基于心脏磁共振的ST段抬高型心肌梗死后微血管阻塞的预测因素及预后分析

Predictors and prognostic analysis of microvascular obstruction after ST-segment elevation myocardial infarction based on cardiac magnetic resonance

摘要:

目的]基于心脏磁共振(CMR)探究急性ST段抬高型心肌梗死(STEMI)患者发生微血管阻塞(MVO)的预测因素以及对患者预后的影响。 [方法]前瞻性纳入2023年9月—2025年6月在心内科接受直接经皮冠状动脉介入治疗(PCI)的急性STEMI患者102例,分别于术后1周及术后6个月行心脏磁共振(CMR)检查。根据CMR结果是否存在MVO征象将患者分为MVO组(n＝48)和无MVO组(n＝54)。分析两组患者临床特征的差异,采用单因素及多因素Logistic回归分析MVO发生的独立危险因素,应用ROC曲线评估危险因素对MVO的预测价值,并进行CMR的检查随访,评估MVO对左心室重塑的影响。 [结果]与无MVO组比较,MVO组入院心率、血小板计数/淋巴细胞计数比值(PLR)、肌酸激酶同工酶(CK-MB)和甘油三酯葡萄糖指数(TyG)等增加,前壁梗死的患者占比高,差异有统计学意义(P＜0.05)。多因素Logistic回归分析结果显示,TyG增加(OR＝6.324,95%CI:1.547～25.854,P＝0.01)、PLR增高(OR＝1.037,95%CI:1.018～1.056,P＜0.001)、入院心率增快(OR＝1.137,95%CI:1.07～1.208,P＜0.001)、CK-MB峰值升高(OR＝1.01,95%CI:1.004～1.016,P＝0.001)是急性STEMI患者直接PCI术后发生MVO的独立危险因素。ROC曲线分析结果提示入院心率(灵敏度0.521,特异度0.907,AUC＝0.76)、TyG(灵敏度0.875,特异度0.519,AUC＝0.666)、PLR(灵敏度0.896,特异度0.426,AUC＝0.688)、CK-MB峰值(灵敏度0.854,特异度0.704,AUC＝0.791)各自对MVO发生的预测价值不高,但它们联合预测模型(灵敏度0.833,特异度0.852,AUC＝0.901)对预测MVO发生的能力显著提升；经过6个月的随访观察,MVO组左心室不良重塑的发生率明显高于无MVO组(42.2%比20.4%,P＝0.022),MVO组6个月后的左心室收缩期末容积指数(LVESVI)及左心室舒张期末容积指数(LVEDVI)明显高于无MVO组[LVESVI:51(39~59) mL/m²比37(30~45) mL/m²,P＜0.001；LVEDVI:81(72~100)mL/m²比70(57~85)mL/m²,P＜0.001]。 [结论]本研究基于急性STEMI患者的CMR参数,识别出TyG增加、PLR增高、CK-MB峰值升高、入院心率增快为MVO的独立危险因素,且联合预测价值更高,出现MVO征象的患者发生左心室不良重塑的风险明显增加。

Abstract:

Aim To investigate the predictive factors for microvascular obstruction (MVO) in patients with acute ST-segment elevation myocardial infarction (STEMI) and its impact on patient prognosis using cardiac magnetic resonance (CMR). Methods A total of 102 patients with acute STEMI who underwent primary percutaneous coronary intervention (PCI) in the Department of Cardiology from September 2023 to June 2025 were prospectively enrolled. CMR was performed on the patients at one week and six months after the operation, respectively. The patients were divided into MVO group (n＝48) and non-MVO group (n＝54) based on the presence or absence of MVO signs on CMR. Differences in clinical characteristics between the two groups were analyzed, and univariate and multivariate Logistic regression analysis were performed to identify independent risk factors of MVO. ROC curves were used to assess the predictive value of risk factors for MVO, and CMR follow-up examinations were conducted to evaluate the impact of MVO on left ventricular remodeling. Results Compared with the non-MVO group, the MVO group had significantly higher admission heart rate, platelet-to-lymphocyte ratio (PLR), creatine kinase-MB (CK-MB), and triglyceride-glucose index (TyG), as well as higher proportion of anterior wall infarction (P＜0.05). Multivariate Logistic regression analysis showed that increased TyG (OR＝6.4,5%CI:1.547～25.854, P＝0.01), elevated PLR (OR＝1.7,5%CI:1.018～1.056, P＜0.001), higher admission heart rate (OR＝1.7,5%CI:1.07～1.208, P＜0.001), and elevated peak level of CK-MB (OR＝1.1,5%CI:1.004～1.016, P＝0.001) were independent risk factors for the occurrence of MVO in patients with acute STEMI after primary PCI. The results of ROC curve showed that admission heart rate (sensitivity:0.521, specificity:0.907, AUC＝0.76), TyG (sensitivity:0.875, specificity:0.519, AUC＝0.666), PLR (sensitivity:0.896, specificity:0.426, AUC＝0.688), CK-MB peak (sensitivity:0.854, specificity:0.704, AUC＝0.791) had limited predictive value for MVO. However, their combined prediction model (sensitivity:0.833, specificity:0.852, AUC＝0.901) significantly improved the ability to predict the occurrence of MVO; after 6 months of follow-up observation, the incidence of left ventricular malignant remodeling in the MVO group was significantly higher than in the non-MVO group (42.2% vs. 20.4%, P＝0.022), and the corresponding left ventricular end-systolic volume index (LVESVI) and left ventricular end-diastolic volume index (LVEDVI) at 6 months were significantly higher in the MVO group than in the non-MVO group (LVESVI:51(39~59) mL/m² vs. 37(30~45) mL/m², P＜0.001; LVEDVI: 81(72~100)mL/m² vs. 70(57~85)mL/m², P＜0.001). Conclusion Based on CMR parameters in acute STEMI patients, this study identified increased TyG, elevated PLR, higher CK-MB peak level, and accelerated admission heart rate as independent risk factors for MVO; Moreover, their combined predictive value was higher, and patients with MVO signs had a significantly increased risk of developing left ventricular malignant remodeling.