Evan Kurniawan　張瑞巖

200025 上海交通大學(xué)醫(yī)學(xué)院附屬瑞金醫(yī)院心內(nèi)科

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高齡老年患者冠狀動(dòng)脈介入治療效果及風(fēng)險(xiǎn)評(píng)估

Evan Kurniawan張瑞巖

200025 上海交通大學(xué)醫(yī)學(xué)院附屬瑞金醫(yī)院心內(nèi)科

【摘要】高齡老年冠狀動(dòng)脈粥樣硬化性心臟病(冠心病)患者合并疾病多，冠狀動(dòng)脈病變復(fù)雜程度高，經(jīng)皮冠狀動(dòng)脈介入治療(PCI)并發(fā)癥的發(fā)生率較高。對(duì)高齡老年患者PCI進(jìn)行風(fēng)險(xiǎn)及預(yù)后評(píng)估非常重要。近年來，隨著PCI操作技術(shù)及策略的改進(jìn)，高齡老年患者PCI的成功率提高，相關(guān)并發(fā)癥發(fā)生率也有所下降。該文對(duì)80歲以上的高齡老年冠心病患者接受PCI的療效、手術(shù)風(fēng)險(xiǎn)、并發(fā)癥及預(yù)后評(píng)估作一綜述。

冠狀動(dòng)脈粥樣硬化性心臟病(冠心病)是高齡老年人的首要死亡原因[1]，接受經(jīng)皮冠狀動(dòng)脈介入治療(PCI)的高齡老年冠心病患者比例逐年增高。80歲以上的冠心病患者行PCI手術(shù)風(fēng)險(xiǎn)增加，既往隨機(jī)對(duì)照研究往往將該部分人群納入排除標(biāo)準(zhǔn)[2-3]。本文介紹80歲以上的高齡老年冠心病人群PCI療效、手術(shù)風(fēng)險(xiǎn)及并發(fā)癥。

1高齡老年冠心病患者的臨床特征

高齡老年冠心病患者往往合并腎功能不全、高血壓、糖尿病、卒中等多種疾病[3-4]。研究發(fā)現(xiàn)，與年輕患者相比，高齡冠心病患者的高血壓、腦血管疾病、外周血管疾病及腎功能衰竭發(fā)生率較高(高血壓：61% 對(duì) 56%，腦血管疾?。?4% 對(duì) 7.8%，外周血管疾?。?5% 對(duì) 11%，腎功能衰竭：9.8%對(duì)4.8%；P<0.01)，且隨著年齡的增長多支血管病變及復(fù)雜病變的發(fā)生率也明顯升高[3]。另一項(xiàng)研究提示，年齡與冠狀動(dòng)脈鈣化密切相關(guān)[5]。這些合并疾病及冠狀動(dòng)脈復(fù)雜病變導(dǎo)致高齡老年患者PCI的難度加大，并發(fā)癥的發(fā)生率更高。

2高齡老年冠心病患者PCI的療效

2.1PCI 與單純藥物治療比較

TIME研究顯示，穩(wěn)定型心絞痛老年患者在藥物治療控制癥狀不佳時(shí)接受PCI，1年心血管不良事件發(fā)生率低于單純藥物治療(19% 對(duì)49%，P= 0.0001)[6]。隨訪4年顯示，接受PCI的高齡老年患者心血管不良事件發(fā)生率低于單純藥物治療(37% 對(duì)68%，P< 0.001)[7]。這說明高齡老年冠心病患者接受PCI比單純藥物治療效果更佳。

對(duì)高齡老年患者的臨床療效而言，維護(hù)及保留軀體功能是很重要的目標(biāo)。接受PCI的高齡老年患者比單純藥物治療患者的生活質(zhì)量更好，且軀體功能及心絞痛癥狀改善比年齡較輕患者更明顯。因此，高齡老年患者接受PCI獲益更大[8]。

2.2PCI 與冠狀動(dòng)脈搭橋術(shù)(CABG)比較

目前，多支病變、左主干病變以及嚴(yán)重鈣化病變是CABG的指征。近年來, 隨著PCI操作技術(shù)的改進(jìn)、橈動(dòng)脈徑路的普及、新一代藥物支架的產(chǎn)生、新型雙聯(lián)抗血小板藥物的出現(xiàn)及強(qiáng)化他汀類藥物的使用，高齡冠心病患者PCI成功率升高(>90%)，同時(shí)PCI相關(guān)并發(fā)癥顯著減少[9]。一項(xiàng)薈萃分析收集了65 000余例高齡老年患者(>80歲)，結(jié)果顯示，PCI組與CABG組30 d死亡率分別為5.4% 和7.3%，1年生存率分別為87%和86%，5年生存率分別為62% 和68%[10]。ASCERT研究顯示，2支或3支血管穩(wěn)定病變的高齡老年冠心病患者，上述兩種血運(yùn)重建策略的1年生存率無顯著差異(6.5% 對(duì)6.2%)，但CABG組長期死亡率(隨訪4年)低于PCI組(16.4% 對(duì)20.8%)[11]。綜合上述研究結(jié)果，對(duì)于高齡老年患者復(fù)雜病變，PCI與CABG的療效相仿。

2.3特殊高齡老年患者PCI

研究提示，對(duì)于左主干病變患者，PCI與CABG的主要終點(diǎn)結(jié)果(死亡、心腦血管不良事件等)相仿。雖然PCI組再次血運(yùn)重建比例較高，但CABG組腦卒中比例更高(1.5% 對(duì)4.3%，P= 0.03)[12]。Conrotto等[13]發(fā)現(xiàn)，左主干病變的高齡老年患者接受PCI及CABG術(shù)后遠(yuǎn)期死亡、腦血管意外及心肌梗死的發(fā)生率沒有差異。

雜交手術(shù)是將左乳內(nèi)動(dòng)脈吻合于左前降支的旁路移植手術(shù)，并置入藥物涂層支架處理非前降支病變，具有較高的遠(yuǎn)期通暢率[14]。高齡老年患者因多合并某些臨床疾病難以耐受CABG術(shù)，可以考慮行雜交手術(shù)。

高齡老年非ST段抬高型心肌梗死(NSTEMI)患者應(yīng)盡早接受血運(yùn)重建治療。Liistro等[15]發(fā)現(xiàn)，高齡NSTEMI患者未行早期血運(yùn)重建治療，死亡率及再次心肌梗死發(fā)生率均高于非高齡患者。GRACE 研究提示，高齡老年NSTEMI患者行PCI術(shù)后6個(gè)月的死亡率比保守治療更低[16]。

目前臨床上高齡老年ST段抬高型心肌梗死(STEMI)患者急性期PCI血運(yùn)重建率較低，老年癡呆、急慢性腎衰竭是導(dǎo)致該結(jié)果的主要原因[17-18]。研究發(fā)現(xiàn)，高齡老年STEMI患者如在12 h內(nèi)開通血管，超過90%的患者可恢復(fù)正常生活能力[19]。高齡老年患者在沒有絕對(duì)禁忌證的情況下，應(yīng)早期接受血運(yùn)重建。

3圍術(shù)期并發(fā)癥

高齡冠心病患者病變更加復(fù)雜，臨床合并癥更多，并發(fā)癥發(fā)生率也更高。研究顯示，高齡老年冠心病患者PCI圍術(shù)期并發(fā)癥較年輕患者增加2～4倍[4]。這些圍術(shù)期并發(fā)癥包括死亡、心肌梗死、腦卒中、對(duì)比劑腎病及出血事件。

3.1對(duì)比劑腎病

PCI術(shù)后患者急性腎功能不全發(fā)生率達(dá)7%， 基線腎功能水平及造影劑用量是首要影響因素[20]。接受PCI的高齡老年患者，因基線腎功能較年輕患者差，其對(duì)比劑腎病的發(fā)生率較高，故需控制對(duì)比劑用量[21-22]。我國的專家共識(shí)推薦，術(shù)前6～12 h及術(shù)后4～12 h以100 mL/h的速度靜脈輸注生理鹽水能降低對(duì)比劑腎病的發(fā)生率[23]。

3.2出血風(fēng)險(xiǎn)及抗血小板藥物選擇

高齡老年患者出血風(fēng)險(xiǎn)高于年輕患者[24]。研究發(fā)現(xiàn)，高齡老年患者凝血功能亢進(jìn)，易引起急性支架內(nèi)血栓形成，同時(shí)老年患者存在凝血調(diào)節(jié)功能退化，導(dǎo)致纖溶亢進(jìn)，出血風(fēng)險(xiǎn)亦較高[25-27]。另外，高齡老年患者體質(zhì)量偏輕，脂肪組織含量相對(duì)增加，對(duì)藥物治療的反應(yīng)更敏感，進(jìn)而放大不良反應(yīng)。PCI后的抗血小板治療是高齡老年患者出血的原因之一[28]。TRITON TIMI 38研究結(jié)果顯示，雖然普拉格雷能降低19%的缺血事件發(fā)生率，但該藥會(huì)導(dǎo)致出血風(fēng)險(xiǎn)上升32%，尤其是>75歲的老年患者出血風(fēng)險(xiǎn)更大，故不推薦>75歲的老年患者口服普拉格雷[29-30]。PLATO研究顯示，對(duì)于年齡>80歲的患者，與氯吡格雷相比，替格瑞洛能降低心源性死亡、心肌梗死及中風(fēng)等主要終點(diǎn)事件的發(fā)生率，且不增加出血風(fēng)險(xiǎn)。這提示替格瑞洛或許是老年患者PCI術(shù)后抗血小板的更佳藥物[31]。

研究顯示，與肝素相比，高齡老年患者應(yīng)用比伐盧定能降低院內(nèi)出血風(fēng)險(xiǎn)[32]。然而，一項(xiàng)隨機(jī)對(duì)照試驗(yàn)的薈萃分析質(zhì)疑了比伐盧定較肝素出血風(fēng)險(xiǎn)小的結(jié)論[33]。在絕大部分臨床中心，肝素仍然是PCI術(shù)中抗血栓形成的基礎(chǔ)藥物之一。一項(xiàng)包括6個(gè)評(píng)估GP Ⅱb/Ⅲa受體拮抗劑療效的大型臨床試驗(yàn)薈萃分析表明，GP Ⅱb/Ⅲa受體拮抗劑的益處隨著年齡的增加而下降，心血管凈獲益率下降<5%，但主要出血時(shí)間增加了70%[34]。因此，高齡老年患者應(yīng)用此類藥物時(shí)應(yīng)酌情減量。

近年來，由于橈動(dòng)脈穿刺并發(fā)癥發(fā)生率較股動(dòng)脈穿刺更低，介入醫(yī)生傾向于選擇橈動(dòng)脈作為首選穿刺點(diǎn)。臨床研究顯示，高齡老年患者經(jīng)橈動(dòng)脈穿刺較經(jīng)股動(dòng)脈穿刺住院并發(fā)癥發(fā)生率更低[35-37]。80歲以上患者經(jīng)橈動(dòng)脈穿刺行旋磨術(shù)治療，手術(shù)成功率可達(dá)90%以上[38]。因此，高齡老年患者接受PCI治療可以選擇橈動(dòng)脈穿刺途徑。

4結(jié)語

對(duì)高齡老年冠心病患者，年齡不應(yīng)該成為影響選擇PCI治療的決定因素。接受PCI的高齡老年患者需要根據(jù)其冠狀動(dòng)脈病變的嚴(yán)重程度、全身狀態(tài)、血栓和出血風(fēng)險(xiǎn)，充分評(píng)估手術(shù)成功可能性、風(fēng)險(xiǎn)及預(yù)后。

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(收稿：2016-02-01修回：2016-02-25)

(本文編輯：梁英超)

doi:10.3969/j.issn.1673-6583.2016.02.005

通信作者：張瑞巖, Email: rjzhangruiyan@aliyun.com