超敏肌钙蛋白T动态变化对重症患者预后的影响

Effect of dynamic changes of high-sensitivity cardiac troponin T on prognosis of critically ill patients

目的总结重症患者超敏肌钙蛋白T(hs-cTnT)动态变化的临床特点,探讨hs-cTnT与患者病情严重程度的相关性及其是否有助于预测患者的临床结局。方法回顾性分析2021年1-8月重庆医科大学附属大学城医院重症医学科收治的ICU时间超过48 h患者197例,收集并分析患者的性别、年龄、基础疾病、血肌酐、急性生理与慢性健康评分(APACHEⅡ评分)、血清hs-cTnT动态变化数据及患者ICU住院时间、总住院时间和住院死亡情况。根据hs-cTnT是否大于正常参考值上限(14 ng/L),分为非心肌损伤组(52例)与心肌损伤组(145例),并将心肌损伤组分为hs-cTnT<100 ng/L(92例)、100~200 ng/L(20例)及>200 ng/L(33例)3个亚组;所有患者再根据是否住院死亡分为非死亡组(155例)与死亡组(42例)。有关指标进行Spearman相关性分析。通过单因素与多因素分析影响重症患者住院死亡的独立危险因素,采用Kaplan-Meier曲线进行分组的生存分析比较,并利用受试者工作特征(ROC)曲线评价相关指标的住院死亡预测价值。结果心肌损伤组与非心肌损伤组患者性别、年龄、合并疾病[高血压、冠心病、慢性心力衰竭(COPD)、慢性阻塞性肺疾病、脓毒症、休克]、血肌酐水平、APACHEⅡ评分、住院病死率及ICU住院时间比较,差异均有统计学意义(P<0.05)。hs-cTnT与APACHEⅡ评分、血肌酐、年龄呈正相关(r=0.468、0.552、0.452,P<0.05)。hs-cTnT>200 ng/L组的生存率明显低于hs-cTnT<100 ng/L组和hs-cTnT 100~200 ng/L组(P均<0.05)。单因素分析发现,年龄、APACHEⅡ评分、血肌酐、hs-cTnT升高、hs-cTnT升高幅度及hs-cTnT升高持续时间是影响患者住院死亡的危险因素(P<0.05),进一步多因素Logistic回归分析显示,hs-cTnT升高及高APACHEⅡ评分是影响重症患者住院死亡的独立危险因素(P<0.05)。ROC曲线结果显示,hs-cTnT联合APACHEⅡ评分预测住院死亡的曲线下面积为0.830(95%CI:0.763~0.897),高于单独APACHEⅡ评分的曲线下面积0.768(95%CI:0.687~0.850)。hs-cTnT>200 ng/L且APACHEⅡ评分≥15分的患者住院病死率达60.87%,明显高于其他危险分层患者住院病死率(P<0.05)。结论hs-cTnT升高及高APACHEⅡ评分是重症患者住院死亡的独立预测因子。联合hs-cTnT和APACHEⅡ评分对于重症患者住院死亡的预测效能优于单独的APACHEⅡ评分。hs-cTnT>200 ng/L且APACHEⅡ评分≥15分的重症患者有更高的死亡风险。

Objective To investigate the clinical characters of dynamic changes of high-sensitivity cardiac troponin T(hs-cTnT)in critically ill patients and to explore the correlation between hs-cTnT and the severity of patients′condition and whether it is helpful to predict the clinical outcome of patients.Methods A retrospective analysis was made of 197 patients who were admitted to the ICU for more than 48 hours in the Department of Critical Care Medicine of the University-Town Hospital Affiliated to Chongqing Medical University from January to August 2021.The data of gender,age,basic diseases,serum creatinine,APACHEⅡscore,dynamic changes of serum hs-cTnT,length of stay in ICU,total length of stay and death in hospital were collected and analyzed.According to whether hs-cTnT was greater than the upper limit of normal reference value(14 ng/L),the patients were divided into non myocardial injury group(52 cases)and myocardial injury group(145 cases).The myocardial injury group was divided into three subgroups,hs-cTnT<100 ng/L(92 cases),100~200 ng/L(20 cases)and>200 ng/L(33 cases).According to whether the patients died in hospital,they were divided into non death group(155 cases)and death group(42 cases).Spearman correlation analysis was carried out for relevant indicators.The independent risk factors affecting the in-hospital death of critically ill patients were analyzed through univariate and multivariate analysis.Kaplan Meier curve was used for survival analysis and comparison in different groups,and receiver operating characteristic(ROC)curve was used to evaluate the predictive value of related indicators.Results There were significant differences in gender,age,combined diseases[hypertension,coronary heart disease,chronic heart failure(COPD),chronic obstructive pulmonary disease,sepsis and shock],blood creatinine level,APACHEⅡscore,in-hospital mortality and ICU length of stay between myocardial injury group and non myocardial injury group(P<0.05).hs-cTnT was positively correlated with APACHEⅡscore,serum creatinine and age(r=0.468,0.552,0.452,P<0.05).The survival rate of hs-cTnT>200 ng/L group was significantly lower than those of hs-cTnT<100 ng/L group and hs-cTnT 100~200 ng/L group(P<0.05).Univariate analysis showed that age,APACHEⅡscore,serum creatinine,hs-cTnT increase,hs-cTnT increase range and hs-cTnT increase duration were the risk factors of in-hospital mortality(P<0.05).Further multivariate logistic regression analysis showed that hs-cTnT increase and high APACHEⅡscore were the independent risk factors of death in critically ill patients(P<0.05).ROC curve results showed that the area under the curve of hs-cTnT combined with APACHEⅡscore in predicting in-hospital mortality was 0.830(95%CI:0.763-0.897),which was higher than that of APACHEⅡscore alone of 0.768(95%CI:0.687-0.850).The in-hospital mortality of patients with hs-cTnT>200 ng/L and APACHEⅡscore≥15 was 60.87%,which was significantly higher than those of patients with other risk stratification(P<0.05).Conclusion Elevated hs-cTnT and high APACHEⅡscore are independent predictors of in-hospital mortality in critically ill patients.The combination of hs-cTnT and APACHEⅡscore is better than ApacheⅡscore alone in predicting the death of severe patients in hospital.Critically ill patients with hs-cTnT>200 ng/L and APACHEⅡscore≥15 have a higher risk of death.