血尿素氮/白蛋白比值联合可溶性生长刺激表达基因2蛋白对急诊重症监护病房老年脓毒症患者心肌损伤的预警价值

Early warning value of blood urea nitrogen to albumin ratio combined with soluble growth stimulation expressed gene 2 on sepsis-induced myocardial injury in elderly patients in emergency intensive care unit

目的:探讨尿素氮与白蛋白比值(BAR)联合可溶性生长刺激表达基因2蛋白(sST2)对急诊重症监护病房(EICU)老年脓毒症患者发生心肌损伤的预警价值。方法:前瞻性分析于2018年8月至2022年8月入住河北医科大学哈励逊国际和平医院急救医学部EICU的符合老年脓毒症诊断条件的患者,根据心肌损伤发生与否分为心肌损伤组和非心肌损伤组,比较两组患者的一般临床资料、实验室指标,计算血尿素氮(BUN)/白蛋白(ALB)比值即BAR;分析组合指标BAR与老年脓毒症患者心肌损伤发生的相关性;采用二分类Logistic回归分析筛选EICU老年脓毒症患者发生心肌损伤的相关因素;采用受试者工作特征曲线(ROC)分析BAR对老年脓毒症患者发生心肌损伤的评估效能;采用MedCalc软件分析联合sST2和BAR对EICU老年脓毒症患者发生心肌损伤的预警价值。结果:最终纳入165例进行分析,其中106例(64.24%)发生了心肌损伤,肺部及腹腔感染的老年脓毒症患者更易发生心肌损伤(均P<0.05)。与未发生心肌损伤组比较,发生心肌损伤的老年脓毒症患者入院时炎症标志物[白细胞计数(WBC)、中性粒细胞与淋巴细胞比值(NLR)、乳酸及降钙素原(PCT)]、组合指标BAR值及sST2均高于未发生心肌损伤组。相关性分析结果显示,发生心肌损伤的老年脓毒症患者入EICU 24 h内的BAR与乳酸、PCT及C-反应蛋白(CRP)均呈正相关,其中与PCT相关性最强(r=0.417,P<0.001);BAR与急性生理学及慢性健康状况(APACHEⅡ)评分呈正相关(r=0.241,P=0.002);BAR与心肌损伤标志物sST2、血清肌钙蛋白I(cTnI)均正相关(r=0.327、0.307,均P<0.05)。Logistic回归分析结果显示,合并感染性休克(OR=2.406,P=0.008)、左心室射血分数(EF)值降低(OR=0.939,P=0.015)、BAR(OR=2.205,P=0.044)及乳酸(OR=1.137,P=0.014)、sST2升高(OR=1.016,P=0.020)是预警老年脓毒症患者发生心肌损伤的独立危险因素。ROC分析结果显示,对EICU老年脓毒症患者心肌损伤的发生,BAR具有较高的预警价值[曲线下面积(AUC)为0.651,P<0.05],最佳界值为0.32(敏感度为77.4%、特异度为60.2%);联合检测BAR和sST2对老年脓毒症患者心肌损伤的发生具有更高的预警价值(AUC为0.697,P<0.05);以0.32截断值为界,BAR<0.32心肌损伤患者的死亡率为36.00%(9/25)、≥0.32心肌损伤患者的死亡率为66.67%(54/81),两组差异有统计学意义(χ2=8.624、P=0.003)。结论:BAR、sST2均是老年脓毒症患者发生心肌损伤的独立危险因素,联合检测BAR和sST2对老年脓毒症患者心肌损伤的发生具有更好的预警价值。

Objective To examine the potential of combining the blood urea nitrogen(BUN)/albumin(ALB)ratio(BAR)with soluble growth stimulation expressed gene 2(sST2)as an early warning indicator for myocardial injury in elderly patients with sepsis in the emergency intensive care unit(EICU).Methods The clinical data of elderly patients with sepsis admitted to the EICU of the Emergency Medicine Department at Harrison International Peace Hospital of Hebei Medical University from August 2018 to August 2022 were prospectively analyzed.The patients were divided into two groups based on the presence or absence of myocardial injury:the myocardial injury group and the non-myocardial injury group.The general clinical data and laboratory indexes of the two groups were compared,and the BAR was calculated.The correlation between BAR and myocardial injury in elderly patients with sepsis was analyzed.Binary Logistic regression analysis was used to identify the risk factors for myocardial injury in elderly patients with sepsis in the EICU.MedCalc software was employed to determine the early warning value of the combined sST2 and BAR for myocardial injury in elderly patients with sepsis in the EICU.Results A total of 165 cases were analyzed,with 106 cases(64.24%)showing myocardial injury.It was found that elderly sepsis patients with lung and abdominal infection were more likely to experience myocardial injury(P<0.05 for all).In comparison to the group without myocardial injury,the levels of inflammatory markers such as white blood cell count(WBC),neutrophil to lymphocyte ratio(NLR),lactic acid,and procalcitonin(PCT),as well as combined markers BAR and sST2,were higher in elderly sepsis patients with myocardial injury upon admission.Correlation analysis results revealed significant positive correlations between BAR and lactic acid,PCT,and C-reactive protein(CRP)within 24 hours of admission to EICU in elderly sepsis patients with myocardial injury.Among these correlations,the strongest was observed between BAR and PCT(r=0.417,P<0.001).Additionally,BAR exhibited a positive correlation with acute physiology and chronic health evaluation scoring system(APACHEⅡ)scores(r=0.241,P=0.002).Furthermore,BAR showed positive correlations with myocardial injury markers sST2 and cTnI(r=0.327,0.307,P<0.05 for all).Logistic regression analysis revealed that septic shock(OR=2.406,P=0.008),decreased left ventricular ejection fraction(EF)(OR=0.939,P=0.015),BAR(OR=2.205,P=0.044),lactic acid(OR=1.137,P=0.014),and sST2 elevation(OR=1.016,P=0.020)were identified as independent risk factors for predicting myocardial injury in elderly patients with sepsis.The results of ROC analysis indicated that BAR had a high early warning value for the occurrence of myocardial injury in elderly patients with EICU sepsis[area under curve(AUC)0.651,P<0.05],with an optimal cut-off value of 0.32(sensitivity 77.4%,specificity 60.2%).Furthermore,the combined detection of BAR and sST2 demonstrated a higher early warning value for the occurrence of myocardial injury in elderly patients with sepsis(AUC 0.697,P<0.05).The mortality rate of patients with myocardial injury below a cut-off value of 0.32 was 36.00%(9/25),while the mortality rate of patients with myocardial injury equal to or above 0.32 was 66.67%(54/81).The difference between the two groups was statistically significant(χ2=8.624,P=0.003).Conclusions Both BAR and sST2 are considered independent risk factors for myocardial injury in elderly patients with sepsis.The combined detection of BAR and sST2 provides a more accurate prediction for the occurrence of myocardial injury in these patients.