Факторы, ассоциированные с госпитальной летальностью при остром инфаркте миокарда

Цель    Определить у пациентов с острым инфарктом миокарда клинико-лабораторные показатели, ассоциирующиеся с госпитальной летальностью, и разработать многофакторную прогностическую модель госпитальной летальности.
Материал и методы    Исследование по регистру острого коронарного синдрома за 2019-2020 гг. Тюменского кардио­логического научного центра филиала Томского НИМЦ. В исследование включено 477 больных острым инфарктом миокарда (ОИМ) с подъемом сегмента ST, 617 - без подъема сегмента ST и 26 - с неуточненным ОИМ. Госпитальная летальность составила 6,0 % (n=67). Клинико-лабораторные параметры оценивали в день поступления. Разделительная способность показателей, ассоциированных с госпитальной летальностью, определена с помощью ROC-анализа. Массив данных каждого количественного параметра переведен в бинарную переменную согласно полученным порогам отсечения с последующим созданием многофакторной модели прогноза госпитальной летальности методом пошагового анализа с обратным включением (Вальда). Нулевую гипотезу отвергали при p<0,05.
Результаты    В многофакторную модель прогноза госпитальной летальности вошли: возраст (порог отсечения 72 года) - ОШ 3,0 (95 % ДИ: 1,5-5,6); модифицированный индекс шока (порог отсечения 0,87) - ОШ 1,5 (95 % ДИ: 1,1-2,0); креатинфосфокиназа МВ (порог отсечения 32,8 ед / л) - ОШ 4,1 (95 % ДИ: 2,2-7,7); гемоглобин (121,5 г / л) - ОШ 1,7 (95 % ДИ: 1,2-2,3); лейкоциты (11,5×109 / л) - ОШ 1,9 (95 % ДИ: 1,3-2,6); скорость клубочковой фильтрации (60,9 мл / мин) - ОШ 1,7 (95 % ДИ: 1,2-2,2); фракция выброса левого желудочка (42,5 %) - ОШ 4,1 (95 % ДИ: 2,0-8,3); размер асинергии миокарда (32,5 %) - ОШ 2,6 (95 % ДИ: 1,4-5,0).
Выводы    Независимыми предикторами госпитальной летальности при ОИМ являются возраст, модифицированный индекс шока, креатинфосфокиназа МВ, количество лейкоцитов в периферической крови, концентрация гемоглобина, фракция выброса левого желудочка, размер асинергии миокарда и скорость клубочковой фильтрации. Модель госпитальной летальности отличалась высоким прогностическим потенциалом: AUC 0,930 (95 % ДИ: 0,905-0,954; р<0,001), при пороге отсечения 0,15 чувствительность 0,851, специфичность 0,850.

1. Roffi M, Patrono C, Collet J-P, Mueller C, Valgimigli M, Andreotti F et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). European Heart Journal. 2016;37(3):267–315. DOI: 10.1093/eurheartj/ehv320

2. Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli-Ducci C, Bueno H et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). European Heart Journal. 2018;39(2):119–77. DOI: 10.1093/eurheartj/ehx393

3. Granger CB. Predictors of Hospital Mortality in the Global Registry of Acute Coronary Events. Archives of Internal Medicine. 2003;163(19):2345–53. DOI: 10.1001/archinte.163.19.2345

4. Antman EM, Cohen M, Bernink PJLM, McCabe CH, Horacek T, Papuchis G et al. The TIMI Risk Score for Unstable Angina/Non–ST Elevation MI: A Method for Prognostication and Therapeutic Decision Making. JAMA. 2000;284(7):835–42. DOI: 10.1001/jama.284.7.835

5. Halkin A, Singh M, Nikolsky E, Grines CL, Tcheng JE, Garcia E et al. Prediction of Mortality After Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction: The CADILLAC risk score. Journal of the American College of Cardiology. 2005;45(9):1397–405. DOI: 10.1016/j.jacc.2005.01.041

6. Baptista SB, Farto e Abreu P, Loureiro JR, Thomas B, Nédio M, Gago S et al. PAMI risk score for mortality prediction in acute myocardial indarction treated with primary angioplasty. Portuguese Journal of Cardiology. 2004;23(5):683–93. PMID: 15279453

7. Бессонов И.С., Кузнецов В.А., Сапожников С.С., Горбатенко Е.А., Шадрин А.А. Шкала оценки риска госпитальной летальности у пациентов с острым инфарктом миокарда с подъемом сегмента ST электрокардиограммы. Кардиология. 2021;61(9):11-9. DOI: 10.18087/cardio.2021.9.n1720

8. Thygesen K, Alpert JS, Jaffe AS, Chaitman BR, Bax JJ, Morrow DA et al. Fourth Universal Definition of Myocardial Infarction (2018). Journal of the American College of Cardiology. 2018;72(18):2231–64. DOI: 10.1016/j.jacc.2018.08.1038

9. Gupta T, Kolte D, Khera S, Agarwal N, Villablanca PA, Goel K et al. Contemporary Sex-Based Differences by Age in Presenting Characteristics, Use of an Early Invasive Strategy, and Inhospital Mortality in Patients With Non–ST-Segment–Elevation Myocardial Infarction in the United States. Circulation: Cardiovascular Interventions. 2018;11(1):e005735. DOI: 10.1161/CIRCINTERVEN-TIONS.117.005735

10. Liu Y-C, Liu J-H, Fang ZA, Shan G-L, Xu J, Qi Z-W et al. Modified shock index and mortality rate of emergency patients. World Journal of Emergency Medicine. 2012;3(2):114–7. DOI: 10.5847/wjem.j.issn.1920-8642.2012.02.006

11. Pei J, Wang X, Xing Z, Chen P, Su W, Deng S et al. Association between admission systolic blood pressure and major adverse cardiovascular events in patients with acute myocardial infarction. PLOS ONE. 2020;15(6):e0234935. DOI: 10.1371/journal.pone.0234935

12. Shiraishi J, Nakamura T, Shikuma A, Shoji K, Nishikawa M, Yanagiuchi T et al. Relationship Between Mean Blood Pressure at Admission and In-Hospital Outcome After Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction. International Heart Journal. 2016;57(5):547–52. DOI: 10.1536/ihj.15-480

13. Dobre D, Kjekshus J, Rossignol P, Girerd N, Benetos A, Dickstein K et al. Heart rate, pulse pressure and mortality in patients with myocardial infarction complicated by heart failure. International Journal of Cardiology. 2018;271:181–5. DOI: 10.1016/j.ijcard.2018.05.017

14. Gouda M, Saad AM, Al-Daydamony MM. Modified Shock Index as a Predictor of In-Hospital Outcome in Cases of ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention. Journal of Cardiology & Current Research. 2016;7(4):11–2. DOI: 10.15406/jccr.2016.07.00255

15. Yu T, Tian C, Song J, He D, Sun Z, Sun Z. Derivation and Validation of Shock Index as a parameter for Predicting Long-term Prognosis in Patients with Acute Coronary Syndrome. Scientific Reports. 2017;7(1):11929. DOI: 10.1038/s41598-017-12180-2

16. Rady MY, Nightingale P, Little RA, Edwards JD. Shock index: a reevaluation in acute circulatory failure. Resuscitation. 1992;23(3):227–34. DOI: 10.1016/0300-9572(92)90006-X

17. Graham LN, Smith PA, Stoker JB, Mackintosh AF, Mary DA. Sympathetic neural hyperactivity and its normalization following unstable angina and acute myocardial infarction. Clinical Science. 2004;106(6):605–11. DOI: 10.1042/CS20030376

18. Chen P, Chen LS, Cao JM, Sharifi B, Karagueuzian HS, Fishbein MC. Sympathetic nerve sprouting, electrical remodeling and the mechanisms of sudden cardiac death. Cardiovascular Research. 2001;50(2):409–16. DOI: 10.1016/S0008-6363(00)00308-4

19. Pramudyo M, Marindani V, Achmad C, Putra ICS. Modified Shock Index as Simple Clinical Independent Predictor of In-Hospital Mortality in Acute Coronary Syndrome Patients: A Retrospective Cohort Study. Frontiers in Cardiovascular Medicine. 2022;9:915881. DOI: 10.3389/fcvm.2022.915881

20. Bangalore S, Messerli FH, Ou F-S, Tamis-Holland J, Palazzo A, Roe MT et al. The association of admission heart rate and in-hospital cardiovascular events in patients with non-ST-segment elevation acute coronary syndromes: results from 135 164 patients in the CRUSADE quality improvement initiative. European Heart Journal. 2010;31(5):552–60. DOI: 10.1093/eurheartj/ehp397

21. Chin CT, Wang TY, Li S, Wiviott SD, deLemos JA, Kontos MC et al. Comparison of the Prognostic Value of Peak Creatine Kinase-MB and Troponin Levels Among Patients With Acute Myocardial Infarction: A Report from the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines. Clinical Cardiology. 2012;35(7):424–9. DOI: 10.1002/clc.21980

22. Bagai A, Schulte PJ, Granger CB, Mahaffey KW, Christenson RH, Bell G et al. Prognostic implications of creatine kinase–MB measurements in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention. American Heart Journal. 2014;168(4):503-511.e2. DOI: 10.1016/j.ahj.2014.06.008

23. Yin Z, Yu B, Liu W, Lan K. Blood transfusion and mortality in myocardial infarction: an updated meta-analysis. Oncotarget. 2017;8(60):102254–62. DOI: 10.18632/oncotarget.19208

24. McKechnie RS, Smith D, Montoye C, Kline-Rogers E, O’Donnell MJ, DeFranco AC et al. Prognostic implication of anemia on in-hospital outcomes after percutaneous coronary intervention. Circulation. 2004;110(3):271–7. DOI: 10.1161/01.CIR.0000134964.01697.C7

25. Bhavanadhar P, Srinivasan VR, Oruganti SS, Adiraju KP. A Prospective Study on Prevalence and Causes of Anaemia in Patients with Acute Coronary Syndrome. Journal of clinical and diagnostic research. 2016;10(7):OC01-5. DOI: 10.7860/JCDR/2016/19091.8106

26. Hussein A, Awad MS, Sabra AM, Mahmoud HEM. Anemia is a nove l predictor for clinical ISR following PCI. The Egyptian Heart Journal. 2021;73(1):40. DOI: 10.1186/s43044-021-00163-8

27. Sabatine MS, Morrow DA, Giugliano RP, Burton PBJ, Murphy SA, McCabe CH et al. Association of Hemoglobin Level s With Clinical Outcomes in Acute Coronary Syndromes. Circulation. 2005;111(16):2042–9. DOI: 10.1161/01.CIR.0000162477.70955.5F

28. Yang Y, Huang Y. Association between serum hemoglobin and major cardiovascular adverse event in Chinese patients with ST‐segment elevation myocardial infarction after percutaneous coronary intervention. Journal of Clinical Laboratory Analysis. 2022;36(1):e24126. DOI: 10.1002/jcla.24126

29. Ducrocq G, Gonzalez-Juanatey JR, Puymirat E, Lemesle G, Cachanado M, Durand-Zaleski I et al. Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial. JAMA. 2021;325(6):552–60. DOI: 10.1001/jama.2021.0135

30. Liebetrau C, Hoffmann J, Dörr O, Gaede L, Blumenstein J, Biermann H et al. Release Kinetics of Inflammatory Biomarkers in a Clinical Model of Acute Myocardial Infarction. Circulation Research. 2015;116(5):867–75. DOI: 10.1161/CIRCRESAHA.116.304653

31. Husser O, Bodi V, Sanchis J, Nunez J, Mainar L, Chorro FJ et al. White Blood Cell Subtypes after STEMI: Temporal Evolution, Association with Cardiovascular Magnetic Resonance – Derived Infarct Size and Impact on Outcome. Inflammation. 2011;34(2):73–84. DOI: 10.1007/s10753-010-9209-0

32. Bodí V, Llacer A, Sanchis J, Nunez J, Nunez E. Prognostic Value of Leukocytosis in Acute Coronary Syndromes: The Cinderella of the Inflammatory Markers. Current Medicinal Chemistry. 2006;13(18):2113–8. DOI: 10.2174/092986706777935221

33. Barron HV, Cannon CP, Murphy SA, Braunwald E, Gibson CM. Association Between White Blood Cell Count, Epicardial Blood Flow, Myocardial Perfusion, and Clinical Outcomes in the Setting of Acute Myocardial Infarction: A Thrombolysis In Myocardial Infarction 10 Substudy. Circulation. 2000;102(19):2329–34. DOI: 10.1161/01.CIR.102.19.2329

34. Barron HV, Harr SD, Radford MJ, Wang Y, Krumholz HM. The association between white blood cell count and acute myocardial infarction mortality in patients ≥65 years of age: findings from the cooperative cardiovascular project. Journal of the American College of Cardiology. 2001;38(6):1654–61. DOI: 10.1016/S0735-1097(01)01613-8

35. Furman MI, Gore JM, Anderson FA, Budaj A, Goodman SG, Avezum Á et al. Elevated leukocyte count and adverse hospital events in patients with acute coronary syndromes: findings from the Global Registry of Acute Coronary Events (GRACE). American Heart Journal. 2004;147(1):42–8. DOI: 10.1016/j.ahj.2003.07.003

36. Wei X-B, Liu Y-H, He P-C, Jiang L, Zhou Y-L, Chen J-Y et al. Additive prognostic value of left ventricular ejection fraction to the TIMI risk score for in-hospital and long-term mortality in patients with ST segment elevation myocardial infarction. Journal of Thrombosis and Thrombolysis. 2017;43(1):1–6. DOI: 10.1007/s11239-016-1407-7

37. Kim HK, Jeong MH, Ahn Y, Kim JH, Chae SC, Kim YJ et al. Hospital discharge risk score system for the assessment of clinical outcomes in patients with acute myocardial infarction (Korea Acute Myocardial Infarction Registry [KAMIR] score). The American Journal of Cardiology. 2011;107(7):965-971.e1. DOI: 10.1016/j.amjcard.2010.11.018

38. Khwaja A. KDIGO Clinical Practice Guidelines for Acute Kidney Injury. Nephron Clinical Practice. 2012;120(4):c179–84. DOI: 10.1159/000339789

39. Dohi T, Kasai T, Miyauchi K, Takasu K, Kajimoto K, Kubota N et al. Prognostic impact of chronic kidney disease on 10-year clinical outcomes among patients with acute coronary syndrome. Journal of Cardiology. 2012;60(6):438–42. DOI: 10.1016/j.jjcc.2012.08.007

40. Gruberg L, Dangas G, Mehran R, Mintz GS, Kent KM, Pichard AD et al. Clinical outcome following percutaneous coronary interventions in patients with chronic renal failure. Catheterization and Cardiovascular Interventions. 2002;55(1):66–72. DOI: 10.1002/ccd.10103

41. Lenci Marques G, Assano Stangler NH, Ferro H, Calisto J, Brehm J, Felicio Morais G et al. Kidney Disease as Risk of In-Hospital Mortality in Patients With Acute Coronary Syndrome. Cureus. 2021;13(11):e19557. DOI: 10.7759/cureus.19557

42. Widimský P, Gregor P, Cervenka V, Vísek V. The role of echocardiography in a coronary care unit. Cor Et Vasa. 1985;27(4):272–9. PMID: 4053618