高龄ST段抬高型心肌梗死患者出院目的地与中期死亡的关系研究

Association between Discharge Destination and Medium-term Mortality in Elderly Patients with ST-segment Elevation Myocardial Infarction

背景由于人口老龄化,ST段抬高型心肌梗死(STEMI)接受经皮冠状动脉介入治疗(PCI)的老年患者数量增加。高龄患者可能会存在多病共存、衰弱、免疫力差、营养状态不良等情况,可能会对其痊愈出院回归家庭产生影响,目前尚未对该人群出院目的地与预后的关联进行全面评估。目的评估接受PCI的高龄(80岁及以上)STEMI生存者的出院目的地与中期死亡的关系。方法回顾性分析2015年12月至2018年12月在海口市人民医院接受PCI的STEMI患者资料。收集患者的一般资料〔年龄、性别、体质指数(BMI)、住院时间、主要既往史(心力衰竭、心肌梗死、PCI、冠状动脉旁路移植术、缺血性卒中、颅内出血、胃肠道出血、外周动脉疾病、血脂异常、糖尿病、高血压、吸烟、慢性肾脏病)、生命体征(收缩压、舒张压、心率、心功能killip分级)、左心室射血分数(LVEF)<40%比例〕,实验室检查结果〔血红蛋白、白蛋白、白细胞计数、C反应蛋白、血糖、住院期间肌酸激酶(CK)峰值〕,冠状动脉病变特点〔左主干病变(LMCA)、左前降支病变(LADA)、左回旋支病变(LCXA)、右冠状动脉病变(RCA)、2支血管病变的患者数以及症状开始到再灌注的时间〕及出院后用药情况〔阿司匹林、氯吡格雷或替格瑞洛、华法林、新型口服抗凝剂、他汀类药物、血管紧张素转化酶抑制剂(ACEI)/血管紧张素Ⅱ受体阻滞剂(ARB)、钙离子受体拮抗剂、β-受体阻滞剂〕、严重衰弱情况。随访开始时间为出院时,截止时间2020年12月,随访终点事件为全因死亡。采用Logistic回归分析探讨全因死亡的影响因素。结果完成随访2450例,根据出院目的分为家庭出院组(2090例)和非家庭出院组(360例)。随访期间370例(17.5%)患者出院后死亡,最常见的死因是感染(21.6%,80/370),其次是猝死(18.9%,70/370)和心力衰竭(16.2%,60/370)。家庭出院组的心血管源性死亡比例高于非家庭出院组(P<0.05)。两组患者累积死亡率的生存曲线比较,差异有统计学意义(P<0.05)。单因素Logistic多元回归分析结果显示:非家庭出院、既往心力衰竭、LADA、白蛋白<35 g/L、LVEF<40%可能是随访期间全因死亡的危险因素(P<0.05);进一步进行多因素Logistic多元回归分析,结果显示:LVEF<40%〔OR=3.161,95%CI(1.564,6.389),P=0.001〕,既往心力衰竭〔OR=4.899,95%CI(1.835,13.078),P=0.002〕、非家庭出院〔OR=2.617,95%CI(1.188,5.765),P=0.049〕、LADA〔OR=2.210,95%CI(1.137,4.295),P=0.019〕、白蛋白<35 g/L〔OR=2.147,95%CI(1.064,4.330),P=0.033〕是随访期间全因死亡的危险因素。结论非家庭出院与高龄STEMI患者的中期死亡风险增加有关,积极寻找非家庭出院的原因,并早期干预,可能会降低高龄STEMI患者中期死亡率。

Background Population ageing has led to an increase in the number of elderly patients with ST-segment elevation myocardial infarction(STEMI)receiving percutaneous coronary intervention(PCI).Coexistence of diseases,frailty,impaired immunity,poor nutritional status and other conditions may occur in elderly patients,which may have an impact on their recovery and return to their families.There is a lack of a comprehensive assessment on the relationship between this group's discharge destination and prognosis.Objective To assess the relationship between discharge destination and medium-term mortality in 80-year-old STEMI survivors receiving PCI.Methods A retrospective analysis was conducted on STEMI patients undergoing PCI in Haikou People's Hospital from December 2015 to December 2018,with the following information collected,including general data〔age,gender,BMI,hospital stays,major medical histories(heart failure,myocardial infarction,PCI,coronary artery bypass grafting,stroke,gastrointestinal bleeding,peripheral arterial disease,dyslipidemia,diabetes,hypertension,smoking,chronic kidney disease,systolic pressure,diastolic pressure,heart rate,Killip classification),proportion of left ventricular ejection fraction(LVEF)<40%〕,laboratory findings〔hemoglobin,albumin,white blood cell count,C-reactive protein,blood glucose,peak CK during hospitalization〕,pathological features of coronary artery〔left main coronary artery(LMCA),left anterior descending artery(LADA),left circumflex artery(LCXA),right coronary artery(RCA),number of patients with 2-vessel disease and time from symptom onset to reperfusion〕,post-discharge medication(aspirin,clopidogrel or ticagrelor,warfarin,new oral anticoagulants,statins,ACEI/ARB,calcium receptor antagonist,β-receptor blocker)and severe debilitating condition.The follow-up started at discharge and ended in December 2020,with the terminal event of being all-cause death.Logistic regression analysis was used to explore the influencing factors of all-cause death.Results In all,2450 patients completed thefollow-up,including 2090 who were discharged to home(home discharge group)and 360 to other facilities(non-home discharge group).During the follow-up period,370 patients(17.5%)died after discharge,and the most common cause of death was infection(21.6%,80/370),followed by sudden death(18.9%,70/370)and heart failure(16.2%,60/370).The cardiovascular death rate of the homedischarge group was higher than that of the non-homedischarge group(P<0.05).Two groups showed significant differences in the cumulative mortality curve(P<0.05).Univariate Logistic regression analysis showed that non-home discharge,previous heart failure,lesions in the LADA,serum albumin<35 g/L,LVEF<40%may be the risk factors of all-cause death during follow-up(P<0.05).Further multivariate Logistic regression analysis showed that LVEF<40%〔OR=3.161,95%CI(1.564,6.389),P=0.001〕,previous heart failure〔OR=4.899,95%CI(1.835,13.078),P=0.002〕,non-homedischarge〔OR=2.617,95%CI(1.188,5.765),P=0.049〕,lesions in the LADA〔OR=2.210,95%CI(1.137,4.295),P=0.019〕,albumin level<35 g/L〔OR=2.147,95%CI(1.064,4.330),P=0.033〕were all risk factors of death during follow-up period.Conclusion There is a relationship between non-family discharge and an increased risk of medium-term mortalityin STEMI patients over the age of 80.Active searching for causes of non-homedischarge and early delivering targeted interventions may reduce the medium-term mortality in thesepatients.