病后24h的血清GDF-15水平与PASP均呈正相关（均P〈0．01）。基线NT—proBNP水平与PASP无相关性（P〉0．05），发病后24h的NT—proBNP水平与PASP有相关性（r=0．335，P〈0．015）。以716．6ng／L为界值时，基线血清GDF-15水平预测STEMI发生后24h心功能Killip分级≥Ⅱ级的敏感度和特异度分别为90．5％和56．3％；以1021．1ng／L为界值预测心功能Killip分级≥Ⅲ级的敏感度和特异度分别为83．3％和72．5％。结论GDF-15升高可能作为STEMI患者术后早期出现充血性心力衰竭的预测因素，其产生预测作用的时相早于NT—proBNP。

Objective To investigate the potential value of growth differentiation factor-15 （GDF-15） in predicting heart failure after coronary intervention for ST-elevation myocardial infarction（STEMI）. Methods From June 2008 to January 2009, 59 STEMI patients and 30 healthy volunteers were enrolled in Peking University Third Hospital. STEMI patients had emergency percutaneous coronary intervention within 6 h after myocardial infarction onset. Serum biomarkers [ GDF-15 and N-terminal pro-brain natriuretic peptide （NT-proBNP）] were measured immediately when STEMI was diagnosed and 24 h later. Killip heart function classification was evaluated and echocardiography was performed to measure pulmonary artery systolic pressure （PASP） 24 h after admission. GDF-15 level was analyzed between STEMI patients and healthy people; correlations of GDF-15 with NT-proBNP, Killip classification and PASP were analyzed. The sensitivity and specificity of serum GDF-15 level in predicting Killip heart function 24 h after STEMI onset were analyzed. Results Serum level of GDF-15 in STEMI patients was significantly higher than that in healthy volunteers [ （ 1 112 ± 543 ） ng/L vs （ 309 ± 239） ng/L] （ P 〈 0.01 ）. Serum levels of GDF-15 in Killip Ⅲ, Ⅳ patients were significantly higher than those in Killip Ⅰ , Ⅱ patients [ baseline ： （ 1 640 ± 483 ）, （ 1 899 ± 214） ng/L vs （781 ± 285 ）, （ 902 ± 276 ） ng/L; 24 h after STEMI onset： （1 514 ±599） ,（2 081±381）ng/L vs （861 ±221）,（917±243）ng/L]（P〈0.05）. Serum level of NT-proBNP in Killip Ⅳ patients 24 h after STEMI onset was significantly higher than that in Kilfip Ⅰ , Ⅱ, Ⅲ patients（ P 〈 0. 05）. GDF-15 levels（ baseline and the level 24 h after onset） were positively correlated with PASP（P 〈0. 01 ）. Baseline NT-proBNP level had no correlation with PASP （ P 〉 0. 05 ） ; NT-proBNP level 24 h after onset had correlation with PASP（ r = 0. 335, P 〈 0. 015 ）. In receiver operating characteristic curve analysis, when using 716. 6 ng/L as the boundary value of GDF-15, sensitivity and specificity in predicting Killip classification≥Ⅱ 24 h after STEMI onset were 90. 5% and 56.3% ; with 716. 6 ng/L as the boundary value, sensitivity and specificity of GDF-15 in predicting Killip classification ≥Ⅲ were 83.3% and 72. 5%. Conclusion Elevated GDF-15 level may be an earlier predictor of heart failure after coronary intervention for STEMI; the predictive value of GDF-15 is better than that of NT-proBNP.