Jiang Yi, Zhu Yuansong, Xiang Zhenxian, Sasmita Bryan Richard, Wang Yaxin, Ming Gong, Chen Siyu, Luo Suxin, Huang Bi
Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Front Cardiovasc Med. 2023 Jan 9;9:1083881. doi: 10.3389/fcvm.2022.1083881. eCollection 2022.
Shock is associated with the activation of the coagulation and fibrinolytic system, and D-dimer is the degradation product of cross-linked fibrin. However, the prognostic value of D-dimer in patients with cardiogenic shock (CS) after acute myocardial infarction (AMI) remains unclear.
We retrospectively analyzed the data of consecutive patients with CS complicating AMI. The primary endpoint was 30-day mortality and the secondary endpoint was the major adverse cardiovascular events (MACEs) including 30-day all-cause mortality, ventricular tachycardia/ventricular fibrillation, atrioventricular block, gastrointestinal hemorrhage, and non-fatal stroke. Restricted cubic spline (RCS) analyses were performed to assess the association between admission D-dimer and outcomes. A multivariable Cox regression model was performed to identify independent risk factors. The risk predictive potency with D-dimer added to the traditional risk scores was evaluated by C-statistics and the net reclassification index.
Among 218 patients with CS complicating AMI, those who died during the 30-day follow-up presented with worse baseline characteristics and laboratory test results, including a higher level of D-dimer. According to the X-tile program result, the continuous plasma D-dimer level was divided into three gradients. The 30-day all-cause mortality in patients with low, medium, and high levels of D-dimer were 22.4, 53.3, and 86.2%, respectively ( < 0.001 for all). The 30-day incidence of MACEs was 46.3, 77.0, and 89.7%, respectively ( < 0.001). In the multivariable Cox regression model, the trilogy of D-dimer level was an independent risk predictor for 30-day mortality (median D-dimer cohort: HR 1.768, 95% CI 0.982-3.183, = 0.057; high D-dimer cohort: HR 2.602, 95% CI 1.310-5.168, = 0.006), a similar result was observed in secondary endpoint events (median D-dimer cohort: HR 2.012, 95% CI 1.329-3.044, = 0.001; high D-dimer cohort: HR 2.543, 95% CI 1.452-4.453, = 0.001). The RCS analyses suggested non-linear associations of D-dimer with 30-day mortality. The enrollment of D-dimer improved risk discrimination for all-cause death when combined with the traditional CardShock score (C-index: 0.741 vs. 0.756, = 0.004) and the IABP-SHOCK II score (C-index: 0.732 vs. 0.754, = 0.006), and the GRACE score (C-index: 0.679 vs. 0.715, < 0.001). Similar results were acquired after logarithmic transformed D-dimer was included in the risk score. The improvements in reclassification which were calculated as additional net reclassification index were 7.5, 8.6, and 12.8%, respectively.
Admission D-dimer level was independently associated with the short-term outcome in patients with CS complicating AMI and addition of D-dimer brought incremental risk prediction value to traditional risk prediction scores.
休克与凝血和纤溶系统的激活有关，D - 二聚体是交联纤维蛋白的降解产物。然而，急性心肌梗死（AMI）后心源性休克（CS）患者中D - 二聚体的预后价值仍不清楚。
我们回顾性分析了连续的并发AMI的CS患者的数据。主要终点是30天死亡率，次要终点是主要不良心血管事件（MACE），包括30天全因死亡率、室性心动过速/心室颤动、房室传导阻滞、胃肠道出血和非致命性卒中。进行受限立方样条（RCS）分析以评估入院时D - 二聚体与预后之间的关联。进行多变量Cox回归模型以识别独立危险因素。通过C统计量和净重新分类指数评估将D - 二聚体添加到传统风险评分中的风险预测效力。
在218例并发AMI的CS患者中，在30天随访期间死亡的患者具有更差的基线特征和实验室检查结果，包括更高水平的D - 二聚体。根据X - tile程序结果，将连续血浆D - 二聚体水平分为三个梯度。低、中、高水平D - 二聚体患者的30天全因死亡率分别为22.4%、53.3%和86.2%（所有P<0.001）。MACE的30天发生率分别为46.3%、77.0%和89.7%（P<0.001）。在多变量Cox回归模型中，D - 二聚体水平三分位数是30天死亡率的独立风险预测因子（中位D - 二聚体组：HR 1.768，95%CI 0.982 - 3.183，P = 0.057；高D - 二聚体组：HR 2.602，95%CI 1.310 - 5.168，P = 0.006），在次要终点事件中观察到类似结果（中位D - 二聚体组：HR 2.012，95%CI 1.329 - 3.044，P = 0.001；高D - 二聚体组：HR 2.543，95%CI 1.452 - 4.453，P = 0.001）。RCS分析表明D - 二聚体与30天死亡率之间存在非线性关联。当与传统的CardShock评分（C指数：0.741对0.756，P = 0.004）、IABP - SHOCK II评分（C指数：0.732对0.754，P = 0.006）和GRACE评分（C指数：0.679对0.715，P<0.001）联合使用时，D - 二聚体的纳入改善了对全因死亡的风险辨别能力。在风险评分中纳入对数转换后的D - 二聚体后获得了类似结果。以额外净重新分类指数计算的重新分类改善分别为7.5%、8.6%和12.8%。
入院时D - 二聚体水平与并发AMI的CS患者的短期预后独立相关，并且将D - 二聚体添加到传统风险预测评分中带来了额外的风险预测价值。
