Predictive value of glycemic gap in predicting nosocomial major adverse cardiovascular events in patients with acute myocardial infarction
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摘要:目的
探讨血糖间隙对急性心肌梗死(AMI)患者院内主要不良心血管事件(MACE)的预测价值。
方法收集2020年10月—2021年5月医院294例AMI患者的临床资料及实验室指标，入院后即刻检测静脉血糖及糖化血红蛋白水平。根据住院期间MACE发生情况将患者分为MACE组和非MACE组。采用单因素及多因素Logistic回归分析影响AMI患者发生MACE的危险因素; 探讨血糖间隙与不良事件的相关性; 采用受试者工作特征(ROC)曲线的曲线下面积(AUC)分析血糖间隙、入院血糖对AMI患者院内发生MACE的预测价值，并评价血糖间隙增强急性冠状动脉事件全球注册评分(GRACE评分)预测AMI患者院内MACE的效能。
结果与非MACE组相比, MACE组血糖间隙及入院血糖增高，差异有统计学意义(P<0.05)。多因素回归分析显示，血糖间隙、入院血糖是AMI患者发生MACE的独立危险因素。ROC曲线表明，血糖间隙及入院血糖对患者院内MACE的发生均有一定的预测价值，其中血糖间隙的AUC为0.750, 最佳临界值为1.511 mmol/L, 敏感度为66.7%, 特异度为74.1%。血糖间隙、GRACE评分单独及联合预测AMI患者院内发生MACE的AUC分别为0.750、0.833、0.859(P<0.05)。
结论血糖间隙与AMI患者的预后相关，能够提高GRACE评分对AMI患者发生MACE的预测价值。
Abstract:ObjectiveTo investigate the value of glycemic gap in predicting nosocomial major adverse cardiovascular events (MACE) in patients with acute myocardial infarction (AMI).
MethodsClinical materials and laboratory indexes of 294 patients with AMI in hospital from October 2020 to May 2021 were collected, they were conducted with detection of venous blood glucose and glycosylated hemoglobin immediately after hospital admission. According to the occurrence of MACE during hospitalization, the patients were divided into MACE group and non-MACE group. Univariate and multivariate Logistic regression were used to analyze the risk factors of MACE in patients with AMI; correlation between glycemic gap and adverse events was discussed; the area under the curve (AUC) of the receiver operating characteristic (ROC) curve was used to analyze the value of glycemic gap and blood glucose at hospital admission in predicting nosocomial MACE in patients with AMI, and the efficacy of glycemic gap in enhancing Global Registry for Acute Coronary Events score (GRACE score) for prediction of nosocomial MACE in patients with AMI was evaluated.
ResultsCompared with the non-MACE group, the glycemic gap and blood glucose at hospital admission in the MACE group were significantly higher (P<0.05). Multivariate regression analysis showed that the glycemic gap and blood glucose at hospital admission were the independent risk factors for MACE in patients with AMI. The ROC curve showed that both the glycemic gap and the blood glucose at hospital admission have a certain predictive value for occurrence of nosocomial MACE, AUC of glycemic gap was 0.750, the optimum critical value was 1.511 mmol/L, the sensitivity was 66.7%, and the specificity was 74.1%. The AUC values of glycemic gap alone, the GRACE score alone and combination of two indexes in predicting occurrence of nosocomial MACE in patients with AMI were 0.750, 0.833 and 0.859, respectively (P<0.05).
ConclusionGlycemic gap is related to the prognosis of patients with AMI, which can increase the value of the GRACE score in predicting occurrence of MACE in patients with AMI.
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表 1 MACE组与非MACE组患者临床基线资料比较(x±s)[n(%)]
基线资料 非MACE组(n=243) MACE组(n=51) 年龄/岁 61.64±13.24 69.33±11.11* 男性 199(81.89) 34(66.67)* 高血压 116(47.74) 23(45.10) 糖尿病 60(24.69) 17(33.33) 血脂异常 101(41.56) 16(31.37) 体质量指数/(kg/m2) 25.33±4.00 25.66±3.47 收缩压/mmHg 132.23±20.04 136.63±24.54 急性ST段抬高型心肌梗死 196(80.66) 46(90.20) 白细胞计数/(×109/L) 10.27±3.14 11.02±3.09 中性粒细胞/(×109/L) 8.51±2.20 8.82±2.17 血红蛋白/(g/L) 143.57±16.93 135.45±17.23* 入院血糖/(mmol/L) 7.56±3.21 8.57±3.62* 糖化血红蛋白/% 6.43±1.49 6.28±1.15 血糖间隙/(mmol/L) 0.92±2.34 2.98±2.82* 总胆固醇/(mmol/L) 4.36±1.01 4.40±1.15 甘油三酯/(mmol/L) 1.64±1.36 1.52±0.64 低密度脂蛋白胆固醇/(mmol/L) 2.74±0.89 2.88±1.03 高密度脂蛋白胆固醇/(mmol/L) 1.52±0.28 1.49±0.24 血肌酐/(μmol/L) 99.80±39.50 107.70±40.10 血钾/(mmol/L) 4.09±0.50 4.11±0.55 NT-proBNP/(pg/mL) 2 321.53±895.21 6 608.71±2 095.72* 超敏肌钙蛋白T峰值/(ng/L) 3 112.56±2 160.53 4 481.62±3 480.98 CK-MB峰值/(ng/mL) 113.21±76.32 165.82±91.22* LVEF/% 54.64±5.26 47.69±7.70* Killip分级Ⅱ~Ⅳ级 35(14.40) 24(47.06)* 多支病变或左主干病变 176(72.43) 45(88.24)* 住院时间/d 6.26±1.89 10.55±2.35* GRACE评分/分 148.97±30.66 193.24±37.08* MACE: 主要不良心血管事件; NT-proBNP: 氨基末端脑利钠肽前体; CK-MB: 肌酸激酶同工酶; LVEF: 左心室射血分数; GRACE评分: 急性冠状动脉事件全球注册评分。 
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表 2 影响院内发生MACE的多因素分析
指标 单因素分析 P 多因素分析 P OR(95%CI) OR(95%CI) 年龄/岁 1.051(1.024~1.080) 0.001 1.033(0.989~1.079) 0.155 入院血糖/(mmol/L) 1.098(1.017~1.181) 0.040 1.405(1.217~1.644) 0.048 血糖间隙/(mmol/L) 1.322(1.177~1.484) 0.001 1.492(1.130~1.970) 0.005 血红蛋白/(g/L) 0.973(0.956~0.991) 0.003 1.010(0.981~1.039) 0.511 CK-MB峰值/(ng/mL) 2.172(1.771~3.015) 0.002 1.332(1.172~1.583) 0.024 NT-proBNP/(pg/mL) 1.781(0.756~2.102) 0.188 — — LVEF/% 0.833(0.786~0.833) 0.001 0.859(0.799~0.924) 0.001 Killip分级Ⅱ~Ⅳ级 5.283(2.741~10.182) 0.001 3.456(1.304~9.208) 0.013 多支病变或左主干病变 2.855(1.164~7.002) 0.022 1.495(1.381~7.278) 0.704 GRACE评分/分 1.036(1.025~1.047) 0.001 1.108(1.071~1.146) 0.001 CK-MB: 肌酸激酶同工酶; NT-proBNP: 氨基末端脑利钠肽前体; LVEF: 左心室射血分数; GRACE评分: 急性冠状动脉事件全球注册评分。
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表 3 血糖间隙与院内MACE的关系(x±s)[n(%)]
指标 血糖间隙<1.511 mmol/L(n=197) 血糖间隙≥1.511 mmol/L(n=97) 年龄/岁 62.28±13.40 64.39±12.75 男性 162(82.23) 71(73.20) 高血压 90(45.69) 49(50.52) 糖尿病 45(22.84) 32(32.99) NT-proBNP/(pg/mL) 2 521.53±995.21 6 402.75±2 395.70* GRACE评分/分 150.70±31.65 168.72±41.00* Killip分级Ⅱ~Ⅳ级 25(12.69) 34(35.05)* LVEF/% 54.18±5.44 51.92±7.63* 多支病变或左主干病变 141(71.57) 80(82.47)* MACE 17(8.63) 34(35.05)* 死亡 2(1.02) 8(8.25)* 心源性休克 8(4.06) 16(16.49)* 恶性心律失常 4(2.03) 13(13.40)* 急性心力衰竭 15(7.61) 25(25.77)* NT-proBNP: 氨基末端脑利钠肽前体; GRACE评分: 急性冠状动脉事件全球注册评分; LVEF: 左心室射血分数; MACE: 主要不良心血管不良事件。
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表 4 血糖间隙联合GRACE评分预测AMI患者院内MACE的ROC曲线分析
变量 AUC 敏感度/% 特异度/% 95%CI P 血糖间隙 0.750 66.7 74.1 0.678~0.821 0.001 GRACE评分 0.833 86.3 67.5 0.772~0.895 0.001 联合 0.859 86.5 74.5 0.807~0.911 0.001
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