瑞金医院援鄂医疗团队建立新型冠状病毒肺炎心肌损伤相关危险因素预测模型

时间:2020-12-16 来源:瑞金医院作者: 点击:2689次

2020年9月,瑞金医院援鄂医疗团队《ESC HEART FAILURE》杂志在线发表题名为"Risk factors for myocardial injury in patients with coronavirus disease 2019 in China."——中国新型冠状病毒肺炎合并心肌损伤危险因素分析的研究论文。


心脏内科闫小响研究员、普外科胡伟国主任医师、感染科项晓刚副研究员为论文的共同通讯作者,范骎住院医师、武汉同济医院朱红玲主治医师为论文的共同第一作者。


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doi: 10.1002/ehf2.13022.


心血管疾病既是新冠肺炎患者的重要合并症,也是常见并发症,对患者的治疗与预后有很大影响。研究发现,出现心肌损伤的患者病情进展常更快,院内死亡风险显著高于非心肌损伤患者。目前多使用高敏肌钙蛋白作为心肌损伤的标志物,然而该指标上升往往提示患者已经发生心肌损伤,且有些地区并不具备检测高敏肌钙蛋白的条件,因此探索心肌损伤危险因素和早期评估模型非常重要。研究旨在从常用指标中发现预测心肌损伤的危险因素,研究并证实合并心肌损伤者预后差,而外周血中性粒细胞/淋巴细胞比值、血肌酐与血清乳酸脱氢酶水平可作为心肌损伤的风险评估指标,能准确区分发生和未发生心肌损伤的患者,并且与是否合并呼吸衰竭、肝肾功能不全等无关。


本研究首次在新冠肺炎患者中建立心肌损伤风险评估模型,利用简单易行的指标早期预测心肌损伤风险,有利于高危患者的识别与干预,为临床诊疗带来便利并提供新的思路。

【Abstract】

Aims: In patients with coronavirus disease 2019 (COVID‐19), the involvement of the cardiovascular system significantly relates to poor prognosis. However, the risk factors for acute myocardial injury have not been sufficiently studied. Thus, we aimed to determine the characteristics of myocardial injury and define the association between routine blood markers and cardiac troponin I, in order to perform a predictive model.

Methods and results: This retrospective cohort study included patients with confirmed COVID‐19 from Wuhan Tongji Hospital (Wuhan, China). Data were compared between those with and without myocardial injury. Kaplan–Meier analysis and Cox regression models were used to describe the association between myocardial injury and poor prognosis. Simple correlation analyses were used to find factors associated with high‐sensitivity cardiac troponin I levels. Univariate and multivariate logistic regression methods were used to explore the risk factors associated with myocardial injury. The area under the receiver operating characteristic curve was used to determine the predictive value of the model. Of 353 patients included in the study, 79 presented myocardial injury. Patients with myocardial injury had higher levels of inflammation markers, poorer liver and kidney function, and more complications compared with patients without myocardial injury. High‐sensitivity cardiac troponin I levels were significantly associated with neutrophil/lymphocyte ratio, creatinine, D‐dimer, lactate dehydrogenase, and inflammatory cytokines and negatively associated with oxygen saturation. It was significantly associated with poor prognosis after adjusting for age, sex, and complications. Multivariate regression showed that myocardial injury was associated with a high neutrophil/lymphocyte ratio (odds ratio 2.30, 95% CI 1.11–4.75, per standard deviation increase, P 1⁄4 0.02), creatinine (3.58, 1.35–8.06, P 1⁄4 0.01), and lactate dehydrogenase (3.39, 1.42–8.06, P 1⁄4 0.01) levels. Using a predictive model, the area under the receiver operating characteristic curve was 0.92 (0.88–0.96).

Conclusions: In patients with COVID‐19, neutrophil/lymphocyte ratio, creatinine, and lactate dehydrogenase are blood markers that could help identify patients with a high risk of myocardial injury at an early stage.


【中文摘要】

目的:在新型冠状病毒肺炎患者,心血管系统受累与患者不良预后显著相关。然而,针对急性心肌损伤相关的危险因素仍缺乏充分的研究。因此,本研究旨在明确新冠肺炎合并心肌损伤的临床特征,分析常规实验室指标与肌钙蛋白I的关系,从而建立风险评估预测模型。

方法和结果:本回顾性队列研究纳入来自武汉同济医院确诊新冠肺炎的住院患者。比较心肌损伤患者和无心肌损伤患者的基线期临床特征,并采用Kaplan-Meier生存曲线分析和Cox回归模型描述心肌损伤与不良预后的关系。之后运用简单相关分析来寻找与高敏肌钙蛋白I水平相关的因素,并采用单因素及多因素Logistic回归分析模型探究心肌损伤的危险因素,而后进一步通过ROC曲线明确其预测价值。研究纳入患者353人,其中79人出现心肌损伤。分析结果显示,与无心肌损伤的患者相比,合并心肌损伤者炎症指标更高,肝肾功能更差,并发症也更多。外周血高敏肌钙蛋白I水平与中性粒细胞/淋巴细胞比值、血肌酐、D-二聚体、乳酸脱氢酶以及炎症因子显著正相关,而与患者氧饱和度呈显著负相关,并且在校正了年龄、性别及并发症后,是预后不良的独立危险因素。多因素回归模型显示,心肌损伤与中性粒细胞/淋巴细胞比值(OR 2.30,95%CI 1.11-4.75,per SD,P=0.02)、血肌酐(3.58,1.35-8.06,P=0.01)和乳酸脱氢酶(3.39,1.42-8.06,P=0.01)显著相关,该预测模型的ROC曲线下面积为0.92(0.88-0.96)。

结论:在新冠肺炎患者,中性粒细胞/淋巴细胞比值、血肌酐和乳酸脱氢酶是帮助早期识别心肌损伤高危患者的重要外周血标志物。




作者简介

胡伟国  主任医师,教授,上海交通大学医学院附属瑞金医院普外科;研究方向:胃癌和结直肠肿瘤的临床诊治与研究。


闫小响  研究员,博士生导师,上海交通大学医学院附属瑞金医院心脏内科;研究方向:冠心病介入治疗和优化策略研究,急性心肌梗死发病机制和临床转化研究。


项晓刚  副研究员,医学博士,硕士生导师,上海交通大学医学院附属瑞金医院感染科;研究方向:危重型病毒性肝炎肝衰竭的发病机制和临床诊治。


范骎  住院医师规范化培训内科基地医师,医学博士,上海交通大学医学院附属瑞金医院心脏内科;研究方向:心力衰竭的基础与临床研究。




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