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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2023, Vol. 20 ›› Issue (10) : 1016 -1022. doi: 10.3877/cma.j.issn.1672-6448.2023.10.003

心血管超声影像学

心肌收缩早期延长对非ST段抬高型急性冠脉综合征患者冠状动脉严重狭窄的预测价值
张婉微, 秦芸芸, 蔡绮哲, 林明明, 田润雨, 金姗, 吕秀章†()   
  1. 100020　首都医科大学附属北京朝阳医院心脏超声科
  • 收稿日期:2022-09-26 出版日期:2023-10-01
  • 通信作者: 吕秀章

Value of myocardial early systolic lengthening in non-ST-segment elevation acute coronary syndrome for predicting severe coronary artery stenosis

Wanwei Zhang, Yunyun Qin, Qizhe Cai, Mingming Lin, Runyu Tian, Shan Jin, Xiuzhang Lyu†()   

  1. Department of Echocardiography, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
  • Received:2022-09-26 Published:2023-10-01
  • Corresponding author: Xiuzhang Lyu
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引用本文：

张婉微, 秦芸芸, 蔡绮哲, 林明明, 田润雨, 金姗, 吕秀章. 心肌收缩早期延长对非ST段抬高型急性冠脉综合征患者冠状动脉严重狭窄的预测价值[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1016-1022.

Wanwei Zhang, Yunyun Qin, Qizhe Cai, Mingming Lin, Runyu Tian, Shan Jin, Xiuzhang Lyu. Value of myocardial early systolic lengthening in non-ST-segment elevation acute coronary syndrome for predicting severe coronary artery stenosis[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2023, 20(10): 1016-1022.

目的

应用二维斑点追踪成像（2D-STl）评价无节段性室壁运动异常的非ST段抬高型急性冠脉综合征（NSTE-ACS）患者的左心室心肌整体及区域收缩早期延长（ESL），探讨ESL参数对冠状动脉严重狭窄的预测价值。

方法

纳入2019年2月至2019年6月首都医科大学附属北京朝阳医院收治的冠脉造影前行超声心动图检查的无节段性室壁运动异常的NSTE-ACS患者171例。根据冠脉造影结果将其分为冠状动脉严重狭窄组123例（至少一支冠状动脉直径狭窄≥70%）和冠状动脉非严重狭窄组48例（各分支冠状动脉直径狭窄<70%）。应用2D-STI获得左心室心肌整体纵向应变（GLS）、整体收缩早期延长时间（GEST）、整体收缩后时间（GPST）及左心室心肌区域纵向应变（TLS），区域收缩早期延长时间（TEST）和区域收缩后时间（TPST），比较两组间的上述参数。应用ROC曲线分析整体和区域参数对冠状动脉严重狭窄的诊断效能，确定曲线下面积（AUC）和截断值。通过Logistic回归分析NSTE-ACS患者冠状动脉严重狭窄的独立影响因素。

结果

与非严重狭窄组相比，冠状动脉严重狭窄患者的GEST、GPST增大，GLS减低（P均<0.05）。严重狭窄冠状动脉灌注区的TEST、TPST较非严重狭窄冠状动脉灌注区增大（P均<0.001），而TLS差异无统计学意义（P=0.227）。心肌GEST>8.9 ms预测冠状动脉严重狭窄的AUC为0.78（敏感度65%，特异度77%），大于GLS（AUC=0.62）和GPST（AUC=0.67）；TEST对严重狭窄冠状动脉灌注区也具有一定区分能力（AUC=0.62，敏感度72%，特异度51%）。心肌GEST是冠状动脉严重狭窄的独立预测因素。

结论

NSTE-ACS冠状动脉严重狭窄患者的左心室整体及区域收缩功能受损，心肌GEST、TESL增大。ESL参数是早期识别无明显室壁运动异常的NSTE-ACS患者存在冠状动脉严重狭窄的可靠依据。

关键词: 超声心动描记术, 斑点追踪成像, 非ST段抬高型急性冠脉综合征, 收缩早期延长, 左心室, 冠状动脉狭窄
Objective

To analyze the early systolic lengthening (ESL) of the left ventricular myocardium by two-dimensional speckle tracking imaging (2D-STI) in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients who had no regional wall motion abnormality, and to explore the predictive value of global and territorial ESL for severe coronary artery stenosis.

Methods

A total of 171 NSTE-ACS patients without obvious regional wall motion abnormality who underwent echocardiography before coronary angiography at Beijing Chaoyang Hospital Affiliated to Capital Medical University from February to June 2019 were enrolled. According to the degree of coronary stenosis, there were 123 subjects in severe coronary artery stenosis group (≥70% diameter stenosis in at least one coronary artery) and 48 subjects in non-severe coronary stenosis group (<70% diameter narrowing in every coronary artery branch). Left ventricular myocardial global longitudinal strain (GLS), time to global early systolic lengthening (GEST), time to global post-systolic shorting (GPST) and territorial longitudinal strain (TLS), time to territorial early systolic lengthening (TEST), and time to territorial post-systolic shorting (TPST) were obtained by 2D-STI. The differences in the above parameters were compared between the two groups. Receiver operating characteristic (ROC) curve analysis was performed to assess the diagnostic efficacy of global and regional parameters for severe coronary artery stenosis by determining their area under the ROC curve (AUC) and cut-off values. A logistic regression model was established to determine the independent predictors of severe coronary stenosis in NSTE-ACS patients.

Results

Compared with the non-severe coronary artery stenosis group, left ventricular GEST and GPST were significantly increased, while GLS was significantly decreased in NSTE-ACS patients with severe coronary artery stenosis (P<0.05 for all). In addition, both myocardial TEST and TPST were significantly increased in regions supplied by severely stenotic coronary arteries compared to non-severely stenotic coronary arteries (P<0.001 for both), while there was no statistically significant difference in left ventricular TLS between regions supplied by severely stenotic coronary arteries and non-severely stenotic coronary arteries (P=0.227). ROC curve analysis showed that myocardial GEST>8.9 ms yielded a specificity of 65% and sensitivity of 77%, and had the highest AUC (0.78) in predicting severe coronary stenosis, superior to GLS (AUC=0.62, P<0.05) and GPST (AUC=0.67, P<0.05). In addition, myocardial TEST could also distinguish regions related to severe coronary artery stenosis and non-severe arteries with moderate diagnostic accuracy (AUC=0.62, sensitivity 72%, specificity 51%). In multivariable logistic regression analysis, only left ventricular myocardial GEST remained an independent predictor of severe coronary artery stenosis in patients with NSTE-ACS.

Conclusions

In NSTE-ACS patients with severe coronary artery stenosis, left ventricular global and territorial systolic function are impaired, and particularly, both myocardial GEST and TEST are significantly increased. ESL parameters may be a reliable index for predicting severe coronary stenosis in NSTE-ACS patients without obvious regional wall motion abnormality.

Key words: Echocardiography, Speckle tracking imaging, Non-ST-segment elevation acute coronary syndrome, Early systolic lengthening, Left ventricle, Coronary stenosis
图1 二维斑点追踪成像显示非ST段抬高型急性冠脉综合征患者左心室心尖三腔心切面的应变-时间曲线。图a为冠状动脉严重狭窄患者，部分心肌节段出现收缩早期延长（ESL）；图b为非冠状动脉严重狭窄患者，不存在明显ESL
图2 收缩早期延长时间（EST）、收缩后时间（PST）测量示意图 注：AVC为主动脉瓣关闭时间；EST为收缩早期延长时间（舒张末期至收缩早期正向峰值应变的时间）；PST为收缩后时间（AVC至全心动周期最大应变的时间）
表1 冠状动脉严重狭窄组与非严重狭窄组一般资料及常规超声心动图参数比较
组别 例数 年龄（岁，） 男性[例（%）] 高血压[例（%）] 糖尿病[例（%）] 高血脂[例（%）] LVEDV（ml，） LVESV（ml，） LVEF（%，） E/e'（）
非严重狭窄组 48 63.2±8.7 27（56.3） 31（64.6） 13（27.1） 43（89.6） 73.5±15.6 27.5±6.4 62.1±2.9 11.4±3.8
严重狭窄组 123 63.6±8.8 75（61.0） 92（74.8） 56（45.5） 108（87.8) 73.6±18.1 28.8±8.4 61.4±3.6 11.7±3.8
统计值 t=0.288 χ2=0.320 χ2=1.784 χ2=4.880 χ2=0.106 t=0.041 t=-0.978 t=1.302 t=-0.488
P值 0.773 0.571 0.182 0.027 0.745 0.967 0.330 0.195 0.626
表2 冠状动脉严重狭窄组与非严重狭窄组左心室整体心肌形变参数比较
组别 例数 GLS（%，） GEST[ms，M（QR）] GPST[ms，M（QR）]
非严重狭窄组 48 -18.5±2.1 5.6（7.0） 15.4（18.5）
严重狭窄组 123 -17.6±2.4 11.5（8.4） 22.3（29.3）
统计值 t=-2.339 Z=-5.650 Z=-3.491
P值 0.020 <0.001 0.003
表3 严重狭窄冠状动脉灌注区与非严重狭窄灌注区心肌形变参数比较
组别 个数 TLS（%，） TEST[ms，M（QR）] TPST[ms，M（QR）]
非严重狭窄灌注区 311 -17.7±3.0 6.6（12.9） 16.8（21.8）
严重狭窄灌注区 202 -17.4±3.2 10.6（12.1） 23.9（34.2）
统计值 t=-1.210 Z=-4.737 Z=-3.491
P值 0.227 <0.001 <0.001
图3 二维斑点追踪成像整体心肌形变参数预测冠状动脉严重狭窄的ROC曲线 注：GLS为整体纵向应变；GEST为整体收缩早期延长时间；GPST为整体收缩后时间
表4 整体和区域心肌形变参数预测冠状动脉严重狭窄的效能分析
参数 AUC（95%CI） 截断值 敏感度（%） 特异度（%） 约登指数 P值
GLS 0.62（0.50~0.71） -18.9% 73 50 0.23 <0.05
GPST 0.67（0.60~0.74） 36.0 ms 33 95 0.28 <0.05
GEST 0.78（0.71~0.84） 8.9 ms 65 77 0.42 <0.05
TLS 0.53（0.48~0.57） -15.3% 25 82 0.07 >0.05
TPST 0.61（0.57~0.65） 30.7 ms 39 78 0.17 <0.05
TEST 0.62（0.58~0.67） 6.8 ms 72 51 0.23 <0.05
表5 预测NSTE-ACS患者冠状动脉严重狭窄的单因素及多因素Logistic回归分析
变量 单因素Logistic回归 多因素Logistic回归
回归系数 标准误 Wald卡方值 OR值 P值 回归系数 标准误 Wald卡方值 OR值 P值
糖尿病 0.81 0.37 4.76 2.25 0.029 0.38 0.42 0.80 1.46 0.371
GLS 0.18 0.08 5.18 1.20 0.023 0.18 0.10 3.72 1.20 0.054
GPST 0.04 0.01 12.08 1.05 0.001 0.02 0.01 2.74 1.02 0.098
GEST 0.20 0.04 24.98 1.23 <0.001 0.18 0.04 16.70 1.20 <0.001
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