胰岛素抵抗与急性冠状动脉综合征患者冠状动脉正性重构的相关性分析

Association of insulin resistance with positive coronary artery remodeling in patients with acute coronary syndrome

目的探讨胰岛素抵抗(insulin resistance,IR)与急性冠状动脉综合征(acute coronary syndrome,ACS)患者冠状动脉正性重构的相关性。方法回顾性分析2020年12月至2021年12月于我院行血管内超声指导(intra vascular ultrasound,IVUS)下血运重建的ACS患者。通过稳态模型评估胰岛素抵抗指数(homeostasis model assessment insulin resistance index,HOMA-IR)并定义HOMA-IR值>2.5为IR阳性。通过IVUS评估病变部位、病变近端及病变远端外弹力膜(external elastic membrane,EEM),并计算重构指数。定义重构指数大于1.05为正性重构;重构指数<0.95为负性重构;0.95≤重构指数≤1.05为中间状态。根据HOMA-IR值将患者分为胰岛素抵抗阳性组(n=46)和胰岛素抵抗阴性组(n=52)。结果共纳入98例ACS患者,共包括111根行IVUS检查评估的靶病变。初步分析发现IR阳性组的重构指数明显高于胰岛素抵抗阴性组[(1.02±0.32)比(0.88±0.28),P=0.018]。进一步分析发现,IR阳性组正性重构比率相对较高(43.4%比15.5%),而负性重构(47.2%比58.6%)及中间状态(9.4%比25.9)比率相对较低。单因素回归分析发现,糖化血红蛋白(hemoglobin A1c,HbA1c)(OR=0.694,95%CI 0.508~0.946,P=0.021)与IR(OR=4.174,95%CI 1.706~10.211,P=0.002)和冠状动脉正性重构紧密相关。进一步通过多因素回归分析校正年龄、性别、HbA1c等混杂因素后,IR仍是冠状动脉正性重构的独立危险因素(OR=3.611,95%CI 1.431~9.111,P=0.007)。受试者工作特征曲线评估发现,HOMA-IR预测冠状动脉正性重构力度中等(曲线下面积0.656,95%CI 0.542~0.771,P=0.0074)。通过计算约登指数发现以HOMA-IR为2.44时预测力度最佳,其灵敏度与特异度分别为63.3%及71.9%。结论通过HOMA-IR评估的IR阳性与ACS患者冠状动脉正性重构独立相关。然而其预测ACS患者冠状动脉正性重构的力度相对较低。

Objective To investigate the association of insulin resistance(IR)with positive coronary artery remodeling in patients with acute coronary syndrome(ACS).Methods The data of the patients with ACS who underwent intravascular ultrasound(IVUS)guided revascularization in our hospital from December 2020 to December 2021 were analyzed retrospectively.The homeostasis model assessment insulin resistance index(HOMA-IR)was assessed by the homeostasis model,and a HOMA-IR value greater than 2.5 was defined as IR positive.The lesion site,the proximal and distal ends of the lesion,the external elastic membrane(EEM)and lumens were assessed by IVUS.The remodeling index was calculated by the formula(EEM at the lesion/mean value of EEM at the proximal and distal reference sites of the lesion).The definition of remodeling index greater than 1.05 was positive remodeling;remodeling index<0.95 was negative remodeling;0.95≤remodeling index≤1.05 was intermediate state.According to HOMA-IR,the patients were divided into insulin resistance positive group and insulin resistance negative group.Results A total of 98 ACS patients were included in this study,including a total of 111 target lesions assessed by IVUS.The preliminary analysis found that the remodeling index of the IR-positive group was significantly higher than that of the IR-negative group[(1.02±0.32)vs.(0.88±0.28),P=0.018].Further analysis found that the IR-positive group had a relatively higher rate of positive remodeling(43.4%vs.15.5%)and a relatively lower rate of negative remodeling(47.2%vs.58.6%)and intermediate remodeling(9.4%vs.25.9%).Univariate regression analysis showed that hemoglobin A1 c(Hb A1 c)(OR=0.694,95%CI 0.508~0.946,P=0.021)was closely associated with IR(OR=4.174,95%CI 1.706~10.211,P=0.002)and positive coronary artery remodeling.After further adjusting for confounding factors such as age,gender,and Hb A1 c by multivariate regression analysis,IR was still an independent risk factor of positive coronary artery remodeling(OR=3.611,95%CI 1.431~9.111,P=0.007).The receiver operating characteristic(ROC)showed that HOMA-IR was moderately powerful in predicting positive coronary artery remodeling(area under the curve 0.656,95%CI 0.542~0.771,P=0.0074).By calculating the Youden index,it was found that the prediction power was the best when the HOMA-IR was 2.44,with a sensitivity and specificity of 63.3%and 71.9%,respectively.Conclusion IR positivity assessed by HOMA-IR was independently associated with positive coronary artery remodeling in ACS patients.However,its power to predict positive coronary remodeling in ACS patients is relatively low.