222例儿童病毒性心肌炎临床分析

A clinical analysis of 222 children with viral myocarditis

目的:探讨暴发性心肌炎患儿的高危因素,为临床早期诊断和干预治疗提供参考。方法:收集2012年1月至2018年1月临床诊断为病毒性心肌炎的患者222例,分为暴发性心肌炎组(n=57)与非暴发性心肌炎组(n=165),采用卡方检验或t检验对2组患儿临床症状及体征、心电图、心脏彩超、血清学检查等进行分析,提取出具有统计学意义(P<0.05)的相关指标进行logistic回归分析,并进行ROC曲线制作。结果:暴发性心肌炎组死亡12例(21.05%),其中7例入院1 d内即死亡,另5例住院期间病情无缓解,要求出院后电话随访死亡;非暴发性心肌炎组无死亡病例。暴发性心肌炎组患儿年龄偏大,呕吐、食欲下降、水肿、末梢循环差、尿量减少、抽搐、意识障碍、低血压等临床表现较非暴发性心肌炎组多见;心电图有病理性Q波、室性早搏、左束支传导阻滞、室速、QRS波延长,血清学检查肌钙蛋白Ⅰ、脑钠肽、血肌酐、尿素氮、谷丙转氨酶升高、低钾血症、左室射血分数、左室短轴缩短率降低等较非暴发性心肌炎组更明显(P<0.05)。Logistic回归分析显示,低血压(OR=7.248,95%CI=1.352~38.860,P=0.021)、左室射血分数降低(OR=63.720,95%CI=8.234~493.115,P=0.000)、QRS波时程延长(OR=1.043,95%CI=1.002~1.085,P=0.039)及年龄(OR=1.193,95%CI=1.013~1.404,P=0.034)是暴发性心肌炎的独立预测因素,左室射血分数ROC曲线下面积为0.737(OR=0.000,95%CI=0.641~0.833),截点值为58.5%,灵敏度0.87,特异度0.64;QRS波时程曲线下面积为0.71(OR=0.000,95%CI=0.625~0.795),截断点值为79.5 ms,灵敏度0.80,特异度0.55,年龄曲线下面积为0.725(OR=0.000,95%CI=0.649~0.802),截断点值3.35岁,灵敏度0.84,特异度0.59。结论:暴发性心肌炎病死率高,低血压、左室射血分数降低是其独立危险因素。

Objective:To investigate the high-risk factors for children with fulminant myocarditis and to provide a reference for early clinical diagnosis and intervention. Methods:A total of 222 children with viral myocarditis diagnosed from January 2012 to January2018 were included in fulminant myocarditis group(n=57)and non-fulminant myocarditis group(n=165). The chi-square test or ttest was used for analysis of clinical symptoms and signs,electrocardiographic and echocardiographic findings,and serological examination results for the two groups of patients. Statistically significant(P<0.05)indices were selected for logistic regression analysis and the plotting of receiver operating characteristic(ROC)curve. Results:In the fulminant myocarditis group,12 patients(21.05%)died.Among them,7 patients died within 1 day of admission. The other 5 patients had no remission during hospitalization and were found to be dead through telephone follow-up after hospital discharge. There was no death in the non-fulminant myocarditis group. The children in the fulminant myocarditis group were older and had more clinical manifestations of vomiting,anorexia,edema,poor peripheral circulation,hypourocrinia,convulsion,hypotension,and disturbance of consciousness,as compared with those in the non-fulminant myocarditis group. The electrocardiogram of the fulminant myocarditis group showed pathological Q waves,ventricular premature beats,left bundle branch block,ventricular tachycardia,and QRS duration prolongation. According to the serological examination,troponin Ⅰ,brain natriuretic peptide,serum creatinine,urea nitrogen,and glutamic-pyruvic transaminase increased,and hypokalemia and reductions in left ventricular ejection fraction(LVEF)and left ventricular fractional shortening were more severe in the fulminant myocarditis group than in the non-fulminant myocarditis group(P<0.05). The logistic regression analysis showed that hypotension(OR =7.248,95% CI=1.352 to 38.860,P=0.021),LVEF reduction(OR=63.720,95%CI=8.234 to 493.115,P=0.000),prolonged QRS duration(OR=1.043,95%CI=1.002 to 1.085,P=0.039),and age(OR=1.193,95% 95%CI=1.013 to 1.404,P=0.034)were independent predictive factors for fulminant myocarditis. The area under the ROC curve(AUC)of LVEF was 0.737(OR=0.000,95%CI=0.641 to 0.833),and the calculation of the Youden index yielded a cut-off value of 58.5%,a sensitivity of 0.87,and a specificity of 0.64. The AUC of QRS duration was 0.71(OR=0.000,95%CI=0.625 to 0.795);the cut-off point value was 79.5 ms,the sensitivity was 0.80,and the specificity was 0.55. The AUC of age was 0.725(OR=0.000,95%CI=0.649 to 0.802);the cut-off point value was 3.35 years,the sensitivity was 0.84,and the specificity was 0.59.Conclusion:The fatality of fulminant myocarditis is high,and hypotension and LVEF reduction are independent risk factors for it.