急性心肌梗死患者早期低钾血症与其近期预后相关性的研究

发布时间：2018-08-01 08:11

【摘要】：急性心肌梗死(Acute myocardial infarction,AMI)是我国人口死亡主要原因之一。在心肌梗死急性期患者各项生命体征指标均会出现不同程度变化,其中电解质变化尤为明显,以往的研究表明,急性心肌梗死后会出现不同水平钾、钠、钙、镁失衡,其中钾稳态失衡与心血管疾病事件和死亡率显著相关。钾离子广泛存在于细胞内液,仅2.00%分布于细胞外液,是心肌细胞功能的关键因素。既往的研究提示低钾血症与心律失常和心源性猝死有关,据此相关研究提出了急性心肌梗死患者血钾应维持在较高水平。随着研究深入,人们发现正常范围血钾亦与心肌梗死后心血管不良事件发生相关,并对于适宜血钾范围各自提出不同的的意见,并且随着?受体阻滞剂、再灌注治疗和早期侵入性治疗的广泛应用,梗死后心律失常发生率已明显下降,亦有研究显示低钾血症患者与正常血清钾患者心律失常发生并无差异,因此,目前对心肌梗死患者的血钾管理是一项富有争议的工作,有必要进一步探究不同水平血清钾与预后的关系。本研究通过回顾性分析,根据不同血清钾梯度分组,探讨不同血钾水平的患者院内心血管不良事件发生有无差异,探究患者院内不良事件发生的危险因素。本研究分为以下两部分:第一部分不同血钾水平急性心肌梗死患者近期预后分析目的:探讨不同血钾水平的急性心肌梗死患者近期预后有无差异。方法:回顾性分析2013年5月至2016年5月连续入院急性心肌梗死病例,采集患者的基线资料(性别、年龄,吸烟史,既往病史)、入院即刻生命体征、血钾、住院期间所有血钾、血液生化指标、再灌注治疗情况,观察住院期间不良事件(恶性心律失常、心源性休克、死亡)。根据入院血钾将患者分为低血钾组(血钾3.50 mmol/L)和正常血钾A组(3.50 mmol/L≤血钾4.50 mmol/L)、正常血钾B组(4.50 mmol/L≤血钾5.50 mmol/L)。观察入院低钾血症发生率、比较各组间恶性心律失常、心源性休克、死亡发生情况。结果:共收集病例232例,男性164例(70.70%),女性68例(29.30%),入院时测血钾平均值3.95 mmol/L,低血钾37例(15.90%),低血钾组平均值3.23 mmol/L。低血钾组与正常血钾A组、正常血钾B组比较性别、年龄、既往病史及经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)治疗间无统计学差异。三组间白细胞、中性粒细胞、尿素氮、肌酐、GFR、肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)存在差异。三组间院内心律失常发生比较:共15例发生室颤,发生率为6.47%,在低血钾组、正常血钾A组、正常血钾B组之间发生存在统计学差异[16.70%(6)vs.3.90%(6)vs7.70%(3),P=0.019]。共13例记录到非持续性室速,各组间发生率为[11.10%(4)vs.5.20%(8)vs2.60%(1),P=0.249]。三组间频发室性早搏、心动过缓、心房颤动发生率比较未见统计学差异。在院期间共死亡23例,病死率9.91%,各组间病死率无统计学意义[13.90%(5)vs.8.40%(13)vs12.80%(5),P=0.497]。结论:AMI入院早期低钾血症患者院内心室颤动发生率较血钾正常患者明显升高,不同血钾范围内室性早搏、心动过缓、心房颤动发生无明显差异;入院血钾在3.50~4.50 mmol/L范围者室颤及院内死亡率最低。第二部分不同水平血钾对急性心肌梗死患者院内心血管不良事件的预测作用目的:探讨血钾对急性心肌梗死患者院内心血管不良事件的危险因素的预测价值方法:回顾性分析2013年5月至2016年5月连续入院急性心肌梗死病例,采集患者的基线资料(性别、年龄,吸烟史,既往病史)、入院即刻生命体征、血钾、住院期间所有血钾、血液生化指标、再灌注治疗情况,观察住院期间不良事件(恶性心律失常、心源性休克、死亡)。根据患者住院期间是否发生室性心律失常(室颤及室速)将患者分为心律失常组与无心律失常组,比较两组患者间患病特征、入院时生命体征、血清学检测、治疗方式有无差异,采用Logistics回归分析探求影响心律失常发生的危险因素及不同水平血钾在心律失常的预测价值。根据住院期间死亡发生情况将患者分为死亡组与存活组,分析患者院内死亡的危险因素及血钾在院内死亡的预测价值。结果:根据在院期间是否发生室性心律失常,将患者分为心律失常组与非心律失常组,两组比较发现:在性别、年龄、合并症、治疗方式间没有统计学差异;心律失常组入院时收缩压明显低于非心律失常组,舒张压及心率无统计学差异。心律失常组Killip评分高于非心律失常组。心律失常组白细胞水平高于非心律失常组,入院血钾低于非心律失常组。两组间血糖、血脂、CK、CK-MB无统计学差异。恶性心律失常多因素Logistic回归显示院内室性心律失常发生的危险因素为:钾异常(3.50 mmol/L,≥4.50 mmol/L)(OR=0.154,95%CI=0.034~0.561,P=0.005),收缩压100mmHg(OR=0.964,95%CI=0.938~0.991,P=0.009),Killip III-IV级(OR=0.217,95%CI=0.059~0.794,P=0.021)。根据在院期间是死亡,将患者分为死亡组与存活组,两组比较发现:总病死率为9.91%(23/232),女性病死率为17.60%(12/68),男性病死率为6.70%(11/164)。两组间性别、年龄、Killip分级存在差异;两组间合并症无差异,死亡组再灌注治疗比例低于存活组。两组间比较入院即刻血钾无统计学差异,两组间红细胞、血红蛋白、肌酐、尿素氮存在统计学差异。梗死部位比较:广泛前壁者病死率明显升高,非ST抬高型心肌梗死病死率较低。两组间心律失常发生及心源性休克发生情况比较:室颤及休克存在统计学差异,室速、房颤、心动过缓比较无统计学差异。死亡直接原因为:心源性休克或心力衰竭17例(73.91%)、心脏室壁瘤破裂1例(4.34%)、心脏骤停3例(13.04%),其中心室颤动1例、心室停顿2例,缺血性脑卒中2例(8.71%)。院内死亡多因素分析示:室颤(OR=0.148,95%CI=0.029~0.76,P=0.023)、心源性休克(OR=0.096,95%CI=0.027~0.339,P0.001)、广泛前壁心肌梗死(OR=0.171,95%CI=0.032~0.920,P=0.040)增加院内死亡风险,PCI(OR=4.899,95%CI=0.872~27.525,P=0.039)治疗是保护性因素。结论:钾异常(3.5mmol/L,≥4.5 mmol/L)增加急性心肌梗死患者院内发生室性恶性心律失常风险,心肌梗死发生后将患者血钾维持在3.50 mmol/L~4.50mmol/L间;血钾异常不直接影响患者院内死亡,但可通过增加室颤发生率、增加死亡风险。
[Abstract]:Acute myocardial infarction (Acute myocardial infarction, AMI) is one of the main causes of population death in China. In acute phase of myocardial infarction, the changes of various vital signs in patients with acute myocardial infarction are changed in varying degrees, and the changes of electrolyte are particularly obvious. Previous studies have shown that acute myocardial infarction will have different levels of potassium, sodium, calcium, and magnesium. The homeostasis of potassium homeostasis is significantly related to cardiovascular events and mortality. Potassium ions are widely distributed in intracellular fluid and only 2% in extracellular fluid. It is a key factor in the function of cardiac myocytes. Previous studies suggest that hypokalemia is associated with arrhythmia and sudden cardiac death. The related research suggests the blood of acute myocardial infarction. Potassium should be maintained at a high level. As the study goes deep, it is found that normal blood potassium is also associated with cardiovascular adverse events after myocardial infarction, and suggests different opinions on the appropriate range of blood potassium, and with the extensive use of receptor blockers, reperfusion therapy and early invasive treatment, arrhythmia after infarction There is no difference between the rate of birth and the occurrence of arrhythmia in patients with hypokalemia and normal serum potassium. Therefore, the management of blood potassium in patients with myocardial infarction is a controversial work. It is necessary to further explore the relationship between different levels of serum potassium and prognosis. This study was divided into two parts: the first part was the analysis of the short-term prognosis of patients with acute myocardial infarction with different blood potassium levels: To explore the acute levels of blood potassium. There is no difference in the short-term prognosis of patients with myocardial infarction. Methods: a retrospective analysis of the cases of acute myocardial infarction in hospital from May 2013 to May 2016 was reviewed. The baseline data (sex, age, smoking history, past medical history), the immediate physical signs of admission, blood potassium, all blood potassium, blood biochemical indexes and reperfusion treatment were observed. Adverse events (malignant arrhythmia, cardiogenic shock, death) were divided into low potassium group (potassium 3.50 mmol/L) and normal blood potassium A group (3.50 mmol/L < 4.50 mmol/L), and normal blood potassium B group (4.50 mmol/L < 5.50 mmol/L). The incidence of hypokalemia in admission was observed and the malignant arrhythmia was compared between the groups. Results: 232 cases were collected in a total of 232 cases, 164 men (70.70%) and 68 women (29.30%). The average value of blood potassium was 3.95 mmol/L, 37 cases of hypokalemia (15.90%), low potassium group was 3.23 mmol/L. low blood potassium group and normal blood potassium A group, and normal blood potassium B group was compared with sex, age, past medical history and percutaneous coronary. There were no statistical differences between percutaneous coronary intervention (PCI) treatment. There were differences between three groups of leukocytes, neutrophils, urea nitrogen, creatinine, GFR, creatine kinase (CK), and creatine kinase isoenzyme (CK-MB). There were 15 cases of ventricular fibrillation in the three groups: 15 cases had ventricular fibrillation, the incidence was 6.47%, and in the hypokalemia group, positive There was a statistical difference between the normal blood potassium A group and the normal blood potassium B group [16.70% (6) vs.3.90% (6) vs7.70% (3), 13 cases of P=0.019]. were recorded to non persistent ventricular tachycardia, the incidence of each group was [11.10% (4) vs.5.20% (8) vs2.60% (1), P=0.249]. three was frequent ventricular premature beat, bradycardia, and the incidence of atrial fibrillation was not statistically different. In hospital, there was no statistical difference. During the period, 23 cases were killed and the mortality rate was 9.91%. The mortality rate between each group was not statistically significant [13.90% (5) vs.8.40% (13) vs12.80% (5). P=0.497]. conclusion: the incidence of ventricular fibrillation in patients with early hypokalemia was significantly higher than that of the normal blood potassium patients. There was no significant difference in the occurrence of ventricular premature beat, bradycardia and atrial fibrillation in different blood potassium models. The hospitalized blood potassium was the lowest in the 3.50~4.50 mmol/L range of ventricular fibrillation and hospital mortality. Second the predictive value of different levels of blood potassium on hospital cardiovascular adverse events in patients with acute myocardial infarction: To explore the predictive value of the risk factors of blood potassium on hospital inward adverse events in patients with acute myocardial infarction: a retrospective analysis of 2013 From May to May 2016, patients with acute myocardial infarction were hospitalized continuously. Baseline data (sex, age, smoking history, past medical history), immediate physical signs, potassium, all blood potassium, blood biochemical indexes, reperfusion treatment during hospitalization were collected, and the adverse events (malignant arrhythmia, cardiogenic shock, death) were observed. According to the patients' ventricular arrhythmia (ventricular fibrillation and ventricular tachycardia) during the period of hospitalization, the patients were divided into arrhythmia group and non cardio arrhythmia group. The characteristics of the two groups were compared, the vital signs, the serological examination, and the treatment methods were different, and the Logistics regression analysis was used to explore the risk factors and different factors affecting the occurrence of arrhythmia. The predictive value of horizontal blood potassium in arrhythmia. According to the incidence of death during hospitalization, the patients were divided into the death group and the survival group. The risk factors of hospital death and the predictive value of blood potassium in hospital death were analyzed. Group two groups found that there was no statistical difference between sex, age, complication and treatment, and the systolic pressure of arrhythmia group was lower than that of non arrhythmia group at admission, and the diastolic pressure and heart rate had no statistical difference. The Killip score of arrhythmia group was higher than that of non arrhythmia group. The level of leukocyte in arrhythmia group was higher than that of non arrhythmia group. The blood potassium of hospital was lower than that of non arrhythmia group. There was no significant difference in blood sugar, blood lipid, CK, CK-MB between the two groups. Multiple factors Logistic regression of malignant arrhythmia showed that the risk factors for the occurrence of ventricular arrhythmia were potassium abnormal (3.50 mmol/L, 4.50 mmol/L) (OR=0.154,95%CI=0.034~ 0.561, P=0.005), systolic pressure 100mmHg (OR=0.964,95%CI=0.938~0.991, P). =0.009), Killip III-IV (OR=0.217,95%CI=0.059~0.794, P=0.021). According to the death in the hospital, the patients were divided into the death group and the survival group. The two groups were found to have a total fatality rate of 9.91% (23/232), a female mortality rate of 17.60% (12/68), and a male mortality rate of 6.70% (11/164). There were differences in sex, age, and Killip classification among the two groups; the two groups were interconnected. There was no difference in complications. The proportion of reperfusion treatment in the death group was lower than that in the survival group. There was no statistical difference between the two groups. There was a statistical difference between the two groups of red blood cells, hemoglobin, creatinine and urea nitrogen. The infarct sites were compared: the mortality rate of the extensive anterior wall patients was significantly higher, the mortality rate of non ST elevation myocardial infarction was lower. The two groups of cardiac arrhythmias were lower. There were statistical differences in ventricular fibrillation and shock. There were no statistical differences in ventricular tachycardia, atrial fibrillation and bradycardia. The direct causes of death were cardiogenic shock or heart failure in 17 cases (73.91%), ventricular aneurysm rupture in 1 cases (4.34%), cardiac arrest in 3 cases (13.04%), ventricular fibrillation in 1 cases, ventricular pause 2. For example, 2 cases of ischemic stroke (8.71%). Multifactor analysis of hospital death: OR=0.148,95%CI=0.029~0.76 (P=0.023), OR=0.096,95%CI=0.027~0.339 (P0.001), extensive anterior wall myocardial infarction (OR=0.171,95%CI=0.032~0.920, P=0.040) increase the risk of hospital death, PCI (OR=4.899,95%CI=0.872~27.525, P=0.039) treatment is protection Conclusions: potassium abnormalities (3.5mmol/L, > 4.5 mmol/L) increase the risk of ventricular arrhythmia in patients with acute myocardial infarction. After the onset of myocardial infarction, the patient's blood potassium is maintained between 3.50 mmol/L~4.50mmol/L, and the blood potassium abnormality does not directly affect the patient's hospital death, but it can increase the risk of death by increasing the incidence of ventricular fibrillation.
【学位授予单位】：蚌埠医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R542.22

【参考文献】