持续性房颤患者多因素分析对评估血栓栓塞危险性的临床价值

Clinical value of multivariate analysis for assessing the risk of thromboembolism in patients with persistent atrial fibrillation

目的:对持续性房颤患者血栓栓塞危险因素进行多因素分析,以探讨其对评估血栓栓塞危险性的临床价值。方法:将69例房颤患者分为两组:血栓栓塞阳性组(30例)和血栓栓塞阴性组(39例);另选47例无房颤的器质性心脏病患者为非房颤组。全部患者用超声心动图测定其左房内径、左室射血分数;用酶联免疫吸附双抗体夹心法测定其左室射血分数、P-选择素、血管性假血友病因子、D-二聚体水平;用发色底物法测定其AT-Ⅲ活性。其中48例房颤患者接受TEE检查,测定其LAA流速及LA SEC,并根据是否发现左房和/或左心耳血栓分为经食道超声心动图血栓阳性组(12例)和经食道超声心动图血栓阴性组(36例)。对结果进行多因素分析。结果:多因素log istic回归分析显示:左房内径增大、左房自发超声对比现象≥2级、血管性假血友病因子和D-D浓度增高左房自发超声对比现象为房颤患者血栓栓塞的独立危险因素;单个危险因素中,诊断房颤血栓栓塞的灵敏度较高的是左房内径,特异度较高的是D-二聚体。随着独立危险因素的增多,诊断血栓栓塞的特异度增高,但灵敏度下降。结论:持续性房颤患者血栓栓塞的独立危险因素是LA内径增大、左房自发超声对比现象≥2级、血管性假血友病因子和D-二聚体浓度增高,且D-二聚体浓度增高的评估价值优于其他因素。结合多个危险因素,可提高诊断房颤血栓栓塞的特异性,更可靠地评估血栓栓塞危险性。

Objective To study the clinic value of thromboembolism risk assessment in patients with persistent atrial fibrillation by making the multivariate analysis for detecting risk factors of them. Methods Sixty-nine patients with persistent atrial fibrillation were divided into 2 groups, thromboembolism group （n = 30）and non-thromboembolism group （n = 39）. Another 47 patients with heart diseases but without atrial fibrillation were selected as controls. All subjects underwent transesophageal echocardiography to detect left atrium diameter, left ventricular cjective fraction. Fortyeight atrial fibrillation patients underwent trans-thoraial echocardiography to detect the blood velocity in left atrial appendage and left atrium spontaneous echo contrast, then the plasma TAT, GMP-140, vWF and D-D levels were assayed with ELISA, the plasma AT-Ⅱ level was assayed with spectrophotometric assay. In the end, the multivariate analysis was made for the resuhs. Results In multivariate logistic regression, increase of left atrium dimension, vWF, D-D,left atrium spontaneous echo contrast ≥ 2 grade （OR = 0. 112, P = 0.028 ） were independently associated with thromboembolism; Among single risk factor, the sensitivity of left atrium dimension to detect thrombus was the highest, and the specificity of D-D was the highest; Along with more independent risk factors, the specificity to diagnose thromboembolism in patients with persistent atrial fibrillation was higher, but the sensitivity was lower. Conclusion Increase of left atrium dimension, vWF, D-D and left atrium spontaneous echo contrast≥2 grade are independent risk factors of thromboembolism in patients with persistent atrial fibrillation. The assessment value of increase of D-D is greater than of others. Considering more risk factors, the specificity of detecting thrombus is higher and the risk assessment of thromboembolism is more reliable.