经皮冠状动脉介入术后不同时期出血的发生率及临床预后

The incidence and clinical prognosis of hemorrhage at different stages after percutaneous coronary intervention

目的:探讨经皮冠状动脉介入(PCI)术后早期(<30 d)、晚期(30～360 d)及极晚期(360 d以上)大出血的发生率及临床预后。方法:连续入选14 990例接受PCI的患者,收集患者术后发生的TIMI大出血及死亡事件。根据出血事件的发生时间出血事件分为:早期、晚期和极晚期。比较不同时期大出血对死亡风险的影响,并与不同时期心肌梗死对死亡的影响相比较。结果:在3年的随访中(中位随访时间19.4个月),早期TIMI大出血36例(0.2%),晚期大出血29例(0.2%),极晚期大出血40例(0.3%)。早期、晚期和极晚期大出血均是死亡的预测因素,其风险比(HR)呈递增趋势(早期:HR=2.61,95%CI:1.81～3.64;晚期:HR:2.80,95%CI:1.40～5.60;极晚期:HR=4.15,95%CI:2.72～6.33)。不同时期的心肌梗死也均是死亡的预测因素,但与出血事件不同的是,心肌梗死对死亡的风险比随随访时间的延长逐渐降低(早期:HR=5.07,95%CI 2.79～9.21;晚期:HR=2.25,95%CI:1.13～4.48;极晚期:HR=1.92,95%CI:1.15～3.20)。结论:PCI术1年后大出血事件仍不少见,且1年以后的大出血事件对远期死亡风险的影响较早期大出血更强。

Objective: To investigate the incidence and prognosis of early(<30 day), late(30-360 day) and very late(≥360 day) major bleeding after PCI. Methods: A total of 14 990 patients undergoing PCI were enrolled and followed up. TIMI major bleeding and mortality were examined. The impacts of early, late and very late bleeding on mortality were evaluated by survival analysis and Cox regression model. Results: During 3 years of follow-up(median 19.4 months), there were 36 early bleeding(0.2%), 29 late bleeding(0.2%) and 40 very late bleeding(0.3%). After adjusting for baseline risk factors, early, late and very late bleeding were all independent predictors of mortality, but with progressively higher hazard ratio when bleeding occurring at later time(early: HR=2.61, 95%CI:1.81-3.64;late HR=2.80, 95%CI:1.40-5.60;very late: HR=4.15, 95%CI:2.72-6.33). Similarly, early, late and very late myocardial infarction were also independent predictors of mortality, but with lower hazard ratio when myocardial infarction occurring at later time(early: HR=5.07, 95%CI:2.79-9.21;late: HR=2.25, 95%CI:1.13-4.48;very late: HR:1.92, 95%CI:1.15-3.20). Conclusions: Major bleeding beyond 1 year after PCI procedure is not uncommon. Very late bleeding complications after PCI have even stronger impact on long-term hazard of mortality.