Erne Paul, Radovanovic Dragana, Seifert Burkhardt, Bertel Osmund, Urban Philip
AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland Department of Cardiology, Clinic St. Anna, Lucerne and University Hospital Zurich, Zurich, Switzerland.
AMIS Plus Data Center, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
BMJ Open. 2015 Mar 2;5(3):e006218. doi: 10.1136/bmjopen-2014-006218.
Compliance with guidelines is increasingly used to benchmark the quality of hospital care, however, very little is known on patients admitted with acute coronary syndromes (ACS) and treated palliatively. This study aimed to evaluate the baseline characteristics and outcomes of these patients.
Prospective cohort study.
Eighty-two Swiss hospitals enrolled patients from 1997 to 2014.
All patients with ACS enrolled in the AMIS Plus registry (n=45,091) were analysed according to three treatment groups: palliative treatment, defined as use of aspirin and analgesics only and no reperfusion; conservative treatment, defined as any treatment including antithrombotics or anticoagulants, heparins, P2Y12 inhibitors, GPIIb/IIIa but no pharmacological or mechanical reperfusion; and reperfusion treatment (thrombolysis and/or percutaneous coronary intervention during initial hospitalisation). The primary outcome measure was in-hospital mortality and the secondary measure was 1-year mortality.
Of the patients, 1485 (3.3%) were palliatively treated, 11,119 (24.7%) were conservatively treated and 32,487 (72.0%) underwent reperfusion therapy. In 1997, 6% of all patients were treated palliatively and this continuously decreased to 2% in 2013. Baseline characteristics of palliative patients differed in comparison with conservatively treated and reperfusion patients in age, gender and comorbidities (all p<0.001). These patients had more in-hospital complications such as postadmission onset of cardiogenic shock (15.6% vs 5.2%; p<0.001), stroke (1.8% vs 0.8%; p=0.001) and a higher in-hospital mortality (25.8% vs 5.6%; p<0.001).The subgroup of patients followed 1 year after discharge (n=8316) had a higher rate of reinfarction (9.2% vs 3.4%; p=0.003) and mortality (14.0% vs 3.5%; p<0.001).
Patients with ACS treated palliatively were older, sicker, with more heart failure at admission and very high in-hospital mortality. While refraining from more active therapy may often constitute the most humane and appropriate approach, we think it is important to also evaluate these patients and include them in registries and outcome evaluations.
ClinicalTrials.gov Identifier: NCT01 305 785.
遵循指南越来越多地被用于衡量医院护理质量，然而，对于因急性冠状动脉综合征（ACS）入院并接受姑息治疗的患者，我们了解得非常少。本研究旨在评估这些患者的基线特征和预后。
前瞻性队列研究。
1997年至2014年，82家瑞士医院招募患者。
根据三个治疗组对纳入AMI S Plus注册研究（n = 45,091）的所有ACS患者进行分析：姑息治疗组，定义为仅使用阿司匹林和镇痛药且未进行再灌注治疗；保守治疗组，定义为包括抗栓药或抗凝药、肝素、P2Y12抑制剂、糖蛋白IIb/IIIa抑制剂但未进行药物或机械再灌注的任何治疗；再灌注治疗组（住院初期进行溶栓和/或经皮冠状动脉介入治疗）。主要结局指标为住院死亡率，次要指标为1年死亡率。
患者中，1485例（3.3%）接受了姑息治疗，11,119例（24.7%）接受了保守治疗，32,487例（72.0%）接受了再灌注治疗。1997年，所有患者中有6%接受了姑息治疗，到2013年这一比例持续降至2%。姑息治疗患者的基线特征在年龄、性别和合并症方面与保守治疗和再灌注治疗患者存在差异（均p<0.001）。这些患者有更多的住院并发症，如入院后发生的心源性休克（15.6%对5.2%；p<0.001）、中风（1.8%对0.8%；p = 0.001）以及更高的住院死亡率（25.8%对5.6%；p<0.001）。出院后随访1年的患者亚组（n = 8316）有更高的再梗死率（9.2%对3.4%；p = 0.003）和死亡率（14.0%对3.5%；p<0.001）。
接受姑息治疗的ACS患者年龄更大、病情更重，入院时心力衰竭更多，住院死亡率非常高。虽然避免采取更积极的治疗通常可能是最人道和合适的方法，但我们认为对这些患者进行评估并将他们纳入注册研究和预后评估也很重要。
ClinicalTrials.gov标识符：NCT01 305 785。
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