急性Stanford A型主动脉夹层患者术前死亡风险因素分析及预测模型构建

Analysis of influencing factors and construction of predictive model of preoperative death in patients with acute Stanford type A aortic dissection

目的探讨急性Stanford A型主动脉夹层(ATAAD)患者术前死亡的影响因素,构建ATAAD患者术前死亡预测模型。方法选择2016年4月至2020年12月河南省胸科医院收治的375例ATAAD患者为研究对象,男293例,女82例;年龄21~81(51.03±7.80)岁。根据术前生存结局将ATAAD患者分为死亡组(n=69)和存活组(n=306)。通过查阅病历收集患者的一般资料、临床表现以及诊断性影像资料;采用单因素分析和logistic回归分析ATAAD患者术前死亡的影响因素,应用R2.1.1软件构建ATAAD患者术前死亡列线图预测模型,应用受试者工作特征(ROC)曲线、Hosmer-Lemeshow检验评估模型预测性能。结果375例ATAAD患者中,术前患者病死率为18.4%(69/375),存活率为81.6%(306/375)。单因素分析结果显示,ATAAD患者术前死亡与性别、年龄、发病至拟行手术间隔时间、昏迷/意识改变、发病后血压、心电图检查结果、心包积液有关(P<0.05)。多因素logistic分析结果显示,年龄≥70岁[比值比(OR)=1.702,P<0.05]、低血压(OR=1.956,P<0.05)、休克(OR=2.690,P<0.05)、心肌缺血(OR=2.130,P<0.05)、心包积液(OR=2.227,P<0.05)是ATAAD患者术前死亡的独立影响因素。根据多因素logistic分析结果绘制术前死亡列线图预测模型,由5个独立的术前死亡预测指标构成,年龄≥70岁为48分,低血压为83分,休克为100分,心肌缺血为95分,心包积液为76分,将各指标得分相加获得总分,总分越高,术前病死率越高。似然比检验显示该模型有统计学意义(χ^(2)=87.287,P<0.05);Wald检验显示模型系数有统计学意义(χ^(2)=116.277,P<0.05)。Logistic回归模型显示模型区分度较高(曲线下面积为0.896,95%置信区间:0.812~0.965,Youden指数为0.670,特异度为0.632,灵敏度为0.863)。Hosmer-Lemeshow检验显示模型具有较好的校准度(χ^(2)=7.354,P>0.05)。结论年龄≥70岁、低血压、休克、心肌缺血、心包积液是ATAAD患者术前死亡的独立影响因素,由年龄≥70岁、低血压、休克、心肌缺血、心包积液构建的术前死亡风险预测模型可用来评估ATAAD患者的术前死亡风险。

Objective To investigate the influencing factors of preoperative death in patients with acute Stanford type A aortic dissection(ATAAD)and construct a prediction model for preoperative death in ATAAD patients.Methods A total of 375 patients with ATAAD admitted to Henan Chest Hospital from April 2016 to December 2020 were selected as the research objects,including 293 males and 82 females,their age ranged from 21 to 81(51.03±7.80)years old.The patients with ATAAD were divided into death group(n=67)and survival group(n=306)according to the preoperative survival outcome.The general data,clinical manifestations and diagnostic imaging data of the patients were collected by consulting medical records;the influencing factors of preoperative death in ATAAD patients were analyzed by univariate analysis and logistic regression,the nomogram prediction model of preoperative death in ATAAD patients was constructed by R2.1.1 software,and the prediction performance of the model was evaluated by receiver operating characteristic(ROC)curve and Hosmer-Lemeshow test.Results Among the 375 ATAAD patients,the preoperative mortality rate was 18.4%(69/375),and the survival rate was 81.6%(306/375).Univariate analysis showed that the gender,age,interval from onset to planned surgery,coma/consultation,blood pressure after onset,electrocardiogram results and pericardial effusion were related to preoperative death of patients with ATAAD(P<0.05).Multivariate logistic analysis showed that age≥70 years old[odds ratio(OR)=1.702,P<0.05],hypotension(OR=1.956,P<0.05),shock(OR=2.690,P<0.05),myocardial ischemia(OR=2.130,P<0.05)and pericardial effusion(OR=2.227,P<0.05)were the independent influencing factors of preoperative death in patients with ATAAD.According to the results of multivariate logistic analysis,the nomogram prediction model of preoperative death was drawn,which was composed of five independent predictors of preoperative death;age≥70 years old was as 48 points,hypotension was as 83 points,shock was as 100 points,myocardial ischemia was as 95 points and pericardial effusion was as 76 points;the total score was obtained by adding the scores of each index;the the total score was higher,the preoperative mortality was higher;likelihood ratio test showed that the model was statistically significant(χ^(2)=87.287,P<0.05);Wald test showed that the model coefficient was statistically significant(χ^(2)=116.277,P<0.05).Logistic regression model showed that the discrimination of the model was high(area under curve was 0.896;95%confidence interval:0.812-0.965;Youden index was 0.670;specificity was 0.632;sensitivity was 0.863).Hosmer-Lemeshow test showed that the model had a good calibration(χ^(2)=7.354,P>0.05).Conclusion Age≥70 years old,hypotension,shock,myocardial ischemia and pericardial effusion are independent influencing factors of preoperative death in patients with ATAAD.The predictive model including age≥70 years old,hypotension,shock,myocardial ischemia and pericardial effusion can evaluate the risk of preoperative of patients with ATAAD.