Analysis of risk factors affecting all-cause mortality in patients with coronary artery disease with mitral regurgitation
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摘要:
目的 冠心病(CAD)发病率持续上升，二尖瓣反流(MR)是最常见的心脏瓣膜疾病，本研究旨在探讨冠心病伴MR患者的临床特征，分析影响预后的危险因素。 方法 本研究纳入2018年1月—2023年12月在新疆维吾尔自治区人民医院住院时诊断为冠心病且伴有二尖瓣反流的813例患者，中位随访时间为2.5年，以全因死亡为终点事件，根据是否发生终点事件将患者分为终点事件组(314例)和非终点事件组(499例)。采用Cox回归分析研究影响患者预后的因素。通过ROC曲线评估左房内径(LAD)、左室舒张期末内径(LVEDD)、左室收缩期末内径(LVESD)对预后的预测能力，并根据Youden指数确定最佳截断值，利用Kaplan-Meier生存曲线分析生存情况。 结果 变量校正后，LAD(HR=1.031，95% CI：1.015~1.048)、LVEDD(HR=1.057，95% CI：1.043~1.071)、LVESD(HR=1.046，95% CI：1.031~1.062)增大均是冠心病伴MR患者发生终点事件的危险因素(P < 0.001)。ROC曲线显示，LAD、LVEDD、LVESD对冠心病伴MR患者远期全因死亡具有预测能力(AUC分别为0.666、0.755、0.761，P＜0.001)，最佳截断值分别为42.5 mm、49.5 mm、37.5 mm；Kaplan-Meier生存曲线显示，超过上述阈值者生存率显著降低(log-rank χ2=59.737、123.156、171.803，P＜0.001)。 结论 心脏超声心动图指标对冠心病伴二尖瓣反流患者预后有预测价值，其中LAD、LVEDD、LVESD增大是患者发生终点事件的危险因素。 Abstract:Objective The incidence of coronary artery disease (CAD) continues to increase, and mitral regurgitation (MR) is the most common heart valve disease. This study aims to investigate the clinical characteristics exhibited by patients diagnosed with coronary artery disease with MR and analyze the risk factors that have a detrimental effect on their prognosis. Methods This study comprised 813 patients diagnosed with coronary artery disease with mitral regurgitation, who were admitted to the Xinjiang Uygur Autonomous Region People's Hospital from January 2018 to December 2023, with a median follow-up period of 2.5 years, and the primary focus of the analysis was all-cause mortality. Patients were categorized into an endpoint event group (n=314) and a non-endpoint event group (n=499) according to the occurrence of an endpoint event. A Cox regression model was used to analyze the correlation between echocardiographic indices and prognosis in the present study, and the predictive ability of left atrial diameter (LAD), left ventricular end-diastolic internal diameter (LVEDD), and left ventricular end-systolic internal diameter (LVESD) for prognosis was assessed by the subjects' operating curves (ROCs), and the optimal cut-off values were determined by the Youden index, and analyzed by using the Kaplan-Meier survival curve. Results After making several adjustments to the data, it was found that LAD (HR=1.031, 95% CI: 1.015-1.048), LVEDD (HR=1.057, 95% CI: 1.043-1.071), LVESD (HR=1.046, 95% CI: 1.031-1.062) were all risk factors for the occurrence of endpoint events in patients with coronary heart disease and MR (P < 0.001). The ROC curve showed that LAD, LVEDD and LVESD could predict long-term all-cause death in patients with coronary heart disease and MR (AUC=0.666, 0.755, 0.761, P < 0.001), and the best cut-off values were 42.5 mm, 49.5 mm and 37.5 mm, respectively. The Kaplan-Meier survival curve showed that the survival rate of patients above the threshold was significantly reduced (log-rank χ2=59.737, 123.156, 171.803, P < 0.001). Conclusion Cardiac echocardiographic indices have been shown to possess a degree of predictive value regarding prognosis in patients suffering from coronary artery disease and mitral regurgitation, and the increase of LAD, LVEDD and LVESD has been identified as a risk factor for endpoint events in patients. -
图 1 LAD、LVEDD、LVESD预测CAD-MR患者预后的ROC曲线
Figure 1. ROC curves of LAD, LVEDD, and LVESD for predicting the prognosis of patients with CAD-MR
图 2 LAD≥42.5 mm时CAD-MR患者全因死亡K-M曲线
Figure 2. K-M curve for all-cause mortality in CAD-MR patients with LAD≥42.5 mm
图 3 LVEDD≥49.5 mm时CAD-MR患者全因死亡K-M曲线
Figure 3. K-M curve for all-cause mortality in CAD-MR patients with LVEDD≥49.5 mm
图 4 LVESD≥37.5 mm时CAD-MR患者全因死亡K-M曲线
Figure 4. K-M curve for all-cause mortality in CAD-MR with LVESD ≥37.5 mm
表 1 2组冠心病伴MR患者一般资料比较
Table 1. Comparison of general data between the two groups of CHD patients with MR
项目 终点事件组(n=314) 非终点事件组(n=499) 统计量 P值 年龄[M(P25, P75)，岁] 74(65，81) 69(60，77) 5.610a ＜0.001 性别[例(%)] 0.466b 0.495 男性 185(58.9) 306(61.3) 女性 129(41.1) 193(38.7) 高血压[例(%)] 210(66.9) 346(69.3) 0.539b 0.463 糖尿病[例(%)] 116(36.9) 178(35.7) 0.135b 0.713 吸烟史[例(%)] 74(23.6) 126(25.3) 0.295b 0.587 经皮冠状动脉介入术[例(%)] 92(29.3) 156(31.3) 0.350b 0.554 NYHA Ⅳ级[例(%)] 131(41.7) 117(23.4) 30.355b ＜0.001 收缩压(x±s，mmHg) 129.35±23.31 131.28±21.90 2.769c 0.006 白细胞(x±s，109/L) 7.20±2.90 7.14±2.66 0.330c 0.741 红细胞[M(P25, P75)，109/L] 4.33(3.74，4.79) 4.45(4.01，4.89) 1.246a 0.087 血红蛋白[M(P25, P75)，g/L] 127(109，142) 133(120，144) -3.760a ＜0.001 D-二聚体[M(P25, P75)，mg/L] 1.04(0.50，2.03) 0.65(0.35，1.42) 4.639a ＜0.001 肌酐[M(P25, P75)，μmol/L] 84.25(67.25，120.38) 75.90(62.40，97.00) 2.017a 0.044 尿酸[M(P25, P75)，μmol/L] 382.82(308.25，492.79) 366.00(289.00，448.84) 3.010a 0.003 注：a为Z值，b为χ2值，c为t值；1 mmHg=0.133 kPa。 
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表 2 2组冠心病伴MR患者超声指标比较(mm)
Table 2. Comparison of ultrasound parameters between the two groups of patients with coronary heart disease and MR (mm)
组别 例数 RVD
(x±s)PAD
[M(P25, P75)]LAD
[M(P25, P75)]IVS
(x±s)LVEDD
[M(P25, P75)]LVESD
[M(P25, P75)]终点事件组 314 22.12±3.37 21.00(20.00，23.00) 44.00(41.75，47.00) 10.99±1.19 56.00(50.00，64.00) 42.00(39.00，46.00) 非终点事件组 499 21.82±2.66 20.00(20.00，22.00) 42.00(38.00，46.00) 10.96±1.42 48.00(45.00，52.00) 34.00(28.00，41.00) 统计量 1.340a 2.863b 6.452b 0.242a 13.078b 14.145b P值 0.181 0.004 ＜0.001 0.809 ＜0.001 ＜0.001 注：a为t值，b为Z值。
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表 3 预测冠心病伴MR组患者发生终点事件的单因素及多因素Cox回归分析
Table 3. Univariate and multivariate Cox regression analyses predicting the occurrence of endpoint events after 2.5 years of follow-up in the group of patients with coronary artery disease with MR
变量 单因素分析 多因素分析 HR(95% CI) P值 HR(95% CI) P值 年龄 1.023(1.013~1.034) < 0.001 1.037(1.026~1.048) < 0.001 RVD 1.021(0.986~1.058) 0.240 0.958(0.917~1.001) 0.053 PAD 1.048(1.010~1.086) 0.012 0.994(0.947~1.043) 0.795 LAD 1.060(1.045~1.076) < 0.001 1.031(1.015~1.048) < 0.001 IVS 1.011(0.932~1.096) 0.797 1.020(0.937~1.110) 0.646 LVEDD 1.077(1.066~1.089) < 0.001 1.057(1.043~1.071) < 0.001 LVESD 1.069(1.056~1.081) < 0.001 1.046(1.031~1.062) < 0.001
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