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急性心肌梗死(acute myocardial infarction,AMI)患者的存活心肌与坏死心肌并存,明确心肌受损的程度及范围对于临床治疗决策具有重要意义[1]。研究表明,AMI后患者的心肌收缩功能改变,特别是存活心肌的比例是影响再发心血管事件的重要因素[2]。核素心肌血流灌注/代谢显像具有简单无创、可量化和易于获得等优点,是判断心肌损伤的部位、范围和程度最理想的方法[3]。本研究应用99Tcm-MIBI SPECT心肌灌注显像(myocardial perfusion imaging,MPI)与18F-FDG PET/CT心肌代谢显像,并分析AMI患者行经皮腔内冠状动脉成形术(percutaneous transluminal coronary angioplasty,PTCA)治疗后左心室收缩功能的变化,为临床治疗方案的选择及预后评估等提供参考。
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由表1可见,A组与B组患者间年龄、性别、体重指数、吸烟史、饮酒史、高血压史、糖尿病史、高脂血症病史和心绞痛病史等差异均无统计学意义。
组别 男性/女性(例) 年龄(岁) 体重指数(kg/m2) 吸烟史 高血压病史 糖尿病史 高血脂症病史 心绞痛病史 A组(n=24) 18/6 53.6±9.3 24.75±3.60 16(66.7%) 17(70.8%) 13(54.2%) 12(50.0%) 16(66.7%) B组(n=12) 9/3 62.2±9.1 25.01±3.79 7(58.3%) 10(83.3%) 7(58.3%) 8(66.7%) 7(58.3%) 检验值 χ2=0.000 t=−2.828 t=−0.201 χ2=0.241 χ2=0.667 χ2=0.056 χ2=0.900 χ2=0.241 P值 1.000 0.110 0.842 0.429 0.403 0.819 0.103 0.429 注:表中,A组:心功能改善组(ΔLVEF≥5%);B组:心功能未改善组(ΔLVEF<5%)。ΔLVEF:左心室射血分数的变化值 表 1 2组急性心肌梗死患者一般临床特征的比较
Table 1. Comparison of general clinical characteristics between the two groups of patients with acute myocardial infarction
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PTCA治疗前,A组与B组的LVEF、PER、cTnI比较,差异无统计学意义(t=−1.075~1.824,P=0.141~0.573),S/N比值的差异有统计学意义(t=0.824,P=0.042);PTCA治疗后,2组LVEF、PER、S/N比值的比较,差异有统计学意义(t=−2.528~−2.366,P=0.016~0.024),而cTnI的差异无统计学意义(t=−1.229,P=0.259)。具体数据见表2。典型病例的心肌灌注/代谢显像见图1。
图 1 急性心肌梗死患者(男性,43岁)PTCA治疗前后的心肌灌注/代谢显像图
Figure 1. Myocardial perfusion/metabolism imaging in patients with acute myocardial infarction (male, 43 years old) before and after percutaneous transluminal coronary angioplasty treatment
组别 LVEF(%) PER(%) S/N比值 cTnI(μg/L) 治疗前 治疗后 治疗前 治疗后 治疗前 治疗后 治疗前 治疗后 A组(n=24) 36±12 47±12 1.54±0.35 2.11±0.48 1.24±1.06 0.73±0.47 1.52±0.41 1.39±0.39 B组(n=12) 39±10 38±10 1.79±0.44 1.71±0.50 0.58±0.37 0.62±0.39 1.02±0.20 1.18±0.67 t值 0.569 −2.528 −1.075 −2.366 0.824 −2.514 −0.844 −1.229 P值 0.573 0.016 0.292 0.024 0.042 0.017 0.141 0.259 注:表中,A组:心功能改善组(ΔLVEF≥5%);B组:心功能未改善组(ΔLVEF<5%)。LVEF:左心室射血分数;PER:高峰射血率;S/N比值:存活心肌/坏死心肌节段数的比值;cTnI:心肌肌钙蛋白I 表 2 2组急性心肌梗死患者的左心室心功能参数的比较(
±s)$\scriptstyle \bar x $ Table 2. Comparison of left ventricular cardiac function parameters between the two groups of patients with acute myocardial infarction (
±s)$\scriptstyle \bar x$ -
对影响患者左心室功能改善的因素进行Logistic回归分析,结果筛选出与治疗后LVEF改善相关的因素,包括患者胸痛时间、心梗位置、存活心肌比例(S/N比值)及首次检查与PTCA治疗的间隔时间,其中S/N比值是患者左心室功能改善的独立影响因素(OR=2.164,P=0.018)。
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由图2的ROC曲线显示,以S/N比值预测PTCA治疗后LVEF改善的界值为0.62,AUC为0.823(95%CI:0.661~0.985),灵敏度为91.54%,特异度为85.71%。PTCA治疗前S/N比值≥0.62的患者(n=25),治疗后平均LVEF明显高于S/N比值<0.62的患者(n=11),且差异有统计学意义(48±10 vs. 39±13,t=−2.315,P=0.015);而治疗前二者的比较,差异无统计学意义(37±12 vs. 38±11,t=−2.315,P=0.015)。
核素心肌显像对急性心肌梗死患者 PTCA后左心室收缩功能变化的评估价值
Evaluation value of radionuclide myocardial imaging on left ventricular systolic function changes in patients with acute myocardial infarction after PTCA
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摘要:
目的 探讨核素心肌灌注/代谢显像对急性心肌梗死(AMI)患者经皮腔内冠状动脉成形术(PTCA)后左心室收缩功能变化的评估价值。 方法 回顾性分析2015年6月至2017年12月于山西医科大学附属第一医院行PTCA治疗的AMI患者36例,其中男性27例、女性9例,年龄(57.9±12.3)岁。所有患者均在AMI发病1周内行PTCA治疗,并于治疗前3天和治疗后6~8个月行99Tcm-甲氧基异丁基异腈SPECT心肌灌注显像(MPI)和18F-氟脱氧葡萄糖PET/CT心肌代谢显像。根据治疗后左心室射血分数(LVEF)的变化值(ΔLVEF)将患者分为2组:A组为心功能改善组(ΔLVEF≥5%);B组为心功能未改善组(ΔLVEF<5%)。采用t检验和χ2检验分析比较2组患者的临床资料、LVEF、高峰射血率(PER)、存活心肌/坏死心肌节段数(S/N)比值及心肌肌钙蛋白I(cTnI)等指标间的差异;采用Logistic回归分析影响左心室收缩功能的相关因素;采用受试者特征工作(ROC)曲线分析预测LVEF改善(ΔLVEF≥5%)的S/N界值。 结果 (1)2组患者的性别、年龄、体重指数、吸烟史、高血压病史、糖尿病史、高脂血症病史、心绞痛病史等差异均无统计学意义(均P>0.05)。(2)PTCA治疗前,A组和B组间LVEF、PER、cTnI的差异无统计学意义,而S/N比值(A组:1.24±1.06,B组:0.58±0.37)的差异有统计学意义(t=0.824,P=0.042);PTCA治疗后,2组间LVEF(A组:47±12,B组:38±10)、PER(A组:2.11±0.48,B组:1.71±0.50)、S/N比值(A组:0.73±0.47,B组:0.62±0.39)的差异有统计学意义(t=−2.528、−2.366、−2.514,P=0.016、0.024、0.017),但cTnI间的差异无统计学意义。(3)Logistic回归分析显示,S/N比值是ΔLVEF的独立影响因素(OR=2.164,P=0.018)。(4)ROC曲线结果显示,以S/N比值预测AMI患者PTCA治疗后ΔLVEF≥5%的界值为0.62,曲线下面积为0.823(95%CI:0.661~0.985),特异度为85.71%,灵敏度为91.54%。 结论 核素心肌灌注/代谢显像对AMI患者行PTCA治疗后左心室收缩功能变化的评估具有重要的临床价值。 -
关键词:
- 心肌梗死 /
- 心肌灌注显像 /
- 正电子发射断层显像计算机体层摄影术 /
- 血管成形术,气囊,冠状动脉 /
- 存活心肌 /
- 坏死心肌
Abstract:Objective To evaluate the value of radionuclide myocardial perfusion/metabolic imaging in the assessment of left ventricular systolic function after percutaneous coronary intervention and percutaneous transluminal coronary angioplasty (PTCA) in patients with acute myocardial infarction (AMI). Methods The present study was a retrospective analysis of 36 patients (male/female, 27/9; age, 57.9±12.3 years) with AMI who were treated with PTCA in the First Affiliated Hospital of Shanxi Medical University from June 2015 to December 2017. All patients received PTCA treatment within 1 week of onset of AMI. SPECT myocardial perfusion imaging and PET/CT myocardial metabolic imaging were performed 3 days before and 6–8 months after treatment. Patients were then divided into two groups, namely, group A (left ventricular ejection fraction (LVEF) change value (ΔLVEF), ΔLVEF≥5%) and group B (ΔLVEF<5%). The t- and χ2 tests were used to compare differences between the two groups in terms of clinical data (LVEF, peak ejection rate (PER), ratio of surviving myocardium/necrotic myocardium (S/N) and cardiac troponini (cTnI) Logistic regression was used to analyze the factors affecting left ventricular systolic function. Receiver operating characteristic (ROC) curve analysis determined the S/N ratio cutoff for improved LVEF values (ΔLVEF≥5%). Results No statistically significant differences in gender, age, body mass index, history of smoking, hypertension, diabetes, hyperlipidemia, and angina were found between the two groups (all P>0.05). Before PTCA treatment, differences in LVEF, PER, and troponin cTnI between groups A and B were not statistically significant but differences in S/N ratio (group A: 1.24±1.06, group B: 0.58±0.37) were statistically significant (t=0.824, P=0.042). After PTCA treatment, differences in LVEF (group A: 47±12, group B: 38±10), PER (group A: 2.11±0.48, group B: 1.71±0.50), and S/N ratio (group A: 0.73±0.47, group B: 0.62±0.39) between the two groups were statistically significant (t=−2.528, −2.366, −2.514; P=0.016, 0.024, 0.017) but the difference in cTnI was not statistically significant. Multivariate Logistic regression analysis showed that the S/N ratio is an independent influencing factor of ΔLVEF (OR=2.164, P=0.018). ROC curve results showed that the S/N ratio could be used to predict the cut-off value (0.62) of ΔLVEF≥5% after PTCA treatment in AMI patients. The area under the curve was 0.823 (95%CI: 0.661–0.985), the specificity was 85.71%, and the sensitivity was 91.54%. Conclusion Radionuclide myocardial perfusion/metabolic imaging has important clinical value in evaluating left ventricular systolic function after PTCA treatment in AMI patients. -
表 1 2组急性心肌梗死患者一般临床特征的比较
Table 1. Comparison of general clinical characteristics between the two groups of patients with acute myocardial infarction
组别 男性/女性(例) 年龄(岁) 体重指数(kg/m2) 吸烟史 高血压病史 糖尿病史 高血脂症病史 心绞痛病史 A组(n=24) 18/6 53.6±9.3 24.75±3.60 16(66.7%) 17(70.8%) 13(54.2%) 12(50.0%) 16(66.7%) B组(n=12) 9/3 62.2±9.1 25.01±3.79 7(58.3%) 10(83.3%) 7(58.3%) 8(66.7%) 7(58.3%) 检验值 χ2=0.000 t=−2.828 t=−0.201 χ2=0.241 χ2=0.667 χ2=0.056 χ2=0.900 χ2=0.241 P值 1.000 0.110 0.842 0.429 0.403 0.819 0.103 0.429 注:表中,A组:心功能改善组(ΔLVEF≥5%);B组:心功能未改善组(ΔLVEF<5%)。ΔLVEF:左心室射血分数的变化值 表 2 2组急性心肌梗死患者的左心室心功能参数的比较(
±s)$\scriptstyle \bar x $ Table 2. Comparison of left ventricular cardiac function parameters between the two groups of patients with acute myocardial infarction (
±s)$\scriptstyle \bar x$ 组别 LVEF(%) PER(%) S/N比值 cTnI(μg/L) 治疗前 治疗后 治疗前 治疗后 治疗前 治疗后 治疗前 治疗后 A组(n=24) 36±12 47±12 1.54±0.35 2.11±0.48 1.24±1.06 0.73±0.47 1.52±0.41 1.39±0.39 B组(n=12) 39±10 38±10 1.79±0.44 1.71±0.50 0.58±0.37 0.62±0.39 1.02±0.20 1.18±0.67 t值 0.569 −2.528 −1.075 −2.366 0.824 −2.514 −0.844 −1.229 P值 0.573 0.016 0.292 0.024 0.042 0.017 0.141 0.259 注:表中,A组:心功能改善组(ΔLVEF≥5%);B组:心功能未改善组(ΔLVEF<5%)。LVEF:左心室射血分数;PER:高峰射血率;S/N比值:存活心肌/坏死心肌节段数的比值;cTnI:心肌肌钙蛋白I -
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