Krishnan Udhay, Brejt Josef A, Schulman-Marcus Joshua, Swaminathan Rajesh V, Feldman Dmitriy N, Goyal Parag, Wong S Chiu, Minutello Robert M, Bergman Geoffrey, Singh Harsimran, Kim Luke K
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, NY.
Division of Cardiology, Weill Cornell Medical College, New York Presbyterian Hospital, NY.
Am J Med. 2018 Jan;131(1):100.e9-100.e20. doi: 10.1016/j.amjmed.2017.06.040. Epub 2017 Aug 8.
Despite advances in ST-segment elevation myocardial infarction (STEMI) systems of care over the last decade, studies have shown no improvement in risk-adjusted mortality. It has been hypothesized that the population presenting to the catheterization laboratory has become sicker over time, in ways not accurately captured by current mortality models. The objective of this study was to examine changes in the clinical characteristics and in-hospital case fatality rate of the STEMI population treated with early percutaneous coronary intervention (PCI).
We conducted a retrospective analysis of a nationwide inpatient database for the period 2004-2012. All patients with a diagnosis of STEMI who underwent PCI within 24 hours of admission were identified. The primary outcome was in-hospital mortality.
From 2004 to 2012 there was a consistent increase in unadjusted in-hospital mortality (3.9% in 2004 and 4.7% in 2012, odds ratio 1.03; 95% confidence interval 1.01-1.04). During this time there was an increase in the proportion of patients with ≥3 Elixhauser comorbidities (14.8% vs 29.0%, P < .001). Intubation or cardiac arrest on presentation increased from 3.2% to 7.8% (P < .001) and had a strong, independent association with mortality. After multivariable adjustment using a model that incorporated the increasing trend in intubation/cardiac arrest, mortality decreased over time (odds ratio 0.95; 95% confidence interval 0.94-0.97).
During a period that corresponds to improvement in STEMI quality of care, risk-adjusted in-hospital mortality declined. An increase in comorbidities, and more importantly in the proportion of patients presenting with extreme-risk features, may explain the overall "null" effect regarding in-hospital mortality despite improvements in timely reperfusion.
尽管在过去十年中ST段抬高型心肌梗死（STEMI）护理系统取得了进展，但研究表明风险调整后的死亡率并无改善。据推测，随着时间的推移，前往导管实验室就诊的人群病情变得更重，而当前的死亡率模型并未准确反映这些情况。本研究的目的是检查接受早期经皮冠状动脉介入治疗（PCI）的STEMI患者的临床特征和院内病死率的变化。
我们对2004年至2012年期间的全国住院患者数据库进行了回顾性分析。确定了所有在入院后24小时内接受PCI治疗的STEMI诊断患者。主要结局是院内死亡率。
从2004年到2012年，未经调整的院内死亡率持续上升（2004年为3.9%，2012年为4.7%，比值比1.03；95%置信区间1.01-1.04）。在此期间，患有≥3种埃利克斯豪泽合并症的患者比例有所增加（14.8%对29.0%，P<0.001）。就诊时插管或心脏骤停的比例从3.2%增加到7.8%（P<0.001），并且与死亡率有强烈的独立关联。在使用纳入插管/心脏骤停增加趋势的模型进行多变量调整后，死亡率随时间下降（比值比0.95；95%置信区间0.94-0.97）。
在STEMI护理质量有所改善的时期，风险调整后的院内死亡率下降。合并症的增加，更重要的是具有极高风险特征的患者比例的增加，可能解释了尽管及时再灌注有所改善，但院内死亡率总体上呈现“无”变化的原因。
