急性心肌梗死患者并发新发房颤的相关临床研究

发布时间：2018-05-16 21:16

本文选题：急性心肌梗死 + 新发房颤　；参考：《复旦大学》2013年博士论文

【摘要】：第一部分急性心肌梗死患者新发房颤预测因素的前瞻性临床研究目的：通过对急性心肌梗死患者的前瞻性临床观察研究,寻找新发房颤的预测因素并对其预测价值进行评估。方法：连续入选2011年9月至2012年4月收住复旦大学中山医院心内科心脏监护室的急性心肌梗死(AMI)患者。在监护室治疗期间对所有入组患者进行24小时持续心电监测,根据住院期间是否出现新发房颤将患者分为房颤组和非房颤组。分析比较两组患者临床特征,实验室指标,心脏超声检测指标以及冠状动脉介入治疗等方面的特征和差异,寻找AMI患者病程中出现新发房颤的预测因素并对其预测价值和准确性进行评估。结果：(1)本组研究中AMI患者住院期间出现新发房颤的比例为9.6%,ST段抬高型心肌梗死(STEMI)与非ST段抬高型心肌梗死(NSTEMI)患者间无明显差异(17/165比15/169,P0.05)。房颤组患者具有高龄(72.16±11.61岁比66.23±11.14岁,P=0.009),入院心率偏快(89.44±26.61bpm比78.07±15.43bpm, P0.001),身高较低(1.64±0.08m比1.67±0.08m,P0.05)的特征。有高血压病的患者在急性心肌梗死期间更容易罹患房颤(84.4%比64.2%,P=0.029)。房颤组患者吸烟率低于非房颤组(28.1%比52.6%,P=0.009)。另外,房颤组患者中继往有脑卒中(21.9%比9.6%,P=0.063)及慢性肾功能不全(9.4%比2.3%,P=0.060)病史的患者比例明显高于非房颤组,但差异未达到统计学意义。两组患者入院血压、心梗类型及部位、糖尿病病史、血脂代谢异常病史以及既往PCI治疗史无明显差别；在危险分层及评估比较中,房颤组患者Crusade评分明显高于非房颤组(P=0.002),CHA2DS2-VASc评分显著升高(P=0.009);两组患者实验室指标比较发现,房颤组患者白细胞计数(P=0.008)、红细胞分布宽度(P=0.037)、cTnT峰值(P=0.029)明显高于非房颤组患者。另外,房颤组患者肾小球滤过率较低(P=0.002),而入院24小时内血浆NT-proBNP水平明显高于非房颤组患者[2295.00(1263.25-4694.50) pg/mL比653.95(193.85-2100.00)pg/mL, P0.001],住院期间NT-proBNP峰值亦明显高于非房颤组患者[(3915.00(2242.00-6550.50) pg/mL比1184.00(435.28-3134.25) pg/mL, P0.001];两组患者超声检测结果比较发现,房颤组患者左心房内径明显大于非房颤组患者(42.63±5.65mm比39.72±4.66mm,P=0.001)。房颤组患者与非房颤组患者间其他实验指标及心脏超声检测结果无明显差异；两组患者冠状动脉病变特点及介入治疗特点比较发现,房颤组患者中接受再血管化治疗的比例明显低于非房颤组(56.3%比79.1%,P0.01),而两组患者冠脉病变血管支数、罪犯血管分布比例以及介入治疗术终病变血管TIMI血流评分无明显差别；房颤组患者于非房颤组患者间住院期间药物治疗策略无显著差异。(2)多因素Logistic回归分析发现,入院心率(OR1.024,95%CI1.003-1.046, P=0.028),左心房内径(OR1.091,95%CI1.008-1.184, P=0.031),入院24小时内NT-proBNP水平(OR1.988,95%CI1.029-3.845, P=0.041)和住院期间NT-proBNP峰值(OR2.745,95%CI1.326-5.683, P=0.007)是AMI患者出现新发房颤的独立危险因素；(3)利用入院24小时内血浆NT-proBNP水平预测急性心肌梗死患者新发房颤的ROC曲线下面积为0.717±0.046,P0.001,最佳预测临界值为1100pg/mL,其预测急性心肌梗死患者新发房颤的敏感度和特异性分别为81.2%和61.3%。根据最佳预测临界值将入组患者分为高、低NT-prpBNP组,比较发现高NT-proBNP组患者住院期间新发房颤的比例明显增高(26/144,18.1%比6/190,3.2%,P0.001)。结论：过快的入院心率、增大的左心房内径、明显升高的入院24小时血浆NT-proBNP水平以及住院期间血浆NT-proBNP峰值是AMI患者新发房颤的独立危险因素,可用于预测AMI患者的新发房颤,可用于指导患者危险分层及早期预防治疗。第二部分合并新发房颤的急性心肌梗死患者血流动力学、神经内分泌和炎症反应激活特点及短期预后的前瞻性临床研究目的：分析合并新发房颤的急性心肌梗死患者血流动力学、神经内分泌和炎症反应激活特点,观察新发房颤对患者短期预后的影响。方法：入选2011年9月至2012年4月收入复旦大学中山医院心内科心脏监护室的急性心肌梗死患者共59例,其中病程中出现新发房颤患者25例为病例组,未出现房颤患者34例为对照组。住院期间,采用NICOM无创心排仪对患者进行一次24小时持续血流动力学监测,比较两组间差异；同时,测定并比较房颤组患者与非房颤组患者入院后第一天及第三天血管紧张素Ⅱ,肾素、醛固酮、肿瘤坏死因子α、白介素-6、髓过氧化物酶及骨保护素水平,比较房颤组与非房颤组患者间差异；对入组患者进行出院后90天随访,主要观察指标为心血管不良事件,包括心源性死亡、再次心肌梗死、再次住院、病变血管再次介入治疗以及脑卒中。评估房颤对AMI患者短期预后的影响。结果：(1)房颤组与非房颤组患者心输出量、心脏指数、心功率及每搏输出量均无明显差异,但房颤组患者每博输出量变化率较非房颤组患者增高(15±2.8%比11.9±2.9%,P0.001),主动脉血流速度峰值显著下降(136.1±48.5比172.1±65.5,P=0.034)。两组患者其他血流动力学监测指标无明显差异：(2)两组患者神经内分泌及炎症反应激活特点比较发现,房颤组患者血管紧张素ⅠI[71.49(57.57-79.62)pg/mL比58.96(50.42-62.67)pg/mL, P=0.010]、肿瘤坏死因子a[1.35(0.93-2.03)pg/mL比0.03(0.03-0.28)pg/mL, P0.001]、髓过氧化物酶[4.04(2.10-6.21)ng/mL比1.97(0.80-3.37),P=0.028]及NT-proBNP水平(3041.0(1525.0-5021.0)pg/mL比674.5(198.9-2242.0)pg/mL, P0.01)均明显高于非房颤组。另外,房颤组患者骨保护素水平明显高于非房颤组患者,但差异未达到统计学意义[(17181.5(13347.8-24684.3)pg/mL比14581.0(9692.5-19566.0) pg/mL,P=0.065)。两组患者间肾素、醛固酮、白介素-6水平无明显差异。Spearman相关分析发现肾素、血管紧张素Ⅱ、肿瘤坏死因子α以及髓过氧化物酶与患者NT-proBNP水平明确相关；(3)对两组患者进行出院后90天短期随访,结果显示房颤组患者短期心血管不良事件发生率明显高于非房颤组患者(8/32,32%比3/32,8.8%,P=0.04),且以心源性死亡为主要不良结局。Kaplan-meier生存分析对显示房颤组患者无事件生存率明显低于非房颤组患者,且以心源性死亡为主要不良事件类型。结论：(1)合并新发房颤的AMI患者无创血流动力学监测结果与非房颤组患者无明显差别,仅每博输出量变异率和主动脉血流速度存在差异；(2)AMI患者出现新发房颤早期神经内分泌和炎症反应激活明显,且伴随起病时间而逐渐增强；(3)新发房颤与AMI患者90天预后明确相关,病程中出现新发房颤的急性心肌梗死患者其90天无事件生存率较窦性心律患者低。心源性死亡是并发新发房颤的AMI患者短期不良心血管事件的主要类型。第三部分血浆NT-proBNP对急性心肌梗死患者新发房颤预测价值的回顾性临床研究目的：探讨N末端B型脑利钠肽前体(NT-proBNP)对急性心肌梗死患者新发房颤的预测价值。方法：采用回顾性临床研究的方法,自2008年1月至2010年12月收住复旦大学附属中山医院心脏监护室的患者中入选AMI患者268例,按照患者住院期间是否出现新发房颤将患者分为房颤组(n=36)和非房颤组(n=232)。比较两组间差异,分析评估入院24小时内血浆NT-proBNP水平对急性心肌梗死患者新发房颤的预测价值和准确性。结果：(1)AMI患者住院期间出现新发房颤的比例为13.4%,STEMI与NSTEMI患者间无明显差异；(2)房颤组患者NT-proBNP水平明显高于非房颤患者[(2166(1571-4871)pg/mL比707(347-1759)pg/mL, P0.001)],平均年龄较大,但左心室射血分数(55.74%±11.02%Vs.60.14%±9.56%,P=0.015),血红蛋白含量(123.00±14.90g/mL Vs.132.66±15.42g/mL, P=0.001)和肾小球滤过率(69.39±20.41ml/min/1.73m2Vs.79.52±21.59ml/min/1.73m2, P=0.009)均低于非房颤组患者；(3)对房颤常见危险因素进行校正后多因素Logistic回归分析显示,明显升高的血浆NT-proBNP水平是AMI患者新发房颤的独立危险因素(OR4.918,95%CI1.662-14.549, P=0.004)。(4)利用入院24小时内患者血浆NT-proBNP预测新发房颤的ROC曲线下面积为0.811,95%可信区间为0.753-0.868,P0.001；以入院24小时内血浆NT-proBNP水平≥796pg/mL作为临界值来预测AMI患者新发房颤的敏感度和特异性分别为100%和53.4%,所有在病程中出现新发房颤的患者入院血浆NT-proBNP水平均高于796pg/mL; 结论：血浆NT-proBNP水平可独立预测急性心肌梗死患者新发房颤的发生,可用于患者危险分层及指导早期预防治疗。
[Abstract]:Part one prospective clinical study of predictors of new onset atrial fibrillation in patients with acute myocardial infarction
Objective: To evaluate the predictive value of new atrial fibrillation (AF) by prospective clinical observation of acute myocardial infarction (AMI).
Methods: the patients who received acute myocardial infarction (AMI) from the Department of Cardiology, Zhongshan hospital, Fudan University from September 2011 to April 2012, were enrolled in the cardiac monitoring room of the Department of Cardiology, Zhongshan hospital. During the intensive care unit, all the patients were monitored continuously. The patients were divided into atrial fibrillation group and non atrial fibrillation group according to whether there were new atrial fibrillation during the hospitalization. The characteristics and differences of clinical features, laboratory indicators, echocardiographic indicators and coronary intervention in the two groups were compared, and the predictive factors for the emergence of new atrial fibrillation in the course of AMI patients were evaluated and their predictive value and accuracy were evaluated.
Results: (1) in the study, the proportion of new onset atrial fibrillation in AMI patients was 9.6%, there was no significant difference between ST segment elevation myocardial infarction (STEMI) and non ST elevation myocardial infarction (NSTEMI) patients (17/165 than 15/169, P0.05). The patients in atrial fibrillation group had a higher age (72.16 + 11.61 years than 66.23 + 11.14 years, P=0.009), and the hospitalized heart rate was faster (89.44). 26.61bpm was 78.07 + 15.43bpm, P0.001), and the height was lower (1.64 + 0.08m than 1.67 + 0.08m, P0.05). Patients with hypertension were more likely to suffer from atrial fibrillation (84.4% to 64.2%, P=0.029) during acute myocardial infarction. The rate of smoking in atrial fibrillation group was lower than that of non atrial fibrillation group (28.1% to 52.6%, P=0.009). The ratio of 21.9% to 9.6%, P=0.063) and chronic renal insufficiency (9.4% to 2.3%, P=0.060) was significantly higher than that in the non atrial fibrillation group, but the difference was not statistically significant. The hospitalized blood pressure, the type and location of myocardial infarction, the history of diabetes, the history of abnormal blood lipid metabolism and the history of PCI treatment were not significantly different in the two groups, and in the risk stratification and evaluation. In the comparison, the Crusade score in the atrial fibrillation group was significantly higher than that in the non atrial fibrillation group (P=0.002), and the CHA2DS2-VASc score increased significantly (P=0.009). The two groups of patients showed that the leukocyte count (P=0.008), the red cell distribution width (P=0.037) and the peak value of cTnT (P=0.029) were significantly higher in the atrial fibrillation group than in the non atrial fibrillation group. In addition, the renal fibrillation group was kidney. The small pellet filtration rate was lower (P=0.002), and the plasma NT-proBNP level was significantly higher than that of the non atrial fibrillation group (1263.25-4694.50) pg/mL ratio (193.85-2100.00) pg/mL, P0.001], and the peak value of NT-proBNP (3915 (2242.00-6550.50) pg/mL ratio 1184 (2242.00-6550.50) pg/mL ratio 1184 (435.28-3134.25) during the 24 hours of admission. P0.001]; two groups of patients with ultrasound examination showed that the left atrial diameter of the atrial fibrillation group was significantly greater than that of the non atrial fibrillation group (42.63 + 5.65mm ratio 39.72 + 4.66mm, P=0.001). There was no significant difference between the other experimental indexes and the echocardiographic results between the patients of atrial fibrillation group and the non atrial fibrillation group; the coronary artery lesion characteristics and intervention in the two groups of patients were not significantly different. It was found that the rate of revascularization in the patients with atrial fibrillation was significantly lower than that in non atrial fibrillation group (56.3% to 79.1%, P0.01), but there was no significant difference in the number of vessels in the two groups, the proportion of the blood vessels in the offender's vessels and the TIMI blood flow score of the end of the interventional therapy. There was no significant difference in the drug treatment strategy during the hospital. (2) multiple factor Logistic regression analysis found the hospitalization heart rate (OR1.024,95%CI1.003-1.046, P=0.028), the left atrium diameter (OR1.091,95%CI1.008-1.184, P=0.031), the NT-proBNP level (OR1.988,95% CI1.029-3.845, P=0.041) and the NT-proBNP peak during the hospitalization (OR2.745,95%CI1.326-5) during the hospital (OR2.745,95%CI1.326-5). .683, P=0.007) is an independent risk factor for the emergence of new atrial fibrillation in AMI patients; (3) the area of the ROC curve under the ROC curve of the patients with acute myocardial infarction is 0.717 + 0.046, P0.001, and the best predictive critical value is 1100pg/mL, using the plasma NT-proBNP level within 24 hours of admission. The sensitivity and specificity of the new onset atrial fibrillation in patients with acute myocardial infarction are measured. 81.2% and 61.3%., respectively, were divided into high and low NT-prpBNP groups based on the best predicted critical values. The ratio of new onset atrial fibrillation in the high NT-proBNP group was significantly higher (26/144,18.1% than 6/190,3.2%, P0.001). Conclusion: the fast admission heart rate, the increased left atrium diameter, and a significantly increased admission of 24 hours of hospitalization. Plasma NT-proBNP levels and plasma NT-proBNP peaks during hospitalization are independent risk factors for new atrial fibrillation in AMI patients, which can be used to predict new atrial fibrillation in AMI patients and can be used to guide patients with risk stratification and early preventive treatment.
A prospective clinical study on hemodynamics, neuroendocrine and inflammatory response activation characteristics and short-term prognosis in the second part of patients with acute myocardial infarction with new atrial fibrillation
Objective: to analyze the hemodynamic, neuroendocrine and inflammatory activation characteristics of patients with acute myocardial infarction with new atrial fibrillation, and to observe the effect of new atrial fibrillation on the short-term prognosis of patients.
Methods: a total of 59 patients with acute myocardial infarction in the Department of Cardiology, Zhongshan hospital, Zhongshan hospital from September 2011 to April 2012, were enrolled in the cardiac monitoring room of the Department of Cardiology, Fudan University. Among them, 25 cases of new atrial fibrillation were found in the course of the disease, and 34 patients without atrial fibrillation were used as the control group. During the period of hospitalization, the patients were held for 24 hours with a NICOM noninvasive heart arrangement. Continuous hemodynamic monitoring was used to compare the differences between the two groups. At the same time, the levels of angiotensin II, renin, aldosterone, tumor necrosis factor alpha, il--6, myeloperoxidase and osteoprotegerin were measured and compared between the atrial fibrillation group and the non atrial fibrillation group at the first and three days after admission, and the differences were compared between the atrial fibrillation group and the non atrial fibrillation group. The patients were followed up 90 days after discharge. The main indicators were cardiovascular adverse events, including cardiogenic death, re myocardial infarction, rehospitalization, re interventional therapy and stroke. The effect of atrial fibrillation on the short-term prognosis of AMI patients was evaluated.
Results: (1) there was no significant difference in cardiac output, cardiac index, cardiac power and per stroke output in atrial fibrillation group and non atrial fibrillation group, but the change rate of per Bo output in atrial fibrillation group was higher than that of non atrial fibrillation group (15 + 2.8% / 11.9 + 2.9%, P0.001), and the peak of aortic blood flow rate decreased significantly (136.1 + 48.5, 172.1 + 65.5, P=0.034). Two groups were affected. There were no significant differences in other hemodynamic monitoring indexes: (2) compared with the activation characteristics of neuroendocrine and inflammatory reaction in the two groups, the angiotensin I I[71.49 (57.57-79.62) pg/mL of atrial fibrillation group was compared with 58.96 (50.42-62.67) pg/mL, P=0.010], a[1.35 (0.93-2.03) pg/mL ratio 0.03 (0.03-0.28) pg/mL, P0.001], and medullary The ratio of oxide enzyme [4.04 (2.10-6.21) ng/mL to 1.97 (0.80-3.37), P=0.028] and NT-proBNP (3041 (1525.0-5021.0) pg/mL ratio 674.5 (198.9-2242.0) pg/mL, P0.01) were significantly higher than that in non atrial fibrillation group. In addition, the level of osteoprotegerin in patients with atrial fibrillation was significantly higher than that in non atrial fibrillation group, but the difference was not statistically significant [(17181.5) (13347.8-24684.3). G/mL was compared to 14581 (9692.5-19566.0) pg/mL, P=0.065). There was no significant difference between the two groups of patients with renin, aldosterone, and interleukin -6, the.Spearman related analysis found that renin, angiotensin II, TNF - alpha, and myeloperoxidase were clearly associated with the patients' NT-proBNP level; (3) two groups of patients were followed up for 90 days after discharge. The results showed that the incidence of short term cardiovascular events in patients with atrial fibrillation was significantly higher than that in non atrial fibrillation group (8/32,32% 3/32,8.8%, P=0.04), and.Kaplan-meier survival analysis with cardiac death as the main adverse outcome was significantly lower than that of non atrial fibrillation group, and cardiac death was the main adverse event in the patients with atrial fibrillation. Event type.
Conclusions: (1) the noninvasive hemodynamic monitoring results of AMI patients with new atrial fibrillation were not significantly different from those in the non atrial fibrillation group. There was a difference in the rate of variation of output per blot and the velocity of aortic blood flow; (2) the activation of neuroendocrine and inflammatory reactions in the early onset atrial fibrillation was obvious in AMI patients and increased with the onset time; (3) The 90 day prognosis of new onset atrial fibrillation is clearly related to the 90 day prognosis. The 90 day non event survival rate of patients with acute myocardial infarction with new atrial fibrillation in the course of the disease is lower than that of the sinus rhythm patients. Cardiac death is the main type of short term adverse cardiovascular events in patients with AMI patients with new atrial fibrillation.
The third part of the retrospective study of plasma NT-proBNP in predicting the incidence of new onset atrial fibrillation in patients with acute myocardial infarction
Objective: To investigate the predictive value of N terminal B type natriuretic peptide precursor (NT-proBNP) in patients with acute atrial fibrillation (AMI).
Methods: 268 patients with AMI were selected from January 2008 to December 2010 with a retrospective clinical study. The patients were divided into atrial fibrillation group (n=36) and non atrial fibrillation group (n=232) according to whether the patients had new atrial fibrillation during the period of hospitalization during the period of hospitalization. The difference between the two groups was compared and evaluated. The predictive value and accuracy of plasma NT-proBNP level in 24 hours of acute myocardial infarction patients with new onset atrial fibrillation.
Results: (1) the proportion of new onset atrial fibrillation in AMI patients was 13.4%, and there was no significant difference between STEMI and NSTEMI patients. (2) the NT-proBNP level in patients with atrial fibrillation was significantly higher than that of non atrial fibrillation patients [(2166 (1571-4871) pg/mL ratio 707 (347-1759) pg/mL, P0.001)], and the average age was larger, but the left ventricular ejection fraction (55.74% + 11.02%Vs.60.14% + 9.56%,) P=0.015), the content of hemoglobin (123 + 14.90g/mL Vs.132.66 + 15.42g/mL, P=0.001) and glomerular filtration rate (69.39 + 20.41ml/min/1.73m2Vs.79.52 + 21.59ml/min/1.73m2, P=0.009) were lower than those in non atrial fibrillation group. (3) multiple factor Logistic regression analysis after correction of common risk factors for atrial fibrillation showed a significant increase in plasma NT-pro BNP level is an independent risk factor for new atrial fibrillation in AMI patients (OR4.918,95%CI1.662-14.549, P=0.004). (4) the area of the ROC curve under the ROC curve of the patient's plasma NT-proBNP in the hospital within 24 hours of admission is 0.753-0.868, P0.001, and the plasma NT-proBNP level > 796pg/mL as the critical value within 24 hours of admission as the critical value. The sensitivity and specificity of new atrial fibrillation in AMI patients were 100% and 53.4% respectively. The average NT-proBNP water in all patients with new onset atrial fibrillation in the course of the disease was higher than that of 796pg/mL.
Conclusion: plasma NT-proBNP level can independently predict the occurrence of new onset atrial fibrillation in patients with acute myocardial infarction, and can be used for risk stratification and early prevention and treatment.
【学位授予单位】：复旦大学
【学位级别】：博士
【学位授予年份】：2013
【分类号】：R542.22;R541.7

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