基于指南的 STEMI 贫血患者治疗：实践模式与院内死亡率的影响：来自 NCDR 的回顾性分析。
Guidelines-based treatment of anaemic STEMI patients: practice patterns and effects on in-hospital mortality: a retrospective analysis from the NCDR.
机构信息
Wake Forest University Health Sciences, Winston-Salem, USA.
出版信息
Eur Heart J Acute Cardiovasc Care. 2013 Mar;2(1):35-43. doi: 10.1177/2048872612471216.
BACKGROUND
Anaemia is associated with an increased risk for morbidity and mortality in ST-elevation myocardial infarction (STEMI) patients. While several physiological mechanisms have been proposed to explain this association, decreased receipt of guidelines-based care may also contribute. We examined the relationship between admission haemoglobin (Hgb) level, receipt of ACC/AHA guidelines-based treatments, and in-hospital outcomes among STEMI patients. We also evaluated whether administration of these treatments modified the association between anaemia and in-hospital mortality in this group.
METHODS AND RESULTS
We analysed data from 92,686 patients diagnosed with STEMI included in the NCDR ACTION Registry-GWTG database from January 2007 to March 2011. Patients were stratified by initial Hgb value: 83.1% (n=77,035) were classified as non-anaemic (Hgb >13.0 g/dl for men, >12.0 g/dl for women), 11.6% (n=10,710) as mildly anaemic (11.1-13.0 g/dl for men, 11.1-12.0 g/dl for women), 4.4% (n=4059) as moderately anaemic (9.1-11.0 g/dl), and 1.0% (n=882) as severely anaemic (<9.0 g/dl). Anaemia was associated with a significantly increased prevalence of other baseline comorbidities and decreased odds of receiving several class I recommended pharmacological treatments (heparin, beta-blockers, and angiotensin-converting enzyme inhibitors, p<0.01). The overall use of reperfusion therapy (fibrinolytic therapy and/or percutaneous coronary intervention) was also lower in anaemic vs. non-anaemic patients (p<0.01). Anaemia was associated higher in-hospital mortality risk, which remained significant after adjustment for use of guidelines-recommended therapies and interventions (p<0.01).
CONCLUSIONS
In a national sample of STEMI patients, anaemia on presentation was associated with decreased receipt of ACC/AHA guidelines-based care and higher in-hospital mortality. However, the higher mortality rates could not be fully explained by differences in in-hospital treatment.
背景
贫血与 ST 段抬高型心肌梗死（STEMI）患者的发病率和死亡率增加相关。虽然已经提出了几种生理机制来解释这种关联，但指南推荐的治疗方法的接受程度降低也可能是原因之一。我们研究了 STEMI 患者入院时血红蛋白（Hgb）水平、接受 ACC/AHA 指南推荐治疗方法与院内结局之间的关系。我们还评估了在该组患者中，这些治疗方法的应用是否改变了贫血与院内死亡率之间的关系。
方法和结果
我们分析了 2007 年 1 月至 2011 年 3 月期间 NCDR ACTION 注册-GWTG 数据库中诊断为 STEMI 的 92686 例患者的数据。根据初始 Hgb 值对患者进行分层：83.1%（n=77035）为非贫血（男性 Hgb>13.0 g/dl，女性 Hgb>12.0 g/dl），11.6%（n=10710）为轻度贫血（男性 Hgb 11.1-13.0 g/dl，女性 Hgb 11.1-12.0 g/dl），4.4%（n=4059）为中度贫血（男性 Hgb 9.1-11.0 g/dl，女性 Hgb 9.1-11.0 g/dl），1.0%（n=882）为重度贫血（<9.0 g/dl）。贫血与其他基线合并症的患病率显著增加以及接受几种 I 类推荐药物治疗（肝素、β受体阻滞剂和血管紧张素转换酶抑制剂）的可能性降低相关（p<0.01）。与非贫血患者相比，接受再灌注治疗（溶栓治疗和/或经皮冠状动脉介入治疗）的贫血患者也较少（p<0.01）。在调整了指南推荐的治疗方法和干预措施的使用后，贫血与院内死亡率风险增加相关，且该相关性仍具有统计学意义（p<0.01）。
结论
在 STEMI 患者的全国样本中，入院时的贫血与接受 ACC/AHA 指南推荐治疗方法的比例降低以及更高的院内死亡率相关。然而，较高的死亡率并不能完全由院内治疗的差异来解释。
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