Hcy和RDW<italic>CV</italic>联合检测在急性心肌梗死中的应用价值探讨

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刘艺军, 刘洪亮, 徐红. Hcy和RDWCV联合检测在急性心肌梗死中的应用价值探讨 . 2014, 29(10): 989-991[LIU Yijun, LIU Hongliang, XU Hong. Investigation on the application significance on the combined detection of Hcy and RDWCV in the diagnosis of acute myocardial infarction . Labratory Medicine, 2014, 29(10): 989-991] 复制到剪切板

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《检验医学》编辑部

Hcy和RDWCV联合检测在急性心肌梗死中的应用价值探讨

刘艺军¹, 刘洪亮², 徐红¹

1.涟水县人民医院检验科, 江苏涟水 223400

2.涟水县人民医院心内科, 江苏涟水 223400

作者简介:刘艺军,男,1963年生,学士,副主任技师,主要从事血液学检验工作。

摘要

目的

探讨同型半胱氨酸(Hcy)和红细胞体积分布宽度变异系数(RDWCV)联合检测对急性心肌梗死(AMI)诊断的临床价值。

方法

检测55例AMI患者、60例肺炎患者和60名健康体检者(正常对照组)的Hcy浓度和RDWCV水平,并对结果进行比较分析。

结果

AMI组Hcy和RDWCV均明显高于肺炎组和正常对照组(P<0.05);联合检测Hcy和RDWCV对AMI诊断的敏感性为92.0%、特异性为86.1%,明显高于Hcy和RDWCV单项检测的敏感性(82.6%、72.8%) 和特异性(80.0%、75.3%)(P<0.05)。

结论

联合检测血Hcy浓度和RDWCV水平可明显提高AMI诊断的敏感性和特异性。

关键词: 同型半胱氨酸; 红细胞体积分布宽度变异系数; 急性心肌梗死; 联合检测; 敏感性; 特异性

中图分类号:R446.11 文献标志码:A 文章编号:1673-8640(2014)10-0989-03

Investigation on the application significance on the combined detection of Hcy and RDWCV in the diagnosis of acute myocardial infarction

LIU Yijun¹, LIU Hongliang², XU Hong

1.Department of Clinical Laboratory, Lianshui People's Hospital, Jiangsu Lianshui 223400, China

2.Department of Cardiology, Lianshui People's Hospital, Jiangsu Lianshui 223400, China

Abstract

Objective

To investigate the clinical significance of the homocysteine (Hcy) and red blood cell distribution width coefficient of variation (RDWCV) combined detection in the diagnosis of acute myocardial infarction (AMI).

Methods

A total of 55 patients with AMI and 60 patients with pneumonia were enrolled, and 60 healthy subjects were enrolled as control group. The levels of Hcy and RDWCV were determined, and the results were compared.

Results

In AMI group, Hcy and RDWCV were significantly higher than those of pneumonia and control groups (P<0.05). The sensitivity of the combined detection of Hcy and RDWCV in the diagnosis of AMI was 92.0%, the specificity was 86.1%, which were higher than those of the single detections of Hcy and RDWCV (82.6%, 72.8% and 80.0%, 75.3%) (P<0 05).

Conclusions

The combined detection of Hcy and RDWCV can significantly improve the sensitivity and specificity in the diagnosis of AMI.

Keyword: Homocysteine; Red blood cell distribution width coefficient of variation; Acute myocardial infarction; Combined detection; Sensitivity; Specificity

Show Figures

急性心肌梗死(AMI)起病急骤,病情发展迅速,病死率很高。诊断一直依据临床症状、心电图和心肌损伤标志物。理想的心肌损伤标志物应该具有高敏感性、特异性和准确性及重复性好,并能在短时间内获得结果。同型半胱氨酸(homocysteine,Hcy)是蛋氨酸的代谢产物。Hcy是近年研究热点,许多研究表明Hcy不仅是心功能紊乱时高度敏感和特异的指标,而且能反映急性心肌缺血的程度,可作为一种AMI诊断指标。红细胞体积分布宽度变异系数(red blood cell distribution width coefficient of variation,RDW CV)是反映红细胞体积异质性的参数,目前正被重新认识,多个研究显示,RDW CV与心血管疾病,尤其是心力衰竭的预后密切相关,可能是一种新的心血管疾病危险标志物^{[ 1, 2, 3, 4]}。我们通过回顾性分析AMI患者Hcy和RDW CV水平及其对AMI诊断的敏感性和特异性,探讨Hcy和RDW CV联合检测对AMI诊断的临床价值。

材料和方法

一、一般资料

选取2012年7月至2013年7月涟水县人民医院心血管内科收治的AMI患者55例,所有病例均经冠状动脉造影(CAG)确诊,诊断标准符合2007年欧洲心脏病学会/美国心脏协会/美国心脏病学会基金会/世界心脏病联盟(ESC/AHA/AcCF/WHF)颁布的关于“急性心肌梗死”诊断和治疗指南。收集同期涟水县人民医院呼吸科收治的60例肺炎患者和涟水县人民医院体检中心提供的60名健康体检者(正常对照组)。AMI组、肺炎组和正常对照组在年龄、性别等方面具有可比性,差异无统计学意义( P>0.05) 。

二、仪器与检测方法

抽取静脉全血各2 mL于分离胶试管和乙二胺四乙酸二钾(EDTA-K₂)抗凝管中,分离胶试管用循环酶法,由日立公司提供的HITACHI 7600全自动生化分析仪进行Hcy检测。EDTA-K₂抗凝管由Sysmex XS-1000i全自动血液分析仪(日本希森美康株式会社)检测RDW CV。具体操作过程按说明书严格进行。Hcy的参考区间:5~15 μmol/L,RDW CV的参考区间:11%~15%。

三、判断标准

以Hcy>15μmol/L、RDW CV>15%为阳性结果。

四、统计学方法

采用SPSS 13.0软件进行统计分析。计量数据以{Invalid MML} ±s表示,组间比较采用配对 t检验。 P<0.05为差异有统计学意义。

结果一、3组间血Hcy和RDW CV水平的比较

AMI组血RDW CV和Hcy水平明显高于肺炎组和正常对照组( P<0.05)。见表1。

表1 3组Hcy和RDW CV水平的比较

二、RDW CV与Hcy联合检测诊断AMI的价值

Hcy和RDW CV联合检测的敏感性为92.0%、特异性为86.1%,明显高于Hcy和RDW CV单项检测的敏感性(82.6%、80.0%)和特异性(75.3%、72.8%)( P<0.05)。见表2。

表2 RDW CV和Hcy联合检测对AMI的诊断价值

讨论

AMI是冠状动脉急性闭塞血流中断所致局部心肌缺血性坏死,冠状动脉急性闭塞至心肌透壁性坏死有一时间窗,根据动物实验研究,这一时间窗大约为6 h,在该时间窗内使冠状动脉再通,可挽救濒临坏死的缺血心肌。因此,对AMI的治疗,时间是最重要的。AMI早期,如具有剧烈心前区疼痛、特征性心电图表现以及血清心肌酶升高等典型表现,早期诊断并不困难。但由于AMI的临床表现差异极大,约25%的患者在发病早期没有典型的临床症状,约50%的AMI患者早期不出现特征性的心电图改变,观察心电图(ECG)的动态变化又难以满足时间窗的要求,容易造成漏诊、误诊而耽误治疗。因此,借助各种心肌损伤标志物的快速检测来达到早期诊断至关重要。

Hcy是蛋氨酸的代谢产物。在病理情况下由胱硫醚转变成半胱氨酸的酶缺乏,Hcy代谢发生障碍。在肝细胞内由蛋氨酸生成的Hcy硫内酯,具有高度反应性,可与低密度脂蛋白的脂蛋白B的游离氨基酸形成肽键Hcy(酯化),从而导致细胞摄取并凝聚低密度脂蛋白与胆固醇沉着^{[ 5]}。此外,尚有其它因素参与内皮损伤及动脉粥样硬化形成过程^{[ 6]}。很多研究结果证实,Hcy是心脑血管疾病独立危险因素^{[ 7]},其机制可能与其能引起脂质过氧化,加速泡沫细胞形成,同时能促进氧自由基和过氧化氢生成,激活血小板黏附和聚集,促进动脉粥样硬化等因素有关。本研究结果显示,AMI组Hcy水平及异常检出率明显高于肺炎患者组和正常对照组( P<0.05)。进一步印证Hcy与AMI关系密切,是AMI的重要危险因素^{[ 8]}。

临床上RDW CV明显增高常见于红细胞破坏(如溶血)、营养不良(铁、维生素B 或叶酸缺乏)或输血后,而AMI患者病理变化基本上与血红蛋白水平无关。0h等^{[ 9]} 研究发现AMI Killip Ⅱ级及以上患者的RDW CV(13.75%)明显高于Killip I级患者的RDW CV(13.07%, P<0.001),但Kiltip Ⅱ级、Ⅲ级、Ⅳ级之间RDW CV的结果没有明显差异性。推测RDW CV可用于判断AMI、心力衰竭发生。RDW CV作为急性心力衰竭独立的预测因子在Pascual-Figal等^{[ 10]}研究中进一步得到证实。1项对100例急性心力衰竭患者RDW CV与心脏超声相关参数关系的研究发现:RDW CV 是急性心力衰竭患者左心室充盈压(LVEP)水平独立预测因子(标准回归系数为0.431, P<0.001) 。RDW CV水平与急性心力衰竭患者长期不良预后之间的关系同样在试验中得到印证。1项对628例急性心力衰竭患者跟踪随访的研究^{[ 11]}发现:在长期随访中,较高基线RDW CV值(中位数水平以上)与低生存率相关,且不受血红蛋白和贫血等因素的影响。这些与RDW CV在慢性心力衰竭中得出的结论不同,提示RDW CV在急性心衰中的作用可能还有其它途径,还需要更多研究来证实。RDW CV升高与AMI患者预后相关^{[ 12]}。Tonelli等^{[ 13]}发现RDW CV每升高1%,AMI患者死亡率升高1.14倍,高水平RDW CV与心源性死亡、新发心力衰竭及休克等相关。Fukuta等^{[ 14]}研究则认为神经激素激活可能是RDW与不良临床事件相关的一个中间机制。研究者对226例AMI患者的RDW CV、B型钠尿肽(BNP)和高敏C反应蛋白(hs-CRP)水平进行分析,发现血浆BNP( r=0.21, P<0.01)与RDW CV相关,而hs-CRP则无相关性( r=0.04, P>0.1)。RDW CV是疾病发展过程中多种病理生理机制(如炎症、营养、神经激素活性、应激等)的综合反映。而对于AMI的患者,可能其应激反应缘故,表现为RDW CV的上升。

在实际工作中,任何单项检测结果都有误诊、漏诊的可能。本研究结果显示,Hcy和RDW CV联合检测诊断AMI的敏感性和特异性明显高于RDW CV、Hcy单项检测的敏感性和特异性。说明了联合检测Hcy和RDW CV对AMI的早期诊断起到相互补充的作用。由于Hcy升高的时间早于RDW CV,因此Hcy明显升高、RDW CV不升高,提示有AMI发生的可能,需要对其进行更严密的监测,引导临床合理用药,继续观察RDW CV的改变;如两者都不高,则发生AMI的可能性较小,可引导临床合理处置。

The authors have declared that no competing interests exist.

参考文献

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2011

3.32

0.0

. 2011, 17(4):292-298 DOI:10.1016/j.cardfail.2010.11.006

Red cell distribution width and mortality in predominantly African-American population with decompensated heart failure

Abstract Introduction Red-cell distribution width (RDW) has been identified as a novel prognostic marker in heart failure patients. However, evidence is limited for its predictive value in the setting of patients hospitalized with decompensated heart failure (DHF) and no data are available for African Americans (AA). Methods and Results Data that included baseline characteristics, laboratory findings, and discharge medications were collected retrospectively on a total of 789 patients with DHF (mean age 62.7 ± 15.1 years, 50% males and 80% AA), admitted to an urban medical center between January 2007 and August 2007, 145 (18.38%) died during median follow-up of 573 days. Unadjusted and adjusted Cox-proportional hazard models were used to analyze predictive value of discharge RDW on mortality. There was a significant negative association between RDW and statin use, blood hemoglobin levels and mean corpuscular volume (MCV); whereas serum creatinine and blood urea nitrogen (BUN) increased with increasing RDW. A statistically significant graded increase in all-cause mortality with higher RDW quartiles (lowest vs highest quartile), independent of hemoglobin and creatinine levels, was found for all patients (adjusted hazard ratio [HR] 3.21; 95% confidence interval [CI]: 1.77–5.83, P P P = 0.019; RDW evaluated as continuous variable). Conclusion Discharge RDW is an independent predictor of all-cause mortality in predominantly AA patients hospitalized with DHF. Further research is warranted to delineate underlying pathophysiological mechanisms including the association between statin use and RDW.

... 红细胞体积分布宽度变异系数(red blood cell distribution width coefficient of variation,RDW CV)是反映红细胞体积异质性的参数,目前正被重新认识,多个研究显示,RDW CV与心血管疾病,尤其是心力衰竭的预后密切相关,可能是一种新的心血管疾病危险标志物^[1,2,3,4] ...

2010

3.32

0.0

. 2010, 16(3):230-238 DOI:10.1016/j.cardfail.2009.11.003

Validation and potential mechanisms of red cell distribution width as a prognostic marker in heart failure

Abstract Background Adverse outcomes have recently been linked to elevated red cell distribution width (RDW) in heart failure. Our study sought to validate the prognostic value of RDW in heart failure and to explore the potential mechanisms underlying this association. Methods and Results Data from the Study of Anemia in a Heart Failure Population (STAMINA-HFP) registry, a prospective, multicenter cohort of ambulatory patients with heart failure supported multivariable modeling to assess relationships between RDW and outcomes. The association between RDW and iron metabolism, inflammation, and neurohormonal activation was studied in a separate cohort of heart failure patients from the United Investigators to Evaluate Heart Failure (UNITE-HF) Biomarker registry. RDW was independently predictive of outcome (for each 1% increase in RDW, hazard ratio for mortality 1.06, 95% CI 1.01-1.12; hazard ratio for hospitalization or mortality 1.06; 95% CI 1.02-1.10) after adjustment for other covariates. Increasing RDW correlated with decreasing hemoglobin, increasing interleukin-6, and impaired iron mobilization. Conclusions Our results confirm previous observations that RDW is a strong, independent predictor of adverse outcome in chronic heart failure and suggest elevated RDW may indicate inflammatory stress and impaired iron mobilization. These findings encourage further research into the relationship between heart failure and the hematologic system.

2011

5.509

0.0

2010

4.497

0.0

. 2010, 160(6):1142-1148 DOI:10.1016/j.ahj.2010.07.033

Prospective evaluation of the association between cardiac troponin T and markers of disturbed erythmpoiesis in patients with heart failure

a Department of Medicine and Radiology, University of North Carolina Chapel Hill, Chapel Hill, NC b Department of Medicine, University of Maryland School of Medicine, Baltimore, MD c Mercy Iowa City, Iowa City, IA d Department of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC e Department of Medicine, Loma Linda University, Loma Linda, CA f Detroit Medical Center, Detroit, MI g University of Texas MD Anderson Cancer Center, Houston, TX h Department of Internal Medicine, University of Cincinnati, Cincinnati, OH i School of Pharmacy, University of North Carolina Chapel Hill, Chapel Hill, NC j Department of Biostatics, University of North Carolina Chapel Hill, Chapel Hill, NC

2012

0.0

... 在肝细胞内由蛋氨酸生成的Hcy硫内酯,具有高度反应性,可与低密度脂蛋白的脂蛋白B的游离氨基酸形成肽键Hcy(酯化),从而导致细胞摄取并凝聚低密度脂蛋白与胆固醇沉着^[5] ...

1999

0.0

... 此外,尚有其它因素参与内皮损伤及动脉粥样硬化形成过程^[6] ...

2010

0.0

... 很多研究结果证实,Hcy是心脑血管疾病独立危险因素^[7],其机制可能与其能引起脂质过氧化,加速泡沫细胞形成,同时能促进氧自由基和过氧化氢生成,激活血小板黏附和聚集,促进动脉粥样硬化等因素有关 ...

2013

0.0

... 本研究结果显示,AMI组Hcy水平及异常检出率明显高于肺炎患者组和正常对照组(P[8] ...

2009

3.32

0.0

. 2009, 15(6):517-522 DOI:10.1016/j.cardfail.2009.01.002

Relation between red cell distribution width with echocardiographic parameters in patients with acute heart failure

Abstract Background Red cell distribution width (RDW) has recently been discovered to be a novel prognostic marker in patients with heart failure. However, the relation between RDW and echocardiographic parameters in acute heart failure (AHF) has not been studied. Methods and Results We analyzed laboratory findings including RDW, N-terminal pro-brain natriuretic peptide (NT-proBNP), and echocardiographic parameters in 100 patients with AHF. The mean RDW was 14.2 ± 2.0% and median NT-proBNP was 5183 pg/mL. The mean left ventricular ejection fraction was 33.1 ± 14.5% and early mitral inflow velocity to early diastolic mitral annular velocity (E/E′), was 21.2 ± 9.4. When the RDW was considered in tertile categories, the highest tertile group (>14.5%) had higher E/E′ ( P P = .02) than the lowest tertile group ( P = .001). The optimal cutoff value of RDW for predicting E/E′ >15, suggesting elevated left ventricular filling pressure (LVFP) was 13.45% (area under the curve 0.633, P 15 was found in logistic regression analysis ( P = .038). Conclusions We found a novel relation between higher levels of RDW and elevated E/E′ in patients with AHF. This novel finding raises the possibility that a simple marker, RDW may be associated with elevated LVFP in patients with AHF.

... 0h等^[9] 研究发现AMI Killip #cod#x02161 ...

2009

5.247

0.0

. 2009, 11(9):840-846

Red blood cell distribution width predicts long-term outcome regardless of anaemia status in acute heart failure patients

Domingo A. Pascual-Figal * ,Juan C. Bonaque,Belen Redondo,Cesar Caro,Sergio Manzano-Fernandez,Jesús Sánchez-Mas,Iris P. Garrido andMariano Valdes

Heart Failure Unit, Cardiology Department, Virgen de la Arrixaca Hospital, School of Medicine, University of Murcia, Murcia, Spain * Corresponding author. Tel: +34 968 369445, Fax: +34 968 369662, Email: dapascual@servicam.com

> Aims To study the long-term prognostic value of red blood cell distribution width (RDW) in patients hospitalized with acute heart failure (AHF) and to compare the value of this measurement with haemoglobin levels and anaemia status.

... RDW CV作为急性心力衰竭独立的预测因子在Pascual-Figal等^[10]研究中进一步得到证实 ...

2007

0.0

. 2007, 50(1):40-47 DOI:10.1016/j.jacc.2007.02.067

Red cell distribution width as a novel prognostic marker in heart failure:data from the CHARM program and the Duke Databank

Objectives The goal of this study was to identify potentially novel laboratory markers of risk in chronic heart failure patients. Background Although a variety of prognostic markers have been described in heart failure, a systematic assessment of routine laboratory values has not been reported. Methods All 2,679 symptomatic chronic heart failure patients from the North American CHARM (Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity) program had a wide range of laboratory measures performed at a core facility, enabling us to assess the relationship between routine blood tests and outcomes using a Cox proportional hazards model. We then replicated our findings in a cohort of 2,140 heart failure patients from the Duke Databank. Results Among 36 laboratory values considered in the CHARM program, higher red cell distribution width (RDW) showed the greatest association with morbidity and mortality (adjusted hazard ratio 1.17 per 1-SD increase, p Conclusions In 2 large contemporary heart failure populations, RDW was found to be a very strong independent predictor of morbidity and mortality. Understanding how and why this marker is associated with outcome may provide novel insights into heart failure pathophysiology.

... 1项对628例急性心力衰竭患者跟踪随访的研究^[11]发现:在长期随访中,较高基线RDW CV值(中位数水平以上)与低生存率相关,且不受血红蛋白和贫血等因素的影响 ...

2012

0.0

... RDW CV升高与AMI患者预后相关^[12] ...

2008

15.202

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... Tonelli等^[13]发现RDW CV每升高1%,AMI患者死亡率升高1 ...

2009

1.233

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... Fukuta等^[14]研究则认为神经激素激活可能是RDW与不良临床事件相关的一个中间机制 ...