ST段抬高型心肌梗死患者微血管阻塞与心脏磁共振测定的整体和局部心肌功能的关系

doi:10.24920/004120

摘要/Abstract

摘要：

目的应用心脏磁共振特追踪技术（cardiac magnetic resonance feature-tracking，CMR-FT）探讨微血管阻塞（microvascular obstruction，MVO）对ST段抬高型心肌梗死（ST segment-elevation myocardial infarction，STEMI）患者整体和局部心功能的影响。

方法回顾性连续纳入经皮冠状动脉介入术治疗成功后且1~7 天进行心脏磁共振（cardiac magnetic resonance，CMR）检查的急性STEMI 患者。依据延迟钆增强成像（late gadolinium enhancement，LGE）将患者分为MVO阳性组和MVO阴性组。参照左心室16节段模型，将左心室心肌分为梗死区、邻近区和遥远区。利用CMR-FT，在电影图像上分别测量左心室整体以及梗死区、邻近区和遥远区的径向应变（radial strain，RS)、周向应变（circumferential strain，CS）及纵向应变（longitudinal strain，LS)，并且采用独立样本t检验比较MVO阳性和MVO阴性患者之间的差异。Logistic回归分析用于探究MVO与LV功能受损的关联。

结果在157名STEMI患者（平均年龄 56.66 ± 11.38 岁）中，发现59例MVO阳性患者（37.58%），且MVO阳性组平均MVO面积为3.00±3.76mL。与MVO阴性患者（n=98）相比，MVO阳性患者LV整体RS（t = -4.30，P<0.001）、整体CS（t = 4.99，P<0.001）、整体LS（t=3.51，P = 0.001）显著降低。MVO阳性患者梗死区RS（t = -3.38，P=0.001）和CS（t = 2.64，P=0.01）相较于MVO阴性的患者显著降低，梗死面积显著增大（t = 8.37，P<0.001）。在单变量Logistic 回归分析中，发生LV MVO [OR= 4.10, 95%CI：2.05~8.19，P<0.001) 、MVO面积[OR=1.38, 95%CI：1.10~1.72，P=0.01]、心率以及LV梗死面积与CS受损显著相关。然而，在多变量Logistic回归分析中只有心率（OR=1.08，95%CI：1.03~1.13，P=0.001）和LV梗死面积（OR=1.10，95% CI：1.03~1.16，P=0.003）是LV整体CS受损的独立影响因素。

结论 MVO阳性的STEMI患者心肌梗死面积较大，并且MVO可使左心室整体和局部心功能恶化。

关键词: 心脏磁共振特征追踪技术, ST段型抬高型心肌梗死, 微血管阻塞, 心肌应变

Abstract:

Objective To investigate the impact of microvascular obstruction (MVO) on the global and regional myocardial function by cardiac magnetic resonance feature-tracking (CMR-FT) in ST-segment-elevation myocardial infarction (STEMI) patients after percutaneous coronary intervention.

Methods Consecutive acute STEMI patients who underwent cardiac magnetic resonance imaging 1 - 7 days after successful reperfusion by percutaneous coronary intervention treatment were included in this retrospective study. Based on the presence or absence of MVO on late gadolinium enhancement images, patients were divided into groups with MVO and without MVO. The infarct zone, adjacent zone, and remote zone were determined based on a myocardial 16-segment model. The radial strain (RS), circumferential strain (CS), and longitudinal strain (LS) of the global left ventricle (LV) and the infarct, adjacent, and remote zones were measured by CMR-FT from cine images and compared between patients with and without MVO using independent-samples t-test. Logistic regression analysis was used to assess the association of MVO with the impaired LV function.

Results A total of 157 STEMI patients (mean age 56.66 ± 11.38 years) were enrolled. MVO was detected in 37.58% (59/157) of STEMI patients, and the mean size of MVO was 3.00 ±3.76 mL. Compared with patients without MVO (n =98 ), the MVO group had significantly reduced LV global RS (t= -4.30, P < 0.001), global CS (t= 4.99, P < 0.001), and global LS ( t= 3.51, P = 0.001). The RS and CS of the infarct zone in patients with MVO were significantly reduced (t= -3.38, P = 0.001; t= 2.64, P = 0.01; respectively) and the infarct size was significantly larger (t= 8.37, P < 0.001) than that of patients without MVO. The presence of LV MVO [OR= 4.10, 95%CI: 2.05 - 8.19, P<0.001) and its size [OR=1.38, 95%CI: 1.10-1.72, P=0.01], along with the heart rate and LV infarct size were significantly associated with impaired LV global CS in univariable Logistic regression analysis, while only heart rate (OR=1.08, 95%CI: 1.03 - 1.13, P=0.001) and LV infarct size (OR=1.10, 95%CI: 1.03 - 1.16, P=0.003) were independent influencing factors for the impaired LV global CS in multivariable Logistic regression analysis.

Conclusion The infarct size was larger in STEMI patients with MVO, and MVO deteriorates the global and regional LV myocardial function.

Key words: cardiac magnetic resonance feature tracking, ST-segment elevation myocardial infarction, microvascular obstruction, myocardial strain, Myocardial function

Ya-Nan Zhao, Jia-Ning Cui, Xing-Hua Zhang, Jin-Feng Li, Shi-Min Chen, Xiu-Zheng Yue, Tao Li. Relationship of Microvascular Obstruction with Global and Regional Myocardial Function Determined by Cardiac Magnetic Resonance after ST-Segment Elevation Myocardial Infarction[J].Chinese Medical Sciences Journal, 2023, 38(1): 11-19.

图/表 6

参考文献 29

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Items	All patients (n = 157)	Patient with MVO (n = 59)	Patient without MVO (n = 98)	P value
Demographic characteristics
Age (yrs, mean ± SD)	56.66 ± 11.38	54.12 ± 11.63	58.18 ± 11.01	0.03
Gender [male n (%)]	136 (86.6)	53 (89.8)	83 (84.7)	0.36
Body mass index [kg/m², mean ± SD]	25.68 ± 3.43	25.76 ± 3.20	25.63 ± 3.57	0.49
Clinical parameters
Family history of CAD [n (%)]	15 (9.6)	5 (8.5)	10 (10.2)	0.72
Hypertension [n (%)]	79 (50.3)	28 (47.5)	51 (52.0)	0.58
Hypercholesterolemia [n (%)]	33 (21.0)	17 (28.8)	16 (16.3)	0.63
Diabetes mellitus [n (%)]	23 (14.6)	11 (18.6)	12 (12.2)	0.27
Smoking [n (%)]	103 (65.6)	42 (71.2)	61 (62.2)	0.25
Drinking [n (%)]	37 (23.6)	13 (22.0)	24 (24.5)	0.73
Heart rate (beats/min, mean ± SD)	71.29 ± 11.61	73.59 ± 11.97	69.91 ± 11.22	0.054
Killip class >Ⅰ [n (%)]	16 (10.2)	7 (11.9)	9 (9.2)	0.59
Multivessel disease [n (%)]	101 (64.3)	36 (60.1)	65 (66.3)	0.501
Infarct related artery [n (%)]				0.52
Left anterior descending artery	69 (43.94)	28 (47.46)	41 (41.84)
Right coronary artery	70 (44.59)	22 (37.29)	48 (48.98)
Left circumflex artery	18 (11.46)	6 (10.17)	12 (12.24)
TIMI flow pre PCI < 3 [n (%)]	148 (94.3)	58 (98.3)	90 (91.8)	0.06
TIMI flow post PCI < 3 [n (%)]	2 (1.3)	1 (1.7)	1 (1.0)	0.72
Blood test results
NT-proBNP (pg/mL, mean ± SD)	1,616.01 ± 1,552.90	1,838.72 ± 2,118.44	1,481.92 ± 1,070.77	0.23
Maximum CK-MB (U/L, mean ± SD)	233.28 ± 163.89	317.34 ± 173.51	182.67 ± 135.31	<0.001
Peak troponin (mg/L, mean ± SD)	7.85 ± 7.84	12.65 ± 9.13	4.95 ± 5.15	<0.001
Medication [n (%)]
Aspirin	156 (99.4)	58 (98.3)	98 (100)	0.16
Statin	156 (99.4)	59 (100)	97 (99.0)	0.33
ACEI/ARB	70 (44.6)	21 (35.6)	49 (50.0)	0.08
Beta-blockers	135 (86.0)	50 (84.7)	85 (86.7)	0.73
Diuretic	76 (48.4)	31 (52.5)	45 (45.9)	0.42

Items	All Patients (n = 157)	Patient with MVO (n = 59)	Patient without MVO (n = 98)	t value	P value^*
LV EDVI (mL/m²)	80.81 ± 18.94	83.31 ± 16.07	79.30 ± 20.40	1.29	0.20
LV ESVI (mL/m²)	43.44 ± 13.40	47.39 ± 13.04	41.06 ± 13.11	2.94	0.004
LV myocardial mass index (g/m²)	59.83 ± 11.61	62.24 ± 9.42	58.37 ± 12.58	2.04	0.04
LV infarct size (mL)	24.96 ± 16.18	36.55 ± 16.55	17.97 ± 11.23	8.37	<0.001
LVEF (%)	46.14 ± 9.23	43.01 ± 9.45	48.02 ± 8.61	-3.41	0.001
LV global WTR (%)	44.25 ± 13.64	40.21 ± 11.62	46.68 ± 14.23	-2.95	0.004
LV GRS (%)	22.70 ± 5.84	20.25 ± 4.75	24.17 ± 5.96	-4.30	<0.001
LV GCS (%)	-14.19 ± 2.80	-12.85 ± 2.52	-14.99 ± 2.66	4.99	<0.001
LV GLS (%)	-11.95 ± 3.28	-10.80 ± 3.39	-12.64 ± 3.03	3.51	0.001
Infarct zone RS (%)	14.46 ± 7.77	12.05 ± 5.83	15.92 ± 8.42	-3.38	0.001
Infarct zone CS (%)	-9.99 ± 5.49	-8.53 ± 4.83	-10.87 ± 5.70	2.64	0.01
Infarct zone LS (%)	-7.34 ± 4.48	-7.13 ± 3.65	-7.47 ± 4.93	0.46	0.65
Adjacent zone RS (%)	22.52 ± 7.59	22.90 ± 7.07	22.29 ± 7.92	0.49	0.63
Adjacent zone CS (%)	-14.71 ± 3.93	-14.42 ± 3.48	-14.89 ± 4.18	0.73	0.47
Adjacent zone LS (%)	-7.25 ± 4.18	-6.50 ± 3.46	-7.69 ± 4.51	1.75	0.08
Remote zone RS (%)	30.31 ± 9.85	31.94 ± 9.84	29.33 ± 9.78	1.62	0.11
Remote zone CS (%)	-17.30 ± 4.39	-17.20 ± 3.99	-17.36 ± 4.63	0.22	0.83
Remote zone LS (%)	-5.15 ± 9.67	-3.60 ± 8.98	-6.09 ± 9.99	1.57	0.12

Items	Univariate Logistic regression		Multivariate Logistic regression
Items	P value	OR [95%CI]	P value	OR [95%CI]
Age (yrs)	0.81	1.00 (0.97 - 1.03)
Gender (Male)	0.06	2.65 (0.97 - 7.24)
Body mass index (kg/m²)	0.27	1.05 (0.96 - 1.16)
Family history of CAD	0.15	2.30 (0.75 - 7.08)
Hypertension	0.23	1.47 (0.78 - 2.76)
Hypercholesterolemia	0.25	0.63 (0.29 - 1.38)
Diabetes mellitus	0.70	1.19 (0.49 - 2.89)
Smoking	0.09	1.80 (0.92 - 3.52)
Drinking	0.06	2.08 (0.98 - 4.42)
Killip class >Ⅰ	0.24	1.89 (0.65 - 5.49)
Heart rate	0.001	1.06 (1.02 - 1.09)	0.001	1.08 (1.03 - 1.13)
Culprit lesion in the LAD (%)	<0.001	3.25 (1.69 - 6.27)
NT-proBNP (pg/mL)	0.01	1.00 (1.00 - 1.00)
Maximum CK-MB (U/L)	<0.001	1.01 (1.00 - 1.01)
Peak troponin (mg/L)	<0.001	1.12 (1.06 - 1.20)
LV EDVI	0.35	1.01 (0.99 - 1.03)
LV ESVI	<0.001	1.08 (1.05 - 1.12)
LV myocardial mass index (g/m²)	<0.001	1.08 (1.04 - 1.12)
LV infarct size (mL)	<0.001	1.11 (1.07 - 1.15)	0.003	1.10 (1.03 - 1.16)
Presence of LV MVO (%)	<0.001	4.10 (2.05 - 8.19)
LV MVO size (mL)	0.01	1.38 (1.10 - 1.72)

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