心脏磁共振在ST段抬高型心肌梗死急性期恶性室性心律失常事件中的评估价值

Clinical value of cardiac magnetic resonance imaging on the evaluation of malignant ventricular arrhythmias in the acute stage of ST-segment elevation myocardial infarction

目的探讨心脏磁共振(CMR)在ST段抬高型心肌梗死(STEMI)患者急性期院内发生恶性室性心律失常(MVA)事件中的评估价值。方法病例对照研究。选取2019年1月至2022年8月江苏省中医院、南通大学附属江阴医院和南京医科大学附属脑科医院胸科院区收治的288例急性STEMI患者为研究对象,均在发病12 h内行急诊经皮冠状动脉介入术(PCI),术后48~72 h行CMR检查,并监测2周内MVA事件。根据是否发生MVA事件分为两组,即MVA组58例和非MVA组230例。比较两组基线资料和CMR参数,通过Cox比例风险模型分析CMR参数对MVA的预测价值,并绘制受试者工作特征(ROC)曲线评估预测模型的准确性。结果在基线资料中,MVA组患者与非MVA组相比年龄较大、高血压和糖尿病的患病率较高、从发病至PCI时间较长、Killip分级2~4级较多、病变血管数2~3支较多、罪犯血管以左主干和前降支病变居多,差异均有统计学意义(均为P<0.05)。在CMR参数中,MVA组患者的左室射血分数(LVEF)、强化后T1值明显低于非MVA组,初始T1值、细胞外间质容积分数(ECV)、梗死面积(IS)均大于非MVA组,差异均有统计学意义(均为P<0.05)。Cox比例风险模型分析显示,年龄、血钾、Killip分级和病变血管数是STEMI患者急性期院内发生MVA事件的独立预测因子;CMR参数中的LVEF(HR=1.14,95%CI:1.06~1.28,P=0.03)、ECV(HR=1.18,95%CI:1.05~1.23,P<0.01)和IS(HR=1.13,95%CI:1.01~1.25,P<0.01)是STEMI患者急性期院内发生MVA事件的独立预测因子。其中,ECV诊断效能最佳,ROC曲线下面积(AUC)为0.855,ECV临界值选取36.4%,当ECV≥36.4%时,MVA发生率明显增加,敏感度88%,特异度89%,约登指数为0.77。IS诊断效能次之,AUC为0.624,临界值选取30.7%,当IS≥30.7%时,MVA发生率明显增加,敏感度74%,特异度62%,约登指数为0.64。LVEF诊断效能最低,AUC为0.578,临界值选取33%,当LVEF≤33%时,MVA发生率明显增加,敏感度82%,特异度73%,约登指数为0.58。结论CMR在STEMI急性期MVA事件中具有较高的预测意义和应用价值。

Objective To investigate the clinical value of cardiac magnetic resonance(CMR)imaging on the evaluation of malignant ventricular arrhythmias(MVA)in the patients with acute stage of ST-segment elevation myocardial infarction(STEMI).Methods This was a case-control study.A total of 288 patients with STEMI admitted in Jiangsu Province Hospital of Chinese Medicine,the Affiliated Jiangyin Hospital of Nantong University and Nanjing Chest Hospital,the Affiliated Brain Hospital of Nanjing Medical University from January 2019 to August 2022 were selected as the study object.According to whether the MVA occurrence,patients were divided into two groups,MVA group(n=58)and non-MVA group(n=230).Both groups of patients underwent primary percutaneous coronary intervention(PCI)within 12 hours of onset,CMR imaging 48-72 hours after operation was performed,and MVA events within 2 weeks were monitored.Baseline data and CMR parameters of the two groups were compared,and the independent predictors of MVA in CMR parameters were analyzed through Cox regression analysis.The receiver operating characteristic curve(ROC curve)was drawn and accuracy of the prediction model was evaluated.Results Compared with the non-MVA group,patients in the MVA group were older,the ratio of hypertension and diabetes was higher,the time from onset to PCI was longer,the ratio of 2-4 grade of Killip classification was higher,the ratio of 2-3 vessels disease was higher,and the culprit vessels were mostly on left main trunk and anterior descending branches(all P<0.05).In terms of CMR parameters,the left ventricular ejection fraction(LVEF)and contrasted T1 values in the MVA group were significantly lower than those in the non-MVA group(both P<0.05).The pre-contrast T1 values,extracellular volume fraction(ECV)and infarct size(IS)in the MVA group were higher than those in the non-MVA group,with significant differences(all P<0.05).Cox regression analysis showed that age,blood potassium,Killip grade,and number of diseased vessels were the independent predictors of MVA events in STEMI patients during the acute phase.LVEF(HR=1.14,95%CI:1.06-1.28,P=0.03),ECV(HR=1.18,95%CI:1.05-1.23,P<0.01)and IS(HR=1.13,95%CI:1.01-1.25,P<0.01)of CMR were the independent predictors of MVA events in STEMI patients during the acute phase.Among them,ECV showed the best diagnostic efficacy,with the AUC of 0.855 and the critical value of 36.4%.When ECV≥36.4%,the risk of MVA significantly increased,with 88%of sensitivity,89%of specificity,and Youden’s Index was 0.77.IS showed second diagnostic efficacy,with the AUC of 0.624 and the critical value of 30.7%.When IS≥30.7%,the risk of MVA significantly increased,with 74%of sensitivity,62%of specificity,and Youden’s Index was 0.64.LVEF had the lowest diagnostic efficacy,with the AUC of 0.578 and the critical value of 33%.When LVEF≤33%,the risk of MVA significantly increased,with 82%of sensitivity,73%of specificity,and Youden’s Index was 0.58.Conclusions CMR imaging has high predictive value on MVA events in STEMI patients during acute phase.