Lenzen Mattie, Scholte op Reimer Wilma, Norekvål Tone M, De Geest Sabina, Fridlund Bengt, Heikkilä Johanna, Jaarsma Tiny, Mårtensson Jan, Moons Philip, Smith Karen, Stewart Simon, Strömberg Anna, Thompson David R, Wijns William
Department of Cardiology, Clinical Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands.
Eur J Cardiovasc Nurs. 2006 Jun;5(2):115-21. doi: 10.1016/j.ejcnurse.2006.01.003. Epub 2006 Mar 10.
It has been recognized that a clinically significant portion of patients with coronary artery disease (CAD) continue to experience anginal and other related symptoms that are refractory to the combination of medical therapy and revascularization. The Euro Heart Survey on Revascularization (EHSCR) provided an opportunity to assess pharmacological treatment and outcome in patients with proven CAD who were ineligible for revascularization.
We performed a secondary analysis of EHS-CR data. After excluding patients with ST-elevation myocardial infarction and those in whom revascularization was not indicated, 4409 patients remained in the analyses. We selected two groups: (1) patients in whom revascularization was the preferred treatment option (n = 3777, 86%), and (2) patients who were considered ineligible for revascularization (n = 632, 14%).
Patient ineligible for revascularization had a worse risk profile, more often had a total occlusion (59% vs. 37%, p < 0.001), were treated more often with ACE-inhibitors (65% vs. 55%, p < 0.001) but less likely with aspirin (83% vs. 88%, p < 0.001). Overall, they had higher case-fatality at 1-year (7.0% vs. 3.7%, p < 0.001). Regarding self-perceived health status, measured via the EuroQol 5D (EQ-5D) questionnaire, these same patients reported more problems on all dimensions of the EQ-5D. Furthermore, in the revascularization group we observed an increase between discharge and 1-year follow up (utility score from 0.85 to 1.00) whereas patients ineligible for revascularization did not improve over time (utility score remained 0.80)
In this large cohort of European patients with CAD, those considered ineligible for revascularization had more co-morbidities and risk factors, and scored worse on self-perceived health status as compared to revascularized patients in the revascularization group. With the exception of ACE-inhibitors and aspirin, there were no major differences regarding drug treatment between the two groups. Given these clinically significant observations, there appears to be a role for nurse-led, multidisciplinary, rehabilitation teams that target clinically vulnerable patients whose symptoms remain refractory to standard medical care.
人们已经认识到，相当一部分冠心病（CAD）患者持续经历心绞痛及其他相关症状，这些症状对药物治疗和血运重建的联合治疗无效。欧洲血运重建调查（EHSCR）为评估无法进行血运重建的确诊CAD患者的药物治疗及预后提供了契机。
我们对EHS-CR数据进行了二次分析。排除ST段抬高型心肌梗死患者及未行血运重建的患者后，4409例患者纳入分析。我们选取了两组：（1）血运重建为首选治疗方案的患者（n = 3777，86%），以及（2）被认为不适合进行血运重建的患者（n = 632，14%）。
不适合进行血运重建的患者风险状况更差，完全闭塞的情况更常见（59%对37%，p < 0.001），更常使用血管紧张素转换酶抑制剂（ACEI）治疗（65%对55%，p < 0.001），但使用阿司匹林的可能性较小（83%对88%，p < 0.001）。总体而言，他们1年时的病死率更高（7.0%对3.7%，p < 0.001）。通过欧洲五维健康量表（EQ-5D）问卷评估自我感知健康状况时，这些患者在EQ-5D的所有维度上报告的问题更多。此外，在血运重建组中，我们观察到出院至1年随访期间有所改善（效用评分从0.85提高到1.00），而不适合进行血运重建的患者未随时间改善（效用评分仍为0.80）。
在这一大型欧洲CAD患者队列中，与血运重建组中接受血运重建的患者相比，被认为不适合进行血运重建的患者合并症和危险因素更多，自我感知健康状况评分更差。除ACEI和阿司匹林外，两组在药物治疗方面无重大差异。鉴于这些具有临床意义的观察结果，对于症状对标准医疗护理仍无反应的临床脆弱患者，由护士主导的多学科康复团队似乎可以发挥作用。
