急性缺血性脑卒中患者预后不良的影响因素及生存分析研究

Influencing factors and survival analysis of poor prognosis in patients with acute ischemic stroke

目的通过探讨急性缺血性脑卒中患者1年预后不良的影响因素并进行生存分析,增强对脑卒中预后不良影响因素的识别,实现更有效的二级预防。方法对2020年9月-2021年10月于北京中医药大学东直门医院、北京中医药大学房山医院、太原市中心医院收治的323例急性缺血性脑卒中患者进行为期1年的随访研究,入院时采集患者的一般资料、中医症状,并进行Essen卒中风险评分量表(ESRS)、神经功能缺损评分量表(NIHSS)评价及影像学检查。根据改良Rankin量表评分分为预后良好组(评分0~2分)和预后不良组(评分3~6分及复发)。终点事件定义为复发(脑出血、脑梗死、心肌梗死)和全因死亡。采用单因素分析和多因素Logistic回归分析急性缺血性脑卒中的独立影响因素,并构建预测模型,采用ROC曲线评价预测模型的预测价值。通过Kaplan-Meier生存分析评价不同梗死病灶数患者(分为单发梗死灶组和多发梗死灶组)的累计生存率。结果与预后良好组相比,预后不良组患者年龄偏大,以女性多见,既往多有冠心病、房颤、缺血性脑卒中/短暂脑缺血发作史,脑梗死发作次数多,NIHSS评分及ESRS评分高,梗死病灶多发,差异均有统计学意义(P均<0.05);多因素Logistic回归分析显示,年龄、梗死病灶数、入院NIHSS评分对不同预后患者的影响差异有统计学意义(P均<0.05);三者联合预测价值最高(AUC 0.787,95%CI:0.729~0.845),敏感度为68.5%,特异度为77.8%。多发梗死灶比单发梗死灶患者复发事件生存率及复合终点事件(全因死亡和复发)生存率均明显下降(P均<0.05);多发梗死灶患者临床特点为既往房颤史、入院NIHSS评分较高,中医证候气虚、阴虚证多见(P均<0.05)。结论年龄、梗死病灶数、入院NIHSS评分是急性缺血性脑卒中患者1年预后不良的独立危险因素,应重视多发梗死灶对结局终点事件生存率的影响,积极控制脑梗死患者的房颤、冠心病等基础疾病,重视急性期气虚阴虚证的治疗。

Objective It is to explore the influencing factors of poor prognosis in patients with acute ischemic stroke within one year and perform survival analysis to enhance the identification of influencing factors in poor prognosis of stroke and achieve more effective secondary prevention.Methods A 1-year follow-up study was conducted on 323 patients with acute ischemic stroke admitted to Dongzhimen Hospital of Beijing University of Chinese Medicine,Fangshan Hospital of Beijing University of Chinese Medicine,and Taiyuan Central Hospital from September 2020 to October 2021,the patients'general information,Chinese medical symptoms,scores of Essen Stroke Risk scores(ESRS)and NIH stroke scale(NIHSS),results of imaging examination were collected at admission.The patients were divided into a good prognosis group(score 0-2)and a poor prognosis group(score 3-6 and recurrence)according to their scores of modified Rankin scale.Endpoint events were defined as recurrence(cerebral hemorrhage,cerebral infarction,myocardial infarction)and all-cause death.Independent influencing factors of acute ischemic stroke were analyzed by univariate analysis and multifactorial logistic regression,and a prediction model was constructed,the predictive value of the prediction model was evaluated by ROC curves.The cumulative survival rates of patients with different numbers of infarct lesions(divided into single infarct lesion group and multiple infarct lesion group)were evaluated by Kaplan-Meier survival analysis.Results Compared with the good prognosis group,the patients in the poor prognosis group were older,more common in females and with history of previous coronary artery disease,atrial fibrillation,and ischemic stroke/transient ischemic attack,more frequently with cerebral infarction attacks,with higher NIHSS score and ESRS score and multiple infarct lesions,the differences were all significant(all P<0.05);multifactorial logistic regression analysis showed that age,number of infarct lesions,and admission NIHSS score had a statistically significant effect on patients with different prognosis(P<0.05),and the predictive value of their combination was the highest(AUC 0.787,95%CI:0.729-0.845),with a sensitivity of 68.5%,and specificity of 77.8%.The survival rates of recurrent events and composite endpoint events(all-cause death and recurrence)in patients with multiple infarct foci were significantly lower than those in patients with single infarct foci;the clinical characteristics of patients with multiple infarct were history of previous atrial fibrillation,higher admission NIHSS score and commonly with syndrome of Qi deficiency or Yin deficiency(all P<0.05).Conclusion Age,number of infarct lesions,and admission NIHSS score are independent risk factors for poor 1-year prognosis of patients with acute ischemic stroke,we should pay attention to the impact of multiple infarct lesions on survival of outcome end events,actively control atrial fibrillation,coronary heart disease and other underlying diseases in patients with cerebral infarction,and pay attention to the treatment of syndrome of Qi and Yin deficiency at acute phase.