赵振燕,吴永健,吴元,徐波,宋光远,裴汉军,王喜梅,唐熠达,杨跃进

• 1:北京协和医学院中国医学科学院心血管病研究所阜外心血管病医院冠心病诊治中心

摘要(Abstract)：

目的探讨非糖尿病患者急性心肌梗死时胰岛素抵抗的相关危险因素,并评估胰岛素抵抗对ST段急性心肌梗死患者住院期间预后的影响和意义。方法从2008年10月到2009年9月,连续入选初次发生ST段抬高急性心肌梗死,且在发病24小时内接受急诊经皮冠状介入治疗的患者,在入院第二天清晨测空腹血糖和胰岛素浓度,出院前均进行口服葡萄糖耐量试验,最后纳入非糖尿病患者124例,以稳态模型胰岛素抵抗指数,即HOMA-IR≥2.5认为存在胰岛素抵抗,评价胰岛素抵抗对急性心肌梗死患者预后的影响。结果 124例患者中,存在胰岛素抵抗的患者占49.2%(61/124),病死率占12.1%(15/124)。胰岛素抵抗组较对照组有较高的入院血糖[(7.88±2.83)mmol/L比(6.93±1.60)mmol/L,P=0.025]、空腹血糖[(7.36±2.33)mmol/L比(6.43±1.81)mmol/L,P=0.014]和胰岛素浓度[(16.68±6.98)mU/L比(6.32±2.32)mU/L,P=0.000],组间比较差异具有统计学意义。多元逐步回归方程提示,体重指数[标准化回归系数(β)=0.244,P=0.021]和空腹血糖(β=0.451,P=0.000)是影响HOMA-IR严重程度的主要因素。多因素logistic回归方程提示,在调整其他因素后,胰岛素抵抗[OR=1.506,95%CI(1.062～2.134),P=0.021]、Killip分级≥Ⅱ[OR=3.007,95%CI(1.165～7.779),P=0.023]和心肌肌酸激酶同工酶峰值[OR=1.004,95%CI(1.000～1.008),P=0.036]是急性心肌梗死患者住院期间死亡的独立危险因素。结论心肌梗死急性期胰岛素抵抗现象普遍存在,是急性心肌梗死患者住院期间预后不良的独立危险因素,体重指数和第二天空腹血糖水平是影响胰岛素抵抗的主要因素。

关键词(KeyWords)： 心肌梗死;胰岛素抵抗,HOMA-IR;预后

Abstract:

Keywords:

基金项目(Foundation): 中华医学会心脑血管疾病血糖管理协作组(CGICC)基金(08010009)

作者(Author): 赵振燕,吴永健,吴元,徐波,宋光远,裴汉军,王喜梅,唐熠达,杨跃进

参考文献(References)：

• [1]Martin BC,Warram JH,Krolewski AS,et al.Role of glucose and insulin resistance in development of type2diabetes mellitus:results of a25-year follow-up study.Lancet,1992,340:925-929.
• [2]Bellodi G,Manicardi V,Malavasi V,et al.Hyperglycemia and prognosis of acute myocardial infarction in patients without diabetes mellitus.Am J Cardiol,1989,64:885-888.
• [3]Stern MP.Diabetes and cardiovascular disease.The"common soil"hypothesis.Diabetes,1995,44:369-374.
• [4]Hu G,Qiao Q,Tuomilehto J,et al.Plasma insulin and cardiovascular mortality in non-diabetic European men and women:a meta-analysis of data from eleven prospective studies.Diabetologia,2004,47:1245-1256.
• [5]Bonora E,Kiechl S,Willeit J,et al.Prevalence of insulin resistance in metabolic disorders:the Bruneck Study.Diabetes,1998,47:1643-1649.
• [6]Trinder P.Determination of blood glucose using an oxidase-peroxidase system with a non-carcinogenic chromogen.J Clin Pathol,1969,22:158-161.
• [7]Trinder P.Determination of blood glucose using4-amino phenazone as oxygen acceptor.J Clin Pathol,1969,22:246.
• [8]Capes SE,Hunt D,Malmberg K,et al.Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes:a systematic overview.Lancet,2000,355:773-778.
• [9]DeFronzo RA,Tobin JD,Andres R.Glucose clamp technique:a method for quantifying insulin secretion and resistance.Am J Physiol,1979,237:E214-223.
• [10]Bonora E,Targher G,Alberiche M,et al.Homeostasis model assessment closely mirrors the glucose clamp technique in the assessment of insulin sensitivity:studies in subjects with various degrees of glucose tolerance and insulin sensitivity.Diabetes Care,2000,23:57-63.
• [11]Consensus Development Conference on Insulin Resistance.5-6November1997.American Diabetes Association.Diabetes Care,1998,21:310-314.
• [12]宋秀霞译,纪立农校.国际糖尿病联盟代谢综合征全球共识定义.中华糖尿病杂志,2005,13:178-180.
• [13]Ridker PM.High-sensitivity C-reactive protein:potential adjunct for global risk assessment in the primary prevention of cardiovascular disease.Circulation,2001,103:1813-1818.
• [14]Libby P,Ridker PM,Maseri A.Inflammation and atherosclerosis.Circulation,2002,105:1135-1143.
• [15]Festa A,D′Agostino R Jr,Howard G,et al.Chronic subclinical inflammation as part of the insulin resistance syndrome:the Insulin Resistance Atherosclerosis Study(IRAS).Circulation,2000,102:42-47.
• [16]Piatti P,Di Mario C,Monti LD,et al.Association of insulin resistance,hyperleptinemia,and impaired nitric oxide release with in-stent restenosis in patients undergoing coronary stenting.Circulation,2003,108:2074-2081.
• [17]Lefroy DC,Crake T,Uren NG,et al.Effect of inhibition of nitric oxide synthesis on epicardial coronary artery caliber and coronary blood flow in humans.Circulation,1993,88:43-54.
• [18]Yao SK,Ober JC,Krishnaswami A,et al.Endogenous nitric oxide protects against platelet aggregation and cyclic flow variations in stenosed and endothelium-injured arteries.Circulation,1992,86:1302-1309.
• [19]Anand SS,Yi Q,Gerstein H,et al.Relationship of metabolic syndrome and fibrinolytic dysfunction to cardiovascular disease.Circulation,2003,108:420-425.