中国医科大学学报  2018, Vol. 47 Issue (9): 834-837

文章信息

刘畅, 柯艳, 赵丽, 崇巍
LIU Chang, KE Yan, ZHAO Li, CHONG Wei
急性消化道出血患者心肌损伤的危险因素分析
Risk Factors for Myocardial Injury with Concomitant Acute Gastrointestinal Hemorrhage
中国医科大学学报, 2018, 47(9): 834-837
Journal of China Medical University, 2018, 47(9): 834-837

文章历史

收稿日期:2018-01-12
网络出版时间:2018-08-28 9:03
急性消化道出血患者心肌损伤的危险因素分析
刘畅1 , 柯艳2 , 赵丽3 , 崇巍1     
1. 中国医科大学附属第一医院急诊科, 沈阳 110001;
2. 中国医科大学附属第一医院信息中心, 沈阳 110001;
3. 中国医科大学附属第一医院放射科, 沈阳 110001
摘要目的 探讨急性消化道出血(GIB)患者心肌损伤的危险因素。方法 选取本科室2016年1月至2016年12月320例急性GIB患者,根据入院72 h内血清肌钙蛋白Ⅰ或超敏肌钙蛋白T是否升高,分为心肌损伤组和无心肌损伤组。比较2组患者性别、年龄、首次外周静脉血红细胞计数、血红蛋白浓度(HGB)、血小板计数、谷丙转氨酶、血清碱性磷酸酶、总胆红素、血清白蛋白、血清尿素、血清肌酐、凝血酶原时间,活化部分凝血活酶时间和纤维蛋白原指标情况,并将上述单因素分析有显著性差异的因素纳入logistic回归多因素分析,以P < 0.05为差异有统计学意义。对多因素分析得出的危险因素绘制受试者工作特征曲线,计算曲线下面积、截断值、灵敏度、特异度、阳性预测值和阴性预测值。结果 logistic回归多因素分析结果提示男性(OR=2.939,P=0.011)、年龄增加(OR=1.037,P=0.003),低HGB(OR=0.987,P=0.013)是急性GIB时心肌损伤发生的独立危险因素。结论 年龄>60岁男性急性GIB患者,应适当放宽输血阈值以降低心肌损伤发生的风险。
关键词急性消化道出血    心肌损伤    危险因素    
Risk Factors for Myocardial Injury with Concomitant Acute Gastrointestinal Hemorrhage
LIU Chang1 , KE Yan2 , ZHAO Li3 , CHONG Wei1     
1. Department of Emergency Medicine, The First Hospital, China Medical University, Shenyang 110001, China;
2. Infomation Center, The First Hospital, China Medical University, Shenyang 110001, China;
3. Department of Radiology, The First Hospital, China Medical University, Shenyang 110001, China
Abstract: Objective To analyze the risk factors for myocardial injury complicated with acute gastrointestinal hemorrhage(GIB). Methods We retrospectively studied 320 patients with acute GIB who presented to the Emergency Department of the First Hospital of China Medical University between January 2016 and December 2016. Based on whether their serum cardiac troponinⅠor high-sensitivity cardiac troponin T levels were elevated within the first 72 hours after admission, patients were divided into a myocardial injury and a non-myocardial injury group. Sex, age, red blood cell and platelet counts, hemoglobin(HGB), and serum levels of alanine aminotransferase, alkaline phosphatase, total bilirubin, albumin, blood urea, creatinine, as well as the prothrombin time, activated partial thromboplastin time, and plasma fibrinogen were analyzed. Factors showing significant differences were included in the multivariate logistic regression analysis, and P < 0.05 was considered statistically significant. A receiver operating characteristic curve was plotted, and the area under the curve, cut-off values, sensitivity, specificity, and positive and negative predictive values were calculated. Results Multivariate logistic regression analysis showed that male sex(OR=2.939, P=0.011), increased age(OR=1.037, P=0.003), and low HGB levels (OR=0.987, P=0.013) were independent risk factors for myocardial injury with concomitant acute GIB. Conclusion In men aged > 60 years with acute GIB, an appropriate increase in transfusion threshold may reduce the risk of myocardial injury.

急性消化道出血(gastrointestinal bleeding,GIB)是急诊科常见疾病之一。美国每年发生GIB90~108例/10万,常见原因有感染、肿瘤、血管性疾病、药物不良反应以及凝血功能障碍[1]。当急性GIB发生时循环血容量减少、血红蛋白大量丢失,心肌细胞供氧能力下降导致心肌细胞氧债增加;另外,失血激活交感神经系统增加心肌细胞氧需求,使心肌缺氧进一步恶化,从而导致心肌损伤[2]。血清肌钙蛋白Ⅰ(cardiac troponinⅠ,cTnⅠ)或超敏肌钙蛋白T(cardiac high sensitivity-troponin T,hs-TNT)水平反映心电图等未能提示的心肌局灶微小坏死[3],具有较高的灵敏度及特异度,广泛应用于心肌损伤检测。对于脓毒症[4]和蛛网膜下腔出血[5]等非心脏源性危重病患者,其血清cTnⅠ和hs-TNT水平升高是院内死亡的危险因素[6-7]。因此应该关注急性GIB患者cTnⅠ和hs-TNT水平,警惕心肌损伤发生。急性GIB时心肌损伤发生率为13%~37%[8-9],有关急性GIB与心肌损伤关系的研究鲜有报道。本研究对急性GIB(包括上消化道和下消化道)患者进行回顾性研究,探讨发生心肌损伤的危险因素,为防止心肌损伤的发生提供依据。

1 材料与方法 1.1 研究对象

回顾性分析2016年1月至2016年12月我院急诊科收治的320例急性GIB患者的病历资料,男233例(72.8%),女87例(27.2%),年龄16~93岁。排除严重肾脏功能不全、慢性贫血以及资料不全患者。

1.2 研究指标及分组

记录患者年龄、性别、首次外周静脉血红细胞计数(red blood cell,RBC)、血红蛋白浓度(hemoglobin,HGB)、血小板计数(platelet,PLT)、谷丙转氨酶(alanine aminotransferase,ALT)、血清碱性磷酸酶(alkaline phosphatase,ALP)、总胆红素(total bilirubin,TBil)、血清白蛋白(albumin,ALB)、血清尿素、血清肌酐(creatinine,CR)、凝血酶原时间(prothrombin time,PT)、活化部分凝血活酶时间(activated partial thromboplastin time,APTT)、纤维蛋白原(fibrinogen,Fg)、cTnⅠ、hs-TNT。根据我院急诊科人血白蛋白治疗的检验学标准,将患者分为低白蛋白血症(ALB < 25 g/L)组和非低白蛋白血症(ALB≥25 g/L)组。根据入院72 h内是否出现cTnⅠ升高(> 0.026 ng/mL)或hs-TNT升高(> 0.1 ng/mL)将患者分为心肌损伤组和无心肌损伤组。

1.3 统计学分析

采用SPSS 22.0统计软件进行分析,将正态分布的计量资料以x±s表示,组间比较采用t检验;非正态分布的计量资料以中位数(四分位数间距)表示,组间比较采用非参数秩和检验;计数资料以例数(构成比)表示,组间比较采用χ2检验,将组间差异显著的指标纳入logistic回归进行多因素分析,P < 0.05为差异有统计学意义。将logistic回归得出的独立危险因素绘制受试者工作特征(receiver operating characteristic,ROC)曲线,计算曲线下面积(areas under the curve,AUC)、截断值、灵敏度及特异度、阳性预测值及阴性预测值。

2 结果 2.1 2组患者临床资料比较

心肌损伤组61例(19.1%),无心肌损伤组259例(80.9%)。与无心肌损伤组比较,心肌损伤组男性构成比、年龄,CR和血清尿素明显升高(均P < 0.05);低白蛋白血症构成比、RBC、HGB和PLT明显降低(均P < 0.05),见表 1

表 1 心肌损伤组与无心肌损伤组之间的比较 Tab.1 Comparison between the myocardial injury and the non-myocardial injury group
Factor Myocardial injury group(n= 61) Non-myocardial injury group(n= 259) P
Age(year) 67(59-79) 62(53-72) 0.012
Gender [n(%)] 0.015
  Male 52(85.2) 181(69.9)
  Female 9(14.8) 78(30.1)
RBC(×1012/L) 2.92(2.43-3.57) 3.35(2.77-4.29) 0.002
HGB(g/L) 85.00(68.50-106.50) 96.00(78.00-124.00) 0.007
PLT(×109/L) 166.00(122.00-220.20) 197.00(139.00-249.00) 0.013
HCT(L/L) 0.26(0.21-0.33) 0.30(0.24-0.38) 0.006
APTT(s) 36.70(33.80-39.80) 36.40(33.60-39.90) 0.835
PT(s) 15.00(14.00-16.50) 14.60(13.80-15.80) 0.138
Fg(g/L) 2.61(1.65-3.68) 2.89(2.17-3.73) 0.157
CR(μmol/L) 79.00(61.00-107.50) 66.50(55.00-83.00) < 0.001
Urea(mmol/L) 7.80(5.60-12.35) 6.80(5.10-10.20) 0.027
ALT(U/L) 32.00(25.00-54.00) 31.00(25.00-42.00) 0.329
ALP(U/L) 65.00(49.00-90.00) 75.00(57.00-97.00) 0.056
TBiL(μmol/L) 12.70(9.35-22.25) 12.40(8.50-17.50) 0.493
ALB [n(%)] 0.002
  Non-hypoalbuminemia 39(63.9) 213(82.2)
  Hypoalbuminemia 22(36.1) 46(21.6)
The continuous variables of the normal distribution are expressed by the mean(standard deviation);the continuous variables of the non-normal distribution are expressed by the median(interquartile range);the count data is represented by the quantity(composition ratio). RBC,red blood cell;HGB,hemoglobin;PLT,platelet;HCT,hematocrit;APTT,activated partial thromboplastin time;PT,prothrombin time;Fg,fibrinogen;CR,creatinine;ALT,alanine aminotransferase;ALP,alkaline phosphatase;TBil,total bilirubin;ALB,albumin.

2.2 心肌损伤危险因素的logistic回归多因素分析

将心肌损伤组与无心肌损伤组间比较有统计学差异的指标纳入logistic回归多因素分析,结果显示:男性(OR = 2.939,P = 0.011)、年龄增加(OR = 1.037,P = 0.003)、低HGB(OR = 0.987,P = 0.013)、低PLT(OR = 0.995,P = 0.006)、高CR(OR = 1.015,P = 0.002)为心肌损伤的危险因素,见表 2

表 2 心肌损伤危险因素的logistic回归多因素分析 Tab.2 Multivariate logistic regression analysis of risk factors for myocardial injury
Factor β OR P 95% CI
Male 1.078 2.939 0.011 1.287-6.710
Age 0.037 1.037 0.003 1.012-1.063
RBC 0.039 1.039 0.940 0.383-2.823
HGB -0.013 0.987 0.013 0.976-0.997
PLT -0.006 0.995 0.006 0.991-0.998
CR 0.015 1.015 0.002 1.006-1.025
Urea 0.028 1.029 0.412 0.961-1.101
Hypoalbuminemia 0.483 1.621 0.197 0.779-3.374
Constant -3.587 < 0.001 0.028
RBC,red blood cell;HGB,hemoglobin;PLT,platelet;CR,creatinine.

2.3 心肌损伤危险因素的ROC曲线分析

对logistic回归多因素分析中的危险因素(年龄增加、低HGB、低PLT和高CR)绘制ROC曲线,见图 1。年龄增加、低HGB、低PLT和高CR的AUC分别为0.603、0.610、0.602和0.649;阴性预测值分别为0.878、0.850、0.864和0.874,见表 3

HGB, hemoglobin; PLT, platelet; CR, creatinine. 图 1 心肌损伤危险因素的ROC曲线 Fig.1 Receiver operating characteristic curve analysis of risk factors for myocardial injury

表 3 心肌损伤危险因素ROC曲线分析 Tab.3 Analysis of risk factors for myocardial injury based on the receiver operating characteristic curve
Factor AUC Cut-off value Sensitivity Specificity Positive predictive value Negative predictive value
Age 0.603 59.50 0.754 0.417 0.234 0.878
HGB 0.610 78.50 0.443 0.7 41 0.287 0.850
PLT 0.602 167.50 0.557 0.664 0.281 0.864
CR 0.649 75.50 0.590 0.672 0.298 0.874
HGB,hemoglobin;PLT,platelet;CR,creatinine.

3 讨论

急性GIB往往掩盖潜在发生的心肌损伤[9]。本研究320例急性GIB患者入院72 h内发生心肌损伤者达61例(19.06%),与ISER等[10]的研究结果一致。本研究logistic回归多因素分析结果显示,男性、年龄增加、低HGB、低PLT以及高CR是急性GIB心肌损伤的危险因素。男性和高龄已公认为是心血管疾病发生风险增加的危险因素[11]。本研究中年龄的阴性预测值为0.878,提示急性GIB患者年龄 < 截断值(59.5)时不易发生急性心肌损伤,这与STRATE等[12-13]针对下消化道出血患者死亡风险研究结果类似。

急性GIB时大量失血导致循环灌注减少、CR升高,PLT大量消耗。本研究logistic分析结果显示低PLT和高CR是急性GIB发生心肌损伤的危险因素,但根据GIB病理生理学发生机制,CR升高和PLT降低与心肌损伤无直接因果关系,因此不能认为两者是心肌损伤的独立危险因素。

HGB直接参与循环氧气的输送,本研究结果显示低HGB是急性GIB心肌损伤的独立危险因素,因此临床上可以据此对心肌损伤进行干预。目前公认的急性GIB输血阈值为HGB < 70 g/L[1],但并未明确将心肌损伤风险考虑在内。本研究中HGB的截断值为78.50 g/L,阴性预测值为0.850,表明如果保持HGB > 78.50 g/L水平,急性GIB患者出现急性心肌损伤的可能性较小。BELLOTTO等[8]发现急性GIB(上消化道)患者中,当HGB < 82 g/L时,cTnⅠ水平明显升高,这与本研究结果相似。可见,在充分止血治疗的前提下,为降低急性GIB患者发生心肌损伤的风险(尤其对于年龄 > 60岁的男性患者),适当放宽输血阈值是十分必要的。

综上所述,男性、年龄增加和低HGB为急性GIB患者发生心肌损伤的独立危险因素。本研究为单中心研究,样本量较小,需进行多中心大样本的前瞻性研究,以便更好地评估急性GIB发生心肌损伤的危险因素,进而指导临床对其进行有效干预。

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