EuroSCORE評(píng)分對(duì)冠狀動(dòng)脈旁路移植術(shù)患者死亡風(fēng)險(xiǎn)的評(píng)估*

劉輝　劉劍萍　張海英　潘傳亮

(重慶醫(yī)科大學(xué)附屬成都第二臨床學(xué)院/成都市第三人民醫(yī)院重癥醫(yī)學(xué)科, 四川 成都 610031)

?

·論著·

EuroSCORE評(píng)分對(duì)冠狀動(dòng)脈旁路移植術(shù)患者死亡風(fēng)險(xiǎn)的評(píng)估*

劉輝劉劍萍張海英潘傳亮

(重慶醫(yī)科大學(xué)附屬成都第二臨床學(xué)院/成都市第三人民醫(yī)院重癥醫(yī)學(xué)科, 四川 成都 610031)

目的評(píng)估歐洲心臟手術(shù)風(fēng)險(xiǎn)評(píng)分系統(tǒng)(EuroSCORE)預(yù)測(cè)冠狀動(dòng)脈旁路移植術(shù)患者在院死亡風(fēng)險(xiǎn)的準(zhǔn)確性。方法收集我院2011年12月～2015年3月冠狀動(dòng)脈旁路移植術(shù)的患者114例，對(duì)所有患者進(jìn)行術(shù)前additive EuroSCORE及l(fā)ogistic EuroSCORE評(píng)分，并根據(jù)additive EuroSCORE評(píng)分分成低危組、中危組、高危組。比較全組及各亞組患者的實(shí)際及預(yù)測(cè)死亡率；比較不同亞組的術(shù)后并發(fā)癥，ICU滯留時(shí)間；應(yīng)用受試者工作特征(receiver operating characteristic，ROC)曲線(xiàn)評(píng)估additive EuroSCORE及l(fā)ogistic EuroSCORE評(píng)分的準(zhǔn)確性；利用speaman相關(guān)系數(shù)分析Euroscore評(píng)分與術(shù)后并發(fā)癥、ICU滯留時(shí)間的相關(guān)性。結(jié)果高危組與中危組、中危組與低危組比較additive EuroSCORE評(píng)分、logistic EuroSCORE評(píng)分、術(shù)后并發(fā)癥，ICU 滯留時(shí)間、預(yù)測(cè)死亡率及實(shí)際死亡率差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；低危組實(shí)際死亡率小于預(yù)期死亡率，有統(tǒng)計(jì)學(xué)意義差異(P<0.05)；中危組、高危組、全組實(shí)際死亡率與預(yù)測(cè)死亡率接近，無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05)；additive 及l(fā)ogistic EuroSCORE評(píng)分ROC曲線(xiàn)下面積接近，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，均大于0.70，對(duì)死亡預(yù)測(cè)有較好的預(yù)見(jiàn)性；additive及l(fā)ogistic EuroSCORE評(píng)分對(duì)應(yīng)的術(shù)后并發(fā)癥、ICU 滯留時(shí)間的Speaman相關(guān)系數(shù)(γ)均>0.5。結(jié)論EUROSCORE評(píng)分系統(tǒng)可較好的用于冠狀動(dòng)脈旁路移植術(shù)患者的術(shù)前評(píng)估。

EUROSCORE ；冠脈動(dòng)脈旁路移植術(shù)；風(fēng)險(xiǎn)評(píng)估

心臟手術(shù)是一高風(fēng)險(xiǎn)手術(shù)，對(duì)其進(jìn)行有效的量化客觀評(píng)估，有利于判斷預(yù)后及規(guī)避手術(shù)風(fēng)險(xiǎn)[1]，減少醫(yī)療糾紛。歐洲心臟手術(shù)風(fēng)險(xiǎn)評(píng)估系統(tǒng)(European system for cardiac operative risk evaluation,Euroscore)是對(duì)心臟手術(shù)患者以死亡作為終點(diǎn)的評(píng)估系統(tǒng)，在歐洲、北美、日本和澳大利亞廣泛應(yīng)用[2]，但其準(zhǔn)確性報(bào)道不一[3-6]。目前我國(guó)心血管外科亦逐漸使用，我院已應(yīng)用到臨床。本文收集相關(guān)資料，對(duì)其準(zhǔn)確性進(jìn)行探討，現(xiàn)報(bào)告如下。

1　臨床資料

1.1病例選擇選取我院2011年12月～2015年3月行冠狀動(dòng)脈旁路移植術(shù)的患者114例，其中男78例，女36例，平均年齡68.20±11.33，均由同組手術(shù)醫(yī)生主刀，術(shù)后帶轉(zhuǎn)運(yùn)呼吸機(jī)轉(zhuǎn)入心臟外科監(jiān)護(hù)室(cardiac surgery intensive care unit,CSICU), 搭橋1～5支，根據(jù)術(shù)前EuroSCORE評(píng)分進(jìn)組，術(shù)后均行有創(chuàng)動(dòng)脈、中心靜脈監(jiān)測(cè)；術(shù)后酌情行picco或漂浮導(dǎo)管監(jiān)測(cè);圍術(shù)期酌情行球囊反搏輔助循環(huán)，經(jīng)治療，患者病情平穩(wěn)，由手術(shù)醫(yī)生及CSICU主任共同評(píng)估轉(zhuǎn)回普通病房。

1.2研究方法術(shù)前對(duì)納入組的患者按照標(biāo)準(zhǔn)進(jìn)行additive Euroscore 和logistic EuroSCORE計(jì)算(由EuroSCORE官方網(wǎng)站http://www.euroscore org提供)，按照additive EuroSCORE評(píng)分值進(jìn)行分組，0～2分進(jìn)入低危組，3～5分進(jìn)入中危組、≥6分進(jìn)入高危組。分別對(duì)各組患者的年齡、性別、EuroSCORE評(píng)分、術(shù)后并發(fā)癥(包括急性呼吸窘迫綜合征、急性腎損傷、多器官功能障礙綜合征、感染、惡性心律失常、急性腦梗塞)、入住CSICU時(shí)間、死亡率進(jìn)行統(tǒng)計(jì)。

2　結(jié)果

2.1EuroSCORE評(píng)分比較本研究示中危組與低危組、高危組與中危組術(shù)前Additive / Logistic EuroSCORE評(píng)分比較差異具有統(tǒng)計(jì)學(xué)意義(P<0.01)，見(jiàn)表1。

2.2術(shù)后結(jié)果比較 本研究示術(shù)后并發(fā)癥發(fā)生率中危組與低危組、高危組與中危組比較差異均有顯著性(P<0.01)；CSICU住院時(shí)間中危組與低危組比較差異有顯著性(P<0.01)、高危組與中危組比較差異有顯著性(P<0.05)；死亡率中危組與低危組、高危組與中危組比較差異均有顯著性(P<0.01)。見(jiàn)表2。

2.328天死亡率與預(yù)期死亡率比較低危組28天死亡率與預(yù)期死亡率比較有顯著性差異(P<0.05)；中危組、高危組、全組 死亡率與預(yù)期死亡率比較無(wú)顯著性差異(P>0.05)，見(jiàn)表3。

2.4EuroSCORE評(píng)分與術(shù)后結(jié)果相關(guān)性比較

additive 及l(fā)ogistic Euroscore評(píng)分對(duì)術(shù)后并發(fā)癥的相關(guān)系數(shù)(γ)分別為0.812及0.826(均P<0.01)；additive 及l(fā)ogistic Euroscore評(píng)分對(duì)入住天數(shù)相關(guān)系數(shù)(γ)分別為0.628和0.639(均P<0.01)。均γ>0.5，見(jiàn)表4。

表1　不同組的EuroSCORE評(píng)分比較

表2　不同組的術(shù)后資料比較

2.5預(yù)測(cè)的鑒別度logistics Euroscore評(píng)分曲線(xiàn)下面積 0.766，additive Euroscore評(píng)分曲線(xiàn)下面積0.754，均大于0.7，提示對(duì)死亡率有較高的鑒別度。兩者相比logistics Euroscore評(píng)分曲線(xiàn)下面積稍大于additive Euroscore評(píng)分曲線(xiàn)下面積，但二者曲線(xiàn)下面積比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，見(jiàn)圖1。

表3　不同組的實(shí)際死亡率與預(yù)期死亡率比較術(shù)中資料比較[n(×10-2)]

表4　EuroSCORE評(píng)分與術(shù)后結(jié)果相關(guān)性

注：中危組與低危組比較①P<0.05, ②P<0.01；高危組與中危組比較③P<0.05, ④<0.01；28天死亡率與預(yù)期死亡率比較⑤P<0.05,⑥P<0.01。

圖1Additive及l(fā)ogistic EuroSCORE評(píng)分對(duì)實(shí)際死亡率的ROC曲線(xiàn)

Figure1ROC curve of Additive and logistic EuroSCORE to mortality

3　討論

隨著醫(yī)療技術(shù)水平的快速發(fā)展，冠狀動(dòng)脈旁路移植術(shù)的患者。有效的風(fēng)險(xiǎn)評(píng)估體系可以讓我們規(guī)避手術(shù)風(fēng)險(xiǎn)。EuroSCORE評(píng)分系統(tǒng)是目前國(guó)際上公認(rèn)評(píng)價(jià)效果肯定、應(yīng)用較廣泛的心臟手術(shù)風(fēng)險(xiǎn)評(píng)估系統(tǒng)之一，是1995～1999年由歐洲心臟內(nèi)外科醫(yī)師等專(zhuān)家收集19030例成人心血管手術(shù)患者共同分析確立的[8-9]。系統(tǒng)通過(guò)對(duì)三個(gè)種類(lèi)、合計(jì)17項(xiàng)高危因素進(jìn)行量化計(jì)分測(cè)算，以評(píng)估心臟手術(shù)圍手術(shù)期風(fēng)險(xiǎn)[10]。較以往的心臟風(fēng)險(xiǎn)評(píng)估體系，EuroSCORE相對(duì)簡(jiǎn)便而且有較高的準(zhǔn)確性，只要對(duì)相關(guān)問(wèn)題回答“是”與“否”即可方便地在病人床邊完成，而利用其官方網(wǎng)站提供的軟件在電腦上可方便地計(jì)算出Logistic評(píng)分，近幾年已有手機(jī)版軟件下載，其方便性使其得到了快速的推廣。 多項(xiàng)研究表明：EuroSCORE評(píng)分系統(tǒng)較其他風(fēng)險(xiǎn)評(píng)估體系對(duì)歐系人種能更準(zhǔn)確的預(yù)測(cè)手術(shù)死亡率及術(shù)后并發(fā)癥的發(fā)生，盡管存在種族差異，EuroSCORE 評(píng)分系統(tǒng)對(duì)亞洲冠脈搭橋的手術(shù)病人亦有一定的預(yù)測(cè)價(jià)值[11-12]。

本研究顯示我院行冠狀動(dòng)脈旁路移植術(shù)的高危病人占絕大多數(shù)，女性最初發(fā)病率低，隨著年齡的增加，有增高趨勢(shì)。logistic Euroscore評(píng)分曲線(xiàn)下面積 0.766，additive Euroscore評(píng)分曲線(xiàn)下面積0.754，均大于0.7，提示對(duì)死亡率有較高的鑒別度，均可預(yù)測(cè)冠狀動(dòng)脈旁路移植術(shù)患者的死亡風(fēng)險(xiǎn)，logistic EuroSCORE評(píng)分ROC曲線(xiàn)下面積稍大，但二者無(wú)統(tǒng)計(jì)學(xué)差異，這與國(guó)內(nèi)外研究相一致[13-14]；研究顯示低危組28天死亡率與預(yù)期死亡率比較有顯著性差異(P<0.05)；中危組、高危組全組28天死亡率與預(yù)期死亡率比較無(wú)顯著性差異(P>0.05)，提示EuroSCORE評(píng)分對(duì)低危組可能高估了死亡率((低危組樣本例數(shù)極少，準(zhǔn)確度需擴(kuò)大樣本量進(jìn)一步研究)；本研究示additive 及l(fā)ogistic Euroscore評(píng)分對(duì)術(shù)后并發(fā)癥的相關(guān)系數(shù)(γ)分別為0.812及0.826(P<0.01).additive 及l(fā)ogistic Euroscore評(píng)分對(duì)入住天數(shù)相關(guān)系數(shù)(γ)分別為0.628和0.639(P<0.01)，說(shuō)明二者對(duì)術(shù)后并發(fā)癥及CSICU入住天數(shù)均有相關(guān)性，二者無(wú)統(tǒng)計(jì)學(xué)差異。以上數(shù)據(jù)證實(shí)additive 及l(fā)ogistic Euroscore評(píng)分與冠脈移植術(shù)患者病情有良好的相關(guān)性，可以預(yù)測(cè)心臟術(shù)后的結(jié)果，對(duì)指導(dǎo)醫(yī)療資源的合理分配有重要意義[15]。

4　結(jié)論

EuroSCORE評(píng)分目前適用于冠狀動(dòng)脈旁路移植術(shù)患者術(shù)后的預(yù)后評(píng)估。但筆者認(rèn)為評(píng)分只能適應(yīng)一定階段，隨著手術(shù)、麻醉、ICU治療技術(shù)的不斷提高，會(huì)讓死亡率逐漸下降[22],評(píng)分系統(tǒng)亦需不斷調(diào)整，中國(guó)醫(yī)科大學(xué)王春、谷天祥等1290例冠脈搭橋手術(shù)的回顧性分析證實(shí)了此趨勢(shì)[23]，國(guó)外報(bào)道也有同樣趨勢(shì)[24]，故需我們不斷多中心研究，以制定出與時(shí)俱進(jìn)的評(píng)分系統(tǒng)，方便臨床工作的使用。

[1]Edwards FH，Peterson ED，Coombs LP，etal. Prediction of operative mortality after valve replacement surgery[J]. Am Coll Cardiol，2001，37(3)：885-892.

[2]Yan CH， Reid C，etal.Validation of the EuroSCORE model in Australia [J].Eur J Cardiothorac Surg 2006 29(4)：441-446.

[3]Siregar S，Groenwold RH, De Heer F,etal. Performance of the original EuroSCORE [J].Eur J Cardiothorac Surg,2012,41(4):746-754.

[4]崔虎軍，肖峰，李巖，等，心臟手術(shù)風(fēng)險(xiǎn)評(píng)估歐洲系統(tǒng)(EuroSCORE )的初步臨床應(yīng)用[J].中國(guó)心血管病研究雜志，2006，4(1)：24-27.

[5]Pinna-Pintora P, Bobbioa M, Colangeloa S,etal. Inaccuracy of four coronary surgery risk-adjusted models to predict mortality in individual patients. Eur J Cardio-thorac Surg,2002,21:199-204.

[6]Gogbashian A, Sedrakyana A, Treasure T,etal. EureSCORE: a systematic review of international performance, Eur J Cardio-thorac Surg,2004,25:695-700.

[7]Grunkemeier GL, Jin R. Receiver operating characteristic curve analysis of clinical risk models [J].Ann Thorac Surg,2001,72(2):323-326.

[8]Roques F, Nashef SA, Michel P,etal. Risk factors and outcome in European cardic surgery: analysis of the EuroSCORE multination database of 19030 patients. Eur J Cardiothroac Surg,1999, 15(6):816-823.

[9]Losay J, Petit J, Lambert V,etal. Percutaneous Closure with Amplatzer device is a safe and efficient alternative to surgery in adults with large atrial septal defects. Am Heart J,2001,142(3)544-548.

[10] Yap CH, Reid C, Yii M,etal. Validation of the EuroSCORE model in Australia. Eur J Cardiothorac Surg[J],2006,29(4):441-446.

[11] Chen CC，Wang CC，Hsieh SR，etal. Application of European system for cardiac operative risk evaluation (EuroSCORE) in coronary artery bypasses surgery for Taiwanese[J].Interactive Cardiovascular and Thoracic Surgery,2004，3(4):562-565.

[12] 王東進(jìn)，李慶國(guó)，王強(qiáng)，等.EuroSCORE對(duì)冠狀動(dòng)脈旁路移植術(shù)后早期死亡的預(yù)測(cè)價(jià)值[J].中華外科雜志，2009,47(8)：583-585.

[13] Parolari A. Pesce LI. Trezzi M.etal. Performance of EuroSCORE in CABG and off-pump coronary artery bypass grafting Single institution experience and Meta-analysis[J].EurHeart J 2009 30(3):297-304.

[14] 潘方立，陳杰.心臟麻醉危險(xiǎn)評(píng)估評(píng)分與歐洲心臟手術(shù)危險(xiǎn)因素評(píng)價(jià)系統(tǒng)對(duì)國(guó)人冠狀動(dòng)脈旁路移植術(shù)預(yù)后預(yù)測(cè)能力的比較[J].上海醫(yī)學(xué)，2011,49(2)：102-105.

[15] Toumpoulis IK, Anagnostopoulos CE. Does EuroSCORE predict length of stay and specific postoperative complications after heart valve surgery [J].Heart Valve Disease,2005,14(2):243-250.

[16] Nowicki ER. What is the future of mortality prediction models in heart valve surgery? Ann Thorac Surg,2005,80:396-398.

[17] 王崇，張冠鑫，韓林，等.EuroSCORE模型對(duì)心瓣膜手術(shù)患者死亡風(fēng)險(xiǎn)的預(yù)測(cè)[J].中國(guó)胸心血管外科臨床雜志，2011,18(3)189-193.

[18] Parolari A, Pesce LL, Trezzi M,etal. EuroSCORE performance in valve surgery: a meta-analysis. Ann Thorac Surg.2010,89(3):787-793.

[19] 程磊,高長(zhǎng)青,肖蒼松,等.新舊兩版風(fēng)險(xiǎn)預(yù)測(cè)模型對(duì)單純二尖瓣置換術(shù)后死亡風(fēng)險(xiǎn)預(yù)測(cè)的比較[J].中國(guó)體外循環(huán)雜志，2015，13(1)33-36.

[20] 俞瑾,詹海婷,徐維昉,等. 不同評(píng)分模型對(duì)維吾爾族患者心臟瓣膜術(shù)死亡風(fēng)險(xiǎn)的預(yù)測(cè)價(jià)值[J].中華實(shí)用診斷與治療雜志, 2014,28(3)241-243.

[21] 中國(guó)心血管外科注冊(cè)登記研究協(xié)作組.非體外循環(huán)冠狀動(dòng)脈旁路移植術(shù)后早期死亡風(fēng)險(xiǎn)預(yù)測(cè)-SinoSCORE與EureSCORE評(píng)分的對(duì)比[J].中華胸心血管外科雜志，2011,27(2)：75-77.

[22] Zhang L, Boyce SW, Hill PC,etal. Off-pump coronary artery bypass grafting improves in-hospital mortality in patients with dialysis-dependent renal failure [J].Cardiovasc Revasc Med,2009,10(1):12-16.

[23] 王春，谷天祥，于洋，等.回顧分析1290例OPCAB手術(shù)EuroSCORE高預(yù)測(cè)風(fēng)險(xiǎn)與低手術(shù)死亡率的關(guān)系 [J]. 山東大學(xué)學(xué)報(bào)，2011,49(7)：109-112.

[24] Lebreton G, Mede S,Inamo J,etal.Limitation in the inter-observer reliability of EuroSCORE:What should change in EuroSCORE Ⅱ ? [J] Eur J Cardiothorac Surg,2011, 40(6):1304-1308.

Validation of EuroSCORE in predicting the in-hospital mortality of Chinese patients undergoing coronary artery bypass grafting

LIU Hui，LIU Jianping,ZHANG Haiying,et al

(DepartmentofIntensiveCareUnit,TheThirdPeople’sHospitalofChengdu/TheSecondAffiliatedHospitalofChengdu,ChongqingMedicalUniversity,Chengdu610031,China)

ObjectiveTo assess the accuracy of European system for cardiac operative risk evaluation (EuroSCORE) in predicting the in- hospital mortality of Chinese patients undergoing coronary artery bypass grafting (CABG).MethodsFrom December 2011 to March 2015，114 patients underwent CABG were collected. They were all scored by the additive EuroSCORE and logistic EuroSCORE. According to the additive EuroSCORE, they were divided into low-risk group (L-group), moderate and high-risk group (M-group and H-group). The mortality with predicted mortality, postoperative complications and the time in cardic surgery intensive care unit were compared between the total group (T-group). We assessed the accuracy of additive EuroSCORE and logistic EuroSCORE by receiver operating characteristic (ROC) curve. Using speaman coefficient correlation, we analyzed the relevance of Euroscore with postoperative complications and the time in ICU. ResultsComparing H-group with M-group, comparing M-group with L-group, There were significant difference (P<0.05) in additive EuroSCORE, logistic EuroSCORE, postoperative complications, residence time of CSICU, predicts mortality and mortality rate between H-group and M-group, and M-group and L-group. The mortality of L-group was lower than that of expected mortalit. Comparing mortality and predicts mortality， There were no significant difference of mortality and predicts mortality in M-group, H-group and T-group. There were no significant difference of additive with logistic EuroSCORE ROC cure. Theirs corresponding Speaman correlation coefficient of the postoperative complications, time in ICU were greater than 0.5. ConclusionEUROSCORE can be better used in coronary artery bypass grafting in patients with preoperative assessment.

EUROSCORE；Coronary artery bypass grafting；Risk assement

四川省醫(yī)藥衛(wèi)生科研基金資助項(xiàng)目(110033)

R 543.3+1

A

10.3969/j.issn.1672-3511.2016.08.026

2015-12-07； 編輯： 張翰林)