急性心肌梗死合并心力衰竭患者预后不良的影响因素分析及预测模型构建  

Influencing factors and construction of a prediction model for poor prognosis in patients with acute myocardial infarction complicated by heart failure

作　　者：朱厚玲 黄珊 马泽涛 吴月惟 ZHU Houling;HUANG Shan;MA Zetao;WU Yuewei(the First Department of Cardiology,the First Hospital Affiliated to Hainan Medical University,Haikou,Hainan,570100)

机构地区：[1]海南医科大学附属第一医院心血管内一科,海南海口570100

出　　处：《实用临床医药杂志》2025年第5期82-87,94,共7页Journal of Clinical Medicine in Practice

基　　金：海南医科大学2024年大学生创新创业训练计划项目(202411810009)。

摘　　要：目的探讨急性心肌梗死(AMI)合并心力衰竭(HF)患者预后不良的影响因素,构建列线图预测模型并验证其性能。方法选取252例AMI合并HF患者作为训练集,根据1年随访结果分为预后不良组60例和预后良好组192例;另选取与训练集例数比例约为1∶3的86例AMI合并HF患者作为验证集。采用Cox回归模型分析预后不良的影响因素,基于筛选结果构建列线图模型,并对模型进行内部验证和外部验证[采用Hosmer-Lemeshoe检验评估拟合优度,绘制校正曲线评估校准度,绘制受试者工作特征(ROC)曲线分析区分度,通过决策曲线分析(DCA)评估临床实用性]。结果训练集与验证集患者的临床资料比较,差异无统计学意义(P>0.05)。预后不良组的血肌酐、心肌肌钙蛋白T(cTnT)水平及年龄≥60岁者占比、发病至入院时间≥4 h者占比、心功能分级Ⅲ~Ⅳ级者占比高于预后良好组,左心室射血分数(LVEF)低于预后良好组,差异有统计学意义(P<0.05)。多因素Cox回归分析结果显示,发病至入院时间、心功能分级、血肌酐、cTnT、LVEF是AMI合并HF患者预后不良的独立影响因素(P<0.05),据此构建列线图模型。内部验证结果显示,该模型拟合优度良好(χ^(2)=13.966,P=0.083),校准度优良,区分度良好[曲线下面积(AUC)为0.831];外部验证结果显示,该模型拟合优度良好(χ^(2)=6.465,P=0.136),校准度优良,区分度良好(AUC为0.884)。DCA结果显示,列线图模型在高风险阈值范围为0.02~0.98时具有良好的临床净获益。结论AMI合并HF患者预后不良的影响因素包括发病至入院时间、心功能分级、血肌酐、cTnT、LVEF,据此构建的列线图预测模型对患者预后不良具有较高的预测价值。Objective To explore the influencing factors for poor prognosis in patients with acute myocardial infarction(AMI)complicated by heart failure(HF),construct a nomogram prediction model,and validate its performance.Methods A total of 252 patients with AMI complicated by HF were selected as training set and divided into poor prognosis group(60 patients)and good prognosis group(192 patients)based on 1-year follow-up results.Additionally,86 patients with AMI complicated by HF,with a ratio approximately 1∶3 to the training set,were selected as validation set.Cox regression models were used to analyze the influencing factors for poor prognosis.A nomogram model was constructed based on the screening results and underwent internal and external validation[Hosmer-Lemeshow test was used to assess goodness of fit,calibration curves were plotted to evaluate calibration,receiver operating characteristic(ROC)curves were drawn to analyze discriminative ability,and decision curve analysis(DCA)was conducted to assess clinical utility].Results There were no statistically significant differences in clinical data between the training set and validation set(P>0.05).The poor prognosis group had higher levels of serum creatinine and cardiac troponin T(cTnT),higher proportions of patients aged≥60 years,with time from onset to admission≥4 hours,with heart function grades Ⅲ to Ⅳ,and a lower left ventricular ejection fraction(LVEF)compared with the good prognosis group(P<0.05).Multivariate Cox regression analysis showed that time from onset to admission,heart function grade,serum creatinine,cTnT,and LVEF were independent influencing factors for poor prognosis in patients with AMI complicated by HF(P<0.05).Based on these results,a nomogram model was constructed.Internal validation results showed that the model had good goodness of fit(χ_(2)=13.966,P=0.083),excellent calibration,and good discriminative ability[area under the curve(AUC)was 0.831].External validation results also showed that the model had good goodness of fit(χ^(2)=6

关 键 词：急性心肌梗死 心力衰竭 列线图模型 COX回归模型 血肌酐 心肌肌钙蛋白T 决策曲线分析 

分 类 号：R542.2[医药卫生—心血管疾病] R541.6[医药卫生—内科学] R319[医药卫生—临床医学]