住院扩张型心肌病患者院内和院外预后分析及风险评估系统创建

In-hospital and post-discharge prognosis and prediction scoring system for patients hospitalized with dilated cardiomyopathy

目的 分析住院扩张型心肌病(DCM)患者院内及院外预后,并创建风险评估系统.方法 入选2009年1月至2013年12月在阜外医院心力衰竭病房住院的成人DCM患者,随访至2015年12月或全因死亡或行心脏移植.定义心力衰竭恶化、猝死或脑卒中导致的死亡为心血管原因死亡.危险因素判定采用多变量Cox回归分析方法.结果 共纳入793例患者,其中35例(4.4%)发生院内死亡,院内死亡与入院收缩压(P)≤106 mmHg(1 mmHg=0.133 kPa)、血清总胆红素浓度(B)≥34.2μmol/L及血清钠离子浓度(S)<135 mmol/L显著相关(P均<0.01),由此建立PBS评分系统,分为低危(评分=0分)、中危(评分=1或2分)和高危(评分=3分)三组,三组患者院内病死率差异有统计学意义(0.6%、3.5%和29.9%,趋势比较P<0.01).其中701例患者完成随访,中位随访34(18,51)个月后,137例死亡、16例行心脏移植,出院后1年、2年及3年的无心脏移植存活率分别为88.4%、82.3%和78.8%.其中3年内发生心血管原因死亡或心脏移植125例,与入院时年龄(A)<30岁、心力衰竭病史(D)>6个月、红细胞体积分布宽度(D)>13.5%、左心室舒张末期内径(L)>75 mm、右心室前后径(R)>25 mm、出院时收缩压(B)≤106 mmHg、出院未应用血管紧张素转化酶抑制剂或血管紧张素受体阻断剂(A)及β受体阻滞剂(B)显著相关(P均<0.01),由此建立A2B2D2LR评分系统,分为低危(评分=0或1分)、中危(评分=2或3分)、高危(评分=4或5分)和极高危(评分≥6分)四组,四组患者3年内心血管原因死亡或行心脏移植的发生率差异有统计学意义(分别为1.2%、11.0%、37.5%和66.7%,趋势比较P均<0.01).结论 PBS评分系统及A2B2D2LR评分系统分别能有效预测住院DCM患者院内死亡及出院后3年内发生心血管原因死亡或行心脏移植的风险.

Objective To investigate the in-hospital mortality and post-discharge prognosis,and to establish prediction scoring systems for patients hospitalized with dilated cardiomyopathy(DCM).Methods Adult patients hospitalized with DCM in Heart Failure Care Unit,Fuwai Hospital from January 2009 to December 2013 were enrolled and followed up to December 2015 or until all-cause death or heart transplantation(HTx).Cardiovascular(CV)death was defined as death from worsening heart failure,sudden death,or stroke.Multivariate Cox regression analysis was used to identify predictors of prognosis.Results A total of 793 patients were enrolled and 35 died during hospitalization(in-hospital mortality rate of 4.4%),which was significantly associated with systolic blood pressure(P)≤106 mmHg(1 mmHg=0.133 kPa),serum total bilirubin(B)≥34.2μmol/L and serum sodium(S)<135 mmol/L on admission(all P value<0.01).Subsequently,we established the PBS scoring system and patients were divided into low risk(score=0),moderate risk(score=1 or 2)and high risk(score=3)with inhospital mortality rates of 0.6%,3.5%and 29.9%(P<0.01 for trend),respectively.During a median period of 34(18,51)months for 701 patients with follow-up after discharge,137 died and other 16 underwent HTx.Transplant-free survival rate at 1-year,2-year and 3-year was 88.4%,82.3%and 78.8%,respectively.Within the 3-year follow-up after discharge,125 patients suffered from CV death or underwent HTx,which was significantly associated with age(A)<30 years,symptom duration of heart failure(D)>6 months,red cell distribution width(D)>13.5%,left ventricular end-diastolic diameter(L)>75 mm,right ventricular diameter(R)>25 mm on admission,systolic blood pressure(B)≤106 mmHg,non-administration of angiotensin converting enzyme inhibitor or angiotensin receptor blocker(A)or beta blocker(B)at discharge(all P value<0.01).Thus,we established the A2B2D2LR scoring system and divided patients into low risk(score=0 or 1),moderate risk(score=2 or 3),high risk(score=4 or 5)and extremely high risk(score=6 or greater)with incidence rates of CV death or HTx within 3 years after discharge of 1.2%,11.0%,37.5%and 66.7%(P<0.01 for trend),respectively.Conclusion The PBS scoring system and A2B2D2LR scoring system can effectively predict the risk of in-hospital mortality and CV death or HTx within the 3-year follow-up after discharge.