Prediction of electrocardiogram QRST angle and QRS group duration for adverse cardiovascular events in elderly patients with acute coronary syndrome
-
摘要: 目的 探究心电图QRST夹角与QRS波群时限对老年急性冠脉综合征(acute coronary syndrome，ACS)患者主要不良心血管事件(major adverse cardiovascular events，MACE)的预测价值。 方法 选择2020年5月—2023年5月我院收治的154例ACS患者为研究对象。根据患者随访期间有无发生MACE，将患者分为MACE组(47例)和非MACE组(107例)。比较2组患者临床资料、QRST夹角及QRS波群时限，多元线性回归分析QRST夹角、QRS波群时限与血管内皮功能指标的相关性，多因素Cox分析QRST夹角、QRS波群时限与MACE发生的关系，采用限制性立方样条模型分析QRST夹角、QRS波群时限与MACE的剂量反应关系，受试者工作特征曲线分析QRST夹角、QRS波群时限的灵敏度和特异度。Log-binomial回归分析计算QRST夹角、QRS波群时限与MACE亚型之间的粗风险比和调整混杂因素后的风险比。 结果 MACE组患者年龄、QRST夹角、QRS波群时限、Gensini积分、血清肌酐、肌钙蛋白I、肌酸激酶同工酶、内皮素-1、血管性假血友病因子、水溶性凝聚素样氧化低密度脂蛋白受体-1水平显著高于非MACE组，收缩压、左心室射血分数、一氧化氮显著低于非MACE组，2组间差异有统计学意义(P < 0.05)。多元线性回归分析结果显示，QRST夹角、QRS波群时限与内皮素-1、血管性假血友病因子、水溶性凝聚素样氧化低密度脂蛋白受体-1存在显著正相关关系(β>0，P < 0.05)，与一氧化氮存在显著负相关关系(β < 0，P < 0.05)。QRST夹角、QRS波群时限是患者发生MACE的独立危险因素，无论是男性还是女性，QRST夹角、QRS波群时限与MACE发生均存在非线性剂量-反应关系。QRST夹角>65°的患者与QRST夹角≤65°的患者在再发心绞痛和非计划再次血运重建方面差异有统计学意义(P < 0.05)，QRS波群时限>110 ms的患者与QRS波群时限≤110 ms的患者在恶性心律失常和非计划再次血运重建方面差异有统计学意义(P < 0.05)。 结论 MACE组患者QRST夹角、QRS波群时限大于非MACE组，QRST夹角、QRS波群时限是老年ACS患者发生MACE的独立危险因素，与MACE发生存在非线性剂量-反应关系。Abstract: Objective To investigate the predictive value of electrocardiogram QRST angle and QRS group duration on major adverse cardiovascular events(MACE) in elderly patients with acute coronary syndrome(ACS). Methods A total of 154 patients with ACS admitted from May 2020 to May 2023 were selected as the study subjects. Patients were divided into MACE group(47 cases) and non-MACE group(107 cases) according to the occurrence of MACE during follow-up. Clinical data, QRST angle and QRS group duration were compared between two groups. The correlation between QRST angle, QRS group duration and vascular endothelial function indexes was analyzed by multiple linear regression. The relationship between QRST angle and QRS group duration and the occurrence of MACE was analyzed by multivariate Cox regression. The dose-response relationship between QRST angle, QRS duration and MACE subtype was analyzed by restricted cubic spline model. The sensitivity and specificity of QRST angle and QRS group duration were analyzed by receiver operating characteristic curves. The crude risk ratio and risk ratio after adjusting for confounding factors were calculated by log-binomial regression analysis. Results The age, QRST angle, QRS group duration, Gensini score, serum creatinine, troponin I, creatine kinase isoenzyme, endothelin-1, von Willebrand factor, and human soluble lectin-like oxidized low density lipoprotein receptor-1 levels in the MACE group were significantly higher than those in the non-MACE group, while the systolic blood pressure, left ventricular ejection fraction, and nitric oxide were significantly lower than those in the non-MACE group, there were significant differences between the two groups(P < 0.05). The results of multiple linear regression analysis showed that the QRST angle and the QRS group duration were positively correlated with endothelin-1, von Willebrand factor, and human soluble lectin-like oxidized low density lipoprotein receptor-1(β>0, P < 0.05), and negatively correlated with nitric oxide(β < 0, P < 0.05). The QRST angle and QRS group duration were independent risk factors for MACE. There was a nonlinear dose-response relationship between the QRST angle and the QRS group duration and MACE in both male and female patients. There were significant differences between patients with QRST angle>65° and patients with QRST angle ≤65° in recurrent angina pectoris and unplanned revascularization(P < 0.05). Patients with QRS group duration>110 ms and those with QRS group duration ≤110 ms had significant differences in malignant arrhythmia and unplanned revascularization(P < 0.05). Conclusion The QRST angle and QRS group duration of patients in the MACE group were higher than those in the non-MACE group. QRST angle and QRS group duration are independent risk factors for the occurrence of MACE in elderly patients with ACS, and have a non-linear dose-response relationship with the occurrence of MACE.
-
-
表 1 Gensini评分标准
冠脉病变部位 评分 狭窄程度 评分 左主干 5 1%~25% 1 左前降支或回旋支近段 2.5 26%~50% 2 左前降支中段 1.5 51%~75% 4 左前降支远段 1 76%~90% 8 左回旋支中远段 1 91%~99% 16 右冠状动脉 1 全闭 32 小分支 0.5 注：每处病变的积分为狭窄程度评分×病变部位评分，每例患者的积分为所有病变积分总和。 
下载: 导出CSV
表 2 不同预后患者临床资料比较
X±S 临床资料 MACE组(47例) 非MACE组(107例) t/χ2 P 一般资料 性别/例(%) 0.338 0.561 男 28(59.57) 69(64.49) 女 19(40.43) 38(35.51) 年龄/岁 68.56±4.13 65.79±5.11 3.274 0.001 BMI/(kg/m2) 24.27±1.20 24.01±1.17 1.260 0.210 吸烟史/例(%) 0.760 0.383 有 31(65.96) 78(72.90) 无 16(34.04) 29(27.10) 饮酒史/例(%) 1.552 0.213 有 33(70.21) 85(79.44) 无 14(29.79) 22(20.56) 高血压/例(%) 1.930 0.165 有 18(38.30) 29(27.10) 无 29(61.70) 78(72.90) 高血脂/例(%) 3.603 0.058 有 21(44.68) 31(28.97) 无 26(55.32) 76(71.03) 糖尿病/例(%) 5.312 0.021 有 14(29.79) 15(14.02) 无 33(70.21) 92(85.98) 心脏病/例(%) 2.273 0.132 有 9(19.15) 11(10.28) 无 38(80.85) 96(89.72) ACS类型/例(%) 0.689 0.406 ST段抬高型心肌梗死 20(42.55) 38(35.51) 非ST段抬高型心肌梗死 27(57.45) 69(64.49) QRST夹角/° 76.18±7.05 70.23±6.86 4.915 < 0.001 QRS波群时限/ms 120.40±11.16 113.31±10.21 3.856 < 0.001 Gensini积分/分 53.81±8.13 50.09±8.07 2.628 0.009 心功能指标 收缩压/mmHg△ 130.15±20.06 139.23±25.37 2.172 0.031 舒张压/mmHg 77.34±13.04 80.30±12.15 1.361 0.175 LVEF/% 50.67±5.12 55.40±6.09 4.649 < 0.001 左心房内径/mm 33.83±4.31 35.01±3.28 1.861 0.065 左心室舒张末内径/mm 53.16±6.27 55.50±7.12 1.945 0.054 左心室收缩末内径/mm 36.47±3.30 37.61±3.95 1.730 0.086 血清指标 WBC/(×109/L) 8.95±3.30 8.39±2.83 1.074 0.285 LDH/(U/L) 336.59±26.15 326.85±30.01 1.926 0.056 NLR 4.70±1.40 4.56±1.12 0.660 0.510 TC/(mmol/L) 4.07±0.53 4.65±0.46 0.114 0.910 TG/(mmol/L) 1.80±0.25 1.78±0.30 0.400 0.690 LDL-C/(mmol/L) 2.75±0.68 2.59±0.70 1.317 0.190 HDL-C/(mmol/L) 1.05±0.13 1.10±0.16 1.885 0.061 MYO/(ng/mL) 53.54±7.20 51.78±6.97 1.429 0.155 SCr/(μmol/L) 73.89±12.27 67.14±11.42 3.301 0.001 cTnI/(ng/mL) 16.72±2.29 10.05±2.41 16.053 < 0.001 CK/(U/L) 360.43±30.11 351.12±29.08 1.810 0.072 CK-MB/(ng/mL) 78.70±10.19 61.27±11.05 9.225 < 0.001 血管内皮功能指标 ET-1/(ng/L) 75.14±11.05 70.25±12.34 2.336 0.021 NO/(μmol/L) 46.27±8.08 50.89±9.53 2.896 0.004 vWF/% 190.58±30.10 180.05±25.12 2.252 0.026 sLOX-1/(ng/L) 4.84±1.13 4.05±1.17 3.898 < 0.001 注：△1 mmHg=0.133 kPa。
下载: 导出CSV
表 3 QRST夹角、QRS波群时限与血管内皮功能指标的相关性分析
项目 ET-1 NO vWF sLOX-1 β(95%CI) P β(95%CI) P β(95%CI) P β(95%CI) P QRST夹角 模型1 1.485
(1.171~2.116)0.005 -1.579
(-2.884~-0.072)0.001 1.356
(1.104~2.180)0.012 1.403
(1.120~2.216)0.010 模型2 1.477
(1.125~2.244)0.007 -1.655
(-2.463~-1.120)< 0.001 1.411
(1.142~2.495)0.010 1.457
(1.145~2.691)0.006 模型3 1.526
(1.204~3.350)0.002 -1.858
(-2.575~-1.064)< 0.001 1.430
(1.051~2.245)0.008 1.512
(1.273~2.909)0.003 QRS波群时限 模型1 1.630
(1.124~2.166)< 0.001 -1.483
(-1.960~-0.595)0.005 1.454
(1.120~2.063)0.007 1.440
(1.131~2.345)0.007 模型2 1.592
(1.033~2.742)0.001 -1.362
(-2.035~-1.112)0.007 1.424
(1.011~1.953)0.009 1.437
(1.082~2.401)0.008 模型3 1.661
(1.132~2.315)< 0.001 -1.507
(-2.114~-0.679)0.002 1.477
(1.108~2.311)0.005 1.520
(1.144~2.316)0.002 注：各模型均纳入154例患者；模型1：未调整模型；模型2：调整性别、年龄、BMI、吸烟史、饮酒史、疾病史；模型3：在模型2的基础上调整心功能指标、血清指标。
下载: 导出CSV
表 4 QRST夹角、QRS波群时限与MACE发生的多因素分析
项目 QRST夹角分类变量a QRST夹角连续变量 P趋势 QRS波群时限分类变量a QRS波群时限连续变量 P趋势 所有患者 模型1 1.327(1.009~1.858) 1.268(1.007~2.133) 0.003 1.696(1.198~2.006) 1.499(1.074~1.732) 0.002 模型2 1.336(1.056~1.692) 1.247(1.037~1.499) 0.001 1.612(1.220~1.892) 1.596(1.018~2.415) < 0.001 男性 模型1b 1.344(1.025~1.978) 1.419(1.072~2.310) 0.001 1.723(1.369~2.977) 1.801(1.269~3.104) < 0.001 模型2 1.405(1.110~1.933) 1.457(1.129~1.945) < 0.001 1.642(1.276~2.318) 1.713(1.305~2.992) < 0.001 女性 模型1b 1.462(1.200~1.852) 1.514(1.103~2.340) < 0.001 1.805(1.323~2.194) 1.782(1.210~1.926) < 0.001 模型2 1.503(1.196~2.930) 1.456(1.148~2.757) < 0.001 1.796(1.449~2.615) 1.764(1.173~2.193) < 0.001 注：各模型均纳入154例患者；a以QRST夹角≤65°、QRS波群时限≤110 ms为参考检验；b调整年龄、BMI、吸烟史、饮酒史、疾病史；模型1：调整基线资料性别、年龄、BMI、吸烟史、饮酒史、疾病史；模型2：调整心功能指标、血清指标、血管内皮功能指标。
下载: 导出CSV
表 5 MACE亚型的log-binomial回归分析
MACE亚型 QRST夹角>65°(73例) QRS波群时限>110 ms(98例) 例数 RR(95%CI) aRR(95%CI) 例数 RR(95%CI) aRR(95%CI) 心源性猝死 2 1.776
(0.859~2.642)1.681
(0.430~2.885)3 1.411
(0.362~1.701)1.383
(0.136~1.594)再发心肌梗死 3 1.582
(0.350~1.694)1.494
(0.338~1.926)2 1.599
(0.341~1.957)1.276
(0.142~1.690)再发心绞痛 8 1.348
(1.032~2.191)1.387
(1.046~1.953)10 1.420
(1.115~3.138)1.290
(0.359~1.584)恶性心律失常 4 1.031
(0.548~2.135)1.288
(0.349~1.892)6 1.634
(0.112~1.914)1.589
(1.180~2.490)心力衰竭 2 1.397
(0.634~1.848)1.457
(0.442~1.789)3 1.037
(0.288~1.469)1.181
(0.176~1.227)非计划再次血运重建 9 1.562
(1.147~2.218)1.864
(1.344~2.288)12 1.583
(1.262~3.140)1.357
(1.171~2.772)
下载: 导出CSV
-
[1] Alshahrani NS, Hartley A, Howard J, et al. Randomized trial of remote assessment of patients after an acute coronary syndrome[J]. J Am Coll Cardiol, 2024, 83(23): 2250-2259. doi: 10.1016/j.jacc.2024.03.398
[2] Singh S, Garg A, Chaudhary R, et al. Meta-analysis of immediate complete vs staged complete revascularization in patients with acute coronary syndrome and multivessel disease[J]. Cardiovasc Revasc Med, 2024, 60(3): 1-8.
[3] 汪凤琴, 张凯, 齐治平, 等. 急性心肌梗死患者心电图平面QRS-T夹角变化及其与恶性心律失常相关性分析[J]. 中国实验诊断学, 2021, 25(6): 808-813.
[4] 皇甫梦婷, 李波. 额面QRS-T夹角在心血管疾病应用的研究进展[J]. 心肺血管病杂志, 2022, 41(10): 1105-1109. doi: 10.3969/j.issn.1007-5062.2022.10.014
[5] 陈昕明, 刘晓亮, 吴伟. ACS患者急诊PCI术后应用比索洛尔QRS-T夹角下降及其与MACE发生的相关性分析[J]. 武汉大学学报(医学版), 2020, 41(4): 621-624.
[6] Wu H. Retrospective analysis of time limit of QRS complex in the electrocardiogram and its clinical significance in patients with acute myocardial infarction[J]. Am J Transl Res, 2021, 13(7): 8004.
[7] 中国医师协会急诊医师分会, 国家卫健委能力建设与继续教育中心急诊学专家委员会, 中国医疗保健国际交流促进会急诊急救分会. 急性冠脉综合征急诊快速诊治指南(2019)[J]. 临床急诊杂志, 2019, 20(4): 253-262. doi: 10.13201/j.issn.1009-5918.2019.04.001
[8] Chopannejad S, Sadoughi F, Bagherzadeh R, et al. Predicting major adverse cardiovascular events in acute coronary syndrome: A scoping review of machine learning approaches[J]. Appl Clin Inform, 2022, 13(3): 720-740.
[9] Li B, Liu X, Wang B, et al. QRS-T angle as a predictor of pul monary arterial hypertension: a review[J]. Medicine(Baltimore), 2023, 102(2): e32320.
[10] Gunduz R, Usalp S. Predictive value of frontal QRS-T angle after cardiac resynchronization therapy[J]. J Electrocardiol, 2021, 68: 24-29.
[11] Hayiroglu MI, Asarcikli LD, Osken A, et al. Frontal QRS-T angle may predict reverse dipping pattern in masked hypertensives[J]. Clin Exp Hypertens, 2022, 44(4): 2043892.
[12] Colluoglu T, Aksu MH, Akın Y, et al. Combined use of frontal plane QRS-T angle and platelet-to-lymphocyte ratio in the risk prediction of ischemic cardiomyopathy in STEMI[J]. Ann Noninvasive Electrocardiol, 2024, 29(1): e13106.
[13] Li Y, Liu Z, Liu T, et al. Risk Prediction for Sudden Cardiac Death in the General Population: A Systematic Review and Meta-Analysis[J]. Int J Public Health, 2024, 69(2024): 1606913.
[14] Borgquist R, Marinko S, Platonov PG, et al. Maximizing QRS duration reduction in contemporary cardiac resynchronization therapy is feasible and shorter QRS duration is associated with better clinical outcome[J]. J Interv Card Electrophysiol, 2023, 66(8): 1799-1806.
[15] Uskach TM, Sharapova YS, Safiullina AA, et al. Predictive value of QRS complex duration in patients with chronic heart failure and atrial fibrillation: retrospective study[J]. Ter Arkh, 2022, 94(4): 503-510.
[16] Wang J, Wu X, Sun J, et al. Prediction of major adverse cardiovascular events in patients with acute coronary syndrome: Development and validation of a non-invasive nomogram model based on autonomic nervous system assessment[J]. Front Cardiovascr Med, 2022, 9(2022): 1053470.
[17] 张源达, 谢而付, 胡德亮. Gensini评分联合NLR对STEMI患者PCI术后1年MACE的预测价值[J]. 江苏医药, 2022, 48(6): 552-556.
[18] 李华平, 薛成年, 陆春雷. 血小板相关指标及Gensini评分在PCI术后预后评估中的作用[J]. 中国循证心血管医学杂志, 2021, 13(9): 1042-1045.
[19] Yoshii T, Matsuzawa Y, Kato S, et al. Endothelial dysfunction predicts bleeding and cardiovascular death in acute coronary syndrome[J]. Int J Cardiol Heart Vasc, 2023, 376(4): 11-17.
[20] 金晶, 吴伟平, 刘五高. 急性冠脉综合征患者实验室指标的诊断意义[J]. 中国卫生检验杂志, 2023, 33(12): 1478-1481.
[21] Pieske B, Morris DA. History of acute coronary syndrome: a common, maybe underestimated, risk factor for heart failure with preserved ejection fraction[J]. Rev Esp Cardiol(Engl Ed), 2021, 74(6): 480-481.
[22] Jin J. Analysis of risk factors and nursing intervention of heart failure after emergency PCI in patients with acute coronary syndrome[J]. Minerva Pediatr(Torino), 2022, 74(6): 813-815.
[23] 王星, 高路, 史慧婷, 等. 经皮冠状动脉介入治疗和左室射血分数恢复对慢性完全闭塞合并射血分数轻度降低的心力衰竭患者预后的影响[J]. 临床心血管病杂志, 2023, 39(4): 276-281.
-
计量
- 文章访问数: 300
- 施引文献: 0