急性心肌梗死治疗指南对我国住院患者治疗及预后的影响

Impact of the acute myocardial infarction guidelines on in-hospital managements and outcome of the patients in China

目的 分析美国心脏病学会/美国心脏协会（ACC/AHA）2004年修订的急性心肌梗死（AMI）治疗指南对我国住院患者早期再灌注治疗、药物治疗和预后的影响,以及目前我国执行指南中存在的差距.方法 应用回顾性研究方法,选择2002年1月至2006年12月在全国12家医院心内科明确诊断为AMI的患者共1 278例,依据指南公布时间,将入选患者分为指南公布前组（2002年1月至2004年8月,A组,734例）和指南公布后组（2004年8月至2006年12月,B组,544例）.比较两组基线特征、住院治疗措施（早期再灌注和药物治疗）、并发症（再发心肌梗死、梗死后心绞痛、充血性心力衰竭、心源性休克和出血）及病死率情况;并分别对两组住院期间治疗措施与病死率进行相关性分析.结果 ①两组AMI患者年龄、性别、收缩压、除陈旧性心肌梗死外的既往史比较差异无统计学意义;B组心功能Killip≥Ⅲ级比例低于A组（7.5%比14.7%,P＜0.01）.②B组早期再灌注治疗总比例高于A组（78.5%比71.2%,P＜0.05）;其中经皮冠状动脉介入治疗（PCI）比例较A组明显升高（71.5%比61.0%,P＜0.01）,而溶栓治疗比例较A组明显降低（8.6%比16.3%,P＜0.01）.⑧两组抗血小板药物总体使用率及其中阿司匹林使用率均大于97.0%,其中B组盐酸噻氯匹定使用率较A组明显下降（8.3%比54.9%）,氯吡格雷和血小板膜糖蛋白Ⅲa/Ⅰ b（GP Ⅲ a/Ⅰ b）类药物使用率均较A组明显升高（83.8%比27.4%,4.8%比0.7%,均P＜0.01）;B组血管紧张素转换酶抑制剂（ACEI）或血管紧张素Ⅰ受体拮抗剂（ARB）类药物总体使用率明显高于A组（98.2%比93.5%,P＜0.01）,其中ARB类药物使用率较A组明显升高（13.6%比4.4%,P＜0.05）,而ACEI类药物使用率较A组明显下降（84.6%比89.1%,P＜0.01）;B组肝素或低分子肝素、β受体阻滞剂、他汀类药物使用率均高于A组（97.4%比94.8%,80.1%比74.8%,87.7%比82.4%,P＜0.05或P＜0.01）.④B组住院期间病死率及再发心肌梗死、梗死后心绞痛发生率均明显低于A组（4.6%比7.6%,2.8%比4.8%,8.4%比12.4%,均P＜0.05）.⑤多因素分析显示：A、B组早期再灌注、抗血小板药物及B组他汀类药物、肝素或低分子肝素与住院期间病死率有独立的显著联系（均P＜0.05）.结论 2004年指南公布后我国AMI患者早期再灌注率和药物治疗的规范化程度明显提高,住院期间病死率及再发心肌梗死和梗死后心绞痛发生率明显降低,且早期再灌注、抗血小板药物、他汀类药物、肝素或低分子肝素与住院期间病死率存在独立的显著联系,与指南要求一致;但目前我国在β受体阻滞剂、ACEI/ARB类药物治疗方面仍然存在着较大提升空间.

Objective To investigate the relationship between the guidelines issued by the American College of Cardiology/American Heart Association （ACC/AHA） in 2004 and the changes in early reperfusion, drug treatment and outcome of inpatients -with acute myocardial infarction （AMI） in China, and to explore what extent the guidelines are followed in the management of AMI in China, and the differences in managements and patients＇ outcome after its issue.Methods A retrospective study of clinical data of 1 278 patients with AMI admitted to 12 Chinese Hospitals from January 2002 to December 2006 was carried out.They were divided into two groups： group A included 734 patients admitted from January 2002 to August 2004, and group B comprised 544 patients admitted from August 2004 to December 2006.The baseline characteristics, early reperfusion, drug treatment, reinfarction, angina pectoris, heart failure,cardiogenic shock, bleeding and death were compared between two groups.The correlation between therapeutic measure and mortality was analyzed to estimate the difference between two groups, and relationship between the differences and the guidelines issued in 2004 was also analyzed.Results ①The age, sex, systolic blood pressure, history of past illness excepting old myocardial infarction of patients with AMI bore no significant difference between two groups.The incidence of Killip≥ Ⅲ in group B was lower significantly than that in group A （7.5% vs.14.7%, P＜0.01）.②Reperfusion therapy was used more often in group B than in group A （78.5% vs.71.2%, P＜0.05）.And percutaneous coronary intervention （PCI）therapy was used more often in group B than in group A （71.5% vs.61.0%, P＜0.01）.However, the rate of lytic treatment was lower in group B than that in group A （8.6% vs.16.3%, P＜0.01）.③ The percentage of use of antiplatelet drug and aspirin was both over 97.0%.The tidopidine was used more frequently in group A than in group B （54.9% vs.8.3%）, and the clopidogrel and glycoprotein Ⅲ a/Ⅰ b antagonists was used more frequently in group B than in group A （83.8% vs.27.4%, 4.8% vs.0.7%,both P ＜ 0.01 ）.The angiotensin-converting enzyme inhibitor/angiotensin Ⅰ receptor antagonist （ACEI/ARB） were administered more frequently in groupB than in group A （98.2% vs.93.5%, P＜0.01）, and the increasing trend of ARB was obvious （13.6% vs.4.4%, P＜0.05）, but the decreasing trend of ACEI was obvious also （84.6% vs.89.1%, P＜0.01）.Heparin/low molecular heparin, β-blocker and statin were used more often in group B than in group A （97.4% vs.94.8%, 80.1% vs.74.8%, 87.7% vs.82.4%, P＜0.05 or P＜0.01）.④ In-hospital mortality, reinfarction, angina pectoris were lower in group B than in group A （4.6% vs.7.6%, 2.8% vs.4.8%, 8.4% vs.12.4%, all P＜0.05）.⑤ Multivariate Logistic regression analysis showed that reperfusion, antiplatelet drug, statin and heparin/low molecular heparin were associated significantly with in-hospital mortality （all P＜0.05）.Conclusion After guideline was issued by ACC/AHA in 2004, the regime of early reperfusion and drug treatment in China had followed more closely the recommendations of the guidelines.At the same time, in-hospital mortality,reinfarctions,angina pectoris were decreased.And the changes in strategy of early reperfusion, antiplatelet drug, statin and heparin/low molecular heparin are closely related with in-hospital mortality.However, current management of AMI in China has not followed the recommendations of guidelines closely.It is essential to promote the use of β-blocker and ACEI/ARB drug treatment in China in accordance with the guidelines.