心肌标志物及超声心动图对高龄脓毒症患者预后的意义

Prognostic significance of myocardial markers and echocardiography in elderly patients with sepsis

目的探讨临床常用的心脏检测指标血清心肌肌钙蛋白T(cTNT)、血清心肌肌钙蛋白I(cTNI)、N端B型利钠肽原(NT-proBNP)及超声心动图与高龄脓毒症患者心脏损害、心功能障碍的关系及对脓毒症预后的判断价值。方法回顾性分析2015年1月至2017年7月在首都医科大学附属北京友谊医院住院的140例高龄脓毒症患者的临床资料,根据患者28 d内是否存活分为存活组(n=90)和死亡组(n=50)。所有患者确诊后检测第1、3、7天血清cTNT、cTNI、NT-proBNP的水平并于确诊当天行超声心动图检查,监测左心室舒张末内径(EDD),左心室收缩末内径(ESD),二尖瓣口舒张早期最大流速与心房收缩期最大流速比值(E/A),右心室内径(RV)及左心室射血分数值(LVEF)。结果死亡组确诊当天cTNT、cTNI、NT-proBNP、EDD、ESD明显高于存活组(P<0.05),LVEF明显低于存活组(P<0.01),两组间E/A及RV比较差异无统计学意义(P>0.05)。脓毒症患者血清cTNT、cTNI、NT-proBNP与EDD、ESD呈正相关(P<0.05),与LVEF呈负相关(P<0.05),与E/A及RV无相关(P>0.05)。脓毒症患者cTNT、cTNI、EDD与死亡率相关(OR>1,P<0.05)。cTNT、cTNI、NT-proBNP、EDD、ESD对脓毒症患者死亡率有一定预测价值,且预测价值排序为cTNT>NT-proBNP>cTNI>EDD>ESD。结论高龄脓毒症患者cTNT、cTNI、NT-proBNP及EDD、ESD与心脏损害、心功能障碍有明显相关性,上述指标越高,患者死亡率越高。cTNT预测病死率的敏感度最好,NT-proBNP预测病死率的特异度最好,二者联合能更好的预测高龄脓毒症患者的预后。

Objective To explore the relationship between those myocardial markers serum cardiac troponin T （ cTNT）, serum cardiac troponin I （cTNI） , N-terminal pro-brain natriuretic peptide （ NT-proB- NP） , echocardiography and myocardial injury in the oldest-old septic patients, as well as to evaluate progno- sis in the oldest-old septic patients. Methods 140 oldest-old septic patients hospitalized in Beijing Friend- ship Hospital from January 1 st, 2015 to Jun 31st, 2017 were collected and analyzed retrospectively. They were divided into survival group （90 cases） death group （50 cases）according to their survival time. Serum cTNT, cTNI and NT-proBNP level at 1, 3 and 7d post-diagnosis were collected and echocardiography left ventricular diastolic diameter （EDD）, left ventricular systolic diameter （ESD）, right ventricular diameter （ RV）, left ventricular ejection fraction （EF） was performed. Results 140 oldest-old septic patients were enrolled in the analysis. There were 90 cases in survival group and 50 cases in death group. Mean values of cTNT, cTNI, NT-proBNP, EDD, ESD in survival group were obviously higher than those in death group （P 〈 0. 05 ）, left ventricular ejection fraction （LVEF） in survival group was lower than that in death group （P 〈0. 01 ）. But there were no difference in E/A and RV between survival group and death group （P 〉 0. 05）. There were positive correlation between cTNT, cTNI, NT-proBNP and EDD, ESD （P 〈 0. 05 ）, negative correlation between cTNT, cTNI, NT-proBNP and LVEF （ P 〈 0. 05） , and no correlation between cTNT, cTNI, NT-proBNP and E/A, RV （P 〉 0. 05）. There were obviously correlation between cTNT, cT- NI, NT-proBNP, EDD, ESD and mortality rate （ OR 〉 1, P 〈 0. 05 ）. It was shown the prognosis value of cTNT, cTNI, NT-proBNP, EDD, ESD to mortality rate in oldest-old septic patient. The prognosis value was cTNT 〉 NT-proBNP 〉 cTNI 〉 EDD 〉 ESD. Conclusions There were obviously correlation between cT NT, cTNI, NT-proBNP, EDD, ESD and myocardium restrain, heart dysfunction as well as mortality rate. cTNT was the best prognosis indicator in sensitivity, and NT-proBNP was the best prognosis indicator in specificity. The combination of cTNT and NT-proBNP can better forecast the prognosis of the oldest-old septic patient.