糖尿病合并轻中度肾功能不全介入诊治术后心功能恶化危险因素分析

Analysis on risk factors of cardiac function worsening in patients with diabetes and mild-to-moderate renal insufficiency after interventional diagnosis and treatment

目的探讨糖尿病合并轻中度肾功能不全患者介入诊治术后心功能的影响因素。方法以2008年12月至2011年10月TRACK-D研究中2型糖尿病合并轻中度肾功能不全同时行冠状动脉或外周血管造影的2998例患者为研究对象,采用病例对照研究方法观察介入诊治术后1个月心功能情况,与入院心功能比较,纽约心脏协会（NYHA）分级心功能恶化1级以上判定为心功能恶化,分析影响心功能恶化的相关临床因素。结果 103例（3.4%）在介入诊治术后1个月内发生心功能恶化。恶化组患者年龄≥60岁、高胆固醇血症、心脏超声提示射血分数〈50%的比例、洋地黄类药物的使用率、对比剂剂量≥250 m L的使用比例、外周血管造影率及外周血管介入诊疗的发生率均高于正常组（P均〈0.05）。正常组围手术期他汀类药物、二氢吡啶类钙离子拮抗剂的使用率高于恶化组（P均〈0.05）。多因素分析显示,年龄≥60岁（OR 2.053,95%CI 1.198~3.517,P=0.009）、围手术期应用他汀类药物（OR 0.536,95%CI 0.325~0.902,P=0.018）和二氢吡啶类钙离子拮抗剂（OR 0.360,95%CI 0.198~0.653,P=0.001）以及对比剂剂量≥250 m L（OR 2.263,95%CI 1.236~4.413,P=0.008）是心功能恶化的独立预测因素。结论糖尿病合并轻中度肾功能不全的患者,年龄≥60岁和对比剂使用剂量≥250 m L可能是介入诊疗术后1个月心功能恶化的危险因素,而围手术期应用他汀类药物及二氢吡啶类钙离子拮抗剂则对心功能可能有保护作用。

Objective To investigate the risk factors of cardiac function worsening in patients with diabetes and mild-to-moderate renal insufficiency after cardiovascular interventional diagnosis and treatment. Methods Between December 2008 and October 2011, a total of 2998 patients who suffered from type 2 diabetes and mild-to-moderate renal insufficiency and underwent elective coronary or peripheral arterial angiography were enrolled.The heart function was evaluated within 1 month after cardiovascular interventional diagnosis and treatment. Risk factors of cardiac function worsening（compared with cardiac function in hospital, NYHA functional class ≥ 1） were explored within 1 month after interventional diagnosis and treatment by case-control study. Results One hundred and three cases out of 2998 included patients suffered deterioration of cardiac function at 1 month after elective coronary or peripheral arterial angiography（ECPAA）. The proportion of patients over or at the age of 60（P=0.006）, with hypercholesterolemia（P=0.016）, left ventricular ejection fraction less than 50%（P=0.028）, ues of digitalis（P=0.035）, the volume of contrast medium more than 250 m L（P=0.003）, peripheral angiography（P=0.006） and interventional therapy（P=0.004） were significantly higher in the deterioration group than those in normal group. The utilization rates of statins and dihydropyridines calcium channel blockers（CCB） were higher in normal group than those in the deterioration group. Multivariable logistic regression analysis showed that being over or at the age of 60（OR 1.046, 95%CI 1.009-1.083, P=0.013）, use of periprocedural statins（OR 0.536, 95%CI 0.325-0.902, P=0.018） and dihydropyridines CCB（OR 0.360, 95%CI 0.198-0.653, P=0.001） and the volume of contrast medium more than 250 m L（OR 2.263, 95%CI 1.236-4.413, P=0.008） were independent predictive factors for the deterioration of cardiac function. Conclusion For patients with type 2 diabetes and mild-to-moderate renal insufficiency, age and doses of contrast medium are independent risk factors of cardiac function worsening after interventional diagnosis and treatment within 1 month, whereas therapies using statins and calcium channel blockers are effective in cardiac function protection.