急性心肌梗死合并心源性休克患者预后因素分析97例

Prognostic factors in patients with acute myocardial infarction combined with cardiogenic shock:analysis of 97 cases

目的分析影响急性心肌梗死(AMI)合并心源性休克(CS)患者预后的因素,为判断预后提供参考并提出可能改善预后的措施。方法回顾性分析2018年12月至2021年12月于河北医科大学第二医院急诊医学科就诊的AMI合并CS患者的临床资料,包括性别、年龄、身体质量指数(BMI);既往史(吸烟、冠心病、心律失常、糖尿病、高血压、高脂血症、脑血管病);APACHEⅡ评分、入院后24 h内最高血管活性药物评分(VIS)、入院后24 h内最快HR;入院后24 h内最差辅助检查值:血乳酸、白细胞计数(WBC)、心肌肌钙蛋白I(cTnI)、丙氨酸转氨酶(ALT)、总胆红素(TBil)、肌酐(Cr)、血清钾、左室舒张末期内径(LVEDD)、左室射血分数(LVEF);是否应用持续性肾脏替代治疗(CRRT)、是否应用主动脉内球囊反搏(IABP)、是否应用体外膜肺氧合(ECMO)等。根据发病30 d的预后情况将患者分为存活组和死亡组,单因素分析比较2组上述指标的差异,采用Logistic回归分析影响AMI合并CS患者预后的独立危险因素,并绘制ROC曲线评价危险因素对患者预后的预测价值。根据患者是否应用ECMO、IABP,分别分为非ECMO组与ECMO组、非IABP组与IABP组,比较APACHE-Ⅱ评分、VIS评分的差异。结果97例患者中30d存活62例(63.9%),死亡35例(36.1%);与存活组比较,死亡组APACHE-Ⅱ评分、VIS评分、WBC、血乳酸均明显升高,死亡组应用IABP比例均明显升高;Logistic回归分析显示WBC、血乳酸是影响AMI合并CS患者30 d预后的独立危险因素,优势比(OR)和95%可信区间(95%CI)分别为1.137(1.012~1.278)、1.166(1.025~1.326),P<0.05;ROC曲线分析显示WBC对应的AUC为0.710,截断值为15.35×10^(9)/L时,敏感度为60.0%,特异度为77.4%,血乳酸对应的AUC为0.756,截断值为6.05 mmol/L时,敏感度为85.7%,特异度为67.7%;与非ECMO组比较,ECMO组APACHE-Ⅱ评分、VIS评分均明显升高;与非IABP组比较,IABP组VIS评分明显升高(均P<0.05)。结论WBC、血乳酸是影响AMI合并CS患者预后的独立危险因素,当入院24小时内WBC最高值>15.35×10^(9)/L、血乳酸最高值>6.05 mmol/L时均提示不良预后。IABP、ECMO等支持手段不能改善AMI合并CS患者预后,与IABP、ECMO支持的患者更为危重有关。

Objective To identify factors that affect the prognosis of patients with acute myocardial infarction(AMI)combined with cardiogenic shock(CS),in order to provide reference for predicting prognosis and propose possible measures to improve prognosis in such patients.Methods A retrospective analysis was performed on the clinical data of patients with AMI and CS who visited the Department of Emergency Medicine of the Second Hospital of Hebei Medical University from December 2018 to December 2021,including gender,age,body mass index(BMI);past history of smoking,coronary heart disease,arrhythmia,diabetes,hypertension,hyperlipidemia,and cerebrovascular disease;APACHEⅡscore,highest vasoactive-inotropic score(VIS)within 24 hours of admission,and fastest heart rate within 24 hours of admission;the worst auxiliary examination values within 24 hours after admission:blood lactate,white blood cell count(WBC),cardiac troponin I(cTnI),alanine aminotransferase(ALT),total bilirubin(TBil),creatinine(Cr),serum potassium,left ventricular end diastolic diameter(LVEDD),left ventricular ejection fraction(LVEF);whether to use continuous renal replacement therapy(CRRT),intra-aortic balloon counterpulsation(IABP),or extracorporeal membrane oxygenation(ECMO),etc.The patients were divided into either a survival group or a death group based on the prognosis after 30 days of onset.Univariate analysis was used to compare the differences in the above indicators between the two groups.Logistic regression analysis was used to identify independent risk factors affecting the prognosis of patients with AMI combined with CS,and receiver operating characteristic(ROC)curves were drawn to evaluate the predictive value of the identified risk factors on patient prognosis.According to whether ECMO or IABP was used,the patients were divided into a non-ECMO group and an ECMO group,or a non-IABP group and an IABP group,and the differences in APACHEⅡscore and VIS were compared between groups.Results Among 97 patients,62(63.9%)survived for 30 days and 35(36.1%)died.Compared with the survival group,the APACHEⅡscore,VIS,WBC,and blood lactate in the death group were significantly increased,and the proportion of patients using IABP in the death group was significantly increased.Logistic regression analysis showed that WBC and blood lactate were independent risk factors affecting the 30-day prognosis of AMI patients with CS[odds ratio(OR)=1.137,95%confidence interval(CI):1.012-1.278,P<0.05;OR=1.166,95%CI:1.025-1.326,P<0.05].ROC curve analysis showed that,using a cutoff value of 15.35×10^(9)/L,the AUC of WBC in predicting prognosis was 0.710,with a sensitivity of 60.0%and specificity of 77.4%.When the cutoff value was 6.05 mmol/L,the AUC of blood lactate is 0.756,with a sensitivity of 85.7%and specificity of 67.7%.Compared with the non-ECMO group,the APACHEⅡscore and VIS in the ECMO group were significantly increased.Compared with the non-IABP group,the VIS of the IABP group was significantly higher(P<0.05).Conclusion WBC and blood lactate are independent risk factors affecting the prognosis of patients with AMI combined with CS.The highest WBC>15.35×10^(9)/L and the highest lactate value>6.05 mmol/L within 24 hours of admission indicate a poor prognosis.Due to the fact that AMI patients with CS supported by IABP and ECMO are more critical,these support measures cannot improve their prognosis.