急性主动脉夹层患者院内及出院后180天内死亡的危险因素分析

Analysis of risk factors for in-hospital and post-discharge death within 180 days in patients with acute aortic dissection

目的分析急性主动脉夹层(AAD)患者院内及出院后180天内死亡的危险因素。方法首次确诊为AAD的患者739例,其中院内及出院后180天内死亡159例记为死亡组,院内及出院后180天内存活580例记为存活组。收集并比较两组患者的一般资料,包括基本信息、既往史、院前时间、发病相关信息、转运相关信息,采用Logistic回归分析法分析AAD患者院内及出院后180天内死亡的危险因素。依据AAD患者的院前时间与院内及出院后180天内结局,绘制受试者工作特征(ROC)曲线,计算约登指数,以约登指数对应的院前时间为截断值,界定AAD患者是否存在院前延迟,依据是否存在院前延迟将AAD患者分为延迟组和未延迟组,比较两组患者院内及出院后180天内的生存率和生存时间。结果死亡组院前时间、主动脉夹层分型、发病时症状、发病时心率、发病时上肢收缩压、入院方式、转诊次数及转诊方式与存活组相比,P均<0.05。Logistic回归分析结果显示,院前时间延长、主动脉夹层分型为A型、发病时有濒死感、发病时心率>100次/分、步行转诊、公共交通工具转诊及转诊次数超过两次是AAD患者院内及出院后180天内死亡的独立危险因素。绘制的ROC曲线下面积为0.777(95%CI为0.742~0.812),说明院前时间对AAD患者院内及出院后180天内结局的预测有较好效度,其约登指数为0.473,此时院前时间为9.25 h,即AAD患者院前延迟时间为9.25 h。延迟组生存率为64.50%,未延迟组生存率为96.60%,两组相比,P均<0.05。结论院前时间延长、主动脉夹层分型为A型、发病时有濒死感、发病时心率>100次/分、步行转诊、公共交通工具转诊及转诊次数超过两次是AAD患者院内及出院后180天内死亡的独立危险因素。AAD患者院前延迟时间为9.25 h,院前时间超过此节点的患者生存率和生存时间将显著下降。

Objective To analyze the factors influencing in-hospital and post-discharge mortality within 180 days in patients with acute aortic dissection(AAD).Methods There were 739 patients diagnosed with AAD for the first time,among which 159 deaths within the hospital and within 180 days after discharge were recorded as the death group,and 580 survivors within the hospital and within 180 days after discharge were recorded as the survival group.The general data of the two groups were collected and compared,including basic information,past medical history,pre-hospital time,morbid‑ity-related information,and transfer-related information,and the risk factors for in-hospital and post-discharge death with‑in 180 days of discharge in patients with AAD were analyzed by Logistic regression analysis.Based on the pre-hospital time and in-hospital and within 180 days after discharge outcomes of AAD patients,we plotted the receiver operating char‑acteristic(ROC)curves,calculated the Jordon index,and used the prehospital time corresponding to the Jordon index as the cut-off value to define whether there was a pre-hospital delay in AAD patients.According to whether there was pre-hos‑pital delay or not,AAD patients were divided into the delayed group and the undelayed group.The survival rates and surviv‑al time of patients in hospital and within 180 days after discharge were compared between the two groups.Results Signifi‑cant differences were found in the pre-hospital time,aortic dissection classification,symptoms at onset,heart rate at on‑set,upper extremity systolic blood pressure at onset,mode of admission,the number of referrals,and mode of referral be‑tween the death group and survival group(all P<0.05).Logistic regression analysis showed that the prolonged pre-hospital time,the aortic dissection classification of A,the sense of near-death at onset,heart rate at onset of>100 beats/min,re‑ferral on foot,public transportation referral and more than two referrals were independent risk factors for in-hospital and post-discharge death within 180 days in patients with AAD.The area under the ROC curve was 0.777(95%CI 0.742-0.812),indicating that the pre-hospital time had good validity in predicting the outcomes of AAD patients in-hospital and within 180 days after discharge,and its Yoden index was 0.473,at which time the pre-hospital time was 9.25 h,i.e.,the pre-hospital delay time of the patients with AAD was 9.25 h.The survival rate was 64.50%in the delayed group and 96.60%in the undelayed group(both P<0.05).Conclusions The prolonged pre-hospital time,aortic dissection classi‑fication as type A,near-death sensation at onset,heart rate>100 beats/min at onset,walk-in referrals,public transporta‑tion referrals,and more than two referrals were independent risk factors for in-hospital and post-discharge deaths within 180 days in patients with AAD.The pre-hospital delay in patients with AAD was 9.25 h,and the survival rate and survival time of patients whose pre-hospital time exceeded this node would decrease significantly.