摘要
背景:慢性并存疾病是ST段抬高型心肌梗死(STEMI)的预后决定因素。本研究旨在确定这种影响是否与治疗措施无关,抑或由治疗措施的不同而引起,及二者相关程度如何。方法:740例发病12h内住院的STEMI患者入选一项基于人群的注册研究,实施该研究的卫生医疗区域内有1所具有经皮冠状动脉介入(PCI)设施的教学医院和5所不具有PCI设施的地区医院。
Background: Chronic comorbidity is a prognostic determinant in ST-segment elevation myocardial infarction(STEMI). This study was aimed at determining to what extent this effect is independent or derives from adoption of different therapeutic strategies. Methods: Seven hundred forty patients with STEMI hospitalized within 12 hours of symptom onset were enrolled in a population-based registry, in a health district comprising 1 teaching hospital with and 5 district hospitals without percutaneous coronary intervention(PCI) facilities. Three categories of increasing chronic comorbidity score(CS-1, n=259; CS-2, n=235;CS-3, n=246)were identified from age-adjusted associations of comorbidities with 1-year survival. Results: Higher CS was associated with lower direct admission or transferal rates to hospital with PCI. Coronary reperfusion therapy(PCI in 91.5%of 470 cases) was adopted less frequently(P< .001) in CS-3(41.9%) than CS-2(69.4%) or CS-1(78.8%). Compared with conservative therapy(n=270), reperfusion therapy reduced 1-year mortality in the whole series not significantly(P=.816) in CS-1 but significantly in CS-2(P=.012) and CS-3(P=.001). This trend persisted after adjusting for age, Killip class, and acute myocardial infarction location(hazard ratio[HR]=0.63[95%CI 0.14-2.80], HR=0.62[95%CI 0.31-1.25], and HR=0.47[95%CI 0.26-0.86] in CS-1, CS-2, and CS-3, respectively). By hypothesizing an extension of coronary reperfusion therapy utilization rate in CS-2 and CS-3 to that in CS-1, from 21(crude analysis) to 20(adjusted analysis) deaths were classified as potentially avoidable. Conclusion: Increased mortality in patients with chronic comorbidity and STEMI derives, at least in part, from underutilization of coronary reperfusion therapy, and might be reduced with a more aggressive therapeutic approach.
