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中华心脏与心律电子杂志 ›› 2022, Vol. 10 ›› Issue (04) : 238 -245. doi: 10.3877/cma.j.issn.2095-6568.2022.04.009

所属专题: 总编推荐

心房颤动

肌酐清除率与中国急诊非瓣膜性心房颤动患者的预后研究
张涛1, 王娟1, 杨艳敏1,(), 朱俊1, 张晗1, 邵兴慧1   
  1. 1. 100037 北京,中国医学科学院 北京协和医学院 国家心血管病中心 心血管疾病国家重点实验室 阜外医院心内科急重症中心
  • 收稿日期:2022-06-16 出版日期:2022-12-25
  • 通信作者: 杨艳敏
  • 基金资助:
    首都临床诊疗技术研究及示范应用(Z191100006619121); 阜外医院院所青年基金(2022FWQN18)

Creatinine clearance and prognosis of Chinese emergency patients with non-valvular atrial fibrillation

Tao Zhang1, Juan Wang1, Yanmin Yang1,(), Jun Zhu1, Han Zhang1, Xinghui Shao1   

  1. 1. Emergency and Intensive Care Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, China
  • Received:2022-06-16 Published:2022-12-25
  • Corresponding author: Yanmin Yang
引用本文:

张涛, 王娟, 杨艳敏, 朱俊, 张晗, 邵兴慧. 肌酐清除率与中国急诊非瓣膜性心房颤动患者的预后研究[J/OL]. 中华心脏与心律电子杂志, 2022, 10(04): 238-245.

Tao Zhang, Juan Wang, Yanmin Yang, Jun Zhu, Han Zhang, Xinghui Shao. Creatinine clearance and prognosis of Chinese emergency patients with non-valvular atrial fibrillation[J/OL]. Chinese Journal of Heart and Heart Rhythm(Electronic Edition), 2022, 10(04): 238-245.

目的

探讨肌酐清除率(CrCl)与中国急诊非瓣膜性心房颤动(房颤)患者预后的影响。

方法

前瞻性纳入2008年11月至2011年10月在中国20家医院急诊就诊的房颤患者,并随访1年。根据CrCl水平,将患者分为4组:CrCl≥80 ml/min组、50 ml/min≤CrCl<80 ml/min组、30 ml/min≤CrCl<50 ml/min组和CrCl<30 ml/min组。主要临床终点事件为全因死亡、心血管死亡、血栓栓塞和大出血事件。应用Cox回归模型分析不同CrCl水平对主要临床终点事件的影响。

结果

共入选863例非瓣膜性房颤患者,年龄为(69.4±13.8)岁,其中女性占57.6%(495/863),基线CrCl为(52.9±24.5) ml/min。1年随访中,126(14.6%,126/863)例患者死亡,不同CrCl组间患者死亡率差异具有统计学意义(3.2%对6.5%对16.2%对40.2%,P<0.001)。心血管死亡和血栓栓塞发生率亦随着CrCl水平的降低而增加。在多因素Cox分析中,与CrCl≥80 ml/min组相比,CrCl<30 ml/min组患者的全因死亡(HR=5.567, 95%CI 1.618~19.876,P=0.007)和心血管死亡(HR=11.939, 95%CI 1.439~99.031, P=0.022)风险最高。但对于血栓栓塞和大出血风险,经多因素校正后,不同CrCl组间差异无统计学意义。

结论

在中国急诊非瓣膜性房颤患者中,全因死亡随着CrCl的降低而增加。CrCl<30 ml/min是全因死亡和心血管死亡的独立危险因素。

Objective

To investigate the effect of creatinine clearance (CrCl) on the prognosis of Chinese emergency department (ED) non-valvular atrial fibrillation (AF) patients.

Methods

This study prospectively enrolled patients with AF who presented to the ED of 20 hospitals in China from November 2008 to October 2011, and were followed up for 1 year. According to the level of CrCl, the patients were divided into 4 groups: CrCl≥80 ml/min, 50 ml/min≤CrCl<80 ml/min, 30 ml/min≤CrCl<50 ml/min and CrCl<30 ml/min. The primary clinical endpoints were all-cause death, cardiovascular death, thromboembolism, and major bleeding. Univariate and multivariate Cox regression models were used to analyze the effects of different CrCl groups on the above events.

Results

In this study, 863 patients with non-valvular AF were selected as the research subjects. The average age of the patients was (69.4±13.8) years, 57.6% (495/863) were female, and the mean baseline CrCl was (52.9±24.5) ml/min. During 1-year follow-up, 126 (14.6%) patients died.The difference of the all-cause death among the four groups was significant (3.2% vs.6.5% vs.16.2% vs.40.2%, P<0.001). Cardiovascular death and thromboembolic rates also increased with decreasing CrCl levels. In multivariate Cox analysis, all-cause death (HR=5.567; 95%CI 1.618-19.876, P=0.007) and cardiovascular death (HR=11.939; 95%CI 1.439-99.031, P=0.022) risk was highest in CrCl<30 ml/min category, compared with the group CrCl≥80 ml/min. However, for the risk of thromboembolism and major bleeding, after multivariate adjustment, no significant difference was found between the different CrCl groups.

Conclusion

Among Chinese ED non-valvular AF patients, all-cause mortality increased with a decrease in CrCl. CrCl<30 ml/min was an independent risk factor for all-cause mortality and cardiovascular mortality.

表1 不同肌酐清除率组间患者基线特征和药物应用情况
项目 CrCl≥80ml/min 50≤CrCl<80ml/min 30≤CrCl<50ml/min CrCl<30ml/min P
例数 95 339 297 132
年龄(岁,
x¯±s
49.8±14.5 55.5±11.2 75.5±9.8 77.1±10.9 <0.001
女性[例(%)] 47(49.5) 196(57.8) 171(57.6) 81(61.4) 0.346
体重(kg,
x¯±s
72.2±12.8 66.0±10.7 62.66±10.66 59.9±10.1 <0.001
收缩压(mmHg,
x¯±s
123.0±19.3 129.9±22.9 134.1±24.5 137.1±25.3 <0.001
舒张压(mmHg,
x¯±s
79.2±13.1 80.1±15.4 79.3±15.8 78.9±15.0 0.837
心率(次/min,
x¯±s
103.9±33.9 105.7±29.8 101.5±30.2 104.8±31.0 0.359
CHA2DS2-VASc评分(分,
x¯±s
1.7±1.7 3.2±1.9 4.5±1.8 4.6±1.9 <0.001
HAS-BLED评分(分,
x¯±s
0.9±0.8 1.6±1.0 2.0±0.9 2.4±0.9 <0.001
吸烟史[例(%)] 21(22.1) 62(18.3) 45(15.2) 22(16.7) 0.432
饮酒史[例(%)] 15(15.8) 22(6.5) 7(2.4) 9(6.8) <0.001
心房颤动类型[例(%)] <0.001

阵发性心房颤动

42 (44.2) 138 (40.7) 88 (29.6) 27 (20.5)

持续性心房颤动

23 (24.2) 68 (20.1) 57 (19.2) 36 (27.3)

永久性心房颤动

30 (31.6) 133 (39.2) 152 (51.2) 69 (52.3)
合并疾病[例(%)]

冠心病

23(24.2) 120(35.4) 162(54.5) 71(53.8) <0.001

陈旧心肌梗死

5(5.3) 28(8.3) 33(11.1) 15(11.4) 0.256

心力衰竭

20(21.1) 107(31.6) 94(31.6) 48 (36.4) 0.100

先天性心脏病

4(4.2) 9(2.7) 4(1.3) 3(2.3) 0.405

高血压

30(31.6) 184(54.3) 209(69.4) 93(70.5) <0.001

糖尿病

7(7.4) 54(15.9) 72(24.2) 26(19.7) 0.01

卒中或TIA史

11(11.6) 69(20.4) 90(30.3) 39(29.5) <0.001

大出血史

1(1.1) 111(3.2) 2(0.7) 5(3.8) 0.070

痴呆/认知障碍

1(1.1) 6(1.8) 0 8(6.1) <0.001

COPD

7(7.4) 34(10.0) 52(17.5) 21(15.9) 0.010

睡眠呼吸暂停

5(5.3) 11(3.2) 7(2.4) 3(2.3) 0.495

甲状腺功能亢进

5(5.3) 8(2.4) 10(3.4) 4(3.0) 0.542
药物[例(%)]

华法林

31(32.6) 71(20.9) 54 (18.2) 54 (18.2) 0.008

TTR≥70%

13(13.7) 37(10.9) 22(7.4) 7(5.3) 0.014

抗血小板药

52(54.7) 234(69.0) 195(65.7) 81(61.4) 0.054

β受体阻断滞剂

54(56.8) 189(55.8) 162(54.5) 69(52.3) 0.890

钙通道阻滞剂

14(14.7) 107(31.6) 117(39.4) 47(35.6) <0.001

地高辛

27(28.4) 100(29.5) 76(25.6) 38(28.8) 0.733

抗心律失常药

14(14.7) 61(18.0) 26(8.8) 11(8.3) 0.002

利尿剂

24(25.3) 1119(35.1) 114(38.4) 60 (45.5) 0.015

ACEI/ARB

28(29.5) 138(40.7) 129(43.3) 51(38.6) 0.111

他汀类

20(21.1) 110(32.4) 130(43.8) 40(30.3) <0.001
图1 不同肌酐清除率组患者1年随访的临床终点事件发生率的比较[1A为四组间全因死亡率的比较;1B为四组间心血管死亡率的比较;1C为四组间血栓栓塞发生率的比较;1D为四组间大出血发生率的比较]CrCl为肌酐清除率(单位为ml/min)
图2 不同肌酐清除率组患者1年随访主要终点事件的Kaplan-Meyer曲线[2A为四组间全因死亡的累积生存分析比较;2B为四组间心血管死亡的累积生存分析比较;2C为四组间血栓栓塞累积风险的比较;2D为四组间大出血累积风险的比较]Crcl为肌酐清除率(单位为ml/min)
表2 单因素Cox分析肌酐清除率对临床终点事件的影响
图3 多因素Cox回归模型分析临床终点事件的独立危险因素[3A为全因死亡的独立危险因素分析;3B为心血管死亡的独立危险因素分析;3C为血栓栓塞的独立危险因素分析;3D为大出血累积风险的独立危险因素分析]
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