2015—2021年主动脉夹层住院患者的临床特点、发病与治疗方式变化趋势

Trends in clinical characteristics, morbidity and treatment ofinpatients with aortic dissection during 2015-2021

目的观察和分析主动脉夹层(AD)住院患者的临床特点、发病与治疗方式变化趋势,并了解入院时情况对发生院内死亡的影响。方法回顾性分析2015—2021年贵州医科大学附属医院首次因AD住院的病例,根据夹层累及范围将其分为Stanford A型(TAAD)和B型主动脉夹层(TBAD),归纳其临床特点、发病与治疗方式变化,同时分析死亡组和存活组的临床特征,采用多因素logistic回归分析入院时情况对发生院内死亡的影响。结果(1)2015—2021年,首次因AD住院患者共437例,TAAD 139例,TBAD 298例,男性占77.6%。70.2%(301例)既往有高血压史,其中治疗过的患者中约有一半(47.8%)治疗不规律。院内死亡46例,其中50%死于30.6 h内。(2)与TBAD患者相比,TAAD患者的心率快,收缩压、舒张压、脉压低(均P<0.05),院内死亡率也高(25.2%比3.7%,χ^(2)=46.472,P<0.001);TAAD表现为胸痛或胸背痛、胸闷、心悸、呼吸困难、意识障碍、恶心或呕吐者较多,TBAD表现为腹痛、大汗者较多(均P<0.05)。(3)7年来,首次因AD住院的患者人数逐年增加。来院方式方面,直接来院的比例由42.1%下降至19.2%,在外院诊断了AD的比例从31.6%增加到59.6%。治疗和结局方面,TAAD患者手术治疗的比例由7.7%(1/13)逐渐增加至83.3%(30/36),死亡率由46.2%(6/13)降至11.1%(4/36),好转率由23.1%(3/13)升高至63.9%(23/36);除个别年限外,TBAD患者的治疗方式及好转率变化不明显,2019—2021年其介入治疗的比例在80%以上,单纯保守治疗的比例在18%左右,死亡率为2.0%~2.9%,好转率在80%以上。(4)死亡患者的收缩压、舒张压、脉压、估算的肾小球滤过率(eGFR)均较存活患者低,心率则较快(均P<0.05)。多因素logistic回归分析结果显示,相较于TBAD,TAAD患者发生院内死亡的风险更高(OR=6.080,95%CI 2.700~13.690,P<0.001);心率增快也会增加院内死亡的风险(OR=1.019,95%CI 1.001~1.037,P=0.035)。结论AD患者住院人数逐年增加,TBAD、男性和有高血压史者较多。TAAD和心率较快的患者院内死亡风险增加。

Objective To observe and analyze the clinical characteristics,morbidity and treatment trend of inpatients with aortic dissection(AD),and to understand the influence of admission condition on the occurrence of in-hospital death.Methods A retrospective analysis was performed.The patients admitted to the Affiliated Hospital of Guizhou Medical University for the first time due to AD from 2015 to 2021 were selected and divided into Stanford Type A aortic dissection(TAAD)and Stanford Type B aortic dissection(TBAD)according to the involvement range of dissection.The clinical characteristics,morbidity and treatment changes of AD patients were summarized.At the same time,the clinical characteristics of the death group and the survival group were analyzed,and the influence of admission condition on the occurrence of in-hospital death was analyzed by multivariate logistic regression analysis.Results(1)From 2015 to 2021,a total of 437 patients were first hospitalized for AD,including 139 for TAAD and 298 for TBAD,with 77.6%being male.In the patients,70.2%(301)had a previous history of hypertension,of Hypertens,December 2023,Vol.31 No.12 which approximately half(47.8%)of the treated patients were treated irregularly.There were 46 in-hospital deaths,50%of which occurred within 30.6 hours.(2)Compared with patients with TBAD,patients with TAAD had faster heart rate,lower systolic,diastolic,and pulse pressure(all P<0.05)and higher in-hospital mortality(25.2%vs 3.7%,χ^(2)=46.472,P<0.001).TAAD mostly presented with chest pain or back pain,chest tightness,palpitation,dyspnea,disturbance of consciousness,nausea or vomiting,while TBAD mostly presented with more abdominal pain and heavy sweating(P<0.05).(3)In the past 7 years,the number of patients hospitalized for the first time for AD increased year by year.Regarding the mode of admission,the proportion of those who came to the hospital directly decreased from 42.1%to 19.2%,and the proportion of those who were diagnosed with AD in other hospitals increased from 31.6%to 59.6%.Regarding treatment and outcome,the proportion of TAAD patients undergoing surgery increased from 7.7%(1/13)to 83.3%(30/36),the mortality rate decreased from 46.2%(6/13)to 11.1%(4/36),and the recovery rate increased from 23.1%(3/13)to 63.9%(23/36).Except for individual years,the treatment methods and recovery rate of TBAD patients did not change significantly.In 2019-2021,the proportion of interventional treatment was above 80%,the proportion of conservative treatment was about 18%,the mortality rate was 2.0%-2.9%,and the recovery rate was above 80%.(4)Patients who died had lower systolic blood pressure,diastolic blood pressure,pulse pressure,and estimated glomerular filtration rate(eGFR)and faster heart rate than surviving patients(all P<0.05).Multivariate logistic regression analysis showed that compared with TBAD,TAAD patients had a higher risk of in-hospital death(OR=6.080,95%CI 2.700-13.690,P<0.001),increased heart rate also increased the risk of in-hospital death(OR=1.019,95%CI 1.001-1.037,P=0.035).Conclusions The number of AD patients hospitalized has been increasing yearly,with more TBAD,men and those with a history of hypertension.Patients with TAAD and a faster heart rate are at increased risk of in-hospital death.