【摘要】 目的 观察重症急性心肌梗死(AMI)患者的血糖控制目标,以及糖尿病对血糖控制目标的影响。方法 以大型、单中心、开放获取的美国重症监护医学信息数据库-Ⅲ(MIMIC-Ⅲ)作为数据来源,选择首次入住重症监护病房(ICU)的成年AMI患者作为研究对象,采用PostgreSQL 11提取感兴趣数据,计算时间加权平均静脉血糖(TWAG),并以7.8 mmol/L为界值将AMI患者分为≥7.8 mmol/L组和<7.8 mmol/L组。以院内死亡、30 d病死率作为主要研究终点。同时进行倾向性评分匹配(PSM)、逆处理概率加权法(IPTW)分析,采用Logistic回归模型分析TWAG与短期预后的关系,并进行亚组分析、交互作用分析。结果 最终队列纳入1 527例患者,其中TWAG<7.8 mmol/L组997例,TWAG≥7.8 mmol/L组530例,PSM后每组纳入419例。PSM前后进行多因素回归分析,TWAG≥7.8 mmol/L组患者院内病死率、30d病死率均显著高于TWAG<7.8 mmol/L组(均P<0.05);IPTW分析中,TWAG≥7.8 mmol/L组患者院内死亡风险[优势比(OR)=2.77,95%可信区间(95%CI)为2.09～3.68]、30 d死亡风险(OR=2.90,95%CI为2.21～3.82)仍显著高于TWAG<7.8 mmol/L组(均P<0.05)。未合并糖尿病的患者,TWAG≥7.8 mmol/L组院内死亡风险升高260%(OR=3.60,95%CI为2.11～6.13),30 d死亡风险升高240%(OR=3.40,95%CI为2.05～5.63);Elixhauser合并症评分≥3分的患者,TWAG≥7.8 mmol/L组院内死亡风险升高204%(OR=3.04,95%CI为1.79～5.19)、30d死亡风险升高222%(OR=3.22,95%CI为1.94～5.36)。而两组糖尿病、Elixhauser合并症评分<3分的患者死亡风险差异无统计学意义(P>0.05)。结论TWAG反映了ICU患者血糖控制的平均状态。TWAG<7.8 mmol/L可使重症AMI患者整体人群、非糖尿病人群的短期预后获益。重症AMI患者的Elixhauser合并症评分升高,更容易从血糖控制中获益。更多还原

【Abstract】 Objective To survey the target of glucose control for critically ill patients with acute myocardial infarction(AMI),and the impact of incorporated diabetes on target of glucose control.Methods The data source obtained was from the large-scale,single-center and open-accessed database for monitoring severe disease,American Medical Information Mart for Intensive Care-Ⅲ(MIMIC-Ⅲ).Adult patients with AMI and admitted into the intensive care unit(ICU) for the first time were selected as the study subjects.PostgreSQL 11 software was used to extract the interested data,venous blood time-weighted average glucose(TWAG) was calculated,7.8 mmol/L blood glucose level was recognized as the dividing value and the patients were divided into a≥7.8 mmol/L group and a <7.8 mmol/L group based on the level of TWAG.The main research end points were in-hospital death and 30-day mortality.In the mean time,propensity score matching(PSM) and inverse probability of treatment weighted(IPTW) analysis were carried out,the Logistic regression model analysis was used to analyze the relationship between the TWAG level and shortterm outcomes,and subgroup and interaction analyses were also performed.Results A total of 1 527 patients were enrolled in the final cohort,there were 997 cases in TWAG <7.8 mmol/L group and 530 cases in TWAG≥7.8 mmol/L group.After propensity score matching,419 cases were enrolled into each group.The multivariate regression analyses were carried out before and after matching,the patients in TWAG≥7.8 mmol/L group showed significantly increased risk of in-hospital death and 30-day mortality as compared to those with TWAG <7.8 mmol/L(all P <0.05).In IPTW analysis,the risk of in-hospital death in patients of TWAG≥7.8 mmol/L group [odds ratio(OR)=2.77,95% confidence interval(95%CI)was 2.09-3.68] and 30-day mortality risk(OR=2.90,95%CI was 2.21-3.82) were still significantly higher than the above risks in patients of TWAG <7.8 mmol/L group(both P <0.05).For those without diabetes,the risks of in-hospital death and 30-day mortality increased by 260%(OR=3.60,95%CI was 2.11-6.13) and by 240%(OR=3.40,95%CI was 2.05-5.63),respectively,in patients with TWAG≥7.8 mmol/L as compared to those in TWAG <7.8 mmol/L group.Similarly,for those patients with Elixhauser complicated disease score≥3,the risk in-hospital mortality was increased by 204%(OR= 3.04,95%CI was 1.79-5.19) and the risk in 30-day mortality was increased by222%(OR= 3.22,95%CI was 1.94-5.36) in patients of TWAG≥7.8 mmol/L group.However,for two groups of patients with diabetes,Elixhauser complicated disease score <3,there was no statistical significant difference in death risk between in hospital and that in 30-day(P> 0.05).Conclusions The TWAG level reflects the average blood glucose control situation during ICU management.TWAG <7.8 mmol/L can benefit the short outcomes of overall severe AMI patients and patients without diabetes.In the critically ill patients with AMI and complicated disease score increase,such as complicated with higher Elixhauser score were more likely to be benefited from blood glucose control.更多还原