急性缺血性卒中患者血清超敏肌钙蛋白Ⅰ水平与90 d预后的关系
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摘要
目的研究急性缺血性卒中患者血清超敏肌钙蛋白Ⅰ(hs-TnⅠ)水平与出院后90 d预后的关系。方法回顾性连续纳入2017年9月至11月于哈尔滨医科大学附属第一医院神经内科就诊的1 717例急性缺血性卒中患者。收集所有患者临床资料,包括入院时生命体征、实验室指标、既往病史等。hs-TnⅠ水平的测定采用化学发光微粒子免疫检测法。入院时卒中严重程度采用美国国立卫生研究院卒中量表(NIHSS)评价,90 d预后采用改良Rankin量表(mRS)评价。依据患者90 d随访时mRS评分,将其分为预后良好(mRS 0～2分)组和预后不良(mRS 3～6分)组。采用多因素Logistic回归分析hs-TnⅠ水平与90 d预后的关系。结果出院后90 d随访,1 717例患者中,预后良好1 322例,预后不良395例,mRS评分0～6分,中位评分2(1,3)分。与预后良好组比较,预后不良组患者女性[44. 6%(176例)比32. 3%(427例),χ~2=20. 05]、年龄[67(58,75)岁比62(54,69)岁,χ~2=50. 22]、入院时NIHSS评分[7 (5,10)分比3 (2,4)分,χ~2=348. 35]和hs-TnⅠ水平[0. 01(0,0. 01)μg/L比0(0,0. 01)μg/L,χ~2=29. 44]、白细胞计数[8. 43 (6. 79,10. 42)×10~9/L比7. 51(6. 21,9. 13)×10~9/L,χ~2=32. 42]、收缩压[150 (140,170) mm Hg比150 (135,165) mm Hg,χ~2=4. 22]、住院时间[8(6,9) d比7 (6,8) d,χ~2=49. 06]、既往卒中病史患者比例[54. 2%(214例)比42. 3%(559例),χ~2=17. 38]及hs-TnⅠ升高[16. 7%(66例)比8. 9%(118例),χ~2=19. 25]、临床恶化[18. 5%(73例)比2. 7%(36例),χ~2=127. 02]患者比例均高于预后良好组,吸烟史患者比例[34. 7%(137例)比44. 0%(582例),χ~2=10. 90]、肌酐[67. 4(56. 4,84. 7)μmol/L比70. 9(60. 8,81. 2)μmol/L,χ~2=4. 26]、血红蛋白[140(126,149) g/L比142(131,153) g/L,χ~2=14. 95]及血细胞比容[42. 2(38. 6,44. 7)%比42. 8(39. 8,45. 6)%,χ~2=13. 16]均低于预后良好组,差异均有统计学意义(均P <0. 05)。多因素Logistic回归分析结果显示,女性(OR=1. 33,95%CI:1. 01～1. 77)、年龄≥60岁(OR=1. 59,95%CI:1. 18～2. 14)、既往卒中病史(OR=1. 46,95%CI:1. 11～1. 92)、入院时NIHSS评分≥5分(OR=11. 49,95%CI:8. 57～15. 4)、hs-TnⅠ升高(OR=1. 56,95%CI:1. 05～2. 32)、临床恶化(OR=14. 71,95%CI:8. 89～24. 33)为90 d预后不良的独立危险因素,血红蛋白升高(OR=0. 62,95%CI:; 0. 43～0. 88)为90 d预后良好的保护因素(均P <0. 05)。结论急性缺血性卒中患者血清hs-TnⅠ升高是90 d预后不良的独立危险因素。
Objective To study the relationship between serum high-sensitive cardiac troponin Ⅰ( hs-TnⅠ) level and prognosis at 9 d in patients with acute ischemic stroke. Methods A total of 1 717 consecutive patients with acute ischemic stroke treated at the Department of Neurology,the First Affiliated Hospital of Harbin Medical University from September to November 2017 were enrolled retrospectively. The clinical data of all patients were collected,including vital signs at admission,laboratory indicators,and past medical history. The levels of hs-TnⅠ were determined by chemiluminescent particle immunoassay. The severity of stroke at admission was assessed by the National Institutes of Health Stroke Scale( NIHSS),and the prognosis at 90 d was evaluated by the modified Rankin scale( mRS). They were divided into good prognosis( mRS 0-2) group and poor prognosis( mRS 3-6) group according to the mRS score at 90 d follow-up. Multivariate logistic regression was used to analyze the relationship between hs-TnⅠ and prognosis at 90 d. Results Follow-up 90 days after discharge,of the 1 717 patients,1 322 had good prognosis,395 had poor prognosis,the mRS score was 0 ～ 6[2( 1,3) ]. Compared with the good prognosis group,female( 44. 6% [n = 176] vs. 32. 3% [n = 427],χ~2= 20. 05),age( 67 [58,75] years vs. 62 [54,69]years,χ~2= 50. 22),NIHSS score at admission( 7 [5,10] vs. 3 [2,4],χ~2= 348. 35],and hs-TnⅠ levels( 0. 01 [0,0. 01]μg/L vs. 0 [0,0. 01]μg/L,χ~2= 29. 44),white blood cell count( 8. 43 [6. 79,10. 42]×10~9/L vs. 7. 51 [6. 21,9. 13] × 10~9/L,χ~2= 32. 42),systolic blood pressure( 150 [140,170]mmHg vs.150 [135,165]mmHg,χ~2= 4. 22),hospital stay( 8 [6,9]d vs. 7 [6,8]d,χ~2= 49. 06),the proportion of patients with previous stroke history( 54. 2% [n = 214]vs. 42. 3% [n = 559],χ~2= 17. 38],and increased hs-TnⅠ( 16. 7 % [n = 66] vs. 8. 9 % [n = 118 ],χ~2= 19. 25) and the proportion of patients in clinical deterioration( 18. 5 % [n = 73] vs. 2. 7 % [n = 36 ],χ~2= 127. 02) were all higher than the those of the good prognosis group. The proportions of patients with smoking history( 34. 7 % [n =137] vs. 44. 0 % [n = 582 ],χ~2= 10. 90 ],creatinine( 67. 4 [56. 4,84. 7]μmol/L vs. 70. 9 [60. 8,81. 2]μmol/L,χ~2= 4. 26),hemoglobin( 140 [126,149]g/L vs. 142 [131,153]g/L,χ~2= 14. 95),and hematocrit( 42. 2 [38. 6,44. 7 %] vs. 42. 8 [39. 8,45. 6 % ],χ~2= 13. 16) were lower than those of the good prognosis group. The differences were statistically significant( P < 0. 05). Multivariate logistic regression analysis showed that female( OR,1. 33,95% CI 1. 01-1. 77),age ≥60 years( OR,1. 59,95% CI 1. 18-2. 14),history of previous stroke( OR,1. 46,95% CI 1. 11-1. 92),NIHSS score ≥5 at admission( OR,11. 49,95% CI 8. 57-15. 4),elevated hs-TnⅠ( OR,1. 56,95% CI 1. 05-2. 32),and clinical deterioration( OR,14. 71,95% CI 8. 89-24. 33) were the independent risk factors for poor prognosis at 90 d,and elevated hemoglobin( OR,0. 62,95 % CI 0. 43-0. 88) was a protective factor of good prognosis at 90 d( all P < 0. 05). Conclusion Elevated serum hs-TnⅠ in patients with acute ischemic stroke was an independent risk factor of poor prognosis at 90 d.
Objective To study the relationship between serum high-sensitive cardiac troponin Ⅰ( hs-TnⅠ) level and prognosis at 9 d in patients with acute ischemic stroke. Methods A total of 1 717 consecutive patients with acute ischemic stroke treated at the Department of Neurology,the First Affiliated Hospital of Harbin Medical University from September to November 2017 were enrolled retrospectively. The clinical data of all patients were collected,including vital signs at admission,laboratory indicators,and past medical history. The levels of hs-TnⅠ were determined by chemiluminescent particle immunoassay. The severity of stroke at admission was assessed by the National Institutes of Health Stroke Scale( NIHSS),and the prognosis at 90 d was evaluated by the modified Rankin scale( mRS). They were divided into good prognosis( mRS 0-2) group and poor prognosis( mRS 3-6) group according to the mRS score at 90 d follow-up. Multivariate logistic regression was used to analyze the relationship between hs-TnⅠ and prognosis at 90 d. Results Follow-up 90 days after discharge,of the 1 717 patients,1 322 had good prognosis,395 had poor prognosis,the mRS score was 0 ～ 6[2( 1,3) ]. Compared with the good prognosis group,female( 44. 6% [n = 176] vs. 32. 3% [n = 427],χ~2= 20. 05),age( 67 [58,75] years vs. 62 [54,69]years,χ~2= 50. 22),NIHSS score at admission( 7 [5,10] vs. 3 [2,4],χ~2= 348. 35],and hs-TnⅠ levels( 0. 01 [0,0. 01]μg/L vs. 0 [0,0. 01]μg/L,χ~2= 29. 44),white blood cell count( 8. 43 [6. 79,10. 42]×10~9/L vs. 7. 51 [6. 21,9. 13] × 10~9/L,χ~2= 32. 42),systolic blood pressure( 150 [140,170]mmHg vs.150 [135,165]mmHg,χ~2= 4. 22),hospital stay( 8 [6,9]d vs. 7 [6,8]d,χ~2= 49. 06),the proportion of patients with previous stroke history( 54. 2% [n = 214]vs. 42. 3% [n = 559],χ~2= 17. 38],and increased hs-TnⅠ( 16. 7 % [n = 66] vs. 8. 9 % [n = 118 ],χ~2= 19. 25) and the proportion of patients in clinical deterioration( 18. 5 % [n = 73] vs. 2. 7 % [n = 36 ],χ~2= 127. 02) were all higher than the those of the good prognosis group. The proportions of patients with smoking history( 34. 7 % [n =137] vs. 44. 0 % [n = 582 ],χ~2= 10. 90 ],creatinine( 67. 4 [56. 4,84. 7]μmol/L vs. 70. 9 [60. 8,81. 2]μmol/L,χ~2= 4. 26),hemoglobin( 140 [126,149]g/L vs. 142 [131,153]g/L,χ~2= 14. 95),and hematocrit( 42. 2 [38. 6,44. 7 %] vs. 42. 8 [39. 8,45. 6 % ],χ~2= 13. 16) were lower than those of the good prognosis group. The differences were statistically significant( P < 0. 05). Multivariate logistic regression analysis showed that female( OR,1. 33,95% CI 1. 01-1. 77),age ≥60 years( OR,1. 59,95% CI 1. 18-2. 14),history of previous stroke( OR,1. 46,95% CI 1. 11-1. 92),NIHSS score ≥5 at admission( OR,11. 49,95% CI 8. 57-15. 4),elevated hs-TnⅠ( OR,1. 56,95% CI 1. 05-2. 32),and clinical deterioration( OR,14. 71,95% CI 8. 89-24. 33) were the independent risk factors for poor prognosis at 90 d,and elevated hemoglobin( OR,0. 62,95 % CI 0. 43-0. 88) was a protective factor of good prognosis at 90 d( all P < 0. 05). Conclusion Elevated serum hs-TnⅠ in patients with acute ischemic stroke was an independent risk factor of poor prognosis at 90 d.
引文
[1] Jauch EC,Saver JL,Adams HP Jr,et al. Guidelines for the early management of patients with acute ischemic stroke:a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J].Stroke,2013,44(3):870-947.
[2] Hamn CW,Bassand JP,Agewall S,et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation:the task force for the management of acute coronary syndromes(ACS)in patients presenting without persistent ST-segment elevation of the European Society of Cardiology(ESC)[J].Eur Heart J,2011,32(23):2999-3054.
[3]汤勇才,任惠铭,黄小媛,等.超敏肌钙蛋白I对早期心肌梗死和脑血管意外的诊断价值[J].热带医学杂志,2018,19(6):787-791.
[4] Thygesen K,Mair J,Giannitsis E,et al. How to use high-sensitivity cardiac troponins in acute cardiac care[J].Eur Heart J,2012,33(18):2252-2257.
[5]中华医学会心血管病学分会,中华医学会检验医学分会.高敏感方法检测心肌肌钙蛋白临床应用中国专家共识(2014)[J].中华内科杂志,2015,54(10):899-904.
[6] Hasirci B,Okay M,Agircan D,et al. Elevated troponin level with negative outcome was found in ischemic stroke[J].Cardiovasc Psychiatry Neurol,2013,2013:953672.
[7]中华医学会神经病学分会.中国急性缺血性脑卒中诊治指南(2014)[J].中华神经科杂志,2015,48(4):246-257.
[8] Hao Z,Wu B,Lin S,et al. Association between renal function and clinical outcome in patients with acute stroke[J]. Eur Neurol,2010,63(4):237-242.
[9] Kim BJ,Lee SH,Shin CW,et al. Ischemic stroke during sleep:its association with worse early functional outcome[J]. Stroke,2011,42(7):1901-1906.
[10] Kong FY,Tao WD,Hao ZL,et al. Predictors of one-year disability and death in Chinese hospitalized women after ischemic stroke[J]. Cerebrovasc Dis,2010,29(3):255-262.
[11] Brott T,Adams HP Jr,Olinger CP,et al. Measurements of acute cerebral infarction:a clinical examination scale[J].Stroke,1989,20(7):864-870.
[12]van Swieten JC,Koudstaal PJ,Visser MC,et al.Interobserver agreement for the assessment of handicap in stroke patients[J]. Stroke,1988,19(5):604-607.
[13] Fischer U,Baumgartner A,Arnold M,et al. What is a minor stroke?[J]. Stroke,2010 41(4):661-666.
[14]严静,余晶波.急性缺血性脑卒中患者血清肌钙蛋白升高的临床意义及相关危险因素[J].现代实用医学,2015,27(10):1302-1303.
[15] Scheitz JF,Nolte CH,Laufs U,et al. Application and interpretation of high-sensitivity cardiac troponin assays in patients with acute ischemic stroke[J]. Stroke,2015,46(4):1132-1140.
[16] Barber M,Morton JJ,Macfarlane PW,et al. Elevated troponin levels are associated with sympathoadrenal activation in acute ischaemic stroke[J]. Cerebrovasc Dis,2007,23(4):260-266.
[17] Ghali J,Allison D,Kleinig T,et al. Elevated serum concentrations of troponin T in acute stroke:what do they mean?[J]. J Clin Neurosci,2010,17(1):69-73.
[18] Su YC,Huang KF,Yang FY,et al. Elevation of troponin I in acute ischemic stroke[J]. Peer J,2016,11(4):e1866.
[19] Di Angelantonio E,Fiorelli M,Toni D,et al. Prognostic significance of admission levels of troponin I in patients with acute ischaemic stroke[J]. J Neurol Neurosurg Psychiatry,2005,76(1):76-81.
[20]张允,陆学胜,张燕,等.缺血性脑卒中急性期血清肌钙蛋白I升高的临床意义[J].实用临床医药杂志,2015,19(21):9-12.
[21]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.高敏心肌肌钙蛋白在急性冠状动脉综合征中的应用中国专家共识[J].中华心血管病杂志,2012,40(10):809-812.
[2] Hamn CW,Bassand JP,Agewall S,et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation:the task force for the management of acute coronary syndromes(ACS)in patients presenting without persistent ST-segment elevation of the European Society of Cardiology(ESC)[J].Eur Heart J,2011,32(23):2999-3054.
[3]汤勇才,任惠铭,黄小媛,等.超敏肌钙蛋白I对早期心肌梗死和脑血管意外的诊断价值[J].热带医学杂志,2018,19(6):787-791.
[4] Thygesen K,Mair J,Giannitsis E,et al. How to use high-sensitivity cardiac troponins in acute cardiac care[J].Eur Heart J,2012,33(18):2252-2257.
[5]中华医学会心血管病学分会,中华医学会检验医学分会.高敏感方法检测心肌肌钙蛋白临床应用中国专家共识(2014)[J].中华内科杂志,2015,54(10):899-904.
[6] Hasirci B,Okay M,Agircan D,et al. Elevated troponin level with negative outcome was found in ischemic stroke[J].Cardiovasc Psychiatry Neurol,2013,2013:953672.
[7]中华医学会神经病学分会.中国急性缺血性脑卒中诊治指南(2014)[J].中华神经科杂志,2015,48(4):246-257.
[8] Hao Z,Wu B,Lin S,et al. Association between renal function and clinical outcome in patients with acute stroke[J]. Eur Neurol,2010,63(4):237-242.
[9] Kim BJ,Lee SH,Shin CW,et al. Ischemic stroke during sleep:its association with worse early functional outcome[J]. Stroke,2011,42(7):1901-1906.
[10] Kong FY,Tao WD,Hao ZL,et al. Predictors of one-year disability and death in Chinese hospitalized women after ischemic stroke[J]. Cerebrovasc Dis,2010,29(3):255-262.
[11] Brott T,Adams HP Jr,Olinger CP,et al. Measurements of acute cerebral infarction:a clinical examination scale[J].Stroke,1989,20(7):864-870.
[12]van Swieten JC,Koudstaal PJ,Visser MC,et al.Interobserver agreement for the assessment of handicap in stroke patients[J]. Stroke,1988,19(5):604-607.
[13] Fischer U,Baumgartner A,Arnold M,et al. What is a minor stroke?[J]. Stroke,2010 41(4):661-666.
[14]严静,余晶波.急性缺血性脑卒中患者血清肌钙蛋白升高的临床意义及相关危险因素[J].现代实用医学,2015,27(10):1302-1303.
[15] Scheitz JF,Nolte CH,Laufs U,et al. Application and interpretation of high-sensitivity cardiac troponin assays in patients with acute ischemic stroke[J]. Stroke,2015,46(4):1132-1140.
[16] Barber M,Morton JJ,Macfarlane PW,et al. Elevated troponin levels are associated with sympathoadrenal activation in acute ischaemic stroke[J]. Cerebrovasc Dis,2007,23(4):260-266.
[17] Ghali J,Allison D,Kleinig T,et al. Elevated serum concentrations of troponin T in acute stroke:what do they mean?[J]. J Clin Neurosci,2010,17(1):69-73.
[18] Su YC,Huang KF,Yang FY,et al. Elevation of troponin I in acute ischemic stroke[J]. Peer J,2016,11(4):e1866.
[19] Di Angelantonio E,Fiorelli M,Toni D,et al. Prognostic significance of admission levels of troponin I in patients with acute ischaemic stroke[J]. J Neurol Neurosurg Psychiatry,2005,76(1):76-81.
[20]张允,陆学胜,张燕,等.缺血性脑卒中急性期血清肌钙蛋白I升高的临床意义[J].实用临床医药杂志,2015,19(21):9-12.
[21]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.高敏心肌肌钙蛋白在急性冠状动脉综合征中的应用中国专家共识[J].中华心血管病杂志,2012,40(10):809-812.
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