入院临床特征对急性心肌梗死患者住院期间不良结局的影响
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摘要
研究背景
急性心肌梗死是心血管疾病的危重症,有很高的病死率和致残率。针对影响急性心肌梗死预后的危险因素的研究一直是临床关注的热点。临床上一般认为急性心肌梗死的预后尤其是急性期预后与患者某些入院时的临床特征相关,但从群体角度探讨有关临床特征与急性心肌梗死住院期间不良结局(死亡、心功能不全)的关系的报道较少,对影响急性心肌梗死住院期间预后相关的危险因素聚集情况未见较大规模的临床流行病学研究及相关报道。
研究目的
探讨入院临床特征对急性心肌梗死患者住院期间不良结局的影响以及相关危险因素的聚集情况,为心肌梗死急性期预后评估和危险因素控制提供临床流行病学依据。
研究方法
以1998年1月到2010年10月期间在苏州大学附属第二医院连续入院的849例急性心肌梗死患者为研究对象,由培训合格的调查员采用统一设计的病例调查表,通过查阅病历档案,收集患者的人口统计学信息、生活方式、危险因素、入院时的血压、心率、病史相关资料、实验室检查结果以及研究结局(心功能评级或死亡)资料。采用SPSS16.0软件进行统计分析。比较不同临床特征急性心肌梗死患者研究结局的差异,不同研究结局的临床特征以及各危险因素与不同研究结局的关联性和相关危险因素的聚集情况。采用多因素logistic回归方法,分析与研究结局的关联,计算比值比(Odds ratio,OR)及95%可信区间(95% Confident interval,95%CI)。
研究结果
1.在纳入的849例急性心肌梗死患者中,男性648例,女性201例,有研究结局患者269例,其中死亡139例,病死率为16.5%,出院心功能≥3级130例,发生率为15.9%。
2.冠心病史、心血管病家族史、脑卒中史和糖尿病史率在不同入院心功者间有显著性差异,表现为心功能2级及以上者冠心病、糖尿病和脑卒中病史率高于心功能1级者(均P<0.05);随入院时心功能分级增加,SBP、DBP、PP、MAP水平显著下降;心率,入院时血糖、血尿酸、血CRP水平、WBC计数和中性粒细胞比率明显升高(均p<0.05)。有并发症者的冠心病史、糖尿病史和脑卒中史率显著的高于无并发症者(均P<0.05)。
3.在多因素Logistic回归模型中,入院DBP、MAP、心率、住院并发症、入院心功能分级、入院血糖水平、血尿酸水平、白细胞计数、中性粒细胞比率与患者住院期间死亡和出院时心功能≥3级危险性相关联。
4.进一步对年龄、入院时SBP、DBP、PP、MAP、心率、血糖、WBC计数和血尿酸的不同水平与患者住院期间死亡和出院时心功能≥3级危险性的关联关系进行多因素Logistic回归分析。
结果显示:⑴以入院年龄50～60岁为参比,入院年龄<50岁、60～69和≥70岁者死亡的OR分别为0.217、1.749和3.618,呈现出低年龄组降低危险性,而高年龄组升高危险性的趋势。入院年龄<50岁、60～69和≥70岁者出院心功能≥3级的OR分别为0.197、1.426和3.035,呈现出与死亡危险性同样的趋势。
⑵以SBP 120-139 mmHg作为参比,入院时SBP≥140 mmHg、100-119 mmHg和<100 mmHg者发生死亡的OR分别为0.753、1.184和5.352,显示SBP越低住院期间发生死亡的危险性越大。入院时SBP≥140 mmHg、100-119 mmHg和<100 mmHg者发生出院心功能≥3级的OR分别为0.757、1.225和4.787,显呈现出与死亡危险性同样的趋势。
⑶以DBP 60～90 mmHg作为参比,入院时DBP>90 mmHg者住院期间发生死亡的OR为0.710,但无统计学意义。入院时DBP <60 mmHg者住院期间发生死亡的OR为4.575,提示入院时DBP过低死亡的危险性增大。入院时DBP <60 mmHg者出院时心功能≥3级的OR为5.346,提示入院时DBP过低出院时心功能≥3级的危险性增大。
⑷以PP 40-50 mmHg作为参比,入院时PP<40mmHg者住院期间发生死亡和出院时心功能≥3级的危险性OR分别为2.458和1.927,提示入院时PP过低发生住院期间死亡和出院时心功能≥3级的危险性增大。入院时PP51-60 mmHg和≥60 mmHg者住院期间发生死亡和出院时心功能≥3级的OR均无统计学意义。
⑸以MAP 80-90mmHg作为参比,入院时MAP 60-79 mmHg和<60 mmHg mmHg者住院期间发生死亡的OR分别为2.575和6.999,入院MAP <60 mmHg患者出院心功能≥3级OR为9.460,表明入院时过低的MAP水平可提高住院期间发生死亡和出院时心功能≥3级的危险性。入院时MAP≥90 mmHg者住院期间发生死亡的OR以及入院时MAP≥90 mmHg和60-79 mmHg者出院时心功能≥3级的OR均无统计学意义。
⑹以入院时心率<70次/分作为参比,入院时心率≥90次/分对住院期间死亡和出院心功能≥3级的危险性分别为2.576和2.752,表明心率加快与住院期间死亡和出院心功能≥3级的危险性相关联。入院时心率70-89次/分对死亡和出院心功能≥3级的危险性均无统计学意义。
⑺以入院时血糖水平<6.1mmol/L作为参比,入院时血糖水平6.1～6.9mmol/L和≥7.0mmol/L对住院期间死亡和出院心功能≥3级的危险性分别是3.590和2.495,4.197和2.613,均具有统计学意义。表明入院血糖水平升高可增加住院期间死亡和出院心功能≥3级的危险性。
⑻以入院时WBC计数<8.0 x109作为参比,入院时WBC计数8.0-10.0 x109对住院期间死亡和出院心功能≥3级危险性均无统计学意义。而入院时WBC计数≥10.0 x109对住院期间死亡和出院心功能≥3级的危险性分别为2.343和2.116,表明入院白细胞水平升高可增加住院期间死亡和出院心功能≥3级的危险性。
⑼以最低组(<289umol/L)作为参比,血尿酸水平289~390umol/L对住院期间死亡和出院心功能≥3级的危险性分别为2.162和2.887(具有统计学意义),而血尿酸水平>390umol/L对住院期间死亡和出院心功能≥3级的危险性分别为3.569和3.347,均具有统计学意义。
⑽以危险因素数量为0个者作为参比,经性别、年龄、吸烟、饮酒、血脂等多因素调整后,危险因素(MAP<60 mmHg、HR≥90 beat/min、入院时血糖≥6.1mmol/L和WBC≥10.0 x109)数量为1、2、≥3个对AMI患者住院期间发生死亡危险性分别是3.101、5.990和12.568,出院心功能≥3级危险性分别是3.714、5.990和14.816,均具有统计学意义。结果提示,多个危险因素聚集时发生死亡、出院心功能≥3级和复合结局的危险性显著增加。
结论:
1、在纳入的849例AMI患者中,住院期间病死率和出院心功能≥3级的发生率为16.5%和15.9%;
2、AMI发病时年龄及入院时有合并症、心功能受损、血压降低、心率加快、血白细胞计数升高、血糖升高和血尿酸升高是不良结局(住院期间死亡和发生出院心功能≥3级)患者的重要临床特征;
3、入院时SBP<100mmHg、DBP<60 mmHg、PP<40 mmHg和MAP<60 mmHg,心率≥90,血糖≥6.1mmol/L,WBC≥10.0 x109和尿酸≥390umol/L可显著的增加住院期间死亡和出院心功能≥3级的危险性。
4、入院时MAP<60 mmHg、心率≥90、血糖≥6.1 mmol/L和WBC≥10.0 x109的相互聚集可显著的增加住院期间死亡和出院心功能≥3级的危险性。
Background
Acute myocardial infarction (AMI) is most serious cardiovascular disease with high fatality and disability rates. Research works has been focused on risk factors of prognosis for AMI in clinical medicine. It has been generally acknowledged that prognosis especially in acute-stage of AMI patients is closely related to admission clinical charicteristics. However, there have been few reports about relationship between admission clinical charicteristics and poor clinical outcomes (death and severe heart failure) in hospitalization among AMI patients in epidemiology. There has been no report about relationship between clustering of risk factors and prognosis during hospitalization among AMI patients.
Purpose
The purposes of this study are to investigate relationship between admission clinical charicteristics and poor clinical outcomes (death and severe heart failure) in hospitalization and relationship between clustering of risk factors and prognosis during hospitalization among AMI patients, and to provide clinical epidemiological basis for evaluation about prognosis and control for risk factors in acue phase of myocardial infarction.
Methods
A total of 849 AMI patients consecutively hospitalized in the Second Affiliated Hospital of Soochow University from January of 1998 to October of 2010 were selected as study subjects. Trained and qualified investigators collected data on information of demographic characteristics, life style risk factors, admission blood pressure, heart rate, medical history, clinical laboratory tests and study outcomes(death and heart failure ) for all subjects from medical records by using questionnaire. Statistic analysis was conducted by using SPSS16.0 software. Demographic characteristics and clinical charicteristics in different groups of AMI patients were described by a median (interquartile range) and rate (or proportion), and compared by nonparameter test andχ2 test. The associations between various clinical charicteristics and risk factors clustering and poor outcomes in-hospital were analyzed by using multiple logistic model. odds ratios (ORs) and 95% confidence interval (95%CI) were calculated.
Results
1. Of total 849 study subjects with AMI, 648 were male and 201 were female. There were 269 patients with study outcomes during hospitalization or at discharge, 139 patients (16.5%) died, and 130 patients(15.9%) had heart failure (NYHA≥3 degree).
2. There were significantly difference in histories of coronary heart disease, stroke and diabetes among AMI patients with different NYHA. Rates for coronary heart disease histroy, stroke histroy and diabetes histroy were significantly higher in AMI patients with NYHA≥2 degree than in those with NYHA=1(all P<0.05). Systolic blood pressure (SBP)、diastolic blood pressure (DBP)、pulse pressure (PP)、mean artery pressure (MAP) decreased and heart rate(HR), admission blood glucose, serum uric acid(UA), c-reactive protein, white blood cell (WBC) count and percentage of neutrophilic granulocyte increased with increased NYHA. Rates for coronary heart disease histroy, stroke histroy and diabetes histroy were significantly higher in AMI patients with complications than in those without complications.
3. In multiple logistic model, DBP, MAP, heart beat, complications, NYHA, admission blood glucose, UA, WBC count and percentage of neutrophilic granulocyte were associated with in-hospital death and NYHA≥3 degree at discharge among AMI patients(all P<0.05).
4. Association between different levels of SBP, DBP, MAP, heart beat, admission blood glucose, UA, WBC count and study outcomes were further analyzed by using multiple logistic model.
⑴Compared to those aged 50～60 years, patients aged <50、60～69and≥70 years had OR of 0.217、1.749 and 3.618 for in-hospital death, respectively, which indicated that young patients had lower risk and elder patients had higher risk. patients aged <50、 60～69and≥70 years had OR of 0.197、1.426and 3.035 for NYHA≥3 degree at discharge respectively, which showed the same tendency as risk of death.
⑵Compared to those with SBP 120-139 mmHg, patients with SBP≥140 mmHg、100-119 mmHg and <100 mmHg had OR of 0.753、1.184 and 5.352(P<0.05) for in-hospital death, respectively, which showed that patients with lower SBP had higher risk of in-hospital death. patients with SBP≥140 mmHg、100-119 mmHg and <100 mmHg had OR of 0.757、1.225 and 4.787 for NYHA≥3 degree at discharge respectively, which showed the same tendency as risk of death.
⑶Compared to those with DBP 60～90 mmHg, patients with DBP>90 mmHg had OR of 0.710 for in-hospital death, but not significant(P>0.05). patients with <60 mmHg had OR of 4.575 and 5.346 (P<0.05) for in-hospital death and NYHA≥3 degree at discharge, respectively, which indicated that the patients with much lower admission DBP had higher risk of in-hospital death and NYHA≥3 degree at discharge.
⑷Compared to those with PP 40-50 mmHg, patients with PP<40mmHg had OR of 2.458 and 1.927 (P<0.05) for in-hospital death and NYHA≥3 degree at discharge, respectively, which indicated that the patients with much lower admission PP had higher risk of in-hospital death and NYHA≥3 degree at discharge. However, the ORs of in-hospital death and NYHA≥3 degree at discharge associated for PP51-60 mmHg and≥60 mmHg were not significant.
⑸Compared to those withMAP 80-90mmHg, patients with MAP 60～79 mmHg and <60 mmHg had OR of 2.575 (P<0.05) and 6.999 (P<0.05) for in-hospital death, respectively, the patients with MAP <60 mmHg had OR of 9.460 for NYHA≥3 degree at discharge, which indicated that the patients with much lower admission MAP had higher risk of in-hospital death and NYHA≥3 degree at discharge. However, the OR of in-hospital death for MAP≥90 mmHg and the ORs of NYHA≥3 degree at discharge associated for MAP≥90 mmHg and 60-79 mmHgwere not significant.
⑹Compared to those with HR <70 beats/min, patients with HR≥90 beats/min had OR of 2.576 (P<0.05) and 2.752 (P<0.05) for in-hospital death and NYHA≥3 degree at discharge, respectively, which indicated that there were association between accelerated heart rate and in-hospital death and NYHA≥3 degree at discharge among AMI patients. However, the OR of in-hospital death and NYHA≥3 degree for 70-89 beats/min were not significant.
⑺Compared to those with admission blood glucose(stress hyperglycemia)<6.1mmol/L, patients with admission blood glucose with 6.1～6.9mmol/L and≥7.0mmol/L had OR of 3.590 (P<0.05) and 2.495 (P<0.05) for in-hospital death, 4.197 (P<0.05) and 2.61 (P<0.05) 3 for NYHA≥3 degree at discharge,which indicated that there were association between increased admission blood glucose and in-hospital death and NYHA≥3 degree at discharge among AMI patients.
⑻Compared to those with WBC count<8.0 x109, patients with WBC count≥10.0 x109 had OR of 2.343 (P<0.05) and 2.116 (P<0.05)for in-hospital death and NYHA≥3 degree at discharge, respectively, the OR of in-hospital death and NYHA≥3 degree for 8.0-10.0 x109 were not significant, which indicated that there were association between increased WBC and in-hospital death and NYHA≥3 degree at discharge among AMI patients.
⑼Compared to those with UA<289 umol/L, patients with UA 289~390umol/L had OR of 2.162 (P<0.05) and 2.887(P<0.05) for in-hospital death and NYHA≥3 degree at discharge, respectively, the patients with UA>390umol/L had OR of 3.569 and 3.347 for in-hospital death and NYHA≥3 degree at discharge, respectively, the ORs were all significant.
⑽Compared to those without risk factors, patients with 1、2、≥3 risk factors clustering (MAP<60 mmHg, HR≥90 beat/min, admission blood glucose≥6.1mmol/L and WBC≥10.0 x109 ) had OR of 3.101, 5.990 and 12.568 (all P<0.05) for in-hospital death, respectively, and OR of 3.714, 5.990 and 14.816 (all P<0.05) for NYHA≥3 degree at discharge, respectively,which indicated that multiple risk factors clustering would increase the risk in-hospital death and NYHA≥3 degree at discharge.
Conclusion
1.Among 849 AMI patients included in this study, the rates of in-hospital fatality and NYHA≥3 degree at discharge were 16.5% and 15.9%, respectively.
2.Age, complications, heart failure, low blood pressure, accelerated heart rate, increased WBC, high admission blood glucose, and high UA were important clinical charicteristics of AMI ptients with poor clinical outcomes.
3.SBP<100mmHg, DBP<60 mmHg, PP<40 mmHg, MAP<60 mmHg,HR≥90 beat/min,admission blood glucose≥6.1mmol/L,WBC≥10.0 x109 and UA≥390umol/L could increase the risk of in-hospital death and NYHA≥3 degree at discharge.
4.Clustering of risk factors including MAP<60 mmHg, HR≥90 beat/min, admission blood glucose≥6.1mmol/L and WBC≥10.0 x109 could increase the risks of in-hospital death and NYHA≥3 degree at discharge among AMI patients.
急性心肌梗死是心血管疾病的危重症,有很高的病死率和致残率。针对影响急性心肌梗死预后的危险因素的研究一直是临床关注的热点。临床上一般认为急性心肌梗死的预后尤其是急性期预后与患者某些入院时的临床特征相关,但从群体角度探讨有关临床特征与急性心肌梗死住院期间不良结局(死亡、心功能不全)的关系的报道较少,对影响急性心肌梗死住院期间预后相关的危险因素聚集情况未见较大规模的临床流行病学研究及相关报道。
研究目的
探讨入院临床特征对急性心肌梗死患者住院期间不良结局的影响以及相关危险因素的聚集情况,为心肌梗死急性期预后评估和危险因素控制提供临床流行病学依据。
研究方法
以1998年1月到2010年10月期间在苏州大学附属第二医院连续入院的849例急性心肌梗死患者为研究对象,由培训合格的调查员采用统一设计的病例调查表,通过查阅病历档案,收集患者的人口统计学信息、生活方式、危险因素、入院时的血压、心率、病史相关资料、实验室检查结果以及研究结局(心功能评级或死亡)资料。采用SPSS16.0软件进行统计分析。比较不同临床特征急性心肌梗死患者研究结局的差异,不同研究结局的临床特征以及各危险因素与不同研究结局的关联性和相关危险因素的聚集情况。采用多因素logistic回归方法,分析与研究结局的关联,计算比值比(Odds ratio,OR)及95%可信区间(95% Confident interval,95%CI)。
研究结果
1.在纳入的849例急性心肌梗死患者中,男性648例,女性201例,有研究结局患者269例,其中死亡139例,病死率为16.5%,出院心功能≥3级130例,发生率为15.9%。
2.冠心病史、心血管病家族史、脑卒中史和糖尿病史率在不同入院心功者间有显著性差异,表现为心功能2级及以上者冠心病、糖尿病和脑卒中病史率高于心功能1级者(均P<0.05);随入院时心功能分级增加,SBP、DBP、PP、MAP水平显著下降;心率,入院时血糖、血尿酸、血CRP水平、WBC计数和中性粒细胞比率明显升高(均p<0.05)。有并发症者的冠心病史、糖尿病史和脑卒中史率显著的高于无并发症者(均P<0.05)。
3.在多因素Logistic回归模型中,入院DBP、MAP、心率、住院并发症、入院心功能分级、入院血糖水平、血尿酸水平、白细胞计数、中性粒细胞比率与患者住院期间死亡和出院时心功能≥3级危险性相关联。
4.进一步对年龄、入院时SBP、DBP、PP、MAP、心率、血糖、WBC计数和血尿酸的不同水平与患者住院期间死亡和出院时心功能≥3级危险性的关联关系进行多因素Logistic回归分析。
结果显示:⑴以入院年龄50～60岁为参比,入院年龄<50岁、60～69和≥70岁者死亡的OR分别为0.217、1.749和3.618,呈现出低年龄组降低危险性,而高年龄组升高危险性的趋势。入院年龄<50岁、60～69和≥70岁者出院心功能≥3级的OR分别为0.197、1.426和3.035,呈现出与死亡危险性同样的趋势。
⑵以SBP 120-139 mmHg作为参比,入院时SBP≥140 mmHg、100-119 mmHg和<100 mmHg者发生死亡的OR分别为0.753、1.184和5.352,显示SBP越低住院期间发生死亡的危险性越大。入院时SBP≥140 mmHg、100-119 mmHg和<100 mmHg者发生出院心功能≥3级的OR分别为0.757、1.225和4.787,显呈现出与死亡危险性同样的趋势。
⑶以DBP 60～90 mmHg作为参比,入院时DBP>90 mmHg者住院期间发生死亡的OR为0.710,但无统计学意义。入院时DBP <60 mmHg者住院期间发生死亡的OR为4.575,提示入院时DBP过低死亡的危险性增大。入院时DBP <60 mmHg者出院时心功能≥3级的OR为5.346,提示入院时DBP过低出院时心功能≥3级的危险性增大。
⑷以PP 40-50 mmHg作为参比,入院时PP<40mmHg者住院期间发生死亡和出院时心功能≥3级的危险性OR分别为2.458和1.927,提示入院时PP过低发生住院期间死亡和出院时心功能≥3级的危险性增大。入院时PP51-60 mmHg和≥60 mmHg者住院期间发生死亡和出院时心功能≥3级的OR均无统计学意义。
⑸以MAP 80-90mmHg作为参比,入院时MAP 60-79 mmHg和<60 mmHg mmHg者住院期间发生死亡的OR分别为2.575和6.999,入院MAP <60 mmHg患者出院心功能≥3级OR为9.460,表明入院时过低的MAP水平可提高住院期间发生死亡和出院时心功能≥3级的危险性。入院时MAP≥90 mmHg者住院期间发生死亡的OR以及入院时MAP≥90 mmHg和60-79 mmHg者出院时心功能≥3级的OR均无统计学意义。
⑹以入院时心率<70次/分作为参比,入院时心率≥90次/分对住院期间死亡和出院心功能≥3级的危险性分别为2.576和2.752,表明心率加快与住院期间死亡和出院心功能≥3级的危险性相关联。入院时心率70-89次/分对死亡和出院心功能≥3级的危险性均无统计学意义。
⑺以入院时血糖水平<6.1mmol/L作为参比,入院时血糖水平6.1～6.9mmol/L和≥7.0mmol/L对住院期间死亡和出院心功能≥3级的危险性分别是3.590和2.495,4.197和2.613,均具有统计学意义。表明入院血糖水平升高可增加住院期间死亡和出院心功能≥3级的危险性。
⑻以入院时WBC计数<8.0 x109作为参比,入院时WBC计数8.0-10.0 x109对住院期间死亡和出院心功能≥3级危险性均无统计学意义。而入院时WBC计数≥10.0 x109对住院期间死亡和出院心功能≥3级的危险性分别为2.343和2.116,表明入院白细胞水平升高可增加住院期间死亡和出院心功能≥3级的危险性。
⑼以最低组(<289umol/L)作为参比,血尿酸水平289~390umol/L对住院期间死亡和出院心功能≥3级的危险性分别为2.162和2.887(具有统计学意义),而血尿酸水平>390umol/L对住院期间死亡和出院心功能≥3级的危险性分别为3.569和3.347,均具有统计学意义。
⑽以危险因素数量为0个者作为参比,经性别、年龄、吸烟、饮酒、血脂等多因素调整后,危险因素(MAP<60 mmHg、HR≥90 beat/min、入院时血糖≥6.1mmol/L和WBC≥10.0 x109)数量为1、2、≥3个对AMI患者住院期间发生死亡危险性分别是3.101、5.990和12.568,出院心功能≥3级危险性分别是3.714、5.990和14.816,均具有统计学意义。结果提示,多个危险因素聚集时发生死亡、出院心功能≥3级和复合结局的危险性显著增加。
结论:
1、在纳入的849例AMI患者中,住院期间病死率和出院心功能≥3级的发生率为16.5%和15.9%;
2、AMI发病时年龄及入院时有合并症、心功能受损、血压降低、心率加快、血白细胞计数升高、血糖升高和血尿酸升高是不良结局(住院期间死亡和发生出院心功能≥3级)患者的重要临床特征;
3、入院时SBP<100mmHg、DBP<60 mmHg、PP<40 mmHg和MAP<60 mmHg,心率≥90,血糖≥6.1mmol/L,WBC≥10.0 x109和尿酸≥390umol/L可显著的增加住院期间死亡和出院心功能≥3级的危险性。
4、入院时MAP<60 mmHg、心率≥90、血糖≥6.1 mmol/L和WBC≥10.0 x109的相互聚集可显著的增加住院期间死亡和出院心功能≥3级的危险性。
Background
Acute myocardial infarction (AMI) is most serious cardiovascular disease with high fatality and disability rates. Research works has been focused on risk factors of prognosis for AMI in clinical medicine. It has been generally acknowledged that prognosis especially in acute-stage of AMI patients is closely related to admission clinical charicteristics. However, there have been few reports about relationship between admission clinical charicteristics and poor clinical outcomes (death and severe heart failure) in hospitalization among AMI patients in epidemiology. There has been no report about relationship between clustering of risk factors and prognosis during hospitalization among AMI patients.
Purpose
The purposes of this study are to investigate relationship between admission clinical charicteristics and poor clinical outcomes (death and severe heart failure) in hospitalization and relationship between clustering of risk factors and prognosis during hospitalization among AMI patients, and to provide clinical epidemiological basis for evaluation about prognosis and control for risk factors in acue phase of myocardial infarction.
Methods
A total of 849 AMI patients consecutively hospitalized in the Second Affiliated Hospital of Soochow University from January of 1998 to October of 2010 were selected as study subjects. Trained and qualified investigators collected data on information of demographic characteristics, life style risk factors, admission blood pressure, heart rate, medical history, clinical laboratory tests and study outcomes(death and heart failure ) for all subjects from medical records by using questionnaire. Statistic analysis was conducted by using SPSS16.0 software. Demographic characteristics and clinical charicteristics in different groups of AMI patients were described by a median (interquartile range) and rate (or proportion), and compared by nonparameter test andχ2 test. The associations between various clinical charicteristics and risk factors clustering and poor outcomes in-hospital were analyzed by using multiple logistic model. odds ratios (ORs) and 95% confidence interval (95%CI) were calculated.
Results
1. Of total 849 study subjects with AMI, 648 were male and 201 were female. There were 269 patients with study outcomes during hospitalization or at discharge, 139 patients (16.5%) died, and 130 patients(15.9%) had heart failure (NYHA≥3 degree).
2. There were significantly difference in histories of coronary heart disease, stroke and diabetes among AMI patients with different NYHA. Rates for coronary heart disease histroy, stroke histroy and diabetes histroy were significantly higher in AMI patients with NYHA≥2 degree than in those with NYHA=1(all P<0.05). Systolic blood pressure (SBP)、diastolic blood pressure (DBP)、pulse pressure (PP)、mean artery pressure (MAP) decreased and heart rate(HR), admission blood glucose, serum uric acid(UA), c-reactive protein, white blood cell (WBC) count and percentage of neutrophilic granulocyte increased with increased NYHA. Rates for coronary heart disease histroy, stroke histroy and diabetes histroy were significantly higher in AMI patients with complications than in those without complications.
3. In multiple logistic model, DBP, MAP, heart beat, complications, NYHA, admission blood glucose, UA, WBC count and percentage of neutrophilic granulocyte were associated with in-hospital death and NYHA≥3 degree at discharge among AMI patients(all P<0.05).
4. Association between different levels of SBP, DBP, MAP, heart beat, admission blood glucose, UA, WBC count and study outcomes were further analyzed by using multiple logistic model.
⑴Compared to those aged 50～60 years, patients aged <50、60～69and≥70 years had OR of 0.217、1.749 and 3.618 for in-hospital death, respectively, which indicated that young patients had lower risk and elder patients had higher risk. patients aged <50、 60～69and≥70 years had OR of 0.197、1.426and 3.035 for NYHA≥3 degree at discharge respectively, which showed the same tendency as risk of death.
⑵Compared to those with SBP 120-139 mmHg, patients with SBP≥140 mmHg、100-119 mmHg and <100 mmHg had OR of 0.753、1.184 and 5.352(P<0.05) for in-hospital death, respectively, which showed that patients with lower SBP had higher risk of in-hospital death. patients with SBP≥140 mmHg、100-119 mmHg and <100 mmHg had OR of 0.757、1.225 and 4.787 for NYHA≥3 degree at discharge respectively, which showed the same tendency as risk of death.
⑶Compared to those with DBP 60～90 mmHg, patients with DBP>90 mmHg had OR of 0.710 for in-hospital death, but not significant(P>0.05). patients with <60 mmHg had OR of 4.575 and 5.346 (P<0.05) for in-hospital death and NYHA≥3 degree at discharge, respectively, which indicated that the patients with much lower admission DBP had higher risk of in-hospital death and NYHA≥3 degree at discharge.
⑷Compared to those with PP 40-50 mmHg, patients with PP<40mmHg had OR of 2.458 and 1.927 (P<0.05) for in-hospital death and NYHA≥3 degree at discharge, respectively, which indicated that the patients with much lower admission PP had higher risk of in-hospital death and NYHA≥3 degree at discharge. However, the ORs of in-hospital death and NYHA≥3 degree at discharge associated for PP51-60 mmHg and≥60 mmHg were not significant.
⑸Compared to those withMAP 80-90mmHg, patients with MAP 60～79 mmHg and <60 mmHg had OR of 2.575 (P<0.05) and 6.999 (P<0.05) for in-hospital death, respectively, the patients with MAP <60 mmHg had OR of 9.460 for NYHA≥3 degree at discharge, which indicated that the patients with much lower admission MAP had higher risk of in-hospital death and NYHA≥3 degree at discharge. However, the OR of in-hospital death for MAP≥90 mmHg and the ORs of NYHA≥3 degree at discharge associated for MAP≥90 mmHg and 60-79 mmHgwere not significant.
⑹Compared to those with HR <70 beats/min, patients with HR≥90 beats/min had OR of 2.576 (P<0.05) and 2.752 (P<0.05) for in-hospital death and NYHA≥3 degree at discharge, respectively, which indicated that there were association between accelerated heart rate and in-hospital death and NYHA≥3 degree at discharge among AMI patients. However, the OR of in-hospital death and NYHA≥3 degree for 70-89 beats/min were not significant.
⑺Compared to those with admission blood glucose(stress hyperglycemia)<6.1mmol/L, patients with admission blood glucose with 6.1～6.9mmol/L and≥7.0mmol/L had OR of 3.590 (P<0.05) and 2.495 (P<0.05) for in-hospital death, 4.197 (P<0.05) and 2.61 (P<0.05) 3 for NYHA≥3 degree at discharge,which indicated that there were association between increased admission blood glucose and in-hospital death and NYHA≥3 degree at discharge among AMI patients.
⑻Compared to those with WBC count<8.0 x109, patients with WBC count≥10.0 x109 had OR of 2.343 (P<0.05) and 2.116 (P<0.05)for in-hospital death and NYHA≥3 degree at discharge, respectively, the OR of in-hospital death and NYHA≥3 degree for 8.0-10.0 x109 were not significant, which indicated that there were association between increased WBC and in-hospital death and NYHA≥3 degree at discharge among AMI patients.
⑼Compared to those with UA<289 umol/L, patients with UA 289~390umol/L had OR of 2.162 (P<0.05) and 2.887(P<0.05) for in-hospital death and NYHA≥3 degree at discharge, respectively, the patients with UA>390umol/L had OR of 3.569 and 3.347 for in-hospital death and NYHA≥3 degree at discharge, respectively, the ORs were all significant.
⑽Compared to those without risk factors, patients with 1、2、≥3 risk factors clustering (MAP<60 mmHg, HR≥90 beat/min, admission blood glucose≥6.1mmol/L and WBC≥10.0 x109 ) had OR of 3.101, 5.990 and 12.568 (all P<0.05) for in-hospital death, respectively, and OR of 3.714, 5.990 and 14.816 (all P<0.05) for NYHA≥3 degree at discharge, respectively,which indicated that multiple risk factors clustering would increase the risk in-hospital death and NYHA≥3 degree at discharge.
Conclusion
1.Among 849 AMI patients included in this study, the rates of in-hospital fatality and NYHA≥3 degree at discharge were 16.5% and 15.9%, respectively.
2.Age, complications, heart failure, low blood pressure, accelerated heart rate, increased WBC, high admission blood glucose, and high UA were important clinical charicteristics of AMI ptients with poor clinical outcomes.
3.SBP<100mmHg, DBP<60 mmHg, PP<40 mmHg, MAP<60 mmHg,HR≥90 beat/min,admission blood glucose≥6.1mmol/L,WBC≥10.0 x109 and UA≥390umol/L could increase the risk of in-hospital death and NYHA≥3 degree at discharge.
4.Clustering of risk factors including MAP<60 mmHg, HR≥90 beat/min, admission blood glucose≥6.1mmol/L and WBC≥10.0 x109 could increase the risks of in-hospital death and NYHA≥3 degree at discharge among AMI patients.
引文
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