急性心肌梗死后新发心房颤动的危险因素及预后分析

Risk factors and prognoses analysis of new-onset atrial fibrillation in patients with acute myocardial infarction

目的探讨急性心肌梗死(AMI)患者新发心房颤动(NOAF)的危险因素及预后。方法前瞻性纳入首都医科大学附属北京安贞医院接受急诊经皮冠状动脉介入治疗(PCI)的ST段抬高型心肌梗死患者468例。按照住院期间是否发生NOAF分为NOAF组37例和非NOAF组431例。比较两组患者的一般临床情况、冠状动脉病变情况、超声心动图、生化指标、C反应蛋白(CRP)、N末端B型利钠肽前体(NT-pro-BNP)、心肌标志物及院内死亡、院内主要心脑血管不良事件(MACCE)。并将可能的相关因素进行logistic多因素回归分析。结果接受急诊PCI的AMI患者中NOAF发病率为7.9%。两组患者在进门-球囊扩张时间、体重、血小板计数、入院血肌酐(SCr)、术后SCr、甘油三酯、总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇、尿酸、糖化血红蛋白、术前用药、病变支数、血栓抽吸、心肌梗死部位、高血压、糖尿病、外周血管病、陈旧性心肌梗死等方面差异无统计学意义,具有可比性。女性所占比例NOAF组高于非NOAF组(32.4%比16.7%,P<0.05),NOAF组年龄显著高于非NOAF组[(66±10)岁比(57±11)岁,P<0.001]。NOAF组患者无复流比例(40.5%比12.6%,P<0.001)、CRP[25.2(15.43,29.97)mg/L比5.21(2.33,16.98)mg/L,P<0.001]、白细胞计数[(11.19±3.44)×109比(9.91±3.23)×109,P=0.022]、NT-pro-BNP[(652.6±108.8)ng/L比(258.3±105.9)ng/L,P<0.001]、肌钙蛋白I(TnI)[20.41(1.78,87.89)μg/L比7.72(1.29,36.39)μg/L,P=0.006]等显著高于非NOAF组患者。而左心室射血分数[(47.70±7.34)%比(53.35±8.05)%,P<0.001]、血红蛋白[137.0(125.5,146.0)g/L比144.0(133.0,156.0)g/L,P=0.042]明显低于非NOAF组患者。NOAF组患者住院时间明显长于非NOAF组患者[(8.7±5.6)d比(6.0±2.3)d,P=0.007]、院内死亡(8.1%比1.4%,P=0.004)及院内MACCE(37.8%比7.7%,P<0.001)显著高于非NOAF组患者。Logistic多因素回归分析显示,年龄(HR1.083,95%CI1.028~1.141,P=0.003)、CRP(HR1.116,95%CI1.049~1.187,P=0.001)、NT-pro-BNP(HR1.463,95%CI1.001~4.064,P=0.001)及无复流(HR4.388,95%CI1.006~19.144,P=0.049)是AMI后NOAF的独立预测因素。结论高龄、CRP、NT-pro-BNP水平升高以及无复流的出现预示AMI患者院内发生NOAF的风险可能增加。

ObjectiveTo explore the risk factors and prognoses of new-onset atrial fibrillation (NOAF) in patients with acute myocardial infarction (AMI). MethodsA total of 468 patients with AMI were admitted into Beijing Anzhen Hospital for emergency pereutaneous coronary intervention (PCI). According to the NOAF occurred during hospitalization, the patients were divided into two groups: the NOAF (n=37) group and the non-NOAF (n=431) group. Parameters including general clinical conditions, coronary lesions, echocardiography, biochemical markers, C-reactive protein (CRP) , N-terminal pro-brain natriuretic peptide (NT-pro-BNP), and myocardial markers were collected. In-hospital mortality and incidence of in-hospital main adverse cardiovascular and cerebrovascular events (MACCE) were compared between the two groups. Logistic multivariate regression analyses were performed for the association between the risk factors and NOAF. ResultsThe incidence of NOAF was 7.9% in AMI patients undergoing emergency PCI. There were no significant differences in door-to-balloon time, weight, platelet counts, baseline serum creatinine (SCr), postoperative SCr, triglyceride, total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, uric acid, glycosylated hemoglobin A1c, preoperative medication, number of lesions, thrombus aspiration, location of myocardial infarction, and history of hypertension, diabetes, peripheral vascular disease and old myocardial infarction between the two groups. The percentage of women was in the NOAF group (32.4% vs. 16.7%, P<0.05) and subjects in this group were significantly elder than those in the non-NOAF groups [(66±10) years vs. (571±11) years, P<0.001]. Moreover, the levels of no-reflow rate (40.5% vs. 12.6%, P<0.001) , CRP [25.2 (15.43, 29.97) mg/L vs.5.21 (2.33, 16.98) mg/L, P<0.001], white blood cell counts [(11.19±3.44)×109vs. (9.91±3.23)×109, P=0.022], NT-pro-BNP [(652.6±108.8) ng/L vs. (258.3±105.9) ng/L, P<0.001], and troponin I (TnI) [20.41(1.78, 87.89) μg/L vs.7.72(1.29, 36.39) μg/L, P=0.006] were significantly higher in the NOAF group than in the non-NOAF group, while left ventricular ejection fraction [(47.70±7.34)% vs. (53.35±8.05)%, P<0.001], and hemoglobin [137.0(125.5, 146.0) g/L vs.144.0(133.0,156.0) g/L, P=0.042] were significantly lower in the NOAF group than the non-NOAF group. Patients in the NOAF group had significantly longer hospital stay than those in the non-NOAF group [(8.7±5.6) d vs. (6.0±2.3) d, P=0.007]. The in-hospital mortality (8.1% vs 1.4% P=0.004) and the incidence of in-hospital MACCE (37.8% vs. 7.7%, P<0.001) in the NOAF group were significantly higher than those in the non-NOAF group. Logistic multivariate regression analyses showed that age (HR 1.083, 95%CI 1.028-1.141, P=0.003), CRP (HR 1.116, 95%CI 1.049-1.187, P=0.001), NT-pro-BNP (HR 1.463, 95%CI 1.001-4.064, P=0.001) and no-reflow (HR 4.388, 95%CI 1.006-19.144, P=0.049) were independent predictors of NOAF after AMI. ConclusionsAge, elevated levels of CRP, NT-pro-BNP, and the absence of no-reflow are risk factors for incident NOAF in patients with AMI in hospital.