乙型肝炎肝硬化食管胃底曲张静脉破裂出血患者合并急性心肌损伤危险因素分析
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摘要
目的分析乙型肝炎肝硬化食管胃底静脉曲张破裂出血患者合并急性心肌损伤的危险因素。方法 2010年7月~2015年12月我院收诊的乙型肝炎肝硬化食管胃底曲张静脉破裂出血患者152例,对他们的临床资料进行回顾性分析。按照不同临床资料进行分类,比较各因素下发生急性心肌损伤的差异,对有统计学差异的因素进行多因素Logistic回归分析,得出独立危险因素。结果在152例乙型肝炎肝硬化食管胃底曲张静脉破裂出血患者中,有65例(42.8%)发生急性心肌损伤;单因素分析显示,年龄≤52岁的患者发生急性心肌损伤比例为34.7%,显著低于>52岁组患者的50.0%(P<0.05),体质指数(BMI)26 kg/m~2的患者发生的比例为37.6%,显著低于>26kg/m~2患者的50.9%(P<0.05),肝功能Child A级患者的发生率低于B级和C级患者(27.6%对43.4%和52.5%,P<0.05),无高血压、无糖尿病、无心脏疾病史、血肌酐(sCr)<81μmol/L和C-反应蛋白(CRP)<16 mg/L的患者发生急性心肌损伤的比例分别为40.0%、39.8%、39.7%、34.3%和31.5%,分别显著低于相应有高血压患者(53.1%)、有糖尿病患者(55.2%)、有心脏疾病史者(61.9%)和血肌酐>81μmol/L患者(49.4%)和CRP>16 mg/L患者(53.2%,P<0.05),血钾>3.7 mmol/L的患者发生急性心肌损伤的比例为46.9%,显著高于血钾≤3.7 mmol/L患者的35.7%(P<0.05);多因素分析显示年龄、肝功能分级、糖尿病、心脏疾病史、sCr、血钾和CRP水平为影响患者发生急性心肌损伤的独立危险因素(P<0.05)。结论乙型肝炎肝硬化食管胃底静脉曲张破裂出血并发急性心肌损伤发生率高,危险因素多样,应注意防治。
Objective To analyze the risk factors for acute myocardial damage in patients with hepatitis B cirrhosis complicated by esophageal and gastric variceal bleeding. Methods Clinical data of 152 patients with hepatitis B cirrhosis and esophageal and gastric variceal bleeding between July 2010 and December 2015 were retrospectively analyzed. Acute myocardial damage were recorded. Independent risk factors were obtained by multivariate Logistic regression analysis. Results There were 65 patients(42.76%) having acute myocardial damage among the 152 patients with hepatitis B liver cirrhosis complicated by esophageal and gastric variceal bleeding;Univariate analysis showed that patients who were younger than 52 years,whose body mass index(BMI)less than 26 kg/m2,had liver function of Child-Pugh class A,had no hypertension,had no diabetes,had no history of heart disease,whose serum creatinine(sCr) levels being lower than 81 μmol/L and C-reactive protein(CRP)levels being lower than 16 mg/L,and blood potassium being lower than 3.7 mmol/L had lower incidence of acute myocardial damage as compared to those in the opposite ones(P<0.05 for all);the multivariate logistic regression analysis revealed that age,liver function class,diabetes mellitus,heart disease history,sCr level,serum potassium and CRP levels were the independent risk factors for acute myocardial damage in patients with hepatitis B cirrhosis and esophageal and gastric variceal bleeding. Conclusion The incidence of acute myocardial damage in patients with hepatitis B cirrhosis and esophageal and gastric variceal bleeding is high,which must be taken into consideration in clinical practice.
Objective To analyze the risk factors for acute myocardial damage in patients with hepatitis B cirrhosis complicated by esophageal and gastric variceal bleeding. Methods Clinical data of 152 patients with hepatitis B cirrhosis and esophageal and gastric variceal bleeding between July 2010 and December 2015 were retrospectively analyzed. Acute myocardial damage were recorded. Independent risk factors were obtained by multivariate Logistic regression analysis. Results There were 65 patients(42.76%) having acute myocardial damage among the 152 patients with hepatitis B liver cirrhosis complicated by esophageal and gastric variceal bleeding;Univariate analysis showed that patients who were younger than 52 years,whose body mass index(BMI)less than 26 kg/m2,had liver function of Child-Pugh class A,had no hypertension,had no diabetes,had no history of heart disease,whose serum creatinine(sCr) levels being lower than 81 μmol/L and C-reactive protein(CRP)levels being lower than 16 mg/L,and blood potassium being lower than 3.7 mmol/L had lower incidence of acute myocardial damage as compared to those in the opposite ones(P<0.05 for all);the multivariate logistic regression analysis revealed that age,liver function class,diabetes mellitus,heart disease history,sCr level,serum potassium and CRP levels were the independent risk factors for acute myocardial damage in patients with hepatitis B cirrhosis and esophageal and gastric variceal bleeding. Conclusion The incidence of acute myocardial damage in patients with hepatitis B cirrhosis and esophageal and gastric variceal bleeding is high,which must be taken into consideration in clinical practice.
引文
[1]中华医学会肝病学分会和感染病学分会.慢性乙型肝炎防治指南(2015年版).实用肝脏病杂志,2016,19(3):Ⅴ-ⅩⅩⅢ.
[2]中国中西医结合学会消化系统疾病专业委员会.肝硬化中西医结合诊治方案.现代消化及介入诊疗,2005,10(2):119-121.
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[4]中国高血压防治指南修订委员会.中国高血压防治指南(2010年修订版).中国实用乡村医生杂志,2012,19(10):165-168.
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[6]周智广.中国1型糖尿病诊治指南.人民卫生出版社,2012:394-396.
[7]中国成人血脂异常防治指南制订联合委员会.中国成人血脂异常防治指南.人民卫生出版社,2007:350-353.
[8]中华人民共和国卫生部.医院感染诊断标准(试行).现代实用医学,2003,8l(7):460-465.
[9]Rudnick S,Shepple B,Keeley E,et al.376 Prevalence and mortality of acute myocardial infarction in cirrhotic patients.Gastroenterology,2014,146(5):S905-S909.
[10]张国民,孙校金,王富珍,等.中国18~59岁人群乙型病毒性肝炎流行病学特征分析及乙型肝炎疫苗免疫策略探讨.中国疫苗和免疫,2013,5(3):266-270.
[11]郭秀丽,徐有青.肝硬化患者并发上消化道出血和急性脑梗塞临床分析.实用肝脏病杂志,2011,14(5):344-345.
[12]王麦换,焦娇.乙型肝炎后肝硬化合并上消化道出血的临床护理体会.国际病毒学杂志,2015,22(s1):294-296.
[13]Kalafateli M,Triantos C K,Nikolopoulou V,et al.Non-variceal gastrointestinal bleeding in patients with liver cirrhosis:a review.Dig Dis Sci,2012,57(11):2743-2754.
[14]张林华.肝硬化合并多器官功能衰竭56例相关因素分析.陕西医学杂志,2013,42(7):883-884.
[15]Cremers I,Ribeiro S.Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis.Therap Adv Gastroenterol,2014,7(5):206-216.
[16]黄锐.肝硬化门脉高压并上消化道出血治疗方法探讨.临床合理用药杂志,2012,31(5):28-29.
[17]Koch A,Buendgens L,Dückers H,et al.Gastrointestinal bleeding in liver cirrhosisat the ICU.ZGastroenterol,2013,51(1):19-25.
[18]Farag ESM,Al-Daydamony MM,Naggar YA.Predictors of myocardial injury in patients with acute upper gastrointestinal bleeding.Egypt Heart J,2014,66(1):18-19.
[19]雷旭,谭华炳.肝硬化性心肌病诊治研究进展.中西医结合心脑血管病杂志,2014,14(11):1394-1396.
[20]Tandon P,Abraldes J G,Keough A,et al.Risk of bacterial infection in patients with cirrhosis and acute variceal hemorrhage,based on child-Pugh class,and effects of antibiotics.Am Gastroenterol Asso Gastroenterol,2014,13(6):1189-1196.
[21]Sarnaik SM,Saladino RA,Manole M,et al.Diastolic hypotension is an unrecognized risk factor forβ-agonist-associated myocardial injury in children with asthma.Pediatr Crit Care Med,2013,14(6):273-279.
[2]中国中西医结合学会消化系统疾病专业委员会.肝硬化中西医结合诊治方案.现代消化及介入诊疗,2005,10(2):119-121.
[3]陈灏珠.实用内科学.13版,北京:人民卫生出版社,2009:425-428.
[4]中国高血压防治指南修订委员会.中国高血压防治指南(2010年修订版).中国实用乡村医生杂志,2012,19(10):165-168.
[5]中华医学会糖尿病学分会.中国2型糖尿病防治指南(2010年版).中国实用乡村医生杂志,2012,20(4):1227-1245.
[6]周智广.中国1型糖尿病诊治指南.人民卫生出版社,2012:394-396.
[7]中国成人血脂异常防治指南制订联合委员会.中国成人血脂异常防治指南.人民卫生出版社,2007:350-353.
[8]中华人民共和国卫生部.医院感染诊断标准(试行).现代实用医学,2003,8l(7):460-465.
[9]Rudnick S,Shepple B,Keeley E,et al.376 Prevalence and mortality of acute myocardial infarction in cirrhotic patients.Gastroenterology,2014,146(5):S905-S909.
[10]张国民,孙校金,王富珍,等.中国18~59岁人群乙型病毒性肝炎流行病学特征分析及乙型肝炎疫苗免疫策略探讨.中国疫苗和免疫,2013,5(3):266-270.
[11]郭秀丽,徐有青.肝硬化患者并发上消化道出血和急性脑梗塞临床分析.实用肝脏病杂志,2011,14(5):344-345.
[12]王麦换,焦娇.乙型肝炎后肝硬化合并上消化道出血的临床护理体会.国际病毒学杂志,2015,22(s1):294-296.
[13]Kalafateli M,Triantos C K,Nikolopoulou V,et al.Non-variceal gastrointestinal bleeding in patients with liver cirrhosis:a review.Dig Dis Sci,2012,57(11):2743-2754.
[14]张林华.肝硬化合并多器官功能衰竭56例相关因素分析.陕西医学杂志,2013,42(7):883-884.
[15]Cremers I,Ribeiro S.Management of variceal and nonvariceal upper gastrointestinal bleeding in patients with cirrhosis.Therap Adv Gastroenterol,2014,7(5):206-216.
[16]黄锐.肝硬化门脉高压并上消化道出血治疗方法探讨.临床合理用药杂志,2012,31(5):28-29.
[17]Koch A,Buendgens L,Dückers H,et al.Gastrointestinal bleeding in liver cirrhosisat the ICU.ZGastroenterol,2013,51(1):19-25.
[18]Farag ESM,Al-Daydamony MM,Naggar YA.Predictors of myocardial injury in patients with acute upper gastrointestinal bleeding.Egypt Heart J,2014,66(1):18-19.
[19]雷旭,谭华炳.肝硬化性心肌病诊治研究进展.中西医结合心脑血管病杂志,2014,14(11):1394-1396.
[20]Tandon P,Abraldes J G,Keough A,et al.Risk of bacterial infection in patients with cirrhosis and acute variceal hemorrhage,based on child-Pugh class,and effects of antibiotics.Am Gastroenterol Asso Gastroenterol,2014,13(6):1189-1196.
[21]Sarnaik SM,Saladino RA,Manole M,et al.Diastolic hypotension is an unrecognized risk factor forβ-agonist-associated myocardial injury in children with asthma.Pediatr Crit Care Med,2013,14(6):273-279.