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目的研究近12年来接受直接经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)的急性ST段抬高心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者近期预后的变化趋势。方法收集北京协和医院自2003年4月至2015年3月行直接PCI的全部STEMI患者资料,根据STEMI的发病时间将患者分为第一组(2003年4月至2007年3月,362例)、第二组(2007年4月至2011年3月,424例)和第三组(2011年4月至2015年3月,417例),分析心血管疾病危险因素、药物和PCI情况以及30 d预后的变化趋势。结果入选1203例行直接PCI的STEMI患者,平均年龄(62.2±12.6)岁,男954例(79.3%)。三组吸烟患者比例分别是62.4%、60.8%、54.0%,有显著降低趋势(P=0.015)。三组患者β阻滞药的使用率分别为90.9%、89.9%、85.9%,有显著降低趋势(P=0.024);血管紧张素转化酶抑制药/血管紧张素Ⅱ受体拮抗药的使用率分别为87.8%、86.3%、70.3%,有显著降低趋势(P<0.001);血小板糖蛋白Ⅱb/Ⅲa受体拮抗药使用率分别为10.8%、51.7%、60.0%,有显著上升趋势(P<0.001),但阿司匹林、P2Y12抑制剂及他汀类的使用率比较,差异均无统计学意义(均P>0.05)。PCI成功率分别为89.0%、92.0%、98.3%,有显著升高趋势(P<0.001)。症状-球囊扩张时间分别为270(180,480)min、270(180,450)min、360(240,540)min,有显著延长趋势(P<0.001);症状-入门时间分别为150(90,330)min、150(90,287)min、180(114,360)min,有显著延长趋势(P=0.010),但入门-球囊扩张时间比较,差异无统计学意义(P=0.379)。在30 d预后方面,全因死亡率分别为9.1%、3.8%、2.9%;心源性死亡率分别为6.9%、2.8%、2.2%;再发心肌梗死率分别为2.5%、1.2%、0.2%;心力衰竭发生率分别为18.2%、14.2%、11.3%,均有显著降低趋势(均P<0.05)。校正相关基线因素后,30 d全因死亡率仍有下降趋势[相对风险(relative risk,RR)0.541,95%置信区间(confidence interval,CI)0.382~0.765,P=0.001]。与第一组相比,第二组(RR 0.397,95%CI 0.214~0.739,P=0.004)和第三组(RR 0.328,95%CI 0.167~0.676,P=0.001)的30 d死亡风险均降低。结论在12年间,行直接PCI的STEMI患者的30 d总死亡率有持续下降趋势。
Objective To study the recent trends of prognosis in patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent direct percutaneous coronary intervention (PCI) in the past 12 years. Methods The data of all STEMI patients who underwent direct PCI from April 2003 to March 2015 in Peking Union Medical College Hospital were collected. Patients were divided into the first group (362 cases from April 2003 to March 2007) according to the onset time of STEMI. , The second group (424 cases in April 2007 to March 2011) and the third group (417 cases in April 2011 to March 2015). The risk factors for cardiovascular diseases, the drug and PCI situation, d prognosis trends. Results A total of 1203 STEMI patients undergoing direct PCI were enrolled. The mean age was (62.2 ± 12.6) years old and 954 (79.3%) were male. The proportions of three groups of smokers were 62.4%, 60.8% and 54.0%, respectively, with a significant decrease (P = 0.015). The usage rates of β blockers were 90.9%, 89.9% and 85.9% in the three groups, respectively (P = 0.024). The rates of use of angiotensin converting enzyme inhibitors and angiotensin Ⅱ receptor antagonists (P <0.001). The rates of platelet glycoprotein Ⅱb / Ⅲa receptor antagonist use were 10.8%, 51.7% and 60.0% respectively, with a significant increase (P <0.001). However, there was no significant difference in the use rates of aspirin, P2Y12 inhibitors and statins (all P> 0.05). PCI success rates were 89.0%, 92.0%, 98.3%, a significant increase (P <0.001). Symptoms - the time of balloon dilatation were 270 (180,480) min, 270 (180,450) min, 360 (240,540) min, 90,287) min and 180 (114,360) min, there was a significant trend of prolongation (P = 0.010). However, there was no significant difference between the time of entry and balloon dilation (P = 0.379). In the 30-day prognosis, all-cause mortality was 9.1%, 3.8% and 2.9% respectively. Cardiac mortality was 6.9%, 2.8% and 2.2% respectively. The rates of recurrent MI were 2.5%, 1.2% 0.2%. The incidences of heart failure were 18.2%, 14.2% and 11.3% respectively, both of which decreased significantly (all P <0.05). After adjusting for the relevant baseline factors, all-cause mortality remained declining 30 days (RR 0.541, 95% confidence interval (CI) 0.382-0.765, P 0.001]. The 30-day risk of death in the second (RR 0.397, 95% CI 0.214-0.739, P = 0.004) and third (RR 0.328, 95% CI 0.167-0.676, P = 0.001) reduce. Conclusion The overall 30-day mortality rate of STEMI patients undergoing direct PCI has been on a downward trend for 12 years.