急性缺血性卒中患者短期和远期转归的影响因素

Influencing factors of short-term and long-term outcomes in patients with acute ischemic stroke

目的 探讨急性缺血性卒中患者短期和远期转归的影响因素.方法 前瞻性纳入2015年3月至2016年3月天津医科大学第二医院神经内科收治的急性缺血性卒中患者,记录患者的人口统计学和基线临床资料.应用改良Rankin量表（modified Rankin Scale,mRS）评估出院或入院后14 d时的短期转归以及发病后1年时的远期转归,转归良好定义为0～2分,转归不良定义为〉2分;并记录死亡或新发心脑血管事件.采用多变量logistic回归分析确定急性缺血性卒中患者短期和远期转归的影响因素.结果 共纳入急性缺血性卒中患者514例,短期转归良好338例（65.8％）,转归不良176例（34.2％）.短期转归良好组年龄、心房颤动、既往卒中或短暂性脑缺血发作（transient ischemic attack,TIA）史、卒中病因学分型、基线美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale,NIHSS）评分、卒中严重程度、肺部感染、吞咽困难和尿失禁与转归不良组差异有统计学意义（P均〈0.05）.多变量logistic回归分析显示,既往卒中或TIA史[优势比（odds ratio,OR）2.188,95％可信区间（confidence interval,CI）1.192～4.014;P=0.011]、基线NIHSS评分（OR 1.504,95％CI 1.362～1.661;P〈0.001）和尿失禁（OR 4.114,95％CI 1.934～8.751;P〈0.001）为短期转归的独立影响因素.共467例患者完成1年随访,远期转归良好315例（67.5％）,转归不良152例（32.5％）.远期转归良好组年龄、缺血性心脏病、既往卒中或TIA史、卒中病因学分型、基线NIHSS评分、卒中严重程度、肺感染、吞咽困难、尿失禁、二级预防使用抗血小板药和他汀类药物与转归不良组差异有统计学意义（P均〈0.05）.多变量logistic回归分析显示,年龄（OR 1.029,95％CI 1.004～1.055;P=0.022）、既往卒中或TIA史（OR 1.983,95％CI 1.082～3.633;P=0.027）、基线NIHSS评分（OR 1.271,95％CI 1.153～1.400;P〈0.001）、尿失禁（OR 4.996,95％CI 2.308～10.813;P〈0.001）、二级预防使用抗血小板药（OR 0.227,95％CI 0.125～0.414;P〈0.001）为远期转归的独立影响因素,基线NIHSS评分（OR 1.184,95％CI 1.070～1.310;P〈0.001）、二级预防使用抗血小板药（OR 0.064,95％CI 0.014～0.284;P〈0.001）为死亡或发生血管事件的独立影响因素.结论 年龄、既往卒中或TIA史、基线NIHSS评分、尿失禁、二级预防抗血小板药与急性缺血性卒中患者的转归独立相关,早期有针对性地对可干预因素进行干预和重视二级预防中抗血小板药的使用能减少复发和改善转归.

Objective To investigate the influencing factors of short-term and long-term outcomes in patients with acute ischemic stroke. Methods From March 2015 to March 2016, patients with acute ischemic stroke treated at the Department of Neurology, the Second Hospital of Tianjin Medical University were enrolled prospectively. The demographic and baseline clinical data of the patients were recorded. The modified Rankin scale（mRS）was used to assess the short-term outcomes at 14 d and one year after onset. Good outcome was defined as mRS 0-2, and poor outcome was defined as 〉 2. Death or new cardiocerebrovascular events were recorded.Multivariable logistic regression analysis was used to determine the influencing factors of short-term and long-term outcomes in patients with acute ischemic stroke.Results A total of 514 patients with acute ischemic stroke were enrolled, including 338 （65.8%） with short-term good outcome and 176 （34.2%） with poor outcome. There were significant differences in age, atrial fibrillation, history of past stroke or transient ischemic attack （TIA）, etiological typing of stroke, baseline NIHSS score, severity of stroke, pulmonary infection, dysphagia, and urinary incontinence between the short-term good outcome group and the poor outcome group （P〈0.05）. Multivariable logistic regression analysis showed that history of past stroke or TIA（odds ratio[OR]2.188, 95% confidence interval[CI] 1.192-4.014;P=0.011）,baseline NIHSS score（OR 1.504,95% CI 1.362-1.661;P=0.001）,and urinary incontinence （OR 4.114, 95% CI 1.934-8.751; P=0.001） were the independent influencing factors of short-term outcome. A total of 467 patients completed 1-year follow-up, including 315 （67.5%）with long-term good outcome and 152（32.5%）with poor outcome.There were significant differences in age,history of ischemic heart disease, stroke or TIA, etiological typing of stroke, baseline NIHSS score, severity of stroke, pulmonary infection, dysphagia, urinary incontinence, secondary prevention of antiplatelet drugs and statins between the long-term good outcome group and the poor outcome group（all P〈0.05）.Multivariable logistic regression analysis showed that age（OR 1.029,95% CI 1.004-1.055; P=0.022）, past history of stroke or TIA（OR 1.983, 95% CI 1.082-3.633; P=0.027）, baseline NIHSS score （OR 1.271, 95% CI 1.153-1.400; P=0.001）, urinary incontinence （OR 4.996, 95% CI 2.308-10.813; P= 0.001）, and secondary prevention using antiplatelet drugs （OR 0.227, 95% CI 0.125-0.414; P=0.001） were the independent influencing factors of long-term outcome. The baseline NIHSS score （OR 1.184, 95% CI 1.070-1.310;P〈0.001） and secondary prevention using antiplatelet agents （OR 0.064, 95% CI 0.014-0.284; P〈 0.001） were the independent influencing factors of death or occurring vascular events. Conclusion Age, past history of stroke or TIA, baseline NIHSS score, urinary incontinence, antiplatelet drugs for secondary prevention were independently associated with the outcomes in patients with acute ischemic stroke. Early and targeted intervention of modifiable factors and the emphasis on the use of antiplatelet agents in secondary prevention might reduce stroke recurrence and improve outcomes.