冠状动脉支架术后肌钙蛋白Ⅰ和内皮素变化的临床意义
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摘要
目的 探讨冠状动脉支架术后肌钙蛋白Ⅰ的变化，预后意义和相关因素，并探讨相应内皮素的变化以及和心肌损伤的关系。方法 观察76例行择期冠状动脉支架术且术前肌钙蛋白Ⅰ和肌酸激酶的心脏同功酶(CK-MB)正常的患者，监测术前，术后12，24小时肌钙蛋白Ⅰ；其中30例监测术前，术后即刻，6小时，24小时的内皮素水平。观察6-12月内主要心血管事件(死亡，心肌梗死，靶病变处血运重建，再发心肌缺血)的发生。结果 36.84％行择期冠状动脉支架术且术前肌钙蛋Ⅰ和CK-MB正常的病例出现术后肌钙蛋白Ⅰ升高。6-12月随访中术后肌钙蛋白Ⅰ升高组和肌钙蛋白Ⅰ正常组主要心血管事件发生无显著性差异，但肌钙蛋白Ⅰ升高组中住院期间再发心肌缺血增加(10／27 vs 7／44，p＜0.05)。肌钙蛋白Ⅰ升高组中，再发心肌缺血均出现在肌钙蛋白Ⅰ峰值大于该组平均峰值者。多元逻辑回归分析示球囊扩张总时间和不稳定性心绞痛与冠状动脉支架术后肌钙蛋白Ⅰ升高有关。30例冠状动脉支架术前后内皮素水平的检测示术后即刻血浆内皮素升高，术后6小时升高更明显，术后24小时恢复到术前水平。肌钙蛋白Ⅰ升高组和正常组的内皮素变化无显著性差异。结论 1．择期冠状动脉支架术后肌钙蛋白Ⅰ可升高。2．冠状动脉支架术后肌钙蛋白Ⅰ升高者近期再发心肌缺血增加。术
后肌钙蛋白I升高和中期随访时心脏事件发生未见明显关系。3.冠状动
脉支架术后肌钙蛋白I升高和球囊扩张总时间及不稳定性心绞痛有关。
4.择期冠状动脉支架术后内皮素普遍升高，术后内皮素升高和心肌损伤
未见明显关系。
Objective To explore change and prognostic value of troponin-I following coronary stenting, and to explore endothelin change and its relation to myocardial injury. Methods Troponin-I was monitored before procedure, 12, 24h after procedure in 76 patients who underwent selective coronary stent implantation and with normal troponin-I and CKMB before procedures, in 30 of whom endothelin was monitored before procedure, and immediately, 6h, 24h after procedure. Major cardiovascular events (death, myocardial infarction, revascularization of target vessel and recurrent myocadial ischemia) were recorded in follow-up of 6-12 months. Results Trponin-I increased following procedure in 36.84% of patients who underwent selective coronary stenting and with normal troponin-I and CKMB levels before procedures. In follow-up of 6-12 months, major cardiovascular events occurred without significant difference in group with elevated trponin-I levels as well as with normal trponin-I levels. But there were more events of in
hospital recurrent myocadial ischemia in group with elevated trponin-I levels than in group with normal trponin-I levels. In group with elevated trponin-I levels, all recurrent myocadial ischemia occurred in patients with peak trponin-I levels above group average level. Total inflation time and unstable angina were associated with trponin-I elevations following PTCA and /or stent implantation. Endothelin increased immediately after procedure, increased more obviously 6h after procedure, and changed back to the original level 24h after procedure. But there was no significant difference of endothelin levels between group of elevated troponin-I level and group of normal troponin-I level. Conclusion 1 .Ttroponin-I increases following some coronary stent implantations. 2. In hospital recurrent myocadial ischemia increases in patients with elevated troponin-I following coronary stenting. Troponin-I elevation following procedure isn't related to major cardiovascular events in intermediate-term follow-up. 3. Elevation of troponin-I following coronary stent implantation is associated with longer total infaltion time and unstable angina. 4. PTCA and/or stent implantation is followed by endothelin release, which don't seem to relate to injury.
后肌钙蛋白I升高和中期随访时心脏事件发生未见明显关系。3.冠状动
脉支架术后肌钙蛋白I升高和球囊扩张总时间及不稳定性心绞痛有关。
4.择期冠状动脉支架术后内皮素普遍升高，术后内皮素升高和心肌损伤
未见明显关系。
Objective To explore change and prognostic value of troponin-I following coronary stenting, and to explore endothelin change and its relation to myocardial injury. Methods Troponin-I was monitored before procedure, 12, 24h after procedure in 76 patients who underwent selective coronary stent implantation and with normal troponin-I and CKMB before procedures, in 30 of whom endothelin was monitored before procedure, and immediately, 6h, 24h after procedure. Major cardiovascular events (death, myocardial infarction, revascularization of target vessel and recurrent myocadial ischemia) were recorded in follow-up of 6-12 months. Results Trponin-I increased following procedure in 36.84% of patients who underwent selective coronary stenting and with normal troponin-I and CKMB levels before procedures. In follow-up of 6-12 months, major cardiovascular events occurred without significant difference in group with elevated trponin-I levels as well as with normal trponin-I levels. But there were more events of in
hospital recurrent myocadial ischemia in group with elevated trponin-I levels than in group with normal trponin-I levels. In group with elevated trponin-I levels, all recurrent myocadial ischemia occurred in patients with peak trponin-I levels above group average level. Total inflation time and unstable angina were associated with trponin-I elevations following PTCA and /or stent implantation. Endothelin increased immediately after procedure, increased more obviously 6h after procedure, and changed back to the original level 24h after procedure. But there was no significant difference of endothelin levels between group of elevated troponin-I level and group of normal troponin-I level. Conclusion 1 .Ttroponin-I increases following some coronary stent implantations. 2. In hospital recurrent myocadial ischemia increases in patients with elevated troponin-I following coronary stenting. Troponin-I elevation following procedure isn't related to major cardiovascular events in intermediate-term follow-up. 3. Elevation of troponin-I following coronary stent implantation is associated with longer total infaltion time and unstable angina. 4. PTCA and/or stent implantation is followed by endothelin release, which don't seem to relate to injury.
引文
1. La Veechia L, Bedogin F, Finocehi Get al. Troponin T, troponin I, and CK-MB mass in the detection after elective coronary stenting. Coron Artery Dis 1996;7:553-540.
2. Ravkilde J, Nissen H, M ickley H, et al.Cardiac troponin T and CK-MB mass release after visually successful percutaneous transluminal coronary angioplasty in stable angina pectoris. Am Heart J 1994;127:13-20.
3. Karim MA, Shirm M, Oskarsson H et al. Significance ofroponin T and CK-MB mass release after percutaneous transluminal coronary angioplasty. Am J Cardiol 1995;76:521-523.
4. Andreas W. Bonz, Bjorn Lengenfelder, Jorg Strotman, et al. Effect of additional temporary Glycoprotein Ⅱb/Ⅲa receptor inhibition on troponin release in elective percutaneous coronary intervention after pretreatment with asprin and clopidogrel (TOPSTAR Trial). J Am Coll Cardiol 2002;40:662-668.
5．贾永平，杨志健，张寄南等．经皮冠状动脉腔内成形术前后血清肌钙蛋白Ⅰ的变化．中国循环杂志 1999；14：356-359．
6．王兴元，贾国良，张清等．冠状动脉支架置入后肌钙蛋白-Ⅰ水平同冠状动脉粥样硬化斑块负荷有关．第四军医大学学报(JFourthMilMedUniv)2002；23(7)：721-724．
7．张大东，卢寿山，蔡煦等．冠状动脉介入术后6小时内肌钙蛋白T和术后早期临床事件的关系．中国介入心脏病学杂志2002；10：451-453．
8．曾学寨，何青，王玻等．冠状动脉支架置入术肌钙蛋白Ⅰ的释放及相关临床因素．中国心血管杂志 2002；7：345-348．
9. Attali P, Aleil B, Petitpas C, etc. Sensitivity and long-trm prognostic value of cardiac troponin-Ⅰ increase shortly after percutaneous transliminal coronary angioplasty. Clin Cardiol 1998;21:353-356.
10. Bertinchant JP, Polg A, Lederman B, etc. Relation of minor cardiac troponin Ⅰ elevation to late cardiac events after uncomplicated elective successful percutaneous transluminal coronary angioplasty for angina pectoris. Am J Cardiol 1999; 84:51-57.
11. Fuchs S, Kornowski R, Mehran R, etc. Prognostic value of cardiac troponin-Ⅰ levels following cathetr-based coronary interventions. Am J Cardiol 2000;85:1077-1082.
12. Timutkaynak T, Ozdemir M, Cengel A, et al. Myocardial injury after apparently successful coronary stenting with or without ballon dilatation:direct versus conventional stenting. Med Sci Monit. 2000 Jul-Aug;6(4):708-12.
13. Atmau Y, Ertas F, Gluec S, et al. Effect of direct stent implantation on minor myocardial injury. J Invasive Cardiol. 2002 Aug;14(8):443-6.
14. Kruger D, Giannitsis E, Sheikhzadeh A, etc. Cardiac release and kinetics of endothelin after uncomplicated percutaneous transluminal coronary angioplasty. Am J Cardiol 1998;81:1421-1426.
15. Hojo Y, Ikeda U, Katsuki T, etc. Release of endothelin-1 and angitensin-Ⅱ induced by Percutaneous transluminal coronary angioplasty. Catheter Cardiovase Interv
2000; 51:42-49.
16．吴宗贵，杜荣增，张国元，等．冠心病患者经皮冠状动脉腔内成形术后血浆内皮素改变及意义．中华心血管病杂志 1997；25：291-292．
17. Genser N, Mair J, Talasz H, etc. Cardiac troponin Ⅰ to diagnose percutaneous transluminal coronary angioplasty-related myocardial injury. Clin Chim Acta 1997;265:207-2017.
18. Abdelmeguid A, Topel E, Whitlow PL, et al. Significance of mild transient release of CK-MB after percutaneous coronary intervention. Circulation 1996; 94: 1528-36.
19. Hillis WS, Birnie D, Cochery A, et al.Troponin T and myocardial damage. Br J Cardiol 1993; 1: 16-21.
20. Simoons ML, van den Brand M, Lincoff Met al. Minimal myocardial damage during coronary intervention is associated with impaired outcome. Eur Hear J 1999;20:1112-9.
21. Kelly D, Arora R, Prognostic significance of mycocardial enzyme release after coronary intervention. Cathet Cardivasc Intervent 1999; 46:292-302.
22. Kong TQ, Charles JD, Meyers SN, et al. Prognostic implication of creatine kinase elevation following elective coronary intervention. JAMA 1997;277:461-6.
23. Johansen O, Brekke m, Stromme JH,et al. Myocardial damage during percutaneous transluminal coronary angioplasty as evidenced by troponin T measurememts. Eur Heart J 1998;19:112-7.
24. Gwaz M, Neumarm F-J, Ott I, et al. Platelet function in acute myocardial imfarction treated with direct angioplasty.Circulation 1996;93:229-37.
25. Johansen O, Brekke M, Stromme JH, etc. Myocardial damage during percutaneous transluminal coronary angioplasty as evidenced by troponin T meassurements. Eur Heart J 1998; 19910: 112-117.
26. Euler DE, Prood CE, spear JF, et al. The interruption of collateral blood flow to the isehemic myocardium by embolization of coronary artery with latex: effect on conduction delay and ventricular arrythmias.Circ RES 1981;49:97-108.
27. Bleier J, Vorderwinkler KP, Fallkensammer J, et al. Different inteacelluar compartmentalizations of cardiac troponin and myosin heavy chain: A casual connection to their different early release after myocardial damage. Clin Chem 1998;44:1912-18.
28. Feng YJ, Chert C, Fallon JT, et al. Comparison of cardiac troponin I, Creatinine kinase-MB, and myoglobin for detection of acute ischemic myocardial injury in a swine model. Am J Clin Pathol 1998;110:70-77.
29. Briguori C, Sheiban I, De Gregorio J, et al. Direct coronary stenting without predilation. J Am Coll Cardiol. 1999; 34: 1910-1915.
30. Herz I, assail A, Solodky A, et al. Effectiveness of coronary stent deplyment without predilation. Am J Cardiol 1999;84:89-91.
31. Webb J, Carere R, Virman R, et al. Petrieval and analysis of particular debris following saphenous vein graft intervention. J Am Coll Cardiol. 1999;34:468-475.
32. Rogers C, Kamovsky M, Eldeman E, et al. Inhibition of experimental neointimal hyperplasia and thrombosis depend on the type of vascular injury and the site of drug adminstration. Circulation 1993; 88: 1215-1221.
33. Ohnishi N, Iwasaki K, Kusachi S, etc. LOW incidence of minor myocardial damage associated with coronary stenting deteced by serum troponin T compareable to that with balloon coronary angioplasty. Jpn Heart J 1998;39:139-146.
2. Ravkilde J, Nissen H, M ickley H, et al.Cardiac troponin T and CK-MB mass release after visually successful percutaneous transluminal coronary angioplasty in stable angina pectoris. Am Heart J 1994;127:13-20.
3. Karim MA, Shirm M, Oskarsson H et al. Significance ofroponin T and CK-MB mass release after percutaneous transluminal coronary angioplasty. Am J Cardiol 1995;76:521-523.
4. Andreas W. Bonz, Bjorn Lengenfelder, Jorg Strotman, et al. Effect of additional temporary Glycoprotein Ⅱb/Ⅲa receptor inhibition on troponin release in elective percutaneous coronary intervention after pretreatment with asprin and clopidogrel (TOPSTAR Trial). J Am Coll Cardiol 2002;40:662-668.
5．贾永平，杨志健，张寄南等．经皮冠状动脉腔内成形术前后血清肌钙蛋白Ⅰ的变化．中国循环杂志 1999；14：356-359．
6．王兴元，贾国良，张清等．冠状动脉支架置入后肌钙蛋白-Ⅰ水平同冠状动脉粥样硬化斑块负荷有关．第四军医大学学报(JFourthMilMedUniv)2002；23(7)：721-724．
7．张大东，卢寿山，蔡煦等．冠状动脉介入术后6小时内肌钙蛋白T和术后早期临床事件的关系．中国介入心脏病学杂志2002；10：451-453．
8．曾学寨，何青，王玻等．冠状动脉支架置入术肌钙蛋白Ⅰ的释放及相关临床因素．中国心血管杂志 2002；7：345-348．
9. Attali P, Aleil B, Petitpas C, etc. Sensitivity and long-trm prognostic value of cardiac troponin-Ⅰ increase shortly after percutaneous transliminal coronary angioplasty. Clin Cardiol 1998;21:353-356.
10. Bertinchant JP, Polg A, Lederman B, etc. Relation of minor cardiac troponin Ⅰ elevation to late cardiac events after uncomplicated elective successful percutaneous transluminal coronary angioplasty for angina pectoris. Am J Cardiol 1999; 84:51-57.
11. Fuchs S, Kornowski R, Mehran R, etc. Prognostic value of cardiac troponin-Ⅰ levels following cathetr-based coronary interventions. Am J Cardiol 2000;85:1077-1082.
12. Timutkaynak T, Ozdemir M, Cengel A, et al. Myocardial injury after apparently successful coronary stenting with or without ballon dilatation:direct versus conventional stenting. Med Sci Monit. 2000 Jul-Aug;6(4):708-12.
13. Atmau Y, Ertas F, Gluec S, et al. Effect of direct stent implantation on minor myocardial injury. J Invasive Cardiol. 2002 Aug;14(8):443-6.
14. Kruger D, Giannitsis E, Sheikhzadeh A, etc. Cardiac release and kinetics of endothelin after uncomplicated percutaneous transluminal coronary angioplasty. Am J Cardiol 1998;81:1421-1426.
15. Hojo Y, Ikeda U, Katsuki T, etc. Release of endothelin-1 and angitensin-Ⅱ induced by Percutaneous transluminal coronary angioplasty. Catheter Cardiovase Interv
2000; 51:42-49.
16．吴宗贵，杜荣增，张国元，等．冠心病患者经皮冠状动脉腔内成形术后血浆内皮素改变及意义．中华心血管病杂志 1997；25：291-292．
17. Genser N, Mair J, Talasz H, etc. Cardiac troponin Ⅰ to diagnose percutaneous transluminal coronary angioplasty-related myocardial injury. Clin Chim Acta 1997;265:207-2017.
18. Abdelmeguid A, Topel E, Whitlow PL, et al. Significance of mild transient release of CK-MB after percutaneous coronary intervention. Circulation 1996; 94: 1528-36.
19. Hillis WS, Birnie D, Cochery A, et al.Troponin T and myocardial damage. Br J Cardiol 1993; 1: 16-21.
20. Simoons ML, van den Brand M, Lincoff Met al. Minimal myocardial damage during coronary intervention is associated with impaired outcome. Eur Hear J 1999;20:1112-9.
21. Kelly D, Arora R, Prognostic significance of mycocardial enzyme release after coronary intervention. Cathet Cardivasc Intervent 1999; 46:292-302.
22. Kong TQ, Charles JD, Meyers SN, et al. Prognostic implication of creatine kinase elevation following elective coronary intervention. JAMA 1997;277:461-6.
23. Johansen O, Brekke m, Stromme JH,et al. Myocardial damage during percutaneous transluminal coronary angioplasty as evidenced by troponin T measurememts. Eur Heart J 1998;19:112-7.
24. Gwaz M, Neumarm F-J, Ott I, et al. Platelet function in acute myocardial imfarction treated with direct angioplasty.Circulation 1996;93:229-37.
25. Johansen O, Brekke M, Stromme JH, etc. Myocardial damage during percutaneous transluminal coronary angioplasty as evidenced by troponin T meassurements. Eur Heart J 1998; 19910: 112-117.
26. Euler DE, Prood CE, spear JF, et al. The interruption of collateral blood flow to the isehemic myocardium by embolization of coronary artery with latex: effect on conduction delay and ventricular arrythmias.Circ RES 1981;49:97-108.
27. Bleier J, Vorderwinkler KP, Fallkensammer J, et al. Different inteacelluar compartmentalizations of cardiac troponin and myosin heavy chain: A casual connection to their different early release after myocardial damage. Clin Chem 1998;44:1912-18.
28. Feng YJ, Chert C, Fallon JT, et al. Comparison of cardiac troponin I, Creatinine kinase-MB, and myoglobin for detection of acute ischemic myocardial injury in a swine model. Am J Clin Pathol 1998;110:70-77.
29. Briguori C, Sheiban I, De Gregorio J, et al. Direct coronary stenting without predilation. J Am Coll Cardiol. 1999; 34: 1910-1915.
30. Herz I, assail A, Solodky A, et al. Effectiveness of coronary stent deplyment without predilation. Am J Cardiol 1999;84:89-91.
31. Webb J, Carere R, Virman R, et al. Petrieval and analysis of particular debris following saphenous vein graft intervention. J Am Coll Cardiol. 1999;34:468-475.
32. Rogers C, Kamovsky M, Eldeman E, et al. Inhibition of experimental neointimal hyperplasia and thrombosis depend on the type of vascular injury and the site of drug adminstration. Circulation 1993; 88: 1215-1221.
33. Ohnishi N, Iwasaki K, Kusachi S, etc. LOW incidence of minor myocardial damage associated with coronary stenting deteced by serum troponin T compareable to that with balloon coronary angioplasty. Jpn Heart J 1998;39:139-146.