急性肺栓塞患者的长期预后因素分析

王杭; 许启霞; 李小晴; 王悦悦

doi:10.16766/j.cnki.issn.1674-4152.003147

急性肺栓塞患者的长期预后因素分析

doi: 10.16766/j.cnki.issn.1674-4152.003147

王杭¹,
许启霞^{1, 2, ,},
李小晴³,
王悦悦¹

1.
蚌埠医学院第一附属医院呼吸与危重症医学科，安徽蚌埠 233004
2.
中国科学技术大学附属第一医院呼吸与危重症医学科，安徽合肥 230000
3.
安庆市立医院感染科，安徽安庆 246001

基金项目:

国家科技支撑计划课题 2011BAI11B17

国家重点研发计划精准医学研究专项项目 2016YFC0905600

详细信息

通讯作者:
许启霞，E-mail: xuqixia11@sina.com

中图分类号: R563.5
计量
- 文章访问数: 375
- HTML全文浏览量: 173
- PDF下载量: 23
- 被引次数: 0
出版历程
- 收稿日期: 2023-01-04
- 网络出版日期: 2023-10-19

Analysis of long-term prognostic factors in patients with acute pulmonary embolism

WANG Hang¹,
XU Qixia^{1, 2
, ,},
LI Xiaoqing³,
WANG Yueyue¹

1.
Department of Respiratory and Critical Care Medicine, the First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, China

摘要

摘要: 目的分析不同病情急性肺栓塞(acute pulmonary embolism, APE)患者的临床资料、实验室检查，探讨APE患者发生不良事件的影响因素，以进行合理治疗改善预后。方法选取2012年5月—2019年6月期间蚌埠医学院第一附属医院单中心入组国家“十二五”“十三五”注册登记研究的APE患者202例，其中191例患者完成至少6个月的随访，146例患者完成36个月随访，随访结局事件为全因死亡率。使用单因素及多因素回归分析研究临床资料及实验室指标对患者长期预后的影响。结果 191例患者在确诊后6个月时随访：存活164例，死亡27例。多因素Cox回归分析显示：基础病为恶性肿瘤或慢性心肺疾病对APE 6个月的预后(短期预后)有显著影响(均P < 0.05)。有146例患者完成36个月的随访，存活111例，累计死亡35例。多因素Cox回归分析显示：合并恶性肿瘤、慢性心肺疾病、低血清白蛋白水平对患者36个月的预后有显著影响。APE长期预后的独立危险因素包括: 合并恶性肿瘤、合并慢性心肺疾病、低血清白蛋白水平。结论合并恶性肿瘤、合并慢性心肺疾病、低血清白蛋白水平是APE患者长期预后的独立危险因素。合并恶性肿瘤、慢性心肺疾病无论是长期预后还是短期预后均较差，低血清白蛋白水平是APE患者长期预后的不良因素。
- 急性肺血栓栓塞症 /
- 危险因素 /
- 长期预后
Abstract: Objective To analyze the clinical data and laboratory tests of patients with acute pulmonary embolism (APE) in different conditions, explore the influencing factors of adverse events in patients with APE, and carry out reasonable treatment to improve the prognosis. Methods A single center of the First Affiliated Hospital of Bengbu Medical College enrolled 202 patients with APE in the national "Twelfth Five-Year Plan" and "Thirteenth Five-Year Plan" registration studies from May 2012 to June 2019, of which 191 patients completed at least 6-month follow-up, and 146 patients completed 3-year follow-up. The follow-up outcome was all-cause mortality. Univariate and multivariate regression were used to analyze the impact of clinical data and laboratory indicators on the long-term prognosis of patients. Results A total of 191 patients were followed up at 6 months after diagnosis: 164 cases survived and 27 died. Multivariate COX regression showed that underlying disease of malignancy or chronic cardiopulmonary disease had a significant effect on APE 6-months prognosis (short-term prognosis, P < 0.05). Totally 146 patients completed the 36-month follow-up, 111 survived and 35 died. Multivariate COX regression showed that the combination of malignant tumors, chronic cardiopulmonary diseases, and low serum albumin levels had a significant impact on the 36-month prognosis of patients. The independent risk factors for the long-term prognosis of APE included combination of malignant tumors, chronic cardiopulmonary diseases, and low serum albumin levels. Conclusion The combination of malignant tumors, chronic cardiopulmonary diseases, and low serum albumin levels are independent factors affecting the long-term prognosis of pulmonary embolism. Combination of malignant tumors and chronic cardiopulmonary diseases, both long-term and short-term prognosis are poor. Low serum albumin level is an adverse factor for long-term prognosis in acute pulmonary embolism.
- Acute pulmonary thromboembolism /
- Risk factors /
- Long-term prognosis

HTML全文

图 1 191例APE患者的累计生存曲线

Figure 1. Cumulative survival curve of 191 patients with APE

下载: 全尺寸图片幻灯片

图 2 恶性肿瘤、慢性心肺疾病、血清白蛋白水平预测APE患者长期预后的ROC曲线

Figure 2. ROC curve of malignant tumors, chronic cardiopulmonary diseases and serum albumin level for predicting long-term prognosis of APE patients

下载: 全尺寸图片幻灯片

表 1 191例APE患者6个月随访结局的单因素分析

Table 1. Univariate analysis of 6-month follow-up outcomes of 191 patients with APE

项目	存活组(n=164)	死亡组(n=27)	统计量	P值
性别(男性/女性，例)	76/88	16/11	1.550^a	0.213
年龄(x±s，岁)	61±16	63±16	0.913^b	0.524
BMI(x±s)	24.4±4.1	23.3±2.4	-1.269^b	0.122
合并慢性心肺疾病[例(%)]	9(5.5)	8(29.6)	16.665^a	0.001
心房颤动[例(%)]	5(3.0)	2(7.4)		0.657^d
高血压[例(%)]	49(29.9)	8(29.6)	0.001^a	0.979
合并恶性肿瘤[例(%)]	19(11.6)	16(59.3)	35.205^a	0.001
D-二聚体阳性[例(%)]	66(40.2)	13(48.1)	0.597^a	0.528
合并DVT[例(%)]	36(22.0)	4(14.8)	0.713^a	0.458
近3月手术创伤史[例(%)]	33(20.1)	5(18.5)	0.307^a	0.999
脉搏＞110次/min	10(6.1)	4(14.8)		0.116^d
贫血[例(%)]	36(22.0)	11(40.7)	4.412^a	0.036
血清白蛋白水平[M(P₂₅, P₇₅)，g/L]	35.6(32.8, 38.8)	34.1(30.0, 37.7)	-1.783^c	0.075
白细胞计数＞10×10⁹/L[例(%)]	60(36.6)	11(40.7)	0.171^a	0.679
eGFR＜60 mL/(min·1.73 m²)[例(%)]	23(14.0)	7(25.9)	2.480^a	0.150
血小板计数(x±s，×10⁹/L)	215.4±101.9	216.4±98.8	0.028^b	0.780
ALT测定值[M(P₂₅, P₇₅), U/L]	33.3(22.0, 22.8)	40.4(20.0，40.0)	-0.724^c	0.469
注：^a为χ²值，^b为t值，^c为Z值, ^d为采用Fisher精确检验。eGFR为由CKD-EPI公式评估的预计肾小球滤过率；ALT为丙氨酸转氨酶；DVT为深静脉血栓栓塞症。贫血指血红蛋白水平男性 < 120 g/L，女性 < 110 g/L。合并慢性心肺疾病指慢性阻塞性肺疾病和慢性心力衰竭病史。D-二聚体≥500 μg/L为阳性。

下载: 导出CSV

表 2 146例APE患者36个月随访结局的单因素分析

Table 2. Univariate analysis of 36-month follow-up outcomes of 146 patients with APE

项目	存活组(n=111)	死亡组(n=35)	统计量	P值
性别(男性/女性，例)	51/60	20/15	1.335^a	0.248
年龄(x±s，岁)	59.6±15.5	63.8±14.4	-1.548^b	0.144
BMI(x±s)	24.4±3.4	23.3±2.4	1.660^b	0.099
合并慢性心肺疾病[例(%)]	2(1.8)	8(22.9)		0.001^d
心房颤动[例(%)]	6(5.4)	1(2.9)		0.999^d
高血压[例(%)]	30(27.0)	7(20.0)	0.694^a	0.405
合并恶性肿瘤[例(%)]	6(5.4)	16(45.7)	33.783^a	0.001
D-二聚体阳性[例(%)]	41(36.9)	16(45.7)	0.861^a	0.353
合并DVT[例(%)]	31(27.9)	6(17.1)	1.636^a	0.201
近3月手术创伤史	22(19.8)	9(25.7)	0.553^a	0.457
脉搏＞110次/min	5(4.5)	4(11.4)		0.218^d
贫血[例(%)]	21(18.9)	12(34.3)	3.592^a	0.058
血清白蛋白水平[M(P₂₅, P₇₅), g/L]	36.7(33.1, 39.1)	33.2(29.9, 37.0)	-4.443^c	0.001
白细胞计数＞10×10⁹/L[例(%)]	39(35.1)	17(48.6)	2.032^a	0.154
eGFR＜60 mL(min·1.73 m²)[例(%)]	21(18.9)	7(20.0)	0.020^a	0.887
血小板计数(x±s，×10⁹/L)	208±86	225±89	-1.050^b	0.284
ALT测定值[M(P₂₅, P₇₅), U/L]	27.0(20.0, 41.0)	28.0(22.0, 45.0)	-0.803^c	0.422
注：^a为χ²值，^b为t值，^c为Z值, ^d为采用Fisher精确检验。eGFR为由CKD-EPI公式评估的预计肾小球滤过率；ALT为丙氨酸转氨酶；DVT为深静脉血栓栓塞症。贫血指血红蛋白水平男性 < 120 g/L，女性 < 110 g/L。合并慢性心肺疾病指慢性阻塞性肺疾病和慢性心力衰竭病史。D-二聚体≥500 μg/L为阳性。

下载: 导出CSV

表 3 影响191例APE患者短期(6个月)预后的多因素分析

Table 3. Multivariate analysis of short-term (6 months) prognosis in 191 patients with APE

变量	B	SE	Wald χ²	P值	HR值	95% CI
合并恶性肿瘤	2.098	0.406	26.650	0.001	8.150	3.675~18.075
合并慢性心肺疾病	2.028	0.444	20.827	0.001	7.596	3.180~18.145
血清白蛋白水平	-0.076	0.043	3.111	0.078	0.927	0.852~1.009
贫血	0.466	0.408	1.305	0.253	0.253	0.717~3.542

下载: 导出CSV

表 4 影响146例APE患者长期(36个月) 预后的多因素分析

Table 4. Multivariate analysis of long-term (36 months) prognosis of 146 patients with APE

变量	B	SE	Wald χ²	P值	HR值	95% CI
BMI	-0.076	0.074	1.039	0.308	0.927	0.801~1.072
合并恶性肿瘤	2.110	0.381	30.662	＜0.001	8.246	3.908~17.400
合并慢性心肺疾病	2.543	0.458	30.877	＜0.001	12.713	5.185~31.169
血清白蛋白水平	-0.160	0.036	19.371	＜0.001	0.852	0.793~0.915
贫血	-0.240	0.403	0.354	0.552	0.787	0.357~1.743

下载: 导出CSV

表 5 恶性肿瘤、慢性心肺疾病、血清白蛋白水平对APE患者长期预后的预测价值

Table 5. Prognostic value of malignant tumor, chronic cardiopulmonary disease and serum albumin level in patients with APE

项目	AUC	95% CI	P值	最佳截断值	灵敏度	特异度
合并恶性肿瘤	0.701	0.615~0.787	0.002		0.457	0.946
合并慢性心肺疾病	0.605	0.533~0.676	＜0.001		0.229	0.982
血清白蛋白水平	0.681	0.580~0.781	0.003	35.8 g/L	0.743	0.586

下载: 导出CSV

参考文献(16)

[1]	KONSTANTINIDES S V, MEYER G, BECATTINI C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society[J]. Eur Heart J, 2020, 41(4): 543-603. doi: 10.1093/eurheartj/ehz405
[2]	ZHAI Z, WANG D, LEI J, et al. Trends in risk stratification, in-hospital management and mortality of patients with acute pulmonary embolism: an analysis from the China pulmonary thromboembolism registry study[J]. Eur Respir J, 2021, 58(4): 1-11.
[3]	李小晴, 许启霞, 庞颖颖. 肺血栓栓塞症预后因素分析[J]. 中华全科医学, 2017, 15(6): 1022-1026. LI X Q; XU Q X. Analysis of prognostic factors in patients with pulmonary thromboembolism[J]. Chinese Journal of General Practice, 2017, 15(6): 1022-1026.
[4]	中华医学会呼吸病学分会肺栓塞与肺血管病学组, 中国医师协会呼吸医师分会肺栓塞与肺血管病工作委员会, 全国肺栓塞与肺血管病防治协作组. 肺血栓栓塞症诊治与预防指南[J]. 中华医学杂志, 2018, 98(14): 1060-1087. doi: 10.3760/cma.j.issn.0376-2491.2018.14.007 Pulmonary embolism and pulmonary vascular Disease Group, Chinese Medical Association Respiratory Branch, Pulmonary embolism and pulmonary Vascular Disease Working Committee, Chinese Medical Doctor Association Respiratory Physician Branch, National pulmonary embolism and pulmonary vascular disease Prevention and Treatment Collaboration group. Guidelines for diagnosis, treatment and prevention of pulmonary thromboembolism[J]. Chinese Medical Journal, 2018, 98(14): 1060-1087. doi: 10.3760/cma.j.issn.0376-2491.2018.14.007
[5]	张拓北. 肺癌患者并发肺栓塞的影响因素及预后[J]. 中国卫生工程学, 2022, 21(1): 75-77. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWX202201023.htm ZHANG T B. Influencing factors and prognosis of pulmonary embolism in patients with lung cancer[J]. Chin J Public Health Eng, 2022, 21(1): 75-77. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGWX202201023.htm
[6]	JACK L, LOCKARD C. Thrombocytosis assiciated with malignant[J]. Arch Intern Med, 1964, 23(9): 497-500.
[7]	ALBERTSEN I E, NIELSEN P B, SOGAARD M, et al. Risk of recurrent venous thromboembolism: a Danish nationwide cohort study[J]. Am J Med, 2018, 131(9): 1067-1074. doi: 10.1016/j.amjmed.2018.04.042
[8]	张丽, 万毅新, 王虹. 肺栓塞患者合并肿瘤与非肿瘤的危险因素分析[J]. 甘肃医药, 2022, 41(10): 881-884. https://www.cnki.com.cn/Article/CJFDTOTAL-GSYY202210006.htm ZHANG L, WAN Y X, WANG H. Analysis of risk factors for pulmonary embolism patients with tumor and non-tumor[J]. Gansu Med J, 2022, 41(10): 881-884. https://www.cnki.com.cn/Article/CJFDTOTAL-GSYY202210006.htm
[9]	付萌, 庞桂芬. 慢性阻塞性肺疾病合并肺栓塞临床诊治进展[J]. 临床医药文献电子杂志, 2018, 5(87): 186-188. https://www.cnki.com.cn/Article/CJFDTOTAL-LCWX201887164.htm FU M, PANG G F. Advances in clinical diagnosis and treatment of chronic obstructive pulmonary disease complicated with pulmonary embolism[J]. Journal of Clinical Medicine Literature, 2018, 5(87): 186-188. https://www.cnki.com.cn/Article/CJFDTOTAL-LCWX201887164.htm
[10]	朱晓敏, 罗健, 李苗苗, 等. 慢性阻塞性肺疾病患者并发静脉血栓栓塞症危险因素的Meta分析[J]. 中华护理杂志, 2019, 54(5): 746-752. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHHL201905031.htm ZHU X M, LUO J, LI M M, et al. Meta-analysis of risk factors for venous thromboembolism in patients with chronic obstructive pulmonary disease[J]. Chin J Nurs, 2019, 54(5): 746-752. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHHL201905031.htm
[11]	KELLER K, BEULE J, COLDEWEY M, et al. The risk factor age in normotensive patients with pulmonary embolism: effectiveness of age in predicting submassive pulmonary embolism, cardiac injury, right ventricular dysfunction and elevated systolic pulmonary artery pressure in normotensive pulmonary embolism patients[J]. Exp Gerontol, 2015, 69: 116-121. doi: 10.1016/j.exger.2015.05.007
[12]	王小强, 王艳, 张艳东, 等. 炎症因子检测对慢性阻塞性肺疾病急性加重期的诊断价值[J]. 山西医药杂志, 2017, 46(7): 802-804. https://www.cnki.com.cn/Article/CJFDTOTAL-SXYY201707029.htm WANG X Q, WANG Y, ZHANG Y D, et al. Diagnostic value of inflammatory factor detection in acute exacerbation of chronic obstructive pulmonary disease[J]. Shanxi Med J, 2017, 46(7): 802-804. https://www.cnki.com.cn/Article/CJFDTOTAL-SXYY201707029.htm
[13]	LITUS E A, PERMYAKOV S E, UVERSKY V N, et al. Intrinsically disordered regions in serum albumin: what are they for?[J]. Cell Biochem Biophys, 2018, 76(1-2): 39-57.
[14]	NICHOLSON J P, WOLMARANS M R, PARK G R. The role of albumin in critical illness[J]. Br J Anaesth, 2000, 85(4): 599-610.
[15]	庞颖颖, 刘海涛. 生物标志物与急性肺栓塞危险分层及预后的关联性研究[J]. 中华全科医学, 2022, 20(2): 199-201, 281. doi: 10.16766/j.cnki.issn.1674-4152.002311 PANG Y Y, LIU H T. Association of biomarkers with risk stratification and prognosis of acute pulmonary embolism[J]. Chinese Journal of General Practice, 2022, 20(2): 199-201, 281. doi: 10.16766/j.cnki.issn.1674-4152.002311
[16]	KUNUTSOR S K, SEIDU S, KATECHIA D T, et al. Inverse association between serum albumin and future risk of venous thromboembolism: interrelationship with high sensitivity C-reactive protein[J]. Ann Med, 2018, 50(3): 240-248.