摘要
目的 探讨植入双腔永久性心脏起搏器(PPM)患者新发心房高频事件(AHRE)的影响因素,构建PPM患者新发AHRE的风险评估模型。方法 回顾性分析2020年8月至2022年8月于甘肃省人民医院心血管内科因房室传导阻滞和病态窦房结综合征接受双腔PPM植入的190例患者。依据纳入、排除标准和起搏器程控随访结果,将143例患者分为AHRE组(27例)和non-AHRE组(116例)。对发生AHRE的患者基于年龄、性别采用倾向性评分按照1∶2比例确立对照组,即AHRE组27例和non-AHRE组54例。比较两组的临床病史、体表心电图、超声心动图、实验室检查和起搏器参数等资料,应用logistic回归分析探讨AHRE的影响因素,筛选有意义的指标构建列线图模型。通过受试者工作特征(ROC)曲线下面积(AUC)和临床决策曲线分析法(DCA)评估不同评分模型的风险评估能力。结果 本研究共纳入81例双腔PPM植入患者,其中男性36例(44.4%),平均年龄(67.9±8.9)岁。与non-AHRE组比较,AHRE组患者的左束支起搏比例较低(P=0.022),CHA_2DS_2-VASc评分和HAVOC评分较高(均为P<0.001),高血压(P=0.007)、冠心病(P=0.041)和β受体阻滞剂服药史(P=0.012)比例较高;AHRE组心房感知较低(P=0.046),左心房前后径(LAAP,P<0.001)、左心室舒张末期内径(P<0.001)、A峰(P=0.042)、起搏QRS持续时间(QRSd,P<0.001)和QTc间期(P=0.026)较大;AHRE组C反应蛋白(P=0.007)、中性粒细胞(P=0.017)、同型半胱氨酸(Hcy,P<0.001)和全身免疫炎症反应指数(P=0.019)较高。多因素logistic回归分析显示,LAAP(OR=1.300)、Hcy(OR=1.115)、起搏QRSd(OR=1.042)和HAVOC评分(OR=1.806)是双腔PPM植入患者新发AHRE的独立影响因素(均为P<0.05)。利用非复合影响因素(LAAP、Hcy和起搏QRSd)构建新的风险评估模型(AHRE-BEE评分),其AUC、敏感度、特异度和阳性似然比均明显优于CHA_2DS_2-VASc评分和HAVOC评分,分别为0.918、0.889、0.833和5.323,而阴性似然比则最低,为0.133(P<0.001)。DCA显示,在20%~80%的阈值概率区间,AHRE-BEE评分的净效益优于其他两个模型。结论 LAAP、Hcy、起搏QRSd和HAVOC评分是双腔PPM植入患者新发AHRE的独立影响因素。由LAAP、Hcy和起搏QRSd构建的AHRE-BEE评分对双腔PPM植入患者新发AHRE具有一定识别作用。
Objective To investigate the influencing factors of new-onset atrial high-rate episodes(AHRE)in patients with dual-chamber permanent pacemakers(PPM)and to develop a risk assessment model for predicting new-onset AHRE in this population.Methods A retrospective analysis was conducted on 190 patients who received dual-chamber PPM implantation due to atrioventricular block and sick sinus syndrome in the Department of Cardiology at Gansu Provincial Hospital from August 2020 to August 2022.According to inclusion and exclusion criteria and pacemaker programming follow-up results,143 patients were divided into AHRE group(27 cases)and non-AHRE group(116 cases).A control group was established for patients with AHRE based on age and gender using a propensity score in a 1∶2 ratio,resulting in 27 cases in AHRE group and 54 cases in non-AHRE group.The clinical data were compared between the two groups.Logistic regression analysis was used to explore the influencing factors of AHRE,and meaningful indicators were selected to construct a nomogram model.The risk assessment capabilities of different scoring models were evaluated using the area under the receiver operating characteristic(ROC)curve(AUC)and clinical decision curve analysis(DCA).Results A total of 81 patients(36 males,44.4%)with dual-chamber PPM implantation were included in this study,with an average age of 67.9±8.9 years.Compared with non-AHRE group,patients in AHRE group had a lower proportion of left bundle branch pacing(P=0.022),higher CHA2DS2-VASc score and HAVOC score(both P<0.001),higher proportion of hypertension(P=0.007),coronary artery disease(P=0.041),and history ofβ-blocker medication(P=0.012);the AHRE group had lower atrial sensing(P=0.046),larger left atrial anteroposterior diameter(LAAP,P<0.001),left ventricular end-diastolic diameter(P<0.001),A-wave(P=0.042),pacing QRS duration(QRSd,P<0.001),and QTc interval(P=0.026);the AHRE group had higher levels of C-reactive protein(P=0.007),neutrophils(P=0.017),homocysteine(Hcy,P<0.001),and systemic immune-inflammatory index(P=0.019).Multivariate logistic regression analysis showed that LAAP(OR=1.300),Hcy(OR=1.115),pacing QRSd(OR=1.042),and HAVOC score(OR=1.806)were independent predictors of new-onset AHRE in patients with dual-chamber PPM implantation(all P<0.05).A new risk assessment model(AHRE-BEE score)was constructed using non-composite predictors(LAAP,Hcy,and pacing QRSd),and its AUC,sensitivity,specificity,and positive likelihood ratio were significantly superior to the CHA2DS2-VASc score and HAVOC score,being 0.918,0.889,0.833,and 5.323,respectively,while the negative likelihood ratio was the lowest at 0.133(P<0.001).DCA showed that in the threshold probability range of 20%to 80%,the net benefit of the AHRE-BEE score was superior to the other two models.Conclusions LAAP,Hcy,pacing QRSd,and HAVOC scores are independent predictors of new-onset AHRE in patients with dual-chamber PPM implantation.The AHRE-BEE score constructed from LAAP,Hcy,and pacing QRSd has certain identification capabilities for new-onset AHRE in patients with dual-chamber PPM implantation.
作者
王鑫
杨小雄
李燕玲
张天成
万敬强
杨保平
谢萍
Wang Xin;Yang Xiaoxiong;Li Yanling;Zhang Tiancheng;Wan Jingqiang;Yang Baoping;Xie Ping(Department of Cardiology,Gansu Provincial Hospital of Traditional Chinese Medicine,Lanzhou 730050,China;Department of Geriatrics,Gansu Second People's Hospital,Lanzhou 730000,China;Department of Cardiology,Gansu Provincial Hospital,Lanzhou 730000,China)
出处
《中国心血管杂志》
北大核心
2025年第5期537-546,共10页
Chinese Journal of Cardiovascular Medicine
关键词
心房高频事件
双腔永久性心脏起搏器
影响因素
列线图
Atrial high-rate episodes
Dual-chamber permanent pacemaker
Influencing factor
Nomogram
作者简介
通信作者:谢萍,电子信箱:pingxie66@163.com。
