Schuster S, Koch A, Schiele R, Burczyk U, Wagner S, Zahn R, Rustige J, Limbourg P, Gülker H, Senges J
Department of Cardiology, St. Antonius Hospital, Kleve, Germany.
Cardiology. 1998 Dec;90(3):212-9. doi: 10.1159/000006846.
An assessment of individual risk factors may identify a subgroup of postinfarction patients at low risk, i.e. patients appropriate for early discharge. Using a large unselected population of the national registry, 'The 60-Minutes Myocardial Infarction Project', we (1) attempted to provide a retrospective analysis of clinical factors and in-hospital mortality in a population living on the 6th hospital day following admission to define a low-risk patient group with a residual in-hospital mortality of less than 1% eligible for early discharge, and (2) to analyze the current impact of risk stratification based on these clinical factors on the length of hospitalization. The study group consisted of 12,045 survivors on the 6th day after admission out of 14,980 patients of the registry with proven Q-wave myocardial infarction. Risk modeling was performed with multiple logistic regression.
A total of 873 patients (7.3%) died after day 6 in hospital. The most important prognostic factors were cardiopulmonary resuscitation prior to admission (odds ratio, OR: 7.2, confidence interval, CI: 5.11-10.22), thrombolysis complicated by severe bleedings (OR: 6.2, CI: 1.2-31. 2) and age >70 years (OR 4.7, CI 3.51-6.39). The other more significant independent predictors of increased mortality were end-stage renal disease, age between 56 and 70 years, systolic blood pressure <95 mm Hg on admission, history of trauma </=2 months, cancer and left-bundle-branch block. Summarizing these nine groups of patients with the strongest association to in-hospital mortality, we defined a high-risk group comprising 79% of the AMI patients with a residual in-hospital mortality of 8.8%. On the other hand, by excluding these nine high-risk patient groups, a low-risk group of 21% of all AMI patients seems to be appropriate for early discharge (residual in-hospital mortality = 1.07%). However, in the current practice, there was no difference regarding the median length of hospital stay between the two risk groups. The low-risk patients were hospitalized 20 days compared to 22 days in the high-risk patients.
Using a simple logistic regression model, which considers clinical factors of the early hospital phase, one fifth of the infarction patients can be stratified to be at low risk, and might be eligible for early hospital discharge. Currently, an individual risk stratification has no impact on the length of hospital stay in Germany.
对个体风险因素进行评估可能会识别出梗死后期低风险患者亚组，即适合早期出院的患者。利用国家登记处大量未经筛选的人群，“60分钟心肌梗死项目”，我们（1）试图对入院后第6个住院日的人群中的临床因素和住院死亡率进行回顾性分析，以确定住院死亡率低于1%、适合早期出院的低风险患者组，（2）分析基于这些临床因素的风险分层对住院时间的当前影响。研究组由登记处14980例经证实为Q波心肌梗死患者中入院后第6天的12045例幸存者组成。采用多元逻辑回归进行风险建模。
共有873例患者（7.3%）在住院第6天后死亡。最重要的预后因素是入院前的心肺复苏（比值比，OR：7.2，置信区间，CI：5.11 - 10.22）、并发严重出血的溶栓治疗（OR：6.2，CI：1.2 - 31.2）和年龄>70岁（OR 4.7，CI 3.51 - 6.39）。其他更显著的死亡率增加的独立预测因素是终末期肾病、年龄在56至70岁之间、入院时收缩压<95 mmHg、创伤史≤2个月、癌症和左束支传导阻滞。总结这九组与住院死亡率关联最强的患者，我们定义了一个高风险组，包括79%的急性心肌梗死患者，住院死亡率为8.8%。另一方面，通过排除这九个高风险患者组，似乎21%的所有急性心肌梗死患者组成的低风险组适合早期出院（住院死亡率=1.07%）。然而，在当前实践中，两个风险组之间的住院中位时间没有差异。低风险患者住院20天，高风险患者住院22天。
使用一个考虑早期住院阶段临床因素的简单逻辑回归模型，五分之一的梗死患者可被分层为低风险，可能适合早期出院。目前，在德国，个体风险分层对住院时间没有影响。
