Kageyama Shigetaka, Mitake Hirotsugu, Nakajima Atsuo, Kodama Keita, Hattori Yusuke, Watanabe Yuzo, Sugiyama Hirofumi, Kawahito Michitomo, Takeuchi Ryosuke, Murata Koichiro, Nawada Ryuzo, Onodera Tomoya
Department of Cardiology, Shizuoka City Hospital, 10-93, Otemachi, Aoi-ku, Shizuoka, 420-8630, Japan.
Heart Vessels. 2020 Aug;35(8):1164-1170. doi: 10.1007/s00380-020-01583-3. Epub 2020 Mar 17.
There has been continuing discussion regarding the treatment strategy for acute type A intramural hematoma (IMH). Most patients are treated conservatively in Japan; hence, predicting fatal events and stratifying risks based on results normally obtained on hospital arrival are important. We aimed to examine the incidences and risk factors of death or need for surgery for acute type A IMH in patients receiving medical treatment and to identify high-risk patients using clinical findings on hospital arrival. From 2011 to 2016, 57 consecutive patients (mean age 72.5 years; male 36.8%) diagnosed with acute type A IMH who were receiving treatment at Shizuoka City Shizuoka Hospital were retrospectively included. Primary endpoint was a composite of cardiovascular death and operation within 1 year after onset. To evaluate sensitivity and specificity of the risk factors and risk score, we estimated the area under the receiver operating characteristic (ROC) curve. Mean follow-up duration was 621 days. Mean systolic blood pressure (SBP) was 129 mmHg. Computed tomography (CT) on arrival showed a mean ascending aorta diameter of 46 mm. Ulcer-like projection (ULP) in the ascending aorta and pericardial effusion (PE) were seen in 33% and 42% of cases, respectively. Twenty-eight patients (49.1%) reached the primary endpoint (cardiovascular death, 7 cases [12.3%]; operation, 21 cases [36.8%]). In univariate analysis of admission values, the primary endpoint group had significantly lower SBP (113.0 ± 28.5 vs 144.3 ± 33.5 mmHg), higher ascending aorta diameter (49.5 ± 8.1 vs 43.6 ± 5.9 mm), and higher frequency of ULP (53.8% vs 13.8%) and PE (58.6% vs 25.0%) than the event-free group. Multivariate analysis showed that ULP on admission CT was a significant predictor of the primary endpoint. The risk score was considered using these risk factors. On admission, the primary endpoint could be predicted with 89.7% sensitivity and 75% specificity (area under the ROC curve 0.823) if the patient had ULP and/or > 2 of the following factors: SBP < 120 mmHg, ascending aorta diameter > 45 mm, and PE. SBP and CT findings on arrival were significantly associated with cardiovascular death and the need for surgery in patients with acute type A IMH receiving initial medical therapy. The novel risk score was useful for predicting cardiovascular death and surgery.
关于急性A型主动脉壁内血肿（IMH）的治疗策略一直存在持续的讨论。在日本，大多数患者接受保守治疗；因此，基于入院时通常获得的结果预测致命事件并进行风险分层很重要。我们旨在研究接受药物治疗的急性A型IMH患者死亡或手术需求的发生率及风险因素，并利用入院时的临床发现识别高危患者。2011年至2016年，静冈市静冈医院连续收治的57例诊断为急性A型IMH的患者（平均年龄72.5岁；男性占36.8%）被纳入回顾性研究。主要终点是发病后1年内心血管死亡和手术的复合终点。为评估风险因素和风险评分的敏感性和特异性，我们估计了受试者工作特征（ROC）曲线下面积。平均随访时间为621天。平均收缩压（SBP）为129mmHg。入院时计算机断层扫描（CT）显示升主动脉平均直径为46mm。升主动脉溃疡样突出（ULP）和心包积液（PE）分别见于33%和42%的病例。28例患者（49.1%）达到主要终点（心血管死亡7例[12.3%]；手术21例[36.8%]）。在对入院值的单因素分析中，主要终点组的SBP显著更低（113.0±28.5 vs 144.3±33.5mmHg），升主动脉直径更大（49.5±8.1 vs 43.6±5.9mm），ULP（53.8% vs 13.8%）和PE（58.6% vs 25.0%）的发生率高于无事件组。多因素分析显示，入院CT上的ULP是主要终点的显著预测因素。使用这些风险因素计算风险评分。入院时，如果患者有ULP和/或以下因素中的2项以上：SBP<120mmHg、升主动脉直径>45mm和PE，则可预测主要终点，敏感性为89.7%，特异性为75%（ROC曲线下面积0.823）。入院时的SBP和CT表现与接受初始药物治疗的急性A型IMH患者的心血管死亡和手术需求显著相关。新的风险评分有助于预测心血管死亡和手术。
