脓毒症心肌损伤后心脏舒缩功能的动态变化
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摘要
目的探讨心脏舒张、收缩功能和心肌损伤指标对脓毒症患者动态变化和预后判断的作用。方法收集脓毒症患者70例。根据28 d的预后分为生存组和死亡组。分别于入重症医学科(ICU)第1和3天应用床旁心脏超声测量二尖瓣舒张早期充盈峰速度E峰(E)与舒张晚期充盈峰速度A峰(A)、二尖瓣环舒张早期速度(e’)的比值,将E/e’及E/A作为评估左心室舒张功能的指标;测量左心室射血分数(LVEF)作为评估左心室收缩功能的指标。监测第1和3天心肌损伤标志物肌钙蛋白(cTnI)及肌酸激酶同工酶(CK-MB)水平。通过Logistic回归方法,对可能影响脓毒症预后的危险因素进行分析。结果两组患者于入ICU第3天的E/e’高于第1天(P<0.05),LVEF低于第1天(P<0.05);死亡组第1和3天的E/e’高于生存组(P<0.05)。两组第3天的cTnI、CK-MB高于第1天(P<0.05),死亡组第3天的cTnI高于生存组(P <0.05)。Logistic回归分析显示,E/e’[■4,(95%CI:1.116,1.982),P=0.003]、cTnI[■,(95%CI:0.907,1.432),P=0.039]是影响脓毒症患者28 d预后的危险因素。结论脓毒症患者存在心肌损伤,心脏舒张及收缩功能发生了动态变化,且高死亡风险脓毒症患者心脏舒缩功能及心肌损伤明显加重。E/e’、cTnI能预测脓毒症患者的预后。
Objective To investigate dynamic changes of diastolic and systolic functions of cardiac and myocardial injury markers in patients with sepsis and risk factors which could affect prognosis. Methods Totally70 patients with sepsis were divided into survival group and death group according to 28-day mortality. Patients in ICU underwent echocardiogram to measure velocities of early diastolic filling wave(E), late filling wave(A) and early diastolic velocity of the mitral annulus(e') on the 1 st day and 3 rd day. E/e' and E/A were used to evaluate left ventricular diastolic function. Left ventricular ejection fraction(LVEF) was measured as evaluation index of left ventricular systolic function on the 1 st day and 3 rd day, meanwhile levels of cardiac troponin(cTnI) and creatine kinase isoenzyme(CK-MB) were monitored. Logistic regression was used to analysis risk factors which could affect prognosis. Results Compared with data on the 1 st day, E/e' increased and LVEF decreased on the 3 rd day in both groups(P < 0.05). Compared with survival group, E/e' is higher on the 1 st day and 3 rd day in death group(P < 0.05);in addition, the levels of cTnI and CK-MB on the 3 rd day were higher than those on the 1 st day(P < 0.05), and the levels of cTnI on the 3 rd day in the death group were higher than those in the survival group(P < 0.05). Logistic regression analysis showed that E/e'(■,(95% CI: 1.116, 1.982), P = 0.003) and cTnI(■,(95% CI:0.907, 1.432), P = 0.039) were risk factors which could affect prognosis of sepsis. Conclusions Dynamic changes of cardiac systolic, diastolic function and myocardial injury are found in patients with sepsis. Cardiac function and myocardial injury are significantly aggravated in patients with high risk of death. E/e' and cTnI have predictive value which could be beneficial to evaluate the prognosis of patients with sepsis.
Objective To investigate dynamic changes of diastolic and systolic functions of cardiac and myocardial injury markers in patients with sepsis and risk factors which could affect prognosis. Methods Totally70 patients with sepsis were divided into survival group and death group according to 28-day mortality. Patients in ICU underwent echocardiogram to measure velocities of early diastolic filling wave(E), late filling wave(A) and early diastolic velocity of the mitral annulus(e') on the 1 st day and 3 rd day. E/e' and E/A were used to evaluate left ventricular diastolic function. Left ventricular ejection fraction(LVEF) was measured as evaluation index of left ventricular systolic function on the 1 st day and 3 rd day, meanwhile levels of cardiac troponin(cTnI) and creatine kinase isoenzyme(CK-MB) were monitored. Logistic regression was used to analysis risk factors which could affect prognosis. Results Compared with data on the 1 st day, E/e' increased and LVEF decreased on the 3 rd day in both groups(P < 0.05). Compared with survival group, E/e' is higher on the 1 st day and 3 rd day in death group(P < 0.05);in addition, the levels of cTnI and CK-MB on the 3 rd day were higher than those on the 1 st day(P < 0.05), and the levels of cTnI on the 3 rd day in the death group were higher than those in the survival group(P < 0.05). Logistic regression analysis showed that E/e'(■,(95% CI: 1.116, 1.982), P = 0.003) and cTnI(■,(95% CI:0.907, 1.432), P = 0.039) were risk factors which could affect prognosis of sepsis. Conclusions Dynamic changes of cardiac systolic, diastolic function and myocardial injury are found in patients with sepsis. Cardiac function and myocardial injury are significantly aggravated in patients with high risk of death. E/e' and cTnI have predictive value which could be beneficial to evaluate the prognosis of patients with sepsis.
引文
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[13]MAHJOUB Y,BENOIT-FALLET H,AIRAPETIAN N,et al.Improvement of left ventricular relaxation as assessed by tissue doppler imaging in fluid-responsive critically ill septic patients[J].Intensive Care Med,2012,38(9):1461-1470.
[14]LIU M,SHEHU M,HERROLD E,et al.Prognostic value of initial elevation in cardiac troponin I level in critically ill patients without acute coronary syndrome[J].Crit Care Nurse,2015,32(2):e1-e10.
[15]夏嘉鼎,苏震,王娜,等.肌钙蛋白I在脓毒性休克致左心室舒张功能障碍患者中的变化和意义[J].实用医学杂志,2017,33(9):1449-1452.
[2]MARTIN G S.Sepsis,severe sepsis and septic shock:changes in incidence,pathogens and outcomes[J].Expert Rev Anti Ther,2012,10(6):701-706.
[3]ESPER A M,MARTIN G S.Extending international sepsis epidemiology:the impact of organ dysfunction[J].Critical Care,2009,13(1):120.
[4]马光,洪广亮,赵光举,等.脓毒症患者血浆B型尿钠肽和肌钙蛋白I的变化及意义[J].中国中西医结合急救杂志,2014,21(2):99-103.
[5]DELLINGER R P,LEVY M M,RHODES A,et al.Surviving sepsis campaign:international guidelines for management of severe sepsis and septic shock,2012[J].Intensive Care Med,2013(2):165-228.
[6]蒋会.脓毒症与心功能障碍的关系研究进展[J].医学综述,2013,19(12):2127-2130.
[7]LANDESBERG G,GILON D,MEROZ Y,et al.Diatolic dysfunction and mortality in severe sepsis and septic shock[J].Eur Heart J,2012,33(07):895-903.
[8]PULIDO J N,AFESSA B,MASAKI M,et al.Clinical spectrum,frequency,and significance of myocardial dysfunction in severe sepsis and septic shock[J].Mayo Clin Proc,2012,87(07):620-628.
[9]郭继鸿.舒张性心衰的新理念[J].临床心电学杂志,2009,18(3):209-221.
[10]陈慧倩,王卫真,叶雪存,等.组织多普勒超声心动图对左室舒张功能的诊断价值[J].实用临床医学,2010,11(8):84-85.
[11]TAL S,GULLER V,GOLAND S.Reversible myocardial dysfunction in septic shock[J].Isr Med Assoc J,2013,15(9):520.
[12]林笑女,姜晓霞,程青虹,等.脓毒症患者左心室舒缩功能的变化及B型钠尿肽诊断价值的探讨[J].中华医学杂志,2014,94(11):816-820.
[13]MAHJOUB Y,BENOIT-FALLET H,AIRAPETIAN N,et al.Improvement of left ventricular relaxation as assessed by tissue doppler imaging in fluid-responsive critically ill septic patients[J].Intensive Care Med,2012,38(9):1461-1470.
[14]LIU M,SHEHU M,HERROLD E,et al.Prognostic value of initial elevation in cardiac troponin I level in critically ill patients without acute coronary syndrome[J].Crit Care Nurse,2015,32(2):e1-e10.
[15]夏嘉鼎,苏震,王娜,等.肌钙蛋白I在脓毒性休克致左心室舒张功能障碍患者中的变化和意义[J].实用医学杂志,2017,33(9):1449-1452.