动脉血乳酸浓度与重症监护室中急性心力衰竭病人住院期间全因死亡风险的关系

Relationship between arterial blood lactic acid concentration and the risk of in-hospital all-cause death of patients with acute heart failure in the intensive care unit

目的探索动脉血乳酸浓度与重症监护室中急性心力衰竭(AHF)病人住院期间全因死亡风险的关系。方法回顾性纳入并分析2008―2019年重症监护数据库Ⅳ(MIMIC-Ⅳ)中的7558例重症AHF病人的临床资料。暴露变量为动脉血乳酸浓度,结局变量为院内全因死亡发生。根据是否发生院内全因死亡,分为存活组(6792例)和死亡组(766例)。比较两组的基线资料,并采用logistic回归模型、限制性三次样条图以及亚组分析来探索乳酸浓度与院内全因死亡率之间的关系。结果与存活组相比,死亡组病人有较高的年龄,合并肝硬化、急性心肌梗死、慢性肾脏病、恶性肿瘤、呼吸衰竭、慢性阻塞性肺病、糖尿病和败血症的比例更高,但是合并高血压的比例较低。另外,死亡组病人的收缩压、碳酸氢盐、血钙、血细胞比容、红细胞、血红蛋白、血小板和白蛋白水平较低,但血清阴离子间隙、血糖、C-反应蛋白、血尿酸、血肌酐、白细胞、N末端B型利钠肽原(NT-proB⁃NP)、简化急性生理学评分Ⅱ(SAPSⅡ)评分和序贯性器官衰竭评分(SOFA)评分均较高,且住院时长更长,更容易使用强心药、血管活性药物和抗感染药物(均P<0.05)。在完全调整后的logistic多元回归模型结果显示,乳酸浓度是AHF病人死亡率的重要独立预测因子[OR=1.42,95%CI:(1.30,1.56),P<0.001]。此外,将乳酸浓度分为四分位数,与最低的四分位数组相比,随着乳酸浓度的升高,院内全因死亡率逐渐升高(P<0.05)。限制性三次样条曲线也显示乳酸与住院全因死亡率呈正相关的线性关系。亚组分析显示,呼吸衰竭与乳酸浓度和院内全因死亡率之间存在相关性相互作用(P<0.05)。结论对于重症监护室中的AHF病人而言,住院期间的动脉血乳酸浓度是院内全因死亡发生的独立预测指标。

Objective To explore the relationship between arterial blood lactic acid concentration and the risk of in-hospital allcause mortality of patients with acute heart failure(AHF)in the intensive care unit(ICU).Methods The clinical data of 7558 AHF patients in the intensive care databaseⅣ(MIMIC-Ⅳ)was analyzed from 2008 to 2019 were retrospectively analyzed.The exposure variable was arterial blood lactic acid concentration,and the outcome variable was in-hospital all-cause death.The patients were assigned into survival group(6792 cases)and death group(766 cases)according to whether all-cause death occurred in hospital.The baseline data of the two groups were compared.Logistic regression model,restricted cubic spline plot and subgroup analysis were used to explore the relationship between lactic acid concentration and in-hospital all-cause mortality.Results Compared with the survival group,patients in the death group were older and more likely to have liver cirrhosis,acute myocardial infarction,chronic kidney disease,malignancy,respiratory failure,chronic obstructive pulmonary disease,diabetes,and sepsis,but less likely to have hypertension.In addition,the dead group had lower levels of systolic blood pressure,bicarbonate,calcium,hematocrit,red blood cells,hemoglobin,platelets and albumin,higher levels of serum anion gap,blood glucose,C-reactive protein,blood urea nitrogen,creatinine,white blood cells,N-terminal B-type natriuretic peptide(NT-proBNP),simplified acute physiological scoreⅡ(SAPSⅡ)and sequential organ failure score(SOFA)score,and longer hospital stay.Meanwhile,patients in dead group also were easier to use cardiotropic drugs,vasoactive drugs and infection-fighting drugs(P<0.05).A fully adjusted logistic multiple regression model revealed that lactic acid concentration was an important independent predictor of mortality in patients with AHF[OR=1.42,95%CI:(1.30,1.56),P<0.001].Furthermore,when lactic acid was divided into quartiles,in-hospital all-cause mortality increased with an increase in lactic acid concentration compared with the lowest quartile(P<0.05).The restricted cubic spline plot also showed a positive linear relationship between lactic acid and in-hospital all-cause mortality.Among subgroups,respiratory failure interacted with a correlational interaction between lactic acid and in-hospital all-cause mortality(P<0.05).Conclusion For AHF patients in the ICU,the arterial blood lactic acid concentration during hospitalization is a significant independent predictor of in-hospital all-cause mortality.