老年急性冠状动脉综合征合并非瓣膜性心房颤动患者全因死亡的影响因素

Influencing factors of all-cause mortality in elderly patients with non-valvular atrial fibrillation and acute coronary syndrome

目的分析老年急性冠状动脉综合征(ACS)合并非瓣膜性心房颤动(NVAF)患者死亡情况,探讨其全因死亡的影响因素。方法回顾性分析2012年1月—2017年12月河南省人民医院诊治的1369例老年(年龄≥65岁)ACS合并NVAF患者的临床资料。1369例均给予个体化综合治疗方案,随访3~10年,记录全因死亡情况,分为死亡组和生存组。比较2组性别比例、年龄、体质量指数、吸烟史、NVAF类型(持续、永久、阵发)、高血压、糖尿病、心力衰竭、外周血管疾病史、缺血性卒中史、出血史、消化系统溃疡史及入院时CHA_(2)DS_(2)-VASc评分、HAS-BLED评分;记录2组住院期间射频消融术、经皮冠状动脉介入治疗(PCI)、冠状动脉旁路移植术(CABG)及抗心律失常、控制心室率、抗凝、抗血小板、降脂等药物应用情况;多因素Cox回归分析老年ACS合并NVAF患者全因死亡的危险因素。结果(1)随访至2020年11月,随访(30.6±14.4)个月,全因死亡149例,存活1220例。死亡组年龄[79.0(73.0,84.0)岁]大于生存组[75.0(70.0,81.0)岁](U=-4.883,P<0.001),体质量指数[24.9(22.0,25.0)kg/m~2]低于生存组[25.0(23.2,26.0)kg/m~2](U=3.025,P=0.003),有心力衰竭(52.3%)、入院HAS-BLED评分[3.0(2.0,3.0)分]及有出血史比率(4.7%)均高于生存组[40.1%、2.0(2.0,3.0)分、2.0%](P<0.05),性别比例,心房颤动类型,入院CHA_(2)DS_(2)-VASc评分,吸烟及有糖尿病、高血压、外周血管疾病史、缺血性卒中史、消化系统溃疡史比率与生存组比较差异均无统计学意义(P>0.05)。(2)死亡组应用利尿剂(73.2%)、地高辛(42.3%)、磺达肝癸钠(6.0%)、替罗非班(4.0%)比率均高于生存组(56.3%、32.2%、2.3%、1.6%)(P<0.05),应用钙通道阻滞剂比率(21.5%)低于生存组(31.1%)(P<0.05),行PCI、CABG、射频消融术及应用胺碘酮、普罗帕酮、β受体阻断剂、血管紧张素转化酶抑制剂/血管紧张素受体拮抗剂、他汀类、硝酸酯类、曲美他嗪、质子泵抑制剂、低分子肝素、阿司匹林、氯吡格雷、替格瑞洛、华法林、新型口服抗凝药比率与生存组比较差异均无统计学意义(P>0.05)。(3)年龄增高(HR=1.058,95%CI:1.033~1.084,P<0.001)、有出血史(HR=2.517,95%CI:1.159~5.466,P=0.020)、应用利尿剂(HR=1.669,95%CI:1.116~2.497,P=0.013)、应用替罗非班(HR=3.022,95%CI:1.301~7.017,P=0.010)是老年ACS合并NVAF患者全因死亡的危险因素,体质量指数24.0~<28.0 kg/m~2(HR=0.657,95%CI:0.460~0.937,P=0.021)是老年ACS合并NVAF患者生存的保护因素。结论高龄、有出血史、应用利尿剂和替罗非班治疗的老年ACS合并NVAF患者全因死亡的风险增加,体质量指数24.0~<28.0kg/m~2者的死亡风险降低。

Objective To analyze the mortality of elderly patients with non-valvular atrial fibrillation(NVAF)and acute coronary syndrome(ACS),and to discuss the influencing factors of all-cause mortality.Methods The clinical data of1369 elderly patients(aged≥65 years)with NVAF and ACS in Henan Provincial People's Hospital from January 2012to December 2017 were retrospectively analyzed.All patients were given individualized comprehensive treatment plan.The follow-up lasted for 3 to 10 years to record the all-cause mortality.Totally 1369 patients were divided into death and survival groups.The gender ratio,age,body mass index,smoking habits,type of NVAF(persistent,permanent,paroxysmal),comorbidities(hypertension,diabetes,heart failure,peripheral vascular disease,ischemic stroke,bleeding,gastrointestinal ulcers),and admission CHA_2DS_2-VASc score and HAS-BLED score were compared between two groups.The radiofrequency ablation,percutaneous coronary intervention(PCI),coronary artery bypass grafting(CABG),and the applications of antiarrhythmic,ventricular rate-controlling,anticoagulant,antiplatelet and antihyperlipidemic drugs in hospital were recorded in two groups.Multivariate Cox regression analysis was performed to assess the influencing factors of all-cause mortality in elderly patients with NVAF and ACS.Results(1)The follow-up lasted for(30.6±14.4)months till November 2020,all-cause mortality developed in 149 patients,and the other 1220patients survived.The patients were older in death group[79.0(73.0,84.7)years]than in survival group[75.0(70.0,81.0)years](U=-4.883,P<0.001),the body mass index was smaller in death group[24.9(22.0,25.0)kg/m~2]than that in survival group[25.0(23.2,26.0)kg/m~2](U=3.025,P=0.003),the proportions of heart failure and bleeding,and admission HAS-BLED score were higher in death group[52.3%,4.7%,3.0(2.0,3.0)]than those in survival group[40.1%,2.0%,2.0(2.0,3.0)](P<0.05),and there were no significant differences in the gender ratio,type of atrial fibrillation,smoking habits,proportions of comorbidities(diabetes,hypertension,peripheral vascular disease,ischemic stroke,gastrointestinal ulcers)and admission CHA_2DS_2-VASc score between two groups(P>0.05).(2)The proportions of applying diuretics,digoxin,fondahexyl sodium and tirofiban were higher in death group(73.2%,42.3%,6.0%,4.0%)than those in survival group(56.3%,32.2%,2.3%,1.6%)(P<0.05),the proportion of applying calcium channel blockers was lower in death group(21.5%)than that in survival group(31.1%)(P<0.05),and there were no significant differences in the proportions of applying PCI,CABG,radiofrequency ablation,amiodarone,propafenone,β-receptor blockers,angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists,statins,nitrates,trimetazidine,proton pump inhibitors,low-molecular heparin,aspirin,clopidogrel,tegretol,warfarin and new oral anticoagulants between two groups(P>0.05).(3)The old age(HR=1.058,95%CI:1.033-1.084,P<0.001),bleeding(HR=2.517,95%CI:1.159-5.466,P=0.020),applying diuretics(HR=1.669,95%CI:1.116-2.497,P=0.013),and applying tirofiban(HR=3.022,95%CI:1.301-7.017,P=0.010)were the risk factor of all-cause mortality in elderly patients with NVAF and ACS,and body mass index of 24.0-<28.0 kg/m~2(HR=0.657,95%CI:0.460-0.937,P=0.021)was the protective factor of survival.Conclusion The risk of all-cause mortality increases in elderly patients with NVAF and ACS when they are old,have bleeding history and apply diuretics and tirofiban,and decreases in those with body mass index of 24.0-<28.0 kg/m~2.