老年急性ST段抬高型心肌梗死患者左心室血栓形成的影响因素及其Nomogram风险预测模型构建

Influencing factors of left ventricular thrombosis in elderly patients with acute ST segment elevation myocardial infarction and the construction of a Nomogram risk prediction model

目的探讨老年急性ST段抬高型心肌梗死(STEMI)患者左心室血栓(LVT)形成的影响因素,并构建Nomogram风险预测模型。方法将华中科技大学同济医学院附属同济医院2020年1月至2023年12月收治的873例急性STEMI患者以7∶3分为训练集(n=611)和验证集(n=262)。根据训练集患者LVT发生情况分为非LVT组(n=549)和LVT组(n=62)。多因素logistic回归分析急性STEMI患者发生LVT的影响因素;利用R软件rms程序包构建预测急性STEMI患者LVT发生风险的Nomogram模型,并通过ROC及Hosmer-Lemeshow检验验证其预测效能。结果与非LVT组比较,LVT组血红蛋白(Hb)[(131.15±15.99)g/L比(143.28±16.71)g/L]和左心室射血分数(LVEF)[(39.99±5.01)%比(45.24±6.69)%]明显较低(t=5.441、5.991,P<0.05),合并室壁瘤(37.10%比20.40%)、基线心肌梗死溶栓治疗(TIMI)血流分级0级(59.68%比44.81%)、未形成冠状动脉侧支循环(88.71%比72.13%)以及未进行急诊经皮冠状动脉介入治疗(PCI)或药物溶栓的占比(69.35%比48.82%)明显较高(χ^(2)=9.022、4.953、7.921、9.403,P<0.05)。多因素Logistic回归显示,Hb(OR=0.948)和LVEF(OR=0.868)为急性STEMI患者发生LVT的保护因素(P<0.05),合并室壁瘤(OR=6.812)、基线TIMI血流分级0级(OR=6.884)、未形成冠状动脉侧支循环(OR=7.273)、未进行急诊PCI或药物溶栓(OR=4.173)为其独立危险因素(P<0.05)。ROC分析显示,训练集AUC为0.871(95%CI 0.830~0.912),验证集为0.838(95%CI 0.731~0.945);Hosmer-Lemeshow检验中训练集χ^(2)=11.379,P=0.181,验证集χ^(2)=11.261,P=0.187。结论急性STEMI患者LVT的发生与Hb、LVEF、室壁瘤、基线TIMI分级、冠状动脉侧支循环形成及是否接受急诊PCI或药物溶栓密切相关,基于这些因素构建的Nomogram预测模型区分度及一致性良好,有助于临床预测。

Objective To explore the influencing factors of left ventricular thrombosis(LVT)formation in elderly patients with acute ST segment elevation myocardial infarction(STEMI)and to construct the Nomogram risk prediction model.Methods A total of 873 elderly acute STEMI patients admitted to Tongji Hospital from January 2020 to December 2023 were separated into the training set(n=611)and the validation set(n=262)at a ratio of 7∶3.According to the occurrence of LVT in the training set,the patients were separated into the non LVT group(n=549)and LVT group(n=62).Multivariate logistic regression was applied to analyze the influencing factors of LVT in the patients.RMS package of R software was applied to construct the Nomogram model for predicting the risk of LVT in the patients;and ROC and Hosmer-Lemeshow tests were applied to verify its predictive performance.Results Compared with the non LVT group,the LVT group had maredly lower hemoglobin(Hb)[(131.15±15.99)g/L vs.(143.28±16.71)g/L]and left ventricular ejection fraction(LVEF)[(39.99±5.01)%vs.(45.24±6.69)%](t=5.441,5.991,P<0.05);the proportions of patients with concomitant ventricular aneurysm(37.10%vs.20.40%),baseline thrombolysis in myocardial infarction(TIMI)blood flow grade 0(59.68%vs.44.81%),no formation of coronary collateral circulation(88.71%vs.72.13%),and no emergency percutaneous coronary intervention(PCI)or drug thrombolysis(69.35%vs.48.82%)were markedly higher(χ^(2)=9.022,4.953,7.921,9.403,P<0.05).Multivariate logistic regression showed that Hb(OR=0.948)and LVEF(OR=0.868)were the protective factors for LVT in the patients(P<0.05),while concomitant ventricular aneurysm(OR=6.812),baseline TIMI blood flow grade 0(OR=6.884),no formation of coronary collateral circulation(OR=7.273),and no emergency PCI or drug thrombolysis(OR=4.173)were the independent risk factors(P<0.05).ROC analysis showed that the AUC of the training set was 0.871(95%CI 0.830-0.912),and the AUC of the validation set was 0.838(95%CI 0.731-0.945);in the Hosmer-Lemeshow test,the training set showed χ^(2)=11.379,P=0.181 and the validation set showedχ2=11.261,P=0.187.Conclusion The occurrence of LVT in the elderly acute STEMI patients is closely related to Hb,LVEF,ventricular aneurysm,baseline TIMI grade,formation of coronary collateral circulation,and receiving emergency PCI or drug thrombolysis.The Nomogram prediction model constructed based on these factors has good discrimination and consistency,which is helpful for clinical prediction.