65岁以上心脑血管疾病共存病例诊治分析

Diagnosis and treatment of patients aged over 65 years with cardiovascular and cerebrovascular comorbidities

目的分析1年内在上海市某医院神经内科和心内科均住院诊疗过的老年患者临床特征及其差异,为慢性病多病共存较普遍的老年患者诊疗提供临床决策支持。方法回顾性分析2012年1月至2019年12月期间在上海市健康医学院附属周浦医院神经内科和心内科1年内住院诊疗过的65岁以上的636例患者的临床资料,采用χ^(2)检验比较两科室就诊时的主次要诊断比例、科室间诊疗不同间隔天数和不同住院天数的构成比及其好转和治愈情况的差异。结果所有就诊患者在心内科诊疗时,前三位主要诊断分别为心脏病、高血压、脑血管病,合计占比91.98%(585/636);在神经内科诊疗时,前三位主要诊断分别为脑血管病,发作性和阵发性疾患,累及认知、感觉、情绪状态和行为的症状和体征,合计占比90.41%(575/636)。神经内科其他诊断中有心血管疾病的比例高于心内科其他诊断中有脑血管疾病的患者比例(88.99%vs 36.64%),差异具有统计学意义(χ^(2)=373.22,P<0.001)。患者在神经内科诊疗时均为共患病(2个或2个以上诊断),而心内科诊断数存在单一诊断(3.30%,21/636),差异具有统计学意义(χ^(2)=85.83,P<0.001);在心内科诊疗时,心内科首诊组比神经内科首诊组未愈或死亡比例高(3.69%vs 0.96%),好转或治愈比例低(96.31%vs 99.04%),差异具有统计学意义(χ^(2)=5.14,P=0.023);在神经内科诊疗时,神经内科首诊组比心内科首诊组未愈或死亡比例高(8.04%vs 0),好转或治愈比例低(91.96%vs 100%),差异具有统计学意义(χ^(2)=27.19,P<0.001)。在心内科和神经内科2次住院时间间隔>180且≤365 d组和间隔时间≤180 d组住院天数和转归比较,差异均无统计学意义(P均>0.05);间隔时间≤90 d组患者神经内科诊断有心血管疾病的比例较高(92.34%vs 87.03%),差异具有统计学意义(χ^(2)=5.40,P=0.020),间隔时间≤90 d组患者心内科诊断有脑血管疾病的比例较高(43.83%vs 32.42%),差异具有统计学意义(χ^(2)=8.31,P=0.004)。结论复杂心脑血管共存病例在心内或神经内科诊疗仍有一定难度,推广联合诊疗的理念,积极完善相关制度,进行多学科会诊可能是老年慢性病共病患者诊疗的有效探索。

Objective To analyze the clinical characteristics and differences of elderly patients hospitalized in the Department of Neurology and Cardiology in a hospital in Shanghai within one year,providing support for the medical decision on diagnosis and treatment strategy of elderly patients with common coexistence of chronic and multiple diseases.Methods We retrospectively analyzed the clinical data of 636 patients aged over 65 years,who had been hospitalized and treated in the Department of Neurology and Cardiology of Zhoupu Hospital Affiliated to Shanghai Medical College within one year from January 2012 to December 2019.The proportion of primary and secondary diagnoses,different hospitalization days between departments,the composition ratio of cases in different interval days,and the improvement and cure rate in the two departments were compared byχ^(2)test.Results In 636 patients,the top three primary diagnoses in the Department of Cardiology,accounting for 91.98%of them,were heart disease,hypertension,and cerebrovascular disease;in the Department of Neurology,the top three primary diagnoses,accounting for 90.41%of them,were cerebrovascular disease,paroxysmal and paroxysmal diseases,and symptoms and signs involving cognition,feeling,emotional state,and behavior.Cardiovascular disease in the secondary diagnosis of Neurology and cerebrovascular disease in the secondary diagnosis of cardiology were statistically different(χ^(2)=373.22,P<0.001);all the patients had been diagnosed with comorbidity(2 or more diagnoses)in the Department of Neurology,but there was a single diagnosis(3.30%,21/636)in the Department of Cardiology,and the difference was statistically significant(χ^(2)=85.83,P<0.001);In the Department of Cardiology,compared to those patients were initially diagnosed in the Department of Neurology,the patients were initially diagnosed in the Department of Cardiology had a higher rate of uncured or death(3.69%vs 0.96%)and a lower rate of improvement or cure(96.31%vs 99.04%),and the difference was statistically significant(χ^(2)=5.14,P=0.023).In the Department of Neurology,compared to those patients were initially diagnosed in the Department of cardiology,the proportion of uncured or death in the those being initially diagnosed in the Department of Neurology(8.04%vs 0)was higher,and the proportion of improvement or cure was lower(χ^(2)=27.19,P<0.001),and there was statistically significant difference(91.96%vs 100%).There was no significant difference in hospitalization days and outcomes between the group with an interval of 180<n≤365 days and the group with an interval of≤180 days(all P>0.05).The proportion of patients with cardiovascular disease diagnosed in the Department of Neurology in the group with interval≤90 days is higher,and the difference was a statistically significant(χ^(2)=5.40,P=0.020);The proportion of patients with cerebrovascular diseases diagnosed in the Department of Cardiology in the interval≤90 days group was higher,and the difference was statistically significant(χ^(2)=8.31,P=0.004).Conclusion There are still some improvements in the diagnosis and treatment of cardiocerebrovascular comorbidity in specialized department of cardiology or neurology.Promoting the concept of joint diagnosis and treatment,actively improving relevant systems,and carrying out multidisciplinary teams may be an effective exploration for diagnosing and treating of elderly patients with chronic diseases.