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重型、危重型新型冠状病毒肺炎患者合并心肌损伤特点及其对转归的影响
卢青¹,王九龙²,张波³,李志刚¹,孔德娜³,熊诗强¹,丁世芳^1*
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(1. 解放军中部战区总医院心血管内科, 武汉 430070; 2. 南方医科大学第一临床医学院, 广州 510515; 3. 解放军中部战区总医院感染内科, 武汉 430070 ^*通信作者)

摘要:

目的分析重型、危重型新型冠状病毒肺炎（COVID-19）患者合并心肌损伤的特点、危险因素及其与转归的关系。方法收集2020年1月至3月于解放军中部战区总医院诊治的重型、危重型COVID-19患者的临床资料。根据病程中是否发生心肌损伤将患者分为非心肌损伤组和心肌损伤组，比较两组患者基线资料、临床表现、辅助检查、治疗和转归情况，分析重型、危重型COVID-19患者发生心肌损伤的危险因素及其对转归的影响。结果纳入56例重型、危重型COVID-19患者，其中非心肌损伤组22例、心肌损伤组34例。两组患者均以男性多见，性别构成在两组间差异无统计学意义（P>0.05）。与非心肌损伤组相比，心肌损伤组患者年龄更大［78.5（70.8，89.0）岁vs 56.5（50.3，68.3）岁，P<0.01］，≥65岁患者占比较高［85.3%（29/34）vs 31.8%（7/22），P<0.01］，合并冠心病的患者占比较高［38.2%（13/34）vs 9.1%（2/22），P<0.05］。就诊症状均以发热（87.5%，49/56）、咳嗽（64.3%，36/56）和乏力（46.4%，26/56）等常见，两组间各症状发生率差异均无统计学意义（P均>0.05）。非心肌损伤组肺部CT表现为片样/斑片样影和磨玻璃影的患者比例高于心肌损伤组［72.7%（16/22）vs 38.2%（13/34），P<0.05］，其余征象在两组间差异均无统计学意义（P均>0.05）。与非心肌损伤组相比，心肌损伤组患者氨基末端B型钠尿肽原、D-二聚体、降钙素原和IL-6水平均较高［4 939.5（1 817.0，9 450.3）pg/mL vs 612.5（301.0， 1 029.5）pg/mL、4 386.5（2 309.5，9 635.3）ng/mL vs 850.5（343.5，2 333.8）ng/mL、0.46（0.23，3.79）ng/mL vs 0.18（0.13，0.39）ng/mL、138.6（41.9，464.8）pg/mL vs 65.1（34.7，99.3）pg/mL］，差异均有统计学意义（P均<0.01）。多因素logistic回归模型分析显示，年龄≥65岁（OR=18.62，95% CI 1.61～215.96，P<0.05）和D-二聚体水平≥ 3 000 ng/mL（OR=15.48，95% CI 1.45～164.77，P<0.05）是重型、危重型COVID-19患者并发心肌损伤的独立危险因素。在治疗和转归方面，两组患者在抗病毒、抗细菌、糖皮质激素等药物的使用方面差异均无统计学意义（P均>0.05）；心肌损伤组患者死亡率与非心肌损伤组相比更高［58.8%（20/34）vs 9.1%（2/22），P<0.01］，且接受气管插管、体外膜肺氧合、连续性血液净化治疗等有创生命支持者均为心肌损伤组患者。结论高龄，男性，合并冠心病和（或）心功能不全，以及D-二聚体、降钙素原和IL-6异常升高是重型、危重型COVID-19患者并发心肌损伤的危险因素；重型、危重型COVID-19患者发生心肌损伤时病情将进一步加重，部分患者甚至需要有创循环呼吸支持，且预后不良，死亡率高，需要更严密、动态地观察上述指标，并针对相关因素积极治疗。

DOI：10.16781/j.0258-879x.2020.06.0596

投稿时间：2020-04-29修订日期：2020-05-21

基金项目:

Characteristics of myocardial injury in severe and critical coronavirus disease 2019 patients and its effect on prognosis

LU Qing¹,WANG Jiu-long²,ZHANG Bo³,LI Zhi-gang¹,KONG De-na³,XIONG Shi-qiang¹,DING Shi-fang^1*

(1. Department of Cardiology, General Hospital of Central Theater Command of PLA, Wuhan 430070, Hubei, China;
2. The First School of Clinical Medicine, Southern Medical University, Guangzhou 510515, Guangdong, China;
3. Department of Infection, General Hospital of Central Theater Command of PLA, Wuhan 430070, Hubei, China
^*Corresponding author)

Abstract:

Objective To analyze the characteristics and related risk factors of myocardial injury in severe and critical coronavirus disease 2019 (COVID-19) patients and their relationship with the prognosis. Methods The clinical data of severe and critical COVID-19 patients treated in General Hospital of Central Theater Command of PLA from Jan. 2020 to Mar. 2020 were collected. The patients were divided into non-myocardial injury group and myocardial injury group. The baseline data, clinical characteristics, auxiliary examination, treatment and prognosis were compared between the two groups, and the risk factors of myocardial injury and the effect on the prognosis of the severe and critical COVID-19 patients were analyzed. Results A total of 56 patients were included, with 22 in the non-myocardial injury group and 34 in the myocardial injury group. Patients were mostly male in both groups, and there was no significant difference in gender composition between the two groups (P>0.05). Compared with the non-myocardial injury group, the age of onset was significantly higher in the myocardial injury group (78.5[70.8, 89.0] years vs 56.5[50.3, 68.3] years, P<0.01), and the proportions of patients over 65 years old and combined with coronary heart disease were significantly greater (85.3%[29/34] vs 31.8%[7/22] and 38.2%[13/34] vs 9.1%[2/22], both P<0.05). In terms of symptoms, fever (87.5%, 49/56), cough (64.3%, 36/56) and fatigue (46.4%, 26/56) were the most common ones, and there were no significant differences between the two groups (all P>0.05). For the CT findings of the lungs, the proportion of patients having patch-like/plaque-like shadows and ground-glass opacities was significantly greater in the non-myocardial injury group versus the myocardial injury group (72.7%[16/22] vs 38.2%[13/34], χ²=6.364, P<0.05), and other signs were not significantly different between the two groups (P>0.05). Compared with the non-myocardial injury group, the levels of N-terminal pro-B-type natriuretic peptide, D-dimer, procalcitonin and IL-6 were significantly higher in the myocardial injury group (4 939.5[1 817.0, 9 450.3] pg/mL vs 612.5[301.0, 1 029.5] pg/mL, 4 386.5[2 309.5, 9 635.3] ng/mL vs 850.5[343.5, 2 333.8] ng/mL, 0.46[0.23, 3.79] ng/mL vs 0.18[0.13, 0.39] ng/mL, and 138.6[41.9, 464.8] pg/mL vs 65.1[34.7, 99.3] pg/mL, respectively), and the differences were significant (all P<0.01). Multivariate logistic regression analysis showed that age ≥ 65 years old (odds ratio[OR]=18.62, 95% confidence interval[CI] 1.61-215.96, P<0.05) and D-dimer level ≥ 3 000 ng/mL (OR=15.48, 95% CI 1.45-164.77, P<0.05) were the independent risk factors for myocardial injury in severe and critical COVID-19 patients. There were no significant differences in the use of antiviral drugs, antibacterial drugs, or glucocorticoids between the two groups (all P>0.05). The mortality rate was significantly higher in the myocardial injury than that in the non-myocardial injury group (58.8%[20/34] vs 9.1%[2/22], P<0.01). Patients who received tracheal intubation, extracorporeal membrane oxygenation, continuous renal replacement therapy (CRRT) and other invasive life support measures were all in the myocardial injury group. Conclusion Older age, male gender, coronary heart disease and (or) cardiac insufficiency, and elevated D-dimer, procalcitonin and IL-6 are the risk factors of myocardial injury in severe and critical COVID-19 patients. Myocardial injury can aggravate the condition and some patients need invasive circulating breathing support, with poor prognosis and high mortality. Therefore, the above indicators need to be observed more closely and dynamically and active treatment should be given according to related factors.