CHA_(2)DS_(2)-VASc评分在心力衰竭患者血栓栓塞风险预测中的应用

Application of the CHA_(2)DS_(2)-VASc score in predicting thromboembolic risk in patients with heart failure

目的分析不同纽约心脏协会(NYHA)心功能分级心力衰竭患者的血栓栓塞风险差异及CHA_(2)DS_(2)-VASc评分对于心力衰竭患者血栓栓塞事件的预测价值。方法回顾性分析4360例心力衰竭住院患者的CHA_(2)DS_(2)-VASc评分,根据心功能的受损状况将其分为NYHAⅠ级组(1180例)、NYHAⅡ级组(1168例)、NYHAⅢ级组(1187例)和NYHAⅣ级组(825例)。采用Logistic回归模型分析NYHA心功能分级对心力衰竭患者罹患血栓栓塞疾病风险的影响,NYHA心功能分级与CHA_(2)DS_(2)-VASc评分之间的线性相关度用Spearman相关系数表示,采用受试者工作特征(ROC)曲线的曲线下面积(AUC)判定CHA_(2)DS_(2)-VASc评分对于心力衰竭患者发生血栓栓塞风险的预测价值。结果4组患者间年龄(F=106.490,P<0.001)、女性(H=79.101,P<0.001)、年龄亚组(H=256.557,P<0.001)、高血压(H=8.092,P=0.044)、糖尿病(H=8.060,P=0.045)、血栓栓塞疾病(H=41.427,P<0.001)、血管疾病(H=40.567,P<0.001)、高脂血症(H=260.762,P<0.001)及心房颤动(H=306.597,P<0.001)比例的比较,差异均有统计学意义。且与NYHAⅠ级组比较,女性比例,NYHAⅡ~Ⅳ级组患者中65~74岁与≥75岁比例,以及患糖尿病、血栓栓塞疾病、血管疾病、心房颤动比例均显著升高(P均<0.05)。Logistic回归模型校正危险因素后发现,NYHAⅢ级[比值比(OR)=1.500,95%置信区间(CI)(1.126,1.999),P=0.006]与NYHAⅣ级[OR=1.688,95%CI(1.239,2.300),P=0.001]均是心力衰竭患者发生血栓栓塞的独立危险因素。心功能级别与CHA_(2)DS_(2)-VASc评分两变量之间呈弱相关(r=0.193,P<0.001)。ROC曲线分析结果显示CHA_(2)DS_(2)-VASc评分[AUC=0.902,95%CI(0.890,0.915),P<0.001]对于心力衰竭患者血栓栓塞风险的预测价值较高。结论心力衰竭患者NYHA心功能分级越高,血栓栓塞风险越高。合并血栓栓塞高危因素时,可采用CHA_(2)DS_(2)-VASc评分系统评估栓塞风险的同时给予恰当的抗凝治疗,降低栓塞事件发生率。

Objective To analyze the differences in thromboembolic risk among patients with heart failure in different New York Heart Association(NYHA)classifications and the value of CHA_(2)DS_(2)-VASc score in predicting thromboembolism.Methods The CHA_(2)DS_(2)-VASc scores of 4360 inpatients with heart failure were analyzed retrospectively.They were divided into four groups,including NYHA classⅠgroup(1180 cases),NYHA classⅡgroup(1168 cases),NYHA classⅢgroup(1187 cases)and NYHA classⅣgroup(825 cases),based on the impairment of cardiac function.The Logistic regression model was used to analyze the association between NYHA classification and thromboembolic risk in patients with heart failure.The linear correlation between NYHA classification and CHA_(2)DS_(2)-VASc score was described using Spearman correlation coefficient.The predictive value of CHA_(2)DS_(2)-VASc score for the risk of thromboembolism in patients with heart failure was determined by the area under the receiver operating characteristic(ROC)curve(AUC).Results The age(F=106.490,P<0.001),female(H=79.101,P<0.001),age subgroup(H=256.557,P<0.001),hypertension(H=8.092,P=0.044),diabetes mellitus(H=8.060,P=0.045),thromboembolic disease(H=41.427,P<0.001),vascular disease(H=40.567,P<0.001),hyperlipidemia(H=260.762,P<0.001)and atrial fibrillation(H=306.597,P<0.001)among the four groups all showed significant differences.In comparison with the NYHA classⅠgroup,the NYHA classⅡ-Ⅳgroups had higher proportions of female,higher rate ratios for age 65-74 subgroup and≥75 subgroup,and higher prevalence of diabetes mellitus,thromboembolism,vascular disease and atrial fibrillation(all P<0.05).The Logistic regression analysis showed that NYHA classⅢ[odds ratio(OR)=1.500,95%confidence interval(CI)(1.126,1.999),P=0.006]and NYHA classⅣ[OR=1.688,95%CI(1.239,2.300),P=0.001]were independent risk factors for thromboembolism in patients with heart failure,after adjustment for risk factors.The NYHA classification was weakly positively correlated with the CHA_(2)DS_(2)-VASc score(r=0.193,P<0.001).The ROC result revealed that the predictive value of CHA_(2)DS_(2)-VASc score[AUC=0.902,95%CI(0.890,0.915),P<0.001]was excellent in thromboembolic risk among patients with heart failure.Conclusions In patients with heart failure,a higher grade of NHYA functional classification appears to confer a higher risk of thromboembolism.We can assess eligibility for anticoagulation using the CHA_(2)DS_(2)-VASc score in heart failure patients at high risk of thromboembolism to reduce the incidence of thromboembolic events.