急性非ST段抬高型心肌梗死患者预后危险因素的分析及预测列线图的建立与验证

吕晓; 黄继良; 晋芹; 但汉良; 高鹏; 白玉豪; 苑智慧; 李树仁; 郝萧

doi:10.13201/j.issn.1001-1439.2022.12.008

急性非ST段抬高型心肌梗死患者预后危险因素的分析及预测列线图的建立与验证

- 1.
  武汉市东西湖区人民医院心内科(武汉，430040)
- 2.
  华北理工大学研究生院
- 3.
  河北医科大学研究生学院
- 4.
  河北省人民医院心内一科

详细信息

通讯作者: 李树仁，E-mail：lsr64@126.com

中图分类号: R542.2

收稿日期: 2022-06-23

刊出日期: 2022-12-13

Analysis of risk factors for the prognosis of patients with non-ST-segment elevation myocardial infarction and construction and validation of a nomogram

- 1.
  Department of Cardiology, People's Hospital of Dongxihu District, Wuhan, 430040, China
- 2.
  Graduate School, North China University of Science and Technology
- 3.
  Graduate College, Hebei Medical University
- 4.
  Department of Cardiology, Hebei General Hospital

More Information

Corresponding author: LI Shuren, E-mail: lsr64@126.com

Received Date: 23 June 2022

Publish Date: 13 December 2022

摘要

摘要: 目的构建单中心急性非ST段抬高型心肌梗死(NSTEMI)患者预后评估模型。方法收集2017年1月—2019年9月入院诊断为NSTEMI的患者497例为研究对象。随访(26.86±11.89)个月，终点为主要不良心血管事件(MACE)。分析NSTEMI患者院外MACE发生的危险因素，构建预测评分系统。结果将研究人群分为训练集和外部验证集。以终点事件为因变量对训练集人群进行分析，显示性别、年龄、吸烟、Killip>2级、GRACE评分、GRACE评分高危及极高危、袢利尿剂、射血分数、白蛋白、尿酸、磷、血红蛋白、院内介入均为相关影响因素。通过单因素、多因素Cox分析等多种统计学方法得到NSTEMI患者1年、2年无MACE事件发生的9个影响因素，建立相应的列线图(C-index=0.711)。与GRACE评分相比，本预测模型的AUC 1年(0.719 vs.0.736)、2年(0.702 vs.0.743)均较高，C-index同样优于GRACE评分(0.582 vs.0.711)。结论性别、年龄、院内介入、肌酐、射血分数、血钾、高密度脂蛋白、尿酸、Killip>2级是院外MACE事件的独立影响因素。基于上述9项影响因素，本研究建立的生存预测模型拥有较好的预测效能及一致性。列线图预测模型具有良好的区分度且较GRACE评分预测价值高，可为NSTEMI患者临床决策及预后预测提供个体化的有效预测工具。
- 急性非ST段抬高型心肌梗死 /
- 预后 /
- 预测列线图
Abstract: Objective To build a single-center prognosis-predicting model of acute non ST-segment elevation myocardial infarction(NSTEMI), Methods A total of 497 patients who were definitely diagnosed with NSTEMI in our hospital from January 2017 to September 2019 were enrolled. The follow-up was(26.86±11.89) months, and the endpoints were major adverse cardiovascular events(MACE). The risk factors of out-of-hospital MACE in NSTEMI patients were analyzed, and a predictive scoring system was built.Results All included patients were divided into the training set and the external validation set. Taking the end-point event as the dependent variable, the analysis of patients in the training set showed that sex, age, smoking, Killip>2, GRACE score, high-risk and extremely high-risk, loop diuretics, ejection fraction, albumin, uric acid, phosphorus, hemoglobin, and in-hospital intervention were all relevant influencing factors. Nine influencing factors of NSTEMI patients without MACE in 1 year and 2 years were screened by univariate and multivariate Cox analysis, and the nomogram was established(C-index=0.711). Compared with GRACE score, the AUC of the nomogram was higher in 1 year(0.719 vs. 0.736) and 2 years(0.702 vs. 0.743), and the C-index was also better than GRACEscore(0.582 vs. 0.711).Conclusion Sex, age, in-hospital interventioni, creatinine, ejection fraction, serum potassium, high density lipoprotein, uric acid, and Killip>2 were independent influencing factors for out-of-hospital MACE. The survival prediction model based on the above nine factors has good prediction efficiency and consistency. The nomogram prediction model has good differentiation and higher prediction value than GRACE score, which can provide an individualized and effective prediction tool for clinical decision-making and prognosis in NSTEMI patients.
- acute non-ST-segment elevation myocardial infarction /
- outcome /
- nomogram

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图 1 预测NSTEMI患者1年、2年无MACE发生生存率的列线图模型

Figure 1. The Nomogram for predicting 1-and 2-year MACE-free survival rate in NSTEMI patients

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表 1 训练集与外部验证集特征比较

Table 1. Characteristics of the training set and external validation set 例(%), X±S

项目	训练集(398例)	外部验证集(99例)	χ²/t值	P值	SMD值
性别			1.325	0.250	0.128
女	117(29.40)	35(35.35)
男	281(70.60)	64(64.65)
年龄			2.475	0.480	0.175
< 60岁	109(27.39)	30(30.30)
60~79岁	217(54.52)	46(46.46)
80~84岁	47(11.81)	16(16.16)
≥85岁	25(6.28)	7(7.07)
心肌梗死	81(20.35)	21(21.21)	0.036	0.850	0.021
PCI	30(7.54)	6(6.06)	0.257	0.612	0.059
糖尿病	147(36.93)	37(37.37)	0.007	0.935	0.009
慢性肾脏病	30(7.54)	10(10.1)	0.704	0.401	0.090
高脂血症	79(19.85)	21(21.21)	0.092	0.762	0.034
贫血	40(10.05)	12(12.12)	0.363	0.547	0.066
脑血管病	119(29.90)	31(31.31)	0.075	0.784	0.031
吸烟	179(44.97)	40(40.40)	0.672	0.412	0.093
饮酒	108(27.14)	24(24.24)	0.340	0.560	0.066
高血压≥2级	255(64.07)	71(71.72)	2.054	0.152	0.164
心率				0.099	0.343
< 50次/min	2(0.50)	1(1.01)
50~69次/min	127(31.91)	26(26.26)
70~89次/min	175(43.97)	42(42.42)
90~109次/min	60(15.08)	26(26.26)
110~149次/min	31(7.79)	4(4.04)
150~199次/min	3(0.75)	0(0)
收缩压			0.560	0.756	0.085
< 120 mmHg	87(21.86)	20(20.20)
120~139 mmHg	254(63.82)	67(67.68)
≥140 mmHg	57(14.32)	12(12.12)
休克指数	0.61±0.22	0.61±0.16	0.139	0.890	0.017
Killip>2级	25(6.28)	9(9.09)	0.982	0.322	0.106
GRACE评分	137.77±39.53	141.22±40.28	0.774	0.439	0.095
GRACE分级			0.905	0.636	0.107
< 109分	74(18.59)	18(18.18)
109~140分	159(39.95)	35(35.35)
>140分	165(41.46)	46(46.46)
GRACE评分高危及极高危	167(41.96)	49(49.49)	1.832	0.176	0.152
袢利尿剂	135(33.92)	34(34.34)	0.006	0.937	0.009
噻嗪类	33(8.29)	10(10.10)	0.328	0.567	0.063
LVEF/%	55.42±10.35	53.87±10.54	-1.327	0.185	0.148
ALB				0.628	0.197
≥35.0 g/L	294(73.87)	78(78.79)
30.0~34.9 g/L	78(19.60)	14(14.14)
25.0~29.9 g/L	23(5.78)	7(7.07)
< 25.0 g/L	3(0.75)	0(0)
UA/(μmol·L^-1)	361.89±109.80	366.10±141.99	0.321	0.749	0.033
Cr			2.777	0.427	0.188
0.40~0.79 mg/dL	82(20.60)	23(23.23)
0.80~1.19 mg/dL	231(58.04)	55(55.56)
1.20~1.59 mg/dL	49(12.31)	16(16.16)
≥1.60 mg/dL	36(9.05)	5(5.05)
血钾/(mmol·L^-1)	4.01±0.48	3.99±0.40	-0.253	0.801	0.030
血磷/(mmol·L^-1)	1.19±0.29	1.18±0.27	-0.302	0.763	0.034
FPG/(mmol·L^-1)	6.83±3.00	6.90±3.05	0.201	0.841	0.022
TC/(mmol·L^-1)	4.33±1.27	4.18±1.09	-1.019	0.309	0.119
HDL-C/(mmol·L^-1)	1.01±0.28	0.99±0.24	-0.466	0.641	0.055
Hb			0.932	0.628	0.115
≥120 g/L	281(70.60)	69(69.70)
90~119 g/L	102(25.63)	28(28.28)
< 90 g/L	15(3.77)	2(2.02)
WBC/(×10⁹·L^-1)	8.37±3.24	9.24±3.77	2.297	0.022	0.246
PLT/(×10⁹·L^-1)	219.6±60.16	229.93±63.39	1.512	0.131	0.167
NLR	5.22±5.36	5.50±5.80	0.447	0.655	0.049
院内介入	229(57.54)	62(62.63)	0.846	0.35	0.104
院内HF	68(17.09)	14(14.14)	0.499	0.480	0.081
院外MACE	70(17.59)	17(17.17)	0.010	0.922	0.053
随访时间/月	26.60±12.05	25.96±11.86	0.476	0.634	0.053

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表 2 训练集中无MACE与MACE组患者基线资料比较

Table 2. Baseline characteristics of non-MACE group and MACE group in the training set 例(%), X±S

项目	无MACE组(328例)	MACE组(70例)	χ²/t值	P值	SMD值
性别			4.601	0.032	0.275
女	89(27.13)	28(40.00)
男	239(72.87)	42(60.00)
年龄			13.439	0.004	0.439
< 60岁	96(29.27)	13(18.57)
60~79岁	182(55.49)	35(50.00)
80~84岁	35(10.67)	12(17.14)
≥85岁	15(4.57)	10(14.29)
心肌梗死	65(19.82)	16(22.86)	0.329	0.566	0.074
PCI	26(7.93)	4(5.71)	0.405	0.524	0.088
糖尿病	118(35.98)	29(41.43)	0.736	0.391	0.112
慢性肾脏病	25(7.62)	5(7.14)	0.019	0.890	0.018
高脂血症	66(20.12)	13(18.57)	0.087	0.768	0.039
贫血	31(9.45)	9(12.86)	0.740	0.390	0.108
脑血管病	92(28.05)	27(38.57)	3.048	0.081	0.225
吸烟	155(47.26)	24(34.29)	3.922	0.048	0.266
饮酒	93(28.35)	15(21.43)	1.399	0.237	0.161
高血压≥2级	203(61.89)	52(74.29)	3.850	0.050	0.268
心率				0.858	0.188
< 50次/min	2(0.61)	0(0)
50~69次/min	106(32.32)	21(30.00)
70~89次/min	146(44.51)	29(41.43)
90~109次/min	48(14.63)	12(17.14)
110~149次/min	24(7.32)	7(10.00)
150~199次/min	2(0.61)	1(1.43)
收缩压			1.451	0.484	0.155
< 120 mmHg	68(20.73)	19(27.14)
120~139 mmHg	213(64.94)	41(58.57)
≥140 mmHg	47(14.33)	10(14.29)
休克指数	0.60±0.20	0.64±0.30	-0.977	0.331	0.144
Killip>2级	14(4.27)	11(15.71)	12.838	< 0.001	0.389
GRACE评分	135.64±38.40	147.76±43.32	-2.341	0.020	0.288
GRACE分级			4.142	0.126	0.272
< 109分	61(18.60)	13(18.57)
109~140分	138(42.07)	21(30.00)
>140分	129(39.33)	36(51.43)
GRACE评分高危及极高危	128(39.02)	39(55.71)	6.598	0.010	0.339
袢利尿剂	104(31.71)	31(44.29)	4.072	0.044	0.261
噻嗪类	25(7.62)	8(11.43)	1.099	0.294	0.130
LVEF/%	56.11±10.21	52.19±10.49	2.904	0.004	0.379
ALB				0.004	0.384
≥35.0 g/L	248(75.61)	46(65.71)
30.0~34.9 g/L	65(19.82)	13(18.57)
25.0~29.9 g/L	14(4.27)	9(12.86)
< 25.0 g/L	1(0.30)	2(2.86)
UA/(μmol·L^-1)	354.93±99.80	394.50±144.40	-2.184	0.032	0.319
Cr			2.010	0.570	0.178
0.40~0.79 mg/dL	69(21.04)	13(18.57)
0.80~1.19 mg/dL	193(58.84)	38(54.29)
1.20~1.59 mg/dL	39(11.89)	10(14.29)
≥1.60 mg/dL	27(8.23)	9(12.86)
血钾/(mmol·L^-1)	3.99±0.47	4.10±0.52	-1.789	0.074	0.227
血磷/(mmol·L^-1)	1.18±0.27	1.27±0.34	-2.396	0.017	0.292
FPG/(mmol·L^-1)	6.80±3.04	7.00±2.84	-0.511	0.610	0.069
TC/(mmol·L^-1)	4.37±1.30	4.12±1.11	1.490	0.137	0.206
HDL-C/(mmol·L^-1)	1.02±0.28	0.97±0.25	1.312	0.190	0.180
Hb			9.862	0.007	0.379
≥120 g/L	241(73.48)	40(57.14)
90~119 g/L	78(23.78)	24(34.29)
< 90 g/L	9(2.74)	6(8.57)
WBC/(×10⁹·L^-1)	8.26±3.10	8.88±3.81	-1.261	0.210	0.177
PLT/(×10⁹·L^-1)	218.88±57.41	222.97±72.06	-0.446	0.657	0.063
NLR	5.01±5.07	6.22±6.51	-1.713	0.088	0.207
院内介入	201(61.28)	28(40.00)	10.693	0.001	0.436
院内HF	51(15.55)	17(24.29)	3.108	0.078	0.220

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表 3 训练集单因素和多因素Cox回归

Table 3. Univariate and multivariate Cox regression analysis of training set

因素	单因素分析		多因素AIC准则
因素	HR(95%CI)	P值	HR(95%CI)	P值
性别	0.580(0.359~0.936)	0.026	0.553(0.327~0.935)	0.027
年龄	1.618(1.246~2.101)	< 0.001	1.293(0.952~1.758)	0.100
Killip>2级	3.520(1.848~6.704)	< 0.001	2.277(1.111~4.665)	0.025
LVEF	0.970(0.951~0.990)	0.003	0.978(0.956~1.001)	0.056
UA	1.003(1.001~1.005)	0.003	1.002(1.000~1.004)	0.055
Cr	1.200(0.985~1.415)	0.063	1.344(0.951~1.899)	0.093
血钾	1.515(0.971~2.364)	0.067	1.600(1.002~2.557)	0.049
HDL-C	0.516(0.168~0.864)	0.047	0.293(0.111~0.774)	0.013
院内介入	0.462(0.287~0.746)	0.002	0.612(0.351~1.067)	0.083

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表 4 预测模型及GRACE评分的初步评价

Table 4. Preliminary evaluation of Nomogram and GRACE score

时间	项目	指标	训练集	外部验证集
1年	本次预测模型	AUC	0.736	0.744
		灵敏度	0.743	0.754
		特异度	0.659	0.669
	GRACE评分	AUC	0.719	0.732
		灵敏度	0.714	0.715
		特异度	0.658	0.695
2年	本次预测模型	AUC	0.743	0.733
		灵敏度	0.737	0.730
		特异度	0.651	0.675
	GRACE评分	AUC	0.702	0.701
		灵敏度	0.679	0.675
		特异度	0.702	0.685

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