冠心病合并糖尿病患者血小板参数与炎症反应的相关性研究
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摘要
第一部分冠心病合并糖耐量减低患者血小板参数与hsCRP的相关性研究
目的：
冠心病患者具有较高的糖代谢受损及糖尿病发生率。近年来研究表明,血小板除具有凝血功能外,尚有调控免疫反应和参与炎症反应的功能。有学者将糖尿病时活性增强的血小板称为“糖尿病血小板”。C反应蛋白(C reactive protein, CRP)是全身炎症反应的非特异性标志,也是目前最可靠的动脉粥样硬化的炎症的标记物,是疗效评估以及预后监测指标。C反应蛋白是一种急性时相蛋白,由肝脏合成。动脉粥样硬化的炎性变化,可以促使肝脏内C反应蛋白合成增加,血清中C反应蛋白含量增加。同时C反应蛋白能增强其他炎性物质的作用,是炎性反应的重要参与者。目前有关冠心病并糖耐量减低人群中血小板参数变化与相互关系的研究国内外报道较少,本研究通过检测冠心病合并糖耐量减低患者血小板四项参数、hsCRP及其相关性,了解冠心病合并糖耐量减低患者炎症程度及血小板的功能状态,为加强糖耐量减低人群心血管并发症的防治提供一定的理论依据。
方法：
研究病例分为二组：A组(冠心病同时合并糖耐量减低)及B组(正常对照组)。A组39名已确诊冠心病(CHD)同时合并糖耐量减低(IGT)的病例来自“阿卡波糖心血管评价(ACE)试验”武汉大学人民医院研究分中心。该试验选自2009年12月～2012年9月在武汉大学人民医院心内科2科住院治疗的冠心病并糖耐量减低(IGT)患者,男25例,女14例；年龄50～76岁,平均63±8岁。B组(病例对照组)来源于武汉大学人民医院心内科二科2011年9月～2012年9月住院患者,均因阵发性室上性心动过速而行射频消融术,年龄之50岁。共收集病例对照组17例,其中男性10例,女性7例,年龄,平均年龄62±5岁(50-71岁)。
观察内容包括：
1.病人性别、年龄、相关危险因素,包括既往冠心病、高血压病、高脂血症及糖尿病史；
2.入院后实验室检查：心肌酶(CTnI, CK-MB,Myo)、糖耐量试验、血小板参数、血脂(TC, TG, HDL,LDL,Lpa)及高敏感度C反应蛋白(hs-CRP);
3.心电图检查；
4.冠状动脉造影或冠脉CTA结果；
统计学：
采用SPSS inc的SPSS10.0软件包进行统计学分析,所有指标均先进行正态性检验。符合正态分布且方差齐的计量资料以均数±标准差(x±SD)表示。不符合正态分布的指标以中位数表示。计数资料采用χ2检验。计量资料组间比较采用One-Way ANOVA检验,组内比较采用t检验。变量间相关性采用Spearman's rho等级相关分析。以p<0.05为差异具有显著性意义。
结果：
1.冠心病合并糖耐量减低患者与对照组患者一般临床特征及实验室检测指标比较：冠心病合并糖耐量减低组与病例对照组比较,空腹血糖高于病例对照组,高密度脂蛋白胆固醇则低于病例对照组,差异显著有统计学意义；体重指数、血压、甘油三酯、总胆固醇、低密度脂蛋白胆固醇差异无统计学意义。
2.血小板参数及hsCRP的比较：A组血小板三项参数MPV、PDW、P-LCR及hsCRP高于B组,PLT则低于B组,差异有统计学意义。
3.糖尿病合并糖耐量减低患者血小板参数及其与hsCRP之间的相关性分析：Spearman's rho等级相关分析表明,在冠心病合并糖耐量减低组PLT与MPV、PDW及P-LCR负相关,P-LCR、PDW、MPV之间正相关。hsCRP与PLT呈负相关,与MPV、PDW及P-LCR呈正相关。
结论：
1.冠心病合并糖耐量减低患者存在较高的血小板活性及C反应蛋白水平。血小板体积增大、活性增加以及C反应蛋白水平增加可能与冠状动脉粥样硬化的形成、血栓的形成有关。
2.冠心病合并糖耐量减低患者血小板活性及C反应蛋白存在相关性,提示二者存在相互作用,并且对冠心病动脉粥样硬化的影响是协同的。
第二部分
冠心病合并糖尿病患者血小板参数与hsCRP的相关性研究
目的：
中国冠心病患者糖代谢紊乱较西方国家更为显著,高达80%的冠心病患者合并糖代谢紊乱。在急性心肌梗死患者中,合并糖代谢异常的比例也非常高,有相当比例是糖代谢紊乱引起的持续性高血糖,而不是应激引起的一过性高血糖。近年来研究表明,血小板除具有凝血功能外,尚参与炎症反应。C反应蛋白(C reactive protein, CRP)是全身炎症反应的非特异性标志。血清C反应蛋白浓度可反映体内炎症介质活动情况,与炎症和组织损伤程度成正比,也是目前最可靠的动脉粥样硬化的炎症的标记物。
目前有关冠心病合并糖尿病人群中血小板参数变化及其与C反应蛋白相互关系的研究国内外报道较少。在本研究的第一部分,我们进行了冠心病合并糖耐量减低患者血小板参数与hsCRP的相关性研究,发现冠心病合并糖耐量减低患者存在较高的血小板活性及C反应蛋白水平,并且血小板活性与C反应蛋白存在相关性,提示二者对冠心病动脉粥样硬化的影响是交互的。本研究将进一步检测冠心病合并糖尿病患者血小板四项参数、hsCRP及血脂等,探讨冠心病合并糖尿病人群血小板参数的变化及其与C反应蛋白的相互关系,掌握其血小板炎症程度及功能状态的变化,为防治糖尿病心血管并发症提供一定的理论依据。
方法：
研究病例分为二组：A组(冠心病同时合并糖尿病),B组(单纯冠心病)。98名冠心病(CHD)合并2型糖尿病(T2DM)患者以及112例冠心病不合并2型糖尿病患者,选自2009年08月～2012年08月在武汉大学人民医院心内科2科住院治疗的冠心病患者,男173例,女37例；年龄34～87岁,平均61±12岁。
临床资料包括：
1.病人性别、年龄、相关危险因素,包括既往冠心病、高血压病、高脂血症及糖尿病史；
2.入院后实验室检查：心肌酶(CTnI, CK-MB, Myo)、糖耐量试验、血小板参数、血脂(TC, TG, HDL, LDL, Lpa)及高敏感度C反应蛋白(hs-CRP);
3.心电图检查；
4.冠状动脉造影或冠脉CTA结果。
统计学方法：
采用SPSS inc的SPSS10.0软件包进行统计学分析,所有指标均先进行正态性检验。符合正态分布且方差齐的计量资料以均数±标准差(x±SD)表示。不符合正态分布的指标以中位数表示。计数资料采用χ2检验。计量资料组间比较采用One-Way ANOVA检验,组内比较采用t检验。变量间相关性采用Spearman's rho等级相关分析。以p<0.05为差异具有显著性意义。
结果：
1.冠心病合并糖尿病患者与对照组患者一般临床资料和实验检测指标比较：
冠心病合并糖尿病组与冠心病组相比,空腹血糖、女性比例高于病例对照组,其差异有统计学意义；年龄、高血压病、吸烟率、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇、甘油三醋及总胆固醇差异无统计学意义。
2.血小板参数及hsCRP的比较：
血小板三项参数MPV、PDW、P-LCR及hsCRP在A组高于B组,PLT则低于B组,差异有统计学意义。
3.血小板参数之间及其与其他变量之间的相关分析：
Spearman's rho等级相关分析表明,在冠心病合并糖尿病组血小板数目与MPV、PDW及P-LCR呈负相关,MPV、PDW及P-LCR之间呈高度正相关。hsCRP与血小板计数呈负相关,与MPV、PDW及P-LCR呈负相关。
结论：
1.冠心病合并糖尿病患者存在较高的血小板活性及C反应蛋白水平。
2.冠心病合并糖尿病患者血小板活性及C反应蛋白存在相关性,提示二者对糖尿病性动脉粥样硬化的发生及发展是相互、协同作用的,应该引起临床研究及临床实践的重视。
第三部分急性心肌梗死合并糖尿病患者全身炎症反应及其对院内主要不良事件的预测价值
目的：
在急性心肌梗死患者中,合并糖代谢异常的比例非常高,有相当比例是糖代谢紊乱引起的持续性高血糖,而不是应激引起的一过性高血糖。急性心肌梗死患者病情发生变化快,极其容易并发心律失常、心力衰竭及猝死,所以预后一般很差。急性心肌梗死合并糖尿病患者相比不合并糖尿病急性心肌梗死患者,其长期预后更差。急性心肌梗死患者的预后评估越来越受到重视。对新入院的急性心肌梗死患者,早期预测危险程度,可以指导下一步的检查及治疗方案,减少住院期间并发症的发生,指导医务工作者有重点地有目的地开展工作,有效地提高生存率。
本研究将检测急性心肌梗死合并糖尿病患者早期全身炎症反应指标(体温、心率、呼吸频率及血液白细胞计数),绘制ROC曲线来确定各系统性炎症反应对院内主要不良事件的预测价值,同时进行多变量(多项测量指标)观察值的ROC曲线分析,探讨四种全身炎症反应指标联合预测急性心肌梗死预后的优点。
方法：
67例均为武汉大学人民医院心内科住院患者,2007年12月～2012年9月住院治疗的急性心肌梗死合并糖尿病患者,男53例,女14例；年龄34～83岁,平均63±15岁。所有病例均为ST段抬高心肌梗死,发病至入院8h内,排除了入院时伴有感染的情况或已经行溶栓治疗。发生院内主要心脏事件(即研究终点：心跳骤停、心脏室速及室颤等高危心律失常、呼吸骤停、急性左心衰、心源性休克、再次心肌梗死及死亡等)的患者,分为A组；未发生院内主要不良事件的患者,分为B组。记录患者入院时病人年龄、性别、发病至入院时间(h)、住院时间(d)；相关危险因素,包括既往高血压病、高脂血症；一般查体项目：入院后记录体温(腋下BT)、心率(HR)、呼吸频率(RR)；入院后实验室检查：肌酐(Cr)、hs-CRP、血糖(GS)、血脂(TC, TG, HDL, LDL, Lpa)、心肌酶(CTnI,CK-MB,Myo)及白细胞计数(WBC);心电图检查等。
统计学
采用SPSS inc的SPSS10.0软件包进行统计学分析,所有指标均先进行正态性检验。不符合正态分布的指标以中位数表示。符合正态分布且方差齐的计量资料以均数±标准差(x±SD)表示。CRP经对数转换达近似正态分布后进行数据分析(为使结果简明仍以变换前数据表示)。计量资料组间比较采用One-Way ANOVA检验,组内比较采用t检验,不符合正态分布的指标采用Manner Whitney u检验。计数资料采用χ2检验。变量间相关性采用Spearman相关系数定量法。以p<0.05为差异具有显著性意义。
采用SPSS10.0软件包绘制应用受试者工作特征ROC曲线(receiver operating characteristic curve, c-statistic),并比较和计算曲线下面积(area under the curve,AUC)。采用Z检验(MedCalc)比较各参数ROC曲线下面积。采用两样本率比较的正态近似法比较各个预测指标的敏感度、特异度及诊断准确度。采用函数法确定各指标的最佳截断点(cutoff point),即敏感度和特异度之和取最大值时所代表的诊断截断值作为最佳截断点(cutoff point)。AUC在0.5-0.7时有较低的准确性,AUC在0.7-0.9时有一定的准确性,AUC超过0.9有较高准确性。AUC=0.5时,说明诊断方法完全不起作用,无诊断价值。应用多变量观察值logistic回归的ROC曲线分析评价四种炎症反应指标联合预测价值。
结果：
1.一般临床资料和实验检测指标
67例急性心肌梗死合并糖尿病患者住院期间共有18例(A组,27%)发生主要不良事件,其中心源性猝死8例,心源性休克2例,急性左心衰2例,需要干预的室速1例、Ⅲ°房室传导阻滞1例,室颤3例,再次心肌梗死1例。A、B二组间年龄、高血压史、吸烟史、血脂、hs-CRP等无显著性差异。患者入院时体温、心率、呼吸频率、WBC、GS、Cr与主要不良事件发生率存在相关性。入院时单次测量心肌酶谱(cTnI, CK-MB及Myo)亦不能预测主要不良事件的发生。
2.体温对AMI近期预后的预测价值
ROC曲线下面积=0.757±0.064,P=0.000,表明预测准确性较高,具有较高的临床预测价值。最佳界点(T<=36.0℃)预测急性心肌梗死合并糖尿病患者院内主要不良事件的敏感度为77.8%,特异度70.0%。
3.心率对AMI近期预后的预测价值
ROC曲线下面积=0.712±0.077,P=0.01,表明预测准确性较高,具有一定的临床预测价值。最佳界点(HR>83bpm)预测急性心肌梗死合并糖尿病患者院内主要不良事件的敏感度为66.7%,特异度67.5%。
4.呼吸频率对AMI近期预后的预测价值
ROC曲线下面积AUC=0.779±0.071,P=0.045(与AUC=0.5比较),表明预测准确性较高,具有较高的临床预测价值。最佳界点(RR>21bpm)预测急性心肌梗死合并糖尿病患者院内主要不良事件的敏感度为50.0%,特异度97.5%。
5.WBC对AMI近期预后的预测价值
AUC=0.664±0.080,P=0.01,(与AUC=0.5比较),表明有一定的预测能力,具有临床预测价值。最佳界点(WBC>11.5万/μl)预测急性心肌梗死合并糖尿病患者院内主要不良事件的敏感度为38.9%,特异度100.0%。
6.四个协变量对急性心肌梗死合并糖尿病患者院内主要不良事件的预测价值
作为急性心肌梗死合并糖尿病预后的预测指标,四个协变量(T、HR、RR、WBC)联合预测的ROC曲线下面积为0.88,且差异有统计学意义(与AUC0.5比较),说明诊断准确性较高,具有极高的临床预测价值。相比单指标(单协变量WBC AUC为0.66),联合指标提高了预测效能。二者AUC比较,p=0.026,差异有显著性。
7.炎症反应积分与住院期间主要不良事件发生率的关系
炎症反应积分：按照以上ROC曲线获得的最佳界点值,将病人入院时T、HR、RR及WBC进行计分,存在其中一项为1分,将炎症反应严重度评为0～4分。
卡方检验发现炎症反应积分与住院期间主要不良事件发生率存在相关性。炎症反应积分0～1组主要不良事件发生率为18.2%,炎症反应积分2～4组主要不良事件发生率为71.4%,二组之间比较,p=0.000,有统计学差异。炎症反应积分2～4组院内主要不良事件发生率明显高于炎症反应积分0～1组,优势比(odds ratio)为11.25(2.80,45.16),p=0.000。炎症反应积分0～1可判别为低危病人,炎症反应积分2～4可预测高度危险病人。
结论：
1.入院时体温、心率、呼吸频率及外周血白细胞计数可以预测急性心肌梗死合并糖尿病患者院内主要不良事件的发生率。
2.本研究首次建立的评价方法简单、易行。炎症反应积分0～1可判别为低危病人,炎症反应积分2～4可判别为高危病人。采用本研究建立的全身炎症反应积分预测急性心肌梗死患者院内预后,给护理人员开展健康教育与心理指导提供显而易见的数据,使病情风险预警时间提前,便于医生早期采取治疗措施。
3.体温、心率、呼吸频率及外周血白细胞计数联合指标预测预后准确性较高,具有极高的临床预测价值。与单一指标相比,联合指标提高了预测效能。
PART I Relationship between Platelet Parameters and C-reaction Protein in Patients with Coronary Heart Disease and Impaired Glucose Tolerance
Objective:
Impaired Glucose Tolerance and Type2diabetes are very frequent in Coronary Heart Disease. Activated platelet plays an important role in atherosclerosis, thrombosis, and inflammation. The platelet in patients with Type2diabetes also called "diabetic platelet".C-reaction protein plays an important role in the developmental progress of atherosclerosis and type2diabetes. There were few reports on platelet function and C-reaction protein in the stage of impaired glucose tolerance in patients with coronary artery disease. The aim of this study was to investigate the change of platelet parameters and C-reaction protein in patients with coronary Heart disease and impaired glucose tolerance.
Methods:
This study cohort included39consecutive patients with patients with coronary Heart disease and impaired glucose tolerance. These patients come from the (Acarbose Cardiovasculer Evaluation)ACE test in Renmin hospital of Wuhan University from Dec2009～Sep2012. These patient was divided into group A included25men and14women, aged50～76years(63±8ys). Group B (normal control group) included patients with PSVT (Paroxysmal supraventricular tachycardia),10men and7women, aged50～71years(62±5ys).These patients received RFCA(Catheter radiofrequency Ablation operation in2nd department of Cardiology, Renmin Hospital of Wuhan university from Sep2011to Sep2012, with age above50ys. The observed parameters were collected at initial admission. These parameters included sex,age,history,CTnI, CK-MB, Myo)、oral glucose tolerance tes、TC, TG, HDL, LDL, Lpa,hs-CRP,blood parametes,EKG,reports of SCA or coronary CA.
Statistical analysis:Results were presented as±SD for continuous normally distributed variables, as median for continuous non-normally distributed data, and as percentages for categorical data. Significance was assumed with a two-sided p value of below0.05. We tested continuous variables by one-way ANOVA for between-group comparisons and Student's t-test for within-group comparisons. If a normal distribution of variables was not presented, the Mann-Whitney Test was used for testing treatment-group differences and the Coefficients of correlation (r) were calculated by the Spearman's rho correlation analysis. The data were analyzed using SPSS for windows10.0(SPSS Inc.).
Results:
1. The subjects in group A had higher levels of fasting plasma glucose and lower levels of high-density lipoprotein cholesterol compared with subjects in group B.
2. The subjects in group A had higher levels of MPV、PDW、P-LCR and hsCRP and lower levels of PLT compared with subjects in group B.
3. Spearman's rho correlation analysis revealed that there were relationships between platelet parameters and hsCRP in patients with coronary Heart disease and impaired glucose tolerance, respectively. PLT was negatively related to MPV、PDW and P-LCR. There were positive relationships between P-LCR、PDW and MPV. The levels of hsCRP were negatively related with PLT and positively related with MPV、 PDW and P-LCR.
Conclusions:
1. There are higher levels of platelet activity and hsCRP in patients with coronary Heart disease and impaired glucose tolerance compared with normal control group. The high levels of platelet activity and hsCRP may induce coronary atherosclerosis and thrombosis.
2. The relationships between platelet parameters and hsCRP in patients with coronary Heart disease and impaired glucose tolerance imply cooperative effects in the development of atherosclerosis. This should be paid attention.
PART Ⅱ:Relationship between Platelet Parameters and C-reaction Protein in Patients with Coronary Heart Disease and Diabetes Mellitus
Objective:
The disorders of glucose metabolism in coronary heart disease are more frequent in P.R.China than in west countries. The combined presence of disorders of glucose metabolism and coronary heart disease is up to80%. The proportion of abnormal glucose metabolism in patients with acute myocardial infarction is very high. The most glucose metabolism disorders are caused by persistent hyperglycemia, rather than a transient hyperglycemia induced by stress. Activated platelet plays an important role in atherosclerosis, thrombosis, and inflammation. The platelet in patients with Type2diabetes also called "diabetic platelet". In recent years, studies have shown that platelet coagulation is still involved in the inflammatory response. C-reactive protein is a non-specific marker of the systemic inflammatory response. Serum C-reactive protein concentrations may reflect inflammatory mediator activities in vivo. And they are proportional to the degree of inflammation and tissue damage. CRP is the most reliable atherosclerosis inflammatory markers. The study on platelet parameters and C reactive protein in patient with coronary heart disease combined with diabetes mellitus is few. In the first part of this study, we performed the study on the relationship between platelet parameters and hsCRP in patients with coronary heart disease and abnormal glucose tolerance, and we found high platelet activity and C reactive protein levels, and the relationship in patients with coronary heart disease and impaired glucose tolerance. This part of study will further detect blood platelet parameters, hsCRP and serum lipids in patients with coronary artery disease combined with type2diabetes.
Methods:
This study included group A (patients with coronary artery disease combined with type2diabetes) and group B (patients with coronary artery disease and without type2diabetes).98consecutive patients with patients with coronary heart disease and T2MD and112consecutive patients with coronary heart disease and without T2MD. These patients come from the inpatients in2nd department of Cardiology, Renmin hospital of Wuhan University from Aug2009-Aug2012. These210patients included173men and37women, aged34～87years(61±12ys). The observed parameters were collected at initial admission. These parameters included sex,age,history,CTnI, CK-MB, Myo)、 oral glucose tolerance test, TC, TG, HDL, LDL, Lpa, hs-CRP,blood parametes,EKG, reports of SCA or coronary CA. Statistical analysis:Results were presented as x±SD for continuous normally distributed variables, as median for continuous non-normally distributed data, and as percentages for categorical data. Significance was assumed with a two-sided p value of below0.05. We tested continuous variables by one-way ANOVA for between-group comparisons and Student's t-test for within-group comparisons. If a normal distribution of variables was not presented, the Mann-Whitney Test was used for testing treatment-group differences and the Coefficients of correlation (r) were calculated by the Spearman's rho correlation analysis. The data were analyzed using SPSS for windows10.0(SPSS Inc.).
Results:
1. The subjects in group A had higher levels of fasting plasma glucose, higher proportion of women compared with subjects in group B.
2. The subjects in group A had higher levels of MPV、PDW、P-LCR and hsCRP, and lower levels of PLT compared with subjects in group B.
3. Spearman's rho correlation analysis revealed that there were relationships between platelet parameters and hsCRP in patients with coronary Heart disease and T2DM, respectively. PLT was negatively related to MPV、PDW and P-LCR. There were positive relationships between P-LCR、PDW and MPV. The levels of hsCRP were negatively related with PLT and positively related with MPV、PDW and P-LCR.
Conclusions:
1. There are higher levels of platelet activity and hsCRP in patients with coronary Heart disease and T2DM compared with normal control group. The high levels of platelet activity and hsCRP may induce coronary atherosclerosis and thrombosis.
2. The relationships between platelet parameters and hsCRP in patients with coronary heart disease and T2DM imply cooperative effects in the development of atherosclerosis. This should be paid attention.
Part III:A New Simplified Immediate System Inflammatory Score for Type2Diabetic Patients Presenting with ST-segment Elevation Acute Myocardial Infarction
Objective:
Patients with diabetic mellitus have worse outcomes after acute myocardial infarction (AMI) occurs than non-diabetics. The body condition changes fast in patients with T2DM and AMI and the arrhythmia, heart failure and sudden death extremely easily occur, so the prognosis is usually poor. The prognosis assessment for patients with T2MD and acute myocardial infarction should be paid more and more attention. Early prediction of the degree of risk for new admissions of patients with acute myocardial infarction can guide the next step of the examination and treatment programs and help to reduce the incidence of complications during hospitalization. The early systemic inflammatory response variables (body temperature, heart rate, respiratory rate, and white blood cell count) were collected in diabetic patients with acute myocardial infarction in this study. The ROC curves were drawn to evaluate the power of various systematic inflammatory response variables and discriminatory combining power of4variables to predict the prognosis of patients with acute myocardial infarction.
Methods:
This study cohort included67consecutive diabetic patients with STEMI during8hours from symptom onset. These diabetic patients with STEMI,53men and14women, aged34～83years(63±15ys), were admitted to the department of cardiology in Renmin Hospital of Wuhan University between Dec2007and Sep2012. An inflammatory score model was developed for predicting in-hospital major adverse events using parameters available at initial admission. These parameters including sex,age,history,CTnI, CK-MB, Myo、TC, TG, HDL, LDL, Lpa, hs-CRP,blood parametes, EKG, reports of SCA or coronary CA.body temperature, heart rate and respiratory rate were collected at admission.
Statistical analysis:Results were presented as x±SD for continuous normally distributed variables, as median for continuous non-normally distributed data, and as percentages for categorical data. Significance was assumed with a two-sided p value of below0.05. We tested continuous variables by one-way ANOVA for between-group comparisons and Student's t-test for within-group comparisons. If a normal distribution of variables was not presented, the Mann-Whitney Test was used for testing treatment-group differences and the Coefficients of correlation (r) were calculated by the Spearman's rho correlation analysis. The data were analyzed using SPSS for windows10.0(SPSS Inc.). ROC(receiver operating characteristic) curves analysis was used to analyze the efficacy of the body temperature, heart rate, respiratory rate and white cell count in the prognosis in diabetic acute myocardial infarction.
Results:
ROC curves (receiver operating characteristic curve, c-statistic) analysis revealed that body temperature, heart rate, respiratory rate and white cell count can predict in-hospital major adverse events with AUC0.757±0.064,0.712±0.077,0.779±0.071, and0.664±0.080, p<0.05, respectively. ROC curves analysis also revealed that the combining predictive ability of the four parameters was strong (c=0.88) and it is better than single variable predictive ability.
An inflammatory score model was developed using the four parameters above to predict in-hospital major adverse events according to the best cutoff values as fellow:(1) BT<=36.℃;(2) HR>83bpm;(3) RR>21bpm; and (4) WBC>11.5×109/L. There was a relationship between inflammatory scores and in-hospital major adverse events (p=0.000)。The rate of major adverse events with score2～4was higher than that with score0～1,71.4%vs.18.2%, p=0.000. The odds ratio(OR) was11.25(2.80,45.16),p=0.000。These patients with score0～1could be classified into low-risk person, while these patients with score2～4could be classified into high-risk person.
Conclusions:
1. The parameters including body temperature, heart rate, respiratory rate and white cell count which were collected on admission can predict major adverse events post-AMI in Type2diabetics.
2. The simple systematic inflammatory score for major adverse events post-AMI in Type2diabetics showed excellent predictive capacity in a population based on cohort of patients with STEMI during8hours from symptom setup.
目的：
冠心病患者具有较高的糖代谢受损及糖尿病发生率。近年来研究表明,血小板除具有凝血功能外,尚有调控免疫反应和参与炎症反应的功能。有学者将糖尿病时活性增强的血小板称为“糖尿病血小板”。C反应蛋白(C reactive protein, CRP)是全身炎症反应的非特异性标志,也是目前最可靠的动脉粥样硬化的炎症的标记物,是疗效评估以及预后监测指标。C反应蛋白是一种急性时相蛋白,由肝脏合成。动脉粥样硬化的炎性变化,可以促使肝脏内C反应蛋白合成增加,血清中C反应蛋白含量增加。同时C反应蛋白能增强其他炎性物质的作用,是炎性反应的重要参与者。目前有关冠心病并糖耐量减低人群中血小板参数变化与相互关系的研究国内外报道较少,本研究通过检测冠心病合并糖耐量减低患者血小板四项参数、hsCRP及其相关性,了解冠心病合并糖耐量减低患者炎症程度及血小板的功能状态,为加强糖耐量减低人群心血管并发症的防治提供一定的理论依据。
方法：
研究病例分为二组：A组(冠心病同时合并糖耐量减低)及B组(正常对照组)。A组39名已确诊冠心病(CHD)同时合并糖耐量减低(IGT)的病例来自“阿卡波糖心血管评价(ACE)试验”武汉大学人民医院研究分中心。该试验选自2009年12月～2012年9月在武汉大学人民医院心内科2科住院治疗的冠心病并糖耐量减低(IGT)患者,男25例,女14例；年龄50～76岁,平均63±8岁。B组(病例对照组)来源于武汉大学人民医院心内科二科2011年9月～2012年9月住院患者,均因阵发性室上性心动过速而行射频消融术,年龄之50岁。共收集病例对照组17例,其中男性10例,女性7例,年龄,平均年龄62±5岁(50-71岁)。
观察内容包括：
1.病人性别、年龄、相关危险因素,包括既往冠心病、高血压病、高脂血症及糖尿病史；
2.入院后实验室检查：心肌酶(CTnI, CK-MB,Myo)、糖耐量试验、血小板参数、血脂(TC, TG, HDL,LDL,Lpa)及高敏感度C反应蛋白(hs-CRP);
3.心电图检查；
4.冠状动脉造影或冠脉CTA结果；
统计学：
采用SPSS inc的SPSS10.0软件包进行统计学分析,所有指标均先进行正态性检验。符合正态分布且方差齐的计量资料以均数±标准差(x±SD)表示。不符合正态分布的指标以中位数表示。计数资料采用χ2检验。计量资料组间比较采用One-Way ANOVA检验,组内比较采用t检验。变量间相关性采用Spearman's rho等级相关分析。以p<0.05为差异具有显著性意义。
结果：
1.冠心病合并糖耐量减低患者与对照组患者一般临床特征及实验室检测指标比较：冠心病合并糖耐量减低组与病例对照组比较,空腹血糖高于病例对照组,高密度脂蛋白胆固醇则低于病例对照组,差异显著有统计学意义；体重指数、血压、甘油三酯、总胆固醇、低密度脂蛋白胆固醇差异无统计学意义。
2.血小板参数及hsCRP的比较：A组血小板三项参数MPV、PDW、P-LCR及hsCRP高于B组,PLT则低于B组,差异有统计学意义。
3.糖尿病合并糖耐量减低患者血小板参数及其与hsCRP之间的相关性分析：Spearman's rho等级相关分析表明,在冠心病合并糖耐量减低组PLT与MPV、PDW及P-LCR负相关,P-LCR、PDW、MPV之间正相关。hsCRP与PLT呈负相关,与MPV、PDW及P-LCR呈正相关。
结论：
1.冠心病合并糖耐量减低患者存在较高的血小板活性及C反应蛋白水平。血小板体积增大、活性增加以及C反应蛋白水平增加可能与冠状动脉粥样硬化的形成、血栓的形成有关。
2.冠心病合并糖耐量减低患者血小板活性及C反应蛋白存在相关性,提示二者存在相互作用,并且对冠心病动脉粥样硬化的影响是协同的。
第二部分
冠心病合并糖尿病患者血小板参数与hsCRP的相关性研究
目的：
中国冠心病患者糖代谢紊乱较西方国家更为显著,高达80%的冠心病患者合并糖代谢紊乱。在急性心肌梗死患者中,合并糖代谢异常的比例也非常高,有相当比例是糖代谢紊乱引起的持续性高血糖,而不是应激引起的一过性高血糖。近年来研究表明,血小板除具有凝血功能外,尚参与炎症反应。C反应蛋白(C reactive protein, CRP)是全身炎症反应的非特异性标志。血清C反应蛋白浓度可反映体内炎症介质活动情况,与炎症和组织损伤程度成正比,也是目前最可靠的动脉粥样硬化的炎症的标记物。
目前有关冠心病合并糖尿病人群中血小板参数变化及其与C反应蛋白相互关系的研究国内外报道较少。在本研究的第一部分,我们进行了冠心病合并糖耐量减低患者血小板参数与hsCRP的相关性研究,发现冠心病合并糖耐量减低患者存在较高的血小板活性及C反应蛋白水平,并且血小板活性与C反应蛋白存在相关性,提示二者对冠心病动脉粥样硬化的影响是交互的。本研究将进一步检测冠心病合并糖尿病患者血小板四项参数、hsCRP及血脂等,探讨冠心病合并糖尿病人群血小板参数的变化及其与C反应蛋白的相互关系,掌握其血小板炎症程度及功能状态的变化,为防治糖尿病心血管并发症提供一定的理论依据。
方法：
研究病例分为二组：A组(冠心病同时合并糖尿病),B组(单纯冠心病)。98名冠心病(CHD)合并2型糖尿病(T2DM)患者以及112例冠心病不合并2型糖尿病患者,选自2009年08月～2012年08月在武汉大学人民医院心内科2科住院治疗的冠心病患者,男173例,女37例；年龄34～87岁,平均61±12岁。
临床资料包括：
1.病人性别、年龄、相关危险因素,包括既往冠心病、高血压病、高脂血症及糖尿病史；
2.入院后实验室检查：心肌酶(CTnI, CK-MB, Myo)、糖耐量试验、血小板参数、血脂(TC, TG, HDL, LDL, Lpa)及高敏感度C反应蛋白(hs-CRP);
3.心电图检查；
4.冠状动脉造影或冠脉CTA结果。
统计学方法：
采用SPSS inc的SPSS10.0软件包进行统计学分析,所有指标均先进行正态性检验。符合正态分布且方差齐的计量资料以均数±标准差(x±SD)表示。不符合正态分布的指标以中位数表示。计数资料采用χ2检验。计量资料组间比较采用One-Way ANOVA检验,组内比较采用t检验。变量间相关性采用Spearman's rho等级相关分析。以p<0.05为差异具有显著性意义。
结果：
1.冠心病合并糖尿病患者与对照组患者一般临床资料和实验检测指标比较：
冠心病合并糖尿病组与冠心病组相比,空腹血糖、女性比例高于病例对照组,其差异有统计学意义；年龄、高血压病、吸烟率、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇、甘油三醋及总胆固醇差异无统计学意义。
2.血小板参数及hsCRP的比较：
血小板三项参数MPV、PDW、P-LCR及hsCRP在A组高于B组,PLT则低于B组,差异有统计学意义。
3.血小板参数之间及其与其他变量之间的相关分析：
Spearman's rho等级相关分析表明,在冠心病合并糖尿病组血小板数目与MPV、PDW及P-LCR呈负相关,MPV、PDW及P-LCR之间呈高度正相关。hsCRP与血小板计数呈负相关,与MPV、PDW及P-LCR呈负相关。
结论：
1.冠心病合并糖尿病患者存在较高的血小板活性及C反应蛋白水平。
2.冠心病合并糖尿病患者血小板活性及C反应蛋白存在相关性,提示二者对糖尿病性动脉粥样硬化的发生及发展是相互、协同作用的,应该引起临床研究及临床实践的重视。
第三部分急性心肌梗死合并糖尿病患者全身炎症反应及其对院内主要不良事件的预测价值
目的：
在急性心肌梗死患者中,合并糖代谢异常的比例非常高,有相当比例是糖代谢紊乱引起的持续性高血糖,而不是应激引起的一过性高血糖。急性心肌梗死患者病情发生变化快,极其容易并发心律失常、心力衰竭及猝死,所以预后一般很差。急性心肌梗死合并糖尿病患者相比不合并糖尿病急性心肌梗死患者,其长期预后更差。急性心肌梗死患者的预后评估越来越受到重视。对新入院的急性心肌梗死患者,早期预测危险程度,可以指导下一步的检查及治疗方案,减少住院期间并发症的发生,指导医务工作者有重点地有目的地开展工作,有效地提高生存率。
本研究将检测急性心肌梗死合并糖尿病患者早期全身炎症反应指标(体温、心率、呼吸频率及血液白细胞计数),绘制ROC曲线来确定各系统性炎症反应对院内主要不良事件的预测价值,同时进行多变量(多项测量指标)观察值的ROC曲线分析,探讨四种全身炎症反应指标联合预测急性心肌梗死预后的优点。
方法：
67例均为武汉大学人民医院心内科住院患者,2007年12月～2012年9月住院治疗的急性心肌梗死合并糖尿病患者,男53例,女14例；年龄34～83岁,平均63±15岁。所有病例均为ST段抬高心肌梗死,发病至入院8h内,排除了入院时伴有感染的情况或已经行溶栓治疗。发生院内主要心脏事件(即研究终点：心跳骤停、心脏室速及室颤等高危心律失常、呼吸骤停、急性左心衰、心源性休克、再次心肌梗死及死亡等)的患者,分为A组；未发生院内主要不良事件的患者,分为B组。记录患者入院时病人年龄、性别、发病至入院时间(h)、住院时间(d)；相关危险因素,包括既往高血压病、高脂血症；一般查体项目：入院后记录体温(腋下BT)、心率(HR)、呼吸频率(RR)；入院后实验室检查：肌酐(Cr)、hs-CRP、血糖(GS)、血脂(TC, TG, HDL, LDL, Lpa)、心肌酶(CTnI,CK-MB,Myo)及白细胞计数(WBC);心电图检查等。
统计学
采用SPSS inc的SPSS10.0软件包进行统计学分析,所有指标均先进行正态性检验。不符合正态分布的指标以中位数表示。符合正态分布且方差齐的计量资料以均数±标准差(x±SD)表示。CRP经对数转换达近似正态分布后进行数据分析(为使结果简明仍以变换前数据表示)。计量资料组间比较采用One-Way ANOVA检验,组内比较采用t检验,不符合正态分布的指标采用Manner Whitney u检验。计数资料采用χ2检验。变量间相关性采用Spearman相关系数定量法。以p<0.05为差异具有显著性意义。
采用SPSS10.0软件包绘制应用受试者工作特征ROC曲线(receiver operating characteristic curve, c-statistic),并比较和计算曲线下面积(area under the curve,AUC)。采用Z检验(MedCalc)比较各参数ROC曲线下面积。采用两样本率比较的正态近似法比较各个预测指标的敏感度、特异度及诊断准确度。采用函数法确定各指标的最佳截断点(cutoff point),即敏感度和特异度之和取最大值时所代表的诊断截断值作为最佳截断点(cutoff point)。AUC在0.5-0.7时有较低的准确性,AUC在0.7-0.9时有一定的准确性,AUC超过0.9有较高准确性。AUC=0.5时,说明诊断方法完全不起作用,无诊断价值。应用多变量观察值logistic回归的ROC曲线分析评价四种炎症反应指标联合预测价值。
结果：
1.一般临床资料和实验检测指标
67例急性心肌梗死合并糖尿病患者住院期间共有18例(A组,27%)发生主要不良事件,其中心源性猝死8例,心源性休克2例,急性左心衰2例,需要干预的室速1例、Ⅲ°房室传导阻滞1例,室颤3例,再次心肌梗死1例。A、B二组间年龄、高血压史、吸烟史、血脂、hs-CRP等无显著性差异。患者入院时体温、心率、呼吸频率、WBC、GS、Cr与主要不良事件发生率存在相关性。入院时单次测量心肌酶谱(cTnI, CK-MB及Myo)亦不能预测主要不良事件的发生。
2.体温对AMI近期预后的预测价值
ROC曲线下面积=0.757±0.064,P=0.000,表明预测准确性较高,具有较高的临床预测价值。最佳界点(T<=36.0℃)预测急性心肌梗死合并糖尿病患者院内主要不良事件的敏感度为77.8%,特异度70.0%。
3.心率对AMI近期预后的预测价值
ROC曲线下面积=0.712±0.077,P=0.01,表明预测准确性较高,具有一定的临床预测价值。最佳界点(HR>83bpm)预测急性心肌梗死合并糖尿病患者院内主要不良事件的敏感度为66.7%,特异度67.5%。
4.呼吸频率对AMI近期预后的预测价值
ROC曲线下面积AUC=0.779±0.071,P=0.045(与AUC=0.5比较),表明预测准确性较高,具有较高的临床预测价值。最佳界点(RR>21bpm)预测急性心肌梗死合并糖尿病患者院内主要不良事件的敏感度为50.0%,特异度97.5%。
5.WBC对AMI近期预后的预测价值
AUC=0.664±0.080,P=0.01,(与AUC=0.5比较),表明有一定的预测能力,具有临床预测价值。最佳界点(WBC>11.5万/μl)预测急性心肌梗死合并糖尿病患者院内主要不良事件的敏感度为38.9%,特异度100.0%。
6.四个协变量对急性心肌梗死合并糖尿病患者院内主要不良事件的预测价值
作为急性心肌梗死合并糖尿病预后的预测指标,四个协变量(T、HR、RR、WBC)联合预测的ROC曲线下面积为0.88,且差异有统计学意义(与AUC0.5比较),说明诊断准确性较高,具有极高的临床预测价值。相比单指标(单协变量WBC AUC为0.66),联合指标提高了预测效能。二者AUC比较,p=0.026,差异有显著性。
7.炎症反应积分与住院期间主要不良事件发生率的关系
炎症反应积分：按照以上ROC曲线获得的最佳界点值,将病人入院时T、HR、RR及WBC进行计分,存在其中一项为1分,将炎症反应严重度评为0～4分。
卡方检验发现炎症反应积分与住院期间主要不良事件发生率存在相关性。炎症反应积分0～1组主要不良事件发生率为18.2%,炎症反应积分2～4组主要不良事件发生率为71.4%,二组之间比较,p=0.000,有统计学差异。炎症反应积分2～4组院内主要不良事件发生率明显高于炎症反应积分0～1组,优势比(odds ratio)为11.25(2.80,45.16),p=0.000。炎症反应积分0～1可判别为低危病人,炎症反应积分2～4可预测高度危险病人。
结论：
1.入院时体温、心率、呼吸频率及外周血白细胞计数可以预测急性心肌梗死合并糖尿病患者院内主要不良事件的发生率。
2.本研究首次建立的评价方法简单、易行。炎症反应积分0～1可判别为低危病人,炎症反应积分2～4可判别为高危病人。采用本研究建立的全身炎症反应积分预测急性心肌梗死患者院内预后,给护理人员开展健康教育与心理指导提供显而易见的数据,使病情风险预警时间提前,便于医生早期采取治疗措施。
3.体温、心率、呼吸频率及外周血白细胞计数联合指标预测预后准确性较高,具有极高的临床预测价值。与单一指标相比,联合指标提高了预测效能。
PART I Relationship between Platelet Parameters and C-reaction Protein in Patients with Coronary Heart Disease and Impaired Glucose Tolerance
Objective:
Impaired Glucose Tolerance and Type2diabetes are very frequent in Coronary Heart Disease. Activated platelet plays an important role in atherosclerosis, thrombosis, and inflammation. The platelet in patients with Type2diabetes also called "diabetic platelet".C-reaction protein plays an important role in the developmental progress of atherosclerosis and type2diabetes. There were few reports on platelet function and C-reaction protein in the stage of impaired glucose tolerance in patients with coronary artery disease. The aim of this study was to investigate the change of platelet parameters and C-reaction protein in patients with coronary Heart disease and impaired glucose tolerance.
Methods:
This study cohort included39consecutive patients with patients with coronary Heart disease and impaired glucose tolerance. These patients come from the (Acarbose Cardiovasculer Evaluation)ACE test in Renmin hospital of Wuhan University from Dec2009～Sep2012. These patient was divided into group A included25men and14women, aged50～76years(63±8ys). Group B (normal control group) included patients with PSVT (Paroxysmal supraventricular tachycardia),10men and7women, aged50～71years(62±5ys).These patients received RFCA(Catheter radiofrequency Ablation operation in2nd department of Cardiology, Renmin Hospital of Wuhan university from Sep2011to Sep2012, with age above50ys. The observed parameters were collected at initial admission. These parameters included sex,age,history,CTnI, CK-MB, Myo)、oral glucose tolerance tes、TC, TG, HDL, LDL, Lpa,hs-CRP,blood parametes,EKG,reports of SCA or coronary CA.
Statistical analysis:Results were presented as±SD for continuous normally distributed variables, as median for continuous non-normally distributed data, and as percentages for categorical data. Significance was assumed with a two-sided p value of below0.05. We tested continuous variables by one-way ANOVA for between-group comparisons and Student's t-test for within-group comparisons. If a normal distribution of variables was not presented, the Mann-Whitney Test was used for testing treatment-group differences and the Coefficients of correlation (r) were calculated by the Spearman's rho correlation analysis. The data were analyzed using SPSS for windows10.0(SPSS Inc.).
Results:
1. The subjects in group A had higher levels of fasting plasma glucose and lower levels of high-density lipoprotein cholesterol compared with subjects in group B.
2. The subjects in group A had higher levels of MPV、PDW、P-LCR and hsCRP and lower levels of PLT compared with subjects in group B.
3. Spearman's rho correlation analysis revealed that there were relationships between platelet parameters and hsCRP in patients with coronary Heart disease and impaired glucose tolerance, respectively. PLT was negatively related to MPV、PDW and P-LCR. There were positive relationships between P-LCR、PDW and MPV. The levels of hsCRP were negatively related with PLT and positively related with MPV、 PDW and P-LCR.
Conclusions:
1. There are higher levels of platelet activity and hsCRP in patients with coronary Heart disease and impaired glucose tolerance compared with normal control group. The high levels of platelet activity and hsCRP may induce coronary atherosclerosis and thrombosis.
2. The relationships between platelet parameters and hsCRP in patients with coronary Heart disease and impaired glucose tolerance imply cooperative effects in the development of atherosclerosis. This should be paid attention.
PART Ⅱ:Relationship between Platelet Parameters and C-reaction Protein in Patients with Coronary Heart Disease and Diabetes Mellitus
Objective:
The disorders of glucose metabolism in coronary heart disease are more frequent in P.R.China than in west countries. The combined presence of disorders of glucose metabolism and coronary heart disease is up to80%. The proportion of abnormal glucose metabolism in patients with acute myocardial infarction is very high. The most glucose metabolism disorders are caused by persistent hyperglycemia, rather than a transient hyperglycemia induced by stress. Activated platelet plays an important role in atherosclerosis, thrombosis, and inflammation. The platelet in patients with Type2diabetes also called "diabetic platelet". In recent years, studies have shown that platelet coagulation is still involved in the inflammatory response. C-reactive protein is a non-specific marker of the systemic inflammatory response. Serum C-reactive protein concentrations may reflect inflammatory mediator activities in vivo. And they are proportional to the degree of inflammation and tissue damage. CRP is the most reliable atherosclerosis inflammatory markers. The study on platelet parameters and C reactive protein in patient with coronary heart disease combined with diabetes mellitus is few. In the first part of this study, we performed the study on the relationship between platelet parameters and hsCRP in patients with coronary heart disease and abnormal glucose tolerance, and we found high platelet activity and C reactive protein levels, and the relationship in patients with coronary heart disease and impaired glucose tolerance. This part of study will further detect blood platelet parameters, hsCRP and serum lipids in patients with coronary artery disease combined with type2diabetes.
Methods:
This study included group A (patients with coronary artery disease combined with type2diabetes) and group B (patients with coronary artery disease and without type2diabetes).98consecutive patients with patients with coronary heart disease and T2MD and112consecutive patients with coronary heart disease and without T2MD. These patients come from the inpatients in2nd department of Cardiology, Renmin hospital of Wuhan University from Aug2009-Aug2012. These210patients included173men and37women, aged34～87years(61±12ys). The observed parameters were collected at initial admission. These parameters included sex,age,history,CTnI, CK-MB, Myo)、 oral glucose tolerance test, TC, TG, HDL, LDL, Lpa, hs-CRP,blood parametes,EKG, reports of SCA or coronary CA. Statistical analysis:Results were presented as x±SD for continuous normally distributed variables, as median for continuous non-normally distributed data, and as percentages for categorical data. Significance was assumed with a two-sided p value of below0.05. We tested continuous variables by one-way ANOVA for between-group comparisons and Student's t-test for within-group comparisons. If a normal distribution of variables was not presented, the Mann-Whitney Test was used for testing treatment-group differences and the Coefficients of correlation (r) were calculated by the Spearman's rho correlation analysis. The data were analyzed using SPSS for windows10.0(SPSS Inc.).
Results:
1. The subjects in group A had higher levels of fasting plasma glucose, higher proportion of women compared with subjects in group B.
2. The subjects in group A had higher levels of MPV、PDW、P-LCR and hsCRP, and lower levels of PLT compared with subjects in group B.
3. Spearman's rho correlation analysis revealed that there were relationships between platelet parameters and hsCRP in patients with coronary Heart disease and T2DM, respectively. PLT was negatively related to MPV、PDW and P-LCR. There were positive relationships between P-LCR、PDW and MPV. The levels of hsCRP were negatively related with PLT and positively related with MPV、PDW and P-LCR.
Conclusions:
1. There are higher levels of platelet activity and hsCRP in patients with coronary Heart disease and T2DM compared with normal control group. The high levels of platelet activity and hsCRP may induce coronary atherosclerosis and thrombosis.
2. The relationships between platelet parameters and hsCRP in patients with coronary heart disease and T2DM imply cooperative effects in the development of atherosclerosis. This should be paid attention.
Part III:A New Simplified Immediate System Inflammatory Score for Type2Diabetic Patients Presenting with ST-segment Elevation Acute Myocardial Infarction
Objective:
Patients with diabetic mellitus have worse outcomes after acute myocardial infarction (AMI) occurs than non-diabetics. The body condition changes fast in patients with T2DM and AMI and the arrhythmia, heart failure and sudden death extremely easily occur, so the prognosis is usually poor. The prognosis assessment for patients with T2MD and acute myocardial infarction should be paid more and more attention. Early prediction of the degree of risk for new admissions of patients with acute myocardial infarction can guide the next step of the examination and treatment programs and help to reduce the incidence of complications during hospitalization. The early systemic inflammatory response variables (body temperature, heart rate, respiratory rate, and white blood cell count) were collected in diabetic patients with acute myocardial infarction in this study. The ROC curves were drawn to evaluate the power of various systematic inflammatory response variables and discriminatory combining power of4variables to predict the prognosis of patients with acute myocardial infarction.
Methods:
This study cohort included67consecutive diabetic patients with STEMI during8hours from symptom onset. These diabetic patients with STEMI,53men and14women, aged34～83years(63±15ys), were admitted to the department of cardiology in Renmin Hospital of Wuhan University between Dec2007and Sep2012. An inflammatory score model was developed for predicting in-hospital major adverse events using parameters available at initial admission. These parameters including sex,age,history,CTnI, CK-MB, Myo、TC, TG, HDL, LDL, Lpa, hs-CRP,blood parametes, EKG, reports of SCA or coronary CA.body temperature, heart rate and respiratory rate were collected at admission.
Statistical analysis:Results were presented as x±SD for continuous normally distributed variables, as median for continuous non-normally distributed data, and as percentages for categorical data. Significance was assumed with a two-sided p value of below0.05. We tested continuous variables by one-way ANOVA for between-group comparisons and Student's t-test for within-group comparisons. If a normal distribution of variables was not presented, the Mann-Whitney Test was used for testing treatment-group differences and the Coefficients of correlation (r) were calculated by the Spearman's rho correlation analysis. The data were analyzed using SPSS for windows10.0(SPSS Inc.). ROC(receiver operating characteristic) curves analysis was used to analyze the efficacy of the body temperature, heart rate, respiratory rate and white cell count in the prognosis in diabetic acute myocardial infarction.
Results:
ROC curves (receiver operating characteristic curve, c-statistic) analysis revealed that body temperature, heart rate, respiratory rate and white cell count can predict in-hospital major adverse events with AUC0.757±0.064,0.712±0.077,0.779±0.071, and0.664±0.080, p<0.05, respectively. ROC curves analysis also revealed that the combining predictive ability of the four parameters was strong (c=0.88) and it is better than single variable predictive ability.
An inflammatory score model was developed using the four parameters above to predict in-hospital major adverse events according to the best cutoff values as fellow:(1) BT<=36.℃;(2) HR>83bpm;(3) RR>21bpm; and (4) WBC>11.5×109/L. There was a relationship between inflammatory scores and in-hospital major adverse events (p=0.000)。The rate of major adverse events with score2～4was higher than that with score0～1,71.4%vs.18.2%, p=0.000. The odds ratio(OR) was11.25(2.80,45.16),p=0.000。These patients with score0～1could be classified into low-risk person, while these patients with score2～4could be classified into high-risk person.
Conclusions:
1. The parameters including body temperature, heart rate, respiratory rate and white cell count which were collected on admission can predict major adverse events post-AMI in Type2diabetics.
2. The simple systematic inflammatory score for major adverse events post-AMI in Type2diabetics showed excellent predictive capacity in a population based on cohort of patients with STEMI during8hours from symptom setup.
引文
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[4]中华医学会糖尿病学分会.中国2型糖尿病防治指南.中华医学杂志2008；8(18)：1227-45.
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