Construction and verification of a model for predicting the risk of left atrial appendage thrombus in patients with non-valvular atrial fibrillation based on nomogram
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摘要:
目的构建非瓣膜性房颤(NVAF)患者左心耳血栓(LAAT)状态预测模型,为临床个体化判断提供参考。 方法选取2018年3月1日~2020年11月30日期间所有在西安交通大学第一附属医院心内科住院患者资料,结合筛选标准共获得NVAF患者530例。根据LAAT状态分为无LAAT组(n=428)和有LAAT组(n=102)。结合国内外研究进展及本单位病例特点广泛收集可能与NVAF患者LAAT形成有关的危险因素,并通过二元Logistic回归分析确定独立危险因素。基于列线图构建NVAF患者LAAT状态模型,并对模型准确性进行评价及内部验证。 结果血栓病史(非LAAT)、房颤病程、房颤发作类型、BNP、Cys-C、LAD等6个危险因素与NAVF患者LAAT状态相关(P均 < 0.05),可作为独立危险因素;基于列线图构建NVAF患者LAAT状态预测模型,C-index为0.74(95%CI:0.69~0.79)。此外,在校准曲线中也表明模型预测能力较好;内部验证集的C-index为0.72(95%CI:0.67~0.77)。 结论基于列线图构建的NVAF患者LAAT状态模型有着良好的实际预测能力,可较准确、直观、个体化地预测NVAF患者LAAT状态。 Abstract:ObjectiveTo construct a model for predicting the risk of left atrial appendage thrombus (LAAT) in patients with nonvalvular atrial fibrillation (NVAF) to provide a reference for individualized clinical judgment. MethodsThe data of all patients hospitalized in the Department of Cardiology of the First Affiliated Hospital of Xi'an Jiaotong University between March 1, 2018 and November 30, 2020 were collected. Then a total of 530 patients with NVAF were obtained according to the screening criteria. It is divided into the non-LAAT group (n=428) and the LAAT group (n=102) based on the presence or absence of LAAT status. Relevant advances in global research and the characteristics of our institution's cases were reviewed, and risk factors that may be associated with LAAT formation in NVAF patients were collected extensively. Independent risk factors associated with LAAT formation were identified by binary logistic regression analysis. A model to predict the risk of LAAT occurrence in NVAF patients was constructed based on nomogram, and the accuracy of the model was evaluated and validated internally. ResultsSix factors, including history of thrombosis, duration of AF, type of AF, BNP, Cys-C, and LAD, were associated with the presence or absence of LAAT status in patients with NAVF (all P < 0.05) and could be used as independent risk factors to predict LAAT formation. Accordingly, a model was constructed to predict the risk of LAAT occurrence in NVAF patients based on nomogram, with a C-index of 0.74 (95%CI: 0.69-0.79). In addition, the prediction accuracy of the model is also shown in the calibration curve. ConclusionThe model for predicting the risk of LAAT in patients with NVAF based on Nomogram has good accuracy and practicability, and can be used to predict the risk of LAAT in patients with NVAF accurately and intuitively. -
Key words:
- thrombus /
- risk factor /
- left atrial appendage /
- atrial fibrillation /
- nomogram
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图 1 非瓣膜性心房颤动患者左心耳血栓形成在超声心动图中的影像学表现
A: 经胸超声心脏心动图检查所示各瓣膜纤细, 形态、启闭运动未见明显异常, 左心耳内未见异常回声, 相关参数: LVEDD 49 mm, LVESD 30 mm, LAD 35 mm, LVEF 66%; B: 经食管超声心动图检查所示非瓣膜性心房颤动患者左心耳内可及大小约12 mm×6 mm强回声团块附着, 形态固定, 相关参数: LVEDD 47 mm, LVESD 32 mm, LAD 43 mm, LVEF 65%; C: 经食管超声心动图检查所示非瓣膜性心房颤动患者左心耳内探及胶冻样稍强回声团块, 形态不固定, 随心搏抖动, 相关参数: LVEDD 52 mm, LVESD 37 mm, LAD 45 mm, LVEF 55%; D: 经食管超声心动图检查所示非瓣膜性心房颤动患者左房及左心耳内可见自发造影现象, 相关参数: LVEDD 43 mm, LVESD 25 mm, LAD 41 mm, LVEF 71%.
Figure 1. Echocardiography feature of left atrial appendage thrombus in patients with non-valvular atrial fibrillation
表 1 与LAAT状态相关危险因素分析
Table 1. Analysis of risk factors related to the LAAT status [n(%)]
风险因素 组别 LAAT状态 χ2 P 无 有 性别 女/男 176/252 52/50 2.876 0.089 年龄(岁) < 55 103(24.1) 14(13.7) 55~60 61(14.3) 10(9.8) 7.997 0.018 > 60 264(61.7) 78(76.5) BMI(18.5~23.9, kg/m2) < 18.5 5(1.2) 2(2.0) 0.739 0.691 18.5~23.9 170(39.7) 37(36.3) > 23.9 253(59.1) 63(61.8) 基础心率(次/min) ≤100 398(93.0) 89(87.3) 7.067 0.029 101~119 21(4.9) 12(11.8) ≥120 9(2.1) 1(1.0) 收缩压(mmHg) 正常/异常 349/79(81.5/18.5) 88/14(86.3/13.7) 0.968 0.325 舒张压(mmHg) 正常/异常 359/69(83.9/16.1) 81/21(79.4/20.6) 0.870 0.351 高血压病 无/有 203/225(47.4/52.6) 41/61(40.2/59.8) 1.456 0.228 糖尿病 无/有 355/73(82.9/17.1) 88/14(86.3/13.7) 0.445 0.505 心力衰竭史 无/有 425/3(99.3/0.7) 100/2(98.0/2.0) 0.375 0.539 血栓病史(非LAAT) 无/有 362/66(84.6/15.4) 73/29(71.6/28.4) 8.614 0.003 周围血管病史 无/有 423/5(98.8/1.2) 101/1(99.0/1.0) 0.025 0.872 吸烟史 无/有 313/115(73.1/26.9) 83/19(81.4/18.6) 2.541 0.111 抗血小板药应用史 无/有 281/147(65.7/34.3) 64/38(62.7/37.3) 0.192 0.661 他汀类药应用史 无/有 296/132(69.2/30.8) 67/35(65.7/34.3) 0.313 0.576 华法林应用史 无/有 402/26(93.9/6.1) 90/12(88.2/11.8) 3.197 0.074 新型抗凝药应用史 无/有 357/71(83.4/16.6) 82/20(80.4/19.6) 0.336 0.562 房颤病程(年) < 1 237(55.4) 18(17.6) 47.084 < 0.001 1~3 81(18.9) 34(33.3) > 3 110(25.7) 50(49.1) 房颤发作类型 阵发/持续 278/150(65.0/35.0) 37/65(36.3/63.7) 26.922 < 0.001 血红蛋白(110~160 g/L) 正常/异常 371/57(86.7/13.3) 90/12(88.2/11.8) 0.065 0.799 MCV(80~100 fL) 正常/异常 404/24(94.4/5.6) 100/2(98.0/2.0) 1.631 0.202 MCHC(320~360 g/L) 正常/异常 427/1(99.8/0.2) 102/0(100.0/0.0) 0.238 0.625 RDW-CV(11~16) 正常/异常 411/17(96.0/4.0) 96/6(94.1/5.9) 0.337 0.562 RDW-SD(35~56) 正常/异常 348/80(81.3/18.7) 75/27(73.5/26.5) 2.629 0.105 MPV(7.5~11.5 fL) 正常/异常 257/171(60.0/40.0) 59/43(57.8/42.2) 0.087 0.768 PDW(15%~17 %) 正常/异常 399/29(93.2/6.8) 93/9(91.2/8.8) 0.256 0.612 HDL-C(1.26~1.90 mmol/L) 正常/异常 321/107(75.0/25.0) 84/18(82.4/17.6) 2.079 0.149 LDL-C(3.37~4.12 mmol/L) 正常/异常 408/20(95.3/4.7) 95/7(93.1/6.9) 0.426 0.514 HbA1c(4%~6 %) 正常/异常 312/116(72.9/27.1) 73/29(71.6/28.4) 0.021 0.883 UA(90~420 μmmol/L) 正常/异常 382/46(89.3/10.7) 84/18(82.4/17.6) 3.071 0.079 Scr(30~110 μmol/L) 正常/异常 427/1(99.8/0.2) 102/0(100.0/0.0) 0.238 0.625 BUN(2.9~7.5 mmol/L) 正常/异常 326/102(76.2/23.8) 74/28(72.5/27.5) 0.403 0.525 Cys-C(0.51~1.09 mg/L) 正常/异常 338/90(79.0/21.0) 59/43(57.8/42.2) 18.455 < 0.001 BNP(≤100 pg/mL) ≤100 88(20.6) 6(5.9) 19.044 < 0.001 101~500 100(23.4) 16(15.7) ≥501 240(56.1) 80(78.4) D-dimer(< 0.5 mg/L) 正常/异常 335/93(78.3/21.7) 75/27(73.5/26.5) 0.803 0.369 INR(0.8~1.5) 正常/异常 369/59(86.2/13.8) 78/24(76.5/23.5) 5.206 0.022 LVEDD(47±4 mm) 正常/异常 302/126(70.6/29.4) 73/29(71.6/28.4) 0.006 0.936 LVESD(33±5 mm) 正常/异常 394/34(92.1/7.9) 86/16(84.3/15.7) 4.908 0.027 LVEF(50%~70%) 正常/异常 416/12(97.2/2.8) 97/5(95.1/4.9) 0.589 0.442 LAD(25~35 mm) 正常/异常 221/207(51.6/48.4) 76/26(74.5/25.5) 16.578 < 0.001 CHADS(20~6) 0 145(33.88) 26(25.49) 5.768 0.056 1~3 263(61.45) 66(64.71) 4~6 20(4.67) 10(9.8) CHA2DS2-VASc(0~9) 0 74(17.29) 9(8.82) 0.104 1~3 285(66.59) 71(69.61) 4~6 66(15.42) 20(19.61) 7~9 3(0.7) 2(1.96) 表 2 LAAT形成相关独立危险因素
Table 2. Independent risk factors related to the LAAT status
危险因素* 分组 回归系数 标准误 Wald P OR 95%CI 下限 上限 年龄 < 55 - - 2.828 0.243 ref. - - 55~60 0.084 0.475 0.031 0.86 1.087 0.429 2.756 > 60 0.514 0.351 2.148 0.143 1.672 0.841 3.327 心率 ≤100 - - 4.084 0.13 ref. - - 101~119 0.708 0.416 2.893 0.089 2.03 0.898 4.59 ≥120 -1.124 1.09 1.065 0.302 0.325 0.038 2.749 血栓病史 有/无 0.647 0.273 5.606 0.018 1.91 1.118 3.265 房颤病程 < 1 - - 4.332 0.015 ref. - - 1~3 0.271 0.316 0.735 0.038 1.718 1.03 2.866 > 3 0.541 0.261 4.298 < 0.001 3.456 2.185 5.467 房颤发作类型 持续/阵发 0.839 0.269 9.741 0.002 2.313 1.366 3.917 Cys-C 异常/正常 0.812 0.254 10.251 0.001 2.252 1.37 3.701 BNP ≤100 - - 6.561 0.038 ref. - - 101~500 0.703 0.505 1.933 < 0.001 2.462 1.514 4.005 ≥501 1.118 0.463 5.827 0.016 3.057 1.234 7.576 INR 异常/正常 0.425 0.299 2.013 0.156 1.529 0.85 2.75 LVESD 异常/正常 -0.338 0.289 1.366 0.242 0.713 0.405 1.257 LAD 异常/正常 0.885 0.255 12.081 0.001 2.423 1.471 3.991 *参考范围见表 1 -
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