胸痛中心模式下急性冠脉综合征救治和预后的年龄差异性分析——一项多中心回顾性研究

Age-related differences in the management and outcome of acute coronary syndrome under the chest pain center model:a multicenter retrospective study

目的分析胸痛中心模式下不同年龄段急性冠脉综合征(ACS)患者救治和预后的差异。方法回顾性分析2017年1月至2019年6月就诊于成都地区11家已建设胸痛中心医院的2 833例ACS患者的临床资料。根据年龄将患者分为<55岁组(569例)、55~64岁组(556例)、65~74岁组(804例)、≥75岁组(904例)4组。收集患者的人口学特征、危险因素、既往史、发病症状和体征、实验室检查、ACS类型和发病至到达医院大门的时间(S-to-D)等临床资料,比较各组患者临床特征、救治情况、院内全因病死率及出院1年内主要不良心脑血管事件(MACCE)发生率的差异。主要终点事件为不同年龄段ACS患者的临床结局,包括院内全因死亡和出院1年内MACCE发生情况。次要终点事件为不同年龄段ACS患者接受经皮冠状动脉介入治疗(PCI)的比例。采用多因素Logistic回归分析影响ACS患者院内全因死亡的危险因素,采用Kaplan-Meier曲线分析不同年龄段组出院1年内MACCE发生率;采用多因素Cox回归分析影响ACS患者1年内MACCE发生的危险因素。结果随着年龄增长,男性患者的比例逐渐减少,<55岁、55~64岁、65~74岁、≥75岁患者的比例分别为87.2%(496/569)、77.0%(428/556)、66.4%(534/804)、60.1%(543/904),合并高血压、糖尿病、冠心病、脑卒中史更常见〔<55岁、55~64岁、65~74岁、≥75岁患有高血压的比例分别为:41.3%(235/569)、52.2%(290/556)、59.7%(480/804)、66.9%(605/904),糖尿病的比例分别为:18.6%(106/569)、25.5%(142/556)、27.0%(217/804)、28.2%(255/904),冠心病的比例分别为:10.1%(57/564)、13.9%(77/555)、17.6%(141/803)、23.7%(213/899),脑卒中史的比例分别为:0.7%(4/564)、4.0%(22/552)、4.5%(36/801)、8.6%(77/894)〕,而有吸烟史、典型胸痛/胸闷和血脂异常的比例明显减少〔吸烟史比例分别为:60.2%(340/565)、48.0%(266/554)、33.7%(270/801)、21.7%(195/899),典型胸痛/胸闷比例分别为:96.9%(536/553)、96.4%(516/535)、91.8%(716/780)、90.2%(776/860),血脂异常比例分别为:11.2%(63/565)、9.2%(51/553)、5.7%(46/802)、4.9%(44/896)〕,S-to-D时间明显延长〔min:176.0(73.5,557.0)、194.5(89.3,682.3)、221.0(98.8,940.5)、270.0(115.0,867.0)〕,血红蛋白(Hb)水平明显降低(g/L:145.44±17.43、135.95±19.25、129.75±19.03、122.19±20.55),非ST段抬高型心肌梗死(NSTEMI)的发生率明显增加〔18.6%(106/569)、20.5%(114/556)、26.6%(214/804)、26.5%(240/904)〕,差异均有统计学意义(均P<0.05),≥75岁患者KillipⅢ~Ⅳ级的比例最高,分别为9.0%和12.6%。与<55岁、55~64岁、65~74岁组比较,≥75岁组患者接受PCI的比例最低,接受PCI的患者院内全因病死率和1年内MACCE发生率均明显低于保守治疗〔6.0%(28/463)比10.4%(45/434),14.6%(43/294)比24.3%(55/226),均P<0.05〕。随着年龄的增长,各年龄段组患者的院内全因病死率和1年内MACCE累积发生率均增加(<55岁、55~64岁、65~74岁、≥75岁组院内全因病死率分别为:0.9%、2.2%、5.5%、8.3%,1年内MACCE发生率分别为:5.0%、6.7%、13.9%、18.7%,均P<0.01)。多因素Logistic回归分析显示:年龄、心源性休克、ST段抬高型心肌梗死(STEMI)、血管病变支数和接受PCI是影响预后的独立危险因素〔优势比(OR)和95%可信区间(95%CI)分别为1.644(1.356~1.993)、11.794(7.469~18.621)、2.449(1.419~4.227)、1.334(1.096~1.624)、0.391(0.247~0.619),均P<0.001〕。Cox回归分析显示:年龄、STEMI、血管病变支数、接受PCI是影响患者出院1年内MACCE发生的独立危险因素〔风险比(HR)和95%CI分别为1.354(1.205~1.521)、1.387(1.003~1.916)、1.314(1.155~1.495)、0.547(0.402~0.745),均P<0.05〕。结论胸痛中心模式下,与其他年龄段ACS患者相比,年龄≥75岁的高龄患者NSTEMI比例增加,而接受PCI的比例降低,临床结局更差;但接受PCI的高龄患者预后优于保守治疗者。

Objective To assess the age-related differences in the management strategies and outcomes of patients with acute coronary syndrome(ACS)under the chest pain center model.Methods Clinical data of 2833 patients with ACS were enrolled in the retrospective observational registry between January 2017 and June 2019 at 11 hospitals with chest pain centers in Chengdu.The patients were divided into four groups according to their ages:<55 years old group(n=569),55-64 years old group(n=556),65-74 years old group(n=804),≥75 years old group(n=904).The collected data included the patients'demographic characteristics,cardiovascular risk factors,medical history,symptoms and signs of onset,experimental examination,types of ACS and the time from the symptom to the hospital(S-to-D),etc.,and the clinical characteristics,management strategies,all-cause mortality in the hospital,and the incidence of major adverse cardiovascular and cerebrovascular events(MACCE)within 1 year after discharge were compared.The primary end point was the clinical outcome of ACS patients in different age groups,including all-cause deaths in the hospital and the incidence of MACCE within 1 year after discharge.The secondary end point was the proportion of ACS patients underwent percutaneous coronary intervention(PCI)in different age groups.Multivariate Logistic regression was used to analyze the risk factors of all-cause deaths in ACS patients.Kaplan-Meier curve was used to express the incidence of MACCE within 1 year after discharge in different age groups.Multivariate Cox regression was used to analyze the factors affecting the incidence of MACCE within 1 year after discharge of ACS patients.Results As age increased,the proportion of male patients gradually decreased,and the percentages of male patients aged<55 years old,55-64 years old,65-74 years old,and≥75 years old were 87.2%(496/569),77.0%(428/556),66.4%(534/804),and 60.1%(543/904),respectively;and ACS patients combined with hypertension,diabetes,coronary heart disease,and stroke history were more common[the percentages of patients with hypertension aged<55 years old,55-64 years old,65-74 years old,≥75 years old were 41.3%(235/569),52.2%(290/556),59.7%(480/804),and 66.9%(605/904);the percentages of diabetes were 18.6%(106/569),25.5%(142/556),27.0%(217/804),and 28.2%(255/904);the percentages of coronary heart disease were 10.1%(57/564),13.9%(77/555),17.6%(141/803),and 23.7%(213/899);the percentages of stroke were 0.7%(4/564),4.0%(22/552),4.5%(36/801),and 8.6%(77/894)].But the percentages of patients with a history of active smoking,typical chest pain/chest tightness and dyslipidemia were significantly reduced[the percentages of smoking history were 60.2%(340/565),48.0%(266/554),33.7%(270/801),and 21.7%(195/899),typical chest pain/chest tightness were 96.9%(536/553),96.4%(516/535),91.8%(716/780),90.2%(776/860);the percentages of dyslipidemia were 11.2%(63/565),9.2%(51/553),5.7%(46/802),and 4.9%(44/896)],the time of S-to-D was significantly prolonged[minutes:176.0(73.5,557.0),194.5(89.3,682.3),221.0(98.8,940.5),and 270.0(115.0,867.0)],hemoglobin(Hb)level was significantly reduced(g/L:145.44±17.43,135.95±19.25,129.75±19.03,122.19±20.55),and the incidence of non-ST-segment elevation myocardial infarction(NSTEMI)increased significantly[18.6%(106/569),20.5%(114/556),26.6%(214/804),26.5%(240/904)],and the differences were statistically significant(all P<0.05).The proportion of Killip gradeⅢ-Ⅳwere the highest in patients aged≥75 years old,9.0%and 12.6%,respectively.Compared with the groups aged<55 years old,55-64 years old,and 65-74 years old,the proportion of patients aged≥75 years old who underwent PCI was the lowest,and the all-cause mortality in the hospital and the incidence of 1-year MACCE of patients underwent PCI were significantly lower than those of patients underwent conservative treatment[6.0%(28/463)vs.10.4%(45/434),14.6%(43/294)vs.24.3%(55/226),both P<0.05].As age increased,the hospital all-cause mortality and the 1-year MACCE incidence increased(all-cause mortality rates in<55 years old,55-64 years old,65-74 years old,≥75 years old groups were 0.9%,2.2%,5.5%,8.3%,and the 1-year MACCE incidences were 5.0%,6.7%,13.9%,18.7%,both P<0.01).The multivariate Logistic regression analysis showed that age,cardiogenic shock,ST-segment elevation myocardial infarction(STEMI),the number of vascular disease and underwent PCI were the independent risk factors of all-cause mortality[the odds ratio(OR)and 95%confidence interval(95%CI)were 1.644(1.356-1.993),11.794(7.469-18.621),2.449(1.419-4.227),1.334(1.096-1.624),0.391(0.247-0.619),all P<0.001].Cox regression analysis showed that age,STEMI,the number of vascular disease and underwent PCI were independent risk factors of the occurrence of MACCE within 1 year after discharge[hazard ratio(HR)and 95%CI were 1.354(1.205-1.521),1.387(1.003-1.916),1.314(1.155-1.495),0.547(0.402-0.745),all P<0.05].Conclusions In the chest pain center model,compared with other age of ACS patients,the proportion of NSTEMI in elderly patients group aged≥75 years old was higher,the proportion of PCI was lower,and the clinical outcome was worse.However,the prognosis of elderly patients receiving PCI treatment was better than the patients receiving conservative treatment.