急性冠脉综合征患者中的风险与治疗矛盾

［摘要］目的　分析评估不同危险分层的急性冠脉综合征患者治疗对指南的依从性．方法　连续分析了1 001位急性冠脉综合征（acute coronary syndrome，ACS）患者．采用GRACE评分将患者分低危及高危组，对比了不同风险组患者住院期间介入及药物治疗策略．采用敏感性分析评估风险-治疗间的关联，并采用多因素分析鉴别低治疗率的独立预测因素．结果　住院期间高危患者较低危患者更少接受冠脉造影和/或再血管化治疗（P＜0.05），循证药物比例在高危患者中亦较低危患者低（P＜0.05）．高龄、高肌酐水平及高GRACE评分是未给予指南推荐治疗的独立预测因素．结论　高死亡风险急性冠脉综合征患者接受再血管化治疗及指南推荐药物治疗比率反而更低，对高危患者严格遵从指南给予循证治疗可能改善临床预后及医疗质量．

Risk-Treatment Paradox in Acute Coronary Syndrome

［Abstract］Objective This study aimed to assess the adherence to guideline-recommended therapies according to risk stratification in the management of acute coronary syndrome（ACS）. Methods We analyzed 1，001 consecutive patients admitted with ACS. Patients were stratified using the GRACE risk score into low- and high-predicted risk of mortality at 6 months. We evaluated the use of hospital angiography，revascularization，and guideline-recommended medications between high and low-risk patients. Results High-risk compared to low-risk patients were less likely to underwent coronary angiography and/or revascularization during the hospitalization. The use of hospital-initiated pharmacotherapies was also lower in high-risk patients（P＜0.05）. Advanced age，increased creatinine level and higher GRACE score were independent predictors for failure to administer evidence-based therapies. Conclusion Patients with ACS at high risk of mortality were paradoxically less likely to undergo revascularization or receive medications according to guidelines. Better adherence to evidence-based therapies in high-risk patients may improve clinical outcome and quality of health care.