De Luca Giuseppe, van't Hof Arnoud W J, Huber Kurt, Gibson C Michael, Bellandi Francesco, Arntz Hans-Richard, Maioli Mauro, Noc Marko, Zorman Simona, Secco Gioel Gabrio, Zeymer Uwe, Gabriel H Mesquita, Emre Ayse, Cutlip Donald, Rakowski Tomasz, Gyongyosi Maryann, Dudek Dariusz
Division of Cardiology, "Maggiore della Carità" Hospital, Eastern Piedmont University, Novara, Italy,
Heart Vessels. 2014 Jan;29(1):15-20. doi: 10.1007/s00380-013-0323-4. Epub 2013 Mar 14.
Despite mechanical reperfusion, the outcome is still unsatisfactory in elderly patients with ST-segment elevation myocardial infarction (STEMI). The vast majority of studies have been conducted without extensive use of glycoprotein (Gp) IIb-IIIa inhibitors, which have been associated with improved perfusion and survival. Thus the aim of the current study was to evaluate the impact of age on the angiographic and clinical outcome patients with STEMI undergoing primary angioplasty with Gp IIb-IIIa inhibitors. Our population is represented by a total of 1,662 patients undergoing primary angioplasty for STEMI included in 11 randomized trials comparing early versus late administration of Gp IIb-IIIa inhibitors. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. Follow-up data were collected between 30 days and 1 year after primary angioplasty. A total of 231 (13.9 %) patients were older than 75 years. Elderly patients showed a larger prevalence of female gender, hypertension, and diabetes, more advanced Killip class at presentation and longer time to treatment, but a smaller prevalence of smoking. All patients were treated with GP IIb-IIIa inhibitors. Elderly patients showed a significantly impaired postprocedural thrombolysis in myocardial infarction (TIMI) flow (TIMI 0-2: 17.7 vs 10.3 %, P = 0.002) and myocardial perfusion (myocardial blush grade 0-1: 38.3 vs 26.5 %, P = 0.001), and higher prevalence of distal embolization (19.2 vs 9.8 %, P < 0.001), whereas no difference was observed in terms of ST-segment resolution. At follow-up, elderly patients showed a significantly higher mortality (3.2 vs 11.0 %, hazard ratio (HR) (95 % confidence interval (CI)) = 3.78 (2.31-6.16), P < 0.001), which was confirmed after adjustment for baseline confounding factors (HR (95 % CI) = 5.01 (2.63-9.55), P < 0.0001). This study showed that among patients with STEMI undergoing primary angioplasty, advanced age is an independent predictor of mortality after primary angioplasty. Higher rates of distal embolization and poor myocardial perfusion, in addition to the worse risk profile, contribute toward explaining the impact of aging on mortality.
尽管进行了机械再灌注治疗，但老年ST段抬高型心肌梗死（STEMI）患者的治疗效果仍不尽人意。绝大多数研究并未广泛使用糖蛋白（Gp）IIb-IIIa抑制剂，而该类抑制剂与改善灌注及提高生存率相关。因此，本研究旨在评估年龄对接受Gp IIb-IIIa抑制剂治疗的STEMI患者血管造影及临床结局的影响。我们的研究对象包括1662例因STEMI接受直接血管成形术的患者，这些患者来自11项比较Gp IIb-IIIa抑制剂早期与晚期给药的随机试验。通过心肌 blush分级和ST段分辨率评估心肌灌注情况。在直接血管成形术后30天至1年收集随访数据。共有231例（13.9%）患者年龄超过75岁。老年患者中女性、高血压和糖尿病的患病率更高，就诊时Killip分级更严重，治疗时间更长，但吸烟率较低。所有患者均接受了Gp IIb-IIIa抑制剂治疗。老年患者术后心肌梗死溶栓（TIMI）血流明显受损（TIMI 0 - 2级：17.7%对10.3%，P = 0.002），心肌灌注也较差（心肌 blush分级0 - 1级：38.3%对26.5%，P = 0.001），远端栓塞的发生率更高（19.2%对9.8%，P < 0.001），而在ST段分辨率方面未观察到差异。随访时，老年患者的死亡率显著更高（3.2%对11.0%，风险比（HR）（95%置信区间（CI））= 3.78（2.31 - 6.16），P < 0.001），在对基线混杂因素进行校正后这一结果得到证实（HR（95% CI）= 5.01（2.63 - 9.55），P < 0.0001）。本研究表明，在接受直接血管成形术的STEMI患者中，高龄是直接血管成形术后死亡率的独立预测因素。除了风险状况较差外，更高的远端栓塞率和较差的心肌灌注也有助于解释衰老对死亡率的影响。
