中国县级医院急性冠状动脉综合征患者氯吡格雷院内使用现况及相关因素

Status of the clopidogrel use in ACS patients and related factors among county hospitals in China

目的了解我国不具备急诊经皮冠状动脉介入治疗(PCI)条件的县级医院中,急性冠状动脉综合征(ACS)患者院内氯吡格雷的使用情况及相关因素。方法前瞻性入选中国15个省份和自治区101家不具备急诊PCI条件的县级医院2011年10月至2014年11月收入院的ACS患者。分析其院内氯吡格雷使用率及早期用药(入院24 h内)、负荷剂量用药(剂量≥300 mg)、双联抗血小板治疗(早期联用阿司匹林)、足量维持用药(剂量≥75 mg/d)的比例。使用广义估计方程控制医院整群效应,分别对氯吡格雷院内用药及负荷剂量用药的相关因素进行单因素和多因素分析。结果共纳入ACS患者14809例,年龄为(64.1±11.6)岁,男性8888例(60%)。院内氯吡格雷使用率为66.4%(9828/14809),不同地域、年度、ACS亚型间比较,差异有统计学意义(P均<0.05)。在氯吡格雷使用者中,早期用药比例达91.3%(8734/9562),双联抗血小板用药比例为89.2%(8526/9562),足量维持用药比例达95.1%(9094/9562),但负荷剂量用药比例仅为41.8%(3995/9562)。多因素分析显示,就诊年份早、非ST段抬高型ACS、高龄、女性、不吸烟、未上过学、入院心率快、合并心房颤动、未进行心电监护、院内未使用其他药物治疗的ACS患者氯吡格雷院内使用率低(P均<0.05);非ST段抬高型ACS、高龄、不吸烟、未上过学、院内未使用其他药物的ACS患者氯吡格雷负荷剂量用药比例低(P<0.05)。结论目前我国县级医院中ACS患者氯吡格雷的用药率及负荷剂量用药比例均较低,有待进一步提高。其中,对非ST段抬高型ACS、高龄、女性、未上过学的患者应予以重点关注。

Objective To observe the use of clopidogrel and related factors for patients with acute coronary syndrome(ACS)in terms of early use,loading dose,dual antiplatelet therapy(DAPT)and maintenance dose hospitalized in non-PCI country hospitals in China.Methods Patients hospitalized for ACS from 101 non-PCI country hospitals across China were recruited prospectively from October 2011 to November 2014.In-hospital clopidogrel use rate,the proportions of early use(within 24 hours),loading dose use(≥300 mg),DAPT(early use combined with aspirin)and maintenance dose use(following dose≥75 mg/d)were analyzed.Generalized estimated equation(GEE)model was used to explore factors associated to in-hospital clopidogrel use and loading dose use in both univariate and multivariate analyses,adjusting for cluster effect.Results A total of 14809 ACS patients were included,with an average age of(64.1±11.6)years and 60%(8888/14809)were male.The in-hospital clopidogrel use rate was 66.4%(9828/14809),which varied across different regions,years and sub-types of ACS(all P<0.05).Among users,the proportions of patients with early use,DAPT and maintenance dose use were 91.3%(8734/9562),89.2%(8526/9562)and 95.1%(9094/9562),respectively,but the proportion of patients received loading dose was only 41.8%(3995/9562).Multivariate analyses showed that patients who admitted to hospital in earlier years and with non-ST elevation ACS,≥75 years old,female,non-smoking,illiterate,heart rate≥100 beats per minute,atrial fibrillation,not on ECG monitoring,and not using other anti-ACS drugs were less likely to receive clopidogrel(all P<0.05).And those clopidogrel users who with non-ST elevation ACS,≥75 years old,non-smoking,illiterate,not using other anti-ACS drugs were less likely to receive loading dose(all P<0.05).Conclusion The use rate of clopidogrel and the loading dose among in-hospital ACS patients are both low and remain to be improved in non-PCI county hospitals in China.Special attention should be paid on non-ST elevation ACS,≥75 years old,female,and illiterate patients to increase the rational use of clopidogrel and the loading dose.