Prediction of Major Adverse Cardiovascular Events Following PCI in NSTEMI Patients Using Combined Myocardial Contrast Echocardiography and Three-dimensional Speckle Tracking Imaging
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摘要:
目的 探讨心肌超声造影心动图（myocardial contrast echocardiography，MCE）联合三维斑点追踪成像（three-dimensional speckle tracking imaging，3D-STI）对非ST段抬高型心肌梗死（non-ST-segment elevation myocardial infarction，NSTEMI）患者经皮冠状动脉介入治疗（percutaneous coronary intervention，PCI）术后主要心血管不良事件（major adverse cardiovascular events，MACEs）的预测作用。 方法 选取2022年5月至2024年3月中国人民解放军联勤保障部队第九二八医院254例NSTEMI患者，行PCI术，根据出院1年内MACEs发生情况分为MACEs组、无MACEs组，比较两组临床资料、常规超声心动图参数、MCE参数[平台期峰值强度（peak intensity，A）、灌注计分指数（perfusion score index，PSI）、曲线斜率（beta value，β）及心肌血流量（myocardial blood flow，A·β）]及3D-STI参数[左室整体面积应变（left ventricular global area strain，LVGAS）、左室整体环向应变（left ventricular global circumferential strain，LVGCS）、左室整体纵向应变（left ventricular global longitudinal strain，LVGLS）、左室整体径向应变（left ventricular global radial strain，LVGRS）]的差异；分析MCE、3D-STI参数与左室射血分数（left ventricular ejection fraction，LVEF）的关系；以受试者工作特征（receiver operating characteristic，ROC）曲线分析MCE、3D-STI参数预测MACEs的价值。 结果 与无MACEs组相比，MACEs组N末端脑钠肽前体（N-terminal pro-brain natriuretic peptide，NT-proBNP）、白介素-6（interleukin-6，IL-6）、可溶性生长刺激表达基因2蛋白（soluble suppression of tumorigenicity 2，sST2）较高，LVEF、血管内皮生长因子（vascular endothelial growth factor，VEGF）较低（P < 0.05）；术后3个月与无MACEs组相比，MACEs组A、β、A·β较低，PSI较高，两组A、PSI、β、A·β术后3个月-术后24 h差值比较有统计学意义（P < 0.05）；术后3个月MACEs组LVGAS、LVGCS、LVGLS、LVGRS均低于无MACEs组，两组LVGAS、LVGCS、LVGLS、LVGRS术后3个月-术后24 h差值比较有统计学意义（P < 0.05）；术后3个月MCE、3D-STI参数联合预测MACEs的AUC为0.933（95%CI：0.895～0.961），术后3个月-术后24 h MCE、3D-STI参数差值联合预测MACEs的AUC为0.915（95%CI：0.873～0.946）。 结论 MCE、3D-STI定量参数联合对NSTEMI患者PCI术后MACEs风险有较高预测价值，监测术后3个月-术后24 h MCE及3D-STI参数的动态变化，有助于早期识别高风险患者，为制定个体化治疗与随访策略提供依据。 -
关键词:
- 非ST段抬高型心肌梗死 /
- 心肌超声造影心动图 /
- 三维斑点追踪成像 /
- 经皮冠状动脉介入治疗 /
- 主要心血管不良事件
Abstract:Objective To investigate the predictive value of myocardial contrast echocardiography （MCE） combined with three-dimensional speckle tracking imaging （3D-STI） for major adverse cardiovascular events （MACEs） following percutaneous coronary intervention （PCI） in patients with non-ST-segment elevation myocardial infarction （NSTEMI）. Methods A total of 254 NSTEMI patients who underwent PCI at the 928th Hospital of the Joint Logistics Support Force, People's Liberation Army from May 2022 to March 2024 were selected. Patients were stratified into MACEs group and non-MACEs group based on the occurrence of MACEs within one year of discharge. Clinical data, conventional echocardiographic parameters, MCE parameters [peak intensity （A）, perfusion score index （PSI）, curve slope （β） and myocardial blood flow （A·β）] and 3D-STI parameters [left ventricular global area strain （LVGAS）, left ventricular global circumferential strain （LVGCS）, left ventricular global longitudinal strain （LVGLS）, left ventricular global radial strain （LVGRS）] were compared between the two groups. The relationships between MCE, 3D-STI parameters and left ventricular ejection fraction （LVEF） were analyzed. Receiver operating characteristic （ROC） curve were used to assess the predictive value of MCE and 3D-STI parameters for MACEs. Results Compared with the non-MACEs group, the MACEs group had higher levels of N-terminal pro-brain natriuretic peptide （NT-proBNP）, interleukin-6 （IL-6）, and soluble suppression of tumorigenicity 2 （sST2）, with lower LVEF and vascular endothelial growth factor （VEGF） levels （P < 0.05）. At 3 months post-operatively, the MACEs group showed lower A, β, A·β values, and higher PSI compared with the non-MACEs group, with significant differences in the changes of A, PSI, β, A·β from 3 months to 24 hours post-operatively between groups （P < 0.05）. At 3 months post-operatively, LVGAS, LVGCS, LVGLS and LVGRS were all lower in the MACEs group than in the non-MACEs group, with significant differences in the changes of these parameters from 3 months to 24 hours post-operatively （P < 0.05）. The combined AUC of MCE and 3D-STI parameters at 3 months post-operatively for predicting MACEs was 0.933 （95%CI: 0.895–0.961）, and the combined AUC using the differences in MCE and 3D-STI parameters between 3 months and 24 hours post-operatively was 0.915 （95%CI: 0.873–0.946）. Conclusion The combined quantitative parameters of MCE and 3D-STI demonstrate high predictive value for MACEs risk following PCI in NSTEMI patients. Monitoring dynamic changes in MCE and 3D-STI parameters from 3 months to 24 hours post-operatively is helpful for early identification of high-risk patients and provides evidence for developing individualized therapeutic and follow-up strategies. -
图 3 术后3个月MCE、3D-STI预测NSTEMI患者PCI术后MACEs风险的ROC曲线
Figure 3. ROC curve of MCE and 3D-STI at 3 months after PCI to predict the risk of MACEs in NSTEMI patients after PCI
图 4 MCE、3D-STI参数动态变化预测NSTEMI患者PCI术后MACEs风险的ROC曲线
Figure 4. ROC curve of dynamic changes of MCE and 3D-STI parameters in predicting the risk of MACEs after PCI in NSTEMI patients
表 1 两组一般资料与临床特征比较[n（%）/（$ \bar x \pm s $）]
Table 1. Comparison of general data and clinical characteristics between the two groups [n（%）/（$ \bar x \pm s $）]
资料 MACEs组（n = 63） 无MACEs组（n = 191） χ2/t P 性别（男/女） 37（58.73）/26（41.27） 102（53.40）/89（46.60） 0.543 0.461 年龄（岁） 63.18 ± 5.69 61.59 ± 5.83 1.888 0.060 体质量指数（kg/m2） 23.86 ± 1.13 24.11 ± 1.09 −1.564 0.119 高血压 30（47.62） 86（45.03） 0.128 0.720 糖尿病 18（28.57） 47（24.61） 0.391 0.532 血脂异常 25（39.68） 64（33.51） 0.794 0.373 吸烟 26（41.27） 67（35.07） 0.782 0.376 饮酒 19（30.16） 48（25.13） 0.617 0.432 发病至PCI术时间（h） 3.72 ± 0.64 3.61 ± 0.58 1.272 0.205 病变支数（支） 1.026 0.311 1 21（33.33） 51（26.70） ≥2 42（66.67） 140（73.30） 
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表 2 两组药物治疗及手术情况比较
Table 2. Comparison of drug treatment and surgical conditions between the two groups
资料 MACEs组（n = 63） 无MACEs组（n = 191） χ2/t P 药物治疗情况 他汀类药物 60（95.24） 186（97.38） 0.184 0.668 抗血小板 58（92.06） 183（95.81） 0.707 0.400 β受体阻滞剂 43（68.25） 136（71.20） 0.198 0.656 ACEI/ARB 51（80.95） 160（83.77） 0.267 0.605 手术情况 支架长度（mm） 25.18 ± 6.87 23.34 ± 7.10 1.798 0.073 支架直径（mm） 2.53 ± 0.72 2.67 ± 0.65 −1.443 0.150
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表 3 两组实验室指标及超声心动图参数比较
Table 3. Comparison of laboratory indicators and echocardiographic parameters between the two groups
资料 MACEs组（n = 63） 无MACEs组（n = 191） χ2/t P 实验室指标 NT-proBNP（ng/L） 448.91 ± 126.18 305.49 ± 93.65 9.620 < 0.001 IL-6（pg/mL） 14.57 ± 3.23 9.86 ± 2.42 12.268 < 0.001 sST2（ng/mL） 27.41 ± 7.75 22.16 ± 5.91 5.636 < 0.001 VEGF（pg/mL） 153.34 ± 31.25 185.67 ± 35.28 −6.481 < 0.001 常规超声心动图参数 LVEF（%） 53.74 ± 5.02 56.81 ± 4.63 −4.468 < 0.001 LVEDV（mL） 149.41 ± 34.92 147.63 ± 40.15 0.315 0.753
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表 4 两组MCE参数比较（$ \bar x \pm s $）
Table 4. Comparison of MCE parameters between the two groups （$ \bar x \pm s $）
参数 MACEs组（n = 63） 无MACEs组（n = 191） t P A（dB） 术后24 h 8.23 ± 2.25 8.34 ± 2.18 −0.345 0.731 术后3个月 10.62 ± 1.94 12.19 ± 2.05 −5.340 < 0.001 差值 2.39 ± 0.58 3.85 ± 1.12 −9.909 < 0.001 PSI 术后24 h 1.74 ± 0.52 1.81 ± 0.49 −0.968 0.334 术后3个月 1.42 ± 0.20 1.25 ± 0.21 5.637 < 0.001 差值 −0.32 ± 0.08 −0.56 ± 0.12 14.815 < 0.001 β（dB/s） 术后24 h 1.21 ± 0.31 1.18 ± 0.34 0.620 0.536 术后3个月 1.49 ± 0.24 1.68 ± 0.33 −4.215 < 0.001 差值 0.28 ± 0.08 0.50 ± 0.10 −15.861 < 0.001 A·β 术后24 h 9.96 ± 2.54 9.84 ± 2.49 0.330 0.742 术后3个月 15.82 ± 2.92 20.48 ± 4.03 −8.469 < 0.001 差值 5.86 ± 1.31 10.64 ± 2.17 −16.507 < 0.001
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表 5 两组3D-STI参数比较[（$ \bar x \pm s $）%]
Table 5. Comparison of 3D-STI parameters between the two groups [（$ \bar x \pm s $）%]
参数 MACEs组（n = 63） 无MACEs组（n = 191） t P LVGAS 术后24 h −18.25 ± 4.36 −18.91 ± 4.54 1.010 0.313 术后3个月 −24.36 ± 5.83 −31.60 ± 7.49 7.001 < 0.001* 差值 −6.11 ± 1.73 −12.39 ± 3.54 13.544 < 0.001* LVGCS 术后24 h −12.59 ± 3.40 −13.04 ± 6.63 0.516 0.606 术后3个月 −16.75 ± 4.16 −22.67 ± 5.63 7.679 < 0.001* 差值 −4.16 ± 1.08 −9.63 ± 2.13 19.553 < 0.001* LVGLS 术后24 h −10.81 ± 2.75 −11.24 ± 2.69 1.094 0.275 术后3个月 −14.49 ± 3.57 −19.71 ± 4.88 7.823 < 0.001* 差值 −3.68 ± 1.03 −8.47 ± 1.25 27.483 < 0.001* LVGRS 术后24 h 23.17 ± 6.10 23.84 ± 6.38 −0.731 0.466 术后3个月 30.55 ± 7.61 39.47 ± 9.82 −6.584 < 0.001* 差值 7.38 ± 1.36 15.63 ± 4.71 −13.699 < 0.001* *P < 0.05。
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表 6 术后3个月MCE、3D-STI对NSTEMI患者PCI术后MACEs风险的预测价值
Table 6. Predictive value of MCE and 3D-STI at 3 months after PCI for MACEs risk in NSTEMI patients after PCI
参数 AUC 95%CI 截断值 敏感度（%） 特异度（%） P MCE A 0.722 0.662～0.776 11.41 dB 60.32 74.35 < 0.001* PSI 0.744 0.686～0.796 1.34 79.39 63.35 < 0.001* β 0.712 0.652～0.767 1.59 dB/s 63.49 69.11 < 0.001* A·β 0.739 0.680～0.792 18.15 60.32 78.01 < 0.001* 3D-STI LVGAS 0.775 0.718～0.825 −26.94% 71.43 70.16 < 0.001* LVGCS 0.757 0.699～0.808 −17.59% 66.67 79.06 < 0.001* LVGLS 0.764 0.707～0.815 −17.26% 80.95 60.21 < 0.001* LVGRS 0.786 0.730～0.835 36.26% 79.39 61.78 < 0.001* *P < 0.05。
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表 7 各联合方案的预测价值分析
Table 7. Analysis of predictive value for various combination therapies
参数 AUC 95%CI 敏感度（%） 特异度（%） 阳性预测值（%） 阴性预测值（%） 阳性似然比 阴性似然比 MCE参数联合 0.841 0.790～0.884 74.60 83.25 49.73 93.86 4.45 0.30 3D-STI参数联合 0.874 0.827～0.912 88.89 73.82 45.22 96.15 3.40 0.15 MCE、3D-STI参数联合 0.933 0.895～0.961 82.54 90.05 65.39 95.49 8.29 0.19
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表 8 术后3个月-术后24 h MCE、3D-STI参数差值对MACEs风险的预测价值
Table 8. Predictive value of MCE and 3D-STI parameter difference between 3 months and 24 hours after operation for MACEs risk
指标差值 AUC 95%CI 截断值 敏感度（%） 特异度（%） P MCE △A 0.718 0.658～0.773 3.12 dB 74.60 63.87 < 0.001* △PSI 0.745 0.687～0.797 −0.44 60.32 78.01 < 0.001* △β 0.737 0.679～0.790 0.39 dB/s 73.02 68.59 < 0.001* △A·β 0.761 0.704～0.812 8.25 60.32 83.77 < 0.001* 3D-STI △LVGAS 0.751 0.694～0.803 −9.25% 69.84 71.20 < 0.001* △LVGCS 0.792 0.737～0.840 −6.89% 66.67 80.63 < 0.001* △LVGLS 0.776 0.719～0.826 −6.08% 79.37 62.30 < 0.001* △LVGRS 0.784 0.728～0.833 11.51% 82.54 64.40 < 0.001* MCE、3D-STI参数差值联合 0.915 0.873～0.946 − 88.89 82.20 < 0.001* 注：△值 = 术后3个月值-术后24 h值；*P < 0.05。
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