Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, Maryland; Division of Cardiology, Johns Hopkins University, Baltimore, Maryland.
Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
J Am Coll Cardiol. 2019 Apr 23;73(15):1890-1900. doi: 10.1016/j.jacc.2019.01.055.
Older adults ≥75 years of age carry an increased risk of mortality after ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock.
The purpose of this study was to examine the use of percutaneous coronary intervention (PCI) in older adults with STEMI and shock and its influence on in-hospital mortality.
We used a large publicly available all-payer inpatient health care database sponsored by the Agency for Healthcare Research and Quality between 1999 and 2013. The primary outcome was in-hospital mortality. The influence of PCI on in-hospital mortality was assessed by quintiles of propensity score (PS).
Of the 317,728 encounters with STEMI and shock in the United States, 111,901 (35%) were adults age ≥75 years. Of these, 53% were women and 83% were Caucasians. The median number of chronic conditions was 8 (interquartile range: 6 to 10). The diagnosis of STEMI and cardiogenic shock in older patients decreased significantly over time (proportion of older adults with STEMI and shock: 1999: 42% vs. 2013: 29%). Concomitantly, the rate of PCI utilization in older adults increased (1999: 27% vs. 2013: 56%, p < 0.001), with declining in-hospital mortality rates (1999: 64% vs. 2013: 46%; p < 0.001). Utilizing PS matching methods, PCI was associated with a lower risk of in-hospital mortality across quintiles of propensity score (Mantel-Haenszel odds ratio: 0.48; 95% confidence interval [CI]: 0.45 to 0.51). This reduction in hospital mortality risk was seen across the 4 different U.S. census bureau regions (adjusted odds ratio: Northeast: 0.41; 95% CI: 0.36 to 0.47; Midwest: 0.49; 95% CI: 0.42 to 0.57; South: 0.51; 95% CI: 0.46 to 0.56; West: 0.46; 95% CI: 0.41 to 0.53).
This large and contemporary analysis shows that utilization of PCI in older adults with STEMI and cardiogenic shock is increasing and paralleled by a substantial reduction in mortality. Although clinical judgment is critical, older adults should not be excluded from early revascularization based on age in the absence of absolute contraindications.
年龄≥75 岁的 ST 段抬高型心肌梗死（STEMI）合并心原性休克的患者死亡率较高。
本研究旨在研究经皮冠状动脉介入治疗（PCI）在 STEMI 合并休克的老年患者中的应用及其对院内死亡率的影响。
我们使用了 1999 年至 2013 年期间由美国医疗保健研究与质量局赞助的一个大型公开的全支付住院医疗保健数据库。主要结局是院内死亡率。通过倾向评分（PS）五分位数评估 PCI 对院内死亡率的影响。
在美国 317728 例 STEMI 合并休克的患者中，有 111901 例（35%）为年龄≥75 岁的成年人。其中，53%为女性，83%为白种人。中位慢性疾病数为 8 种（四分位间距：6 至 10）。老年患者的 STEMI 和心原性休克的诊断在过去的时间里明显减少（年龄≥75 岁的 STEMI 和休克患者的比例：1999 年：42% vs. 2013 年：29%）。同时，老年患者中 PCI 的使用率增加（1999 年：27% vs. 2013 年：56%，p<0.001），院内死亡率也随之下降（1999 年：64% vs. 2013 年：46%；p<0.001）。利用 PS 匹配方法，在倾向评分的五分位数中，PCI 与较低的院内死亡率风险相关（Mantel-Haenszel 优势比：0.48；95%置信区间[CI]：0.45 至 0.51）。这种降低院内死亡率的风险在 4 个不同的美国人口普查局区域都有体现（调整后的优势比：东北部：0.41；95%CI：0.36 至 0.47；中西部：0.49；95%CI：0.42 至 0.57；南部：0.51；95%CI：0.46 至 0.56；西部：0.46；95%CI：0.41 至 0.53）。
这项大型的当代分析表明，在 STEMI 合并心原性休克的老年患者中，PCI 的应用正在增加，同时死亡率也大幅降低。尽管临床判断至关重要，但在没有绝对禁忌症的情况下，不应该因为年龄而将老年患者排除在早期血运重建之外。
