急性心肌梗死合并卒中病史患者危险因素及住院转归的分析

Analysis of risk factors and clinical outcomes in patients with acute myocardial infarction and history of stroke

目的：探讨合并缺血性卒中的急性心肌梗死患者的危险因素、临床发病及住院转归特点。方法回顾性分析2005年1月-2012年3月在首都医科大学宣武医院确诊并收治入院的771例急性心肌梗死患者，依照既往是否合并缺血性卒中分为卒中组（387例）和对照组（384例）。通过病例对照分析比较两组患者的心血管病危险因素、临床发病特点及住院转归情况。观察终点事件为住院期间急性缺血性卒中、脑出血及全因死亡。结果（1）卒中组和对照组患者年龄中位数分别为71（37～91）和62（29～90）岁，卒中组女性患者多于对照组（分别为125和91例），合并高血压[分别为72.9％（282例）和47.6％（183例）]和2型糖尿病[分别为39.0％（151例）和20.8％（80例）]的发生率高，两组差异均有统计学意义（均P＜0.01）。（2）卒中组患者发病至入院时间长于对照组（中位数11和4 h），出现心电图非ST段抬高型心肌梗死发生率[分别为16.0％（62例）和1.8％（7例）]较高，合并应激性胃溃疡[分别为7.0％（27例）和2.1％（8例）]、心房颤动[分别为10.6％（41例）和3.9％（15例）]和急性肺水肿——心功能Killip≥Ⅱ级[分别为51.9％（201例）和37.8％（145例）]发生率更高；冠状动脉造影左主干或3支病变的发生率卒中组较对照组[52.9％（126/238）和32.4％（97/299）]更多，差异均有统计学意义（均P＜0.05）。（3）卒中组与对照组患者新发卒中的发生率[分别为5.7％（22例）和1.8％（7例）]和住院期间病死率[分别为13.7％（53例）和7.6％（29例）]差异均有统计学意义（均P＜0.01）。结论既往明确有卒中病史的急性心肌梗死患者年龄大，女性患者发生率更高且大多合并高血压及糖尿病等危险因素。这些患者往往合并消化道溃疡和心力衰竭等并发症，且冠状动脉造影多显示多支病变，住院期间更容易出现心脑血管缺血事件。

Objective To investigate the risk factors,clinical characteristics and outcomes in patients with acute myocardial infarction and history of stroke. Methods A total of 771 patients with acute myocardial infarction diagnosed and admitted to Xuanwu Hospital,Capital Medical University from January 2005 to March 2012 were analyzed retrospectively. They were divided into either a stroke group （n=387）or a control group （n=384）according to whether they had previous ischemic stroke or not. The risk factors for cardiovascular disease,clinical characteristics of the disease,and clinical outcomes of the patients in both groups were compared through the case control analysis. The endpoint events observed were acute ischemic stroke,cerebral hemorrhage,and cause of death during hospitalization. Results （1）The median age of the patients in both stroke and control groups was 71 （37-91 ）and 62 （29-90 ）years respectively. The female patients in the stroke group were more than those in the control group （n=125 vs. n=91）. The incidence of complicated with hypertension （72. 9%[n=282]and 47. 6%[n=183]） and type 2 diabetes mellitus （39. 0%[n=151]and 20. 8%[n=80]respectively）were high. There was significant difference between the two groups （P〈0. 01）. （2）The time from the onset to admission in patients of the stroke group was longer than that in patients of the control group （median 11 h vs. 4 h）. The incidence of non-ST segment elevation myocardial infarction （16. 0%[n = 62 ]and 1. 8%[n = 7 ] respectively）was higher. The incidences of complicated with gastric stress ulcer （7. 0%[n =27 ]and 2. 1%[n=8]respectively）,atrial fibrillation （10. 6%[n=41]and 3. 9%[n=15]respectively）,and acute pulmonary edema-cardiac function Killip class≥Ⅱ（51. 9%[n =201 ]and 37. 8%[n =145 ] respectively）were more higher. The findings of coronary angiography in patients of the stroke group were that the incidence of left main coronary artery or 3 -branch lesion higher than that of the control group （52. 9%[126/238]and 32. 4%[97/299]respectively）. There was significant difference （P〈0. 05）. （3）The incidence of new stroke in patients of the stroke group （5. 7%[n =22 ]and 1. 8%[n =7 ] respectively）and in hospital mortality （13. 7%[n=53]and 7. 6%[n=29]respectively）were higher than those of the control group. There were significant differences （P〈0. 01）. Conclusion The age of the patients with acute myocardial infarction with previous identified history of stroke is older. The incidence of female patients is higher than that of the non-stroke patients,and most of them have risk factors that complicated with hypertension and diabetes mellitus. These patients often have the complications with peptic ulcer disease and heart failure,and their coronary angiography often show multi-branch lesions,and they are more prone to ischemic cardio-cerebrovascular events during the hospitalization.