盛樂智　陳秋靜　張　奇　陸 林　沈衛(wèi)峰　張瑞巖

200025 上海交通大學醫(yī)學院附屬瑞金醫(yī)院心臟科心血管病研究所

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血清S100B、S100A6、S100P水平升高與急性冠脈綜合征的相關(guān)性研究

盛樂智陳秋靜張奇陸 林沈衛(wèi)峰張瑞巖

200025 上海交通大學醫(yī)學院附屬瑞金醫(yī)院心臟科心血管病研究所

【摘要】目的：探討血清終末糖基化產(chǎn)物受體(RAGE)的配基S100B、S100A6、S100P水平與急性冠脈綜合征(ACS)相關(guān)性。方法：連續(xù)收集882例冠狀動脈造影患者，檢測血清S100B、S100A6、S100P、游離RAGE(sRAGE)、腫瘤壞死因子(TNF)-α水平；根據(jù)臨床表現(xiàn)及實驗室資料,將患者分為對照組(n=251)、穩(wěn)定型心絞痛(SA)組(n=211)及ACS組(n=420)。結(jié)果：ACS組血清S100B、S100A6、S100P和TNF-α水平[(103.73±56.90)ng/L、(5.28±4.15) μg/L、(8.73±7.96) μg/L、(87.82±39.30)ng/L]均顯著高于SA組[(81.93±27.65) ng/L、(4.36±2.45) μg/L、(3.41±3.08) μg/L、(71.88±30.70) ng/L]和對照組[(78.00±22.71) ng/L、(3.97±2.57) μg/L、(3.38±2.74) μg/L、(57.07±27.23) ng/L，P<0.01]；ACS組血清sRAGE水平高于對照組[(724.01±320.37) ng/L 對(652.55±351.24) ng/L，P<0.01]。進一步將ACS組分為ST段抬高型心肌梗死(STEMI)和不穩(wěn)定型心絞痛/非ST段抬高型心肌梗死(UA/NSTEMI)2個亞組進行分析，STEMI亞組的S100B、S100A6、S100P水平高于UA/NSTEMI亞組；ACS組血清S100B水平與肌鈣蛋白I(cTnI)峰值水平相關(guān)(P<0.05)，血清S100P水平與肌酸激酶同工酶(CK-MB)及cTnI峰值水平均有相關(guān)性(P<0.01)。多元回歸分析發(fā)現(xiàn)，S100B、S100A6、S100P和傳統(tǒng)危險因素均與ACS發(fā)病相關(guān)。結(jié)論：血清S100B、S100A6、S100P水平與ACS相關(guān)，與心肌缺血的損傷程度相關(guān)，它們在ACS的病理生理過程中發(fā)揮重要作用。

【關(guān)鍵詞】急性冠脈綜合征；S100B；S100A6；S100P；終末糖基化產(chǎn)物受體

終末糖基化產(chǎn)物受體(RAGE)與心血管疾病及糖尿病并發(fā)癥密切相關(guān)，RAGE及其配基在動脈粥樣硬化形成及心肌缺血再灌注損傷中起關(guān)鍵作用[1-4]。S100蛋白超家族是RAGE的配體，由超過25個成員組成，在調(diào)節(jié)炎癥反應、組織退行性變、細胞增殖分化以及維持內(nèi)穩(wěn)中發(fā)揮重要作用[5]。一些S100家族成員如S100B、S100A6、S100P在體外實驗中被證實與RAGE結(jié)合并產(chǎn)生作用[6]，而關(guān)于S100B、S100A6和S100P是否參與了動脈粥樣硬化形成或心肌缺血后病變的相關(guān)臨床研究較少。

本研究檢測分析急性冠脈綜合征(ACS)患者和穩(wěn)定型心絞痛(SA)患者血清S100B、S100A6、S100P水平，出于研究需要，同時檢測游離RAGE(sRAGE)及腫瘤壞死因子(TNF)-α水平。因為sRAGE這種可溶性蛋白質(zhì)被金屬蛋白酶從細胞膜上切割后，可競爭性地與RAGE配體結(jié)合，發(fā)揮干預炎性配體的作用，對S100-RAGE軸產(chǎn)生影響；而細胞因子TNF-α在炎癥反應早期有致炎癥作用，后期則具有抗炎和免疫調(diào)節(jié)作用，具有雙重效應[7]。

1對象與方法

1.1研究對象

選擇2014年3月至2015年2月在我院心臟科接受冠狀動脈(冠脈)造影術(shù)(CAG)的882例患者。這些患者因嚴重或頑固胸悶、胸痛癥狀而入院，經(jīng)危險分層評估后，選擇侵入性或缺血驅(qū)動性策略，立即或擇期接受血管造影檢查[8]。SA、不穩(wěn)定型心絞痛(UA)、非ST段抬高型心肌梗死(NSTEMI)的定義依據(jù)美國心臟病學會(ACC)/美國心臟協(xié)會(AHA)2010指南，ST段抬高型心肌梗死(STEMI)的診斷依據(jù)其2013指南，2型糖尿病的診斷依據(jù)美國糖尿病協(xié)會標準[9]。由于心力衰竭可能對S100蛋白水平有潛在影響，故排除陳舊性心肌梗死和(或)嚴重心力衰竭患者。外傷史、惡性腫瘤、結(jié)締組織病、心臟瓣膜病、心肌病、感染及嚴重腎功能衰竭亦納入排除標準。

根據(jù)臨床表現(xiàn)和各項檢查結(jié)果，將患者分為對照組(n=251，管腔狹窄≤30%)、SA組(n=211)和ACS組(n=420)，其中ACS組又分為STEMI組(n=260)和UA/NSTEMI組(n=160)。

本研究經(jīng)醫(yī)院倫理委員會批準，并征得所有患者知情同意。

1.2方法

1.2.1CAG

通過橈動脈或股動脈路徑行CAG，心外膜主要冠脈包括左主干、前降支、回旋支和右冠狀動脈，左主干狹窄≥50%者可認為已達到雙支病變。

1.2.2生化檢測

所有血樣本均取空腹血，ACS患者在入院24 h內(nèi)采血，所有血樣本經(jīng)離心后取上層血清儲存于-80 ℃環(huán)境以備用。按照標準實驗室技術(shù)檢測血糖、糖化血紅蛋白、尿素氮、肌酐、尿酸、血脂項目，心肌酶譜包括肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、肌鈣蛋白I(cTnI)。使用酶聯(lián)免疫試劑盒檢測血清S100B、S100A6、S100P、sRAGE、TNF-α水平。

1.2.3統(tǒng)計分析

所有數(shù)據(jù)采用SPSS15.0軟件進行分析，計量資料以均數(shù)±標準差表示,分類資料描述為頻率或百分比，組間差異進行卡方檢驗；連續(xù)變量正態(tài)分布采用Kolmolgorov-Smirnov檢驗，非正態(tài)分布的連續(xù)變量進行對數(shù)或平方根轉(zhuǎn)換,組間比較采用單因素方差分析，變量間的相關(guān)分析采用Pearson和Spearman相關(guān)，構(gòu)建Logistic多元回歸模型評估發(fā)生ACS的獨立因素。以P<0.05為差異具有統(tǒng)計學意義。

2結(jié)果

2.1臨床資料和生化檢測

SA和ACS組中老年、男性和吸煙者均多于對照組(P<0.01)，高血壓和高脂血癥的比例也高于對照組(P<0.01)，2型糖尿病的發(fā)病率在3組間無統(tǒng)計學差異。生化檢測顯示SA和ACS組的低密度脂蛋白膽固醇(LDL-C)、載脂蛋白B、血尿素氮和肌酐水平高于對照組，但高密度脂蛋白膽固醇(HDL-C)和載脂蛋白A水平則低于對照組(P<0.01)；ACS組患者較SA組患者多支病變更為常見(P<0.01)。

2.2血清S100B、S100A6、S100P和炎癥因子水平

ACS組血清S100B、S100A6、S100P水平較其他兩組顯著升高，SA和對照組之間無明顯差異；對照組、SA組、ACS組的TNF-α水平依次遞升；ACS組的sRAGE水平高于對照組，與SA組并無顯著差異，見表1。

表1　各組血清S100蛋白、sRAGE及炎癥因子水平比較

注：與對照組比較,(1)P<0.01;與SA組比較,(2)P<0.01；與UA/NSTEMI組比較，(3)P<0.05

進一步比較ACS組亞組間的差異，STEMI組患者的S100B、S100A6、S100P、TNF-α水平均高于UA/NSTEMI組,而sRAGE水平無差異。

另外，S100B水平在SA組中與S100A6水平顯著相關(guān)(r=0.167,P<0.05)，在ACS組中與S100P顯著相關(guān)(r=0.313,P<0.001)。在所有分組中，S100A6水平均與TNF-α水平相關(guān)(P<0.05)。2.3血清S100B、S100A6、S100P與心肌缺血損傷程度的相關(guān)性

分析ACS組患者血清S100B、S100A6、S100P水平與心肌酶譜的關(guān)系，以探討此3種蛋白水平能否反映心肌缺血損傷嚴重度。結(jié)果發(fā)現(xiàn)血清S100B水平與cTnI的峰值水平相關(guān)(r=0.144,P<0.05)，S100P水平與CK-MB(r=0.229,P<0.001)及cTnI(r=0.190,P<0.01)峰值水平均相關(guān)。

2.4Logistic多元回歸分析

采用多元回歸分析法，將傳統(tǒng)心血管危險因素和炎癥因子進行修正，發(fā)現(xiàn)年齡、吸煙史、低水平HDL-C、TNF-α、S100B、S100A6、S100P均與ACS患者獨立相關(guān)，而sRAGE則未能進入回歸方程，見表2。

表2　ACS多因素分析

3討論

本研究發(fā)現(xiàn)，血清S100B、S100A6、S100P水平與ACS相關(guān)，與心肌缺血的損傷程度相關(guān)，說明這些S100家族成員在ACS的病理生理過程中發(fā)揮了重要作用。既往研究表明，一些S100蛋白家族成員參與心血管疾病,如S100B、S100A1、S100A4和S100A8等[5]。本研究發(fā)現(xiàn)，ACS患者血清S100B、S100A6、S100P水平增高，并且與心肌缺血的損傷程度相關(guān)。S100B可由膠質(zhì)細胞、少突細胞等多種神經(jīng)組織細胞表達分泌至胞外，并介導生物學功能。以往有細胞生物實驗研究發(fā)現(xiàn)，S100B能活化RAGE調(diào)節(jié)性炎癥通道，提高黏附分子和炎癥因子的表達，導致動脈粥樣硬化形成，且缺血的心肌細胞能表達并分泌S100B[6,10-11]。目前關(guān)于S100A6的研究主要集中在腫瘤和纖維化疾病，但相關(guān)研究表明，心肌細胞、血管平滑肌細胞和內(nèi)皮細胞均可表達S100A6[11-14]。有研究發(fā)現(xiàn)，心肌梗死后心肌細胞的S100B和S100A6蛋白及信使核糖核酸水平上調(diào)[15-19]。我們的研究則證實, ACS患者血清S100A6水平升高，并與TNF-α相關(guān)，提示S100A6與炎癥密切相關(guān)。許多腫瘤組織和腫瘤細胞系中發(fā)現(xiàn)S100P升高[20-22]。體內(nèi)和體外實驗表明，S100P可以激活絲裂原活化蛋白激酶(MAPK)和核轉(zhuǎn)錄因子-κB(NF-κB)通路，通過上調(diào)細胞周期因子周期蛋白D1和周期蛋白依賴性激酶，促進腫瘤細胞增殖；而抑制RAGE，能拮抗并消除這些效應[23-25]。本研究首次證實S100P參與了心肌梗死。

既往有研究認為，冠狀動脈疾病或ACS患者的sRAGE水平降低[26-28]，然而本研究發(fā)現(xiàn)，ACS患者sRAGE水平高于對照組。結(jié)果不一致的原因首先可能在于樣本量的差異；其次糖尿病患者在本研究中所占比例很高，而糖尿病會影響sRAGE水平[27]。

S100蛋白、高遷移率族蛋白(HMGB1、HMGB2)和b-縮氨酸淀粉體等配基與RAGE結(jié)合能誘發(fā)炎癥反應[1-3]；而抑制RAGE與相關(guān)配基結(jié)合，能顯著減少心肌損傷和細胞凋亡[4、29-30]，說明RAGE-配體調(diào)節(jié)機制密切參與心肌缺血損傷。心肌缺血或壞死促進了梗死區(qū)及梗死周邊區(qū)域S100B、S100A6、S100P、RAGE等炎癥因子的產(chǎn)生，從而激活了S100-RAGE軸，誘發(fā)炎癥因子的表達進一步增加，大量的S100族蛋白和其他炎癥因子的釋放加劇心肌損傷、細胞凋亡和心肌重構(gòu)，形成惡性循環(huán)，導致心功能不全。

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(收稿：2015-06-17 修回：2015-11-21)

(本文編輯：丁媛媛)

Association of increased S100B, S100A6 and S100P in serum levels with acute coronary syndrome.

SHENGLezhi,CHENQiujing,ZHANGQi,LULin,SHENWeifeng,ZHANGRuiyan.

DepartmentofCardiology,RuijinHospital,InstituteofCardiovascularDiseases,SchoolofMedicine,ShanghaiJiaotongUniversity,Shanghai200025,China

【Abstract】Objective： To investigate whether the serum levels of receptor for advanced glycation endproduct (RAGE) and ligands S100B, S100A6 and S100P were related to acute coronary syndrome (ACS). Methods： Serum levels of S100B, S100A6, S100P, soluble RAGE (sRAGE), and TNF- were analyzed in 882 consecutive patients. Based upon clinical and laboratory findings, the patients were categorized as control group (n=251), stable angina (SA) group (n=211), and ACS group (n=420). Results： Serum S100B, S100A6, S100P and TNF-α levels[(103.73±56.90)ng/L,(5.28±4.15) μg/L,(8.73±7.96) μg/L,(87.82±39.30)ng/L] were higher in ACS group than in SA group [(81.93±27.65) ng/L,(4.36±2.45) μg/L,(3.41±3.08) μg/L,(71.88±30.70) ng/L]as well as in control group[(78.00±22.71) ng/L,(3.97±2.57) μg/L,(3.38±2.74) μg/L,(57.07±27.23) ng/L(each P<0.01)], and sRAGE levels were higher in ACS patients versus controls[(724.01±320.37) ng/L vs (652.55±351.24) ng/L , with P<0.01]. These bio-measurements were further made by classifying ACS patients into ST-segment elevation myocardial infarction (STEMI) and unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI) subgroups, and STEMI patients had the higher S100B, S100A6 and S100P levels than UA/NSTEMI patients.In ACS group,S100B level was correlated with troponin I(cTnI)level(P<0.05),while S100P level was correlated with CK-MB and cTnI levels(P<0.01). In multivariable regression analysis,S100B,S100A6,S100P and conventional risk factors were independently associated with ACS in patients. Conclusion： It indicates that serum levels of S100B, S100A6 and S100P are associated with ACS, and that serum levels of these proteins are related to the severity of myocardial infarction, implying that they are involved in the pathophysiology of ACS.

【Key words】Acute coronary syndrome; S100B; S100A6; S100P; Receptor for advanced glycation end products

doi:10.3969/j.issn.1673-6583.2016.02.015

通信作者：張瑞巖，Email:zhangruiyan@263.net