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
DOI: 10.12677/acm.2025.1551464, PDF, HTML, XML,   
作者: 王亚楠:内蒙古科技大学包头医学院研究生院,内蒙古 包头;高 雯*:内蒙古巴彦淖尔市医院心血管内科,内蒙古 巴彦淖尔
关键词: 共病老年急性心肌梗死炎症指标经皮冠状动脉介入Multimorbidity Elderly Acute Myocardial Infarction Inflammatory Markers Percutaneous Coronary Intervention
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.
文章引用:王亚楠, 高雯. 多病共患的老年急性心肌梗死患者临床特点及预后分析[J]. 临床医学进展, 2025, 15(5): 1032-1044. https://doi.org/10.12677/acm.2025.1551464

1. 引言

冠状动脉粥样硬化性心脏病(CHD)简称为冠心病,随着人口增长和年龄结构的变化,CHD成为目前全世界范围内的主要死亡原因之一[1]。我国逐步迈入深度老龄化,老年人口占比进一步增加,而老年人是CHD的高发群体[2]。多病共存,由美国学者Feinstein首次提出[3],现在通常将一个个体同时合并2种或2种以上慢性疾病的状态定义为共病[4]。共病在患有CHD的老年人中普遍存在,国内研究发现[5],近90%的老年急性冠脉综合征(ACS)患者存在多病共患问题。

急性心肌梗死(AMI)是冠心病的严重类型,病情凶险,是全球范围内致死、致残的主要疾病之一[6]。共病可能导致AMI患者临床症状不典型,增加早期诊断难度,延误治疗时机[7]。共病影响着患者血运重建策略的选择,随着共病数量的增加,血运重建率(包括PCI或冠状动脉旁路移植术)下降,高共病患者的血运重建率显著低于无或低水平共病患者[8]。多病共患意味着多药治疗。不同类型药物的复杂性、药物相互作用的风险,以及随着处方数量增加而增加的用药错误风险可能反过来抵消现代医学的好处[9]。研究发现[10],存在两种或多种合并症的老年AMI患者临床情况更严重,需要更多的药物治疗,心、肾功能较差,冠状动脉病变更严重,院内并发症的发生率更高,预后较差。

多病共患的老年AMI患者数量逐年增加,其临床特点和预后与无共病患者存在显著差异。然而,目前针对多病共患的老年AMI患者的系统性研究较少。本研究通过分析多病共患的老年AMI患者的临床特点及预后,旨在为临床医生提供更精准的诊断和治疗依据,帮助改善患者预后,同时减轻社会和家庭的经济负担。

2. 资料与方法

2.1. 对象

本研究为回顾性研究,选取2022年01月至2023年03月期间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,纳入标准:(1) 入选患者均符合2018年第四版心肌梗死通用定义的诊治标准[11];(2) 年龄 ≥ 60周岁。排除标准:(1) 有陈旧性心肌梗死病史;(2) 合并主动脉夹层、肺动脉栓塞、急性心肌炎、急性心包炎等需与AMI鉴别的疾病,合并结构性心脏病(如原发性心肌病、心脏瓣膜病、先天性心脏病);(3) 多器官功能衰竭、免疫系统疾病、血液系统疾病、晚期肿瘤患者;(4) 合并严重的感染性疾病;(5) 临床资料不全及失访患者。本研究经本院伦理委员会批准同意,所有研究对象及家属均签署知情同意书。

2.2. 方法

2.2.1. 数据收集及相关定义

收集所有研究对象以下临床资料:一般资料;合并症情况;辅助检查情况;记录疾病特征、治疗情况以及出院用药;记录院内不良事件发生情况。所有研究对象均通过电话或门诊随访,记录出院1年内不良事件发生情况:包括全因死亡、再发心梗、非计划再次血运重建、恶性心律失常、需要住院的心衰、缺血性卒中、出血。

共病:将一个个体同时合并2种或2种以上慢性疾病的状态定义为共病[4]。纳入分析的共病包括:高血压、糖尿病、血脂异常、脑梗死、慢性肺病、甲状腺功能异常、高尿酸血症/痛风、慢性肾功能不全、外周动脉疾病。直接PCI:定义为症状发生后12小时内进行的PCI或者是在症状发生后的12~24小时之间,但是仍然有持续缺血的临床症状或心电图改变[12]。冠脉病变支数评定:采用标准Judkins技术完成冠状动脉造影,在不同的投射方位下摄影使左、右冠状动脉及其主要分支得到清楚的显影,观察血管情况并采集完整图像,由至少两位经验丰富的介入医师评定造影结果。冠脉病变支数评定:冠脉病变范围包括左主干(LM)、左前降支(LAD)、左回旋支(LCX)、右冠状动脉(RCA),主要分支如对角支病变归属于所属主支;LAD、LCX或RCA任何一支狭窄 ≥ 50%为有意义病变;两支及以上有病变者定为多支病变;对于LM病变者,不论有无合并其他血管病变,均归为多支病变[13]。冠状动脉血管正常或狭窄程度 < 50%为冠脉造影阴性。根据受累冠脉统计病变血管支数,分别为零支病变、单支病变、多支病变。

2.2.2. 分组与研究终点

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);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)。

研究终点为发生院内死亡或随访期内出现任何不良事件(包括全因死亡、再发心梗、非计划再次血运重建、恶性心律失常、需要住院的心衰、缺血性卒中、出血)。

2.3. 统计学方法

运用SPSS 26.0 (SPSS Inc., Chicago, USA)软件进行统计分析。正态性检验采用Shapiro-Wilk检验,符合正态的计量资料采用(X ± SD)表示,两组均数间比较用t检验,多组均数间比较采用方差分析,方差分析有统计学意义的事后两两比较采用LSD法。不符合正态的计量资料采用P50 (P25, P75)表示,两组间比较用Mann-Whitney U检验,多组间比较采用Kruskal-Wallis检验。计数资料采用率进行统计描述,统计推断采用卡方检验、校正卡方检验或Fisher确切概率法。采用Kaplan-Meier分析合并不同共病个数对生存结局的影响。统计分析取双侧检验,检验水准取α = 0.05。

3. 结果

3.1. 不同共病数量组一般临床资料比较

表1可见,性别(P = 0.029)和BMI (P < 0.001)在三组之间存在显著差异,随着共病数量的增加,女性比例、BMI呈上升趋势;其余变量在三组之间无显著差异(P > 0.05)。

Table 1. Comparison of basic characteristics of the three groups of subjects

1. 三组研究对象的基本特征比较

≤1种共病组

(n = 145)

2种共病组

(n = 83)

≥3种共病组

(n = 66)

c2/F值

P值

性别,n (%)

7.079

0.029

男性

109 (75.17)

54 (65.06)

38 (57.58) 1

女性

36 (24.83)

29 (34.94)

28 (42.42)

年龄,岁

70.00 ± 6.74

69.17 ± 6.98

69.05 ± 6.67

0.632

0.533

民族,n (%)

-

0.726

汉族

138 (95.17)

80 (96.39)

62 (93.94)

蒙族/满族

7 (4.83)

3 (3.61)

4 (6.06)

吸烟,n (%)

48 (33.10)

32 (38.55)

19 (28.79)

1.612

0.447

肥胖,n (%)

18 (12.41)

12 (14.46)

15 (22.73)

3.786

0.151

BMI, kg/m2

23.58 ± 3.51

25.03 ± 3.461

25.49 ± 3.451

8.577

<0.001

注:1与≤1种共病组比,P < 0.05;2与2种共病组比,P < 0.05。

表2可见,随着共病数量的增加,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,差异有统计学意义(P < 0.05)。进一步组间两两比较,2种共病组和≥3种共病组的TG、TC、白细胞计数、血小板计数、血浆纤维蛋白原显著高于≤1种共病组(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)。其余指标差异无统计学意义(P > 0.05)。

Table 2. Comparison of clinical indicators among the three groups

2. 三组研究对象的临床指标比较

≤1种共病组

(n = 145)

2种共病组

(n = 83)

≥3种共病组

(n = 66)

c2/F值

P值

白细胞,×109/L

9.33 ± 3.30

10.21 ± 3.351

10.97 ± 4.761

4.794

0.009

血红蛋白,g/L

142.40 ± 16.26

147.34 ± 18.53

137.82 ± 18.411,2

5.557

0.004

血小板,×109/L

200.75 ± 52.67

215.04 ± 48.50

230.56 ± 71.331

6.583

0.002

尿酸,μmol/L

318.94 ± 71.90

322.60 ± 96.60

360.05 ± 109.631,2

5.188

0.006

白蛋白,g/L

40.28 ± 4.33

41.36 ± 4.12

39.82 ± 3.89

2.795

0.063

TC, mmol/L

4.53 ± 0.91

4.97 ± 1.261

4.89 ± 1.441

4.779

0.009

HDL-C, mmol/L

1.12 ± 0.28

1.08 ± 0.23

1.06 ± 0.30

1.187

0.307

LDL-C, mmol/L

2.87 ± 0.79

3.16 ± 1.13

3.04 ± 1.18

2.300

0.102

纤维蛋白原,g/L

3.17 ± 1.04

3.51 ± 1.171

3.56 ± 1.251

3.927

0.021

左室舒张末期内径,mm

47.10 ± 5.10

46.71 ± 4.68

48.11 ± 6.42

1.332

0.266

左室收缩末期内径,mm

33.61 ± 4.90

33.00 ± 4.31

34.56 ± 5.88

1.810

0.166

LVEF, %

54.58 ± 7.74

55.14 ± 7.31

54.06 ± 8.94

0.350

0.705

血肌酐,μmol/L

77.00 (65.00, 90.00)

74.00 (63.50, 85.50)

79.50 (64.25, 97.75)

2.428

0.297

AST, U/L

31.00 (22.00, 65.00)

29.00 (22.50, 59.50)

31.00 (19.00, 68.50)

0.370

0.831

ALT, U/L

21.00 (15.00, 30.00)

22.00 (15.00, 37.00)

21.00 (16.25, 40.75)

2.276

0.320

TG, mmol/L

1.24 (0.83, 1.75)

1.56 (1.15, 2.22)1

1.83 (1.20, 3.03)1,2

32.819

<0.001

D二聚体,mg/l FEU

0.36 (0.24, 0.77)

0.39 (0.25, 0.66)

0.46 (0.23, 0.94)

0.429

0.807

肌钙蛋白峰值,pg/ml

6745.00 (2000.00, 21,284.00)

8700.00 (2256.50, 17,000.00)

5250.00 (1577.00, 17,000.00)

0.463

0.793

CK-MB峰值,U/L

98.00 (40.00, 184.00)

96.00 (40.00, 184.00)

76.00 (33.25, 138.75)

2.635

0.268

NT-proBNP (max), pg/ml

1190.00 (471.00, 2644.00)

1660.00 (599.50, 3445.00)

1420.00 (657.25, 4810.00)

5.127

0.077

注:1与≤1种共病组比,P < 0.05;2与2种共病组比,P < 0.05。

3.2. 不同共病数量组疾病特征比较

表3可见,≤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;下壁右室正后壁心肌梗死P值未达到显著性水平(P = 0.099),但在三组中的比例呈现一定上升趋势。

Table 3. Comparison of location and type of MI among the three groups

3. 三组研究对象心梗部位、类型的比较

≤1种共病组

(n = 145)

2种共病组

(n = 83)

≥3种共病组

(n = 66)

c2/F值

P值

前壁,n (%)

51 (35.17)

19 (22.89)

11 (16.67) 1

9.040

0.011

前壁高侧壁,n (%)

4 (2.76)

2 (2.41)

2 (3.03)

-

1.000

高侧壁,n (%)

2 (1.38)

2 (2.41)

2 (3.03)

-

0.651

前间壁,n (%)

3 (2.07)

0 (0.00)

0 (0.00)

-

0.439

下壁,n (%)

31 (21.38)

17 (20.48)

8 (12.12)

2.675

0.262

下壁正后壁,n (%)

10 (6.90)

12 (14.46)

12 (18.18) 1

6.595

0.037

下壁侧壁,n (%)

1 (0.69)

0 (0.00)

0 (0.00)

-

1.000

下壁右室,n (%)

8 (5.52)

6 (7.23)

5 (7.58)

0.430

0.806

下壁右室正后壁,n (%)

6 (4.14)

9 (10.84)

7 (10.61)

4.627

0.099

NSTEMI, n (%)

29 (20.00)

16 (19.28)

19 (28.79)

2.478

0.290

Killip ≥ 3级,n (%)

20 (13.79)

15 (18.07)

21 (31.82) 1

9.628

0.008

注:1与≤1种共病组比,P < 0.05;2与2种共病组比,P < 0.05。

表4结果显示,罪犯血管的分布在三组之间存在显著差异(P = 0.004);在≤1种共病组中,LAD为罪犯血管的比例显著高于2种和≥3种共病组(P < 0.05)。

3.3. 不同共病数量组治疗情况比较

表5可见,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);≤1种共病组的直接PCI比例显著高于另外两组(P = 0.003)。其余指标在三组之间无显著差异(P > 0.05)。

根据表6的数据可见,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。其余药物的应用在三组间无显著差异(P > 0.05)。

Table 4. Comparison of culprit vessels among the three groups of subjects

4. 三组研究对象罪犯血管比较

≤1种共病组

(n = 133)

2种共病组

(n = 70)

≥ 3种共病组

(n = 52)

c2/F值

P值

罪犯血管,n (%)

15.539

0.004

LAD

62 (46.62)

20 (28.57)1

16 (30.77)1

LCX

12 (9.02)

19 (27.14)

8 (15.38)

RCA

59 (44.36)

31 (44.29)

28 (53.85)

注:1与≤1种共病组比,P < 0.05;2与2种共病组比,P < 0.05。

Table 5. Comparison of admission and treatment among the three groups

5. 三组研究对象入院治疗情况比较

≤1种共病组

(n = 145)

2种共病组

(n = 83)

≥3种共病组

(n = 66)

c2/F值

P值

未行PCI,n (%)

16 (11.03)

21 (25.30)1

21 (31.82)1,2

14.640

<0.001

直接PCI,n (%)

114 (78.62)

59 (71.08)

37 (56.06)1,2

11.318

0.003

择期PCI,n (%)

15 (10.34)

3 (3.61)

8 (12.12)

4.100

0.129

临时起搏器,n (%)

6 (4.14)

3 (3.61)

5 (7.58)

-

0.521

IABP, n (%)

3 (2.07)

0 (0.00)

1 (1.52)

-

0.561

溶栓,n (%)

11 (7.59)

5 (6.02)

7 (10.61)

1.093

0.579

病变支数,n (%)

1.088

0.580

单支

28 (19.31)

12 (14.46)

10 (15.15)

多支

117 (80.69)

71 (85.54)

56 (84.85)

药物洗脱支架,n (%)

102 (70.34)

48 (57.83)

40 (60.61)

4.217

0.121

注:1与≤1种共病组比,P < 0.05;2与2种共病组比,P < 0.05。

Table 6. Comparison of medication at discharge among the three groups

6. 三组研究对象出院用药情况比较

≤1种共病组

(n = 145)

2种共病组

(n = 83)

≥3种共病组

(n = 66)

c2/F值

P值

阿司匹林,n (%)

128 (88.28)

77 (92.77)

58 (87.88)

1.355

0.508

氯吡格雷,n (%)

135 (93.10)

74 (89.16)

55 (83.33)

4.777

0.092

替格瑞洛,n (%)

6 (4.14)

8 (9.64)

7 (10.61)

3.947

0.139

他汀类,n (%)

141 (97.24)

82 (98.80)

62 (93.94)

-

0.269

β受体阻滞剂,n (%)

38 (26.21)

42 (50.60)1

27 (40.91)1

14.320

<0.001

ACEI/ARB,n (%)

25 (17.24)

25 (30.12)1

24 (36.36)1

10.310

0.006

利尿剂,n (%)

50 (34.48)

37 (44.58)

36 (54.55)1

7.860

0.020

注:1与≤1种共病组比,P < 0.05;2与2种共病组比,P < 0.05。

3.4. 不同共病数量组院内不良事件、出院1年内不良事件发生情况比较

表7结果显示,随着共病数量增加,心力衰竭(P = 0.013)发生率、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);2种和≥3种共病组再发心绞痛的发生率显著高于≤1种共病组(P = 0.016)。进一步组间两两比较,与≤1种共病组比,≥3种共病组的心力衰竭、心源性休克、再发心绞痛和院内不良事件发生率显著升高(P < 0.05)。

Table 7. Comparison of in-hospital adverse events among the three groups

7. 三组研究对象院内不良事件比较

≤1种共病组

(n = 145)

2种共病组

(n = 83)

≥3种共病组

(n = 66)

c2/F值

P值

再发心梗,n (%)

1 (0.69)

0 (0.00)

1 (1.52)

-

0.478

支架内血栓,n (%)

0 (0.00)

0 (0.00)

1 (1.52)

-

0.224

心力衰竭,n (%)

52 (35.86)

36 (43.37)

38 (57.58) 1

8.745

0.013

恶性心律失常,n (%)

16 (11.03)

9 (10.84)

11 (16.67)

1.550

0.461

心源性休克,n (%)

9 (6.21)

3 (3.61)

10 (15.15) 1,2

7.742

0.021

心脏破裂/室壁瘤形成,n (%)

1 (0.69)

1 (1.20)

0 (0.00)

-

1.000

再发心绞痛,n (%)

3 (2.07)

8 (9.64) 1

6 (9.09) 1

-

0.016

缺血性卒中/出血,n(%)

1 (0.69)

1 (1.20)

1 (1.52)

-

0.793

死亡,n (%)

4 (2.76)

1 (1.20)

4 (6.06)

-

0.269

院内不良事件,n (%)

63 (43.45)

44 (53.01)

43 (65.15) 1

8.733

0.013

注:1与≤1种共病组比,P < 0.05;2与2种共病组比,P < 0.05。

根据表8的数据,出院1年内,≥3种共病组死亡率最高(7.69%),但三组间无显著差异(P = 0.127);需要住院的心衰事件在≥3种共病组发生率最高(9.09%),P值接近临界显著性(P = 0.075);对比不良结局,三组整体比较有显著差异(P = 0.018),≥3种共病组不良结局风险显著升高。

Table 8. Comparison of adverse events among the three groups within 1 year after discharge

8. 三组研究对象出院1年内不良事件发生情况比较

≤1种共病组

(n = 145)

2种共病组

(n = 83)

≥3种共病组

(n = 66)

c2/F值

P值

全因死亡,n (%)

5 (3.45)

1 (1.20)

5 (7.69)

3.910

0.127

再发心梗,n (%)

3 (2.07)

3 (3.61)

1 (1.52)

0.851

0.693

非计划再次血运重建,n (%)

8 (5.52)

1 (1.20)

3 (4.55)

2.554

0.314

恶性心律失常,n (%)

2 (1.38)

1 (1.20)

1 (1.52)

0.392

1.000

需要住院的心衰,n (%)

8 (5.52)

1 (1.20)

6 (9.09)

4.948

0.075

缺血性卒中,n (%)

2 (1.38)

0 (0.00)

1 (1.52)

1.224

0.604

出血,n (%)

3 (2.07)

0 (0.00)

2 (3.03)

2.221

0.364

不良结局,n (%)

27 (18.62)

7 (8.43)

17 (25.76)2

8.019

0.018

注:1与≤1种共病组比,P < 0.05;2与2种共病组比,P < 0.05。

3.5. 结局是否良好与共病数量的关系

根据出院1年内是否发生过不良事件及是否院内死亡,将研究对象分为结局良好组(243例)和结局不良组(51例),研究合并共病数量与预后结局的关系。表9显示,合并共病数量在两组间的分布存在显著差异(c2值 = 10.654,P值 = 0.005);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%),结局良好组中,≤1种共病的患者比例较高(50.62% vs. 43.14%)。

Table 9. Comparison of the relationship between the number of coexisting comorbidities and prognostic outcomes

9. 合并共病数量与预后结局关系的比较

结局良好组(n = 243)

结局不良组(n = 51)

c2

P值

合并共病数量,n (%)

10.654

0.005

≤1种

123 (50.62)

22 (43.14)

2种

74 (30.45)

9 (17.65)

≥3种

46 (18.93)

20 (39.22)

3.6. 预后分析

表10显示,不同共病数量组的平均生存时间存在显著差异(c² = 10.934, P = 0.004),≥3种共病组的平均生存时间为46.26周,且该组生存时间显著短于≤1种共病组和2种共病组(P < 0.05)。

Table 10. Comparison of survival time between groups with different numbers of comorbidities combined

10. 合并不同共病数量组的生存时间比较

平均生存时间,周

c2

P值

合并共病数量,n (%)

10.934

0.004

≤1种

48.86 (47.14, 50.58)

2种

49.32 (47.10, 51.54)

≥3种

46.26 (42.98, 49.55)1,2

注:1与≤1种共病组比,P < 0.05;2与2种共病组比,P < 0.05。

Kaplan-Meier生存曲线分析患者1年预后显示,不同共病数量组之间的生存时间存在显著差异(PLog Rank = 0.004,图1);从曲线趋势来看,≥3种共病组的累积生存率明显低于≤1种和2种共病组,提示共病数量越多(尤其是 ≥ 3种),累积生存率越低,生存时间越短。

4. 讨论

多病共存是一种全球现象,解决多病共存问题仍然是国际社会面临的主要挑战之一[14]。Wang等[15]研究显示,我国老年人多病共患率高达81.3%,其中心血管疾病是最常见的合并症之一。本研究数据显示,约有50%的老年AMI患者合并2种及以上疾病。

多病共存有着显著的性别差异。本研究中,随着合并共病数量的增加,女性患者比例呈上升趋势(P = 0.029)。这与以前的研究是一致的[16],女性更容易患多病共存,可以解释为女性可能更关注自己的健康状况,不太可能漏报疾病,以及绝经期和绝经后女性体内激素的变化伴随着多种慢性疾病风险的增加,这些可能导致更高的多种疾病患病率。心血管疾病(CVD)是女性易发生的慢性病共病之一[17]。研究发现[18],对于CVD,尽管男性和女性具有典型的心血管危险因素,但每个因素的相对重要性可能具有性别

Figure 1. Kaplan-Meier survival curve analysis

1. Kaplan-Meier生存曲线分析

差异;例如吸烟对女性的危害更大,吸烟能够通过对内皮壁的生化作用下调雌激素依赖性血管舒张;与男性相比,年轻女性患高胆固醇血症的相对风险较低,然而绝经后TC和LDL水平分别有所增加。

白细胞在动脉粥样硬化的起始、进展和斑块不稳定性中起着核心作用,它们通过介导炎症反应、吞噬脂质、释放蛋白酶和促血管生成因子等机制,促进斑块的形成、发展和最终破裂[19]。近期有研究[20] 探讨慢性低度炎症(通过INFLA-score衡量)与心脏代谢共病(CMM,定义为两种或两种以上的心脏代谢疾病共存,例如冠心病、糖尿病、高血压和脑卒中)风险之间的关系,INFLA-score综合了白细胞计数、血小板计数、C反应蛋白和粒细胞与淋巴细胞比值四个炎症标志物,结果发现随着INFLA-score的增加,CMM的风险显著增加。纤维蛋白原作为炎症标志物之一,也可以反映慢性低度炎症状态;在多病共患(≥2种慢性病)患者中,纤维蛋白原水平显著升高[21]。本研究中随着共病数量的增加,老年AMI患者的白细胞计数、血小板计数、纤维蛋白原均有升高,差异有统计学意义(P < 0.05),进一步证实了炎症指标在心血管疾病及共病中的重要意义。贫血/低血红蛋白会使心肌氧供减少,心输出量增加,长期如此会导致左心室肥厚和心力衰竭;同时贫血/低血红蛋白可能是慢性炎性共病(如类风湿关节炎、慢性感染)作用的结果;炎症本身又可以加速动脉粥样硬化和心血管事件的发生[22]。本研究显示,≥3种共病组的老年AMI患者血红蛋白水平显著低于前两组(P = 0.004)。高尿酸可损伤血管内皮,加速动脉粥样硬化,尿酸结晶沉积可能直接损伤血管壁,高尿酸血症还可能加剧糖尿病病人糖脂代谢紊乱,促进心血管并发症,同时尿酸升高导致血管收缩、水钠潴留,进一步升高血压,增加心脏负荷;血清尿酸动态变化是心脏代谢共病(CMM)进展的重要预测因子,提醒临床需重视尿酸的监测,因为其不仅仅对心血管产生危害,更与多种心脏代谢性疾病的发展密不可分[23]。TC、TG和LDL-C血清含量升高是AMI的公认危险因素[24]。本研究中,随着共病数量的增加,三组研究对象TG、TC水平逐步升高,差异有统计学意义(P < 0.05)。更有研究表明脂质代谢紊乱通过多种分子机制影响多种疾病的发生和发展,导致多病共发[25]

本研究中,≤1种共病组LAD为罪犯血管的比例显著高于其余两组(P < 0.05)。分析原因可能是[26] LAD是左冠状动脉的主干分支,供应左心室前壁及室间隔,血流动力学压力较高,易受动脉粥样硬化影响;LAD中段因血管弯曲和剪切力变化,易形成脂质核心斑块,导致急性血栓事件;以及≤1种共病组患者中经典的冠心病危险因素较少,造成了LAD作为罪犯血管比例较高的现象。

共病影响着老年AMI患者治疗策略的选择。Breen等人[8]一项针对ACS的研究发现,高共病患者的血运重建率显著低于无或低水平共病患者。另一项关于非ST段抬高型ACS的研究[27]也有类似发现。本研究中2种和≥3种共病组未行PCI的比例显著高于≤1种共病组(P < 0.001)。可能是共病会增加PCI术后的出血风险,或患者高龄、心肾功能差、合并症多要求药物保守治疗,或在转运至我院前已静脉溶栓成功而未行急诊PCI,以及共病导致患者症状不典型,就医及诊断延迟以致超出急诊PCI最佳时间窗,还有部分患者行冠脉造影后发现冠脉三支弥漫病变或合并左主干严重病变,医生建议择期行冠状动脉旁路移植术(CABG)所以最终未行PCI。Surve等[28]的综述中提到,共病(如糖尿病、慢性肾病、左心室功能不全等)、高龄是选择血运重建策略的重要影响因素;如糖尿病患者常伴有弥漫性血管病变和钙化,增加了PCI术后再狭窄和血栓风险,因此指南通常推荐CABG用于合并糖尿病的多支病变患者;LVEF降低的患者更倾向于选择CABG,CABG通过多支血管重建可更有效地恢复心肌灌注,改善长期预后;肾功能不全患者易发生对比剂肾病(PCI相关)或术后急性肾损伤(CABG相关),需综合评估肾功能和手术风险。在院外用药方面,本研究发现随着共病数量增加,利尿剂的使用率逐渐升高,这与之前我们发现高共病患者院内心力衰竭较多、Killip分级高有直接关联;β受体阻滞剂、ACEI/ARB在2种和≥3种共病组中使用率显著升高(P < 0.05),分析原因可能是这些药物对冠心病、高血压、糖尿病、心力衰竭均有益处,而共病患者常合并这些疾病,促使β受体阻滞剂、ACEI/ARB使用率上升。

多病共患对老年AMI患者出现院内并发症与预后影响显著。Qin等人[10]研究显示,老年AMI患者院内死亡率随共病数量显著上升,心律失常、急性心力衰竭、心脏破裂等不良事件发生率在高共病组也明显升高。在另一项研究中[29],共病数量与AMI患者院内死亡率呈逐步增加的关系,每增加一种共病,院内死亡风险也随之增加。本研究中,与≤1种共病组比,≥3种共病组的院内心力衰竭、心源性休克、再发心绞痛和总院内不良事件发生率显著升高(P < 0.05)。可能原因为共病通过各自的病理途径加重心血管负担和系统性炎症,如糖尿病导致内皮功能障碍、慢性肾脏病的尿毒症毒素加剧心肌缺血;慢性肾病患者可能因担心造影剂肾病风险而未行PCI,导致再灌注不足;多支血管病变和左主干受累比例增加,进一步恶化血流动力学状态。严研等人[5]的研究显示,共病数量越多,1年净临床不良事件(全因死亡、再发心梗或出血的复合终点)风险越高,死亡率随着共病数量增加显著升高。既往研究表明,共病数量对一年MACE和全因死亡率具有中等预测能力[10]。本研究中,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%),从Kaplan-Meier曲线趋势看,≥3种共病组的累积生存率明显低于≤1种和2种共病组,提示共病数量越多(尤其是≥3种),累积生存率越低,生存时间越短。与既往研究结果一致。

本研究存在一些局限性:本研究仅收集了巴彦淖尔市医院的临床数据,可能存在选择偏倚;本研究侧重于对共病数量的研究,未能评估具体共病种类可能导致的不良后果;未能考虑患者的社会经济地位、教育水平、医疗保险状况等因素,这些因素可能影响治疗方案和预后。在未来的研究中,可扩大数据来源、深入分析共病种类、纳入社会经济因素等,全面评估多病共患对老年AMI患者临床特点及预后的影响。

综上所述,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。

NOTES

*通讯作者。

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