Analyzing the risk factors of acute myocardial injury in acute upper gastrointestinal bleeding patients
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摘要: 目的 分析急性上消化道出血患者并发急性心肌损伤患者的临床特点，探讨其发生急性心肌损伤的危险因素。方法 收集我院2019年1月1日—2020年8月31日期间急诊就诊的226例老年上消化道出血患者的临床病例资料，其中男166例，女60例；分为急性心肌损伤组70例和无急性心肌损伤组156例。比较2组患者的临床指标差异，获得其发生急性心肌损伤的危险因素。结果 多因素分析显示年龄增大，合并冠心病、慢性肾脏病，入院后红细胞比容谷值低、血肌酐高、尿素氮峰值高、尿素氮持续不降低、B型脑钠肽高、合并感染是急性上消化道出血患者并发急性心肌损伤的独立危险因素。临界值为B型脑钠肽峰值396 pg/mL、尿素氮峰值13.65 mmol/L可用于急性上消化道出血患者并发急性心肌损伤的诊断，诊断敏感度分别为77.1%和65.7%，特异度分别为79.5%和70.5%，阳性预测值分别为62.8%和50.0%，阴性预测值分别为88.6%和82.1%，准确率分别为78.8%和69.0%。结论 高龄，合并冠心病、慢性肾脏病病史，入院后血尿素氮高、持续不降低，B型脑钠肽高的急性上消化道出血患者更容易并发急性心肌损伤，遇到此类患者应适当放宽输血指征，并注意监测肌钙蛋白。Abstract: Objective To investigate the clinical characteristics and identify risk factors for acute myocardial injury in acute upper gastrointestinal bleeding patients.Methods Patients suffered from acute upper gastrointestinal bleeding from January 2019 to August 2020 were retrospectively reviewed in this study. They were divided into acute myocardial injury group(injury group) and non-acute myocardial injury group(non-injury group). We compared demographic and clinical features, laboratory findings on admission. The statistical analysis was performed to obtain the risk factors for acute myocardial injury in acute upper gastrointestinal bleeding patients.Results Two hundred and twenty six patients were enrolled in our study, of which 31.0% were complicate by acute myocardial injury. And the mortality in injury group was 8.6%, in non-injury group was 1.9%. Logistic regression analysis showed that the independent risk factors for concomitant acute myocardial injury in acute upper gastrointestinal bleeding patients included: age, coronary arterial disease, chronic kidney disease, hematocrit, peak blood urea nitrogen, serum creatinine, B-typenatriuretic peptide and coexisting infection. When cut-off value of peak B-type natriuretic peptide and peak blood urea nitrogen were used for diagnosis of acute myocardial injury, sensitivity was 77.1% and 65.7%, respectively. Specificity was 79.5% and 70.5%, respectively. Positive predictive value was 62.8% and 50.0%, respectively. Negative predictive value was 88.6% and 82.1%, respectively.Conclusion These risk factors for concomitant acute myocardial injury in acute upper gastrointestinal bleeding patients were developed to help identify high-risk patients and help the clinicians to make decision for preventive intervention.
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表 1 2组患者临床资料的单因素分析
例(%)，X±S，M(P25，P75) 因素 心肌损伤组(n=70) 无心肌损伤组(n=156) 统计值 P 一般资料 年龄/岁 70.8±12.5 60.5±18.4 -3.021 0.003 男/女 46/24 120/36 1.557 0.212 高血压 40(57.1) 58(37.2) 3.920 0.048 糖尿病 24(34.3) 32(20.5) 2.759 0.097 脑梗死 20(28.6) 34(21.8) 0.610 0.435 冠心病 32(45.7) 28(17.9) 9.551 0.002 心力衰竭 16(22.9) 12(7.7) 5.119 0.024 周围血管病 8(11.4) 4(2.6) 2.219 0.136 肝硬化 4(5.7) 22(14.1) 0.947 0.330 长期用药史a) 26(37.1) 44(28.2) 0.903 0.342 慢性肾脏病 14(20.0) 8(5.1) 4.506 0.034 慢性贫血 18(25.7) 24(15.4) 1.704 0.192 消化道出血史 16(22.9) 44(28.2) 0.354 0.552 吸烟史 40(57.1) 64(41.0) 2.526 0.112 酗酒史 14(20.0) 32(20.5) 0.004 0.950 入院体征 收缩压/mmHg 111.0(98.0，138.0) 117.5(101.8，142.0) -0.593 0.553 舒张压/mmHg 65.6±14.6 69.5±14.2 1.338 0.184 心率/(次·min-1) 100.0(85.0，114.0) 93.6±20.7 -1.665 0.096 发热 4(5.7) 0 - 0.090 辅助检查 血乳酸/(mmol·L-1) 1.7(1.1，2.8) 1.4(0.8，2.1) -2.067 0.039 白细胞总数/(×109·L-1) 10.9(8.9，16.3) 9.7±4.0 -2.710 0.007 血红蛋白/(g·L-1) 83.0(65.0，109.0) 93.5(67.8，118.0) -1.360 0.174 血红蛋白谷值/(g·L-1) 64.6±21.9 76.9±26.4 2.398 0.018 红细胞比容/% 24.7±8.3 28.2±8.0 2.153 0.034 红细胞比容谷值/% 19.4±6.2 23.6±6.5 3.228 0.002 C反应蛋白 1.9(0.5，31.2) 1.1(0.5，3.2) -1.431 0.152 尿素氮/(mmol·L-1) 14.9(10.6，17.7) 10.9±5.3 -3.313 0.001 尿素氮峰值/(mmol·L-1) 15.8±6.2 10.9(7.5，14.9) -3.521 < 0.001 尿素氮持续不降低b) 28(40.0) 8(5.1) 19.411 < 0.001 血肌酐/(μmol·L-1) 89.0(66.0，153.0) 69.0(60.0，88.3) -3.401 0.001 尿素氮/血肌酐比值 40.2±15.1 31.7(23.8，41.9) -1.981 0.048 入院血糖/(mmol·L-1) 9.1(7.0，12.2) 7.8(6.7，9.9) -1.798 0.072 入院白蛋白/(g·L-1) 34.9±5.9 38.9±5.3 -2.965 0.003 肌钙蛋白T峰值/(ng·mL-1) 0.2(0.1，1.0) 0 -8.481 < 0.001 B型脑钠肽峰值/(ng·mL-1) 1543.0(399.9，4399.0) 65.8(13.8，354.0) -5.333 < 0.001 左室射血分数/% 57.0(51.0，66.0) 65.0(55.0，68.0) -2.632 0.008 活动度/% 80.7±18.8 88.8±18.7 -2.015 0.044 D-二聚体 0.6(0.3，2.0) 0.4(0.1，1.0) -2.164 0.030 急性上消化道出血病因 2.910 0.573 肿瘤 20(28.6) 32(20.5) 消化性溃疡 34(48.6) 82(52.6) 食管胃底静脉曲张破裂出血 6(8.6) 26(16.7) 药物 6(8.6) 6(3.8) 其他c) 4(5.7) 10(6.4) 合并感染 16(22.9) 4(2.6) 9.946 0.002 住院时间/d 9.0(8.0，10.0) 6.0(5.0，7.0) 76.219 < 0.001 在院病死率/% 8.6(6/70) 1.9(3/156) 4.154 0.042 注：1 mmHg=0.133 kPa。a)长期用药史：非甾体消炎药、氯吡格雷、激素、抗凝药(包括华法林和新型口服抗凝药)；b)尿素氮持续不降低：入院后3 d尿素氮值比入院时尿素氮值升高或无变化；c)其他：包括贲门黏膜撕裂综合征、血管畸形等。 
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表 2 急性上消化道出血患者并发急性心肌损伤的多因素logistic回归分析
危险因素 B SE Wald χ2 P OR 95%CI 年龄 0.040 0.014 7.947 0.005 1.041 1.012~1.070 冠心病 1.175 0.536 4.807 0.028 3.238 1.133~9.258 慢性肾功能不全 1.531 0.665 5.305 0.021 4.625 1.256~17.024 血肌酐 0.013 0.006 4.523 0.033 1.013 1.001~1.025 尿素氮峰值 0.127 0.042 9.107 0.003 1.136 1.046~1.234 尿素氮持续不降低a) 2.512 0.619 16.498 < 0.001 12.333 3.669~41.454 红细胞比容谷值 -0.393 0.168 5.457 0.019 0.675 0.485~0.939 B型脑钠肽峰值 0.001 0.000 10.434 0.001 1.001 1.000~1.001 合并感染 2.421 0.822 8.682 0.003 11.259 2.249~56.357 注：a)尿素氮持续不降低：定义为入院后3 d尿素氮值比入院时尿素氮值升高或无变化。
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表 3 急性上消化道出血患者并发急性心肌损伤的ROC曲线
检验结果变量 曲线下面积 标准误差 P 95%CI B型脑钠肽峰值 0.814 0.047 < 0.001 0.722~0.906 尿素氮峰值 0.708 0.053 < 0.001 0.604~0.811
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表 4 临床指标对急性上消化道出血患者并发急性心肌损伤的临界值和预测价值
临床指标 临界值 敏感度/% 特异度/% 阳性预测值/% 阴性预测值/% 准确率/% B型脑钠肽峰值 396 pg/mL 77.1 79.5 62.8 88.6 78.8 尿素氮峰值 13.65 mmol/L 65.7 70.5 50.0 82.1 69.0
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