周 鶴，王效增，王 耿，梁振洋，韓雅玲

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老年女性急性ST段抬高型心肌梗死患者行急診PCI的臨床特點(diǎn)及冠狀動(dòng)脈病變特點(diǎn)分析

周 鶴，王效增*，王 耿，梁振洋，韓雅玲*

（沈陽(yáng)軍區(qū)總醫(yī)院心內(nèi)科，沈陽(yáng) 110016）

探討急性ST段抬高型心肌梗死（STEMI）行急診經(jīng)皮冠狀動(dòng)脈介入治療（PCI）的老年女性患者臨床及冠脈病變特點(diǎn)?；仡櫺苑治隽?006年至2012年我院連續(xù)收入的首次診斷為STEMI并接受急診PCI術(shù)的女性患者366例。根據(jù)年齡分為兩組：老年組（≥65歲；＝211）和非老年組（＜65歲；＝155）。分析兩組患者臨床及冠脈病變特點(diǎn)。與非老年組患者相比，老年組中糖尿病發(fā)生率和空腹血糖值均顯著較高（＜0.05），吸煙者的比例和腎小球?yàn)V過(guò)率顯著較低（＜0.05），老年組患者冠脈三支病變率顯著增加（＜0.05），靶血管為左前降支（left anterior descending branch，LAD）的概率顯著降低（＜0.05）。老年組和非老年組患者接受急診PCI的成功率分別為98.58%和98.87%。不同年齡階段的女性STEMI患者具有不同的危險(xiǎn)因素特點(diǎn)，老年女性STEMI患者較非老年女性患者，冠狀動(dòng)脈病變更為復(fù)雜。

老年人；女性；急性心肌梗死；經(jīng)皮冠脈介入治療

隨著人口老齡化，以急性ST段抬高型心肌梗死（ST-segment elevation myocardial infarction，STEMI）入院的老年患者越來(lái)越多。在老年患者中，女性罹患心血管疾病的人數(shù)超過(guò)了男性，且女性患者具有危險(xiǎn)因素多、冠狀動(dòng)脈病變復(fù)雜等特點(diǎn)[1,2]，冠心病已成為威脅女性健康的“頭號(hào)殺手”[3]。本文回顧性分析沈陽(yáng)軍區(qū)總醫(yī)院心內(nèi)科行急診經(jīng)皮冠狀動(dòng)脈介入治療（percutaneous coronary intervention，PCI）的STEMI女性患者，探討老年女性急性心肌梗死臨床及急診PCI的特點(diǎn)。

1 對(duì)象與方法

1.1 研究對(duì)象

回顧性分析了2006年至2012年我院連續(xù)收入的首次診斷為STEMI并接受急診PCI術(shù)的女性患者366例。納入標(biāo)準(zhǔn)：（1）STEMI 符合美國(guó)心臟病學(xué)會(huì)（American College of Cardiology，ACC）/美國(guó)心臟協(xié)會(huì)（American Heart Association，AHA）的診斷標(biāo)準(zhǔn)[4]；（2）于發(fā)病12h內(nèi)行急診PCI。排除標(biāo)準(zhǔn)：（1）既往具有PCI病史；（2）未于12h內(nèi)行急診PCI。根據(jù)年齡分為兩組：老年組（≥65歲；＝211）和非老年組（＜65歲；＝155）。

1.2 研究方法

入院后立即行心電圖、心肌酶學(xué)檢查并確定診斷。術(shù)前頓服阿司匹林（aspirin）300mg、氯吡格雷（clopidogrel）600mg。急診行冠狀動(dòng)脈造影判定梗死相關(guān)靶血管，若靶血管病變處狹窄≥70%和（或）心肌梗死溶栓試驗(yàn)(thrombolysis in myocardial infarction，TIMI）≤2級(jí)，根據(jù)病變情況參考血管直徑選擇器械、球囊、支架，迅速行PCI術(shù)。術(shù)后予以阿司匹林100mg口服，氯吡格雷75mg或150mg（2周后改為75mg）口服。

1.3 統(tǒng)計(jì)學(xué)處理

2 結(jié) 果

2.1 兩組患者基線資料比較

老年組中糖尿病發(fā)生率和空腹血糖值均顯著高于非老年組患者（＜0.05），吸煙者的比例和腎小球?yàn)V過(guò)率顯著低于非老年組患者（＜0.05；表1）。

2.2 兩組患者PCI術(shù)特點(diǎn)比較

與非老年組患者相比，老年組患者冠脈三支病變率顯著增加（＜0.05），靶血管為左前降支（left anterior descending， LAD）的概率顯著降低（＜0.05；表2）。老年組和非老年組PCI成功率分別為98.58%和98.87%。在老年組患者中，PCI未成功者3例：2例導(dǎo)絲未能通過(guò)病變；1例支架植入術(shù)后無(wú)復(fù)流。在非老年組患者中，PCI未成功者2例，均為支架植入術(shù)后無(wú)復(fù)流。

2.3 兩組患者住院期間死亡率的比較

兩組患者術(shù)中無(wú)死亡病例，術(shù)后住院期間（約7d）共死亡8例（2.19%）：老年組5例（3例死于心源性休克或急性左心衰，1例死于心臟破裂，1例因介入術(shù)后腦出血死亡）；非老年組3例（2例術(shù)后因心臟破裂死亡，1例死于心源性休克或急性左心衰）。兩組患者住院期間死亡率無(wú)統(tǒng)計(jì)學(xué)差異（＞0.05）。

3 討 論

研究表明女性冠心病的發(fā)生、發(fā)展同體內(nèi)雌激素的變化緊密相關(guān)[5,6]。國(guó)內(nèi)既往的研究報(bào)道多著重于男性冠心病患者的臨床表現(xiàn)及PCI術(shù)特點(diǎn)[7,8]，但是缺乏不同年齡階段女性的大樣本相關(guān)研究報(bào)道。

表1 基線資料比較

LVEF: left ventricular ejection fraction; TG: triglycerides; TC: total cholesterol; LDL-C: low-density lipoprotein cholesterol; HDL-C: high-density lipoprotein cholesterol; FBG: fasting blood glucose; CK-MB: creatine kinase-MB; PLT: platelet; eGFR: estimated glomerular filtration rate

表2 兩組患者PCI術(shù)特點(diǎn)比較

PCI: percutaneous coronary intervention

文獻(xiàn)報(bào)道了心血管疾病的9種可控危險(xiǎn)因素，包括：吸煙、高血壓、高血脂、糖尿病、腹型肥胖、缺乏鍛煉、酗酒、食用水果或蔬菜過(guò)少和心理因素[9,10]。本研究結(jié)果表明，不同年齡階段女性患者冠心病危險(xiǎn)因素不同：老年女性患者糖尿病的發(fā)生率較高，同時(shí)空腹血糖水平也高于非老年患者；而非老年組患者吸煙占有更高的比例，差異均具有統(tǒng)計(jì)學(xué)意義。由此可見(jiàn)，隨著女性年齡的增加，應(yīng)盡快改變不良生活方式，積極防治各種冠心病危險(xiǎn)因素的發(fā)生、發(fā)展，針對(duì)不同年齡階段特點(diǎn)展開(kāi)綜合防治。

本研究的冠狀動(dòng)脈造影及PCI結(jié)果顯示，老年組患者發(fā)病時(shí)病情較重，三支血管病變所占比例38.4%，顯著高于非老年組患者（＜0.05），這同國(guó)內(nèi)外研究相似[11?13]，說(shuō)明老年女性患者急診PCI術(shù)較為復(fù)雜。同時(shí)老年患者還具有癥狀發(fā)作不典型、就診不及時(shí)、對(duì)急性心肌梗死的危險(xiǎn)性認(rèn)知不足、急診PCI治療接受程度差、全身基礎(chǔ)狀態(tài)差、合并多種疾病等特點(diǎn)，這也從另一方面反映了老年女性急性心肌梗死患者預(yù)后差的原因。

本研究顯示，老年女性STEMI患者的住院病死率為2.19%，這一結(jié)果與國(guó)外報(bào)道的男性STEMI接受急診PCI患者的住院死亡率相似[14]。老年組和非老年組患者接受急診PCI的成功率分別為98.58%和98.87%，說(shuō)明在技術(shù)成熟的心臟中心，老年女性STEMI患者行PCI術(shù)可取得較好的近期效果。

綜上所述，與非老年女性STEMI患者相比，老年女性患者的冠狀動(dòng)脈病變更為復(fù)雜。提示對(duì)不同年齡階段的女性患者，防治冠心病危險(xiǎn)因素存在一定的差異。本研究為回顧性資料且樣本量較小，尚存在一定的局限性，有待于更大規(guī)模的前瞻性研究對(duì)女性STEMI患者的臨床及冠狀動(dòng)脈病變特點(diǎn)進(jìn)行分析。

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（編輯: 呂青遠(yuǎn)）

Clinical features and coronary lesion characteristics in elderly women with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

ZHOU He, WANG Xiao-Zeng*, WANG Geng, LIANG Zhen-Yang, HAN Ya-Ling*

(Department of Cardiology, General Hospital of Shenyang Military Command, Shenyang 110016, China)

To explore the clinical features and coronary lesion characteristics in the elderly female patients diagnosed as acute ST-segment elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI).A retrospective study was conducted on 366 consecutive female patients who were first diagnosed as acute STEMI and underwent primary PCI in our hospital from 2006 to 2012. The patients were divided into the aged group (≥65 years old,＝211) and the non-aged group (＜65 years old,＝155). The clinical features and coronary lesion characteristics of the 2 groups were analyzed.Compared with the non-aged group, the aged group had significantly higher incidence of diabetes, higher fasting blood glucose, lower percentage of smokers, lower glomerular filtration rate, larger amount of triple-vessel disease, and less involved lesions in the left anterior descending branch (LAD) (all＜0.05). The success rates of PCI in the aged group and the non-aged group were 98.58% and 98.87%, respectively.Female STEMI patients have different characteristics in risk factors among different ages. The aged female elderly patients have more complicated coronary lesions than the non-aged ones.

aged; feminity; acute myocardial infarction; percutaneous coronary intervention

R541.4

A

10.11915/j.issn.1671-5403.2016.02.024

2015?11?30;

2015?12?10

王效增, E-mail: wxiaozeng@163.com; 韓雅玲, E-mail: hanyaling@126.net