肺循环血流动力学参数对急性冠状动脉综合征患者预后的预测价值  

Prognostic value of pulmonary hemodynamic parameters for predicting survival in acute coronary syndrome

作　　者：全睿琳 黄石安 庞玲品 罗鹏 钱钰玲 陈小曦 单广良[3] 何建国[1] Quan Ruilin;Huang Shi'an;Pang Lingpin;Luo Peng;Qian Yuling;Chen Xiaoxi;Shan Guangliang;He Jianguo(Department of Cardiovascular Disease,Fuwai Hospital,National Center for Cardiovascular Diseases,Chinese Academy of Medial Sciences and Peking Union Medical College,Beijing 100037,China;Department of Cardiovascular Disease,Affiliated Hospital of Guangdong Medical University,Zhanjiang 524002,China;Department of Epidemiology and Statistics,Institute of Basic Medical Sciences,Chinese Academy of Medial Sciences,School of Basic Medicine,Peking Union Medical College,Beijing 100005,China)

机构地区：[1]中国医学科学院北京协和医学院国家心血管病中心阜外医院心血管内科,北京100037 [2]广东医科大学附属医院心血管内科,湛江524002 [3]中国医学科学院基础医学研究所北京协和医学院基础学院流行病学与卫生统计学系,北京100005

出　　处：《中华医学杂志》2022年第38期3012-3018,共7页National Medical Journal of China

基　　金：国家重点研发计划(2016YFC1304400);国家科技支撑计划(2011BAI11B15)。

摘　　要：目的探讨肺循环血流动力参数对急性冠状动脉综合征(ACS)患者预后的预测价值。方法连续纳入左心疾病相关性肺动脉高压多中心前瞻性登记注册数据库2013年1月至2016年11月住院期间接受冠状动脉造影及左、右心导管术的ACS患者,以全因死亡作为主要研究终点,采用Lasso回归筛选具有预测价值的肺血流动力学参数,并将参数纳入全球ACS事件注册(GRACE)评分中分析,比较纳入前后模型的预后预测能力。结果共纳入251例患者,年龄(63.7±11.5)岁,其中男198例(78.9%),女53例(21.1%),中位随访34.7个月。右心导管术所测平均肺动脉压(mPAP,HR=1.068,95%CI:1.015~1.123)、肺动脉收缩压(sPAP,HR=1.033,95%CI:1.002~1.065)和舒张压梯度(DPG,HR=1.094,95%CI:1.008~1.187)是ACS患者预后的预测因素(均P<0.05)。251例患者的中位GRACE评分为123分,预测全因死亡的C指数为0.703(95%CI:0.615~0.791)。在GRACE风险评分的基础上分别加上mPAP或DPG后,模型预测全因死亡的C指数分别提高至0.715(95%CI:0.629~0.801)和0.711(95%CI:0.625~0.797)。比较纳入mPAP或DPG前后的模型,综合判别改善指数分别为4.3%(95%CI:0.2%~13.5%,P=0.030)和3.0%(95%CI:0.2%~11.1%,P=0.020)。结论肺血流动力学参数对ACS患者的预后具有预测价值,可提高现有ACS风险评估模型对患者预后的预测能力。Objective To explore the characteristics and prognostic value of pulmonary hemodynamics in patients with acute coronary syndrome(ACS).Methods From a prospective multicenter registry study of pulmonary hypertension due to left heart disease,consecutive ACS patients who underwent coronary angiography in combination with left and right heart catheterization during hospitalization between January 2013 and November 2016 were involved.The primary endpoint was all-cause mortality.The prognostic variables identified by the Lasso analysis were included in the Global Registry of Acute Coronary Events(GRACE)score.Model performance was evaluated before and after the addition of hemodynamic parameters.Results A total of 251 patients were enrolled,with age of(63.7±11.5)years.A total of 198 males(78.9%)and 53 females(21.1%)were recruited,and the median follow-up time was 34.7 months.Right heart catheterization-assessed mean pulmonary arterial pressure(mPAP),systolic pulmonary arterial pressure(sPAP)and diastolic pressure gradient(DPG)were found to be significant predictors for survival in ACS.Adjusted for age and sex,the adjusted HR(95%CI)of mPAP,sPAP and DPG were 1.068(1.015-1.123),1.033(1.002-1.065)and 1.094(1.008-1.187),respectively(P<0.05).Applied to the present cohort of 251 patients,the median of the GRACE score was 123 points,with a C-index of 0.703(95%CI:0.615-0.791)for predicting mortality.After the addition of mPAP or DPG to the GRACE score,the C-index increased to 0.715(95%CI:0.629-0.801)or 0.711(95%CI:0.625-0.797),respectively.When comparing two models before and after the addition of mPAP or DPG,the integrated discriminatory index(IDI)was 4.3%(95%CI:0.2%-13.5%,P=0.030)and 3.0%(95%CI:0.2%-11.1%,P=0.020),respectively.Conclusion Pulmonary hemodynamics can be predictive for survival in ACS patients,providing incremental prognostic value to risk assessment in ACS.

关 键 词：急性冠状动脉综合征 右心导管术 肺血流动力学 预后 队列研究 

分 类 号：R541.4[医药卫生—心血管疾病]