重症患者新发房颤的危险因素及B型钠尿肽和超敏C-反应蛋白的预测价值

Risk factors of new-onset atrial fibrillation in critically ill patients and predictive value of B-type natriuretic peptide and high-sensitive C-reactive protein

目的探讨重症患者新发心房颤动(NOAF)的危险因素并评估B型钠尿肽(BNP)及超敏C-反应蛋白(hs-CRP)对NOAF的预测价值.方法回顾分析2018年1月至2019年12月入住南京中医药大学附属医院重症监护病房(ICU)并接受至少48 h重症监护或器官功能支持的成人患者临床资料,排除入院前已经存在阵发性心房颤动(房颤)或持续性房颤、入院前曾使用抗心律失常药物、已行心脏永久起搏器置入以及入住ICU 3 h内未检测BNP和hs-CRP的患者,根据房颤发生情况将患者分为NOAF组及非NOAF组.观察入选患者住院48 h内房颤发作情况.比较两组间临床资料及相关实验室检查指标,寻找可能预测因素,对相关因素进行二元Logistic回归分析,绘制受试者工作特征曲线(ROC)评估相关因素的预测价值.结果共入选108例患者,在入住ICU 48 h内37例出现NOAF,中位年龄85(71,89)岁;71例未发生房颤,中位年龄73(63,83)岁.两组患者除年龄外,性别、血压、心率以及高血压、糖尿病、冠心病、慢性阻塞性肺疾病(COPD)和慢性肾脏病(CKD)发生率比较差异均无统计学意义;两组间急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、白细胞计数(WBC)、血浆肌酐、心肌肌钙蛋白水平以及去甲肾上腺素使用情况比较差异亦无统计学意义.NOAF组血清BNP和血浆hs-CRP水平均明显高于非NOAF组〔BNP(ng/L):577.0(202.5,1485.0)比210.0(121.0,777.0),hs-CRP(mg/L):75.09(39.59,160.90)比48.00(14.73,118.70),均P<0.05〕.二元Logistic回归分析显示,年龄、血清BNP水平及血浆hs-CRP水平均与NOAF相关,年龄和BNP、hs-CRP水平单独检测及三者联合预测NOAF的ROC曲线下面积(AUC)分别为0.680〔95%可信区间(95%CI)为0.579~0.782〕、0.657(95%CI为0.547~0.767)、0.630(95%CI为0.525~0.735)和0.745(95%CI为0.651~0.839),均P<0.05.结论年龄、血清BNP及血浆hs-CRP水平是重症患者发生NOAF的危险因素,可以三者联合预测重症患者NOAF的发生.

Objective To explore the risk factors of new-onset atrial fibrillation(NOAF)in critically ill patients and to evaluate the predictive value of B-type natriuretic peptide(BNP)and high-sensitive C-reactive protein(hs-CRP)for NOAF.Methods A retrospective study was conducted;the clinical data from adult patients who were admitted to the department of intensive care unit(ICU)of the Affiliated Hospital of Nanjing University of Chinese Medicine from January 2018 to December 2019 and were given at least 48 hours of intensive care or organ function support were analyzed.The following patients were excluded:the patients with paroxysmal or persistent atrial fibrillation,having got anti-arrhythmic drugs,with permanent pacemaker implantation before admission and the patients after admission into the ICU for 3 hours whose BNP and hs-CRP were not detected.According to the NOAF occurrence situation,the patients were divided into a NOAF group and a none-NOAF group(control group).The AF occurrence situations were observed within 48 hours after the enrolled patients'admission into the ICU.The clinical data and related laboratory test indicators were compared between the two groups;it was necessary to find the possible predictive factors for the occurrence of atrial fibrillation,binary Logistic regression analysis was performed on the related factors,and the receiver operative characteristic curve(ROC)was drawn to evaluate the predictive value of the related factors.Results A total of 108 patients were enrolled in this study.37 patients developed NOAF within 48 hours after admission into the ICU,the median age was 85(71,89)years old;71 patients didn't develop NOAF,among them,the median age was 73(63,83)years old.Except age,there were no statistical significant differences in other general data and accompanying diseases,such as gender,blood pressure,heart rate,incidences of hypertension,diabetes,coronary heart disease,chronic obstructive pulmonary disease(COPD),and chronic kidney disease(CKD)between the two groups;there were also no significant differences in acute physiology and chronic health evaluationⅡ(APACHEⅡ)score,white blood cell count(WBC),plasma creatinine,troponin levels and the use of norepinephrine between the two groups.Compared with the patients without NOAF,the levels of serum BNP[ng/L:577.0(202.5,1485.0)vs.210.0(121.0,777.0)]and plasma hs-CRP[mg/L:75.09(39.59,160.90)vs.48.00(14.73,118.70)]in the NOAF group were significantly higher(both P<0.05).Binary Logistic regression analysis showed that age,the levels of serum BNP and plasma hs-CRP were correlated with NOAF,and the age,BNP and hs-CRP levels were in separate manner and above 3 factors were in combination to calculate the area under the ROC(AUC)to look for the predicting power concerning the occurrence of NOAF,and their results were 0.680[95%confidence interval(95%CI)was 0.579-0.782],0.657(95%CI was 0.547-0.767),0.630(95%CI was 0.525-0.735)and 0.745(95%CI was 0.651-0.839),respectively,all P<0.05.Conclusion The risk factors of NOAF in critically ill patients include age,serum BNP and plasma hs-CRP levels,among which any one of the risk factors or the three factors in combination can predict the occurrence of NOAF in critically ill patients.