年龄如何影响急性心肌梗死的治疗？一项前瞻性队列研究。

How should age affect management of acute myocardial infarction? A prospective cohort study.

作者信息

Barakat K, Wilkinson P, Deaner A, Fluck D, Ranjadayalan K, Timmis A

机构信息

Department of Cardiology, Royal Hospitals NHS Trust, London Chest Hospital, UK.

出版信息

Lancet. 1999 Mar 20;353(9157):955-9. doi: 10.1016/S0140-6736(98)07114-1.

DOI:10.1016/S0140-6736(98)07114-1

PMID:10459903

Abstract

BACKGROUND

About 75% of patients with acute myocardial infarction are older than 70 years, but patients in this age group are commonly treated less vigorously than younger patients. This differential treatment may partly reflect clinicians' misconceptions about the outlook of such patients, and the importance of age in clinical decisions. We examined how age does and should affect the management of patients and risk stratification in acute myocardial infarction.

METHODS

In this prospective cohort study, we recruited 1225 consecutive patients admitted with acute myocardial infarction to a district general hospital in east London. The primary endpoint was death. We used tabulation and regression methods to analyse the association between age group and clinical variables.

FINDINGS

Patients aged 70 years or older took a longer time to arrive in hospital and were less likely to receive thrombolysis or discharge beta-blockers than patients younger than 60 years: odds ratio 0.63 (95% CI 9.45-0.88) for thrombolysis and 0.25 (0.16-0.37) for beta-blockade, adjusted for sex, diabetes, previous acute myocardial infarction, Q wave infarction, and left-ventricular failure. Left-ventricular failure was the strongest independent predictor of death within 1 year of infarction with a hazard ratio of 4.76 (3.53-6.43), adjusted for age, sex, diabetes, and Q wave infarction. Patients aged 70 years or older without left-ventricular failure had significantly better survival at 1 year after acute myocardial infarction than patients under 60 years with left-ventricular failure. 70.8% (62.2-78.2) of the older patients who survived to hospital discharge were still alive 3 years later.

INTERPRETATION

Elderly patients with acute myocardial infarction were treated less vigorously than younger patients. The prognosis of acute myocardial infarction, however, was substantially affected by the development of left-ventricular failure and other clinical indices, such that many older patients had a better outlook than younger patients with adverse clinical factors. In planning risk-based management, consideration of age independently of clinical status is inappropriate.

摘要

背景

约75%的急性心肌梗死患者年龄超过70岁，但该年龄组患者的治疗力度通常低于年轻患者。这种差异治疗可能部分反映了临床医生对这类患者预后的误解，以及年龄在临床决策中的重要性。我们研究了年龄如何以及应该如何影响急性心肌梗死患者的管理和风险分层。

方法

在这项前瞻性队列研究中，我们招募了1225例连续入住伦敦东部一家地区综合医院的急性心肌梗死患者。主要终点是死亡。我们使用列表和回归方法分析年龄组与临床变量之间的关联。

结果

70岁及以上的患者到达医院的时间更长，与60岁以下的患者相比，接受溶栓治疗或出院时使用β受体阻滞剂的可能性更小：溶栓治疗的比值比为0.63（95%CI 9.45 - 0.88），β受体阻滞剂治疗的比值比为0.25（0.16 - 0.37），对性别、糖尿病、既往急性心肌梗死、Q波梗死和左心室衰竭进行了校正。左心室衰竭是梗死1年内死亡的最强独立预测因素，风险比为4.76（3.53 - 6.43），对年龄、性别、糖尿病和Q波梗死进行了校正。70岁及以上无左心室衰竭的患者在急性心肌梗死后1年的生存率明显高于60岁以下有左心室衰竭的患者。70.8%（62.2 - 78.2）存活至出院的老年患者3年后仍存活。