老年急性冠状动脉综合征患者经皮冠状动脉介入治疗住院期间合并上消化道出血的危险因素分析  

The prognosis of elderly patients with acute coronary syndromes combined with upper gastrointestinal hemorrhage during hospitalization following percutaneous coronary intervention

作　　者：傅亮[1] 史济华[1] 罗庆锋[1] 陈浩[2] Fu Liang;Shi Jihua;Luo Qingfeng;Chen Hao(Department of Gastroenterology,Beijing Hospital,National Center of Gerontology,Institute of Geriatric Medicine,Chinese Academy of Medical Sciences,Beijing 100730,China;Department of Cardiology,Beijing Hospital,National Center of Gerontology,Institute of Geriatric Medicine,Chinese Academy of Medical Sciences tBeijing 100730,China)

机构地区：[1]北京医院消化内科国家老年医学中心中国医学科学院老年医学研究院,100730 [2]北京医院心内科国家老年医学中心中国医学科学院老年医学研究院,100730

出　　处：《中华老年医学杂志》2021年第7期863-867,共5页Chinese Journal of Geriatrics

摘　　要：目的评估住院期间老年急性冠状动脉综合征(ACS)合并上消化道出血患者随访2年发生出血事件和缺血事件的风险,分析再发出血的相关因素.方法回顾性病例对照研究,连续纳入2015年1月1日至2018年12月31日在北京医院行经皮冠状动脉介入治疗(PCI)老年ACS患者,根据住院期间是否发生上消化道出血分为出血组(51例)和对照组(2834例),比较两组患者随访出院后2年不良心血管事件(MACE)和再发出血情况,分析影响有临床意义出血(BARC 2型、3型和5型)的相关因素.结果出血组患者中位出血时间为PCI术后3.3d,主要原因为胃十二指肠溃疡(43例,84.3%).与对照组比较,出血组患者体质指数低,更多合并心房颤动、慢性肾脏病、消化性溃疡病史,多表现为ST段抬高型和非ST段抬高型心肌梗死,替格瑞洛、口服抗凝药使用率高,而质子泵抑制剂使用率低,且冠状动脉病变≥2支、GRACE评分、替罗非班和抽吸导管使用率较高(均P<0.05),完全血运重建率低于对照组(P<0.05).随访(22.4±1.5)个月,与对照组比较,出血组的MACE(19例比698例,37.3%比24.6%,HR=1.655,95%CI:1.026~2.673,χ^(2)=4.513,P=0.026)和再发有临床意义出血(10例比283例,19.6%比10.0%,HR=2.242,95%CI:1.209~4.157,χ^(2)=5.083,P=0.024)的发生率高于对照组.Logistic多因素回归分析结果显示:年龄≥70岁(RR=1.813,95%CI:1.021~3.219)、慢性肾脏病≥2期(RR=1.623,95%CI:1.196~2.202)、消化性溃疡病史(RR=2.152,95%CI:1.156~4.006)、替格瑞洛(RR=2.014,95%CI:1.253~3.237)、口服抗凝剂(RR=1.352,95%CI:1.032~1.771)为影响有临床意义出血的独立危险因素,而质子泵抑制剂为其保护因素(RR=0.573,95%CI:0.345~0.952).结论老年ACS患者住院期间上消化道出血病史可增加随访2年再发有临床意义出血和MACE发生风险.高龄、慢性肾脏病≥2期、消化性溃疡病史、术前应用替格瑞洛和口服抗凝剂是其独立危险因素,质子泵抑制剂可降低再发出血风险Objective To assess the future risk o£bleeding events and ischemic events in a two-year follow-up of elderly patients with acute coronary syndromes(ACS)who experienced upper gastrointestinal bleeding during hospitalization,and to analyze the related factors for the recurrence.Methods This was a retrospective case-control study.Elderly ACS patients who underwent percutaneous coronary intervention(PCI)in Beijing Hospital from January 1,2015 to December 31,2018 were continuously included.According to whether upper gastrointestinal bleeding occurred during hospitalization,they were divided into the bleeding group(n=51)and the control group(n=2834).Baseline data were compared between the two groups.The incidence of major adverse cardiovascular events(MACE)and the recurrence of bleeding defined by the Bleeding Academic Research Consortium(BARC)consensus classification were monitored during the 2-year followed-up.Related factors for clinically significant bleeding events(BARC type 2,3 and 5)were analyzed.Results The median bleeding time in the bleeding group was 3.3 days after PCI,and the main cause was gastroduodenal ulcer(43 cases,84.3%).Compared with the control group,patients in the bleeding group had a lower body mass index,a higher proportion of patients with a history of atrial fibrillation,chronic kidney ddisease,peptic ulcer,ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction,higher usage rates of ticagrelor and oral anticoagulants,a lower usage rate of proton pump inhibitor(PPI),a higher proportion of patients with coronary artery disease involving≥2 vessels,higher GRACE scores)higher usage rates of tirofiban and aspiration catheters and a lower complete revascularization rate(P<0.05).Patients were followed up for(22.4±1.5)months.Compared with the control group,the incidence of MACE(19 cases or 37.3%vs.698 cases or 24.6%,HR=1.655,95%CI:1.026-2.673,χ^(2)=4.513,P<0.05)and the recurrence of clinically significant bleeding(BARC type 2,3 and 5)(10 cases or 19.6%vs.283

关 键 词：胃肠道出血 急性冠状动脉综合征 危险因素 

分 类 号：R541.4[医药卫生—心血管疾病] R573.2[医药卫生—内科学]