Chen Yunxia, Li Chunsheng
Department of Emergency, Beijing Chaoyang Hospital, Affiliated to Capital Medical University, Beijing 100020, China. Corresponding author: Li Chunsheng, Email:
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2014 Feb;26(2):115-9. doi: 10.3760/cma.j.issn.2095-4352.2014.02.012.
To evaluate the prognostic and stratified value of adrenomedullin (AM) in community acquired pneumonia (CAP) patients in the emergency department (ED).
A prospective observational study was conducted. Adult patients who fulfilled the CAP criteria admitted to the ED of Beijing Chaoyang Hospital from August 2011 to November 2012 were enrolled. Serum AM was detected, pneumonia severity index (PSI) score and CURB-65 score were calculated at enrollment. AM level, PSI and CURB-65 scores were compared between patients with severe CAP (SCAP) and non-SCAP (NSCAP), survivors and non-survivors. The prognostic and stratified value of AM, PSI score and CURB-65 score was assessed by logistic regression analysis and receiver operating characteristic (ROC) curve.
511 CAP patients, including 127 of SCAP, were enrolled. The 28-day mortality of the study was 34.2% (175/511). AM, PSI score and CURB-65 score in SCAP patients were much higher than those in NSCAP patients, and were higher in non-survivors than those in survivors. Using logistic regression analysis, AM and CURB-65 score were independent predictors of SCAP [AM: odds ratio (OR)=1.127, 95% confidence interval (95%CI): 1.096-1.158, P=0.000; CURB-65 score: OR=1.421, 95%CI: 1.072-1.882, P=0.014]. Combination of AM and CURB-65 score [area under ROC curve (AUC): 0.822, 95%CI: 0.781-0.863, P=0.000] improved the accuracy of both AM (AUC: 0.808, 95%CI: 0.766-0.850, P=0.000) and CURB-65 score (AUC: 0.644, 95%CI: 0.590-0.698, P=0.000) in predicting SCAP (sensitivity: 81.1% vs. 75.6%, 70.9%; specificity: 70.1% vs. 72.9%, 52.3%; positive predictive value: 46.6% vs. 48.0%, 33.0%; negative predictive value: 91.7% vs. 90.0%, 84.5%). AM and PSI score were independent predictors of 28-day mortality (AM: OR=1.084, 95%CI: 1.060-1.108, P=0.000; PSI score: OR=1.019, 95%CI: 1.011-1.027, P=0.000). The accuracy of AM (AUC: 0.724, 95%CI: 0.678-0.770, P=0.000) and PSI score (AUC: 0.731, 95%CI: 0.686-0.776, P=0.000) in predicting the risk of 28-day mortality was improved with the combination of AM and PSI score (AUC: 0.803, 95%CI: 0.763-0.843, P=0.000; sensitivity: 78.3% vs. 69.1%, 77.7%; specificity: 70.5% vs. 65.5%, 58.9%; positive predictive value: 56.6% vs. 51.1%, 49.6%; negative predictive value: 85.9% vs. 80.3%, 83.5%).
AM is valuable for prognosis and stratification of CAP patients in ED. Combination of AM and CURB-65 score is useful for the diagnosis of SCAP. Combination of AM and PSI score improves the prognostic performance in predicting 28-day mortality.
评估肾上腺髓质素（AM）在急诊科（ED）社区获得性肺炎（CAP）患者中的预后及分层价值。
进行一项前瞻性观察性研究。纳入2011年8月至2012年11月在北京朝阳医院急诊科就诊且符合CAP标准的成年患者。入院时检测血清AM，计算肺炎严重程度指数（PSI）评分和CURB-65评分。比较重症CAP（SCAP）患者与非重症CAP（NSCAP）患者、存活者与非存活者之间的AM水平、PSI及CURB-65评分。通过逻辑回归分析和受试者工作特征（ROC）曲线评估AM、PSI评分及CURB-65评分的预后及分层价值。
共纳入511例CAP患者，其中127例为SCAP患者。研究的28天死亡率为34.2%（175/511）。SCAP患者的AM、PSI评分及CURB-65评分远高于NSCAP患者，非存活者高于存活者。采用逻辑回归分析，AM和CURB-65评分是SCAP的独立预测因素[AM：比值比（OR）=1.127，95%置信区间（95%CI）：1.096 - 1.158，P = 0.000；CURB-65评分：OR = 1.421，95%CI：1.072 - 1.882，P = 0.014]。AM与CURB-65评分联合[ROC曲线下面积（AUC）：0.822，95%CI：0.781 - 0.863，P = 0.000]提高了AM（AUC：0.808，95%CI：0.766 - 0.850，P = 0.000）和CURB-65评分（AUC：0.644，95%CI：0.590 - 0.698，P = 0.000）预测SCAP的准确性（敏感性：81.1%对75.6%、70.9%；特异性：70.1%对72.9%、52.3%；阳性预测值：46.6%对48.0%、33.0%；阴性预测值：91.7%对90.0%、84.5%）。AM和PSI评分是28天死亡率的独立预测因素（AM：OR = 1.084，95%CI：1.060 - 1.108，P = 0.000；PSI评分：OR = 1.019，95%CI：1.011 - 1.027，P = 0.000）。AM与PSI评分联合（AUC：0.803，95%CI：0.763 - 0.843，P = 0.000）提高了AM（AUC：0.724，95%CI：0.678 - 0.770，P = 0.000）和PSI评分（AUC：0.731，95%CI：0.686 - 0.776，P = 0.000）预测28天死亡风险的准确性（敏感性：78.3%对69.1%、77.7%；特异性：70.5%对65.5%、58.9%；阳性预测值：56.6%对51.1%、49.6%；阴性预测值：85.9%对80.3%、83.5%）。
AM对ED中CAP患者的预后及分层有价值。AM与CURB-65评分联合有助于SCAP的诊断。AM与PSI评分联合可提高预测28天死亡率的预后性能。
