列线图模型预测冠心病患者经皮冠状动脉介入治疗术后因严重支架内再狭窄导致再次血运重建的研究

A study on the prediction of severe in-stent restenosis leading to repeat revascularization after percutaneous coronary intervention in patients with coronary heart disease by Nomogram model

目的分析冠心病患者经皮冠状动脉介入治疗(PCI)术后因严重支架内再狭窄(ISR)导致再次血运重建的危险因素,并建立预测模型,筛选出高危人群,以期更为准确地指导冠心病患者的临床治疗及预后评估。方法纳入2013年6月至2019年6月于徐州医科大学附属医院行PCI术并再次于本院复查冠状动脉造影(CAG)的患者1083例(复查CAG间隔时间≥6个月),根据患者是否因ISR导致再次行血运重建,将其分为因严重ISR行血运重建(ISR-Revasc)组(209例)、无或轻中度ISR无需行血运重建(N-Revasc)组(874例)。回顾性分析两组患者临床病例资料,包括一般情况、实验室检查、PCI术情况等,比较两组患者临床资料特点,利用logistic回归分析冠心病患者PCI术后因严重ISR导致再次血运重建的危险因素,并构建列线图预测模型。结果logistic多因素回归分析显示:脂蛋白a[Lp(a)]>300 mg/L(OR 3.579,95%CI 2.561~5.003,P<0.001)、低密度脂蛋白胆固醇(LDL-C)>1.8 mmol/L(OR 1.834,95%CI 1.294~2.599,P=0.001)、糖尿病病史(OR 2.426,95%CI 1.637~3.595,P<0.001)、多支病变(OR 1.844,95%CI 1.133~3.002,P=0.014)、支架置入长度(OR 1.025,95%CI 1.014~1.037,P<0.001)是冠心病患者PCI术后因严重ISR导致再次血运重建的独立危险因素。建立简易的列线图模型,对模型进行验证:受试者工作特征曲线下面积为0.766,标准误0.0184(95%CI 0.740~0.791),Hosmer-Lemeshow拟合优度检验χ^(2)=8.948,P=0.347>0.05,采用Bootstarp内部验证法并绘制校准曲线,提示模型准确度、区分度、符合度良好,具有一定的临床价值。结论Lp(a)>300 mg/L、LDL-C>1.8 mmol/L、糖尿病病史、多支病变、支架置入长度是冠心病患者PCI术后因严重ISR导致再次血运重建的独立危险因素。本研究构建的列线图预测模型对PCI术后冠心病患者是否因严重ISR需要进行再次血运重建有一定的预测价值。

Objective To analyze the risk factors of repeat revascularization caused by severe in-stent restenosis(ISR)in patients with coronary heart disease(CHD)after percutaneous coronary intervention(PCI),and to establish a prediction model to screen high-risk patients,and to accurately guide the clinical treatment and prognosis evaluation.Methods From June 2013 to June 2019 in Xuzhou Medical College Affi liated Hospital,a total of 1083 patients treated with PCI and with a follow up of coronary angiography(CAG)with an interval of 6 months or more were enrolled.According to ISR,the patients were divided into serious ISR group(209 cases)and without or mild-to-moderate ISR(N-Revasc)group(874 cases).The clinical data,including general situation,laboratory examination and PCI operation,was analyzed retrospectively.The characteristics of the two groups were compared.The risk factors of repeat revascularization caused by severe ISR after PCI in patients with CHD were analyzed by logistic regression and nomogram prediction model was established.Results Multivariate logistic regression analysis showed that lipoproteina[Lp(a)]>300 mg/L(OR 3.579,95%CI 2.561-5.003,P<0.001),low density lipoprotein cholesterin(LDL-C)>1.8 mmol/L(OR 1.834,95%CI 1.294-2.599,P=0.001),history of diabetes(OR 2.462,95%CI 1.637-3.595,P<0.001),multivessel lesions(OR 1.844,95%CI 1.133-3.002,P=0.014)and length of stent(OR 1.025,95%CI 1.014-1.037,P<0.001)were independent risk factors for repeat revascularization due to severe ISR in patients with CHD after PCI.A simple nomogram model was established to validate the model:the area under the ROC curve(AUC)=0.766,the standard error was 0.0184,the 95%CI was 0.740-0.791,Hosmer-Lemeshow goodness of fit test χ^(2)=8.948,P=0.347>0.05,the Bootstarp internal validation method was used and the calibration curve was drawn,indicating that the model accuracy,diff erentiation and compliance were good,which had certain clinical value.Conclusions Lp(a)>300 mg/L,LDL-C>1.8 mmol/L,history of diabetes,multi-vessel lesions,and the length of stent were independent risk factors for repeat revascularization due to severe ISR after PCI in patients with CHD.The nomogram prediction model constructed in this study has a certain predictive value.