Mantovani Francesca, Campo Gianluca, Guerri Elisa, Manca Francesco, Calzolari Massimo, Tortorella Giovanni, D'Amore Sergio Musto, Pignatelli Gianluca, Guiducci Vincenzo, Navazio Alessandro
Cardiology Unit, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy.
Cardiology Unit, Cardiovascular Institute, Translational Medicine Department, University of Ferrara, 44121 Ferrara, Italy.
J Clin Med. 2022 Oct 20;11(20):6179. doi: 10.3390/jcm11206179.
Background: Contemporary guidelines advocate for early invasive strategy with coronary angiography in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). Still, the impact of an invasive strategy in older patients remains controversial and may be challenging in spoke hospitals with no catheterization laboratory (cath-lab) facility. Purpose: The purpose of this study was to analyse the characteristics and outcomes of patients ≥80 years old with NSTE-ACS admitted to spoke hospitals. Methods: Observational−retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals of our cardiology network, where a service strategy (same-day transfer between a spoke hospital and a hub centre with a cath-lab facility in order to perform coronary angiography) was available. Patients were followed up for 1 year after the admission date. Results: From 2013 to 2017, 639 patients were admitted for NSTE-ACS; of these, 181 (28%) were ≥80 years old (median 84, IQR 82−89) and represented the study cohort. When the invasive strategy was chosen (in 105 patients, or 58%), 98 patients (93%) were initially managed with a service strategy, whereas the remainder of the patients were transferred from the spoke hospital to the hub centre where they completed their hospital stay. Of the patients managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 10 (10%). These patients remained in the hub centre, while the rest of the patients were sent back to the spoke hospitals, with no adverse events observed during the back transfer. The median time to access the cath-lab was 50 h (IQR 25−87), with 73 patients (70%) reaching the invasive procedure <72 h from hospital admission. A conservative strategy was associated with: older age, known CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD and atrial fibrillation (all p < 0.03). At the 1-year follow-up, the overall survival was significantly higher in patients treated with an invasive strategy compared to patients managed conservatively (94% ± 2 vs. 54% ± 6, p < 0.001; HR: 10.4 [4.7−27.5] p < 0.001), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0−4.0]; p < 0.001). Conclusions: An invasive strategy may confer a survival benefit in the elderly with NSTE-ACS. The same-day transfer between a spoke hospital and a hub centre with a cath-lab facility (service strategy) is safe and may grant access to the cath-lab in a timely fashion, even for the elderly.
当代指南提倡对非ST段抬高型急性冠状动脉综合征（NSTE-ACS）患者采用早期侵入性策略进行冠状动脉造影。然而，侵入性策略对老年患者的影响仍存在争议，并且在没有导管实验室（cath-lab）设施的基层医院实施可能具有挑战性。目的：本研究旨在分析入住基层医院的80岁及以上NSTE-ACS患者的特征和结局。方法：对我们心脏病学网络中两家基层医院收治的所有连续NSTE-ACS患者进行观察性回顾性研究，这两家医院采用了一种服务策略（基层医院与设有cath-lab设施的中心医院之间进行当日转运，以便进行冠状动脉造影）。患者在入院日期后随访1年。结果：2013年至2017年，639例患者因NSTE-ACS入院；其中，181例（28%）年龄≥80岁（中位数84岁，四分位间距82-89岁），构成研究队列。当选择侵入性策略时（105例患者，即58%），98例患者（93%）最初采用服务策略进行管理，其余患者从基层医院转至中心医院并在那里完成住院治疗。在采用服务策略管理的患者中，10例（10%）在侵入性手术后需要改变策略。这些患者留在中心医院，其余患者被送回基层医院，转回过程中未观察到不良事件。进入cath-lab的中位时间为50小时（四分位间距25-87小时），73例患者（70%）在入院后<72小时接受了侵入性手术。保守策略与以下因素相关：年龄较大、已知冠心病、出现左心室功能障碍症状的临床表现、较低的射血分数、肾衰竭、较高的GRACE评分、外周动脉疾病和心房颤动（所有p<0.03）。在1年随访时，与保守治疗的患者相比，采用侵入性策略治疗的患者总体生存率显著更高（94%±2 vs. 54%±6，p<0.001；风险比：10.4[4.7-27.5]，p<0.001），即使在调整年龄、血清肌酐、已知既往冠心病和射血分数后（调整后风险比：2.0[1.0-4.0]；p<0.001）。结论：侵入性策略可能使老年NSTE-ACS患者获得生存益处。基层医院与设有cath-lab设施的中心医院之间的当日转运（服务策略）是安全的，即使对老年人也可能及时进入cath-lab。
