心率-血压乘积在急性心肌梗死后心力衰竭发生风险中的预测价值

Prognostic value of the rate-pressure product in predicting heart failure after acute myocardial infarction

摘要:

目的]探讨基于心肺运动试验(CPET)获取的峰值心率-血压乘积(RPP peak)在急性心肌梗死(AMI)患者的心力衰竭发生风险中的预测价值及其在风险分层中的作用。 [方法]本研究为一项回顾性队列研究,纳入2018年1月—2023年12月期间在哈尔滨医科大学附属第二医院、广东省人民医院及鹤岗市人民医院早期接受标准化踏车式症状限制型CPET的3 172例AMI患者。根据是否发生急性心肌梗死后心力衰竭(Post-MI HF)分为Post-MI HF组和非Post-MI HF组。采用Cox回归分析评估RPP peak与Post-MI HF风险的关联性,使用限制性立方样条(RCS)分析其与Post-MI HF风险的线性关系,通过ROC曲线评估RPP peak的预测性能。为探索其在风险分层中的作用,根据RPP peak三分位数将研究对象分为T1、T2、T3三组,通过Kaplan-Meier生存曲线比较不同RPP peak水平下Post-MI HF的无事件累计生存率,并进一步行Cox回归分析三组间的风险差异。 [结果]经纳排标准筛选后,共纳入2 221例AMI患者,其中有237例发生Post-MI HF。Cox回归分析显示,RPP peak升高是Post-MI HF发生的独立保护因素,每升高1个单位Post-MI HF风险降低9%(HR＝0.914,95%CI:0.883~0.944,P＜0.001)。RCS曲线分析提示RPP peak与Post-MI HF风险呈线性关系(P_nonlinear＝0.978)。ROC曲线分析显示,RPP peak在预测1年、3年和5年Post-MI HF风险时,其曲线下面积(AUC)均优于单一指标峰值心率(HR peak)与峰值收缩压(SBP peak)。Kaplan-Meier生存曲线显示,不同RPP peak水平组间Post-MI HF发生呈显著的风险梯度关系(Log-rank P＜0.001),且随着RPP peak水平升高,无事件生存率逐步提高。进一步的Cox回归分析显示,与T1组相比,T2组(HR＝0.488,95%CI:0.363~0.657,P＜0.001)和T3组(HR＝0.308,95%CI:0.219~0.434,P＜0.001)的Post-MI HF风险显著降低。 [结论]RPP peak是Post-MI HF发生的独立预测指标,并与其发生风险呈线性负相关,对AMI患者Post-MI HF的早期预防和风险分层具有重要的临床意义。

Abstract:

Aim To investigate the predictive value of peak rate-pressure product (RPP peak) derived from cardiopulmonary exercise testing (CPET) for the risk of heart failure after acute myocardial infarction (AMI), and to evaluate its role in risk stratification. Methods This retrospective cohort study included AMI patients who underwent early standardized symptom-limited cycle ergometer-based CPET between January 2018 and December 2023 at the Second Affiliated Hospital of Harbin Medical University, Guangdong Provincial People's Hospital, and Hegang People's Hospital. Patients were classified into heart failure after acute myocardial infarction (Post-MI HF) and non-Post-MI HF groups based on the occurrence of Post-MI HF. Cox proportional hazards regression was used to assess the association between RPP peak and the risk of Post-MI HF. Restricted cubic spline (RCS) analysis was applied to examine the dose-response relationship between RPP peak and post-MI HF risk. Time-dependent receiver operating characteristic (ROC) curves were used to evaluate the predictive performance of RPP peak. For risk stratification, patients were categorized into tertiles (T1, T2 and T3) according to RPP peak levels. Kaplan-Meier survival curves were constructed to compare cumulative event-free survival across tertiles, and Cox regression analysis was further performed to quantify risk differences among groups. Results After applying inclusion and exclusion criteria, 2 221 AMI patients were included, among whom 237 developed post-MI HF. Cox regression analysis demonstrated that elevated RPP peak was an independent protective factor for Post-MI HF, with each one-unit increase in RPP peak associated with a 9% reduction in Post-MI HF risk (HR＝0.4,5%CI:0.883~0.944, P＜0.001). RCS analysis indicated a linear association between RPP peak and Post-MI HF risk (P_nonlinear＝0.978). ROC curves analysis showed that RPP peak achieved higher area under the curve (AUC) values for predicting 1-, 3-, and 5-year Post-MI HF compared with peak heart rate (HR peak) and peak systolic blood pressure (SBP peak) alone. Kaplan-Meier analysis revealed a significant graded relationship between RPP peak tertiles and Post-MI HF risk (Log-rank P＜0.001), with higher RPP peak levels associated with improved survival. Further Cox regression analysis showed that, compared with the lowest tertile (T1), the risk of post-MI HF was significantly lower in T2 (HR＝0.8,5%CI:0.363~0.657, P＜0.001) and T3 (HR＝0.8,5%CI:0.219~0.434, P＜0.001). Conclusions RPP peak is an independent predictor of Post-MI HF and is linearly and inversely associated with Post-MI HF risk. These findings highlight the clinical value of RPP peak for early risk assessment, prevention, and risk stratification in AMI patients.