急性冠状动脉综合征类型对老年患者介入治疗远期预后的影响

The Impact of Acute Coronary Syndrome Types on the Long-term Prognosis of Elderly Patients Undergoing Percutaneous Coronary Intervention

目的比较不同类型急性冠状动脉综合征(acute coronary syndrome,ACS)对60岁以上老年患者行经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗的远期预后影响。方法连续纳入2013年1月至12月在中国医学科学院阜外医院行PCI治疗、年龄≥60岁的ACS患者,根据ACS类型分为ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI,n=540)组和非ST段抬高型急性冠状动脉综合征(non-ST-segment elevation acute coronary syndrome,NSTEACS,n=2314)组。术后随访2年,记录主要心脑血管不良事件(major adverse cardiovascular and cerebrovascular events,MACCE,包括全因死亡、心源性死亡、心肌梗死、血运重建、脑卒中)。两组间进行倾向性评分匹配,并采用Cox回归方法比较MACCE的独立危险因素。根据年龄、性别、左心室射血分数(left ventricular ejection fraction,LVEF)、估算肾小球滤过率(estimated glomerular filtration rate,eGFR)、是否三支病变等进行亚组分析。结果两组的基本特点、冠状动脉病变及介入治疗情况差异显著。与NSTEACS组相比,STEMI组患者1年、2年的全因死亡,MACCE风险显著升高(P<0.001)。Kaplan-Meier生存分析显示,STEMI患者1年全因死亡风险高,而第二年死亡风险升高不明显,NSTEACS患者1年和2年全因死亡风险差异不显著。多因素Cox回归分析显示,STEMI是全因死亡(HR=2.68,95%CI:1.55-4.63,P<0.001)、心源性死亡(HR=3.08,95%CI:1.52-6.25,P=0.002)的独立危险因素;而倾向性评分匹配后,两组的MACCE无显著差异,STEMI也不再是MACCE的预测因素;而年龄增加、LVEF<40%是全因死亡和心源性死亡的独立危险因素。亚组分析结果显示:老年女性STEMI患者全因死亡风险显著高于男性患者(交互检验P值=0.023),而高龄、心功能减低、三支病变及肾功能减低的老年患者,ACS类型不影响全因死亡风险。结论STEMI患者1年、2年全因死亡和MACCE风险高于NSTEACS患者。STEMI是全因死亡和MACCE的独立危险因素;倾向性评分匹配后,STEMI不再是全因死亡、心源性死亡和MACCE的独立危险因素。老年女性STEMI患者的全因死亡风险显著高于男性。高龄增加老年患者的死亡风险,但其作用与ACS类型无关。

Objective To explore the long-term prognosis factors between different types of elderly patients with acute coronary syndrome(ACS)over 60 years old undergoing percutaneous coronary intervention(PCI).Methods All consecutive ACS patients presenting for PCI between January 2013 and December 2013 in Fuwai hospital were included.We evaluated 2-year major adverse cardiovascular and cerebrovascular events(MACCE,including allcause death,cardiac death,myocardial infarction,revascularization and stroke)following PCI.The patients were divided into STEMI group(n=540)and NSTEACS group(n=2314)according to ECG type,and matched with the propensity score.Cox regression analysis was used to analyze the independent risk factors of major cardiovascular and cerebrovascular adverse events.Subgroups were analyzed according to age,gender,LVEF,eGFR and three vessel diseases.Results There were significant differences between STEMI and NSTEACS groups in basic characteristics,coronary artery disease and intervention.1-year and 2-year follow-up showed that compared with NSTEACS,STEMI patients had significantly higher risk of all-cause death and MACCE.KaplanMeier survival analysis showed that patients with STEMI had a high risk of all-cause mortality at 1 year but not at 2 years,and the risk of all-cause mortality at 1 and 2 years did not differ significantly between NSTEACS patients.Multivariate Cox regression analysis showed that STEMI was independent risk factor of all-cause death(HR=2.68,95%CI:1.55-4.63,P<0.001)and cardiac death(HR=3.08,95%CI:1.52-6.25,P<0.001).After propensity score matching,there was no significant difference in MACCE events between the two groups.STEMI was no longer a predictor of MACCE events.The increasing of age and LVEF<40%were independent risk factors for all-cause death and cardiac death.Subgroup analysis showed that the risk of all-cause mortality was significantly higher in older female patients with STEMI than in male patients(p for interaction=0.023).However,in subgroup of older than 75 years,reduced cardiac function,three vessel disease and reduced renal function,the type of ACS did not affect the risk of all-cause mortality.Conclusion The 1-year and 2-year risks of all-cause death and MACCE were higher in patients with STEMI than in patients with NSTEACS.STEMI was an independent risk factor for all-cause death and MACCE.After propensity score matching,STEMI was no longer an independent risk factor for all-cause death and MACCE.The risk of all-cause mortality in elderly women with STEMI is significantly higher than that in men.The increasing of age exacerbates the risk of mortality in elderly patients,but not related to the type of ACS.