80 岁以上急性非 ST 段抬高型心肌梗死患者介入治疗与保守治疗临床疗效对比

背景与目的：急性非 ST 段抬高心肌梗死（non-ST-elevation myocardial infarction，NSTEMI）是80 岁以上老人入院常见的原因，但目前相关的临床研究很少，对于高龄NSTEMI 患者最优治疗方式也一直备受争议。本研究为了探索80 岁以上NSTEMI高龄患者是否可以从介入治疗获益。

方法：本研究连续回顾收集 2014 年 9 月至 2017 年 8 月来我院治疗的 80 岁以上NSTEMI 患者，最终纳入符合条件的 190 例患者。根据患者接受的治疗方式，所有患者被分为保守治疗组（n=69）和介入治疗组（n=121）。收集两组患者临床基线资料如年龄、性别、身体质量指数 (Body Mass Index，BMI)、既往史、用药情况等，并进行对比分析。对患者进行随访，记录患者预后和死亡情况。建立多因素分析模型，分析高龄NSTEMI 患者介入治疗方式的影响因素。以患者死亡为主要研究终点，再次入院和随访期间再发心绞痛、心力衰竭、心房颤动、急性心肌梗死和脑梗死不良心血管事件为次要研究终点，建立 Cox 回归模型，分析不同治疗策略和死亡的相关性。Kaplan-Meier 曲线比较分析两组高龄患者的生存率情况。考虑到混杂因素的

影响，使用逆概率加权法（Inverse Probability of Treatment Weighting，IPTW）进行对变量校正分析，进一步比较两组患者结局事件情况。

结果：随访期间发现介入治疗组死亡率为 17.4%，保守治疗组死亡率为 42.0%，介入治疗组死亡率远远低于保守治疗组，两组差异具有统计学意义（P = 0.0002）。介入治疗组患者再入院率为 14.9％，保守治疗组的再入院率 7.2％，介入治疗组再入院率高于保守治疗组，然而差异却不具有统计学意义（P =0.121）。两组间再发心绞痛、心肌梗死、心力衰竭、心房颤动、脑梗死发生率均不具有统计学意义

（P >0.05）。保守治疗组患者利尿剂使用率 41(59.4%)，显著高于介入治疗组33(27.3%)，两组差异具有统计学意义（P <0.0001）。多因素分析结果表明，肌酐水平（OR = 1.01，95％CI：0.10–1.03，P = 0.05）和利尿剂的使用（OR = 3.65，95％CI：1.56-8.53，P = 0.003）与高龄NSTEMI 患者是否行介入治疗密切相关。通过构建4 个多元 Cox 回归模型，结果表明，保守治疗组死亡率分别是介入治疗组的 3.45倍（95％CI：1.77–6.75，P = 0.0003；不进行校正因素）；3.02 倍（95％CI：1.52-6.01，P = 0.0017；校正性别与年龄），2.93 倍（95％CI：1. 46–5.86，P = 0.0024；校正

年龄、性别、高血压、糖尿病、高脂血症与贫血因素），2.47 倍（95％CI：1.20-5.07，P = 0.0137；校正年龄、性别、高血压、糖尿病、高脂血症、贫血、心肌梗死史、CABG 史，III 度房室传导阻滞和肾功能不全等因素）。IPTW 调整后，结果表明保守治疗组患者死亡发生率是介入治疗组的 2.71 倍；而两组间再发心绞痛、新发心力

衰竭、新发心房颤动、新发急性心肌梗死、新发脑梗死和再次入院等次要终点的发生率都没有达到统计学差异。与接受介入治疗的患者相比，接受保守治疗的患者，随着时间的延长，存活率显著降低（P <0.001）。

结论：本研究表明，与保守治疗策略相比，介入治疗策略能明显降低 80 岁以上NSTEMI 患者死亡率，但两组之间再次入院和再发心绞痛、心肌梗死、心力衰竭、心房颤动、脑梗死等不良心血管事件发生率差异不具有统计学意义。介入治疗策略更适合中国的NSTEMI 高龄老年患者。

Invasive versus conservative strategy in consecutive patients aged 80 years or older

with non-ST-segment elevation myocardial infarction in China

Background and objectives: Non-ST-segment elevation myocardial infarction(NSTEMI) are common causes of admission to the elderly aged 80 years or older.

Currently, the optimal treatment of elderly patients with NSTEMI has been controversial.And few studies were reported related to the elderly patients. The study aims to investigate whether the very elderly patients with NSTEMI will benefit from an invasive strategy versus a conservative strategy.

Methods: 190 consecutive patients aged 80 years or older with NSTEMI were finally recruited in the retrospective study from September 2014 to August 2017. According to the patient acceptable treatment strategy, 69 patients received conservative strategy and 121 patients received invasive strategy. Clinical baseline data such as patient age, gender,

Body Mass Index (BMI), previous history, medication status, and other data were collected. Patients were followed up and the prognosis and mortality were recorded. The primary outcome was death. Readmission or angina pectoris, myocardial infarction, heart failure, atrial fibrillation, cerebral infarction during follow-up were secondary study outcome. Multivariate analysis models were established to analyze the influential factors of invasive strategy. Multivariate Cox regression models were used to assess the statistical association between strategies and mortality. The survival probability was further analyzed. Considering the influence of confounding factors, Inverse Probability of Treatment Weighting (IPTW) was used and the outcomes of the two groups were further compared.

Results: During follow-up, the primary outcome occurred in 17.4% patients in the invasive group and in 42.0% patients in the conservative group (P = 0.0002). The readmission rate in the invasive group (14.9%) was higher than that in the conservative group (7.2%), while the different was not statistically significant (P = 0.121). The incidence of angina pectoris, myocardial infarction, heart failure, atrial fibrillation,

cerebral infarction was not statistically significant between the two groups (P> 0.05). The diuretic use rate of patients in the conservative group was 59.4% (41/69), which was significantly higher than that of 27.3% (33/121) in the invasive group. The difference between the two groups was statistically significant (P <0.0001). Multivariate analysis demonstrated that creatinine level (OR = 1.01, 95% CI: 0.10–1.03, P = 0.05) and use of

diuretic (OR = 3.65, 95% CI: 1.56–8.53, P = 0.003) were closely correlated with invasive strategy in elderly patients with NSTEMI. Hazard ratios (HRs) for multivariate Cox

regression models were 3.45 (95% CI: 1.77–6.75, P = 0.0003), 3.02 (95% CI: 1.52–6.01, P = 0.0017; adjusted for confounding factors, age, gender), 2.93 (95% CI: 1. 46–5.86, P = 0.0024; adjusted for confounding factors, age, gender, hypertension, diabetes, hyperlipemia, anemia) and 2.47 (95% CI: 1.20–5.07, P = 0.0137; adjusted for confounding factors, age, gender, hypertension, diabetes, hyperlipemia, anemia, previous

myocardial infarction, previous coronary artery bypass graft (CABG), III degree atrioventricular block and renal insufficiency). After IPTW adjustment, the results also

showed that the death rate of patients in the conservative group was 2.71 times than that of the invasive group. However, the incidences of secondary outcomes such as recurrent angina, heart failure, atrial fibrillation, acute myocardial infarction,cerebral infarction and re-admission were still not statistically significant. Compared with the patients received invasive strategy, the conservative group had remarkably reduced survival probability with time since treatment (P < 0.001).

Conclusions: An invasive strategy is superior to a conservative strategy in reducing mortality of patients aged 80 years or older with NSTEMI. However, the differences of the incidence of angina pectoris, myocardial infarction, heart failure, atrial fibrillation, cerebral infarction and the readmission rate during follow-up between conservative group and invasive group were both not statistically significant. Our results suggest that an invasive strategy is more suitable for the very elderly patients with NSTEMI in China.