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中华诊断学电子杂志 ›› 2024, Vol. 12 ›› Issue (02) : 73 -79. doi: 10.3877/cma.j.issn.2095-655X.2024.02.001

临床研究

光学相干断层成像在急性心肌梗死冠状动脉分层斑块病变中的应用
郭方明1, 赵明俐1, 颜凡辉1, 刘萌萌1, 王阳1, 赵英杰1, 刘远航1, 张艳芬1, 詹景冬1,†()   
  1. 1. 132011　吉林市中心医院心内科
  • 收稿日期:2024-02-19 出版日期:2024-05-26
  • 通信作者: 詹景冬
  • 基金资助:
    吉林省卫生健康技术创新项目(2019J04)

Optical coherence tomography in the application of layered coronary plaque lesions in acute myocardial infarction

Fangming Guo1, Mingli Zhao1, Fanhui Yan1, Mengmeng Liu1, Yang Wang1, Yingjie Zhao1, Yuanhang Liu1, Yanfen Zhang1, Jingdong Zhan1,†()   

  1. 1. Department of Cardiology, Jilin Central Hospital, Jilin 132011, China
  • Received:2024-02-19 Published:2024-05-26
  • Corresponding author: Jingdong Zhan
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引用本文：

郭方明, 赵明俐, 颜凡辉, 刘萌萌, 王阳, 赵英杰, 刘远航, 张艳芬, 詹景冬. 光学相干断层成像在急性心肌梗死冠状动脉分层斑块病变中的应用[J]. 中华诊断学电子杂志, 2024, 12(02): 73-79.

Fangming Guo, Mingli Zhao, Fanhui Yan, Mengmeng Liu, Yang Wang, Yingjie Zhao, Yuanhang Liu, Yanfen Zhang, Jingdong Zhan. Optical coherence tomography in the application of layered coronary plaque lesions in acute myocardial infarction[J]. Chinese Journal of Diagnostics(Electronic Edition), 2024, 12(02): 73-79.

目的

探讨光学相干断层成像(OCT)在急性心肌梗死(AMI)冠状动脉分层斑块病变中的应用价值。

方法

选择自2019年1月至2022年10月在吉林市中心医院心血管内科行冠脉造影(CAG)，且造影后对靶血管行OCT检查并确诊斑块侵蚀导致的60例AMI患者，根据罪犯病变是否存在分层，将患者分为分层斑块发生侵蚀组(n＝28)和非分层斑块发生侵蚀组(n＝32)。比较患者的一般资料、既往病史、心血管用药史、临床生化指标、CAG和OCT特征。

结果

60例斑块侵蚀引起的AMI患者中，分层斑块发生侵蚀28例，占46.67%。分层斑块发生侵蚀组低密度脂蛋白胆固醇水平[(3.38±0.27)mmol/L]和糖化血红蛋白水平[(7.38±0.24)%]明显高于非分层斑块侵蚀患者[(2.42±0.15)mmol/L，(6.00±0.58)%]，均差异有统计学意义(t＝6.00，3.23；均P<0.05)。CAG示，与非分层斑块发生侵蚀组相比，分层斑块发生侵蚀组罪犯血管更多见于冠脉左前降支[18/28(64.29%)，12/32(37.50%)]、病变长度更长[(28.64±4.38)mm，(15.23±4.32)mm]、病变更复杂(B2/C型)[16/28(57.14%)，8/32(25.00%)](χ2＝4.29，t＝11.92，χ2＝6.43；均P<0.05)。OCT示，与非分层斑块发生侵蚀组相比，分层斑块发生侵蚀组纤维帽更薄[(91.78±7.89)μm，(120.89±7.18)μm]、脂质斑块弧度更大[(270.21±59.89)°，(206.58±58.61 )°]、最小管腔面积更小[(1.25±0.21)mm2，(1.77±0.24)mm2]、面积狭窄率更高[(88.38±9.56)%，(76.45±8.38)%](t＝14.96，2.48，8.87，2.56；均P<0.05)。分层斑块发生侵蚀组薄纤维帽斑块[20/28(71.43%)，14/32(43.75%)]、胆固醇结晶[15/28(53.57%)，8/32(25.00%)]、巨噬细胞浸润[19/28(67.86%)，12/32(37.50%)]、滋养血管[8/28(28.57%)，2/32(6.25%)]、血栓负荷[25/28(89.29%)，21/32(65.63%)]比例均较非分层斑块发生侵蚀组更多，均差异有统计学意义(χ2＝4.66，5.16，5.51，3.87，4.67；均P<0.05)。与非分层斑块发生侵蚀组相比，分层斑块发生侵蚀组植入支架长度更长[(30.00±5.64)mm，(18.00±7.42)mm]、更多的支架膨胀不全[14/28(50.00%)，8/32(25.00%)]、更多的支架贴壁不良[12/28(42.86%)，6/32(18.75%)]、植入支架后需要更大的球囊后扩张[22/28(78.57%)，10/32(31.25%)]、支架植入后更高的后扩张压力[(18.00±2.68)atm，(14.00±2.46)atm](1 atm＝101.3 kPa)(t＝9.32，χ2＝4.02，3.87，4.25，t＝2.47；均P<0.05)。两组患者术后12个月累计发生的主要不良心血管事件(MACE)为靶血管血运重建，分别为1例和2例，分层斑块发生侵蚀组靶血管血运重建率(2/28，7.14%)高于非分层斑块发生侵蚀组(1/32，3.13%)，但差异无统计学意义(P＝0.594)。

结论

分层斑块侵蚀与病变特征及患者临床表现密切相关，OCT在评估分层斑块侵蚀AMI患者PCI治疗效果方面具有潜在的应用前景，可提供个体化治疗指导。

关键词: 心肌梗死, 经皮冠状动脉介入治疗, 体层摄影术，光学相干, 分层斑块, 支架贴壁不良
Objective

To explore the application value of optical coherence tomography (OCT) in layered coronary plaque lesions in acute myocardial infarction (AMI).

Methods

From January 2019 to October 2022, 60 patients diagnosed with AMI due to plaque erosion after undergoing coronary angiography (CAG) and OCT on target vessels at the Cardiovascular Department of Jilin Central Hospital were collected. Based on OCT image findings, the patients were categorized into a layered plaque erosion group (28 cases) and a non-layered plaque erosion group (32 cases). The 2 groups of patients′ demographic data, previous disease history, cardiovascular medication history, clinical biochemical data, CAG data and OCT data were all compared.

Results

In 60 cases of AMI patients, 28 cases had layered plaque erosion, accounting for 46.67%. In the layered plaque erosion group, the levels of low-density lipoprotein [(3.38±0.27)mmol/L] and glycosylated hemoglobin [(7.38±0.24)%]were significantly higher than those in non-layered plaque erosion patients [(2.42±0.15)mmol/L, (6.00±0.58)%], and the differences were statistically significant (t=6.00, 3.23, all P<0.05). CAG showed that compared to non-layered plaque erosion group, the erosion of layered plaques were more commonly seen in the left anterior descending branch of the coronary artery [18/28(64.29%), 12/32(37.50%)], with longer lesion lengths [(28.64±4.38)mm, (15.23±4.32)mm], and more complex lesions (B2/C type) [16/28(57.14%), 8/32(25.00%)], and the differences were statistically significant (χ2=4.29, t=11.92, χ2=6.43, all P<0.05). Regarding OCT characteristics of target vessels, comparing to non-layered plaque erosion group, the fibrous cap was thinner [(91.78±7.89)μm, (120.89±7.18)μm], the lipid plaque radian was larger [(270.21±59.89)°, (206.58±58.61)°], the minimum lumen area (MLA) was smaller [(1.25±0.21)mm2, (1.77±0.24)mm2], and the degree of vascular stenosis was more severe [(88.38±9.56)%, (76.45±8.38)%] in layered plaque erosion group (t=14.96, 2.48, 8.87, 2.56, all P<0.05). Compared to those in non-layered plaque erosion group, the macrophages [19/28(67.86%), 12/32(37.50%)], nourishing vessels [8/28(28.57%), 2/32(6.25%)], cholesterol crystallization [15/28(53.57%), 8/32(25.00%)], clot burden [25/28(89.29%), 21/32(65.63%)], and thin-cap fibroatheroma [20/28(71.43%), 14/32(43.75%)] were found more frequently in layered plaque erosion group (χ2=5.51, 3.87, 5.16, 4.67, 4.66, all P<0.05). The stent length [(30.00±5.64)mm, (18.00±7.42)mm], stent expansion ratio [14/28(50.00%), 8/32(25.00%)], stent malapposition [12/28(42.86%), 6/32(18.75%)] were significantly different between the layered plaque erosion and non-layered plaque erosion in AMI patients (t=9.32, χ2=4.02, 3.87, all P<0.05). Compared to non-layered plaque erosion group, AMI patients with layered plaque erosion might have more aggressive post-dilatations [22/28(78.57%), 10/32(31.25%)], and have higher post stent expansion pressure [(18.00±2.68)atm, (14.00±2.46)atm] (1 atm=101.3 kPa) (χ2=4.25, t=2.47, all P<0.05). In the 2 groups, the accumulated major adverse cardiovascular events (MACE) at 12 months postoperatively were related to target vessel revascularization, with 1 case and 2 cases, respectively. The target vessel revascularization rate in the layered plaque erosion group(2/28, 7.14%) was higher than that in the non-layered plaque erosion group (1/32, 3.13%), but the difference was not statistically significant (P=0.594).

Conclusion

The erosion of layered plaques is closely related to the characteristics of lesions and clinical manifestations of patients. OCT has potential application prospects in evaluating the therapeutic effects of PCI in AMI patients with eroded layered plaques, providing personalized treatment guidance.

Key words: Myocardial infarction, Percutaneous coronary intervention, Tomography, optical coherence, Layered plaque, Stent malapposition
表1 两组急性心肌梗死患者一般临床资料比较[例(%)]
项目 分层斑块发生侵蚀组(n＝28) 非分层斑块发生侵蚀组(n＝32) χ2值 P值
男性 23(82.14) 28(87.50) 0.05 >0.05
高血压病 11(39.29) 9(28.13) 0.84 >0.05
2型糖尿病 20(71.43) 16(50.00) 2.86 >0.05
高脂血症 24(85.71) 21(65.63) 3.21 >0.05
吸烟史 23(82.14) 21(65.63) 2.08 >0.05
临床表现        
急性非ST段抬高型心肌梗死 10(35.71) 12(37.50) 0.72 >0.05
急性ST段抬高型心肌梗死 18(64.29) 20(62.50) 0.72 >0.05
药物治疗        
阿司匹林 25(89.29) 28(87.50) 0.04 >0.05
P2Y12受体拮抗剂 10(35.71) 12(37.50) 0.02 >0.05
他汀类药物 25(89.29) 28(87.50) 0.04 >0.05
ACEI或ARB 20(71.43) 21(65.63) 0.23 >0.05
β受体阻滞剂 16(57.14) 21(65.63) 0.45 >0.05
钙通道阻滞剂 12(42.86) 12(37.50) 0.18 >0.05
表2 两组急性心肌梗死患者临床生化指标比较(±s)
项目 分层斑块发生侵蚀组(n＝28) 非分层斑块发生侵蚀组(n＝32) t值 P值
总胆固醇(mmol/L) 4.48±0.86 4.39±0.67 0.17 >0.05
低密度脂蛋白胆固醇(mmol/L) 3.38±0.27 2.42±0.15 6.00 <0.05
高密度脂蛋白胆固醇(mmol/L) 1.33±0.38 1.24±0.39 0.39 >0.05
甘油三酯(mmol/L) 1.97±0.47 1.96±0.48 0.04 >0.05
糖化血红蛋白(%) 7.38±0.24 6.00±0.58 3.23 <0.05
肾小球滤过率ml/(min·1.73 m2) 86.00±24.40 87.40±26.80 0.21 >0.05
表3 两组AMI患者CAG与OCT参数的比较
项目 分层斑块发生侵蚀组(n＝28) 非分层斑块发生侵蚀组(n＝32) 统计量 P值
罪犯血管        
前降支[例(%)] 18(64.29) 12(37.50) χ2＝4.29 <0.05
回旋支[例(%)] 6(21.42) 9(28.12) χ2＝0.36 >0.05
右冠状动脉[例(%)] 4(14.29) 11(34.38) χ2＝3.21 >0.05
血管造影        
B2/C型[例(%)] 16(57.14) 8(25.00) χ2＝6.43 <0.05
病变长度(mm，±s) 28.64±4.38 15.23±4.32 t＝11.92 <0.05
OCT评估        
脂质斑块[例(%)] 15(53.57) 15(46.87) χ2＝5.16 >0.05
纤维斑块[例(%)] 6(21.43) 9(28.13) χ2＝0.40 >0.05
钙化斑块[例(%)] 7(25.00) 8(25.00) χ2＝5.16 >0.05
最薄纤维帽厚度(μm，±s) 91.78±7.89 120.89±7.18 t＝14.96 <0.05
薄纤维帽粥样硬化斑块[例(%)] 20(71.43) 14(43.75) χ2＝4.66 <0.05
脂质长度(mm，±s) 10.68±4.68 8.29±2.21 t＝2.58 >0.05
平均脂质弧(°，±s) 270.21±59.89 206.58±58.61 t＝2.48 <0.05
巨噬细胞浸润[例(%)] 19(67.86) 12(37.50) χ2＝5.51 <0.05
胆固醇结晶[例(%)] 15(53.57) 8(25.00) χ2＝5.16 <0.05
血栓负荷[例(%)] 25(89.29) 21(65.63) χ2＝4.67 <0.05
滋养血管[例(%)] 8(28.57) 2(6.25) χ2＝3.87 <0.05
最小管腔面积(mm2，±s) 1.25±0.21 1.77±0.24 t＝8.87 <0.05
参考管腔面积(mm2，±s) 6.74±2.13 7.95±2.48 t＝2.01 >0.05
面积狭窄率(%，±s) 88.38±9.56 76.45±8.38 t＝2.56 <0.05
表4 两组AMI患者介入治疗及支架术后OCT结果比较
项目 分层斑块发生侵蚀组(n＝28) 非分层斑块发生侵蚀组(n＝32) 统计量 P值
介入手术        
预扩张[例(%)] 21(75.00) 18(56.25) χ2＝2.31 >0.05
后扩张[例(%)] 22(78.57) 10(31.25) χ2＝4.25 <0.05
后扩张压力(atm，±s) 18.00±2.68 14.00±2.46 t＝2.47 <0.05
支架直径(mm，±s) 2.95±0.36 3.06±0.38 t＝1.14 >0.05
支架长度(mm，±s) 30.00±5.64 18.00±7.42 t＝9.32 <0.05
无复流[例(%)] 2(7.14) 2(6.25) χ2＝1.00 >0.05
OCT定性评估        
支架膨胀不全[例(%)] 14(50.00) 8(25.00) χ2＝4.02 <0.05
支架断裂[例(%)] 0 0    
支架边缘夹层[例(%)] 3(10.71) 4(12.50) － >0.05
支架不规则突出[例(%)] 5(17.86) 3(9.38) － >0.05
支架贴壁不良[例(%)] 12(42.86) 6(18.75) χ2＝3.87 <0.05
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