慢性阻塞性肺疾病患者的 ST 段抬高型心肌梗死：二维斑点追踪超声心动图评估右心室收缩功能障碍的预后意义。
ST-Segment Elevation Myocardial Infarction in Patients With Chronic Obstructive Pulmonary Disease: Prognostic Implications of Right Ventricular Systolic Dysfunction as Assessed with Two-Dimensional Speckle-Tracking Echocardiography.
机构信息
Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands.
Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands.
出版信息
J Am Soc Echocardiogr. 2019 Oct;32(10):1277-1285. doi: 10.1016/j.echo.2019.05.016. Epub 2019 Jul 13.
BACKGROUND
Right ventricular (RV) systolic function in patients admitted with ST-segment elevation myocardial infarction (STEMI) with chronic obstructive pulmonary disease (COPD) and its impact on prognosis have not been characterized. The present study aims to compare the prevalence of RV systolic dysfunction in COPD versus non-COPD patients with STEMI and evaluate the prognostic implications.
METHODS
One hundred seventeen STEMI patients with COPD with transthoracic echocardiography performed within 48 hours of admission were retrospectively selected. Matched on age, gender, and infarct size (determined by cardiac biomarkers and left ventricular ejection fraction [LVEF]), 207 non-COPD patients were selected. RV dysfunction was defined based on tricuspid annular plane systolic excursion <17 mm (TAPSE), tricuspid annular systolic velocity <6 cm/s (S'), RV fractional area change <35% (FAC), and RV longitudinal free wall strain (FWSL) measured with speckle-tracking echocardiography >-20%. Patients were followed for the occurrence of all-cause mortality.
RESULTS
RV assessment was feasible in 112 COPD and 199 non-COPD patients (mean age, 69 ± 10; 74% male; mean, LVEF 47% ± 8%). Patients with COPD had significantly lower RV FAC (38% ± 11% vs 40% ± 9%; P = .04), equal TAPSE and S' (17.9 ± 3.7 vs 18.1 ± 3.8 mm, P = .72; and 8.4 ± 2.2 vs 8.5 ± 2.2 cm/sec, P = .605, respectively) and more impaired RV FWSL (-21.1% ± 6.6% vs -23.4% ± 6.5%, P = .005), compared with patients without COPD. RV dysfunction was more prevalent in patients with COPD, particularly when assessed with RV FWSL (46% vs 32%; P = .021). During a median follow-up of 30 (interquartile range 1.5-44) months, 49 patients died (16%). Multivariate models stratified for COPD status showed that RV FWS >-20% was independently associated with 5-year all-cause mortality (hazard ratio, 2.05; 95% CI, 1.12-3.76; P = .020), after adjusting for age, diabetes, peak troponin level, and LVEF. Interestingly, RV FAC < 35%, S'< 6 cm/sec, and TAPSE < 17 mm were not independently associated with survival.
CONCLUSION
In a STEMI population with relatively preserved LVEF, COPD patients had significantly worse RV FWSL compared with patients without COPD. Moreover, RV FWSL > -20% was independently associated with worse survival. In contrast, conventional parameters were not associated with survival.
背景
患有 ST 段抬高型心肌梗死（STEMI）合并慢性阻塞性肺疾病（COPD）的患者的右心室（RV）收缩功能及其对预后的影响尚未明确。本研究旨在比较 COPD 与非 COPD STEMI 患者 RV 收缩功能障碍的发生率，并评估其预后意义。
方法
回顾性选择了 117 例 STEMI 合并 COPD 患者，他们在入院后 48 小时内接受了经胸超声心动图检查。根据年龄、性别和梗死面积（由心脏标志物和左心室射血分数[LVEF]确定）与 COPD 患者相匹配，选择了 207 例非 COPD 患者。RV 功能障碍定义为三尖瓣环平面收缩期位移（TAPSE）<17mm、三尖瓣环收缩期速度（S'）<6cm/s、RV 节段面积变化率（FAC）<35%和 RV 纵向游离壁应变（FWSL）<-20%。使用斑点追踪超声心动图测量。患者接受了全因死亡率的随访。
结果
在 112 例 COPD 和 199 例非 COPD 患者中（平均年龄 69±10 岁，74%为男性，平均 LVEF 为 47%±8%），RV 评估是可行的。COPD 患者的 RV FAC 明显更低（38%±11%比 40%±9%，P=0.04），TAPSE 和 S' 相等（17.9±3.7 比 18.1±3.8mm，P=0.72；8.4±2.2 比 8.5±2.2cm/s，P=0.605），RV FWSL 受损更严重（-21.1%±6.6%比-23.4%±6.5%，P=0.005）。与无 COPD 患者相比，COPD 患者 RV 功能障碍更为常见，尤其是使用 RV FWSL 评估时（46%比 32%，P=0.021）。在中位随访 30（四分位间距 1.5-44）个月期间，有 49 名患者死亡（16%）。按 COPD 状态分层的多变量模型显示，RV FWS>-20%与 5 年全因死亡率独立相关（危险比，2.05；95%置信区间，1.12-3.76；P=0.020），调整年龄、糖尿病、峰值肌钙蛋白水平和 LVEF 后。有趣的是，RV FAC<35%、S'<6cm/s 和 TAPSE<17mm 与生存无关。
结论
在 LVEF 相对保留的 STEMI 人群中，与无 COPD 患者相比，COPD 患者的 RV FWSL 明显更差。此外，RV FWSL>-20%与生存不良独立相关。相比之下，传统参数与生存无关。
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