急性心肌梗死患者血浆PCSK9水平对临床不良事件发生的预测价值分析

Analysis of the Predictive Value of Plasma PCSK9 Level on Clinical Adverse Events in Patients with Acute Myocardial Infarction

目的探讨急性心肌梗死(acute myocardial infarction,AMI)患者血浆前蛋白转化枯草杆菌蛋白酶9(PCSK9)水平对临床不良事件发生的预测价值。方法选取2017年1月~2018年12月在延安大学附属医院确诊的急性心肌梗死患者271例,平均年龄55.1±9.9岁,其中男性172例(63.47%),按出院后第1月、3月、6月、12月进行随访,随访1年,主要随访方式为电话随访和门诊随访,记录临床不良事件。共59例发生临床不良事件(21.77%)。ROC曲线结果显示:血浆PCSK9诊断AMI患者临床不良事件的最佳预测值为309.6ng/ml(曲线下面积、敏感度和特异度分别为0.773,0.779和0.746),据此将研究对象分为PCSK9(L)组(PCSK<309.6ng/ml),共163例,平均年龄55.1±9.4岁,男性102例;PCSK9(H)组(PCSK≥309.6ng/ml),共108例,平均年龄54.9±10.6岁,男性70例。比较PCSK9(H)组和PCSK9(L)组患者实验室指标血浆PCSK9、血清总胆固醇(TCHO)、三酰甘油(TG)、高密度脂蛋白胆固醇(HDL-C)、低密度脂蛋白胆固醇(LDL-C)、血糖(GLU)、年龄、性别、既往史(吸烟、饮酒、糖尿病、高血压、高脂血症、冠心病)、入院时Killip心功能分级、左心射血分数及临床不良事件发生率。Cox回归分析血浆PCSK9水平对AMI患者临床不良事件的预测价值。结果PCSK9(H)组和PCSK9(L)组血浆PCSK9水平为386±70.31ng/ml vs 232±53.17ng/ml,差异有统计学意义(t=24.545,P=0.000),血清LDL-C水平为2.71±0.62mmol/L vs 2.19±0.57mmol/L,差异有统计学意义(t=3.616,P=0.037)。PCSK9(H)组和PCSK9(L)组复合心血管不良事件发生率为23.15%vs 11.66%,差异有统计学意义(χ^2=6.308,P=0.012),心力衰竭发生率为13.89%vs 5.52%,差异有统计学意义(χ^2=5.634,P=0.018)。经Log Rank检验:PCSK9(H)组和PCSK9(L)组非复合心血管事件生存率组间差异有统计学意义(χ^2=12.735,P=0.007)。经多因素Cox回归分析,血浆PCSK9水平是AMI患者复合心血管不良事件及心力衰竭的独立危险因素(HR=1.507~1.517,95%CI:1.218~1.735,均P<0.05)。结论血浆PCSK9水平是AMI患者临床不良心血管事件的独立危险因素。

Objective To investigate the predictive value of proprotein convertase subtilisin kexin type9(PCSK9)level on clinical adverse events in patients with acute myocardial infarction(AMI).Methods 271 patients with acute myocardial infarction diagnosed in the Affiliated Hospital of Yan’an University from January 2017 to December 2018 were selected,with average age 55.1±9.9 years and 172 cases(63.47%)of men.The patients were followed up for 1 year according to the first month,3 months,6 months and 12 months after discharge.The main follow-up methods were telephone follow-up and outpatient follow-up,and clinical adverse events were recorded,59 cases had clinical adverse events(21.77%).ROC curve results showed that:The optimal predictive value of plasma PCSK9 for the diagnosis of clinical adverse events in AMI patients was 309.6ng/ml(area under the curve was 0.773,sensitivity was 0.779,and specificity was 0.746).Therefore,subjects were divided into PCSK9(L)group(PCSK<309.6ng/ml,a total of 163 patients,average age 55.1±9.4 years,102 males)and PCSK9(H)group(PCSK≥309.6ng/ml,a total of 108 patients,average age 54.9±10.6 years,70 males).The laboratory indexes(PCSK9,TCHO,TG,HDL-C,LDL-C,Glu),age,gender,past history(smoking,drinking,diabetes,hypertension,hyperlipidemia,coronary heart disease)and Killip heart function at admission were compared between PCSK9(H)group and PCSK9(L)group classification,left ventricular ejection fraction and incidence of clinical adverse events.Cox regression analysis was carried out to determine the predictive value of PCSK9 in plasma for clinical adverse events in patients with AMI.Results The plasma PCSK9 level in PCSK9(H)group and PCSK9(L)group were 386±70.31 ng/ml vs 232±53.17 ng/ml,respectively,with tistically significant differences(t=24.545,P=0.000),and the serum LDL-c level were 2.71±0.62 mmol/L vs 2.19±0.57 mmol/L,respectively,with statistically significant differences(t=3.616,P=0.037).The incidence of cardiovascular adverse events in the PCSK9(H)and PCSK9(L)groups were 23.15%vs 11.66%,respectively,with statistically significant differences(χ^2=6.308,P=0.012),and the incidence of heart failure were 13.89%vs 5.52%,respectively,with statistically significant differences(χ^2=5.634,P=0.018).By Log Rank test,there was a statistically significant difference between the PCSK9(H)group and the PCSK9(L)group in the survival rate of non-complex cardiovascular events(χ^2=12.735,P=0.007).By multivariate Cox regression analysis,plasma PCSK9 level was an independent risk factor for combined cardiovascular adverse events and heart failure in AMI patients(HR=1.507~1.517,95%CI:1.218~1.735,all P<0.05).Conclusion Plasma PCSK9 level is an independent risk factor for clinically adverse cardiovascular events in AMI patients.