建立风险评分预测急性ST段抬高型心肌梗死患者的冠心病监护病房需求

Constructing a predictive risk score for the needs of coronary care unit care in patients with ST-segment elevation myocardial infarction

目的建立入院时病情稳定且接受经皮冠状动脉介入疗法(PCI)治疗的急性ST段抬高型心肌梗死(STEMI)患者入住冠心病监护病房(CCU)的风险预测评分,以筛选需要CCU的患者。方法回顾性分析吉林大学第一医院2017年11月至2018年10月805例行PCI治疗的入院时病情稳定STEMI患者的临床资料。将2017年11月至2018年7月654例患者作为建模组,有CCU需求125例,无CCU需求529例;2018年8月至2018年10月151例患者作为验证组,有CCU需求28例,无CCU需求123例。通过二元Logistic回归分析建立风险预测模型并确定评分标准,根据受试者工作特征(ROC)曲线最佳约登指数确定临界值。结果805例STEMI患者中,有CCU需求153例(19.01%),其中泵衰竭(心力衰竭和心源性休克)最多见(113例)。建模组中,最终年龄(60~74岁,OR=1.513,95%CI 0.945~2.424,P=0.085;≥75岁,OR=2.740,95%CI 1.371~5.478,P=0.004)、总缺血时间>4 h(OR=1.701,95%CI 1.022~2.831,P=0.041)、入院休克指数≥0.8(OR=1.910,95%CI 1.178~3.099,P=0.009)、多支血管病变(OR=2.090,95%CI 1.272~3.432,P=0.004)、术前病变血管心肌梗死溶栓治疗(TIMI)血流分级0级(OR=2.099,95%CI 1.313~3.353,P=0.002)、急性前壁心肌梗死(OR=3.696,95%CI 2.347~5.819,P<0.001)、既往有脑卒中史(OR=3.927,95%CI 2.057~7.500,P<0.001)共7个变量是行PCI治疗的STEMI患者有CCU需求的独立危险因素。评分标准:年龄<60岁为0分、60~74岁为1分、≥75岁为2分,总缺血时间>4 h为1分,入院休克指数≥0.8为2分,多支血管病变为2分,术前病变血管TIMI血流分级0级为2分、急性前壁心肌梗死为3分,既往有脑卒中病史为3分,总分15分。0~6分患者为低风险,7~15分为高风险。ROC曲线分析结果显示,建模组中,风险预测评分诊断STEMI患者有CCU需求的曲线下面积(AUC)为0.740(95%CI 0.692~0.788,P=0.580);验证组中,风险预测评分预测STEMI患者有CCU需求的AUC为0.755(95%CI 0.658~0.853,P=0.755)。结论基于年龄、总缺血时间、入院休克指数、多支血管病变、术前病变血管TIMI血流分级、急性前壁心肌梗死和既往有脑卒中史建立了预测入院时病情稳定且行PCI治疗的STEMI患者有CCU需求的风险预测评分,用于识别发生并发症的高风险患者,帮助医生进行CCU决策,为合理分配有限的CCU资源提供简便、实用的临床工具。

Objective To construct a risk prediction score for the needs of coronary care unit(CCU)care in stable condition acute ST-segment elevation myocardial infarction(STEMI)patients who receive percutaneous coronary intervention(PCI)treatment.Methods The clinical data of 805 STEMI patients who accepted PCI in the First Hospital of Jilin University from November 2017 to October 2018 were retrospectively analyzed.Among the patients,654 patients from November 2017 to July 2018 were served as the modeling group,the patients with needs of CCU had 125 cases,and the patients without needs of CCU had 529 cases;151 patients from August 2018 to October 2018 were served as the validation group,the patients with needs of CCU had 28 cases,and the patients without needs of CCU had 123 cases.Binary Logistic regression analysis was used to establish the risk prediction model and determine the score standards.The critical value was determined according to the best Youden index of receiver operating characteristic(ROC)curve.Results Among 805 patients with STEMI,153 cases(19.01%)had the needs of CCU,and the most common reason was pump failure(heart failure and cardiogenic shock,113 cases).In the modeling group,age(60 to 74 years old,OR=1.513,95%CI 0.945 to 2.424,P=0.085;≥75 years old,OR=2.740,95%CI 1.371 to 5.478,P=0.004),total ischemic time>4 h(OR=1.701,95%CI 1.022 to 2.831,P=0.041),admission shock index≥0.8(OR=1.910,95%CI 1.178 to 3.099,P=0.009),multi-vessel disease(OR=2.090,95%CI 1.272 to 3.432,P=0.004),preoperative diseased vessels thrombolysis in myocardial ischemia(TIMI)blood flow grade 0(OR=2.099,95%CI 1.313 to 3.353,P=0.002),acute anterior myocardial infarction(OR=3.696,95%CI 2.347 to 5.819,P<0.001)and previous history of stroke(OR=3.927,95%CI 2.057 to 7.500,P<0.001)were independent risk factors for CCU needs in STEMI patients undergoing PCI.The scoring criteria were as followings:age<60 years old was given 0 score,60 to 74 years old 1 score,≥75 years old 2 score;total ischemic time>4 h in 1 score,admission shock index≥0.82 scores,multi-vessel disease 2 scores,preoperative diseased vessels TIMI blood flow grade 02 scores,acute anterior myocardial infarction 3 scores,previous history of stroke 3 scores,and the total score was 15 scores.The patients with 0 to 6 scores were low-risk,and the patients with 7 to 15 scores were high-risk.ROC curve analysis result showed that,in modeling group,the area under curve(AUC)of risk prediction score for predicting the needs of CCU in STEMI patients was 0.740(95%CI 0.692 to 0.788,P=0.580);in validation group,the AUC of risk prediction score for predicting the needs of CCU in STEMI patients was 0.755(95%CI 0.658 to 0.853,P=0.755).Conclusions A predictive risk score based on seven risk factors such as age,total ischemic time,admission shock index,multi-vessel disease,preoperative diseased vessels TIMI blood flow grade,acute anterior myocardial infarction and previous history of stroke is constructed in order to predict the needs of CCU in STEMI patients with stable condition who receive PCI treatment.It can be used to help doctors to identify high-risk patients before the admission to CCU,thus providing simple and practical clinical tool for rational allocation of limited CCU resources.