Page 21 - 2023-08-中国全科医学

·918· http: //www.chinagp.net E-mail: zgqkyx@chinagp.net.cn March 2023, Vol.26 No.8

developed by foreign scholars，yet the former one has been found to have limited predictive value in Chinese HCM patients.
Objective To develop a risk prediction model for thrombotic events in Chinese patients with HCM. Methods A retrospective
cohort study design was used. Five hundred and thirty-seven HCM patients who admitted to West China Hospital of Sichuan
University from 2010 to 2018 were recruited. Post-discharge health status was collected by use of telephone follow-up or checking
the treatment status recorded in the electronic medical record system once every 6 to 12 months until a composite thrombotic event
（defined as the endpoint event） or death occurred or the determined thrombotic risk assessment day of this study（2019-12-31）.
Univariate and multvariate Cox regression analyses were applied to build a thrombotic risk prediction model，and its internal
validation was tested in a resample using the bootstrapping technique. Results Due to data missing，24 cases were excluded，
and the other 513 cases were finally included. During a median follow-up of 4.2 years（IQR：1.3-6.2 years），thrombotic events
occurred in 42 cases（8.18%），with an annual morbidity rate of 2.10%〔95%CI（1.47%，2.73%）〕. By multivariate Cox
regression analysis，age，prior thrombotic event and left ventricular ejection fraction（LVEF） were identified（P<0.05） and
used for constructing the formula of SAAE score （S=prior stroke and other thrombotic events，A=atrial fibrillation，A=age，
E=LVEF） for predicting thrombotic events after being weighted based on the regression coefficient. Internal validation suggested
that SAAE score could discriminate thrombotic events in the whole population｛Harrell's C-index=0.773〔95%CI（0.688，
0.858）〕｝，with a calibration slope of 1.006，and could well discriminate 1-year，3-year and 5-year thrombotic events
（Harrell's C-index=0.790，0.799，0.735），with a good calibration ability. In addition，the SAAE score also performed well
in distinguishing thrombotic events in patients with or without atrial fibrillation｛Harrell's C-index=0.669〔95%CI（0.548，
0.791）〕，0.647〔95%CI（0.498，0.795）〕｝，with good calibration ability. Besides that，SAAE score could partially
discriminate 1-year，3-year and 5-year thrombotic events in these two groups，with certain calibration ability. For three groups
（whole study population，patients with/without atrial fibrillation），SAAE score could discriminate the risk of thrombotic events（either
low，moderate or high） excellently. For the whole study population，SAAE score was better than HCM Risk-CVA score in
distinguishing thrombotic events（P=0.013）. Decision curve analysis showed the net benefit of SAAE score was better than HCM
Risk-CVA score at different prediction time points（1，3 and 5 years）. Conclusion This thrombotic events risk prediction
model developed by us for Chinese HCM patients，namely SAAE score，could well stratify the risk of thrombotic events.
【Key words】 Cardiomyopathy，hypertrophic；Thromboembolism；Stroke；Atrial fibrillation；Age；Ejection
fraction；Score models

肥 厚 型 心 肌 病（hypertrophic cardiomyopathy， 事件风险预测模型，对于指导临床决策具有重要的临床
HCM）是一种以左心室壁肥厚为特征的疾病 ［1-2］ 。 意义。鉴于此，本研究拟构建适合中国 HCM 患者的 TE
HCM 常出现各种临床表现并伴随多种并发症，其中血 事件风险预测模型。
栓栓塞（thromboembolism，TE）事件发生率相对较高， 1 对象与方法
既往文献提示在 HCM 患者中，TE 事件的年发病率约为 1.1 研究对象 本研究系回顾性队列研究，收集
1.0%，明显高于一般人群 ［3-4］ ；如患者合并心房颤动， 2010—2018 年在四川大学华西医院就诊的 537 例 HCM
则 TE 事件年发病率更高 ［5-7］ 。作为 HCM 的一个重要 患者病例资料。本研究遵循《赫尔辛基宣言》的原则，
并发症，TE 事件可导致 HCM 患者预后不良及生存率降 并经四川大学华西医院生物医学研究伦理委员会批准
低 ［2，5-6，8-10］ 。 （批准文号：2019-1147）。由于为回顾性研究，委员
因此，如能在 HCM 患者中识别易发生 TE 事件的 会批准知情同意豁免。
高风险患者，则可以采取相应的预防措施，一定程度上 1.2 HCM 诊断标准、相关定义与基线数据收集 根据
降低 TE 事件发生的可能性。关于如何识别高危患者， 2014 年欧洲心脏病学协会指南 ［2］ ，HCM 的诊断是基于
相对于单个预测指标，在临床实践中通常使用风险预 左心室壁肥厚，并需排除负荷增加如高血压、主动脉瓣
测模型帮助临床决策，从而为患者做出合理的治疗选 狭窄和先天性主动脉瓣下隔膜等引起的左心室壁肥厚，
择 ［11-12］ ，因风险预测模型综合了某个疾病不同的病理 并排除了其他可能导致心肌肥厚的疾病，如已知的代谢
生理特征，可整体评估患者的预后。目前针对 HCM 患 疾病（如 Anderson-Fabry 病）或肥厚型心肌病综合征（如
者 TE 事件的风险预测，仅国外学者构建了两个模型： Noonan 综合征）等。成年人 HCM 的诊断标准为 ［2］ 左
HCM Risk-CVA ［9］ 及 French HCM score ［13］ 。既往研究 心室舒张末期室壁厚度≥ 15 mm，或者有明确家族史者
发现 HCM Risk-CVA 模型对于中国 HCM 患者的临床价 左心室舒张末期室壁厚度≥ 13 mm。本研究使用超声心
值较为有限 ［14］ 。因此，构建适合中国 HCM 患者的 TE 动图评估左心室壁肥厚等指标，严格按照目前国际通用