血压变异性和中医证型与急性心肌梗死患者预后的相关性

【作者】 刘颖；

【导师】 陈改玲；

【作者基本信息】 北京中医药大学 ， 中西医结合临床（专业学位）， 2024， 硕士

【摘要】 背景:血压变异性(BPV)与心血管疾病的关系越来越受到关注,但关于BPV与急性心肌梗死(AMI)预后的关系研究结果不一致。目前评估BPV的指标尚未统一,使用比较多的BPV评估指标有标准差(SD)、变异系数(CV)和平均真实变异性(ARV)。AMI患者主要不良心血管事件(MACE)发生的风险依然较高,新近研究显示中西医结合治疗有可能进一步降低AMI患者MACE的发生。目的:本研究旨在探讨入院首个24小时BPV与AMI患者短期和长期全因死亡率之间的关系,以及中医证型及24小时BPV与AMI患者住院期间MACE的关系。方法:通过提取分析MIMIC-Ⅳ 2.0数据库中AMI患者数据进行回顾性队列研究。根据AMI患者进入重症监护室(ICU)的第一个24小时血压计算血压的ARV和CV。分别根据ARV四分位数分为4组和CV三分位数分为3组,以住院死亡率、30天死亡率、1年死亡率、3年死亡率为结局指标,采用Logistic回归分析和Cox 比例风险回归分析、Kaplan-Meier曲线和限制性立方样条曲线,对AMI患者24小时BPV与全因死亡率之间的关系进行统计分析。同时,提取中日友好医院冠心病监护病房住院的AMI患者的临床资料。采用ARV评估患者的BPV,根据患者入住冠心病监护病房第一天血压数据计算24小时ARV。根据患者住院期间是否发生MACE分为MACE组和N-MACE组,探讨两组患者之间24小时ARV、中医证型、实验室指标等有无差异。以MACE为结局指标,采用Logistic回归分析AMI患者24小时ARV与MACE之间的关系。结果:从MIMIC-Ⅳ 2.0筛选出1291名符合纳排标准的AMI患者。1.在调整混杂因素后,logistic或Cox多因素回归分析结果显示,24小时收缩压(SBP)ARV不能预测AMI患者的死亡率;24小时舒张压(DBP)ARV最高组与住院死亡率(OR:2.216,95%CI 1.102-4.456)、30 天死亡率(HR:2.291,95%CI 1.260-4.168)、1 年死亡率(HR:1.933,95%CI 1.316-2.840)、3 年死亡率(HR:1.743,95%CI 1.235-2.461)增加显著相关。KM生存曲线显示,无论是SBP还是DBP,ARV最高组患者的1年和3年生存概率显著低于其他分位组。限制性立方样条曲线结果示,当DBP-ARV<8.04时,AMI患者的死亡风险随着ARV的升高先减低再增加;当DBP-ARV>8.04时,AMI患者的30天死亡风险随着ARV的升高而先增加再减低,1年及3年死亡风险随着ARV的升高而升高,到达一定水平后趋于稳定。2.多因素分析结果显示,与CV最低的Q1组相比,24小时SBP-CV最高的Q3组与住院期间(OR:3.333,95%CI 1.725-6.439)、30 天(OR:1.868,95%CI 1.201-2.904)、1年(OR:1.420,95%CI 1.058-1.907)死亡率增加显著相关;24小时DBP-CV的Q2、Q3组均与住院期间[(OR:2.608,95%CI 1.289-5.276);(OR:2.671,95%CI 1.307-5.459)]、30 天[(OR:2.052,95%CI 1.241-3.393);(OR:2.352,95%CI 1.410-3.923)]、1 年[(OR:1.849,95%CI 1.329-2.571);(OR:1.850,95%CI 1.324-2.583)]、3 年[(OR:1.751,95%CI 1.299-2.360);(OR:1.817,95%CI 1.346-2.455)]死亡率增加显著相关。KM生存曲线显示,无论是SBP还是DBP,CV最高的Q3组患者的30天、1年和3年生存概率显著低于其他分位组。3.纳入冠心病监护病房AMI患者87例,结果显示AMI患者中医证型分布:气虚血瘀>气阴两虚>痰瘀互结>气滞血瘀>寒凝心脉。与痰瘀互结组、气滞血瘀组相比,气虚血瘀组、气阴两虚组的MACE发生率存在统计学差异(P<0.05)。logistic分析显示AMI患者24小时SBP-ARV和24小时DBP-ARV与住院期间MACE发生无显著相关性(P>0.05)。结论:AMI患者首个24小时DBP-ARV与短期、长期全因死亡风险增高显著相关,24小时DBP-ARV与AMI患者全因死亡之间呈非线性关系;24小时SBP-CV与短期、1年死亡率风险增高显著相关,24小时DBP-CV与短期、长期全因死亡风险增高显著相关。气虚血瘀证是AMI患者的主要证型,相比实证AMI患者,虚证AMI患者更易发生MACE。更多还原

【Abstract】 Background:The relationship between blood pressure variability(BPV)and cardiovascular disease is receiving increasing attention,but research results on the relationship between BPV and the prognosis of acute myocardial infarction(AMI)are inconsistent.The risk of major adverse cardiovascular events(MACE)in patients with AMI remains high,and recent studies have shown that integrated traditional Chinese and Western medicine treatment may further reduce the incidence of MACE in patients with AMI.Objectives:This study aimed to explore the relationship between BPV within the first 24 hours of admission and short-term and long-term all-cause mortality in patients with AMI,as well as the relationship between traditional Chinese medicine syndrome types and 24-hour BPV and MACE during hospitalization in patients with AMI.Methods:Retrospective cohort study was conducted by extracting and analyzing the data of patients with AMI from the MIMIC-Ⅳ 2.0 database.Calculated the average true variability(ARV)and coefficient of variation(CV)of blood pressure based on the first 24-hour blood pressure of patients with AMI entering the intensive care unit(ICU).Divided patients into 4 groups based on ARV quartiles and 3 groups based on CV tertiles,with in-hospital mortality,30-day mortality,1-year mortality,and 3-year mortality as outcome measures.Logistic regression analysis,Cox proportional hazards regression analysis,Kaplan Meier curve,and restricted cubic spline curve were used to statistically analyze the relationship between 24-hour BPV and all-cause mortality in patients with AMI.At the same time,clinical data of patients with AMI admitted to coronary heart disease intensive care unit of China-Japan Friendship Hospital were extracted.Used ARV to evaluate the patient’s BPV,and calculated the 24-hour ARV based on the patient’s blood pressure data on the first day of admission to the coronary heart disease intensive care unit.Divided patients into MACE group and N-MACE group based on whether they have experienced MACE during hospitalization,and explored whether there are differences in 24-hour ARV,traditional Chinese medicine syndrome types,laboratory indicators,etc.between the two groups of patients.Using MACE as the outcome measure,logistic regression was used to analyze the relationship between 24-hour ARV and MACE in patients with AMI.Results:1291 patients with AMI were screened from MIMIC-Ⅳ 2.0 according to the inclusion criteria.After adjusting for confounding factors,logistic or Cox multivariate regression analysis showed that 24-hour systolic blood pressure(SBP)ARV could not predict mortality in patients with AMI.The highest 24-hour diastolic blood pressure(DBP)ARV group was significantly associated with an increase in in-hospital mortality(OR:2.216,95%CI 1.102-4.456),30-day mortality(HR:2.291,95%CI 1.260-4.168),1-year mortality(HR:1.933,95%CI 1.316-2.840),and 3-year mortality(HR:1.743,95%CI 1.235-2.461).The KM survival curve showed that regardless of whether it is SBP or DBP,patients of the highest ARV group have significantly lower 1-year and 3-year survival probabilities than other groups.The results of the restricted cubic spline curve showed that when DBP-ARV<8.04,the risk of death in patients with AMI decreased first and then increased with the increase of ARV;When DBP-ARV>8.04,the 30-day mortality risk of patients with AMI increased first and then decreased with the increase of ARV.The 1-year and 3-year mortality risk increased with the increase of ARV and stabilized after reaching a certain level.2.The results of multivariate analysis showed that compared with the Q1 group with the lowest CV,the Q3 group with the highest 24-hour SBP-CV was significantly associated with an increase in in-hospital(OR:3.333,95%CI 1.725-6.439),30-day(OR:1.868,95%CI 1.201-2.904),and 1-year(OR:1.420,95%CI 1.058-1.907)mortality;The Q2 and Q3 groups of 24-hour DBP-CV were all significantly associated with an increase in in-hospital[(OR:2.608,95%CI 1.289-5.276);(OR:2.671,95%CI 1.307-5.459)],30-day[OR:2.052,95%CI 1.241-3.393);(OR:2.352,95%CI 1.410-3.923)],1-year[OR:1.849,95%CI 1.329-2.571);(OR:1.850,95%CI 1.324-2.583)],3-year[OR:1.751,95%CI 1.299-2.360);(OR:1.817,95%CI 1.346-2.455)mortality.The KM survival curve showed that regardless of whether it is SBP or DBP,the Q3 group with the highest CV has significantly lower 30-day,1-year,and 3-year survival probabilities compared to other groups.3.87 patients with AMI admitted to the coronary heart disease intensive care unit were enrolled,and the results showed that the distribution of traditional Chinese medicine syndromes in patients with AMI was as follows:Qi deficiency and blood stasis>Qi yin deficiency>Phlegm and blood stasis>Qi stagnation and blood stasis>Cold coagulation of the heart meridian.Compared with the Phlegm and blood stasis group and the Qi stagnation and blood stasis group,there was a statistical difference(P<0.05)in the incidence of MACE between the qi deficiency and blood stasis group and the qi yin deficiency group.Logistic analysis showed that there was no significant correlation between 24-hour SBP-ARV and 24-hour DBP-ARV in patients with AMI and the occurrence of MACE during hospitalization(P>0.05).Conclusion:The first 24-hour DBP-ARV in patients with AMI was significantly associated with an increased risk of short-term and long-term all-cause mortality,and there was a non-linear relationship between 24-hour DBP-ARV and all-cause mortality in patients with AMI.24-hour SBP-CV was significantly associated with an increased risk of short-term and one-year mortality,while 24-hour DBP-CV was significantly associated with an increased risk of short-term and long-term all-cause mortality.Qi deficiency and blood stasis syndrome is the main syndrome type of AMI patients,and compared to empirical patients with AMI,deficiency syndrome patients with AMI were more prone to MACE.更多还原