急性ST段抬高型心肌梗死患者行急诊经皮冠状动脉介入治疗术后发生院内死亡的危险因素分析

Analysis of risk factors of in-hospital death in patients with acute ST-segment elevation myocardial infarction after primary percutaneous coronary intervetion

目的评估接受直接经皮冠状动脉介入治疗(PPCI)的ST段抬高型心肌梗死(STEMI患者住院期间的死亡因素。方法回顾性分析2016年9月至2018年6月在河北省人民医院心脏中心接受PPCI的392例STEMI患者的临床资料,根据是否发生院内死亡分为存活组和死亡组。通过logistic回归分析筛选出与死亡相关的危险因素。结果 392例STEMI行PPCI的患者中27例(6.9%)发生院内死亡。logistic单因素回归分析显示,性别(女)、年龄≥65岁、收缩压>140 mmHg(1 mmHg=0.133 kPa)、Killip心功能分级≥Ⅲ级、糖尿病、既往心房颤动史、院前应用他汀类药物、完全闭塞、多支病变、术后心肌梗死溶栓治疗试验(TIMI)血流≤Ⅱ级、术中心搏骤停、术中主动脉内球囊反搏、术后心搏骤停、术后心室颤动、术后心房颤动、术后室性心动过速、术后高度房室传导阻滞、术后消化道出血、白细胞计数、中性粒细胞计数、钙离子浓度、肌酐、尿酸、肌酸激酶同工酶(CK-MB)峰值、左心室射血分数(LVEF)≤40%是与死亡相关的危险因素,而术后使用血管紧张素转换酶抑制药/血管紧张素Ⅱ受体拮抗药、β阻滞药、他汀类、螺内酯药物是与患者生存相关的保护因素(均P<0.05)。logistic多因素回归分析显示,年龄≥65岁(OR 3.552,95%CI 1.086~11.62,P=0.036)、LVEF≤40%(OR 6.754,95%CI 1.982~23.02,P=0.002)、CK-MB峰值>25 U/L(OR 4.243,95%CI 1.219~14.77,P=0.023)、发病至球囊扩张时间≥195 min(OR3.490,95%CI 1.079~11.29,P=0.037)、术后TIMI血流分级≤Ⅱ级(OR 8.425,95%CI2.899~24.49,P<0.001)为STEMI患者行急诊PPCI术后发生院内死亡的独立预测因素。结论高龄、心功能差、CK-MB峰值升高、发病至球囊扩张时间、PPCI术后慢血流为STEMI患者行PPCI术后发生院内死亡的危险因素。

Objective To evaluate the risk factors of death during hospitalization in patients with ST-segment elevation myocardial infarction(STEMI) undergoing primary percutaneous coronary intervention(PPCI). Methods The clinical data of 392 patients with STEMI who were treated with PPCI in the Heart Center of Hebei General Hospital from September 2016 to June 2018 were analyzed retrospectively. They were divided into survival group and death group according to the occurrence of in-hospital death. The risk factors associated with death were screened by Logistic regression analysis. Results A total of 27 of 392(6.9%) patients with STEMI died during hospitalization. The results of univariate Logistic regression showed sex(female),age≥65 years, systolic blood pressure>140 mm Hg(1 mm Hg=0.133 k Pa), Killip grade≥Ⅲ grade, diabetes mellitus,previous history of atrial fibrillation, pre-hospital use of statins, complete occlusion, multi-vessel disease, postoperative TIMI blood flow≤Ⅱgrade, intraoperative cardiac arrest, intraoperative IABP, postoperative cardiac arrest, ventricular fibrillation, atrial fibrillation, ventricular tachycardia, high atrioventricular block, gastrointestinal bleeding, white blood cell count, neutrophil count, serum calcium concentration, serum creatinine, serum uric acid, peak value of CK-MB and left ventricular ejection fraction≤40% were positively correlated with death. The use of ACEI/ARB, β blocker, statins and spironolactone after operation was negatively correlated with death, and there was significant difference between the two groups(P<0.05). Multivariate logistic regression analysis showed age≥65 years old(OR 3.552,95%CI 1.086-11.62,P =0.036),LVEF≤40%(OR 6.754, 95%CI 1.982-23.02,P =0.002),peak value of CK-MB>25 U/L(OR 4.243,95%CI 1.219-14.77,P =0.023), time from symptom onset to balloon≥195 min(OR 3.490,95%CI 1.079-11.29,P =0.037)and postoperative TIMI blood flow≤Ⅱgrade(OR 8.425,95%CI 2.899-24.49,P<0.001)were independent predictors of hospital death after PPCI in STEMI patients. Conclusions Elderly ages, poor cardiac function, elevated peak value of CK-MB, time from onset of symptoms to opening of coronary artery and slow blood flow after PCI were the key risk factors of hospital death in patients with STEMI after PPCI.