Value of fragmented QRS combined with Global Registry of Acute Coronary Events score in prediction of short-term cardiac death events in patients with acute non-ST-segment elevation myocardial infarction
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摘要:目的
研究入院时碎裂QRS波(fQRS)联合全球急性冠状动脉事件注册危险(GRACE)评分对急性非ST段抬高型心肌梗死(NSTEMI)患者住院期间及出院后6个月内心源性死亡事件的预测价值。
方法纳入344例NSTEMI患者, 根据入院时纳入患者心电图有无fQRS波将患者分为fQRS波组(n=145)、无fQRS波组(n=199)。根据GRACE评分不同将患者分为低危组(112例)、中危组(126例)及高危组(106例)。观察患者住院期间及出院后6个月内心源性死亡事件。比较不同组患者各参数及死亡事件的发生情况; 采用受试者工作特征(ROC)曲线比较fQRS波、GRACE评分及两者联合预测短期心源性死亡事件的预测价值。
结果344例NSTEMI患者共随访(5.55±1.37)个月，发生心源性死亡患者24例。fQRS波组患者糖尿病病史、心肌梗死病史、冠状动脉三支病变占比以及NT-proBNP水平均高于无fQRS波组，左室射血分数(LVEF)水平低于无fQRS波组，差异有统计学意义(P < 0.05)。fQRS波组心源性死亡者占比为10.34%, 高于无fQRS波组的4.51%, 差异有统计学意义(P < 0.05)。高危组心源性死亡发生率高于中危组和低危组，差异有统计学意义(P < 0.05)。多因素Logistics回归分析显示, fQRS波、GRACE评分是NSTEMI患者短期内心源性死亡的危险因素(OR=2.739, 95%CI: 1.123~6.637, P=0.002; OR=10.861, 95%CI: 2.426~48.621, P=0.027)。fQRS波组ROC预测心源性死亡事件的曲线下面积为0.609(95%CI: 0.556~0.661), GRACE评分预测的ROC曲线下面积为0.735(95%CI: 0.685~0.781); 两者联合预测的ROC曲线下面积为0.748; ROC曲线下面积比较结果显示，联合检测的ROC曲线下面积大于单独GRACE评分检测和fQRS波检测。
结论fQRS波、GRACE评分以及两者联合均能预测NSTEMI患者短期心源性死亡事件。fQRS波联合GRACE评分对NSTEMI患者短期心源性死亡事件有更好的预测价值。
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关键词:
- 急性非ST段抬高型心肌梗死 /
- 碎裂QRS波 /
- GRACE评分 /
- 心源性死亡 /
- 预测价值
Abstract:ObjectiveTo study the value of fragmented QRS wave (fQRS) combined with the Global Registry of Acute Coronary Events(GRACE) score in predicting cardiac death during hospitalization and within 6 months after discharge in patients with acute non-ST segment elevation myocardial infarction (NSTEMI).
MethodsA total of 334 NSTEMI patients were enrolled, patients were divided into fQRS wave group (n=145) and non-fQRS wave group (n=199) according to the presence or absence of fQRS in the ECG at admission. According to different GRACE scores, the patients were divided into low risk group (112 cases), medium risk group (126 cases) and high risk group (106 cases). Cardiac deaths during hospitalization and within 6 months afterdischarge were observed. Patients' indicators and occurrence of death events among different groups were compared. Receiver Operating Characteristic (ROC) curve was used to compare the predictive values of fQRS, GRACE score alone and their combination in predicting short-term cardiac death events.
ResultsA total of 344 patients with NSTEMI were followed up for (5.55±1.37) months, and 24 patients had cardiac death events. The proportions of patients with type 2 diabetes mellitus, pre-myocardial infarction, the triple-vessel disease and the level of NT-proBNP in the fQRS wave group were higher than those in the non-fQRS wave group, the level of LVEF in the fQRS wave group was lower than that in wave non-fQRS group (P < 0.05). Ratio of cardiac death in the fQRS wave group was higher than that in the non-fQRS wave group (10.34% versus 4.51%, P < 0.05). The incidence of cardiac death in the high risk group was significantly higher than that in the middle risk group and the low risk group (P < 0.05). Multivariate Logistics regression analysis showed that fQRS wave and GRACE score were the risk factors of short-term cardiac death in patients with NSTEMI (OR=2.739, 95%CI, 1.123 to 6.637, P=0.002; OR=10.861, 95%CI, 2.426 to 48.621, P=0.027). The area under the ROC curve in predicting cardiac death in the fQRS wave group was 0.609 (95%CI, 0.556 to 0.661), was 0.735 by GRACE score (95%CI, 0.685 to 0.781), and was 0.748 by combined prediction (95%CI, 0.698 to 0.793). Further comparison of the area under the ROC curve showed that the area under the ROC curve of combined detection was larger than that by GRACE score or fQRS wave alone(P < 0.001).
ConclusionFQRS wave, GRACE score and their combination can predict short-term cardiac death in patients with NSTEMI. The fQRS wave combined with GRACE score has better predictive value for short-term cardiac death in patients with NSTEMI.
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表 1 NSTEMI患者短期不良心血管事件情况[n(%)]
不良心血管事件 发生情况 心力衰竭 68(19.77) 再梗死/心绞痛再住院 44(12.79) 心源性死亡 24(7.00) 恶性心律失常 22(6.40) 心源性休克 21(6.10) 心肌梗死机械并发症 3(0.87) 卒中 8(2.33) 出血 10(2.91) 
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表 2 fQRS波组及无fQRS波组主要基线水平、住院治疗及死亡事件比较(x±s)[n(%)][M(P25, P75)]
指标 无fQRS波组(n=199) fQRS波组(n=145) 男 138(69.35) 108(74.48) 年龄/岁 66.00(56.00, 73.00) 67.00(57.00, 76.00) 体质量/kg 70.00(60, 75) 69.00(60.50, 76.00) BMI/(kg/m2) 24.65(22.50, 26.60) 24.22(22.50, 26.40) 吸烟史 110(55.28) 75(51.72) 高血压病史 135(67.84) 102(70.34) 糖尿病病史 59(29.65) 59(40.69)* 既往心肌梗死病史 17(8.54) 24(16.55)* 高脂血症病史 21(10.55) 20(13.79) 心率/(次/min) 78.00(69.00, 89.00) 80 (68.00, 87.50) 收缩压/mmHg 138.00±21.39 138.00±23.64 心功能Killip分级 Ⅰ级 160(80.40) 111(76.55) Ⅱ级 33(16.58) 26(17.93) Ⅲ级 5(2.52) 3(2.07) Ⅳ级 1(0.50) 5(3.45) 院前心跳骤停 2(1.00) 0 三支病变 52(26.13) 57(39.31)* 入院后PCI术 151(75.88) 109(75.17) 双联抗血小板 199(100.00) 145(100.00) 他汀类药物 199(100.00) 145(100.00) 肌酐/(umol/L) 78.00(62.20, 94.00) 76.00(62.80, 99.00) cTnI/(ng/mL) 3.22(1.17, 10.00) 3.64(1.20, 13.02) CKMB/(ng/mL) 17.20(5.62, 38.43) 19.50(6.55, 42.98) Myo/(ng/mL) 111.00 (55.90, 342.70) 137.00(54.30, 405.90) LVEF/% 55.00(53.00, 58.00) 52.00(47.00, 56.00)* NT-proBNP/(pg/mL) 1 026.12(456.25, 2 670.80) 2 194.32(714.40, 4 337.12)* 心源性死亡 9(4.51) 15(10.34)* BMI: 体质量指数; cTnI: 肌钙蛋白; CKMB: 肌酸激酶同工酶; Myo: 肌红蛋白; NT-proBNP: 氨基末端脑钠肽前体;
LVEF: 左室射血分数。与无fQRS波组比较, *P < 0.05。
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表 3 不同GRACE风险评分患者主要基线水平、住院治疗情况及死亡事件比较(x±s)[n(%)][M(P25, P75)]
指标 低危组(n=112) 中危组(n=126) 高危组(n=106) 男 91(81.25) 91(72.22) 64(60.38) 年龄/岁 55.00(48.25, 63.75) 66.00(62.00, 72.00)** 76.51(71.00, 81.13)**# 体质量/kg 75.00(66.00, 80.00) 70.00(62.00, 73.25)** 63.50(55.00, 70.00)**# BMI/(kg/m2) 25.95(23.89, 27.44) 24.22(22.49, 26.05)** 23.31(21.25, 24.96)**# 吸烟史 70(62.50) 71(56.35)** 44(41.5)**# 高血压病史 70(62.50) 93(73.81) 74(69.81) 糖尿病病史 34(30.36) 42(33.33) 42(39.61) 心肌梗死病史 9(8.00) 18(14.29) 14(13.21) 高脂血症病史 19(15.57) 12(9.52) 10(9.43) 心率/(次/min) 76.50(67.02, 83.75) 76.50(68.14, 84.40) 83.50(72.00, 96.00)**# 收缩压/mmHg 148.16±20.04 136.89±20.98** 129.89±22.43** 心功能Killip分级 Ⅰ级 108(96.43) 116(92.06) 47(44.34)**# Ⅱ级 4(3.57) 9(7.14) 46(43.49)**# Ⅲ级 0 1(0.80) 7(6.60)**# Ⅳ级 0 0 6(5.66)**# 院前心跳骤停 0 0 2(1.89) 三支病变 28(25.00) 42(33.33) 39(36.79) 入院后PCI术 90(80.36) 103(81.75) 67(63.21) 双联抗血小板治疗 112(100.00) 126(100.00) 106(100.00) 他汀类药物 112(100.00) 126(100.00) 106(100.00) 肌酐/(μmol/L) 70.85(60.15, 85.75) 80.65(63.85, 94.00) 83.00(66.00, 111.25)** cTnI/(ng/mL) 2.70(1.12, 8.54) 3.43(0.96, 9.74) 4.86(1.83, 14.23)** CKMB/(ng/mL) 19.07(6.12, 41.13) 16.68(5.89, 39.85) 16.95(16.24, 75.37) Myo/(ng/mL) 112.00(50.38, 368.70) 126.00(55.93, 376.21) 137.00(53.33, 369.39) LVEF/% 56.00(52.50, 60.00) 55.00(52.00, 58.00) 53.00(45.00, 55.00)**# NT-proBNP/(pg/mL) 714.00(326.00, 2 173.50) 1 041.00(541.06, 2 757.67) 3 163.52(1 150.09, 5 531.43)**# 心源性死亡 2(1.78) 5(3.97) 17(16.04)**# BMI: 体质量指数; cTnI: 肌钙蛋白; CKMB: 肌酸激酶同工酶; Myo: 肌红蛋白; NT-proBNP: 氨基末端脑钠肽前体;
LVEF: 左室射血分数。与低危组比较, **P < 0.01; 与中危组比较, #P < 0.05。
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表 4 入院时fQRS波、GRACE评分以及两者联合预测NSTEMI患者短期心源性死亡事件
项目 AUC P 95%CI 敏感度/% 特异度/% fQRS波 0.609 0.037 0.556~0.661 62.50 59.38 GRACE评分 0.735 < 0.001 0.685~0.781 70.83 72.19 fQRS波联合GRACE评分 0.748 < 0.001 0.698~0.793 83.33 54.69
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