2021 年第 5 期 第 16 卷

急性心肌梗死患者左心室射血分数中等范围与急性肾损伤的关系

The relationship between left ventricular ejection fraction mid-range and acute kidney injury in patients with acute myocardial infarction

作者：朱佳佳刘文娴

英文作者：Zhu Jaijia Liu Wenxian

单位：首都医科大学附属北京安贞医院心内科监护室北京市心肺血管疾病研究所100029

英文单位：Intensive Care Unit of Department of Cardiology Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart Lung and Blood Vessel Diseases Beijing 100029 China

关键词：急性心肌梗死；急性肾损伤；左心室射血分数

英文关键词：Acutemyocardialinfarction;Acutekidneyinjury;Leftventricularejectionfraction

• 摘要：

• 目的 分析急性心肌梗死（AMI）患者左心室射血分数（LVEF）中等范围与急性肾损伤（AKI）的关系。方法 回顾性分析2018年1月至2019年3月于首都医科大学附属北京安贞医院就诊的1 429例 AMI发病24 h内患者的临床资料。根据患者是否发生AKI分为AKI组（245例）和无AKI组（1 184例）；根据LVEF水平分为LVEF降低组（LVEF＜40%，125例）、LVEF中等范围组（LVEF 为40%~49%，240例）和LVEF保留组（LVEF≥50%，1 064例）。记录患者基线资料、入院时情况以及在院治疗情况并分析AMI患者发生AKI的危险因素。结果 AKI组年龄、肾功能不全、脑血管病史、经皮冠状动脉介入史比例均高于无AKI组；入院时心率、肌钙蛋白I、血肌酐、C反应蛋白水平均高于无AKI组，LVEF水平低于无AKI组；Killip分级Ⅲ~Ⅳ级、估算肾小球滤过率（eGFR）＜60 ml/（min·1.73 m2）比例均高于无AKI组（均P＜0.05）。AKI组在院期间使用血管紧张素转换酶抑制剂（ACEI）/血管紧张素Ⅱ受体拮抗剂（ARB）、β受体阻滞剂比例均低于无AKI组，住院时间、发生心源性休克（CS）及死亡比例均长于/高于无AKI组（均P＜0.05）。LVEF降低组、LVEF中等范围组、LVEF保留组AKI发病率分别为33.6%（42/125）、18.8%（45/240）及14.8%（158/1 064），组间比较差异有统计学意义（χ2=16.493，P＜0.001）；入院时心率、Killip分级Ⅲ~Ⅳ级比例、肌钙蛋白I、血肌酐水平、eGFR＜60 ml/（min·1.73 m2）比例、在院期间发生CS、死亡比例均呈下降趋势（均P＜0.05）。多因素Logisitic回归分析结果显示，LVEF＜40%、LVEF为40%~49%、肾功能不全、Killip分级Ⅲ~Ⅳ级、eGFR＜60 ml/(min·1.73 m2)均为AMI患者发生AKI的独立危险因素；使用ACEI/ARB、β受体阻滞剂均为AMI患者发生AKI的保护因素（均P＜0.05）。结论 除LVEF<40%外，LVEF中等范围也是AMI患者发生AKI的独立危险因素。对LVEF中等范围的AMI患者，要做到早期识别和诊治，延缓AMI患者心功能和肾功能恶化。

• Objective To analyze the relationship between left ventricular ejection fraction(LVEF) mid-range and acute kidney injury(AKI) in patients with acute myocardial infarction(AMI). Methods From January 2018 to March 2019, clinical data of 1 429 patients with AMI within 24 h of onset admitted to Beijing Anzhen Hospital, Capital Medical University were retrospectively analyzed. According to occurrence of AKI, patients were divided into AKI group and non-AKI group; according to LVEF level, the patients were divided into LVEF reduced group(LVEF<40%, 125 cases), LVEF mid-range group(LVEF at 40%-49%, 240 cases) and LVEF preserved group(LVEF≥50%, 1 064 cases). The baseline data, condition on admission and hospitalization were recorded. The risk factors of AKI in patients with AMI were analyzed. Results The age and rates of renal insufficiency, cerebrovascular disease history and percutaneous coronary intervention history in AKI group were higher than those in non-AKI group; on admission, heart rate, troponin I, serum creatinine, C-reactive protein levels in AKI group were higher than those in non-AKI group, and LVEF level in AKI group was lower than that in non-AKI group; rates of Killip Ⅲ-Ⅳ grade and estimated glomerular filtration rate (eGFR)<60 ml/（min·1.73 m2） in AKI group were higher than those in non-AKI group (all P<0.05). During hospitalization, the rates of using angiotensin converting enzyme inhibitors(ACEI)/angiotensin Ⅱ receptor blockers(ARB) and β-blockers in AKI group were lower, length of stay was longer, and rates of cardiogenic shock(CS) and death were higher than those in non-AKI group(all P<0.05). The morbidity of AKI in LVEF reduced group, LVEF mid-range group and LVEF preserved group was 33.6%（42/125）, 18.8%（45/240） and 14.8%（158/1 064）, respectively, and the difference was statistically significant（χ2=16.493， P＜0.001）; the heart rate, Killip Ⅲ-Ⅳ grade rate, troponin I, serum creatinine levels, eGFR<60 ml/（min·1.73 m2） rate on admission, and incidences of CS and death during hospitalization showed downward trends(all P<0.05). Multivariate Logistic regression analysis showed that LVEF<40%, LVEF at 40%-49%, renal insufficiency, Killip Ⅲ-Ⅳ grade, eGFR<60 ml/(min·1.73 m2) were independent risk factors of AKI in patients with AMI; using ACEI/ARB and β-blockers were protective factors of AKI in patients with AMI(all P<0.05). Conclusions In addition to LVEF<40%, LVEF mid-range is also an independent risk factor of AKI in patients with AMI. Early recognition, diagnosis and treatment of AMI patients with LVEF mid-range should be done to delay the deterioration of cardiac and renal function.