甘宁青新四省区10年急性心肌梗死患者血管紧张素转化酶抑制剂和血管紧张素受体阻滞剂的应用及影响因素

The factors influence the use of angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers （ACEI/ARB） in patients with acute myocardial infarction in Gansu, Ningxia, Qinghai and Xinjiang from2001 to 2011

目的了解甘宁青新四省区急性心肌梗死（AMI）患者中血管紧张素转化酶抑制剂和血管紧张素受体阻滞剂（ACEI／ARB）的使用情况，并探讨其影响因素。方法研究数据来源于一项覆盖全国31个省的冠心病医疗结果评价研究——China PEACE回顾性AMI研究，本研究使用甘宁青新四省区8家协作医院（其中三级医院2家、二级医院6家）数据进行分析。通过调查甘宁青新四省区8家协作医院2001、2006、2011三个特定年份的研究病历，分析ACEI／ARB的使用情况，并采用二元logistic回归方法探讨其使用的影响因素。结果共人选311例患者，其中中国指南I类推荐组300例，指南Ⅱa类推荐组11例。指南Ⅰ类推荐患者2001年、2006年和2011年ACEI／ARB使用率分别为69．57％，82．19％和60．77％（P=0．033），指南1Ia类推荐患者的ACEI／ARB使用率分别为40％，0％和60％（P=0．525）。不同年份ACEI／ARB使用率在I类推荐患者中差异有统计学意义，而在IIa类推荐患者中差异无统计学意义。在3个研究年份中，ACEIs使用率均显著高于ARBs。多因素分析显示吸烟、卒中、高血压、心力衰竭和收缩压水平是影响ACEI／ARB使用的独立相关因素，即吸烟（OR=2．0，95％CI：1．2～3．6）、合并高血压（OR=2．3，95％CI：1．3～4．1）、心力衰竭（OR=3．1，95％CI：1．7～5．8）的患者更容易接受ACEI／ARB类药物，而有卒中史（OR=0．3，95％CI：0．1～0．8）、入院时收缩压〈90mmHg（1mmHg=0．133kPa）（OR=0．1，95％CI：0～0．5）的患者使用ACEI／ARB类药物比例较低。结论甘宁青新欠发达地区，急性心肌梗死患者住院期间规范服用ACEI／ARB总体比例仍较低，ACEI／ARB使用率并未随着医疗条件的进步、经济的发展、信息的普及而增高，尤其是合并卒中史、低血压患者，而合并高血压、心力衰竭、吸烟者更易接受ACEI／ARB类药物，主要原因考虑医生对冠心病规范用药指南理解不透彻、对药物不良反应顾忌，也与患者对疾病认知程度低，重视不足有关。

Objective To investigate the rate of employing angiotensin converting enzyme inhibitors/angiotensin receptor blockers （ACEI/ARB） therapy in patients with acute myocardial infarction （AMI） in Gansu, Ningxia, Qinghai and Xinjiang provinces from 2001 to 2011, in order to determine the factors affecting the use of ACEI/ARB. Methods The original data of this study were obtained from the China PEACE, a national retrospective study of AMI to evaluate clinical outcome of coronary heart disease from 31 provinces. A part of these data was selected from 8 cooperative hospitals （2 hospitals were tertiary class and 6 hospitals were secondary class ） from Gansu, Ningxia, Qinghai and, Xinjiang provinces for further analyses. The clinical data of AMI patients in 2001, 2006 and 2011 were collected to analyze the use of ACEI/ARB therapy in each of these years. Binary logistic regression analysis was used to identify factors influencing the use of ACEI/ARB. Results Of 311 eligible patients included, 300 were categorized into Class Ⅰ AMI and 11 into Class Ⅱ a AMI according to Chinese guidelines. From 2001 to 2011, there was significant change in the use of ACEI/ARB in term of percentage in patients with Class [ AMI （69. 57% , 82. 19% and 60. 77%, P = 0. 033）, but such change did not occur in patients with Class Ⅱ a AMI （40%, 0% and 60% , P = 0. 525）. Among three specific years, the percentage of ACEIs employed was noticeably higher than that of ARBs. Binary logistic regression analysis showed that patients with hypertension OR = 2.3, 95%CI： 1.3-4.1）, heart failure （OR=1.95, 95%CI： 1.7-5.8）, smoking indulgence OR= 2. 0, 95% CI：1. 2 -3.6） were more likely to be treated with ACEI/ARB, and patients with prior stroke （OR=0.3, 95%CI：0.1 -0.8） , systolic blood pressure〈90 mmHg （OR=0.1, 95%CI： 0-0.5） were less likely to be treated with ACEI/ARB. Conclusions In underdeveloped areas such as Gansu, Ningxia, Qinghai and Xinjiang provinces, the overall proportion of rational and necessary use of ACEI/ARB use in patients with AMI during hospitalization is still low. The rational use of ACEI/ARB lags behind the advance of medical condition progress, economic development and information availability, especially in patients with a history of stroke, low blood pressure. Patients with hypertension, heart failure, smoking indulgence were more likely to get ACEIZARB therapy. The main reasons of this phenomenon were attributed to firstly the thorough understanding of standard medication guide to coronary heart disease to be lacking among some professionals, secondly, the side effects of these drugs to be unnecessary worried about among certain of doctors, and thirdly, low awareness of the pathogenesis of AMI disease and the lack of concerning for patients to be existent.