Balzi Daniela, Barchielli Alessandro, Buiatti Eva, Franceschini Caterina, Lavecchia Rinaldo, Monami Matteo, Santoro Giovanni Maria, Carrabba Nazario, Margheri Massimo, Olivotto Iacopo, Gensini Gian Franco, Marchionni Niccolò
Epidemiology Unit, Local Health Unit 10, Florence, Italy.
Am Heart J. 2006 May;151(5):1094-1100. doi: 10.1016/j.ahj.2005.06.037.
Chronic comorbidity is a prognostic determinant in ST-segment elevation myocardial infarction (STEMI). This study was aimed at determining to what extent this effect is independent or derives from adoption of different therapeutic strategies.
Seven hundred forty patients with STEMI hospitalized within 12 hours of symptom onset were enrolled in a population-based registry, in a health district comprising 1 teaching hospital with and 5 district hospitals without percutaneous coronary intervention (PCI) facilities. Three categories of increasing chronic comorbidity score (CS-1, n = 259; CS-2, n = 235; CS-3, n = 246) were identified from age-adjusted associations of comorbidities with 1-year survival.
Higher CS was associated with lower direct admission or transferal rates to hospital with PCI. Coronary reperfusion therapy (PCI in 91.5% of 470 cases) was adopted less frequently (P < .001) in CS-3 (41.9%) than CS-2 (69.4%) or CS-1 (78.8%). Compared with conservative therapy (n = 270), reperfusion therapy reduced 1-year mortality in the whole series not significantly (P = .816) in CS-1 but significantly in CS-2 (P = .012) and CS-3 (P = .001). This trend persisted after adjusting for age, Killip class, and acute myocardial infarction location (hazard ratio [HR] = 0.63 [95% CI 0.14-2.80], HR = 0.62 [95% CI 0.31-1.25], and HR = 0.47 [95% CI 0.26-0.86] in CS-1, CS-2, and CS-3, respectively). By hypothesizing an extension of coronary reperfusion therapy utilization rate in CS-2 and CS-3 to that in CS-1, from 21 (crude analysis) to 20 (adjusted analysis) deaths were classified as potentially avoidable.
Increased mortality in patients with chronic comorbidity and STEMI derives, at least in part, from underutilization of coronary reperfusion therapy, and might be reduced with a more aggressive therapeutic approach.
慢性共病是ST段抬高型心肌梗死（STEMI）的一个预后决定因素。本研究旨在确定这种影响在多大程度上是独立的，或者是源于采用了不同的治疗策略。
在一个卫生区纳入了740例症状发作后12小时内住院的STEMI患者，该卫生区包括1家有经皮冠状动脉介入治疗（PCI）设施的教学医院和5家没有PCI设施的区级医院。根据共病与1年生存率的年龄校正关联，确定了三类慢性共病评分增加的患者（CS-1，n = 259；CS-2，n = 235；CS-3，n = 246）。
较高的共病评分与较低的直接入院或转至有PCI的医院的比率相关。CS-3组（41.9%）采用冠状动脉再灌注治疗（470例中的91.5%接受PCI）的频率低于CS-2组（69.4%）或CS-1组（78.8%）（P <.001）。与保守治疗（n = 270）相比，再灌注治疗在CS-1组中未显著降低整个系列的1年死亡率（P =.816），但在CS-2组中显著降低（P =.012），在CS-3组中显著降低（P =.001）。在调整年龄、Killip分级和急性心肌梗死部位后，这种趋势仍然存在（CS-1、CS-2和CS-3组的风险比[HR]分别为0.63 [95% CI 0.14 - 2.80]、0.62 [95% CI 0.31 - 1.25]和0.47 [95% CI 0.26 - 0.86]）。假设将CS-2和CS-3组的冠状动脉再灌注治疗利用率提高到CS-1组的水平，从21例（粗分析）到20例（校正分析）死亡被归类为可能可避免的。
慢性共病合并STEMI患者死亡率增加至少部分源于冠状动脉再灌注治疗的利用不足，采用更积极的治疗方法可能会降低死亡率。
