血清胆碱酯酶在急性失代偿性心力衰竭患者预后评估中的作用

The role of serum cholinesterase in the prognosis assessment of patients with acute decompensated heart failure

目的探讨血清胆碱酯酶(serum cholinesterase,CHE)水平在急性失代偿性心力衰竭(acute decompensated heart failure,ADHF)患者预后中的作用。方法前瞻性收集2018年1月至2020年6月急诊入院的ADHF患者,最终纳入研究244例,记录患者的临床资料、实验室结果,依据CHE四分位数的第一和第三分位对患者分组并进行随访,对组间临床资料、实验室结果进行比较。随访的主要终点是心血管死亡和因心衰恶化住院的复合终点,次要终点是全因死亡和心血管死亡。应用Cox比例风险模型或时依Cox回归或分层Cox比例风险分析识别主要和次要终点发生风险,并构建临床、生物标志物和两者的复合模型。Kaplan-Meier法绘制不同CHE分组的生存曲线并比较其差异。应用受试者工作特征(ROC)曲线比较CHE水平和其他营养和预后指标的曲线下面积,以识别复合终点事件。结果在350(100,683)d的随访期内,158例患者发生复合终点事件。在调整了主要混杂因素的多变量Cox分析中,胆碱酯酶水平与复合终点显著相关。Cox比例风险分析显示:无论临床模型、生物标志物还是两者的复合模型,CHE水平与复合终点、全因病死率和心血管病死率显著相关(P均<0.05)。Kaplan-Meier生存分析显示,低胆碱酯酶水平组患者发生复合终点的风险高于中等和高胆碱酯酶水平患者(78.1%vs.66.7%vs.46.7%,P<0.001);ROC曲线分析显示:CHE预测复合终点的曲线下面积为0.736(95%CI,0.664~0.888)。全球荟萃分析组慢性心力衰竭(MAGGIC)风险评分添加胆碱酯酶后,复合终点预测的曲线下面积从0.704增加至0.762,P=0.038)。结论胆碱酯酶可作为预测ADHF患者不良结局的简单有效的预后指标。

Objective To explore the role of serum cholinesterase(CHE)levels in the prognosis of patients with acute decompensated heart failure(ADHF).Methods Total of 244 consecutive patients with ADHF who were admitted to the emergency department and were successfully discharged were prospectively enrolled from January 2018 to June 2020.Patients were divided into groups according to the first and third quartile of CHE level and the clinical data,laboratory tests and other nutritional indices were recorded after discharge,and then were followed up.The primary end points were the composites of cardiovascular death and hospitalization for worsening HF(composite end points).The secondary end points were all-cause mortality and cardiovascular death.Cox proportional risk analysis,time-dependent Cox regression model or stratified cox regression were used to identify the risk of primary and secondary endpoints.Clinical,biomarker and the compound models of clinical and biomarker were constructed.Kaplan-Meier method was used to plot the survival curves of different groups and compare their differences.Receiver Operating characteristics(ROC)curves were used to compare the area under the curve for CHE levels and other nutritional or prognostic indicators to identify composite end-point events.Results During a follow-up period of 350(100,683)days,158 patients reached the composite end points.In the multivariable Cox analysis,cholinesterase level was significantly associated with the composite end points after adjustment for major confounders.Cox proportional risk analysis or time-dependent Cox regression model showed that CHE level was significantly associated with the composite end points,all-cause mortality and cardiovascular mortality in both clinical,biomarker and composite models(all P<0.05).A Kaplan–Meier analysis revealed that patients with low cholinesterase levels had significantly greater risk of reaching the composite end points than those with middle or high cholinesterase levels(78.1%vs 66.7%vs.46.7%,P<0.001);Cholinesterase level showed the largest area under the receiver operating characteristic curve(AUROC)of 0.736(95%CI,0.664-0.888)for prediction of the composite end points among other nutritional indices.The AUROC of the Global Meta-Analysis Group Chronic Heart Failure(MAGGIC)Risk Score for prediction of the composite end points was increased from 0.704 to 0.762(P=0.038),when cholinesterase level was added.Conclusions Cholinesterase may serve as a simple and effective prognostic marker for predicting adverse outcomes in ADHF patients.