急性心肌梗死合并慢性肾脏病患者的临床特点分析
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摘要
目的:探讨急性心肌梗死(AMI)合并慢性肾脏病(CKD)患者的临床特点。方法:回顾性分析华中科技大学同济医学院附属协和医院心内科收治的792例AMI患者,分为合并CKD组(263例)和非CKD组(529例),收集患者的临床基线资料、实验室检查、心电图、心脏超声、冠状动脉(冠脉)造影资料进行比较分析。结果:AMI合并CKD患者组高龄、女性、主诉"喘气"、高血压史、陈旧性心肌梗死、心力衰竭、心源性休克、室性心动过速、心室颤动、院内死亡发生率均显著高于非CKD组(P<0.01);而非CKD组合并血脂异常、吸烟史的比例更高(P<0.01)。AMI合并CKD≥3期的患者中老年人更常见(P<0.01),AMI合并CKD4-5期患者心力衰竭及心源性休克的发生率显著增加(P<0.05);合并CKD组的N-末端B型脑钠肽前体(NT-proBNP)水平、糖化血红蛋白、血肌酐、血清白蛋白、血尿酸、胱抑素水平、左房内径明显高于非CKD组(P<0.01);左室射血分数(LVEF)显著低于非CKD组(P<0.01);右束支传导阻滞、冠脉三支病变、钙化病变、左主干病变比例显著高于非CKD组(P<0.05)。结论:AMI合并CKD患者的临床症状常不典型,合并高血压者比例较高,更易出现心源性休克,冠脉病变更为严重,左心功能降低更为明显,预后更差。
Objective:To investigate the clinical characteristics of acute myocardial infarction(AMI)patients presenting with chronic kidney disease(CKD).Method:Seven hundred and ninety two patients with acute myocardial infarction admitted to Union Hospital,affiliated to Tongji Medical College of Huazhong University of Science and Technology from January 2014 to December 2017 were divided into CKD group(n=263)and non-CKD group(n=529).The baseline clinical data,laboratory tests,electrocardiogram,echocardiography and coronary angiography data were collected.Result:The proportion of elderly,female,complaining of dyspnea,histories of hypertension and old myocardial infarction,incidences of heart failure,cardiogenic shock,ventricular tachycardia,ventricular fibrillation,in-hospital mortality in AMI patients with CKD were significantly higher than that in non-CKD group(P<0.01),while the proportion of dyslipidemia and current smoking were higher in non-CKD group(P<0.01).The elderly patients were more common in AMI patients presenting with CKD stages 3 to 5(P<0.01),while incidences of heart failure including cardiogenic shock increased significantly in AMI patients presenting with CKD stages 4 to 5(P<0.05).The levels of NT-proBNP,glycosylated glycoprotein,serum creatinine,serum albumin,serum uric acid,cystatin,and left atrial diameter were significantly higher than those in non-CKD group(P<0.01).Left ventricular ejection fraction(LVEF)was significantly lower in CKD group(P<0.01),while the incidences of right bundle branch block,triple-vessel lesions,calcification lesion,left main artery lesion of coronary artery were significantly higher in CKD group(P<0.05).Conclusion:The symptoms of AMI patients presenting with CKD were often atypical and hypertension was more often seen.Cardiogenic shock was more likely to occur,coronary artery lesions were more severe,and left ventricular function was decreased more significantly,which lead to worse prognosis in the AMI patients with CKD.
Objective:To investigate the clinical characteristics of acute myocardial infarction(AMI)patients presenting with chronic kidney disease(CKD).Method:Seven hundred and ninety two patients with acute myocardial infarction admitted to Union Hospital,affiliated to Tongji Medical College of Huazhong University of Science and Technology from January 2014 to December 2017 were divided into CKD group(n=263)and non-CKD group(n=529).The baseline clinical data,laboratory tests,electrocardiogram,echocardiography and coronary angiography data were collected.Result:The proportion of elderly,female,complaining of dyspnea,histories of hypertension and old myocardial infarction,incidences of heart failure,cardiogenic shock,ventricular tachycardia,ventricular fibrillation,in-hospital mortality in AMI patients with CKD were significantly higher than that in non-CKD group(P<0.01),while the proportion of dyslipidemia and current smoking were higher in non-CKD group(P<0.01).The elderly patients were more common in AMI patients presenting with CKD stages 3 to 5(P<0.01),while incidences of heart failure including cardiogenic shock increased significantly in AMI patients presenting with CKD stages 4 to 5(P<0.05).The levels of NT-proBNP,glycosylated glycoprotein,serum creatinine,serum albumin,serum uric acid,cystatin,and left atrial diameter were significantly higher than those in non-CKD group(P<0.01).Left ventricular ejection fraction(LVEF)was significantly lower in CKD group(P<0.01),while the incidences of right bundle branch block,triple-vessel lesions,calcification lesion,left main artery lesion of coronary artery were significantly higher in CKD group(P<0.05).Conclusion:The symptoms of AMI patients presenting with CKD were often atypical and hypertension was more often seen.Cardiogenic shock was more likely to occur,coronary artery lesions were more severe,and left ventricular function was decreased more significantly,which lead to worse prognosis in the AMI patients with CKD.
引文
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[8] Chen HH,Wu CJ,Chen YC,et al.Metabolic syndrome is associated with severe coronary artery disease and poor cardiac outcome in end-stage renal disease patients with acute coronary syndrome[J].Coron Artery Dis,2006,17(7):593-596.
[9] Abid L,Charfeddine S,Kammoun S,et al.Cystatin C:A prognostic marker after myocardial infarction in patients without chronic kidney disease[J].J Saudi Heart Assoc,2016,28(3):144-151.
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[11] Baber U,Stone GW,Weisz G,et al.Coronary plaque composition,morphology,and outcomes in patients with and without chronic kidney disease presenting with acute coronary syndromes[J].JACC Cardiovasc Imaging,2012,5(3 Suppl):S53-61.
[12] Franczyk-Skóra B1,Gluba A,Banach M,et al.Acute coronary syndromes in patients with chronic kidney disease [J].Curr Vasc Pharmacol,2013,11(5):758-767.
[13] Parfrey PS,Foley RN,Harnett JD,et al.Outcome and risk factors for left ventricular disorders in chronic uraemia[J].Nephrol Dial Transplant,1996,11(7):1277-1285.
[14] Chen SC,Su HM,Hung CC,et al.Echocardiographic parameters are independently associated with rate of renal function decline and progression to dialysis in patients with chronic kidney disease[J].Clin J Am Soc Nephrol,2011,6(12):2750-2758.
[15] Naito K,Anzai T,Yoshikawa T,et al.Impact of chronic kidney disease on postinfarction inflammation,oxidative stress,and left ventricular remodeling[J].J Card Fail,2008,14(10):831-838.
[2] Kidney Disease:Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group.KDIGO 2017 Clinical Practice Guideline Update for the Diagnosis,Evaluation,Prevention,and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD)[J].Kidney Int Suppl,2017,7:1-59.
[3] 王朝晖,苏冠华.关注急性冠脉综合征合并慢性肾病及其抗栓治疗策略[J].临床心血管病杂志,2017,33(7):615-618.
[4] Washam JB,Herzog CA,Beitelshees AL,et al.Pharmacotherapy in chronic kidney disease patients presenting with acute coronary syndrome:a scientific statement from the American Heart Association[J].Circulation,2015,131(12):1123-1149.
[5] Shroff GR,Frederick PD,Herzog CA.Renal failure and acute myocardial infarction:clinical characteristics in patients with advanced chronic kidney disease,on dialysis,and without chronic kidney disease.A collaborative project of the United States Renal Data System/National Institutes of Health and the National Registry of Myocardial Infarction[J].Am Heart J,2012,163(3):399-406.
[6] Sosnov J,Lessard D,Goldberg RJ,et al.Differential symptoms of acute myocardial infarction in patients with kidney disease:a community-wide perspective[J].Am J Kidney Dis,2006,47(3):378-384.
[7] Wright RS,Reeder GS,Herzog CA,et al.Acute myocardial infarction and renal dysfunction:a high-risk combination[J].Ann Intern Med,2002,137(7):563-570.
[8] Chen HH,Wu CJ,Chen YC,et al.Metabolic syndrome is associated with severe coronary artery disease and poor cardiac outcome in end-stage renal disease patients with acute coronary syndrome[J].Coron Artery Dis,2006,17(7):593-596.
[9] Abid L,Charfeddine S,Kammoun S,et al.Cystatin C:A prognostic marker after myocardial infarction in patients without chronic kidney disease[J].J Saudi Heart Assoc,2016,28(3):144-151.
[10] Widimsky P,Rychlik I.Renal disease and acute coronary syndrome[J].Heart,2010,96(1):86-92.
[11] Baber U,Stone GW,Weisz G,et al.Coronary plaque composition,morphology,and outcomes in patients with and without chronic kidney disease presenting with acute coronary syndromes[J].JACC Cardiovasc Imaging,2012,5(3 Suppl):S53-61.
[12] Franczyk-Skóra B1,Gluba A,Banach M,et al.Acute coronary syndromes in patients with chronic kidney disease [J].Curr Vasc Pharmacol,2013,11(5):758-767.
[13] Parfrey PS,Foley RN,Harnett JD,et al.Outcome and risk factors for left ventricular disorders in chronic uraemia[J].Nephrol Dial Transplant,1996,11(7):1277-1285.
[14] Chen SC,Su HM,Hung CC,et al.Echocardiographic parameters are independently associated with rate of renal function decline and progression to dialysis in patients with chronic kidney disease[J].Clin J Am Soc Nephrol,2011,6(12):2750-2758.
[15] Naito K,Anzai T,Yoshikawa T,et al.Impact of chronic kidney disease on postinfarction inflammation,oxidative stress,and left ventricular remodeling[J].J Card Fail,2008,14(10):831-838.