冠状动脉内血管性血友病因子裂解蛋白酶活性和全球急性冠状动脉事件注册评分对急诊经皮冠脉介入术治疗ST段抬高型心肌梗死病人住院期间主要心血管不良事件的预测价值

Predictive value of intracoronary ADAMTS13 activity and GRACE score for MACE during hospitalization in STEMI patients undergoing emergency PCI

目的 探讨冠状动脉内血管性血友病因子裂解蛋白酶(ADAMTS13)活性和全球急性冠状动脉事件注册(GRACE)评分对ST段抬高型心肌梗死(STEMI)行急诊经皮冠脉介入术(PCI)的病人住院期间主要心血管不良事件(MACE)的预测价值。方法 选取2019年10月至2021年6月在潍坊医学院附属医院住院的162例STEMI接受急诊PCI治疗的病人,根据住院期间是否发生MACE,分为MACE组(38例)和无MACE组(124例)。记录两组病人的重要临床特征、GRACE评分。采用荧光共振能量转换法(FRETS-VWF73)分别测定两组病人急诊PCI术前外周血和冠脉内的ADAMTS13活性。四格表χ~2检验及独立样本t检验比较两组病人的重要临床特征、GRACE评分。Pearson相关性分析探讨ADAMTS13活性与GRACE评分的相关性。多因素logistic回归分析MACE的独立危险因素。应用受试者操作特征曲线(ROC曲线)分析冠脉内ADAMTS13活性、GRACE评分以及联合诊断对MACE的预测效能。结果 两组比较,MACE组病人糖尿病史、吸烟史更多,年龄较大、外周血血小板计数更低、凝血酶原时间(PT)更长、N端脑钠肽前体(NT-proBNP)和肌钙蛋白I(cTnI)更高(P<0.05);MACE组病人GRACE评分更高[(187.26±35.50)分比(153.87±32.95)分,P<0.001],术前外周血[(59.01±4.56)%比(63.86±5.75)%]和冠脉内[(46.37±5.43)%比(54.26±5.70)%]的ADAMTS13活性更低(均P<0.001)。术前冠脉内ADAMTS13活性与GRACE评分中等强度负相关(r=-0.40,P<0.001),而外周血ADAMTS13活性与GRACE评分无明显相关性(r=-0.08,P=0.457)。多因素logistic回归分析,糖尿病史和GRACE评分为MACE的独立危险因素[OR=2.513,95%CI:(2.045,3.381),P=0.007;OR=1.089,95%CI:(1.033,1.147),P=0.001],术前冠脉内ADAMTS13活性是MACE的保护性因素[OR=0.568,95%CI:(0.429,0.753),P=0.001]。术前冠脉内ADAMTS13活性、GRACE评分诊断MACE的AUC及其95%CI分别为0.833(0.735,0.932)和0.746(0.624,0.867),截断值分别为50.95%和158.50分,联合诊断的AUC为0.893(0.824,0.962)。结论 GRACE评分增高、术前冠脉内ADAMTS13活性降低均是接受急诊PCI治疗的STEMI病人住院期间MACE的独立危险因素,二者联合诊断的预测价值更高。

Objective To investigate the predictive value of intracoronary a disintegrin and metalloprotease with thrombospondin motifs 13(ADAMTS13) activity and the Global Registry of Acute Coronary Events(GRACE) score for major adverse cardiovascular events(MACE) during hospitalization in patients undergoing emergency percutaneous coronary intervention(PCI) for ST-segment elevation myocardial infarction(STEMI).Methods A total of 162 patients with STEMI treated with emergency PCI who were hospitalized at the Affiliated Hospital of Weifang Medical College from October 2019 to June 2021 were selected and divided into a MACE group(38 patients) and a nonMACE group(124 patients) according to whether MACE occurred during hospitalization.The important clinical features and GRACE scores of patients in both groups were recorded.The activity of ADAMTS13 in peripheral blood and intracoronary arteries before emergency PCI was measured by the fluorescence resonance energy transfer assay using a truncated,synthetic 73-aminoacid VWF peptide as a substrate for the determination of ADAMTS-13 activity(FRETS-VWF73).The chi-square test and independent samples t test were used to compare the important clinical characteristics and GRACE scores of the two groups of patients.Pearson correlation analysis was performed to explore the correlation between ADAMTS13 activity and GRACE score.Multivariate logistic regression analysis of the independent risk factors for MACE.The receiver operating characteristic(ROC) curve was applied to analyze the predictive efficiency of intracoronary ADAMTS13 activity,GRACE score,and combined diagnosis on MACE.Results Compared with nonMACE patients,patients with MACE had a greater history of diabetes,smoking history,older age,lower peripheral platelet count,longer prothrombin time(PT),and higher N-terminal B-type brain natriuretic peptide precursor(NT-proBNP) and troponin I(cTnI) levels.Patients in the MACE group had a higher GRACE score(187.26±35.50 vs.153.87±32.95,P<0.001),and the activity of ADAMTS13 in preoperative peripheral blood [(59.01±4.56)% vs.(63.86±5.75)%] and intracoronary blood [(46.37±5.43)% vs.(54.26±5.70)%] was significantly lower(P<0.001).Preoperative intracoronary ADAMTS13 activity was moderate(r=-0.40,P<0.001),whereas peripheral blood ADAMTS13 activity was not significantly correlated with GRACE score(r=-0.08,P=0.457).According to multivariate logistic regression analysis,a history of diabetes and GRACE score were independent risk factors for MACE [OR=2.513,95%CI:(2.045,3.381),P=0.007;OR=1.089,95%CI:(1.033,1.147),P=0.001],and preoperative intracoronary ADAMTS13 activity was a protective factor for MACE [OR=0.568,95%CI:(0.429,0.753),P=0.001].The areas under the curve(AUCs) of GRACE score and ADAMTS 13 activity for diagnosing of MACE were 0.833 [95%CI:(0.735,0.932)] and 0.746 [95%CI:(0.624,0.867)],with cutoff values were50.95% and 158.50 points,respectively,and the AUC for combined diagnosis was 0.893 [95%CI:(0.824,0.962)].Conclusion Higher GRACE scores and lower intracoronary ADAMTS13 activity before PCI were both the independent risk factors for MACE during hospitalization in STEM I patients undergoing emergency PCI,and the combined diagnosis of the two had higher predictive value.