摘要
目的:本研究旨在探讨HAS-BLED评分和CHA_(2)DS_(2)-VASc评分系统对心脏外科术后因心原性休克置入体外膜肺氧合(ECMO)装置的患者出血和血栓事件发生风险的预测能力,为ECMO置入术后管理、降低不良事件风险提供依据。方法:回顾性分析2008年2月至2018年4月中国医学科学院阜外医院280例心脏外科术后因心原性休克接受ECMO辅助循环治疗的患者的临床资料,主要观察结局为ECMO置入术后48 h至出院前发生的出血和血栓事件,出院后所有患者接受电话随访及问卷调查。用Logistic回归分析评估ECMO置入术后48 h至出院前出血和血栓事件的危险因素。用ROC曲线分析和Hosmer-Lemeshow拟合优度检验评估HAS-BLED评分、CHA_(2)DS_(2)-VASc评分分别预测ECMO置入术后48 h至出院前出血、血栓事件的分辨力和校准度,并与ATRIA评分和ORBIT评分进行比较。结果:ECMO置入术后48 h至出院前发生出血事件17例(6.07%),血栓事件11例(3.93%);HAS-BLED评分≥3分(高危)者(20.4%,10/49)中出血发生率明显高于HAS-BLED评分2分(中危)者(11.1%,5/45)和0~1分(低危)者(1.1%,2/186),CHA_(2)DS_(2)-VASc评分≥2分(高危)者(10.9%,10/92)中血栓事件发生率也高于CHA_(2)DS_(2)-VASc评分1分(中危)者(1.2%,1/93)和0分(低危)者(0%,0/95),差异均有统计学意义(P均<0.05)。出院后平均随访(382.0±175.5)d,所有患者未再发生出血和血栓事件。多因素回归分析显示,ECMO置入术后48 h至出院前出血事件的独立预测因素包括饮酒或服药史(OR=29.824)、肝肾功能异常(OR=38.942)。ROC曲线分析显示,HAS-BLED评分预测ECMO置入术后48 h至出院前出血事件的AUC为0.70,而ATRIA评分和ORBIT评分的AUC均为0.54;CHA_(2)DS_(2)-VASc评分预测ECMO置入术后48 h至出院前血栓事件的AUC为0.80,ATRIA评分和ORBIT评分的AUC均为0.55。HAS-BLED评分预测出血事件和CHA_(2)DS_(2)-VASc评分预测血栓事件的校准度均高(P均=1.0)。结论:HAS-BLED评分≥3分、CHA_(2)DS_(2)-VASc评分≥2分提示ECMO置入术后患者有较高的出血和血栓事件发生风险。与ATRIA评分和ORBIT评分相比,HAS-BLED评分和CHA_(2)DS_(2)-VASc评分的分辨力和校准度更高。
Objectives:We aimed to explore the predictive value of HAS-BLED and CHA_(2)DS_(2)-VASc scores after extra corporeal membrane oxygenation(ECMO)implantation in patients with postcardiotomy cardiogenic shock(PCCS)and provide clinical evidence of using these scores to guide the postoperative management and reduce the adverse events in these patients.Methods:This retrospective analysis enrolled 280 PCCS patients,who were hospitalized in our department and received ECMO implantation from 2008 to 2018.We observed in these patients.The primary endpoint was bleeding events and thrombotic events between 48 hours after ECMO implantation and discharge,patients were followed up for a mean of(382.0±175.5)days.Logistic regression analysis was used to determine risk factors of bleeding events and thrombotic events between 48 hours after ECMO implantation and discharge.AUC statistic(ROC curve)and the Hosmer-Lemeshow(HL)goodness-of-fit statistic were used to define the predictive value of HAS-BLED and CHA_(2)DS_(2)-VASc scores on risk of bleeding events and thrombotic events between 48 hours after ECMO implantation and discharge.The results were compared with ATRIA and ORBIT scores,respectively.Results:Bleeding events occurred in 17 patients(6.07%)and TE occurred in 11 patients(3.93%).HAS-BLED score≥3 was associated with a significantly higher risk of bleeding events compared with HAS-BLED score 2 or 0-1(20.4%[10/49]vs.11.1%[5/45]vs.1.1%[2/186],both P<0.05).CHA_(2)DS_(2)-VASc score≥2 was associated with a higher risk of thrombotic events compared with CHA_(2)DS_(2)-VASc score 1 or 0(10.9%[10/92]vs.1.2%[1/93]vs.0%[0/95],both P<0.05).There was no recurrence of bleeding events and thrombotic events during follow up.Multivariate logistic regression analysis showed that drug use and alcohol consumption(OR=29.824)and abnormal liver or kidney function(OR=38.942)were independent predictors for bleeding events.ROC curve showed that AUC of HAS-BLED model for bleeding events was 0.70,while AUC of ATRIA and ORBIT were 0.54.ROC curve showed that AUC of CHA_(2)DS_(2)-VASc model for thrombotic events was 0.80,while AUC of ATRIA and ORBIT were 0.55.The calibration value of HAS-BLED and CHA_(2)DS_(2)-VASc was high(both P=1.0).Conclusions:PCCS patients with baseline HAS-BLED score of≥3 and CHA_(2)DS_(2)-VASc scores score of≥2 confer significantly higher risks of bleeding and thrombotic events following ECMO implantation.HAS-BLED and CHA_(2)DS_(2)-VASc scores have better discrimination and calibration ability than ATRIA and ORBIT scores.
作者
雷白
侯剑峰
胡盛寿
LEI Bai;HOU Jianfeng;HU Shengshou(Adult Cardiac Surgery Center,National Center for Cardiovascular Diseases and Fuwai Hospital,CAMS and PUMC,Beijing(100037),China)
出处
《中国循环杂志》
CSCD
北大核心
2021年第6期567-573,共7页
Chinese Circulation Journal
基金
国家重点研发计划项目(2016YFC1300900)。
作者简介
通信作者:胡盛寿,Email:huss@fuwaihospital.org。
