| BackgroundCardiogenic shock(CS)is one of the common and critical complications in patients with acute myocardial infarction(AMI),which is characterized by heart failure leading to tissue hypoperfusion and tissue hypoxia.The heart is unable to maintain sufficient blood flow to meet the metabolic demands of the tissue,resulting in progressive and potentially irreversible organ dysfunction.There are 40,000 to 50,000 patients with AMI-related CS in the United States each year,and its incidence accounts for about 5%to 10%of all patients with AMI.Similarly,in our country,the incidence of CS in the population with acute ST-segment elevation myocardial infarction is 6%to 10%.Despite the rapid development of modern medicine and the improvement of diagnosis and treatment echnology for patients with AMI,once cardiogenic shock occurs,the mortality of patients complicated with AMI and CS remains a concern,with a 30-day mortality of approximately 40%and a 1-year mortality of nearly 50%.This high mortality can be attributed in part to the recognition of the disease,delayed detection,and inappropriate management.Therefore,identifying patients at risk of shock in the early stage of hospitalization for AMI is a high priority and effective goal,so that early development of treatment strategies and related treatment escalation are of great significance for the survival and prognosis of patients.Some studies have explored the incidence,mortality and other epidemiological characteristics of CS,but the current understanding of the risk factors related to CS in patients with AMI is still insufficient.At the same time,due to the complexity and heterogeneity of CS itself,there are few biomarkers applied to clinical practice.Inflammatory markers are involved in the occurrence and development of many cardiovascular diseases,and the occurrence of CS is also affected by systemic inflammatory response.Neutrophil to lymphocyte ratio(NLR)is an inflammatory index based on two inflammatory immune cells.It is mainly used to evaluate the inflammatory and immune response related mechanisms involved in the occurrence and development of a certain disease,and has prognostic significance in various cardiovascular and non-cardiovascular diseases.Recent studies have shown that NLR is closely related to adverse cardiovascular events and mortality in patients with AMI.Meta-analysis has confirmed that high NLR usually predicts high mortality.In AMI patients undergoing stent intervention,the in-hospital and long-term prognosis are poor if NLR is increased during preoperative evaluation.However,the relationship between NLR and CS in patients with AMI has not been elucidated.Aims1.To investigate the clinical characteristics and risk factors of CS in patients with AMI,and to explore the risk factors of in-hospital death in patients with CS after AMI.2.To explore the predictive value of NLR for CS after AMI,to provide ideas for early identification of CS occurrence and targeted treatment.MethodsIn this study,a retrospective analysis method was adopted to screen patients by inclusion and exclusion criteria,and 979 patients diagnosed with AMI admitted to a Grade-A hospital in Shandong Province from October 8,2014 to July 29,2022 were included.The outcome was defined as CS during hospitalization.The clinical data of patients were sorted out and the patients were divided into CS group and non-CS group according to whether CS occurred in hospital after AMI.The general data,laboratory test results and hospital treatment of patients in the two groups were analyzed and compared,and the NLR value was calculated by blood routine at admission.Logistic regression analysis was used to analyze the independent related factors of in-hospital CS after AMI,and the odd ratio(OR)and 95%confidence interval(95%CI)were calculated.Cox regression analysis was used to explore the risk factors for in-hospital mortality in patients with CS after AMI,and the hazard ratio(HR)and 95%CI were calculated.Receiver operating characteristic(ROC)curve was drawn to evaluate the predictive value of NLR for in-hospital CS after AMI.Two risk groups were defined by determining the best truncation value of NLR based on the maximum approximate entry index,and the performance of this best truncation value was evaluated in further subgroup analysis.R 4.2.2 was used to analyze the data,and P<0.05 was considered statistically significant.ResultsIn this study,clinical data of 979 patients with AMI were collected,of which 81 patients(8.3%)developed CS and 898 patients(91.7%)did not develop CS.The history of myocardial infarction was significantly higher in the CS group than in the non-CS group(16.00%vs.6.57%,P=0.004).The NLR and blood glucose in the CS group were significantly higher than those in the non-CS group,and the difference was statistically significant(P<0.001).In terms of drug application,the application of NO AC,ACEI/ARB drugs and vasoactive drugs in the CS group was higher than that in the non-CS group,and the difference was statistically significant(P<0.05).In terms of invasive treatment measures,the application rate of stent implantation in the CS group was lower than that in the non-CS group(24.70%vs.45.00%,P=0.001),and the application rate of IABP and ECMO in the CS group was also higher than that in the non-CS group(all P<0.001).Compared with the non-CS group,the CS group had a higher incidence of renal dysfunction(24.70%vs 1.56%,P<0.001),and a higher mortality(59.30%vs 2.40%,P<0.001).Multivariate Logistic regression analysis showed that previous myocardial infarction(OR:2.78,95%CI:1.36-5.34,P<0.001),blood glucose(OR:1.11,95%CI:1.04-1.18,P<0.001),NLR(OR:1.17,95%CI:1.05-1.30,P<0.001)was an independent risk factor for CS after AMI,and stent implantation was a protective factor for CS after AMI(OR:0.55,95%CI:0.31-0.95,P=0.004).Multivariate Cox regression analysis showed that ACEI/ARB use was associated with reduced in-hospital mortality in patients with AMI-CS(HR:0.36,95%CI:0.13-0.96,P=0.042).ROC curve analysis results showed that blood glucose and NLR had predictive value for CS after AMI,and the area under ROC curve(AUC)for predicting AMI-Cs when blood glucose>5.6mmol/L was 0.639(95%CI:0.5744-0.703,P<0.001),the sensitivity was 75.31%,the specificity was 50.11%;When NLR≥4.754,the AUC of AMI-CS was 0.724(95%CI:0.6590.790,P<0.001),the sensitivity was 65.43%,and the specificity was 77.28%.Patients with AMI were divided into high NLR group(NLR≥4.754)and low NLR group(NLR<4.754)according to the optimal NLR truncation value obtained by ROC curve analysis.Subgroup analysis after stratification according to age,systolic blood pressure,blood glucose and creatinine showed that in the subgroup<64 years old,the risk of in-hospital CS in the high NLR group was 15.12 times higher than that in the low NLR group(95%CI:6.31-42.09,P<0.05),while the HR of CS in patients≥64 years old was 3.97.In the subgroup with systolic blood pressure>128mmHg,patients with a high NLR level had 5.18 times the risk of developing in-hospital CS compared with those with a low NLR level(95%CI:2.23-11.91,P<0.05),while patients with systolic blood pressure<128mmHg had a HR of 6.71(95%CI:3.69-12.65,P<0.05).Based on the subgroup analysis of blood glucose and creatinine values,the HR of patients with blood glucose≥5.58mmol/L and<5.58mmol/L were 4.93(95%CI:2.80-8.95,P<0.05)and 7.16(95%CI:2.86-18.43,P<0.05).While the HR of creatinine≥75μmol/L and creatinine<75μmol/L were 6.54(95%CI:3.60-12.44,P<0.05)and 5.26(95%CI:2.34-12.02,P<0.05),respectively.Conclusion1.History of myocardial infarction,blood glucose and NLR are risk factors for CS after AMI,and stent implantation is a protective factor for CS after AMI.2.The in-hospital mortality of patients with CS after AMI is higher,and the use of ACEI/ARB drugs is related to the reduction of in-hospital mortality in patients with AMI-CS.3.NLR is a simple and new inflammatory index.The incidence of CS in AMI patients with NLR≥4.754 is higher,and NLR is helpful to predict the occurrence of CS in AMI patients. |
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