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Impact of Frailty on the Short-term Prognosis of Hospitalized Elderly Patients with Coronary Heart Disease:A Prospective Cohort Study
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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。 Abstract:Objective To analyze the effect of frailty on the short-term prognosis of hospitalized older patients with coronary heart disease. Methods The clinical data were prospectively collected and analyzed in elderly patients with coronary heart disease that were hospitalized in Peking Union Medical College Hospital from December 2017 to November 2018. According to whether they were combined with frailty, the patients were divided into frailty group and non-frailty group.All the patients were followed up, and endpoint events included unscheduled return visits, major adverse cardiac and cerebral events (MACCE), and death from all causes. Multivariate Cox regression was used to analyze the relationship between frailty and the prognosis of patients with coronary heart disease. The Kaplan-Meier method and Log-Rank test were used to compare the MACCE-free survival curves between patients with and without frailty. Results A total of 345 elderly patients with coronary heart disease who met the inclusion and exclusion criteria were selected for this study, including 250 cases of stable coronary heart disease and 95 cases of acute coronary syndrome. There were 74 cases (21.4%) in the frailty group including 38 cases of mild frailty and 36 cases of moderate frailty, and 271 cases (78.6%) in the non-frailty group. The median follow-up time was 351(300, 394) days, and 3 cases were lost to follow-up. Compared with the non-frailty group, the incidence of unscheduled return visits (36.1% vs. 21.5%) and all-cause mortality (11.1% vs. 4.1%) in the frailty group increased (all P < 0.05), and there is no significant difference in the incidence of MACCE (9.7 % vs. 4.8%) between the two groups (P > 0.05). The results of multivariate Cox regression analysis showed that mild and moderate frailty were risk factors for all causes of death in patients with stable coronary heart disease (HR=4.169, 95% CI: 1.055-16.474, P=0.042), but had no significant effect on unscheduled return visits (HR=1.704, 95% CI: 0.947-3.066, P=0.075) and MACCE (HR=1.268, 95% CI: 0.331-4.863, P=0.729). In patients with acute coronary syndrome, mild and moderate frailty had no significant effect on unscheduled return visits (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) and death from all causes (HR=1.445, 95% CI: 0.210-9.964, P=0.708). The Kaplan-Meier curve showed that there was no significant in the MACCE-free survival curve between the two groups (P > 0.05). Conclusions The prevalence of mild and moderate frailty in hospitalized older patients with coronary heart disease is high, which may increase the risk of short-term mortality for those with stable coronary heart disease. -
Key words:
- elderly /
- coronary heart disease /
- frailty /
- prognosis
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 -
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值 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 
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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值 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
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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值 SE值 P值 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
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