多病共患的老年急性心肌梗死患者临床特点及预后分析

Clinical Characteristics and Prognosis Analysis of Elderly Patients with Acute Myocardial Infarction Complicated by Multiple Diseases

摘要: 目的：本研究探讨多病共患的老年急性心肌梗死(AMI)患者的临床特点及预后。方法：收集2022年01月至2023年03月巴彦淖尔市医院急诊科收住院的年龄 ≥ 60岁首次明确诊断为AMI的患者294例作为研究对象，根据合并共病数量分为：≤1种共病组(145例)、2种共病组(83例)、≥3种共病组(66例)，再根据出院1年内是否发生不良事件及是否院内死亡，分为结局良好组(243例)和结局不良组(51例)。对比不同共病数量组的基本特征、临床指标、疾病特征、治疗情况、院内不良事件以及一年内不良事件发生情况，对比结局良好组和结局不良组的共病分布情况，对比不同共病数量组的生存时间并采用Kaplan-Meier曲线分析共病数量对生存结局的影响。结果：根据共病数量分组后，女性(P = 0.029)比例、BMI (P < 0.001)随着共病数量增加呈上升趋势。随着共病数量增加，三组白细胞计数、血小板计数、尿酸、TG、TC、纤维蛋白原水平升高(P < 0.05)；与2种共病组比较，≥3种共病组的血红蛋白水平显著降低，尿酸、TG指标显著升高(P < 0.05)。≤1种共病组的前壁心肌梗死发生率显著高于其余两组(P = 0.011)；≥3种共病组的下壁正后壁心肌梗死(P = 0.037)和Killip ≥ 3级(P = 0.008)发生率显著高于≤1种共病组；在≤1种共病组中，LAD为罪犯血管的比例显著高于另外两组(P<0.05)。2种和≥3种共病组的未行PCI比例显著高于≤1种共病组(P < 0.001)；对于β受体阻滞剂，2种和≥3种共病组的使用率显著高于≤1种共病组(P<0.001)；利尿剂(P = 0.020)、ACEI/ARB (P = 0.006)随着共病数量增加使用率增加。三组间院内心力衰竭(P=0.013)、总院内不良事件(P = 0.013)发生率呈上升趋势；≥3种共病组的心源性休克发生率显著高于其余两组(P = 0.021)。出院1年内≥3种共病组不良结局风险显著升高(P < 0.05)。结局不良组中，≥3种共病的患者比例显著高于结局良好组(39.22% vs. 18.93%)。≥3种共病组的平均生存时间显著短于≤1种和2种共病组(P < 0.05)；Kaplan-Meier曲线显示≥3种共病组的累积生存率明显低于≤1种和2种共病组(P < 0.05)。结论：在多病共患的老年AMI患者中，随着共病数量增加，女性占比增加，患者的炎症及代谢紊乱加剧，病情更为复杂，心功能更差，进行血运重建的可能性降低，院外用药负担增加，发生院内不良事件的风险上升，生存时间缩短，预后恶化。

Abstract: Objective: To examine the clinical characteristics and prognostic outcomes of elderly patients with multimorbidity and acute myocardial infarction (AMI). Methods: A total of 294 patients aged 60 years or older who were admitted to the emergency department of Bayannur Hospital between January 2022 and March 2023 and diagnosed with acute myocardial infarction (AMI) for the first time were recruited as research subjects. These patients were divided into three groups according to the number of comorbidities: one or fewer comorbidities group (145 cases), two comorbidities group (83 cases), and three or more comorbidities group (66 cases). Additionally, according to the occurrence of adverse events and in-hospital mortality within one year post-discharge, patients were further divided into a good outcome group (n = 243) and a poor outcome group (n = 51). The study compared basic characteristics, clinical indicators, disease features, treatment regimens, in-hospital adverse events, and the incidence of adverse events within one year across groups stratified by the number of comorbidities. Furthermore, the distribution of comorbidities was analyzed between the good outcome and poor outcome groups. Survival times among groups with varying numbers of comorbidities were compared using Kaplan-Meier curves to evaluate the impact of comorbidity burden on survival outcomes. Results: After stratification based on the number of comorbidities, the proportion of women (P = 0.029) and BMI (P < 0.001) increased as the number of comorbidities rose. With an increasing number of comorbidities, white blood cell count, platelet count, uric acid, triglycerides (TG), total cholesterol (TC), and fibrinogen levels were significantly elevated across all three groups (P < 0.05). Compared to the groups with two comorbidities, the group with three or more comorbidities exhibited a significantly lower hemoglobin level and significantly higher uric acid and TG indices (P < 0.05). The incidence of anterior myocardial infarction in the one or fewer comorbidity group was significantly higher than in the other two groups (P = 0.011). The incidences of inferior and posterior myocardial infarction (P = 0.037) and Killip grade ≥ 3 (P = 0.008) were significantly higher in the three or more comorbidities group compared to the one or fewer comorbidity group. In the one or fewer comorbidity group, the proportion of left anterior descending artery (LAD) as the culprit vessel was significantly higher than in the other two groups (P < 0.05). The proportion of non-percutaneous coronary intervention (non-PCI) was significantly higher in the two and three or more comorbidities groups compared to the one or fewer comorbidity group (P < 0.001). The use of β-blockers was significantly higher in the two and three or more comorbidities groups compared to the one or fewer comorbidity group (P < 0.001). The use of diuretics (P = 0.020) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) (P = 0.006) increased with the number of comorbidities. The incidence of in-hospital heart failure (P = 0.013) and total in-hospital adverse events (P = 0.013) showed an upward trend across the three groups. The incidence of cardiogenic shock in the three or more comorbidities group was significantly higher than in the other two groups (P = 0.021). Within one year post-discharge, the risk of adverse outcomes was significantly increased in the three or more comorbidities group (P < 0.05). The proportion of patients with three or more comorbidities in the poor outcome group was significantly higher than in the good outcome group (39.22% vs. 18.93%). The average survival time of patients with three or more comorbidities was significantly shorter than that of patients with one or fewer and two comorbidities (P < 0.05). Kaplan-Meier analysis revealed that the cumulative survival rate of the three or more comorbidities group was significantly lower than that of the one or fewer comorbidity group and two comorbidities group (P < 0.05). Conclusion: In elderly AMI patients with multimorbidity, with the increase of the number of comorbidities, the proportion of women increases, the inflammation and metabolic disorders of patients become more complex, the heart function is worse, the possibility of revascularization is reduced, the burden of out-of-hospital medication is increased, the risk of in-hospital adverse events is increased, the survival time is shortened, and the prognosis is worsened.