中国呼吸与危重监护杂志

中国呼吸与危重监护杂志

血小板增多与慢性阻塞性肺疾病伴低危肺栓塞患者住院全因死亡的相关性分析

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目的 探索血小板增多与慢性阻塞性肺疾病(简称慢阻肺)伴低危肺栓塞患者住院全因死亡的相关性。 方法 采用临床多中心回顾性研究,选取 2005 年 10 月至 2017 年 2 月因急性肺栓塞住院的慢阻肺患者,根据肺栓塞严重指数(PESI)排除中高危肺栓塞患者,纳入慢阻肺伴低危肺栓塞患者作为研究对象。采集入院时血小板计数,将患者分为血小板增多组与非血小板增多组。比较两组患者临床特征及预后,使用多元回归分析血小板增多与住院全因死亡的相关性,并调整混杂变量。 结果 纳入慢阻肺合并低危肺栓塞的 874 例成年患者中,191 例(21.9%)合并血小板增多。与非血小板增多组比较,血小板增多组具有更低的体重指数[(20.9±3.3)kg/m2 比(25.1±3.8)kg/m2P=0.01]、更低水平的第 1 秒用力呼气容积[(0.9±0.4)L 比(1.3±0.3)L,P=0.001]和动脉血氧分压[(7.8±1.2)kPa 比(9.7±2.3)kPa,P=0.003],以及更高的心血管合并症发生率和肺动脉收缩压[(46.5±20.6)mm Hg比(34.1±12.6)mm Hg,P=0.001]。校正混杂因素后,血小板增多与住院全因死亡相关(OR=1.53,95%CI 1.03~2.29),而口服抗血小板药物(OR=0.71,95%CI 0.31~0.84)为保护性因素。 结论 血小板增多是慢阻肺伴低危肺栓塞患者住院全因死亡的独立危险因素,抗血小板治疗可能对这类高危人群具有保护性作用。

Objective To explore the relationship between thrombocytosis and all-cause in-hospital mortality in patients with chronic obstructive pulmonary disease (COPD) and low-risk pulmonary embolism (PE). Methods In a multicenter retrospective study on clinical characteristics, COPD patients with proven acute PE between October 2005 and February 2017 were enrolled. The patients in risk classes III-V on the basis of the PESI score were excluded. The patients with COPD and low-risk PE were divided into two groups of those with thrombocytosis and without thrombocytosis after extracting platelet count on admission. The clinical characteristics and prognosis of the two groups were compared. Multivariate logistic regression was performed to reveal an association between thrombocytosis and all-cause in-hospital mortality after confounding variables were adjusted. Results A total of 874 consecutive patients with COPD and PE at low risk were enrolled in which 191 (21.9%) with thrombocytosis. Compared with those without thrombocytosis, the thrombocytopenic group had significantly lower body mass index [(20.9±3.3) kg/m2 vs. (25.1±3.8) kg/m2, P=0.01], lower levels of forced expiratory volume in one second (FEV1) [(0.9±0.4) L vs. (1.3±0.3) L, P=0.001] and lower partial pressure of oxygen in the arterial blood (PaO2) [(7.8±1.2) kPa vs. (9.7±2.3) kPa, P=0.003]. The COPD patients with thrombocytosis had a higher proportion of cardiovascular complications as well as higher level of systolic pulmonary arterial pressure (sPAP) [(46.5±20.6) mm Hg vs. (34.1±12.6) mm Hg, P=0.001]. Multivariate logistic regression analysis after adjustment for confounders revealed that thrombocytosis was associated with all-cause mortality in hospitalized patients with COPD and low-risk PE (adjusted OR=1.53, 95%CI 1.03–2.29), and oral antiplatelet treatment was a protective factor (adjusted OR=0.71, 95%CI 0.31–0.84). Conclusions Thrombocytosis is an independent risk factor for all-cause in-hospital mortality in COPD patients with PE at low risk. Antiplatelet therapy may play a protective role in the high-risk cohort.

关键词: 慢性阻塞性肺疾病; 肺栓塞; 血小板增多; 肺动脉高压; 死亡率

Key words: Chronic obstructive pulmonary disease; Pulmonary embolism; Thrombocytosis; Pulmonary hypertension; Mortality

引用本文: 郭璐, 杨阳, 蒋红丽, 龚道明, 高凌云, 杨雁, 张静, 钟甜, 刘跃建, 解郑良. 血小板增多与慢性阻塞性肺疾病伴低危肺栓塞患者住院全因死亡的相关性分析. 中国呼吸与危重监护杂志, 2018, 17(1): 20-26. doi: 10.7507/1671-6205.201708041 复制

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1. Vogelmeier CF, Criner GJ, Martinez FJ, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary. Eur Respir J, 2017, 49(3). pii: 1700214.
2. Guo L, Chughtai AR, Jiang H, et al. Relationship between polycythemia and in-hospital mortality in chronic obstructive pulmonary disease patients with low-risk pulmonary embolism. J Thorac Dis, 2016, 8(11): 3119-3131.
3. Aleva FE, Voets LWLM, Simons SO, et al. Prevalence and localization of pulmonary embolism in unexplained acute exacerbations of COPD: a systematic review and meta-analysis. Chest, 2017, 151(3): 544-554.
4. Squizzato A, Donadini MP, Galli L, et al. Prognostic clinical prediction rules to identify a low-risk pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost, 2012, 10(7): 1276-1290.
5. Furie B, Furie BC. Thrombus formation in vivo. J Clin Invest, 2005, 115(12): 3355-3362.
6. Tabuchi A, Kuebler WM. Endothelium-platelet interactions in inflammatory lung disease. Vascul Pharmacol, 2008, 49(4-6): 141-150.
7. Gawaz M, Langer H, May AE. Platelets in inflammation and atherogenesis. J Clin Invest, 2005, 115(12): 3378-3384.
8. Maclay JD, McAllister DA, Johnston S, et al. Increased platelet activation in patients with stable and acute exacerbation of COPD. Thorax, 2011, 66(9): 769-774.
9. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J, 2014, 35(43): 3033-3069.
10. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J, 2005. 26(2): 319-338.
11. Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). J Am Soc Echocardiogr, 2003, 16(10): 1091-1110.
12. McLaughlin VV, Archer SL, Badesch DB, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association developed in collaboration with the American College of Chest Physicians; American Thoracic Society, Inc. ; and the Pulmonary Hypertension Association. J Am Coll Cardiol, 2009, 53(17): 1573-1619.
13. Schumann G, Canalias F, Joergensen PJ, et al. IFCC reference procedures for measurement of the catalytic concentrations of enzymes: corrigendum, notes and useful advice. International Federation of Clinical Chemistry and Laboratory Medicine (IFCC)--IFCC Scientific Division. Clin Chem Lab Med, 2010, 48(5): 615-621.
14. Roussos C, Koutsoukou A. Respiratory failure. Eur Respir J, 2003, 22(Suppl 47): 3s-14s.
15. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Am J Clin Nutr, 1998, 68(4): 899-917.
16. McDonald TP, Cottrell M, Clift R. Effects of short-term hypoxia on platelet counts of mice. Blood, 1978, 51(1): 165-175.
17. Wedzicha JA, Cotter FE, Empey DW. Platelet size in patients with chronic airflow obstruction with and without hypoxaemia. Thorax, 1988, 43(1): 61-64.
18. Wedzicha JA, Syndercombe-Court D, Tan KC. Increased platelet aggregate formation in patients with chronic airflow obstruction and hypoxaemia. Thorax, 1991, 46(7): 504-507.
19. Kumakura H, Kanai H, Aizaki M, et al. The influence of the obesity paradox and chronic kidney disease on long-term survival in a Japanese cohort with peripheral arterial disease. J Vasc Surg, 2010, 52(1): 110-117.
20. Lainscak M, von Haehling S, Doehner W. Body mass index and prognosis in patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease. J Cachexia Sarcopenia Muscle, 2011, 2(2): 81-86.
21. Man SFP, Leipsic JA, Man JP, et al. Is atherosclerotic heart disease in COPD a distinct phenotype?. Chest, 2011, 140(3): 569-571.
22. Shapira-Rootman M, Beckerman M, Soimu U, et al. The prevalence of pulmonary embolism among patients suffering from acute exacerbations of chronic obstructive pulmonary disease. Emerg Radiol, 2015. 22(3): 257-260.
23. de Lucas-Ramos P, Izquierdo-Alonso JL, Rodriguez-Gonzalez Moro JM, et al. Chronic obstructive pulmonary disease as a cardiovascular risk factor. Results of a case-control study (CONSISTE study). Int J Chron Obstruct Pulmon Dis, 2012, 7: 679-686.
24. Chang CL, Robinson SC, Mills GD, et al. Biochemical markers of cardiac dysfunction predict mortality in acute exacerbations of COPD. Thorax, 2011, 66(9): 764-768.
25. Thomsen M, Ingebrigtsen TS, Marott JL, et al. Inflammatory biomarkers and exacerbations in chronic obstructive pulmonary disease. JAMA, 2013, 309(22): 2353-2361.
26. Marchena Yglesias PJ, Nieto Rodríguez JA, Serrano Martínez S, et al. Acute-phase reactants and markers of inflammation in venous thromboembolic disease: correlation with clinical and evolution parameters. An Med Interna, 2006, 23(3): 105-110.
27. Harrison MT, Short P, Williamson PA. Thrombocytosis is associated with increased short and long term mortality after exacerbation of chronic obstructive pulmonary disease: a role for antiplatelet therapy?. Thorax, 2014, 69(7): 609-615.
28. Collaborative overview of randomised trials of antiplatelet therapy--III: reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. Antiplatelet Trialists' Collaboration. BMJ, 1994, 308(6923): 235-246.
29. Short PM, Lipworth SI, Elder DH, et al. Effect of beta blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study. BMJ, 2011(342): d2549.
30. Fruchter O, Yigla M, Kramer MR. Lipid profile and statin use: the paradox of survival after acute exacerbation of chronic obstructive pulmonary disease. Am J Med Sci, 2015, 349(4): 338-343.