ST段抬高型心肌梗死患者雷帕霉素洗脱支架-经皮冠状动脉介入治疗后支架内再狭窄的影响因素及Nomogram模型构建研究

Influencing Factors of In-stent Restenosis and Nomogram Model Construction in Patients with ST-segment Elevation Myocardial Infarction after Sirolimus-eluting Stent-percutaneous Coronary Intervention

背景雷帕霉素洗脱支架(SES)-经皮冠状动脉介入治疗(PCI)是ST段抬高型心肌梗死(STEMI)患者的主流治疗方式,但术后支架内再狭窄(ISR)发生率较高,极易导致患者疾病复发甚至再行PCI。目前关于STEMI患者SES-PCI后ISR影响因素的Nomogram预测模型构建尚处于空白期。目的探讨STEMI患者SES-PCI后ISR的影响因素并构建Nomogram模型,以便于早期识别ISR高风险患者并给予积极治疗。方法选取廉江市人民医院2015年1月—2017年1月收治的STEMI患者213例,患者均行PCI并植入SES。根据末次随访时ISR发生情况将所有患者分为非支架内再狭窄(No-ISR)组和ISR组。比较两组患者的临床资料,绘制受试者工作特征曲线(ROC曲线)以评价相关因素预测STEMI患者SES-PCI后ISR的最佳截断值;采用多元Cox比例风险回归分析STEMI患者SES-PCI后ISR的危险因素,构建Nomogram模型并进行内部验证。结果所有患者随访4~40个月,平均随访时间(32.5±8.5)个月,其中98例(46.0%)患者SES-PCI后发生ISR。ISR组患者中男性比例、糖尿病发生率、靶区病变狭窄率、支架直径<3 mm者所占比例、支架长度≥30 mm者所占比例、空腹血糖(FBG)、C反应蛋白(CRP)、总胆固醇(TC)、低密度脂蛋白(LDL)、白细胞计数(WBC)、尿酸(UA)、中性粒细胞与淋巴细胞比值(NLR)高于No-ISR组,靶区病变长度大于No-ISR组(P<0.05)。ROC曲线分析结果显示,靶区病变狭窄率、靶区病变长度、FBG、CRP、TC、LDL、WBC、UA、NLR预测STEMI患者SES-PCI后ISR的曲线下面积(AUC)分别为0.711、0.806、0.741、0.757、0.765、0.727、0.749、0.785、0.828,最佳截断值分别为81.5%、16.0 mm、6.1 mmol/L、7.2 mg/L、5.0 mmol/L、3.0 mmol/L、11.7×10^9/L、6.5 mg/dl、5.0。多元Cox比例风险回归分析结果显示,糖尿病[HR=1.949,95%CI(1.434,2.649)]、靶区病变长度≥16.0 mm[HR=1.447,95%CI(1.068,1.961)]、支架长度≥30 mm[HR=1.408,95%CI(1.022,1.940)]、UA≥6.5 mg/dl[HR=2.843,95%CI(2.071,3.901)]、NLR≥5.0[HR=2.447,95%CI(1.747,3.428)]是STEMI患者SES-PCI后ISR的独立危险因素(P<0.05)。将糖尿病、靶区病变长度、支架长度、UA、NLR作为构建预测STEMI患者SES-PCI后ISR发生风险的Nomogram模型的指标,采用内部数据进行验证,一致性指数(CI)为0.792[95%CI(0.635,0.892)]。结论糖尿病、靶区病变长度≥16.0 mm、支架长度≥30 mm、UA≥6.5 mg/dl、NLR≥5.0是STEMI患者SES-PCI后发生ISR的独立危险因素,而整合该指标构建Nomogram模型对STEMI患者SES-PCI后ISR发生风险的预测效能较好。

Background Sirolimus-eluting stent(SES)-percutaneous coronary intervention(PCI)is the main treatment of ST-segment elevation myocardial infarction(STEMI).However,the incidence of in-stent restenosis(ISR)after operation is high,which can easily lead to disease recurrence and even PCI.At present,the construction of Nomogram model for predicting the influencing factors of ISR in STEMI patients after SES-PCI is still in a blank period.Objective To explore the influencing factors of ISR in patients with STEMI after SES-PCI,and construct Nomogram model,in order to identify patients with high ISR risk early and give active treatment.Methods 213 STEMI patients admitted to Lianjiang People’s Hospital from January 2015 to January 2017 were selected.All patients underwent PCI and implanted SES,and they were divided into NoISR group and ISR group according to the incidence of ISR at the last follow-up.Clinical data were compared between the two groups,and ROC curve was drawn to evaluate the best cut-off value of related factors in predicting ISR in STEMI patients after SES-PCI;risk factors of ISR in STEMI patients after SES-PCI were analyzed by multivariate Cox proportional hazards regression analysis,and the Nomogram model was constructed and verified internally.Results All patients were followed-up for 4-40 months,the mean follow-up time was(32.5±8.5)months,among which 98 cases(46.0%)occurred ISR after SES-PCI.The proportion of male patients,incidence of diabetes,incidence of target lesions stenosis,proportion of patients with stent diameter<3 mm,proportion of patients with stent length≥30 mm,fasting blood glucose(FBG),C reactive protein(CRP),total cholesterol(TC),low-density lipoprotein(LDL),white blood cell count(WBC),uric acid(UA),neutrophil to lymphocyte ratio(NLR)in ISR group were higher than those in No-ISR group,length of target lesions in ISR group were bigger than those in No-ISR group(P<0.05).ROC curve analysis showed that,the AUC of target lesions stenosis,length of target lesions,FBG,CRP,TC,LDL,WBC,UA,NLR predicting ISR in STEMI patients after SES-PCI was 0.711,0.806,0.741,0.757,0.765,0.727,0.749,0.785 and 0.828,respectively;the best cutoff values was 81.5%,16.0 mm,6.1 mmol/L,7.2 mg/L,5.0 mmol/L,3.0 mmol/L,11.7×10^9/L,6.5 mg/dl and 5.0,respectively.Multivariate Cox proportional hazards regression analysis showed that,diabetes mellitus[HR=1.949,95%CI(1.434,2.649)],target lesions length≥16.0 mm[HR=1.447,95%CI(1.068,1.961)],stent length≥30 mm[HR=1.408,95%CI(1.022,1.940)],UA≥6.5 mg/dl[HR=2.843,95%CI(2.071,3.901)],NLR≥5.0[HR=2.447,95%CI(1.747,3.428)]were independent risk factors of ISR in STEMI patients after SES-PCI(P<0.05).Diabetes mellitus,target lesion length,stent length,UA,NLR were used as Nomogram model indexes to predict the risk of ISR in patients with STEMI after SES-PCI,the internal data were used for validation,and the CI was 0.792[95%CI(0.635,0.892)].Conclusion Diabetes mellitus,target lesion length≥16.0 mm,stent length≥30 mm,UA≥6.5 mg/dl,NLR≥5.0 are independent risk factors of ISR in STEMI patients after SES-PCI,and integrating these indexes to construct Nomogram model for in STEMI patients after SES-PCI,the predictive effect of ISR risk is good.