脂蛋白(a)联合TyG指数对冠心病合并 2型糖尿病患者首次PCI术后非致命性 心肌梗死的预测价值

Predictive Value of Lipoprotein(a) Combined with TyG Index for Non-Fatal Myocardial Infarction after First PCI in Patients with Coronary Heart Disease Complicated with Type 2 Diabetes

摘要: 目的：探究脂蛋白(a) (lipoprotein(a), Lp(a))联合甘油三酯–葡萄糖指数(triglyceride-glucose index, TyG)对冠心病(coronary heart disease, CHD)合并2型糖尿病(type 2 diabetes mellitus, T2DM)患者首次经皮冠状动脉介入(percutaneous coronary intervention, PCI)术后非致命性心肌梗死的预测价值。方法：回顾性分析2020年1月至2023年1月首次在青岛大学附属医院接受PCI术治疗的586例CHD合并T2DM患者的临床资料，对患者进行术后随访并记录非致命性心肌梗死发生情况。根据术后是否发生非致命性心肌梗死，将患者分为非致命性心梗组(n = 115)和无非致命性心梗组(n = 471)。比较两组患者强效他汀使用率；采用Bootstrap重抽样法(重抽样1000次)校正ROC曲线的AUC及95%置信区间以验证模型稳定性；同时纳入糖化血红蛋白(HbA1c)作为对照指标。采用多因素Cox比例风险回归模型分析术后发生非致命性心肌梗死的危险因素，绘制受试者工作特征(receiver operating characteristic, ROC)曲线并计算曲线下面积(area under the curve, AUC)，评估Lp(a)、TyG指数单独及联合检测对术后非致命性心梗的预测效能。结果：非致命性心梗组患者的Lp(a)水平、TyG指数均显著高于无非致命性组(均P < 0.05)，而两组患者强效他汀使用率无显著差异(P = 1.000)。多因素Cox回归分析显示，高Lp(a)水平(HR = 3.240, 95% CI: 2.237~4.692, P < 0.05)和高TyG指数(HR = 3.330, 95% CI: 2.297~4.829, P < 0.001)是CHD合并T2DM首次PCI术后发生非致命性心肌梗死的独立危险因素；同时高Lp(a)联合高TyG指数的患者术后发生非致命性心肌梗死的风险最高(HR = 13.380, 95% CI: 6.578~27.213, P < 0.001)。ROC曲线分析显示，Lp(a)、TyG指数及二者联合模型的AUC分别为0.626，0.657，0.727。TyG指数的AUC (0.657)显著高于HbA1c (0.538) (Z = 4.290, P < 0.001)。经Bootstrap 1000次重抽样验证，Lp(a)和TyG指数联合模型平均AUC为0.637 (95% CI: 0.575~0.701)，提示模型稳定性良好。结论：Lp(a)、TyG指数与CHD合并T2DM患者首次PCI术后非致命性心肌梗死的发生显著相关，且二者联合检测的预测效能优于单一指标，经Bootstrap验证模型稳定性良好，可作为术后非致命性心肌梗死的有效预测指标。

Abstract: Objective: To explore the predictive value of lipoprotein(a) (Lp(a)) combined with the triglyceride-glucose (TyG) index for non-fatal myocardial infarction after the first percutaneous coronary intervention (PCI) in patients with coronary heart disease (CHD) with type 2 diabetes mellitus (T2DM). Methods: A retrospective analysis was conducted on the clinical data of 586 patients with CHD complicated by T2DM who underwent PCI for the first time at Qingdao University Hospital between January 2020 and January 2023. Patients were followed up postoperatively, and the occurrence of non-fatal myocardial infarction was recorded. Patients were categorized into a non-fatal MI group (n = 115) and a non-fatal MI-free group (n = 471) based on postoperative non-fatal MI occurrence. The use of high-intensity statins was compared between the two groups. Bootstrap resampling (1000 resamples) was employed to correct the AUC and 95% confidence interval of the receiver operating characteristic (ROC) curve to validate model stability. Glycated hemoglobin (HbA1c) was included as a control indicator. Multivariate Cox proportional hazards regression analysis was performed to identify risk factors for postoperative non-fatal myocardial infarction. ROC curves were plotted, and the area under the curve (AUC) was calculated to evaluate the predictive performance of Lp(a) and TyG index, both individually and in combination, for postoperative non-fatal myocardial infarction. Results: Patients in the non-fatal myocardial infarction group exhibited significantly higher Lp(a) levels and TyG indices compared to the non-non-fatal group (both P < 0.05), while there was no significant difference in the use of intensive statins between the two groups (P = 1.000). Multivariate Cox regression analysis revealed that elevated Lp(a) levels (HR = 3.240, 95% CI: 2.237~4.692, P < 0.05) and high TyG index (HR = 3.330, 95% CI: 2.297~4.829, P < 0.001) were independent risk factors for non-fatal myocardial infarction after initial PCI in patients with CHD and T2DM, while patients with both elevated Lp(a) and high TyG index exhibited the highest risk of postoperative non-fatal myocardial infarction (HR = 13.380, 95% CI: 6.578~27.213, P < 0.001). ROC curve analysis revealed AUC values of 0.626, 0.657, and 0.727 for Lp(a), TyG index, and the combined model, respectively. The TyG index AUC (0.657) was significantly higher than those of glycated hemoglobin (HbA1c) (0.538) (Z = 4.290, P < 0.001). Bootstrap resampling (n = 1000) validated the combined Lp(a) and TyG index model with a mean AUC of 0.637 (95% CI: 0.575~0.701), indicating good model stability. Conclusions: Lp(a) and TyG index are significantly correlated with the occurrence of non-fatal myocardial infarction in patients with CHD and T2DM after their first PCI procedure. The predictive performance of their combined detection is superior to that of either index alone. The model’s stability has been verified through Bootstrap analysis, indicating that it can serve as an effective predictor of non-fatal myocardial infarction after the procedure.