Application of trypsin-like to preparation of product for evaluating prognosis of interventional therapy of acute ST segment elevation myocardial infarction

Abstract

The invention relates to the field of biomarkers, in particular to application of trypsin-like to preparation of a product for evaluating prognosis of interventional therapy of acute ST segment elevation myocardial infarction. On the basis, the invention further provides a prediction model capable of evaluating the acute ST segment elevation myocardial infarction interventional therapy prognosis, and the model comprises a tryptase expression level, a traditional TIMI risk scoring system and clinical information of a patient. The method has extremely high prediction accuracy on whether MACE occurs after acute ST segment elevation myocardial infarction interventional therapy, can be effectively used for clinically and early identifying high-risk groups with poor prognosis of STEMI patients, and provides powerful support for treatment decision and prognosis management of the patients.

Description

Technical Field

[0001] The present invention relates to the field of biomarkers, and in particular, to the use of a tryptase in the preparation of a product for evaluating the prognosis of interventional treatment of acute ST-segment elevation myocardial infarction. Background Art

[0002] Ischemic heart disease is one of the leading causes of death worldwide, of which acute ST-segment elevation myocardial infarction (STEMI) is the most serious type. Primary percutaneous coronary intervention (PPCI) is the most important treatment for STEMI. In STEMI patients, there is a strong inflammatory response during plaque rupture, thrombosis, and reperfusion.

[0003] It is known that multiple cell types are involved in inflammatory responses, including macrophages, lymphocytes, dendritic cells, and mast cells (MCs). Among them, cardiac MCs are mainly distributed in the coronary artery adventitia and cardiac interstitium. MCs are activated through multiple pathways after myocardial infarction, producing a variety of inflammatory cytokines (such as tumor necrosis factor-α, interferon-γ, interleukin-6), histamine, chymotrypsin, tryptase, and matrix metalloproteinases to participate in atherosclerotic plaque rupture, inappropriate ventricular remodeling, and myocardial fibrosis. Among them, tryptase is stored in MCs in the form of vesicles, which is the gold standard for evaluating the degree of MC activation. In clinical studies, MC activators, immunoglobulin E, increased significantly in the acute phase of STEMI. Serum tryptase was negatively correlated with the ST segment resolution rate and left ventricular ejection fraction (LVEF) on the electrocardiogram 2 hours after PPCI.

[0004] However, to date, the relationship between acute tryptase and long-term major adverse cardiovascular events (MACE) in STEMI patients is still unclear. Summary of the invention

[0005] In order to fill the gap in the prior art, the present invention provides an application of tryptase in preparing a product for evaluating the prognosis of interventional treatment of acute ST-segment elevation myocardial infarction (STEMI).

[0006] First, in a first aspect, the present invention provides a use of tryptase in preparing a product for evaluating the prognosis of interventional treatment of acute ST-segment elevation myocardial infarction (STEMI).

[0007] In a second aspect, the present invention provides an application of a prognosis prediction model in the preparation of a product for evaluating the prognosis of interventional treatment of acute ST-segment elevation myocardial infarction (STEMI), wherein the prognosis prediction model is composed of the expression level of tryptase in a patient sample and the patient's clinical information, and the clinical information includes the traditional TIMI risk scoring system (age, hypertension, diabetes, angina pectoris, systolic blood pressure, heart rate, Killip grade, weight, electrocardiogram, time of consultation), complete revascularization, segmental motion abnormalities, left ventricular ejection fraction, hemoglobin and left ventricular global longitudinal strain data.

[0008] In one embodiment, the application refers to substituting the tryptase expression level in the patient sample and the patient's clinical information into the nomogram, and obtaining the patient's 1-year, 3-year, and 5-year MACE-free probability through the nomogram.

[0009] In one embodiment, the patient sample is patient plasma.

[0010] In a preferred embodiment, the plasma is from a blood sample collected 6 hours after the patient completes PPCI treatment.

[0011] In one embodiment, the aforementioned product is a kit. BRIEF DESCRIPTION OF THE DRAWINGS

[0012] The accompanying drawings are used to provide a further understanding of the present invention and constitute a part of the specification. Together with the embodiments of the present invention, they are used to explain the present invention and do not constitute a limitation of the present invention. In the accompanying drawings: Figure 1 The difference in endpoint events between the tryptase increase group and the tryptase decrease group; Figure 2 KM curves of various endpoint events in the tryptase increase group and the tryptase decrease group; Figure 3 LASSO regression analysis for major adverse cardiovascular events. The adjustment parameter (λ) was selected by 10-fold cross validation (A), and the LASSO coefficient curve of the variable (B); Figure 4 To compare the discriminatory ability of different prediction models and determine the incremental prognostic value of tryptase. (A) is the nomogram of model 5; (B) is the ROC curve of the two analysis models; (C) is the comparison of the discriminatory ability of the two analysis models. DETAILED DESCRIPTION

[0013] The preferred embodiments of the present invention are described below in conjunction with the accompanying drawings. It should be understood that the preferred embodiments described herein are only used to illustrate and explain the present invention, and are not used to limit the present invention.

[0014] Example 1 Screening of biomarkers and establishment of diagnostic model Study Design and Population This is a single-center prospective cohort study that included STEMI patients who completed PPCI and visited Peking University Third Hospital from July 2020 to July 2023. Inclusion criteria were 1) aged 18 years and above and under 80 years, regardless of gender; 2) met the STEMI diagnostic criteria (diagnostic criteria: ischemic chest pain lasting ≥30 minutes; ST segment elevation or new left bundle branch block in two or more adjacent leads on the electrocardiogram; with or without elevated myocardial markers); 3) completed PPCI and opened the culprit vessel; 4) agreed to participate in this study and signed the informed consent form. Exclusion criteria were: 1) combined with chronic renal insufficiency, glomerular filtration rate <30ml / min / 1.73m 2 ; 2) Infectious or tumorous diseases; 3) Combined with allergic or autoimmune diseases; 4) Patients are currently using or planning to use long-term oral or intravenous glucocorticoids. This study followed the Declaration of Helsinki and was approved by the Ethics Committee of Peking University Third Hospital.

[0015] Data Collection The general demographic characteristics, including gender, age, past medical history, medication history, laboratory tests, and echocardiogram results were collected through the inpatient electronic medical record system. All patients underwent selective coronary angiography. Two experienced surgeons determined the culprit vessel based on the electrocardiogram and coronary angiography results and performed PPCI treatment. After surgery, the clinician decided on the use of secondary prevention drugs for coronary heart disease based on the patient's condition.

[0016] Tryptase detection Blood samples were collected using EDTA anticoagulant 6 hours after the patient completed PPCI treatment and immediately stored in a 4°C refrigerator. Within 30 minutes after blood collection, the samples were centrifuged at 3000 rpm for 10 minutes at 4°C to obtain plasma, which was then frozen in a -80°C refrigerator until analysis. Repeated freezing and thawing of samples was avoided during this period. The level of tryptase in plasma was detected according to the manufacturer's product instructions (ml060170B, mlbio, Shanghai China).

[0017] To observe the stability of tryptase detection between different batches, 50 patients were randomly selected for repeated testing. The consistency of the results between different batches was calculated, the model was single randomization, and the type was consistency. The results showed that the consistency was excellent: the consistency between observers could reach 0.999 (95%CI: 0.999-1.000).

[0018] Follow-up strategy Patient follow-up information was obtained through the outpatient or inpatient system. For patients who did not have regular follow-up in the outpatient clinic, telephone follow-up was conducted once every six months. The primary endpoint of this study was MACE, including cardiac death, all-cause death, rehospitalization due to heart failure, and recurrent coronary events (recurrent myocardial infarction, unplanned PCI, and coronary artery bypass grafting). The secondary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), including MACE and stroke. The above events were independently judged by two experienced cardiologists who were unaware of the tryptase concentration to determine whether they were target events. If the judgments of the two doctors were inconsistent, a third senior doctor would make the decision.

[0019] Statistical methods According to the results of the preliminary study, 51 patients were included and divided into the exposed group and the non-exposed group based on the median TPS of 1.62 ng / ml. After 1 year of follow-up, 3 patients (12.00%) in the non-exposed group (25 cases) and 6 patients (23.08%) in the exposed group (26 cases) developed MACE. The sample size was calculated using PASS, with β=0.10 and α=0.05, requiring a sample size of 492 cases. According to the loss rate of 10%, a total of 541 patients were required.

[0020] Normally distributed continuous variables were expressed as mean ± standard deviation, and the independent sample t test was used for comparison between the two groups. Non-normally distributed continuous variables were expressed as quartiles, and the rank sum test was used for comparison between the two groups. Categorical variables were expressed as number of cases and percentages, and the chi-square test was used for comparison. The relationship between tryptase and traditional cardiovascular risk factors was evaluated by drawing restricted cubic bar charts (RCS). According to the optimal cutoff value of tryptase, the patients were divided into the tryptase-increased group and the tryptase-decreased group. The Kaplan-Meier method was used for survival analysis, and the survival curves of the two groups were drawn. The inter-group comparison was performed by log-rank. LASSO regression was used to screen the variables for COX multivariate analysis. The risk stratification effect of tryptase on MACE was determined by COX multivariate regression to adjust potential confounding factors, and the HR value was calculated with a 95% CI. The patients were classified according to general demographic data to evaluate the predictive effect of tryptase on the prognosis of STEMI patients in different subgroups.

[0021] result 1. Population characteristics A total of 823 STEMI patients who visited Peking University Third Hospital from July 2020 to July 2023 were screened, 42 patients were excluded due to other diseases, and 31 patients were excluded due to less than 8 months of follow-up. A total of 750 patients were included in the final analysis, of which 514 patients were randomly selected as the screening set and 236 patients were selected as the validation set. Among the 514 screening set patients, the age was 59.27 ± 13.26 years, 87 patients were female (16.93%), and 199 patients had anterior wall myocardial infarction (38.72%) (Table 1). During the median follow-up time of 13.28 (10.47, 37.61) months, 85 (16.54%) MACEs and 89 (17.32%) MACCEs occurred, including 12 (2.33%) cardiac deaths, 22 (4.28%) all-cause deaths, 17 (3.31%) rehospitalizations due to HF, 51 (9.92%) recurrent coronary events, and 6 (1.17%) strokes.

[0022] Table 1 Clinical characteristics of acute ST-segment elevation myocardial infarction treated with primary coronary intervention

[0023]

[0024] The optimal cutoff value of 2.20 ng / ml was determined by the ROC curve of tryptase on MACE to detect whether the tryptase concentration in the patient sample was higher or lower than the optimal cutoff value, and the patients were divided into an elevated tryptase group and a reduced tryptase group. In the elevated tryptase group, the proportion of patients requiring device assistance (intra-aortic balloon counterpulsation and extracorporeal membrane oxygenation), anterior myocardial infarction and Killip grade II and above, thrombus in myocardial infarction (TIMI) risk score and creatine kinase isoenzyme peak were higher than those in the reduced tryptase group, while hemoglobin, LVEF and left ventricular strain were lower than those in the reduced tryptase group. There were no statistically significant differences in age, gender, comorbidities and secondary prevention medications for coronary heart disease between the two groups (Table 1). The incidence of MACE, the composite endpoint of rehospitalization for heart failure and cardiac death, and recurrent coronary events in the elevated tryptase group were significantly higher than those in the reduced tryptase group ( Figure 1 ).

[0025] 2. Relationship between tryptase and prognosis of STEMI patients The Kaplan-Meier method was used to further analyze the survival of the two groups. There were significant differences in MACE (HR 2.60 (1.68, 4.01), P <0.001), cardiac death and rehospitalization due to heart failure (HR 3.02 (1.44-6.33), P = 0.002), and recurrent coronary events (HR 2.31 (1.31, 4.10), P = 0.003) between the patients with elevated tryptase and those with reduced tryptase. Figure 2 ).

[0026] 3. Correlation between tryptase and MACE risk In univariate COX regression analysis, Killip grade (HR 2.65, 95%CI: (1.70 -4.14), P<0.001), multivessel disease (HR 2.02, 95%CI: (1.21 - 3.37), P=0.007), complete revascularization (HR0.29, 95%CI: (0.18 - 0.46), P<0.001), hemoglobin (HR 0.98, 95%CI: (0.97 -0.99), P<0.001), tryptase (HR 1.98, 95%CI: (1.70 - 2.34), P<0.001), CKMB peak >300U / L (HR2.33, 95%CI: (1.47 - 3.70), P<0.001), left ventricular ejection fraction (HR 0.94, 95%CI: (0.92 - 0.95), P<0.001), segmental motion abnormalities (HR 2.42, 95%CI: (1.04 - 5.63), P=0.039) and the absolute value of left ventricular longitudinal strain (HR 0.79, 95%CI: (0.74 - 0.85), P=0.002) were all predictors of MACE.

[0027] In order to reduce the risk of overfitting, the variables in Table 1 were included in the LASSO regression to screen COX multivariate regression variables. Using 10-fold fork validation folds, the lambda value with the smallest mean square error was selected, and multivessel disease, complete revascularization, left ventricular ejection fraction, segmental dyskinesis, hemoglobin, absolute value of left ventricular longitudinal strain, and tryptase were included in the COX multivariate analysis ( Figure 3 Multivariate analysis showed that tryptase (HR 1.56 (1.29 - 1.88), P<0.001) was an independent influencing factor for the long-term MACE after PPCI in STEMI patients (Table 2).

[0028] Table 2. COX regression analysis of major adverse cardiovascular events and major adverse cardiovascular and cerebrovascular events

[0029] 4. COX regression to control confounding variables According to the rough model of univariate COX regression analysis, elevated tryptase is a risk factor for poor prognosis in STEMI patients (HR 1.98 (1.70 - 2.34), P<0.001). After adding demographic characteristics and comorbidities to model 2, and adding multivessel disease, complete revascularization, door-to-balloon time, hemoglobin, left ventricular ejection fraction, left ventricular longitudinal strain, and coronary artery disease drug treatment to model 3, tryptase still has a significant effect on the prognosis of STEMI patients (HR 1.96 (1.57 -2.4589), P<0.001). And according to the optimal cutoff value of tryptase, it is used as a binary variable, which is still of great significance for prognosis. (Table 3) Table 3: COX regression model of tryptase on major adverse cardiovascular events

[0030] Note: The variables in each model are: Model 1: Tryptase Model 2: adjusted for sex, age, smoking, hypertension, diabetes, and hyperlipidemia Model 3: Model 2 was adjusted for multivessel disease, complete revascularization, door-to-balloon time, hemoglobin, left ventricular ejection fraction, left ventricular longitudinal strain, and beta-blockade, angiotensin-converting enzyme inhibitors, and angiotensin receptor antagonists.

[0031] According to the optimal cut-off value of tryptase, the patients were divided into the elevated group and the decreased group. Example 2 Evaluation of the performance of the trypsin prediction model In order to study the incremental value of tryptase in predicting MACE, the traditional TIMI risk scoring system (age, hypertension, diabetes, angina, systolic blood pressure, heart rate, Killip grade, weight, electrocardiogram, and time of consultation) was used as model 4, and variables with multivariate COX regression p < 0.05 (complete revascularization, segmental dyskinesis, left ventricular ejection fraction, hemoglobin, tryptase, and left ventricular global longitudinal strain) were further added to construct model 5, and a nomogram was drawn (the values ​​of the variables TIMI risk score, complete revascularization, segmental dyskinesis, left ventricular ejection fraction, hemoglobin, tryptase, and left ventricular global longitudinal strain were obtained within 24 hours after surgery). The score of each variable in model 5 corresponding to the first row of the nomogram was calculated, and each score was added. According to the total score, the probability of being free of MACE in 1 year, 3 years, and 5 years can be calculated for the patient ( Figure 4A). The results showed that compared with model 4, model 5 containing tryptase had a higher ability to discriminate MACE events (AUC: 0.877 vs. 0.628, p<0.001). The sensitivity and specificity of model 5 were 83.2% and 88.5%, respectively ( Figure 4 B and C).

[0032] In order to prove that tryptase also has the same predictive value in MACCE, sensitivity analysis was performed using MACCE instead of MACE. In the group with elevated tryptase, the incidence of MACCE was still significantly higher than that in the group with decreased tryptase ( Figure 1 ). Kaplan–Meier survival curve analysis showed that there was a difference in prognosis between the two groups MACCE (HR 2.77 (1.81- 4.23), P < 0.001) ( Figure 2 In the multivariate regression model, tryptase was still an important predictor of MACCE (HR 2.07 (1.52-2.83), P < 0.001) (Table 2).

[0033] Example 3 Clinical application of trypsin prediction model To further verify the predictive accuracy of Model 5, we used 236 validation set patients randomly selected from previously collected plasma markers for validation. Among the 236 validation set patients, the age was 60.18 ± 11.75 years, 43 (18.22%) were female, and the median follow-up time was 21.45 (10.47, 32.61) months.

[0034] Model 5 and its nomogram were used to predict the probability of being free of MACE in the validation set for 1, 3, and 5 years, including cardiac death, all-cause death, rehospitalization due to heart failure, and recurrent coronary events (recurrent myocardial infarction, unplanned PCI, and coronary artery bypass grafting), and patient information was collected through clinical monitoring and follow-up. Two experienced cardiologists who were unaware of the tryptase concentration independently judged whether the above events were target events. If the two doctors disagreed, a third senior doctor would make the decision.

[0035] Among the patients in the validation set, 36 cases (15.25%) of MACE occurred, of which 15 occurred within one year, of which 12 (80.00%) were the same as predicted by Model 5, and 224 patients did not have MACE, of which 185 (83.71%) were the same as predicted by Model 5; 33 cases occurred within three years, of which 26 (78.79%) were the same as predicted by Model 5, and 260 patients did not have MACE, of which 207 (79.61%) were the same as predicted by Model 5. The results showed that Model 5 had a very high predictive value for whether MACE would occur in STEMI patients after PPCI surgery.

[0036] Obviously, those skilled in the art can make various changes and modifications to the present invention without departing from the spirit and scope of the present invention. Thus, if these modifications and variations of the present invention fall within the scope of the claims of the present invention and their equivalents, the present invention is also intended to include these modifications and variations.

Claims

1. Application of a tryptase in the preparation of a product for evaluating the prognosis of interventional treatment of acute ST-segment elevation myocardial infarction (STEMI).

2. Application of a prognosis prediction model in the preparation of a product for evaluating the prognosis of interventional treatment of acute ST-segment elevation myocardial infarction (STEMI), wherein: The prognostic prediction model is composed of the tryptase expression level in the patient sample and the patient's clinical information, which includes the traditional TIMI risk scoring system (age, hypertension, diabetes, angina pectoris, systolic blood pressure, heart rate, Killip grade, weight, electrocardiogram, and time of consultation), complete revascularization, segmental motion abnormalities, left ventricular ejection fraction, hemoglobin, and left ventricular global longitudinal strain data.

3. The use according to claim 2, characterized in that The application refers to substituting the tryptase expression level in the patient sample and the patient's clinical information into the nomogram, and obtaining the patient's 1-year, 3-year, and 5-year MACE-free probability through the nomogram.

4. The use according to claim 2 or 3, characterized in that The patient sample refers to patient plasma.

5. The use according to claim 4, characterized in that The plasma was obtained from a blood sample drawn 6 hours after the patient completed PPCI treatment.

6. The use according to claim 1 or 2, characterized in that: The product is a test kit.

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