PCI术后的STEMI患者营养不良患病率及预后意义

Prevalence and Prognostic Significance of Malnutrition in STEMI Patients after PCI

摘要: 背景：在许多疾病中，营养不良与疾病的发生及预后有着密切的关系，有相关研究表明营养不良与多种心血管疾病不良预后密切相关，但现在并无公认的适用于心血管疾病的营养状态评价标准，同时现有关于PCI术后的STEMI患者的研究多数为单一营养状态评分与预后的研究，因此本研究使用三种不同的营养状态评分探究PCI术后的STEMI患者营养不良的发病率及预后意义并进行横向比较。目的：本研究旨在调查PCI术后的STEMI患者的营养不良患病率及探究其临床相关性及对患者预后的影响。方法：本研究选取2020.01~2022.12期间于我院就诊并行PCI的STEMI患者554例。收集患者临床基本资料、实验室检验结果、超声心动图及冠状动脉造影结果。使用控制营养状态评分(COUNT)、老年营养风险指数(GNRI)和预后营养指数(PNI)评估患者营养状态，并根据营养状态和是否发生全因死亡分组。探究营养不良的患病率及与全因死亡率之间的关系。结果：1) 根据COUNT、GNRI及PNI评分，中重度营养不良患者分别为84 (15.2%)、277 (50.0%)和46 (8.3%)；其中457 (82.4%)例患者至少被一种营养状态评分评估为营养不良。虽然低体重指数与营养不良发生有相关性，但是在肥胖(BMI ≥ 28 kg/m²)患者中仍有3.9%至66.2%的患者被评估为营养不良。2) 在中位815.50 (531.75, 1115.50)天的随访中，共有80 (14.4%)例患者发生了全因死亡结局。与营养状态正常的患者相比，营养状态为重度营养不良的患者全因死亡风险明显增加(重度营养不良患者多因素Cox回归分析中的全因死亡风险比(95%置信区间)为COUNT：121.628 (7.774~1902.946)；GNRI：5.884 (1.321~26.197)；PNI：9.293 (3.027~28.531)；均p < 0.05)。3) GRACE、COUNT、GNRI、PNI及BMI与患者全因死亡事件的ROC曲线AUC为0.817至0.612，使用NRI及IDI检验不同指标的预测能力，其中GRACE评分预测效能最强，各营养状态评分间预测效能未见显著差异，COUNT和NRI评分检验效能明显高于BMI，PNI与BMI未见显著差异。4) 将营养状态评分分别与GRACE评分联合均能提升GRACE评分对PCI术后STEMI患者全因死亡的预测价值，其中COUNT评分提升最显著(IDI: 0.034 (0.007~0.114), NRI: 0.265 (0.052~0.439), p < 0.001)。结论：营养不良在PCI术后的STEMI患者中普遍存在。营养不良是PCI术后STEMI患者全因死亡的独立预测因子。

Abstract: Background: In many diseases, there is a close relationship between malnutrition and the occurrence and prognosis of the disease. Some studies have shown a close association between malnutrition and adverse outcomes in various cardiovascular diseases. However, there is currently no universally recognized nutritional assessment standard applicable to cardiovascular diseases. Moreover, existing studies on post-PCI STEMI patients mostly focus on individual nutritional status scores and prognosis. Therefore, this study aims to explore the incidence and prognostic significance of malnutrition in post-PCI STEMI patients using three different nutritional status scores and to conduct a cross-sectional comparison. Objective: This study aims to investigate the prevalence of malnutrition and explore its clinical relevance and impact on patient prognosis in post-PCI STEMI patients. Methods: This study selected 554 STEMI patients who underwent PCI at our hospital between January 2020 and December 2022. Clinical baseline data, laboratory test results, echocardiography, and coronary angiography results of the patients were collected. The patients’ nutritional status was assessed using the Controlling Nutritional Status Score (COUNT), Geriatric Nutritional Risk Index (GNRI), and Prognostic Nutritional Index (PNI). Patients were grouped based on nutritional status and occurrence of all-cause mortality to explore the incidence of malnutrition and its relationship with all-cause mortality. Results: 1) Based on COUNT, GNRI, and PNI scores, 84 (15.2%), 277 (50.0%), and 46 (8.3%) patients were classified as having moderate to severe malnutrition, respectively. Among them, 457 (82.4%) patients were assessed as malnourished by at least one nutritional status score. Although low body weight index was correlated with malnutrition, 3.9% to 66.2% of patients in the obese group (BMI ≥ 28 kg/m²) were still assessed as malnourished. 2) During a median follow-up of 815.50 (531.75, 1115.50) days, 80 (14.4%) patients experienced all-cause mortality. Patients with severe malnutrition had a significantly increased risk of all-cause mortality compared to those with normal nutritional status (multivariate Cox regression analysis hazard ratios for all-cause mortality in severe malnutrition patients were COUNT: 121.628 (7.774~1902.946); GNRI: 5.884 (1.321~26.197); PNI: 9.293 (3.027~28.531); all p < 0.05). 3) The ROC curve AUC for GRACE, COUNT, GNRI, PNI, and BMI in predicting all-cause mortality events ranged from 0.817 to 0.612. Using NRI and IDI tests to assess the predictive ability of different indicators, the GRACE score had the strongest predictive efficacy, while there was no significant difference in predictive efficacy between the various nutritional status scores. COUNT and NRI scores had significantly higher predictive efficacy than BMI, and there was no significant difference between PNI and BMI. 4) Combining nutritional status scores with the GRACE score improved the predictive value for all-cause mortality in post-PCI STEMI patients, with COUNT score showing the most significant improvement (IDI: 0.034 (0.007~0.114), NRI: 0.265 (0.052~0.439), p < 0.001). Conclusion: Malnutrition is common in post-PCI STEMI patients. Malnutrition is an independent predictor of all-cause mortality in post-PCI STEMI patients.