Krumholz H M, Forman D E, Kuntz R E, Baim D S, Wei J Y
Charles A. Dana Research Institute, Boston, Massachusetts.
Ann Intern Med. 1993 Dec 1;119(11):1084-90. doi: 10.7326/0003-4819-119-11-199312010-00005.
To determine the outcome of very elderly patients who had coronary revascularization during hospitalization for an acute myocardial infarction.
Retrospective cohort study.
Community-based tertiary-care teaching hospital.
A total of 1215 consecutive patients 80 years and older were hospitalized with a myocardial infarction between 1985 and 1990. The study sample included all 93 patients (8%) who had cardiac catheterization before discharge and had not been excluded from study because of the following: severe valvular disease, absence of significant coronary disease, or death before a decision about revascularization could be made.
Survival, quality of life, and functional status at least 1 year after discharge.
After catheterization, 41 patients had angioplasty, 18 had coronary artery bypass surgery, and 34 did not have revascularization. Among the patients alive at discharge, those who had revascularization had a high likelihood of achieving a good or excellent quality of life (angioplasty, 86% [31 of 36]; surgery, 89% [16 of 18]; medical therapy, 44% [11 of 25]) and of being able to care for themselves (angioplasty, 89% [32 of 36], surgery, 89% [16 of 18], medical therapy, 52% [13 of 25]). Mortality rates at 1 year were 24% (95% CI, 15% to 47%) for the angioplasty group, 6% (CI, 0% to 27%) for the surgery group, and 44% (CI, 27% to 62%) for the medical therapy group. In a Cox proportional hazards model that adjusted for clinical, demographic, hemodynamic, and anatomic differences between the groups, the performance of coronary revascularization was associated with increased survival (hazard ratio, 0.42; CI, 0.18 to 0.98).
A small percentage of very elderly patients with complicated acute myocardial infarctions, selected by their physicians for invasive cardiovascular procedures, can tolerate these procedures, avoid serious complications, return to independent living, and have excellent probability of survival. Although our results suggest that coronary revascularization may have benefited these patients, the study design did not permit definite conclusions, and future studies are needed to resolve this important question.
确定在急性心肌梗死住院期间接受冠状动脉血运重建的高龄患者的预后。
回顾性队列研究。
以社区为基础的三级医疗教学医院。
1985年至1990年间，共有1215例80岁及以上的连续心肌梗死患者住院。研究样本包括所有93例（8%）在出院前接受心导管检查且未因以下原因被排除在研究之外的患者：严重瓣膜疾病、无明显冠状动脉疾病或在做出血运重建决定前死亡。
出院后至少1年的生存率、生活质量和功能状态。
心导管检查后，41例患者接受了血管成形术，18例接受了冠状动脉搭桥手术，34例未进行血运重建。在出院时存活的患者中，接受血运重建的患者获得良好或优秀生活质量的可能性较高（血管成形术，86%[36例中的31例]；手术，89%[18例中的16例]；药物治疗，44%[25例中的11例]），并且能够自理（血管成形术，89%[36例中的32例]，手术，89%[18例中的16例]，药物治疗，52%[25例中的13例]）。血管成形术组1年死亡率为24%（95%CI，15%至47%），手术组为6%（CI，0%至27%），药物治疗组为44%（CI，27%至62%）。在一个对组间临床、人口统计学、血流动力学和解剖学差异进行调整的Cox比例风险模型中，冠状动脉血运重建与生存率提高相关（风险比，0.42；CI，0.18至0.98）。
一小部分因复杂急性心肌梗死而被医生选择进行侵入性心血管手术的高龄患者能够耐受这些手术，避免严重并发症，恢复独立生活，并且有很高的生存概率。尽管我们的结果表明冠状动脉血运重建可能使这些患者受益，但研究设计不允许得出明确结论，需要未来的研究来解决这个重要问题。
