Kuch B, Bolte H-D, Hoermann A, Meisinger C, Loewel H
I. Med. Klinik, Klinikum Augsburg, Lehrkrankenhaus der Ludwig Maximilians Universität München, Germany.
Eur Heart J. 2002 May;23(9):714-20. doi: 10.1053/euhj.2001.2947.
To examine the general influence of the definition of fatal and non-fatal acute myocardial infarction and coronary deaths on the estimation of in-hospital case-fatality, and to show how the definition of acute myocardial infarction influences time-trends of hospital mortality over 11 years.
As part of the World Health Organization's MONICA (multinational Monitoring of Trends and Determinants in Cardiovascular Disease) Project in Augsburg all patients aged 25-74 years with a suspected diagnosis of acute myocardial infarction who were hospitalized in the study region's major clinic were registered prospectively between 1985 to 1995 (n=4889). Patient information, including short-term survival status, was obtained from medical records, by interview of surviving patients, and municipal death certificate files which were validated by an extended identification and validation process. In-hospital case fatality was estimated according to different definitions which closely followed the international MONICA criteria. Epidemiological definitions comprised definite and possible acute myocardial infarction, and events with unclassifiable deaths, while the clinical definition was restricted to definite infarction. Overall, case fatality by the epidemiological definitions was 28 to 29.8% (23.5% of those treated in a coronary care unit) compared to 13.5% using the clinical definition. While over the 11 years, the reduction in case fatality according to the epidemiological definitions was modest, highly significant decreases were observed by applying the clinical definition (from 15.8% in 1985-1988 to 10.8% in 1993-1995, P<0.001 adjusted for age and sex). The discrepancy in case fatality between the definitions is explained by the high proportion of patients who die very early (about 70% of all fatal events during the first 24 h) with the consequence of missing data which may preclude a definite diagnosis of acute myocardial infarction.
Applying a broader definition of acute myocardial infarction reveals that in-hospital mortality is higher than believed until now, and it implies that our efforts must be intensified to reduce overall in-hospital coronary heart disease mortality.
探讨致命性和非致命性急性心肌梗死及冠心病死亡的定义对住院病死率估计的总体影响，并展示急性心肌梗死的定义如何影响11年间医院死亡率的时间趋势。
作为世界卫生组织在奥格斯堡开展的MONICA（心血管疾病趋势和决定因素多国监测）项目的一部分，1985年至1995年间，对研究区域主要诊所收治的所有年龄在25 - 74岁、疑似诊断为急性心肌梗死的患者进行了前瞻性登记（n = 4889）。通过查阅病历、对存活患者进行访谈以及经过扩展的身份识别和验证程序验证的市政死亡证明文件，获取了包括短期生存状况在内的患者信息。根据与国际MONICA标准密切相关的不同定义来估计住院病死率。流行病学定义包括确诊和可能的急性心肌梗死以及死因无法分类的事件，而临床定义仅限于确诊梗死。总体而言，采用流行病学定义的病死率为28%至29.8%（在冠心病监护病房接受治疗的患者中为23.5%），而采用临床定义的病死率为13.5%。在这11年期间，根据流行病学定义，病死率的下降幅度较小，而采用临床定义时观察到病死率显著下降（从1985 - 1988年的15.8%降至1993 - 1995年的10.8%，经年龄和性别调整后P < 0.001）。不同定义之间病死率的差异是由于极早期死亡患者的比例较高（约占所有致命事件的70%发生在最初24小时内），导致数据缺失，从而可能无法明确诊断急性心肌梗死。
采用更宽泛的急性心肌梗死定义表明，住院死亡率高于目前的认知，这意味着我们必须加大努力以降低总体住院冠心病死亡率。
