摘要
目的构建ST段抬高型急性心肌梗死(STEMI)经皮冠状动脉介入(PCI)治疗后并发恶性心律失常的列线图模型,并验证该模型的准确性。方法选取2020年1月至2023年1月在陕西中医药大学第二附属医院接受PCI治疗的STEMI病人620例,所有参与者均被跟踪观察了6个月。根据随访期间是否出现恶性心律失常事件,将受试者分为发生恶性心律失常组(72例)和未发生恶性心律失常组(548例)。采用logistic回归分析来确定导致STEMI病人在PCI手术后并发恶性心律失常的独立风险因素,并基于这些发现构建了一个列线图模型。使用Bootstrap方法对建立的模型进行了准确性的内部验证,同时通过受试者操作特征曲线(ROC曲线)评估了该临床模型的预测性能,并利用决策曲线分析(DCA)评价了模型对于实际应用的价值。结果与未发生恶性心律失常组相比,发生组年龄更大[(68.65±6.87)岁比(60.76±5.98)岁,t=10.34,P<0.01],糖尿病比例更高(59.7%比37.2%,χ^(2)=13.44,P<0.01),术前心功能Killip 3~4级比例更高(52.8%比29.6%,χ^(2)=15.70,P<0.01),术后TIMI≤2级比例更高(33.3%比16.2%,χ^(2)=12.48,P<0.01),发病至PCI时间更长[(7.65±1.87)h比(6.78±1.26)h,t=5.16,P<0.01],白细胞计数更高[(13.87±2.35)×10^(9)/L比(10.56±2.74)×10~9/L,t=11.01,P<0.01]。另外,左室射血分数(LVEF)较低[(49.54±6.92)%比(51.34±6.60)%,t=-2.10,P=0.039],低密度脂蛋白胆固醇(LDL-C)更高[(3.79±0.98)mmol/L比(3.55±0.90)mmol/L,t=2.04,P=0.045],脑钠肽(BNP)更高[(305.31±66.37)ng/L比(287.81±68.69)ng/L,t=2.10,P=0.039],肌钙蛋白I(cTnI)更高[(0.75±0.04)μg/L比(0.74±0.04)μg/L,t=2.08,P=0.040]。多因素分析显示,术后TIMI分级、年龄、糖尿病史、术前Killip分级、白细胞计数及发病至PCI时间为独立危险因素。列线图预测效能良好[AUC=0.89,95%CI:(0.72,0.93)],内部验证C-index=0.88,95%CI:(0.82,0.92),模型校准度佳,决策曲线显示在较宽阈值范围内具临床净获益。结论术后TIMI血流等级、年龄、糖尿病病史、术前心功能Killip分级、白细胞水平以及发病至PCI的时间是影响STEMI病人PCI术后并发恶性心律失常的重要独立风险因素。所构建的列线图模型能够有效地预测此类病人的临床预后,并且具有较高的临床实用价值。
Objective To construct a nomogram model for predicting malignant arrhythmia in ST-segment elevation myocardial infarction(STEMI)patients after percutaneous coronary intervention(PCI)and to validate the accuracy of the model.Methods Samples were selected from all STEMI patients who underwent PCI at the Second Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine between January 2020 and January 2023.All participants were followed up for six months.Based on the occurrence of malignant arrhythmia during follow-up,the subjects were divided into two groups:the malignant arrhythmia group(72 cases)and the non-malignant arrhythmia group(548 cases).Logistic regression analysis was used to identify independent risk factors for malignant arrhythmia in STEMI patients after PCI,and a nomogram model was constructed based on these findings.The Bootstrap method was employed for internal validation of the model's accuracy.The predictive performance of the clinical model was evaluated using the receiver operating characteristic curve(ROC curve),and its practical application value was assessed using decision curve analysis(DCA).Re⁃sults Compared with the non-malignant arrhythmia group(n=548),the malignant arrhythmia group(n=72)had higher age[(68.65±6.87)years vs.(60.76±5.98)years,t=10.34,P<0.01],a higher prevalence of diabetes(59.7%vs.37.2%,χ^(2)=13.44,P<0.01),more patients with preoperative Killip class 3-4(52.8%vs.29.6%,χ^(2)=15.70,P<0.01),more postoperative TIMI flow≤2(33.3%vs.16.2%,χ^(2)=12.48,P<0.01),longer onset-to-PCI time[(7.65±1.87)h vs.(6.78±1.26)h,t=5.16,P<0.01],and higher white blood cell counts[(13.87±2.35)×10^(9)/L vs.(10.56±2.74)×10^(9)/L,t=11.01,P<0.01].Moreover,LVEF was lower[(49.54±6.92)%vs.(51.34±6.60)%,t=−2.10,P=0.039],while LDL-C[(3.79±0.98)mmol/L vs.(3.55±0.90)mmol/L,t=2.04,P=0.045],BNP[(305.31±66.37)ng/L vs.(287.81±68.69)ng/L,t=2.10,P=0.039],and cTnI[(0.75±0.04)μg/L vs.(0.74±0.04)μg/L,t=2.08,P=0.040]were higher in the malignant arrhythmia group.Multivariable analysis identified postoperative TIMI flow grade,age,diabetes,preoperative Killip class,white blood cell count,and onset-to-PCI time as independent risk factors.The nomogram showed good discrimination[AUC=0.89,95%CI:(0.72,0.93)]and internal validation[C-index=0.88,95%CI:(0.82,0.92)]with good calibration;decision curve analysis demonstrated net clinical benefit across a broad threshold range.Conclusions The study demonstrates that postoperative TIMI flow grade,age,history of diabetes,preoperative Killip classification,white blood cell count,and time from symptom onset to PCI are significant independent risk factors for malignant arrhythmia in STEMI patients after PCI.The constructed nomogram model effectively predicts the clinical outcomes of such patients and holds substantial clinical applicability.
作者
吕玮坤
王文丽
董欢乐
张骞
翟夏
陈敏娜
张望
邢雪
牛铁
董静
LÜWeikun;WANG Wenli;DONG Huanle;ZHANG Qian;ZHAI Xia;CHEN Minna;ZHANG Wang;XING Xue;NIU Tie;DONG Jing(Department of Cardiovascular Medicine,the Second Affiliated Hospital of Shaanxi University of Traditional Chinese Medicine,Xi'an,Shaanxi 712000,China)
出处
《安徽医药》
2026年第2期341-347,共7页
Anhui Medical and Pharmaceutical Journal
基金
陕西省重点研发计划项目(2020SF-277、2023-YBSF-674)。
关键词
ST段抬高型心肌梗死
经皮冠状动脉介入治疗
心律失常
心性
疾病预测模型
冠状动脉粥样硬化心脏病
临床预后
左心功能
ST-segment elevation myocardial infarction
Percutaneous coronary intervention
Arrhythmias,cardiac
Disease prediction model
Coronary atherosclerotic heart disease
Clinical prognosis
Left ventricular function
