Gottlieb Shmuel, Goldbourt Uri, Boyko Valentina, Barbash Gabriel, Mandelzweig Lori, Behar Solomon
Neufeld Cardiac Research Institute, Sheba Medical Center, Tel Hashomer, and Bikur Cholim Hospital, Jerusalem, Israel.
Am J Geriatr Cardiol. 1995 Nov;4(6):17-31.
The number of elderly patients experiencing myocardial infarction (MI) is growing rapidly, and their hospital mortality rate remains high, although mortality after acute MI declined in the 1990s. The in-hospital and first-year mortality rates in 5,839 patients with acute MI in 1981-1983 were compared with 1,014 consecutive patients admitted in 1992 to the coronary care units in Israel. The clinical characteristics of gender, prior MI, and acute MI location were similar in the age subgroups in both periods. Patients admitted in 1981-1983 did not receive thrombolytic therapy, percutaneous transluminal coronary angioplasty (PTCA), or coronary artery bypass grafting (CABG), whereas in those admitted in 1992, the frequency of thrombolytic therapy in the age subgroups at or below 55 years, 56-74 years, and at or above 75 years decreased with advanced age (56%, 48%, and 24%, respectively, P is less than.0001). The frequency of PTCA also declined (11%, 7%, and 3%, respectively, P is less than.002). The in-hospital mortality rate for the entire study population declined from 18% in 1981-1983 to 11% in 1992 (adjusted odds ratio [OR] 0.49; 95% confidence interval, 0.39-0.62). The decline in in-hospital mortality was more marked among patients aged 56-74 (18.0%-10.0%; OR 0.48) and those aged at or above 75 years (35.0%-21.5%; OR 0.44), than among patients aged at or below 55 years (6.9%-4.3%; OR 0.70). This decline was most marked in reperfused patients, particularly the very elderly (OR 0.31; 95% CI 0.14-0.69). The cumulative first-year mortality declined by 40% (from 25.5% in 1981-1983 to 17.9% in 1992, hazard ratio (HR) 0.61; 95% CI 0.52-0.72). The decline was more marked among patients aged 56-74 years (26.2%-16.5%; HR 0.56) and those aged at or above 75 years (49.6%-37.6%; HR 0.58) than among counterparts aged at or below 55 years (10.2%-7.9%; HR 0.86). The decline was most marked in reperfused patients, particularly the very elderly (HR 0.31; 95% CI 0.16-0.59). In conclusion, (1) during the last decade in Israel, cumulative first-year mortality after an acute MI declined by 40% and was most marked in patients aged greater than 55 years and in particular the very elderly (at or above 75 years); (2) the main improvement in survival was achieved early after the acute MI, and was maintained thereafter during the first postinfarction year; 3) the favorable outcome in 1992 is related to changes in patients management, mainly reperfusion therapy (thrombolysis, PTCA, CABG); and (4) reperfusion therapy in elderly patients with acute MI should be considered systematically unless specific contraindications are present.
经历心肌梗死（MI）的老年患者数量正在迅速增长，尽管急性心肌梗死后的死亡率在20世纪90年代有所下降，但其医院死亡率仍然很高。将1981 - 1983年5839例急性心肌梗死患者的住院死亡率和第一年死亡率与1992年以色列冠心病监护病房连续收治的1014例患者进行比较。两个时期年龄亚组中的性别、既往心肌梗死和急性心肌梗死部位的临床特征相似。1981 - 1983年收治的患者未接受溶栓治疗、经皮腔内冠状动脉成形术（PTCA）或冠状动脉旁路移植术（CABG），而1992年收治的患者中，55岁及以下、56 - 74岁和75岁及以上年龄亚组的溶栓治疗频率随年龄增长而降低（分别为56%、48%和24%，P＜0.0001）。PTCA的频率也下降（分别为11%、7%和3%，P＜0.002）。整个研究人群的住院死亡率从1981 - 1983年的18%降至1992年的11%（校正比值比[OR]0.49；95%置信区间，0.39 - 0.62）。56 - 74岁患者（18.0% - 10.0%；OR 0.48）和75岁及以上患者（35.0% - 21.5%；OR 0.44）的住院死亡率下降比55岁及以下患者（6.9% - 4.3%；OR 0.70）更明显。这种下降在再灌注患者中最为明显，尤其是高龄患者（OR 0.31；95% CI 0.14 - 0.69）。累积第一年死亡率下降了40%（从1981 - 1983年的25.5%降至1992年的17.9%，风险比[HR]0.61；95% CI 0.52 - 0.72）。56 - 74岁患者（26.2% - 16.5%；HR 0.56）和75岁及以上患者（49.6% - 37.6%；HR 0.58）的下降比55岁及以下患者（10.2% - 7.9%；HR 0.86）更明显。这种下降在再灌注患者中最为明显，尤其是高龄患者（HR 0.31；95% CI 0.16 - 0.59）。总之，（1）在以色列过去十年中，急性心肌梗死后的累积第一年死亡率下降了40%，在年龄大于55岁尤其是高龄患者（75岁及以上）中最为明显；（2）生存的主要改善在急性心肌梗死后早期实现，并在梗死第一年期间得以维持；（3）1992年的良好结局与患者管理的变化有关，主要是再灌注治疗（溶栓、PTCA、CABG）；（4）除非存在特定禁忌证，应系统考虑对急性心肌梗死老年患者进行再灌注治疗。
