第一部分摘要

研究背景及意义：冠状动脉粥样硬化性心脏病是影响老年人健康的主要原因之一。老年患者常合并有高血压、糖尿病、血脂异常等多种疾病，并且老年患者体质衰弱、临床表现不典型、脏器功能减退等各种因素均增加冠心病的治疗风险。正因为病情的复杂性，既往研究多忽视老年群体。CAMI研究表明，老年ACS患者早期再灌注治疗尤其直接PCI安全有效，与无再灌注治疗相比显著降低死亡率。目前，老年冠心病患者多支冠脉血管病变行PCI治疗的血运重建程度是否对患者的预后产生影响之类的报道非常少。更缺乏大规模中国老年冠心病患者的相关临床数据。所以本研究的目的是对单中心大样本接受经皮冠状动脉介入治疗的老年冠心病患者的2年长期随访结果进行分析，互相探索讨论血运重建程度对老年冠心病多支病变患者预后的影响，为临床治疗决策提供参考。

目的：比较老年冠心病多支病变患者中不同血运重建策略对远期预后的影响。

方法：连续入选2013年1月至12月中国医学科学院阜外医院1 152例≥60岁多支病变行经皮冠状动脉介入治疗（PCI）患者，按年龄分为60~64岁组（n=465例）、65~69岁组（n=315例）、70~74岁（n=223例）和≥75岁（n=149例）4个年龄组，并排除既往有冠状动脉旁路移植手术病史、冠脉单支病变的患者。研究人群随访2年。研究的主要终点被定义为全因死亡、心肌梗死、再次血运重建、脑卒中和支架内血栓形成。t检验和卡方检验用于比较基线数据。Kaplan-Meier方法用于比较终点事件的发生率。多因素Cox回归分析用于比较完全和不完全血运重建患者的两年预后。

p<0.05被认为有统计学意义。

结果：535例（46.4%）患者接受完全血运重建。完全血运重建患者有9.5%发生主要不良心脑血管事件（MACCE），而不完全血运重建患者中有14.7%发生MACCE。多因素Cox生存分析显示，完全血运重建组MACCE显著低于不完全血运重建组（HR=0.697, 95%CI：0.493~0.986，P=0.041）；亚组分析显示，ACS患者（HR=0.647，95%CI：0.419～0.998，P=0.049）和双支病变患者（HR=0.386，95%CI：0.158~0.946，P=0.037）在完全血运重建中获益更大，稳定性冠心病患者在完全血运重建中并无明显获益（HR=0.774, 95%CI：0.434~1.379，P=0.384）。

结论：完全血运重建是60岁以上老年多支冠脉病变患者长期MACCE发生的独立预测因素，ACS患者行完全血运重建获益更大，稳定性冠心病患者在完全血运重中无获益。

第二部分摘要

目的：比较不同类型急性冠脉综合征（ACS）对60岁以上老年患者行经皮冠状动脉介入（PCI）治疗的远期预后影响。

方法：连续纳入年龄≥60岁的2013年1月至12月在中国医学科学院阜外医院行经皮冠状动脉介入治疗的急性冠脉综合征患者，根据急性冠脉综合征类型分为STEMI和NSTEACS两组，并排除既往有冠状动脉旁路移植（CABG）手术病史的患者。随访两年患者并记录主要心脑血管不良事件（MACCE，包括全因死亡、心原性死亡、心肌梗死、再次血运重建和脑卒中）。用t检验、皮尔森卡方检验等方法进行基线资料间的比较。用倾向性评分匹配方法调整基线资料的不平衡因素。并用Cox回归方法比较主要心脑血管不良事件的独立危险因素。根据年龄、性别、LVEF、eGFR、是否三支病变等进行亚组分析。P<0.05被认为有统计学意义。

结果：STEMI（n=540）和NSTEACS（n=2314）的基本特点、冠状动脉病变及介入治疗情况差异显著。2年随访结果显示，与NSTEACS相比，STEMI患者全因死亡（4.3% vs. 1.6%, p<0.001）、心原性死亡（2.8% vs. 0.8%, p<0.001）和MACCE（16.1% vs. 12.5%, p=0.025）风险显著升高。多因素Cox回归分析显示，STEMI是全因死亡（HR=2.68, 95%CI:1.55-4.63, p<0.001）、心原性死亡（HR=3.08, 95%CI:1.52-6.25, p=0.002）的独立危险因素；而倾向性评分匹配后，两组的主要心脑血管不良事件无显著差异，STEMI也不再是主要心脑血管不良事件的预测因素；而年龄增加、LVEF<40%是全因死亡和心原性死亡的独立危险因素。亚组分析结果显示：老年女性STEMI患者全因死亡风险显著高于男性患者（交互检验p值=0.023）。ACS类型不影响高龄、心功能减低、三支病变及肾功能减低亚组的全因死亡风险。

结论：（1）STEMI患者2年全因死亡、心原性死亡和MACCE风险高于NSTEACS患者；倾向性评分匹配后两组风险均无显著差异；（2）STEMI是全因死亡、心原性死亡和MACCE的独立危险因素；倾向性评分匹配后，STEMI不再是全因死亡、心源性死亡和MACCE的独立危险因素；（3）老年女性STEMI患者的全因死亡风险显著高于男性。（4）高龄增加老年患者的死亡风险，但高龄患者ACS类型与死亡风险不相关。

PART 1

Bacground and significance: Coronary atherosclerotic heart disease is one of the leading bad effects for the elderly. Elderly patients often have many diseases, such as hypertension, diabetes mellitus, and dyslipidemia, and various factors, such as the debilitating body condition, atypical clinical manifestationsm, and reduced organ function of elderly patients, increase the treatment risk of coronary heart disease. Because of the complexity of the condition, previous studies mostly ignored the elderly patients. The CAMI study demonstrated that early reperfusion therapy especially with primary PCI in elderly patients with ACS is safe and effective and significantly reduces mortality compared with no reperfusion therapy group. At present, whether the degree of revascularization by PCI in elderly patients with multivessel coronary artery disease has an impact on th prognosis of patients has rarely been reported. More relevent clinical data of large-scale Chinese elderly patients with CHD are lacking. Therefore, the aim of this study was to investigate the effect of the degree of revascularization on the prognosis of elderly patients with multivessel coronary disease by analyzing the results of 2 year follow up in a single center, large sample of elderly patients with coronary artery disease who underwent PCI, and to provide a reference for clinical treatment decisions. 

Objectives：To compare the effects of different revascularization strategies on long-term prognosis in elderly patients with multi-vessel coronary artery disease. 

Methods：From 2013 January to December, 1152 consecutive patients undergoing any PCI in Fuwai Hospital with multi-vessel coronary artery disease aged 60 and above were evaluated, and excluding patients with a previous history of coronary artery bypass graft surgery, single coronary artery disease patients. A 2 year follow up was taken for the study group patients. The study primary endpoint was defined as: all-cause death, myocardial infarction, revascularization, stroke and stent thrombosis. Comparisons of baseline data were performed using t-tests, Chi square tests, and propensity score mating was used to adjust for imbalances at baseline. The Kaplan-Meier method was used to compare the incidence of end-point events. We grouped according to ages, 60-64 years old group (n=465 cases), 65-69 years old group (n=315 cases), 70-74 years old group(n=223 cases) and ≥75 years old group (n=149 cases). Then used multivariable Cox regression method for survival analysis. The primary endpoints were defined as all-cause death, myocardial infarction, revascularization, stroke, and stent thrombosis. 

Results：535 (46.4%) patients underwent complete revascularization. 9.5% of patients with complete revascularization had major adverse cardiovascular and cerebrovascular events (MACCE), and 14.7% of patients with incomplete revascularization had MACCE events. Multivariate Cox survival analysis showed that MACCE in the complete revascularization group was significantly lower than that in the incomplete revascularization group(HR=0.697, 95%CI 0.493～0.986，P=0.041). Subgroup analysis showed that ACS group(HR=0.647, 95%CI：0.419～0.998，P=0.049) and double-vessel coronary disease group(HR=0.386, 95%CI：0.158～0.946，P=0.037) benefited more from complete revascularization. However, stable coronary heart disease group did not benefit from complete revascularization(HR=0.774, 95%CI：0.434～1.379，P=0.384). 

Conclusions：Complete revascularization in patients with multi-vessel coronary artery disease older than 60 years of age is superior to incomplete revascularization. ACS patients benefit more from complete revascularization. Stable coronary heart disease patients do not benefit from complete revascularization.

PART 2

Objectives： To explore the long-term prognosis factors between different types of elderly patients with acute coronary syndrome(ACS) over 60 years old undergoing percutaneous coronary intervention(PCI).

Methods： All consecutive ACS patients presenting for PCI between January, 2013 and December, 2013 in Fuwai hospital were included. We evaluated 2-year major adverse cardiovascular and cerebrovascular events (MACCE, including all-cause death, cardiac death, myocardial infarction, revascularization and stroke) following PCI. The patients were divided into STEMI and NSTEACS according to ECG type, and patients with previous surgical history of coronary artery bypass grafting (CABG), primary PCI and CABG were excluded. Patients were followed for 2 years, and major cardio cerebrovascular adverse events (MACCE, including all-cause death, cardiac death, myocardial infarction, revascularization, and stroke) were recorded. Comparisons between baseline data were performed by student's t-test and Pearson's chi square test. Propensity score matching was used to adjust for imbalances in baseline data. And the Cox regression method was used to compare the independent risk factors of major cardio cerebrovascular adverse events. Subgroup analyses were performed according to age, gender, LVEF, eGFR, and presence or absence of three vessel disease. P < 0.05 was considered statistically significant.

Results： There were significant differences between STEMI (n = 540) and NSTEACS (n = 2314) in basic characteristics, coronary artery disease and intervention. 2-year follow-up showed that compared with NSTEACS, STEMI patients had significantly higher risk of all-cause death (4.3% vs. 1.6%, p<0.001), cardiac death (2.8% vs. 0.8%, p<0.001) and MACCE (16.1% vs. 12.5%, p=0.025). Multivariate Cox regression analysis showed that STEMI was independent risk factor of all-cause death (HR = 2.68, 95% CI: 1.55-4.63, P < 0.001) and cardiac death (HR = 3.08, 95% CI: 1.52-6.25, P < 0.001). After propensity score matching, there was no significant difference in MACCE events between the two groups. STEMI was no longer a predictor of MACCE events. The increasing of age and LVEF < 40% were independent risk factors for all-cause death and cardiac death. Subgroup analysis showed that the risk of all-cause mortality was significantly higher in older female patients with STEMI than in male patients (p for interaction = 0.023). However, in subgroup of older than 75 years, reduced cardiac function, three vessel disease and reduced renal function, the type of ACS did not affect the risk of all-cause mortality. 

Conclusions：(1) The 2-year risks of all-cause death, cardiac death, and MACCE were higher in patients with STEMI than in patients with NSTEACS; there was no significant difference between the 2 groups after propensity score matching. (2) STEMI was an independent risk factor for all-cause death, cardiac death, and MACCE. After propensity score matching, STEMI was no longer an independent risk factor for all-cause death, cardiac death, and MACCE. (3) The risk of all-cause mortality in elderly women with STEMI is significantly higher than that in men. (4) The increasing of age exacerbates the risk of mortality in elderly patients, but not related to the type of ACS.