沙库巴曲缬沙坦治疗老年急性心肌梗死合并心力衰竭后胰岛素样生长因子-1水平对心室重塑的预测价值

The Predictive Value of Insulin-Like Growth Factor-1 Levels After Sacubitril/Valsartan Treatment for Elderly Patients With Acute Myocardial Infarction and Heart Failure on Ventricular Remodeling

摘要

目的 探究老年急性心肌梗死合并心力衰竭患者经沙库巴曲缬沙坦治疗后胰岛素样生长因子-1 （insulin-like growth factor-1，IGF-1）水平对心室重塑的预测价值。方法 选取 2021 年 5 月至 2024 年 5 月于陇南市第一人民医院收治的 120 例老年急性心肌梗死合并心力衰竭患者为研究对象，所有患者均接受经皮冠状动脉介入治疗（percutaneous coronary intervention，PCI），术后予沙库巴曲缬沙坦治疗。根据治疗 4 周后 IGF-1 的中位数水平（118.6 ng∙mL^-1）将患者分为低水平组（n= 65）和高水平组（n= 55），比较 2 组患者的一般资料，构建 Logistic 回归模型，模型 1 至模型 4 逐步纳入协变量分层校正，并采用方差膨胀因子（variance inflation factor，VIF）筛查剔除多重共线性变量，分析老年急性心肌梗死合并心力衰竭患者 IGF-1 水平与心室重塑发生风险的独立相关性；另根据左心室舒张末期容积指数增加率（percentage change in left ventricular end-diastolic volume index，ΔLVEDVI）将患者分为左心室重塑组（ΔLVEDVI > 20%， n= 67）和无左心室重塑组（ΔLVEDVI ≤ 20%，n= 53），比较 2 组患者的一般资料，构建中介模型，分析一氧化氮（nitric oxide，NO）、内皮型一氧化氮合酶（endothelial nitric oxide synthase，eNOS）、白细胞介素-6 （interleukin-6，IL-6）、在 IGF-1 与左心室重构之间的中介效应。结果 不同 IGF-1 水平患者的导管介入时间、空腹血糖、糖化血红蛋白（glycated hemoglobin，HbA1c）、C 反应蛋白（C-reactive protein，CRP）、NO、eNOS、IL-6、左心室质量指数（left ventricular mass index，LVMI）、舒张期室间隔厚度（interventricular septal thickness，IVST）及舒张期左室后壁厚度（left ventricular posterior wall thickness，LVPWT）水平差异均具有统计学意义（P< 0.05）；经 Logistic 回归分层校正协变量、VIF 筛查剔除共线性变量后，IGF-1 与患者心室重塑发生风险仍存在独立相关性。中介效应模型分析结果显示，NO、eNOS、IL-6 均在 IGF-1 与左心室重塑之间发挥部分中介效应（P< 0.001）。结论 老年急性心肌梗死合并心力衰竭、急诊 PCI 术后患者经沙库巴曲缬沙坦治疗 4 周后，血清 IGF-1 水平与心室重塑发生风险呈独立负相关，IGF-1 水平越低，患者发生心室重塑的风险越大。治疗后 IGF-1 可作为潜在生物标志物用于评估老年心力衰竭患者心室重塑发生风险，为阐释心室重塑的发生机制及心力衰竭的防治提供新的思路。

Abstract

Objective To explore the predictive value of insulin-like growth factor-1 (IGF-1) level for ventricular remodeling in elderly patients with acute myocardial infarction complicated by heart failure after sacubitril/valsartan treatment. Methods A total of 120 elderly patients with acute myocardial infarction complicated by heart failure admitted to Longnan First People's Hospital from May 2021 to May 2024 were enrolled as subjects. All patients received percutaneous coronary intervention (PCI) followed by sacubitril/ valsartan treatment after procedure. According to the median level of IGF-1 (118.6 ng·mL^-1) after 4 weeks of treatment, the patients were divided into low-level group (n= 65) and high-level group (n= 55), and the general data of the two groups were compared. Logistic regression models were constructed, with covariates gradually included for stratified adjustment from model 1 to model 4. The variance inflation factor (VIF) was used to detect and eliminate collinear variables, so as to analyze the independent correlation between IGF-1 level and the risk of ventricular remodeling in elderly patients with acute myocardial infarction complicated by heart failure. In addition, the patients were divided into left ventricular remodeling group (ΔLVEDVI > 20%,n= 67) and left ventricular non-remodeling group (ΔLVEDVI ≤ 20%, n= 53) according to the percentage change in left ventricular end-diastolic volume index (ΔLVEDVI). The general data of the two groups were compared, and a mediation model was established to analyze the mediating roles of nitric oxide (NO), endothelial nitric oxide synthase (eNOS), interleukin-6 (IL-6) between IGF-1 and left ventricular remodeling. Results There were statistically significant differences in PCI procedure time, fasting blood glucose, glycated hemoglobin (HbA1c), C-reactive protein (CRP), NO, eNOS, IL-6, left ventricular mass index (LVMI), end-diastolic interventricular septal thickness (IVST) and end-diastolic left ventricular posterior wall thickness (LVPWT) among patients with different IGF-1 levels (P< 0.05). After stepwise adjustment of covariates by Logistic regression and elimination of collinear variables by VIF screening, IGF-1 still showed an independent correlation with the risk of ventricular remodeling. The mediation model analysis showed that NO, eNOS and IL-6 all exerted partial mediating effects between IGF-1 and left ventricular remodeling (P< 0.001).Conclusion In elderly patients with acute myocardial infarction complicated by heart failure after PCI, serum IGF-1 level is independently and negatively correlated with the risk of ventricular remodeling after 4 weeks of sacubitril/valsartan treatment. The lower the IGF-1 level, the higher the risk of ventricular remodeling. Post- treatment IGF-1 can be used as a potential biomarker to assess the risk of ventricular remodeling in elderly patients with heart failure, providing new insights for elucidating the mechanism of ventricular remodeling and the prevention and treatment of heart failure.

关键词

沙库巴曲缬沙坦 / 急性心肌梗死 / 心力衰竭 / 胰岛素样生长因子-1 / 心室重塑

Key words

sacubitril/valsartan / acute myocardial infarction / heart failure / insulin-like growth factor-1 / ventricular remodeling

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基金资助

陇南市科学技术局项目(2023-S·SZ-56)