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衰弱对住院老年冠心病患者短期预后的影响:前瞻性队列研究

张宁 朱文玲 刘晓红 陈伟 康军仁 朱鸣雷 田然

张宁, 朱文玲, 刘晓红, 陈伟, 康军仁, 朱鸣雷, 田然. 衰弱对住院老年冠心病患者短期预后的影响:前瞻性队列研究[J]. 协和医学杂志, 2021, 12(1): 59-66. doi: 10.12290/xhyxzz.20190150
引用本文: 张宁, 朱文玲, 刘晓红, 陈伟, 康军仁, 朱鸣雷, 田然. 衰弱对住院老年冠心病患者短期预后的影响:前瞻性队列研究[J]. 协和医学杂志, 2021, 12(1): 59-66. doi: 10.12290/xhyxzz.20190150
ZHANG Ning, ZHU Wen-ling, LIU Xiao-hong, CHEN Wei, KANG Jun-ren, ZHU Ming-lei, TIAN Ran. Impact of Frailty on the Short-term Prognosis of Hospitalized Elderly Patients with Coronary Heart Disease:A Prospective Cohort Study[J]. Medical Journal of Peking Union Medical College Hospital, 2021, 12(1): 59-66. doi: 10.12290/xhyxzz.20190150
Citation: ZHANG Ning, ZHU Wen-ling, LIU Xiao-hong, CHEN Wei, KANG Jun-ren, ZHU Ming-lei, TIAN Ran. Impact of Frailty on the Short-term Prognosis of Hospitalized Elderly Patients with Coronary Heart Disease:A Prospective Cohort Study[J]. Medical Journal of Peking Union Medical College Hospital, 2021, 12(1): 59-66. doi: 10.12290/xhyxzz.20190150

衰弱对住院老年冠心病患者短期预后的影响:前瞻性队列研究

doi: 10.12290/xhyxzz.20190150
基金项目: 

中国医学科学院医学与健康科技创新工程 2018-I2M-1-002

详细信息
    通讯作者:

    朱文玲  电话:010-69154063, E-mail:zhuwenling@263.net

  • 中图分类号: R543.3

Impact of Frailty on the Short-term Prognosis of Hospitalized Elderly Patients with Coronary Heart Disease:A Prospective Cohort Study

Funds: 

CAMS Innovation Fund for Medical Sciences 2018-I2M-1-002

More Information
  • 摘要:   目的  探讨衰弱对住院老年冠心病患者短期预后的影响。  方法  前瞻性收集并分析2017年12月至2018年11月在北京协和医院住院治疗的老年冠心病患者临床资料。根据是否合并衰弱,将患者分为衰弱组和非衰弱组。对两组患者随访,终点事件包括非常规就诊、主要不良心脑血管事件(major adverse cardiac and cerebral events,MACCE)、全因死亡。采用多因素Cox回归分析衰弱与冠心病患者预后的关系。绘制两组无MACCE的Kaplan-Meier生存曲线,并采用Log-Rank检验进行比较。  结果  共345例符合纳入和排除标准的老年冠心病患者入选本研究,包括稳定性冠心病250例,急性冠状动脉综合征95例。衰弱组74例(21.4%),其中轻度衰弱38例、中度衰弱36例,非衰弱组271例(78.6%)。中位随访时间351(300, 394)d,失访3例。与非衰弱组比较,衰弱组非常规就诊发生率(36.1%比21.5%)、全因死亡率(11.1%比4.1%)均升高(P均<0.05),MACCE发生率(9.7%比4.8%)无显著差异(P>0.05)。多因素Cox回归分析结果显示,轻度和中度衰弱是稳定性冠心病患者全因死亡的危险因素(HR=4.169,95% CI:1.055~16.474,P=0.042),对其非常规就诊(HR=1.704,95% CI:0.947~3.066,P=0.075)、MACCE(HR=1.268,95% CI:0.331~4.863,P=0.729)无显著影响。在急性冠状动脉综合征患者中,轻度和中度衰弱对其非常规就诊(HR=1.159,95% CI:0.342~3.924,P=0.812)、MACCE(HR=0.822,95% CI:0.092~7.369,P=0.861)及全因死亡(HR=1.445,95% CI:0.210~9.964,P=0.708)均无显著影响。Kaplan-Meier生存曲线显示,衰弱组和非衰弱组患者的无MACCE生存曲线无显著差异(P>0.05)。  结论  住院老年冠心病患者合并轻中度衰弱的比率较高,其可能增加稳定性冠心病患者近期死亡风险。
    作者贡献:张宁、康军仁、田然负责资料整理、统计分析,并撰写论文; 朱文玲、刘晓红、陈伟、朱鸣雷负责研究设计,指导论文写作。
    利益冲突  无
  • 图  1  衰弱组与非衰弱组住院老年冠心病患者的无MACCE的Kaplan-Meier生存曲线图

    表  1  衰弱与非衰弱住院老年冠心病患者的一般临床资料比较

    指标 患者总数(n=345) 衰弱组(n=74) 非衰弱组(n=271) P
    年龄[M(P25, P75),岁] 74(69, 79) 80(75, 84) 72(68, 77) <0.001
    男性[n(%)] 208(60.3) 34(45.9) 174(64.2) 0.004
    BMI(x±s,kg/m2) 24.93±4.416 24.75±4.435 25.06±3.125 0.576
    跌倒史[n(%)] 92(26.7) 29(39.2) 63(23.2) 0.006
    尿失禁[n(%)] 76(22.0) 31(41.9) 45(16.6) <0.001
    MNA-SF评分[M(P25, P75),分] 12(11, 13) 11(10, 13) 12(11, 14) <0.001
    急性冠状动脉综合征[n(%)] 95(27.5) 14(18.9) 81(29.9) 0.031
    接受PCI或CABG治疗[n(%)] 279(80.9) 59(79.7) 220(81.2) 0.273
    合并2型糖尿病[n(%)] 144(41.7) 40(54.1) 104(38.4) 0.015
    Charlson共病指数[M(P25, P75)] 1(0, 2) 2(1, 3) 1(0, 2) <0.001
    长期用药种类[M(P25, P75),种] 7(5, 9) 8(6, 10) 6(5, 9) 0.001
    ADL评分[M(P25, P75),分] 6(5, 6) 5(4, 5) 6(6, 6) <0.001
    IADL评分[M(P25, P75),分] 8(7, 8) 5(3, 6) 8(8, 8) <0.001
    手握力[M(P25, P75),kg] 26.9(20.1, 33.4) 18.35(15.45, 25.98) 28.2(22.4, 34.9) <0.001
    步速[M(P25, P75),m/s] 0.86(0.67, 1.01) 0.56(0.42, 0.71) 0.9(0.80, 1.05) <0.001
    不能完成平衡测试[n(%)] 85(24.6) 50(67.6) 35(12.9) <0.001
    白蛋白[M(P25, P75),g/L] 40(38, 43) 40(36, 42.25) 40(38, 43) 0.025
    前白蛋白[M(P25, P75),mg/L] 225.86±49.01 210.86±57.59 229.95±45.67 0.010
    糖化血红蛋白[M(P25, P75),%] 6.1(5.7, 7.1) 6.4(5.78, 7.6) 6.1(5.7, 6.9) 0.016
    尿酸[M(P25, P75),mmol/L] 340(283.5, 405) 362.5(313.75, 457.25) 336(280, 389) 0.003
    超敏C反应蛋白[M(P25, P75),mg/L] 1.2(0.51, 2.75) 2.27(0.74, 4.92) 1.03(0.48, 2.30) <0.001
    甘油三酯[M(P25, P75),mmol/L] 1.16(0.87, 1.59) 1.19(0.90, 1.64) 1.15(0.85, 1.58) 0.299
    低密度脂蛋白胆固醇[M(P25, P75),mmol/L] 1.95(1.59, 2.4) 1.87(1.54, 2.37) 1.97(1.60, 2.40) 0.513
    BMI:体质量指数; MNA-SF:简易营养评估量表; PCI:经皮冠状动脉介入术; CABG:冠状动脉旁路移植术; ADL:日常生活活动能力; IADL:工具性日常生活活动能力
    下载: 导出CSV

    表  2  两组患者随访期间非常规就诊、主要不良心脑血管事件、全因死亡情况比较[n(%)]

    指标 患者总数(n=342) 衰弱组(n=72) 非衰弱组(n=270) P
    非常规就诊 84(24.6) 26(36.1) 58(21.5) 0.010
      感染性疾病 17(20.2) 3(11.5) 14(24.1) 0.715
      心绞痛/急性心肌梗死 19(22.6) 9(34.6) 10(17.2) 0.006
      心律失常 5 (6.0) 3(11.5) 2(3.4) 0.031
      充血性心力衰竭 2(2.4) 1(3.8) 1(1.7) 0.314
      卒中 4(4.8) 1(3.8) 3(5.2) 0.846
      急性肠梗阻 3(3.6) 2(7.7) 1(1.7) 0.052
      跌倒致骨折 6(7.1) 2(7.7) 4(6.9) 0.000
      其他原因 28(33.3) 5(19.2) 23(39.7) 0.891
    主要不良心脑血管事件 20(5.8) 7(9.7) 13(4.8) 0.196
      心血管病死亡 11(55.0) 3(42.9) 8(61.5) 0.607
      卒中 4(20.0) 1(14.3) 3(23.1) 0.846
      急性心肌梗死 3(15.0) 2(28.6) 1(7.7) 0.052
      新发或加重的心力衰竭 2(10.0) 1(14.3) 1(7.7) 0.314
    全因死亡 19(5.6) 8(11.1) 11(4.1) 0.043
      心血管病死亡 11(57.9) 3(37.5) 8(72.7) 0.607
      重症肺炎继发多脏器衰竭 4(21.1) 3(37.5) 1(9.1) 0.008
      肿瘤 1(5.3) 1(12.5) 0(0) 0.052
      糖尿病酮症酸中毒 1(5.3) 1(12.5) 0(0) 0.052
      死亡原因不详 2(10.5) 0(0) 2(18.2) 0.464
    衰弱组失访2例,非衰弱组失访1例
    下载: 导出CSV

    表  3  衰弱对住院老年冠心病患者预后影响的多因素Cox回归分析

    指标 因素 β SE P HR 95% CI
    全因死亡
      稳定性冠心病 性别 1.291 0.791 0.103 3.635 0.771~17.132
    年龄 0.021 0.052 0.685 1.021 0.923~1.131
    Charlson共病指数 0.054 0.184 0.769 1.056 0.736~1.514
    衰弱 1.428 0.701 0.042 4.169 1.055~16.474
      急性冠状动脉综合征 性别 -0.422 0.880 0.632 0.656 0.117~3.684
    年龄 -0.082 0.065 0.209 0.921 0.811~1.047
    Charlson共病指数 0.587 0.335 0.079 1.799 0.933~3.468
    衰弱 0.368 0.985 0.708 1.445 0.210~9.964
    非常规就诊
      稳定性冠心病 性别 -0.414 0.256 0.105 0.661 0.400~1.091
    年龄 -0.010 0.022 0.644 0.990 0.949~1.033
    Charlson共病指数 0.059 0.085 0.490 1.060 0.898~1.253
    衰弱 5.330 0.300 0.075 1.704 0.947~3.066
      急性冠状动脉综合征 性别 0.403 0.484 0.405 1.496 0.580~3.862
    年龄 0.000 0.037 0.994 1.000 0.931~1.074
    Charlson共病指数 0.178 0.217 0.414 1.194 0.780~1.828
    衰弱 0.148 0.623 0.812 1.159 0.342~3.924
    主要不良心脑血管事件
      稳定性冠心病 性别 0.453 0.620 0.465 1.573 0.467~5.300
    年龄 0.067 0.049 0.168 1.070 0.972~1.177
    Charlson共病指数 0.201 0.170 0.238 1.222 0.876~1.707
    衰弱 0.238 0.686 0.729 1.268 0.331~4.863
      急性冠状动脉综合征 性别 -0.156 0.857 0.856 0.856 0.160~4.586
    年龄 0.041 0.065 0.529 1.042 0.917~1.185
    Charlson共病指数 0.389 0.438 0.374 1.476 0.625~3.484
    衰弱 -0.195 1.119 0.861 0.822 0.092~7.369
    下载: 导出CSV
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  • 收稿日期:  2019-07-29
  • 录用日期:  2020-03-24
  • 刊出日期:  2021-01-30

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