2014年欧洲肥厚型心肌病诊断和管理指南心脏性猝死风险评估模型临床应用评估及心血管不良事件危险因素的预测分析

摘要

目的 评估2014年欧洲肥厚型心肌病诊断和管理指南心脏性猝死风险评估模型(HCM Risk-SCD模型)对中国肥厚型心肌病(HCM)患者心脏性猝死(SCD)的预测价值,并探讨预测HCM其他心血管不良事件的指标.方法 回顾性纳入2014年10月至2016年10月在第四军医大学西京医院肥厚型心肌病诊疗中心就诊的成人HCM患者207例.采集入选患者的心电图、超声心动图及心脏磁共振检查结果,应用HCM Risk-SCD模型进行SCD评分.查看入选患者随访记录,观察其终点事件情况,随访截止于2017年3月.终点事件分为一级和二级终点,一级终点指SCD或SCD等位事件,二级终点指发生急性心肌梗死、因心力衰竭住院、血栓栓塞或终末期HCM任意一项.复合终点指患者发生一级或二级终点事件.结果 (1)随访及发生终点事件的情况:本研究中有随访记录的患者207例,平均随访350(230,547)d.其中,8例(3.9％)达到一级终点,21例(10.1％)达到二级终点.(2) HCM Risk-SCD模型效能验证:根据有无一级终点,将患者分为SCD组(8例)和无SCD组(199例).猝死相关危险因素中,晕厥在SCD组发生的比例较无SCD组高(P=0.003),余两组间差异无统计学意义(P均＞0.05).SCD组SCD评分≥4分的患者比例较无SCD组高(P=0.009).(3)SCD评分相关因素分析:根据HCM Risk-SCD模型计算SCD评分,将患者分为低危组(SCD评分＜4分)122例(59％)、中危组(4分≤SCD评分＜6分)42例(20％)和高危组(SCD评分≥6分)43例(21％).高危组患者的年龄小于低危组,且心率较中、低危组快(P均＜0.05).心电图参数中,低危组、中危组和高危组窦性心律患者所占比例逐渐降低(P=0.004),但左心室肥厚患者所占比例逐渐升高(P=0.025);高危组V1导联P波终末电势绝对值大于低危组(P=0.002),中、高危组平面QRS-T夹角大于低危组(P=0.004).超声心动图参数中,高危组左心室质量指数(LVMI)高于低危组(P=0.040),中、高危组最大左心室流出道压力阶差均高于低危组(P=0.000);高危组二尖瓣环收缩期峰值速度(s')低于中、低危组,但左心房前后径(LAD)和左心房容积指数(LAVI)高于中、低危组(P均＜0.05).心脏磁共振参数中,高危组钆延迟增强(LGE)心肌容积、质量和比例均高于低危组(P均＜0.05).Spearman相关分析显示,SCD评分与心率(r=0.161,P=0.019)、平面QRS-T夹角(r=0.669,P=0.001)、LVMI (r=0.206,P=0.004)、LAVI (r=0.284,P=0.000)、s'(r=-0.245,P=0.001)、LGE质量占左心室心肌质量的百分比(LGE％,r=0.351,P=0.000)相关.(4)心血管不良事件的预测分析:根据有无复合终点,将患者分为心血管不良事件组(29例)和无不良事件组(178例).不良事件组纽约心脏协会(NYHA)心功能Ⅲ/Ⅳ级患者所占比例、左心房前后径(LAD)和左心房容积指数(LAVI)均高于无不良事件组,而s'和二尖瓣环舒张早期峰值速度(e')则低于无不良事件组(P均＜0.05).ROC分析结果显示LAD、LAVI、e'和s'均可预测心血管不良事件,即LAD≥39 mm[曲线下面积(AUC) 0.702,95％CI0.604～0.799,P=0.001]、LAVI≥49.6 ml/m2 (AUC 0.700,95％CI0.567～0.833,P=0.001)、e'≤≤6.5 cm/s(AUC 0.716,95％CI 0.616～0.817,P=0.000)、s' ≤6.6 cm/s (AUC0.764,95％CI 0.676～0.853,P=0.000)的患者,更易发生心血管不良事件.结论 HCM Risk-SCD模型对本中心HCM患者发生SCD具有一定预测价值.心电图平面QRS-T夹角和心脏磁共振LGE％与HCM患者SCD评分的相关性最好.常规超声心动图参数LAD、LAVI、e'和s对HCM患者心血管不良事件具有预测价值.%Objective To evaluate the predicting value of the 2014 European Society of Cardiology (ESC) guidelines risk prediction model for sudden cardiac death (HCM Risk-SCD) in Chinese patients with hypertrophic cardiomyopathy (HCM),and to explore the predictors of adverse cardiovascular events in Chinese HCM patients.Methods The study population consisted of a consecutive 207 HCM patients admitted in our center from October 2014 to October 2016.All patients were followed up to March 2017.The 5-year SCD probability of each patient was estimated using HCM Risk-SCD model based on electrocardiogram,echocardiography and cardiac magnetic resonance (CMR) examination results.The primary,second,and composite endpoints were recorded.The primary endpoint included SCD and appropriate ICD therapy,identical to the HCM Risk-SCD endpoint.The second endpoint included acute myocardial infarction,hospitalization for heart failure,thrombus embolism and end-stage HCM.The composite endpoint was either the primary or the second endpoint.Patients were divided into the 3 categories according to 5-year SCD probability assessed by HCM Risk-SCD model:low risk group＜4％,intermediate risk group ≥4％ to＜6％,and high risk group≥6％.Results (1) Prevalence of endpoints:All 207 HCM patients completed the follow-up (350 (230,547) days).During follow-up,8 (3.86％) patients reached the primary endpoints (3 cases of SCD,3 cases of survival after defibrillation,and 2 cases of appropriate ICD discharge);21 (10.14％) patients reached the second endpoints (1 case of acute myocardial infarction,16 cases of heart failure hospitalization,2 cases of thromboembolism,and 2 cases of end-stage HCM).(2) Predicting value of HCM Risk-SCD model:Patients with primary endpoints had higher prevalence of syncope and intermediate-high risk of 5-year SCD,as compared to those without primary endpoints (both P＜0.05).(3) Predicting value of HCM Risk-SCD model:The low risk group included 122 patients (59％),the intermediate risk group 42 (20％),and the high risk group 43 (21％).There was a clear trend towards to higher heart rate,higher values of PTFv1 and plane QRS-T angle,higher left ventricular mass index (LVMI),elevated maximal left ventricular outflow tract pressure gradient (LVOT-PGmax),enlarged left atrial dimension(LAD) and volume index (LAVI),reduced systolic mitral annular velocity (s'),and higher late gadolinium enhancement (LGE) volume and mass in patients with high risk of 5-year of SCD,as compared to those with low-intermediate risk (all P＜0.05).Moreover,5-year SCD probability was positively correlated with heart rate,plane QRS-T angle,LVMI,LAVI,LGE％,and negatively correlated with s'(r=0.161,P=0.019;r=0.669,P=0.001;r=0.206,P=0.004;r=0.284,P=0.000;r=0.351,P=0.000;r=-0.245,P=0.001;respectively).(4) LAD,LAVI,e' and s' were independent predictors for poor outcomes.HCM patients with LAD≥39 mm,LAVI≥49.6 ml/m2,e' ≤6.5 cm/s and s'≤ 6.6 cm/s were more likely to have adverse cardiovascular events (AUC 0.702,95％ CI 0.604-0.799,P=0.001;AUC 0.700,95％ CI 0.567-0.833,P=0.001;AUC 0.716,95％CI 0.616-0.817,P=0.000;AUC 0.764,95％CI 0.676-0.853,P=0.000,respectively).Conclusions The HCM Risk-SCD model is of value in predicting SCD for Chinese HCM patients.The plane QRS-T angle and LGE％ are the best predictors of 5-year SCD risk in Chinese HCM patients.Moreover,conventional echocardiographic parameters,including LAD,LAVI,e' and s',are useful to predict adverse cardiovascular events among Chinese HCM patients.