222例儿童病毒性心肌炎临床分析

A clinical analysis of 222 children with viral myocarditis

摘要:

目的：探讨暴发性心肌炎患儿的高危因素，为临床早期诊断和干预治疗提供参考。方法：收集2012年1月至2018年1月临床诊断为病毒性心肌炎的患者222例，分为暴发性心肌炎组（n=57）与非暴发性心肌炎组（n=165），采用卡方检验或t检验对2组患儿临床症状及体征、心电图、心脏彩超、血清学检查等进行分析，提取出具有统计学意义（P<0.05）的相关指标进行logistic回归分析，并进行ROC曲线制作。结果：暴发性心肌炎组死亡12例（21.05%），其中7例入院1 d内即死亡，另5例住院期间病情无缓解，要求出院后电话随访死亡；非暴发性心肌炎组无死亡病例。暴发性心肌炎组患儿年龄偏大，呕吐、食欲下降、水肿、末梢循环差、尿量减少、抽搐、意识障碍、低血压等临床表现较非暴发性心肌炎组多见；心电图有病理性Q波、室性早搏、左束支传导阻滞、室速、QRS波延长，血清学检查肌钙蛋白Ⅰ、脑钠肽、血肌酐、尿素氮、谷丙转氨酶升高、低钾血症、左室射血分数、左室短轴缩短率降低等较非暴发性心肌炎组更明显（P<0.05）。Logistic回归分析显示，低血压（OR=7.248，95%CI=1.352~38.860，P=0.021）、左室射血分数降低（OR=63.720，95%CI=8.234~493.115，P=0.000）、QRS波时程延长（OR=1.043，95%CI=1.002~1.085，P=0.039）及年龄（OR=1.193，95%CI=1.013~1.404，P=0.034）是暴发性心肌炎的独立预测因素，左室射血分数ROC曲线下面积为0.737（OR=0.000，95%CI=0.641~0.833），截点值为58.5%，灵敏度0.87，特异度0.64；QRS波时程曲线下面积为0.71（OR=0.000，95%CI=0.625~0.795），截断点值为79.5 ms，灵敏度0.80，特异度0.55，年龄曲线下面积为0.725（OR=0.000，95%CI=0.649~0.802），截断点值3.35岁，灵敏度0.84，特异度0.59。 结论：暴发性心肌炎病死率高，低血压、左室射血分数降低是其独立危险因素。

Abstract:

Objective：To investigate the high-risk factors for children with fulminant myocarditis and to provide a reference for early clinical diagnosis and intervention. Methods：A total of 222 children with viral myocarditis diagnosed from January 2012 to January 2018 were included in fulminant myocarditis group（n=57） and non-fulminant myocarditis group（n=165）. The chi-square test or t-test was used for analysis of clinical symptoms and signs，electrocardiographic and echocardiographic findings，and serological exami－nation results for the two groups of patients. Statistically significant（P<0.05） indices were selected for logistic regression analysis and the plotting of receiver operating characteristic（ROC） curve. Results：In the fulminant myocarditis group，12 patients（21.05%） died. Among them，7 patients died within 1 day of admission. The other 5 patients had no remission during hospitalization and were found to be dead through telephone follow-up after hospital discharge. There was no death in the non-fulminant myocarditis group. The children in the fulminant myocarditis group were older and had more clinical manifestations of vomiting，anorexia，edema，poor pe－ripheral circulation，hypourocrinia，convulsion，hypotension，and disturbance of consciousness，as compared with those in the non-ful－minant myocarditis group. The electrocardiogram of the fulmi－nant myocarditis group showed pathological Q waves，ventricular premature beats，left bundle branch block，ventricular tachycar－dia，and QRS duration prolongation. According to the serological examination，troponin Ⅰ，brain natriuretic peptide，serum creati－nine，urea nitrogen，and glutamic-pyruvic transaminase increased，and hypokalemia and reductions in left ventricular ejection fraction（LVEF） and left ventricular fractional shortening were more severe in the fulminant myocarditis group than in the non-fulminant my－ocarditis group（P<0.05）. The logistic regression analysis showed that hypotension（OR=7.248，95%CI＝1.352 to 38.860，P=0.021），LVEF reduction（OR=63.720，95%CI=8.234 to 493.115，P=0.000），prolonged QRS duration（OR=1.043，95%CI＝1.002 to 1.085，P=0.039），and age（OR=1.193，95% 95%CI=1.013 to 1.404，P=0.034） were independent predictive factors for fulminant myocarditis. The area under the ROC curve（AUC） of LVEF was 0.737（OR=0.000，95%CI=0.641 to 0.833），and the calculation of the Youden index yielded a cut-off value of 58.5%，a sensitivity of 0.87，and a specificity of 0.64. The AUC of QRS duration was 0.71（OR=0.000，95%CI=0.625 to 0.795）；the cut-off point value was 79.5 ms，the sensitivity was 0.80，and the specificity was 0.55. The AUC of age was 0.725（OR=0.000，95%CI=0.649 to 0.802）；the cut-off point value was 3.35 years，the sensitivity was 0.84，and the specificity was 0.59. Conclusion：The fatality of fulminant myocarditis is high，and hypotension and LVEF reduction are independent risk factors for it.