Risk factors and predictive value of fragmented QRS in patients with acute ST-segment elevation myocardial infarction after emergency PCI
-
摘要: 目的 分析急性ST段抬高型心肌梗死(STEMI)患者行急诊经皮冠状动脉(冠脉)介入术(percutaneous coronary intervention，PCI)后48 h内出现碎裂QRS波(fQRS)的危险因素，并进一步探讨其对术后1年内发生主要不良心血管事件(MACE)的预测价值。 方法 回顾性分析徐州医科大学附属医院2018年9月—2021年3月行PCI治疗的STEMI患者225例，术后随访12个月。根据患者心电图检查结果是否存在fQRS波，分为fQRS组和非fQRS组，比较两组患者的一般资料、血液学指标、左心室射血分数(LVEF)、冠脉造影结果、Gensini评分、心脏磁共振示微循环阻塞(microvascular obstruction，MVO)及期间MACE的发生情况。 结果 与非fQRS组相比，fQRS组患者血小板计数、中性粒细胞计数、超敏C-反应蛋白、肌钙蛋白T、肌酸激酶同工酶峰值更高，MVO发生率更高，梗死相关动脉狭窄程度更严重，Gensini评分更高，1年内MACE发生率显著增加，术后LVEF更低，均差异有统计学意义(P < 0.05)。多因素logistic回归分析显示，血小板计数、中性粒细胞计数、cTnT峰值、梗死相关动脉(IRA)狭窄程度、MVO及LVEF是STEMI患者PCI术后出现fQRS的独立影响因素；年龄、Gensini评分、fQRS及MVO的发生是STEMI患者PCI术后发生MACE的独立危险因素。 结论 fQRS与STEMI患者的cTnT峰值、CK-MB水平、IRA狭窄程度以及Gensini评分密切相关，是PCI术后1年内发生MACE的独立预测因子。
-
关键词:
- 急性ST段抬高型心肌梗死 /
- 经皮冠状动脉介入治疗 /
- 碎裂QRS波 /
- 主要不良心血管事件
Abstract: Objective To analyze the risk factors of fragmented QRS complex(fQRS) in electrocardiogram within 48 hours in patients with STEMI after primary percutaneous coronary intervention(PCI), and to further explore its predictive value for adverse cardiovascular events within 1 year after PCI. Methods A retrospective cohort study was conducted, enrolling 225 patients diagnosed with ST-segment elevation myocardial infarction(STEMI) who underwent PCI at the Affiliated Hospital of Xuzhou Medical University between September 2018 and March 2021, and were followed up for 12 months. The patients were divided into fQRS group and non-fQRS group in the electrocardiogram examination within 48 hours after admission. General data, hematological indexes, left ventricular ejection fraction(LVEF), coronary angiography results, Gensini score, and microvascular obstruction(MVO) detected by cardiac magnetic resonance imaging and major adverse cardiovascular adverse events(MACE) were recorded and compared between the two groups. Results Compared with the non-fQRS group, the platelet count, neutrophil count, high-sensitivity C-reactive protein, troponin T, peak creatine kinase isoenzyme in fQRS group were significantly higher, the incidence of MVO was higher, the stenosis degree of Infarction related artery was more severe, Gensini score was higher, the incidence of MACE within one year was significantly increased, while the postoperative left ventricular ejection fraction was significantly lower, and the differences were statistically significant(P < 0.05). Multivariate logistic regression analysis showed that platelet count, neutrophil count, peak cTnT, degree of IRA stenosis, MVO and LVEF were independent risk factors for fQRS after PCI in STEMI patients. In addition, multivariate Logistic regression analysis of MACE showed that age, Gensini score, fQRS and MVO were independent risk factors for MACE after PCI in STEMI patients. Conclusion fQRS is closely related to peak cTnT, CK-MB level, IRA stenosis degree and Gensini score in patients with STEMI. and is an independent predictor of MACE within 1 year after PCI. -
-
表 1 两组临床资料比较
Table 1. Comparison of clinical data
例(%), X±S, M(P25, P75) 项目 非fQRS组(126例) fQRS组(99例) P 年龄/岁 54.06±13.14 56.12±11.78 0.366 男性 107(84.92) 89(89.90) 0.269 吸烟史 55(43.65) 47(47.47) 0.567 高血压史 60(47.62) 42(42.42) 0.437 糖尿病史 35(27.78) 18(18.18) 0.092 冠心病史 1(0.80) 0(0) 0.324 BMI/(kg/m2) 25.79±3.23 26.42±3.62 0.331 收缩压/mmHg 128.22±20.71 126.66±21.49 0.134 舒张压/mmHg 81.37±14.02 81.25±13.49 0.587 胸痛到球囊时间/h 5.5(3.0，9.35) 5.0(3.5，7.5) 0.567 门球时间/min 62.47±17.17 61.29±17.34 0.818 Killip分级 0.466 Ⅰ~Ⅱ级 124(98.41) 96(96.97) Ⅲ~Ⅳ级 2(1.59) 3(3.03) N/(×109/L) 7.46(6.30，9.51) 9.99(7.84，11.62) < 0.001 PLT/(×109/L) 206.00(165.00，230.00) 235.00(193.00，276.50) < 0.001 hs-CRP/(mg/L) 11.95(5.08，36.50) 18.50(7.20，47.95) 0.046 cTnT峰值/(ng/mL) 2.51(1.30，3.72) 5.04(3.45，8.32) < 0.001 CK-MB峰值/(ng/mL) 100.23(41.55，221.80) 221.00(86.03，300.00) 0.001 LDL-C/(mmol/L) 2.57(2.06，3.19) 2.90(2.31，3.26) 0.063 血清肌酐/(μmol/L) 70.00(62.25，77.00) 70.00(63.00，78.00) 0.705 LVEF/% 57.7±8.6 49.4±6.7 < 0.001 MVO 47(37.30) 72(72.72) < 0.001 
下载: 导出CSV
表 2 两组冠脉病变及Gensini评分比较
Table 2. Comparison of coronary artery lesions and gensini score
例(%), M(P25, P75) 项目 非fQRS组(126例) fQRS组(99例) P 罪犯血管 0.039 LAD 55(43.65) 60(60.60) LCX 22(17.46) 11(11.11) RCA 49(38.89) 28(28.28) 血管病变数目 0.008 单支病变 44(34.92) 35(35.35) 双支病变 52(41.27) 24(24.24) 3支病变 30(23.81) 40(40.40) 狭窄程度/% 95.00(90.00，100.00) 99.50(90.00，100.00) 0.003 支架直径/mm 3.00(2.75，3.50) 3.00(2.50，3.50) 0.084 支架总长度/mm 29.00(21.00，35.25) 28.00(20.00，33.00) 0.396 植入支架/个 0.824 1 107(84.92) 83(83.84) 2 19(15.08) 16(16.16) Gensini评分 34(24，43) 47(34，57) < 0.001 血栓抽吸 14(11.11) 15(15.15) 0.627 LAD：左前降支；LCX：左回旋支；RCA：右冠脉。
下载: 导出CSV
表 3 fQRS波出现的单因素及多因素logistic分析
Table 3. Univariate and multivariate analyses of fQRS
因素 单因素分析 多因素分析 OR 95%CI P OR 95%CI P IRA RCA 1 LAD 1.909 1.057~3.448 0.032 0.641 0.258~1.595 0.339 LCX 0.875 0.370~2.068 0.761 单支病变 1 双支病变 0.580 0.301~1.119 0.104 3支病变 1.676 0.876 3.207 0.119 狭窄程度 1.058 1.022~1.095 0.001 1.058 1.022~1.095 0.020 Gensini评分 1.060 1.039~1.082 < 0.001 1.065 1.010~1.123 0.032 N 1.272 1.150~1.408 < 0.001 1.239 1.073~1.431 0.004 PLT 1.010 1.006~1.015 < 0.001 1.014 1.007~1.022 < 0.001 hs-CRP 1.003 0.998~1.009 0.268 cTnT峰值 1.572 1.376~1.796 < 0.001 1.263 1.050~1.519 0.013 CK-MB峰值 1.004 1.001~1.006 0.002 0.997 0.993~1.001 0.114 LVEF 0.873 0.837~0.911 < 0.001 0.896 0.850~0.944 < 0.001 MVO 4.482 2.532~7.933 < 0.001 3.631 1.486~8.872 0.005
下载: 导出CSV
表 4 两组住院期间发生MACE情况
Table 4. Comparison of MACE during Hospitalization
例(%) MACE 非fQRS组
(126例)fQRS组
(99例)P 心源性死亡 2(1.59) 3(3.03) 0.074 再次冠脉血运重建 3(2.38) 9(9.09) 0.026 顽固性心绞痛 7(5.56) 13(13.13) 0.047 心梗后心衰 2(1.59) 7(7.07) 0.028
下载: 导出CSV
表 5 MACE(-)亚组及MACE(+)亚组一般临床资料比较
Table 5. Comparison of general clinical data between the MACE(-) subgroup and the MACE(+) subgroup
例(%), X±S, M(P25, P75) 参数 MACE(-)亚组(179例) MACE(+)亚组(46例) P 年龄/岁 55.0(45.0，64.0) 62.0(53.0，67.0) 0.005 男性 127(70.95) 31(67.39) 0.638 吸烟史 80(44.69) 22(47.83) 0.703 高血压史 80(44.69) 23(50.00) 0.519 糖尿病史 41(22.91) 16(34.78) 0.099 BMI/(kg/m2) 25.9±3.3 26.1±2.7 0.647 心率/(次/min) 87.0(69.5，106.3) 80.0(69.5，99.3) 0.374 收缩压/mmHg 128.0±21.7 125.8±18.4 0.533 舒张压/mmHg 81.7±14.3 79.8±11.5 0.412 胸痛到球囊时间/h 5.00(3.00，8.8.63) 5.50(3.50，9.00) 0.481 门球时间/min 62.0±17.0 61.9±18.1 0.994 罪犯血管 0.508 LAD 88(49.16) 27(58.70) LCX 27(15.08) 6(13.04) RCA 64(35.75%) 13(28.26) 血管病变数目 0.369 单支血管 66(36.87) 13(28.26) 双支血管 61(34.08) 15(32.61) 3支血管 52(29.05) 18(39.13) 狭窄程度/% 99.00(90.00，100.00) 99.00(90.00，100.00) 0.084 支架直径/mm 3.00(2.75，3.50) 3.00(2.50，3.50) 0.273 支架总长度/mm 29.00(20.75，33.00) 29.00(21.00，38.00) 0.446 植入支架/个 0.080 1 155(86.59) 35(76.09) 2 24(13.41) 11(23.91) Gensini评分 34(24，42) 48(34，57) < 0.001 血栓抽吸 22(12.29) 7(15.22) 0.853 N/(×109/L) 8.41(6.70，10.52) 8.69(6.86，10.86) 0.738 PLT/(×109/L) 217.00(172.75，257.00) 218.00(177.00，250.00) 0.971 hs-CRP/(mg/L) 13.95(5.90，39.88) 18.30(6.50，38.30) 0.403 cTnT峰值/(ng/mL) 3.19(1.43，4.97) 4.55(3.16，6.90) 0.001 CK-MB峰值/(ng/mL) 138.05(42.48，285.60) 170.00(53.01，300.00) 0.253 LDL-C/(mmol/L) 2.73(2.19，3.22) 2.87(2.15，3.26) 0.904 血清肌酐/(μmol/L) 70.00(63.00，78.00) 70.00(59.00，75.00) 0.507 LVEF/% 55.1±8.8 50.0±7.5 < 0.001 MVO 83(46.37) 36(78.26) < 0.001 fQRS 65(36.31) 34(73.91) < 0.001
下载: 导出CSV
表 6 MACE的logistic分析
Table 6. Univariate and multivariate analyses of MACE
因素 单因素分析 多因素分析 OR 95%CI P OR 95%CI P 年龄 1.041 1.011~1.071 0.008 1.037 1.004~1.071 0.026 Gensini 1.033 1.016~1.050 < 0.001 1.028 1.005~1.053 0.018 cTnT 1.134 1.022~1.258 0.018 0.848 0.711~1.013 0.069 LVEF 0.932 0.896~0.971 0.001 0.978 0.930~1.028 0.376 MVO 4.164 1.948~8.901 < 0.001 3.204 1.303~7.883 0.011 fQRS 4.969 2.406~10.262 < 0.001 3.317 1.362~8.007 0.008
下载: 导出CSV
-
[1] Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes[J]. Eur Heart J, 2023, 44(38): 3720-3826. doi: 10.1093/eurheartj/ehad191
[2] Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation[J]. Eur Heart J, 2021, 42(14): 1289-1367. doi: 10.1093/eurheartj/ehaa575
[3] Xie F, Qian LJ, Goldsweig A, et al. Event-free survival following successful percutaneous intervention in acute myocardial infarction depends on microvascular perfusion[J]. Circ Cardiovasc Imaging, 2020, 13(6): e010091. doi: 10.1161/CIRCIMAGING.119.010091
[4] Shanmuganathan M, Masi A, Burrage MK, et al. Acute response in the noninfarcted myocardium predicts long-term major adverse cardiac events after STEMI[J]. JACC Cardiovasc Imaging, 2023, 16(1): 46-59. doi: 10.1016/j.jcmg.2022.09.015
[5] Luo GM, Li Q, Duan JW, et al. The predictive value of fragmented QRS for cardiovascular events in acute myocardial infarction: a systematic review and meta-analysis[J]. Front Physiol, 2020, 11: 1027. doi: 10.3389/fphys.2020.01027
[6] Chan JSK, Zhou JD, Lee SR, et al. Fragmented QRS is independently predictive of long-term adverse clinical outcomes in Asian patients hospitalized for heart failure: a retrospective cohort study[J]. Front Cardiovasc Med, 2021, 8: 738417. doi: 10.3389/fcvm.2021.738417
[7] Zangiabadian M, Sharifian Ardestani M, Rezaee M, et al. Fragmented QRS, a strong predictor of mortality and major arrhythmic events in patients with nonischemic cardiomyopathy: a systematic review and meta-analysis[J]. Health Sci Rep, 2024, 7(2): e1888. doi: 10.1002/hsr2.1888
[8] Türkmen S, Bozkurt M, Hoşoǧlu Y, et al. Significance of fragmented QRS and predictors of outcome in ST-elevation myocardial infarction[J]. J Res Med Sci, 2024, 29: 23.
[9] 郑一歌, 李树仁. 短暂性ST段抬高型心肌梗死机制及最佳介入时机的研究进展[J]. 临床心血管病杂志, 2024, 40(9): 763-768. doi: 10.13201/j.issn.1001-1439.2024.09.014
[10] Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: executive summary: a report of the American college of cardiology/American heart association joint committee on clinical practice guidelines[J]. Circulation, 2022, 145(3): e4-e17. doi: 10.1161/CIR.0000000000001039
[11] 中华医学会心血管病学分会. 急性ST段抬高型心肌梗死诊断和治疗指南(2019)[J]. 中华心血管病杂志, 2019, 47(10): 766-783.
[12] Mair J, Jaffe A, Lindahl B, et al. The clinical approach to diagnosing peri-procedural myocardial infarction after percutaneous coronary interventions according to the fourth universal definition of myocardial infarction-from the study group on biomarkers of the European Society of Cardiology(ESC)Association for Acute CardioVascular Care(ACVC)[J]. Biomarkers, 2022, 27(5): 407-417. doi: 10.1080/1354750X.2022.2055792
[13] Das MK, Khan B, Jacob S, et al. Significance of a fragmented QRS complex versus a Q wave in patients with coronary artery disease[J]. Circulation, 2006, 113(21): 2495-2501. doi: 10.1161/CIRCULATIONAHA.105.595892
[14] Rampidis GP, Benetos G, Benz DC, et al. A guide for gensini score calculation[J]. Atherosclerosis, 2019, 287: 181-183. doi: 10.1016/j.atherosclerosis.2019.05.012
[15] Frantz S. Herzrhythmusstörungen[J]. Dtsch Med Wochenschr, 2020, 145(8): 509. doi: 10.1055/a-0952-9549
[16] Sung KT, Chang SH, Chi PC, et al. QRS fragmentation in preserved ejection fraction heart failure: functional insights, pathological correlates, and prognosis[J]. J Am Heart Assoc, 2023, 12(6): e028105. doi: 10.1161/JAHA.122.028105
[17] Weber C, Habenicht AJR, von Hundelshausen P. Novel mechanisms and therapeutic targets in atherosclerosis: inflammation and beyond[J]. Eur Heart J, 2023, 44(29): 2672-2681. doi: 10.1093/eurheartj/ehad304
[18] Ajoolabady A, Pratico D, Lin L, et al. Inflammation in atherosclerosis: pathophysiology and mechanisms[J]. Cell Death Dis, 2024, 15(11): 817. doi: 10.1038/s41419-024-07166-8
[19] 彭毅, 陈晓玲, 杨徐. 碎裂QRS波群对老年非ST段抬高性心肌梗死患者临床诊断及冠状动脉病变程度的预测价值[J]. 中国急救医学, 2018, 38(2): 133-137.
[20] Dehghani MR, Shariati A, Haghjou A, et al. Prognostic value of fragmented QRS complex in patients with acute myocardial infarction[J]. Herz, 2021, 46(3): 285-290. doi: 10.1007/s00059-020-04940-0
[21] Kurtul A, Duran M. Fragmented QRS complex predicts contrast-induced nephropathy and in-hospital mortality after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction[J]. Clin Cardiol, 2017, 40(4): 235-242. doi: 10.1002/clc.22651
[22] Bordbar A, Mahmoodi K, Anasori H, et al. Correlation of left ventricular ejection fraction drop and fragmented QRS with ST-segment elevation myocardial infarction[J]. ARYA Atheroscler, 2021, 17(5): 1-8.
-
计量
- 文章访问数: 35
- 施引文献: 0