接受经皮冠状动脉介入治疗急性ST段抬高心肌梗死患者并发消化道出血的风险分析

Risk analysis of gastrointestinal bleeding in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

目的本研究旨在探讨急性ST段抬高心肌梗死患者上消化道出血(UGIB)的院内发病率、危险及预测因素。方法病例对照研究。回顾性分析2018年1月至2022年1月在北京安贞医院住院治疗的急性ST段抬高心肌梗死患者2 791例患者,年龄21~89(68±11)岁,男性2 302例(82.5%)、女性489例(17.5%)。按照住院期间是否合并上消化道出血分组为:UGIB组(61例)、非UGIB组(2 730例)。对两组患者的基线临床情况、冠脉病变情况、院内死亡、院内不良事件等进行比较分析。并对可能导致UGIB的危险因素进行logistic回归分析。结果 STEMI后UGIB的院内发病率为2.2%(61/2 791)。UGIB组住院时间显著延长[8(6,12)比5(4,7)d,Z=3.28,P<0.001],UGIB组患者的院内病死率显著高于非UGIB组[9.8%(6/61)比 0.8%(23/2 730),χ^(2)=0.63,P=0.001]。合并UGIB患者的年龄明显高于非UGIB患者[(63±11)比(58±11)岁,t=-3.75,P<0.001]。UGIB组患者血肌酐水平显著高于非UGIB组患者[80(62,98)比73(64,84)mmol/L,Z=1.68,P=0.007],UGIB组患者红细胞计数显著低于非UGIB组患者[4.1(3.8,4.6)×10^(12)/L 比 4.6(4.2,4.9)×10^(12)/L,Z=2.61,P<0.001],UGIB组患者血红蛋白浓度显著低于非UGIB组患者[129(109,141)比141(130,152)g/L,Z=2.52,P<0.001]。UGIB组患者脑利钠肽水平显著高于非UGIB组患者[331(165,644)比181(89,333)ng/L,Z=2.42,P<0.001]。将可能导致UGIB的危险因素带入logistic回归分析结果显示,年龄(OR=1.045,95%CI 1.009~1.082,P=0.013)、血红蛋白(OR=1.594,95%CI 1.150~2.210,P=0.005)、红细胞压积(OR=0.181,95%CI 0.060~0.546,P=0.002)、平均血红蛋白浓度(OR=0.845,95%CI 0.752~0.951,P=0.005)是STEMI患者是否并发UGIB的独立危险因素。对院内死亡的危险因素进行logistic分析发现,是否并发UGIB是STEMI患者院内死亡的独立危险因素(OR=2.954,95%CI 0.635~13.751,P=0.024)。结论本研究中STEMI患者在院内并发UGIB的发生率达2.2%,且并发UGIB的STEMI院内病死率增加至9.8%。并发UGIB是STEMI患者院内死亡的独立危险因素。STEMI患者院内发生UGIB最重要的预测因素是年龄、血红蛋白、红细胞压积及平均血红蛋白浓度。

Objective Of all spontaneous bleeding complications in patients with acute ST-elevation myocardial infarction(STEMI),upper gastrointestinal bleeding(UGIB)is the most common and of specific interest,because it can be prevented by several prophylactic measures.The purpose of this study was to investigate the in-hospital incidence,associated outcomes,and predictors of UGIB after STEMI.Methods In this retrospective study,we analyzed the records of 2791 patients with acute STEMI admitted to Beijing Anzhen Hospital Affiliated to Capital Medical University between January 2018 and January 2022.The patients were divided into the UGIB group(n=61)and non-UGIB group(n=2730)according to the presence or absence of upper gastrointestinal hemorrhage,respectively.Baseline clinical conditions,coronary lesions,in-hospital deaths,and in-hospital adverse events were compared between the two groups.Logistic regression analysis was also performed for risk factors that could lead to UGIB.Results The in-hospital incidence of UGIB after STEMI was 2.2%(61/2791).Hospital stay was significantly longer in the UGIB group[8(6,12)days vs.5(4,7)days,Z=3.28,P<0.001]and in-hospital mortality was significantly higher in the UGIB group than in the non-UGIB group(9.8%vs.0.8%,χ^(2)=0.63,P=0.001).Patients with UGIB were significantly older than those without UGIB(63±11 years vs.58±11 years,t=-3.75,P<0.001).The serum creatinine level of UGIB patients was significantly higher than that of non-UGIB patients[(80(62,98)mmol/L vs.73(64,84)mmol/L,Z=1.68,P=0.007],the red blood cell count of UGIB patients was significantly lower than that of non-UGIB patients[4.1(3.8,4.6)×10^(12)/L vs.4.6(4.2,4.9)×10^(12)/L,Z=2.61,P<0.001],and the hemoglobin concentration of UGIB patients was significantly lower than that of non-UGIB patients[129(109,141)g/L vs.141(130,152)g/L,Z=2.52,P<0.001].Brain natriuretic peptide levels were significantly higher in UGIB patients than in non-UGIB patients[331(165,644)ng/L vs.181(89,333)ng/L,Z=2.42,P<0.001].Logistic regression analysis showed that age(OR=1.045,95%CI 1.009-1.082,P=0.013);hemoglobin(OR=1.594,95%CI 1.150-2.210,P=0.005);hematocrit(OR=0.181,95%CI 0.060-0.546,P=0.002);and mean hemoglobin concentration(OR=0.845,95%CI 0.752-0.951,P=0.005)were independent risk factors for UGIB in patients with STEMI.Logistic regression analysis of risk factors for in-hospital death revealed that concurrent UGIB was an independent risk factor for in-hospital death in patients with STEMI(OR=2.954,95%CI 0.635-13.751,P=0.024).Conclusions The incidence of in-hospital UGIB in STEMI patients was 2.2%,and the in-hospital mortality rate of STEMI complicated with UGIB increased to 9.8%.Concurrent UGIB was an independent risk factor for in-hospital death in patients with STEMI.The most important predictors of in-hospital UGIB in patients with STEMI were age,hemoglobin,hematocrit,and mean hemoglobin concentration.