| Objective:In recent years,some epidemiological studies have shown that pulse pressure(PP)is a strong predictor of mortality for many cardiovascular diseases.However,few studies have reported the relationship between PP and adverse events in patients with type A acute aortic dissection(TAAAD)during hospital stay.This study retrospectively evaluated the association of presenting PP with in-hospital outcomes,specifically all-cause mortality,in TAAAD patients.Meanwhile,the risk factors of in-hospital death in TAAAD patients were explored and a clinical prediction model(CPM)was constructed to provide a theoretical basis and reference for clinical decision-making and intervention.Methods:This study recruited 488 TAAAD patients admitted to the Department of Cardiovascular Surgery of Shandong Provincial Hospital from January 2015 to December 2021.The patients were divided into four groups according to the presenting PP:narrow(PP≤40 mmHg),normal(40<PP≤56 mmHg),mildly elevated(56<PP≤75 mmHg),and markedly elevated(PP>75 mmHg).SPSS Statistics 26.0 was used to statistically analyze the differences in clinical data of the four groups and to study the relationship between PP and in-hospital death of patients in each group.Then,with in-hospital death as the dependent variable,univariate and multivariate binary logistic regression analysis was used to explore the risk factors of in-hospital death in TAAAD patients.A CPM was constructed and a Nomogram was drawn based on the results of regression analysis.The CPM was assessed from three aspects:differentiation,calibration degree,and clinical application value.Results:1.The 488 participants had a mean age of 51.50±11.01 years and 70.49%of them were male.107 cases received medical treatment and 381 cases received surgical treatment.100 cases(20.49%)died in hospital,among which 52 cases(48.60%)died after medical treatment and 48 cases(12.60%)died after surgical treatment.2.The relationship between presenting PP and in-hospital mortality displayed a J-curve association,with significantly higher mortality rates in patients with markedly elevated PP as well as in those with narrow PP(28.93%and 27.91%,respectively).The in-hospital mortality was 12.80%and 16.03%in the normal and mildly elevated groups,respectively.This relationship was mainly from increased rates of in-hospital complications in patients with PP≤40 mmHg and PP>75 mmHg(stroke,liver dysfunction,and renal failure in patients with PP>75 mmHg;syncope,myocardial ischemia/infarction,and pericardial effusion in patients with PP≤40 mmHg).3.Multivariate binary logistic regression analysis showed that PP>75 mmHg(P=0.001),syncope(P=0.007),D-dimer(P<0.001),and creatinine level(P=0.024)were independent risk factors for death in hospital,and surgery(P<0.001)was the protective factor.The CPM was created based on the above variables.The Area under the curve(AUC)of the Receiver operating characteristic curve(ROC)was 0.825(95%CI,0.780-0.870)and the C-index value was 0.825.The results of the Hosmer-Lemeshow goodness-of-fit test showed that χ=7.510,P=0.483>0.05.The calibration curve graph showed that the calibration curve(Apparent line)and diagonal line(Ideal line)jointed closely.The prediction model was verified internally by the Bootstrap sampling method,and the corrected curve basically overlapped with the diagonal line.The clinical Decision Curve Analysis(DCA)indicated that the threshold value ranging from 0.01 to 0.72 could bring net benefits to patients.Conclusions:1.Presenting PP showed a clear J-curve relationship with in-hospital mortality in patients with TAAAD,and this association was related to increased rates of comorbid conditions at the edges of the curve.2.PP>75 mmHg,syncope,D-dimer,and creatinine were independent risk factors for in-hospital death in patients with TAAAD,while surgery was a protective factor.3.The CPM constructed based on the variables screened by multivariate logistic regression analysis had great discriminatory power,a good calibration degree,and a high value of clinical application. |
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