2006、2011年中国中部农村急性心肌梗死患者住院早期氯吡格雷的应用情况及影响因素

Assessment of Early Clopidogrel Therapy Use among Acute Myocardial Infarction Patients in Central-rural China in 2006 and 2011

目的评估2006、2011年中国中部农村地区急性心肌梗死(AMI)患者住院早期氯吡格雷的应用情况,并探讨其应用的影响因素。方法采用两阶段随机抽样设计,抽取中部农村AMI患者代表性样本。第一阶段,采用简单随机抽样确定协作医院。第二阶段,在协作医院中采用系统随机抽样方法,抽取研究病历,提取临床信息,评估住院早期(入院24 h内)氯吡格雷应用率。采用广义估计方程的多水平Logistic回归模型分析影响住院早期氯吡格雷应用的因素。结果共计35家医院的1464份AMI病历纳入研究。中位年龄为65岁,女性患者占30.7%。2006至2011年,AMI患者住院早期氯吡格雷应用率从3.98%增加至48.72%(P<0.0001)。多因素模型分析中,高血压患者住院早期氯吡格雷应用率高于非高血压患者(OR=1.65,95%CI=1.21~2.26,P=0.001),吸烟患者更易接受氯吡格雷早期治疗(OR=1.87,95%CI=1.19~2.95,P=0.007),入院时存在胸部不适患者早期氯吡格雷应用率高于未合并胸部不适患者(OR=2.17,95%CI=1.35~3.49,P=0.001)。结论 2006至2011年,我国中部农村AMI患者住院早期氯吡格雷应用严重不足的局面开始改善,但其应用率与指南推荐之间还存在极大差距。因此,亟待全面提高早期氯吡格雷应用,进一步改善AMI患者的临床结局。

Objective To explore the application and influencing factors of early clopidogrel use in patients with acute myocardial infarction（AMI） in the central-rural region of China in 2006 and 2011.MethodsA representative sample of patients in central-rural region of China admitted to hospital for AMI was created from a two-stage random sampling.In the first phase,a simple random-sampling procedure was used to identify participating hospitals.In the second stage,we selected patients admitted to each participating hospitals for AMI with a systematic sampling approach.Then we obtained clinical information via central medical record abstraction for each patient.For analysis of early clopidogrel therapy（within 24 hours of admission） status,we used multilevel Logistical regression models with the use of generalized estimating equations.Results We identified 1464 patients eligible for early clopidogrel therapy.From 2006 to 2011,the early application rate of clopidogrel increased significantly,from 3.98% to 48.72%（P〈0.0001）.Logistic regression analysis showed that patients with hypertension were more likely to receive early clopidogrel（OR=1.65,95% CI=1.21-2.26,P=0.001）,smokers were associated with greater likelihood to receive early clopidogrel（OR=1.87,95% CI=1.19-2.95,P=0.007）,and patients with chest discomfort during hospitalization indicated association with higher likelihood of early clopidogrel use within 24 hours of admission（OR=2.17,95% CI=1.35-3.49,P=0.001）.Conclusions Early clopidogrel use in AMI patients has been improved from 2006 to 2011.However,tremendous gap still exists between guidelines and clinical practice.Quality improvement initiatives are in urgent need to support further improvements in early clopidogrel use for AMI patients.