1、中国循证心血管医学杂志2022年11月第14卷第11期 Chin J Evid Based Cardiovasc Med,November,2022,Vol.14,No.11 1386 论著 PCI术后发生主要不良心血管事件的危险因素分析和Nomogram模型的构建王雨桐1,闫伟2,徐怡楠1,顾怡钰1,张铭炀1,杨昕宇1,宋钰萌1,蒋廷波1作者单位:1 215000 苏州,苏州大学附属第一医院心血管内科;2 215000 苏州,苏州大学附属第一医院老年科【摘要】目的 研究急性ST段抬高性心肌梗死(STEMI)患者行经皮冠状动脉介入治疗(PCI)术后主要不良心血管事件(MACE)发生的独立危险因
2、素并构建其Nomogram模型。方法 应用病例对照研究设计,将2013年8月至2018年7月因STEMI于苏州大学附属第一医院行PCI的患者875例纳入本研究。收集患者的基本信息、实验室检查、心脏超声等指标,按照MACE的发生情况将病例分为病例组与对照组。使用R程序中Logistics回归分析PCI术后出现MACE发生的独立危险因素,并建立Nomogram模型。应用Calibration曲线和受试者工作曲线(ROC)分析模型预测效能。结果 与对照组相比,病例组患者脑卒中/短暂性脑缺血发作(TIA)和高血压的比例更高,心功能更差,病变血管数目更多,年龄更高;两组的肾小球滤过率(eGFR)、谷草转
3、氨酶(AST)、白细胞(WBC)、血清肌酐(Cr)、超敏C反应蛋白(hs-CRP)、室上性心动过速和室颤发生率、肌酸激酶同工酶(CK-MB)、左室收缩末期内径(LVESd)的差异均有统计学意义(P0.05)。多因素Logistic回归显示,吸烟(OR=1.67,95%CI:1.132.47,P=0.027)、高血压(OR=2.04,95%CI:1.363.95,P=0.002)、Killip分级3级(OR=5.48,95%CI:2.4112.46,P0.001)、LVESd40 mm(OR=1.6,95%CI:1.062.4,P=0.103)、hs-CRP10 mg/L(OR=1.27,95%
4、CI:0.871.87,P=0.947)为PCI术后MACE发生的独立危险因素。构建Nomogram预测模型,ROC曲线分析得出的曲线下面积(AUC)为0.666(95%CI:0.61410.7172,P0.001),模型截断值为34分,灵敏度0.574,特异度0.685(P0.05)。结论 基于R-Logistic回归显示吸烟、高血压、Killip分级3级、LVESd40 mm、超敏C反应蛋白10 mg/L为PCI术后出现不良心血管事件结局的独立危险因素,建立Nomogram风险模型可以预测患者的个体化风险,对临床诊疗决策起到一定的辅助作用。【关键词】急性ST段抬高性心肌梗死;经皮冠状动脉介
5、入术;主要不良心血管事件;Nomogram模型【中图分类号】R542.22 【文献标志码】A 开放科学(源服务)标识码(OSID)Risk factors of major adverse cardiovascular events and establishment of Nomogram model after percutaneous coronary intervention Wang Yutong*,Yan Wei,Xu Yinan,Gu Yiyu,Zhang Mingyang,Yang Xinyu,Song Yumeng,Jiang Tingbo.*Department of Ca
6、rdiovascular Medicine,First Affiliated Hospital of Soochow University,Suzhou 215000,China.Corresponding author:Jiang Tingbo,E-mail:jtb_Abstract Objective To study the independent risk factors of major adverse cardiovascular events(MACE)occurred in patients with acute ST-segment elevation myocardial
7、infarction(STEMI)after percutaneous coronary intervention(PCI),and a Nomogram model was established.Methods STEMI patients(n=875)undergone PCI were chosen by using case-control study design from the First Affiliated Hospital of Soochow University from Aug.2013 to July 2018.The baseline data and resu
8、lts of laboratory examinations and echocardiography were collected from the patients.All patients were divided,according MACE occurrence state,into case group and control group.The independent risk factors of MACE after PCI were analyzed by using Logistics regression analysis in R program,and a Nomo
9、gram model was established.The predictive efficacy of Nomogram model was analyzed by using Calibration curve and ROC curve.Results The percentages of patients with stroke or transient ischemic attack(TIA)and hypertension were higher,heart function was worse,number of diseases vessels were more and a
10、ge was elder in case group compared with control group.The differences in estimated glomerular filtration rate(eGFR),aspertate aminotransferase(AST),white blood cell(WBC),serum creatinine(SCr),high sensitivity C-reactive protein(hs-CRP),supraventricular tachycardia(SVT),ventricular fibrillation(VF),
11、creatine kinase-MB isoenzyme(CK-MB)and left ventricular end-systolic diameter(LVESd)had statistical significance between 2 groups(P0.05).The results of multi-factor Logistic regression analysis showed that smoking(OR=1.67,95%CI:1.132.47,P=0.027),hypertension(OR=2.04,95%CI:1.363.95,P=0.002),Killip gr
12、ade3(OR=5.48,95%CI:2.4112.46,P40 mm(OR=1.6,95%CI:通讯作者:蒋廷波,E-mail:jtb_doi:10.3969/j.issn.1674-4055.2022.11.23 1387 中国循证心血管医学杂志2022年11月第14卷第11期 Chin J Evid Based Cardiovasc Med,November,2022,Vol.14,No.11急性心肌梗死(AMI)是世界范围内最严重和最具致死性的冠脉疾病1,其中心电图显示梗死相应导联ST段抬高的类型称为急性ST段抬高性心肌梗死(STEMI),在我国的发病率呈现快速增长的态势2。早期经皮冠
13、状动脉介入治疗(PCI)进行血运重建是AMI的首选治疗方法,能显著改善症状并降低死亡率3,而PCI术后患者发生的不良结局一直是临床关注的重点。由于不能预防新的狭窄,PCI术后仍有再狭窄、再次血运重建的风险4,5。个体存在的危险因素不同,患者之间的生活质量和其他疾病发生概率也显著不同。因此,本研究探讨PCI术后患者出现主要不良心血管事件(MACE)的危险因素,寻找合适的风险评估模型,对临床决策具有一定指导意义。1 资料与方法1.1 研究对象与分组 本研究共纳入2013年8月至2018年7月因STEMI于苏州大学附属第一医院行支架植入术的患者875例,排除数据缺失者最终纳入710例,其中男性577
14、例,女性133例,年龄5074(577)岁,均行PCI。STEMI的诊断为美国心脏协会(AHA)定义的标准6,7:肌钙蛋白99th正常参考值上限或肌酸激酶同工酶(CK-MB)99th正常参考值上限的动态改变,心电图表现为ST段弓背向上抬高或新出现的左束支传导阻滞,伴有下列情况之一或以上者:持续缺血性胸痛、超声心动图显示节段性室壁活动异常、冠状动脉(冠脉)造影异常。排除依据:其他原因引起的胸痛;未直接行PCI。1.2 方法1.2.1 治疗方式 所有患者根据指南推荐术前予阿司匹林300 mg+氯吡格雷300 mg(或替格瑞洛180 mg)负荷,术后予循证医学推荐的药物,如阿司匹林100 mg qd
15、+氯吡格雷75 mg qd或阿司匹林100 mg qd+替格瑞洛90 mg bid双抗,他汀类药物调脂5。双抗药物使用1年后酌情调整为阿司匹林单抗,其余无禁忌症则终生服药。1.2.2 资料收集 收集患者的临床资料,包括一般信息,既往病史,药物服用情况,生命体征,血常规及生化检查,常规心脏彩超结果等并收集患1.062.4,P=0.103)and hs-CRP10 mg/L(OR=1.27,95%CI:0.871.87,P=0.947)were independent risk factors of MACE occurrence after PCI.A Nomogram predictive m
16、odel was established and results of ROC curve analysis showed that AUC was 0.666(95%CI:0.61410.7172,P0.001),cutoff value of the model was 34,sensitivity was 0.574 and specificity was 0.685(P40 mm and hs-CRP10 mg/L were independent risk factors of MACE occurrence after PCI.The establishment of Nomogram risk model can predict individualized risk in patients,and has some assistant effects on making decisions of clinical diagnosis and treatment.Key wordsAcute ST-segment elevation myocardial infarcti