行经皮冠状动脉介入治疗的急性ST段抬高型心肌梗死患者院内死亡危险因素分析

Risk factors for in-hospital death in patients with acute ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention

目的 回顾性分析2801例行经皮冠状动脉介入治疗(PCI)的急性ST段抬高型心肌梗死(STEMI)患者入院时生命体征及再灌注时间与院内死亡的关系。方法 选取2015年10月至2019年2月在泰达国际心血管病医院序贯入院行直接PCI的STEMI患者,以是否发生院内死亡将研究对象分为死亡组(49例)和生存组(2752例)。采用多因素Logistic回归及受试者工作特征(ROC)曲线分析STEMI患者院内死亡的危险因素。结果 基线临床资料比较分析发现两组患者年龄、舒张压(DBP)差异均有统计学意义(均P<0.05)。死亡组平均年龄为(67.04±9.43)岁,平均DBP为(61.19±11.56)mmHg(1 mmHg=0.133 kPa);生存组平均年龄为(62.05±11.45)岁,平均DBP为(81.76±15.78)mmHg。生存组中位胸痛症状发生至到达医院大门(S-to-D)时间较死亡组短(184.0 min比218.0 min),差异有统计学意义(P=0.014)。多因素Logistic回归分析结果显示,S-to-D时间>240 min的STEMI患者发生院内死亡的风险是S-to-D时间≤240 min患者的4.92倍(OR 4.92,95%CI 1.31~18.50,P=0.018),DBP<70 mmHg的STEMI患者发生院内死亡的风险是DBP≥70 mmHg患者的4.39倍(OR 4.39,95%CI 1.19~16.15,P=0.026)。倾向性评分匹配后多因素Logistic回归分析结果显示,S-to-D时间>240 min的STEMI患者发生院内死亡的风险是S-to-D时间≤240 min患者的3.07倍(OR 3.07,95%CI 1.03~9.13,P=0.044),到达医院大门至球囊扩张(D-to-B)时间>90 min的STEMI患者发生院内死亡的风险是D-to-B时间≤90 min患者的3.84倍(OR 3.84,95%CI 1.22~12.10,P=0.021)。ROC曲线分析显示,S-to-D时间预测院内死亡的ROC曲线下面积(AUC)为0.667(0.538~0.796,P=0.046),D-to-B时间预测院内死亡的AUC为0.635(0.510~0.759,P=0.108)。结论 低DBP(DBP<70 mmHg)、再灌注时间延长(S-to-D时间>240min及D-to-B时间>90min)与患者院内死亡的发生显著相关。S-to-D时间对STEMI患者院内死亡的预测作用强于D-to-B时间。

Objective To analyze the risk factors for in-hospital death in patients with ST-segment elevation myocardial infarction(STEMI)undergoing primary percutaneous coronary intervention(PCI). Methods A total of 2801 patients with STEMI who were successively admitted to the chest pain center for primary PCI from October 2015 to February 2019 were selected. The subjects were divided into death group(n=49) and survival group(n=2752) according to whether they died in hospital. Multi-variate logistic regression analysis was used to explore the risk factors for in-hospital death in patients with STEMI, and receiver operating characteristic(ROC) curve was used to predict the risk factors for in-hospital death in STEMI patients undergoing primary PCI. Results Univariate analysis showed that there were significant differences in age and diastolic blood pressure between the two groups(both P<0.05). The mean age of the death group was(67.04±9.43) years, and the mean diastolic blood pressure was(61.19±11.56) mmHg(1 mmHg=0.133 kPa). The mean age of the survival group was(62.05±11.45) years, and the mean diastolic blood pressure was(81.76±15.78) mmHg. The time of symptom onset to door(S-to-D) in survival group was shorter than that in death group(184.0 min vs. 218.0 min), and the difference was statistically significant(P=0.014). Multivariate logistic regression analysis after propensity score matching showed that the risk of in-hospital death in STEMI patients with S-to-D time >240 min was 3.07 times higher than that in patients with S-to-D time≤240 min(OR 3.07, 95%CI 1.03–9.13, P=0.044), the risk of in-hospital death was 3.84 times higher in STEMI patients with D-to-B time>90 min than in patients with D-to-B time≤90 min(OR 3.84, 95%CI 1.22–12.10, P=0.021). ROC curve analysis showed that the area under curve(AUC) of in-hospital death at S-to-D time was 0.667(0.538–0.796, P=0.046). The AUC of in-hospital death at D-to-B time was 0.635(0.510–0.759, P=0.108). Conclusions Low diastolic blood pressure(diastolic blood pressure<70 mmHg) and prolonged reperfusion time(S-to-D time>240 min or D-to-B time>90 min) were significantly associated with in-hospital death. S-to-D time was stronger than D-to-B time in predicting in-hospital death in STEMI patients.