急诊科急性心肌梗死后并发急性心力衰竭患者远期预后及其影响因素研究

目的探究北京地区首诊于急诊科的急性心肌梗死(acute myocardial infarction,AMI)后并发急性心力衰竭(acute heart failure,AHF)患者5年生存状况以及预后相关影响因素。方法将北京地区AHF注册登记研究中AMI后并发AHF的患者纳入研究,以5年全因死亡作为终点对患者进行随访,构建多因素Cox风险比例回归模型,探究影响AMI后并发AHF患者5年全因死亡的独立危险因素。结果共计395例患者纳入研究,245例(62%)于5年随访期内死亡。入院时心率(HR=1.006,95%CI:1.001~1.011,P=0.022)、左心室前壁心肌梗死(HR=1.383,95%CI:1.058~1.806,P=0.017)、Killip心功能分级Ⅳ级(HR=1.836,95%CI:1.246~2.704,P=0.002)、并发心房颤动(HR=1.402,95%CI:1.010~1.945,P=0.043)、既往慢性肾脏病(HR=1.753,95%CI:1.235~2.488,P=0.002)、卒中或短暂性脑缺血发作病史(HR=1.272,95%CI:0.865~1.277,P=0.088)、脑钠肽/N-末端脑钠肽前体水平位于第三分位数(HR=1.597,95%CI:1.026~2.486,P=0.038)为5年全因死亡的独立危险因素;血清钠水平(HR=0.978,95%CI:0.956~1.001,P=0.064)、接受再灌注治疗(HR=0.558,95%CI:0.412~0.755,P<0.001)、随访期间坚持服用利尿剂(HR=0.626,95%CI:0.433~0.905,P=0.013)、β-受体阻滞剂(HR=0.455,95%CI:0.329~0.628,P<0.001)、抗血小板药物(HR=0.521,95%CI:0.381~0.714,P<0.001)以及他汀类药物(HR=0.650,95%CI:0.477~0.886,P=0.006)为独立保护性因素。结论AMI后并发AHF患者接受再灌注治疗及其他指南推荐的药物治疗比例偏低,远期预后差,通过规范诊疗措施有希望改善患者的长期预后。

Risk factors and long-term outcome of patients presenting to emergency departments with acute heart failure after acute myocardial infarction

Objective To investigate the 5-year survival and prognostic factors of patients with acute myocardial infarction(AMI)complicated with acute heart failure(AHF)who were first diagnosed in emergency department in Beijing.Method Patients diagnosed with AHF after AMI in the Beijing Acute Heart Failure Registry(Beijing AHF Registry)were included in this study.The outcomes of interest were 5-year all-cause mortality.Cox regression models were adopted to examine 5-year outcomes and associated predictors.Result A total of 395 patients were included in the study,245(62%)died during the 5-year follow-up.Heart rate(HR=1.006,95%CI:1.001~1.011,P=0.022),left ventricular anterior wall myocardial infarction(HR=1.383,95%CI:1.058~1.806,P=0.017),Killip class IV(HR=1.836,95%CI:1.246~2.704,P=0.002),atrial fibrillation(HR=1.402,95%CI:1.010~1.945,P=0.043),previous chronic kidney disease(HR=1.753,95%CI:1.246~2.704,P=0.002),previous stroke/transient ischemic attack(HR=1.272,95%CI:0.865~1.277,P=0.088),BNP/NT proBNP level in the third quartile(Q3,HR=1.597,95%CI:1.026~2.486,P=0.038)were the independent risk factors.Serum sodium(HR=0.978,95%CI:0.956~1.001,P=0.064),receiving reperfusion therapy(HR=0.558,95%CI:0.412~0.755,P<0.001),adherence to diuretics(HR=0.626,95%CI:0.433~0.905,P=0.013),beta blockers(HR=0.455,95%CI:0.329~0.628,P<0.001),antiplatelet drugs(HR=0.521,95%CI:0.433~0.905,P=0.013),and statins(HR=0.650,95%CI:0.477~0.886,P=0.006)were independent protective factors.Conclusion The proportion of patients with AHF after AMI receiving reperfusion therapy and guideline recommended drug therapies was low,and the long-term prognosis of these patients was poor.Thus,there was still room to improve the prognosis of patients by optimizing the treatment strategy.