作者：王星雨1，胡思琪2，李武林1，游达礼1，姜婷婷1，豆振锋1，王飞1，胡善友1，吴晓1

单位：

1.201800上海市，上海健康医学院附属嘉定区中心医院急诊科　2.201800上海市嘉定区南翔镇社区卫生服务中心全科医学科

Units：

1.Department of Emergency, Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences, Shanghai 201800, China 2.Department of General Practice, Nanxiang Town Community Healthcare Center of Jiading District, Shanghai 201800, China

关键词：

心肌梗死；2型心肌梗死；机械通气；危重症；ICU；影响因素分析

Keywords：

Myocardial infarction; Type 2 myocardial infarction; Mechanical ventilation; Critical illness; ICU; Root cause analysis

CLC：

R 542.22

DOI：

10.12114/j.issn.1008-5971.2022.00.029

Funds：

上海市嘉定区卫生健康委员会科研课题计划项目（2019-KY-09）

摘要：

背景　心肌氧供需失衡是导致2型心肌梗死（T2MI）发生的主要因素，而机械通气是患者因机体缺 氧而采取的治疗方式，故推测机械通气患者T2MI发生风险高，但目前临床针对该类患者的T2MI诊断存在一定难度。 目的　探讨ICU机械通气患者发生T2MI的影响因素，以期为临床识别T2MI高风险人群提供参考。方法　选取2017— 2019年上海健康医学院附属嘉定区中心医院ICU收治的危重症患者585例，经纳入与排除标准最终纳入287例机械通气 患者，根据T2MI发生情况将其分为T2MI组130例和非T2MI组157例。比较两组的一般资料、疾病类型、氧供需失衡因 素。采用多因素Logistic回归分析探讨ICU机械通气患者发生T2MI的影响因素。结果　T2MI组患者糖尿病发生率、慢性 心力衰竭发生率、急性生理学及慢性健康状况评分系统Ⅱ（APACHE Ⅱ）评分、院内死亡率及心肌肌钙蛋白（cTn） 基线、最低、最高水平高于非T2MI组（P＜0.05）。本组患者疾病类型以肺部疾病为主，占48.8%（140/287），T2MI 组患者中重症肺炎、感染性休克、出血性疾病者占比高于非T2MI组，社区获得性肺炎（非重症）、多发伤者占比低于 非T2MI组（P＜0.05）。T2MI患者重度贫血、呼吸衰竭、多器官功能障碍综合征（MODS）、急性肾损伤（AKI）、休 克及出血性事件发生率高于非T2MI组（P＜0.05）。多因素Logistic回归分析结果显示，APACHE Ⅱ评分〔OR=1.070， 95%CI（1.021，1.121）〕、呼吸衰竭〔OR=4.847，95%CI（2.533，9.277）〕、休克〔OR=5.922，95%CI（2.558， 13.710）〕、出血性事件〔OR=7.963，95%CI（1.392，45.561）〕是ICU机械通气患者发生T2MI的独立影响因素（P ＜0.05）。结论　本组ICU机械通气患者T2MI发生率为45.3%，APACHE Ⅱ评分、呼吸衰竭、休克、出血性事件是ICU机 械通气患者发生T2MI的独立影响因素。

Abstract：

Background The main mechanism of type 2 myocardial infarction (T2MI) is the imbalance of myocardial oxygen supply and demand. Mechanical ventilation is a treatment for hypoxia, therefore, it is speculated that patients with mechanical ventilation have a high risk of T2MI, but it is difficult to diagnose T2MI in clinic. Objective To explore the influencing factors of T2MI in ICU patients with mechanical ventilation, in order to provide a reference for clinical identification of high-risk T2MI population. Methods A total of 585 critical illness patients admitted to the ICU of Jiading District Central Hospital Affiliated Shanghai University of Medicine & Health Sciences from 2017 to 2019 were recruited. After the inclusion and exclusion criteria, 287 patients with mechanical ventilation were finally included, and they were divided into T2MI group (n=130) and non-T2MI group (n=157) according to incidence of T2MI. General data, disease type, related factors of oxygen supplyimbalance were compared between the two groups. Multivariate Logistic regression analysis was used to discuss the influencing factors of T2MI in ICU patients with mechanical ventilation. Results Incidence of diabetes mellitus and chronic heart failure, Acute Physiology and Chronic Health Evaluation System Ⅱ (APACHE Ⅱ) score, hospital mortality rate and baseline, minimum and maximum level of cardiac troponin (cTn) in the T2MI group were higher than those of the non-T2MI group (P < 0.05) . The main type of disease in this group was pulmonary diseases，accounting for 48.8% (140/287) , proportion of severe pneumonia, septic shock, hemorrhagic disease in the T2MI group were higher than those of the non-T2MI group, proportion of community acquired pneumonia (non-severe) , multiple trauma were lower than those of the non-T2MI group (P < 0.05) . Incidence of severe anemia, respiratory failure, multiple organ dysfunction syndrome (MODS) , acute kidney injury (AKI) , hemorrhagic events, shock were also significantly higher than those of the non-T2MI group (P < 0.05) . Multivariate Logistic regression analysis results showed that, APACHEⅡ score [OR=1.070, 95%CI (1.021, 1.121) ] , respiratory failure [OR=4.847, 95%CI (2.533, 9.277) ] , shock [OR=5.922, 95%CI (2.558, 13.710) ] , hemorrhagic events [OR=7.963, 95%CI (1.392, 45.561) ] were independent influencing factors of T2MI in ICU patients with mechanical ventilation (P < 0.05) . Conclusion The incidence of T2MI in ICU patients with mechanical ventilation is 45.3% in this group, and APACHE Ⅱ score, respiratory failure, shock, hemorrhagic events are independent influencing factors of T2MI in ICU patients with mechanical ventilation.

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