老年急性缺血性脑卒中患者外周血中解聚蛋白样金属蛋白酶-4表达水平与颈动脉斑块不稳定和患者预后的关系

The expression level of disaggregin-like Metalloproteinase-4 in elderly acute ischemic stroke and the influence of carotid plaque instability and the prognosis of patients

目的 探讨老年急性缺血性脑卒中患者外周血中解聚蛋白样金属蛋白酶-4(A disintegrin-like and metalloproteinase with thrombospondin type l motifs,ADAMTS-4)水平与颈动脉斑块不稳定和患者预后的关系。方法 收集2019年1月-2020年12月在本院接受溶栓治疗的老年急性缺血性脑卒中患者148例;根据彩色多普勒超声检测将患者分为无斑块组、斑块稳定组和斑块不稳定组,分析组间ADAMTS-4的水平差异及ADAMTS-4水平对斑块不稳定的影响;根据出院3个月改良Rankin(Modified rankin scale,mRS)评分将患者分为预后良好组(mRS评分≤2分)、预后不良好组(mRS评分>2分),比较2组的一般临床资料;Logistic多因素回归分析患者预后不良的危险因素;受试者工作特征曲线(Receiver operating characteristic curve,ROC)检测脑梗死面积、斑块稳定情况和ADAMTS-4水平评估预后不良的临床价值。结果 颈动脉粥样硬化斑块检出率为81.8%(121/148),其中无斑块27例(无斑块组)、斑块稳定70例(斑块稳定组)、斑块不稳定51例(斑块不稳定组);无斑块组、斑块稳定组和斑块不稳定组外周血ADAMTS4水平分别为(36.2±5.6)、(62.5±9.5)、(106.2±13.7)mg/L(F=23.625,P<0.001),且斑块不稳定组ADAMTS4水平最高;ADAMTS-4水平为斑块不稳定的独立危险因素OR(95%CI)=2.625(1.056~5.632),P<0.001);ADAMTS-4水平诊断斑块不稳定的最佳截断值为92.3 mg/L,曲线下面积(Area under the curve,AUC)(95%CI)为0.895(0.847~0.932),特异度为78.3%,敏感度为83.5%;单因素分析显示脑梗死面积、颈动脉狭窄程度、斑块稳定情况、脑梗死部位和ADAMTS-4水平与患者预后不良有关;Logistic多因素回归分析显示大面积脑梗死、斑块不稳定和ADAMTS-4水平增高为患者预后不良的独立危险因素;大面积脑梗死、斑块不稳定和ADAMTS-4水平评估患者预后不良的AUC(95%CI)分别为0.712(0.689~0.751)、0.802(0.789~0.841)和0.884(0.841~0.910);ADAMTS-4水平评估患者预后不良的临床价值高于斑块稳定情况和脑梗死面积(Z=4.065,P=0.013;Z=6.321,P<0.001)。结论 ADAMTS-4水平增高为颈动脉斑块不稳定和患者预后不良的独立危险因素,可作为颈动脉斑块不稳定和患者预后不良的诊断指标。

Objective To detect the level of disaggregated protein-like metalloproteinase-4(ADAMTS-4) in the peripheral blood of elderly patients with acute cerebral infarction,and to analyze the effect on carotid plaque instability and patient prognosis.Methods A total of 148 elderly patients with acute cerebral infarction who received thrombolytic therapy in our hospital from January 2019 to December 2020 were analyzed and the patients were divided into plaque-free group,plaque-stable group and plaque unstable group based on color doppler ultrasound detection.Compared the level of ADAMTS-4 between different groups and the influence of ADAMTS-4 on plaque instability.According to the Modified-Rankin-Scale(mRS) score at the follow-up 3 months after discharge,the patients were divided into good prognosis group(mRS score≤2 points) and poor prognosis group(mRS score>2 points).The general clinical data between the two groups were compared,logistic multivariate regression to analyze the risk factors that affect the poor prognosis of patients.Receiver operating curve(ROC) detected infarct size,unstable plaque and ADAMTS-4 to evaluate the clinical value of poor prognosis.Results The detection rate of carotid atherosclerotic plaque was 81.8%(121/148),including 27 cases without plaque(plaque-free group),70 cases with stable plaque(plaque-stable group),and 51 cases with unstable plaque(plaque unstable group).The ADAMTS4 levels in peripheral blood of the plaque-free group,plaque-stable group,and plaque-unstable group were 36.2±5.6 mg/L,62.5±9.5 mg/L,and 106.2±13.7 mg/L,respectively.There were statistical differences among the groups(F=23.625,P<0.001),and the ADAMTS4 level was the highest in the plaque unstable group.ADAMTS-4 was an independent risk factor for plaque instability OR(95%CI)=2.625(1.056~5.632),P<0.001).The best cut-off value of ADAMTS-4 for diagnosing plaque instability was 92.3 mg/L,the area under the curve(AUC)(95%CI) was 0.895(0.847~0.932),the specificity was 78.3%,and the sensitivity was 83.5%.Univariate analysis showed that the size of cerebral infarction,carotid artery stenosis,plaque stability,infarct location and ADAMTS-4 level were related to the poor prognosis of patients.Logistic multivariate regression analysis showed that extensive cerebral infarction,unstable plaque,and increased ADAMTS-4 levels were independent risk factors affecting the poor prognosis of patients.The AUC(95%CI) of patients with large-area cerebral infarction,plaque instability,and ADAMTS-4 levels assessed poor prognosis were 0.712(0.689~0.751),0.802(0.789~0.841) and 0.884(0.841~0.910),respectively,The clinical value of ADAMTS-4 in assessing poor prognosis of patients was higher than that of plaque instability and infarct size(Z=4.065,P=0.013;Z=6.321,P<0.001).Conclusion ADAMTS-4 was an independent risk factor for carotid plaque instability and poor prognosis,and might be used as a diagnostic index for carotid plaque instability and poor prognosis.