老年急性心肌梗死患者救治及预后的性别差异研究

Sex-specific Analysis of the Management and Outcome of Elderly Patients with Acute Myocardial Infarction

背景老年女性急性心肌梗死(AMI)患者可能在救治和预后方面有异于老年男性AMI患者。而目前中国关于老年AMI患者救治现状和预后的性别差异研究较少。目的分析不同性别老年AMI患者的救治情况、院内死亡率和1年心血管死亡率的差异。方法选取2017年1月至2019年6月于成都地区11家综合医院就诊的1579例老年(>60岁)AMI患者为研究对象,其中男1056例,女523例。比较不同性别AMI患者的临床特征、治疗现状及1年预后情况,采用Kaplan-Meier法绘制不同性别患者出院后1年内心血管死亡的生存曲线,采用多因素Cox比例风险回归分析探讨患者出院后1年内心血管死亡的影响因素。结果女性吸烟、饮酒、PCI史和COPD史、典型胸痛/胸闷症状发生的比例、肌酐水平、双联抗血小板药物及降脂药物的应用比例低于男性(P<0.05),女性年龄、合并糖尿病史比例、心率、Killip分级≥Ⅱ级比例、三酰甘油、总胆固醇水平、症状发作至导丝通过的时间(S-to-B时间)、首次医疗接触至导丝时间(FMC-to-B时间)、院内全因死亡率高于男性(P<0.05)。女性出院后1年内心血管相关死亡率高于男性(P<0.05)。多因素Cox比例风险回归分析显示,性别〔HR=1.830,95%CI(1.029,3.255),P=0.040〕、年龄〔HR=1.063,95%CI(1.031,1.095),P<0.001〕、ST段抬高型心肌梗死(STEMI)〔HR=2.382,95%CI(1.380,4.113),P=0.002〕、心源性休克〔HR=2.474,95%CI(1.259,4.859),P=0.009〕、肌酐〔HR=1.004,95%CI(1.001,1.006),P=0.003〕和PCI〔HR=0.228,95%CI(0.135,0.386),P<0.001〕是老年AMI患者出院后1年内心血管死亡的影响因素。结论老年AMI患者院内行再灌注治疗措施的比例无性别差异,但救治效率和预后存在差异。女性AMI患者院内救治效率更低、心肌总缺血时间更长、药物使用比例更低,且院内全因死亡率和1年内心血管死亡率更高。

Background There may be sex-specific differences in the treatment and outcome of elderly people with acute myocardial infarction(AMI).However,few studies have reported sex-specific differences in management and prognosis of older Chinese people with AMI.Objective To assess the sex-specific differences in management strategies,inhospital mortality and cardiovascular mortality within one year after discharge in older Chinese people with AMI.Methods We consecutively enrolled 1579 elderly(>60 years of age)patients with AMI admitted to 11 tertiary general hospitals in Chengdu between January 2017 and June 2019,including 1056 men and 523 women.Sex-specific analysis of clinical characteristics,management strategies and 1-year outcome were performed.Kaplan-Meier estimator was used to describe the incidences of cardiovascular death within one year after discharge between men and women and the associated factors were explored using multivariate Cox proportions hazards regression analysis.Results Female patients had lower prevalence of smoking,and alcohol consumption,history of percutaneous coronary intervention and chronic obstructive pulmonary disease,typical symptoms including chest pain and chest tightness,and use of dual antiplatelet agents and statins,and lower mean creatinine levels than male patients(P<0.05).Moreover,female patients had older mean age,diabetes,and higher mean heart rate,greater prevalence of Killip class≥Ⅱ,and higher mean level of total cholesterol,longer mean symptom-onset-to-balloon time and first medical contact to balloon dilation time,and higher in-hospital mortality rate(P<0.05).Furthermore,the cardiovascular mortality rate within one year after discharge was higher in women(P<0.05).Multivariate Cox proportions hazards regression analysis showed sex〔HR=1.830,95%CI(1.029,3.255),P=0.040〕,age〔HR=1.063,95%CI(1.031,1.095),P<0.001〕,ST-segment elevation myocardial infarction〔HR=2.382,95%CI(1.380,4.113),P=0.002〕,cardiogenic shock〔HR=2.474,95%CI(1.259,4.859),P=0.009〕,creatinine〔HR=1.004,95%CI(1.001,1.006),P=0.003〕and PCI〔HR=0.228,95%CI(0.135,0.386),P<0.001〕were associated with cardiovascular death within one year after discharge.Conclusion The rates of reperfusion treatment in older women and men with AMI were similar,but there were differences in treatment efficiency and outcome.Older women with AMI had lower in-hospital treatment efficacy,longer total myocardial ischemia time,lower prevalence of pharmacological treatment,and higher in-hospital all-cause mortality and cardiovascular mortality within one year after discharge.