老年心力衰竭的诊治进展

<正>心血管疾病在老年人中患病率高,同时由于人口老龄化及医学技术的发展,使既往死于急性心肌梗死、脑卒中及急性心力衰竭的患者得以存活。美国Framinghan研究结果显示,心力衰竭发病率在50～59岁为1%,50岁以后,每增加10岁,患病率增加1倍;心力衰竭是≥65岁老年人住院的主要原因;老年心力衰竭预后差,5年生存率为25%～50%,低于多数的恶性肿瘤,也是老年人死亡的最常见原因,猝死发生率是正常人的5倍~([1])。截至2015年底,我国≥60岁老年人口已达2.22亿,其中≥80岁者占13.9%,≥80岁人群心力衰竭患病率近     

住院患者静脉血栓栓塞症风险评估

正静脉血栓栓塞症(venous thromboembolism,VTE)包括肺栓塞和深静脉血栓形成,在住院患者中有较高的发生率和病死率。近10%~30%的住院患者可能会发生VTE;急性重症患者中,存在明确VTE的占5%~15%~[1]。一项尸检资料显示,10%的住院患者死亡原因是肺栓塞,这其中有2/3为内科而非手术患者~[2]。因此对于住院患者,早期识别VTE危险因素和积极预防显得极为关键。     

75岁及以上人群经皮冠状动脉介入术后短期死因分析

目的:分析≥75岁老年冠心病患者经皮冠状动脉介入(PCI)治疗后18个月的死亡原因。方法:单中心回顾性研究连续入选2015年1-12月行PCI的≥75岁患者,收集其临床资料,并随访,分析患者死亡原因。结果:451例老年患者行PCI,平均随访17个月,死亡53例。院内及术后6个月的死亡率分别为17%(9例)和50.9%(27例)。院内、6、12、18个月的全因(心血管)死亡率分别为:2%(2%)、5.8%(4.8%)、8.7%(5.5%)、12.1%(7.4%)。累计生存曲线显示,术后160d的全因死亡及心血管死亡的Kaplan-Meier曲线走势趋近。术后6个月最常见的死因为:心力衰竭(13.2%)、猝死(9.4%)和心源性休克(7.5%)。此后,非心血管死亡占57.7%。至随访结束,最常见死因为心力衰竭(24.5%)。结论:≥75岁的冠心病患者PCI术后的最初160d,心血管死亡是主要死因;应注重防治心力衰竭。     

老年慢性心力衰竭患者出现甲状腺功能减退对预后的影响

目的观察老年慢性心力衰竭患者中不同甲状腺功能状态对临床预后和心功能状态的影响。方法回顾性分析2007年1月至2010年12月共4年期间居住于深圳市龙岗社区65岁以上的老年慢性心力衰竭患者的病历档案和就诊记录,并对有基线甲状腺功能检查的患者进行横断面的电话随访调查,随访指标包括全因死亡、心血管死亡、再住院、心力衰竭急性发作和急性心肌梗死等复合终点。结果共入选曾做过基线甲状腺功能检测的心力衰竭患者277例,其中甲状腺功能减退组[促甲状腺激素(TSH)升高或三碘甲状腺氨酸(T3)降低]83例,占30%。随访时间3.8(3～5)年。甲状腺功能减退组有30例发生复合终点事件,而甲状腺功能正常组有48例发生复合终点事件,两组比较差异有统计学意义[35.7%(30/83)vs.24.8%(48/194),P<0.01]。结论老年慢性心力衰竭患者中合并甲状腺功能减退者的预后较差。     

老年稳定性冠心病合并急性下呼吸道感染近期心血管事件和死亡风险评价

目的探讨老年稳定性冠状动脉粥样硬化性心脏病(冠心病)患者,合并急性下呼吸道感染近期(90 d)心血管事件(CVEs)及全因死亡的发生情况及相关危险因素。方法采用前瞻性队列观察研究方法,连续入选2011年1月至2013年12月在解放军总医院因急性下呼吸道感染(ALRTI)住院的稳定性冠心病(s CAD)老年患者,作为感染组,同期住院的稳定性s CAD患者作为非感染组。随访两组近期阶段的7 d(D7)、30 d(D30)、90 d(D90)发生CVEs及全因死亡情况。结果共有426例老年s CAD患者纳入最终分析。其中,感染组257例,非感染组169例,平均年龄88±5岁。随访阶段的D7、D30、D90期间,整个队列的CVEs发生率分别为7.5%、15.0%和24.6%,全因死亡的发生率分别为0.7%,2.6%和8.7%。感染组与非感染组发病后三个不同阶段的CVEs和全因死亡的发生率比较,CVEs发生率在D7(10.9%vs.2.4%,P=0.001)、D30(20.6%vs.6.5%,P0.001)和D90(31.9%vs.13.6%,P0.001)均明显高于非感染组;全因死亡发生率在D7(1.2%vs.0%,P=0.28)、D30(3.9%vs.0.6%%,P=0.021)和D90(13.2%vs.1.8%,P0.001)阶段也显著高于非感染组。感染组的CVEs多集中在感染后的30 d之内,其中冠脉事件则集中在2周内,非感染组的事件无时间规律。多因素回归分析显示:急性下呼吸道感染(OR=2.162,95%CI:1.023~4.569,P=0.043)、慢性肾脏病(OR=2.086,95%CI:1.085~4.013,P=0.028)、入院时呼吸≥24次/min(OR=1.093,95%CI:1.006~1.187,P=0.036)和入院时心率≥125次/分(OR=1.018,95%CI:1.000~1.037,P=0.045)与90 d CVEs及全因死亡的复合终点风险增加独立相关。发生CVEs的患者,近期死亡率明显高于未发生CVEs者(P=0.004)。结论老年s CAD患者,发生急性下呼吸道感染后,显著增加近期多种心血管事件和全因死亡风险。有效预防和积极治疗下呼吸道感染,有望可能减少老年冠心病患者的心血管事件和死亡。     

骨科老年住院患者死亡情况分析

目的分析骨科老年住院患者的死亡情况。方法对北京军区总医院骨科2011年1月至2015年12月期间老年住院患者死亡病例进行回顾性分析,包括患者一般情况、入院诊断、合并内科疾病及死亡原因等。结果共收集54例死亡患者,男性26例,女性28例,平均年龄82.3岁。57.4%的死亡患者因髋部骨折入院。合并内科疾病最常见的为高血压,占44.4%。同时患有≥3种疾病的患者占48.1%。肺部感染是死亡最常见的原因,占70.3%。结论骨科老年住院死亡患者中以髋部骨折最常见,多数患者通常合并多种内科疾病,肺部感染是死亡的主要原因。     

间歇充气加压治疗预防内科重症患者静脉血栓栓塞症的临床效果分析

目的 分析间歇充气加压治疗预防内科重症患者静脉血栓栓塞症的临床效果。方法 选择2012年2月—2014年2月我院收治的内科重症患者90例,按照住院顺序将患者分为观察组和对照组,各45例。对照组患者术后仅接受常规护理干预,观察组患者在常规护理干预的基础上采用间歇充气加压治疗。治疗结束后记录两组患者术后静脉血流峰速度及平均速度,统计术后静脉血栓栓塞症发生率。结果 术后观察组静脉血流峰速度及平均速度均高于对照组(P<0.05);观察组患者静脉血栓栓塞症发生率为6.7%,低于对照组的24.4%(P<0.05)。结论 间歇充气加压治疗能有效改善内科重症患者肢体静脉血液回流速度,进而预防静脉血栓栓塞症的发生。     

间歇充气加压治疗预防内科重症患者静脉血栓栓塞症的临床效果分析

目的分析间歇充气加压治疗预防内科重症患者静脉血栓栓塞症的临床效果。方法选择2012年2月—2014年2月我院收治的内科重症患者90例,按照住院顺序将患者分为观察组和对照组,各45例。对照组患者术后仅接受常规护理干预,观察组患者在常规护理干预的基础上采用间歇充气加压治疗。治疗结束后记录两组患者术后静脉血流峰速度及平均速度,统计术后静脉血栓栓塞症发生率。结果术后观察组静脉血流峰速度及平均速度均高于对照组(P0.05);观察组患者静脉血栓栓塞症发生率为6.7%,低于对照组的24.4%(P0.05)。结论间歇充气加压治疗能有效改善内科重症患者肢体静脉血液回流速度,进而预防静脉血栓栓塞症的发生。     

冠状动脉介入治疗对75岁及以上非ST段抬高型心肌梗死患者远期预后的影响

目的 探讨PCI对老年(年龄≥75岁)非ST段抬高型心肌梗死(NSTEMI)患者远期预后的影响。方法 回顾性分析2018年5月1日～2020年5月1日泰州市人民医院及苏北人民医院心血管内科住院的老年NSTEMI患者209例,根据医师建议以及患者偏好分为PCI组142例,保守组67例。通过门诊复诊、电话以及住院病历系统随访,中位随访时间730 d。分析全因死亡、心力衰竭再住院发生率。使用Graphpad prism 8.0软件绘制Kaplan-Meier生存曲线。采用Cox风险模型分析PCI对全因死亡、心力衰竭再住院的影响。结果 PCI组吸烟比例明显高于保守组,年龄、肌酐水平明显低于保守组(P<0.05,P<0.01)。PCI组全因病死率、心力衰竭再住院率明显低于保守组(12.7%vs 28.4%,P<0.01;23.9%vs 38.8%,P<0.05)。Kaplan-Meier生存曲线显示,PCI组全因病死率和心力衰竭再住院率明显低于保守组(HR=0.41,95%CI:0.20～0.82,P_{log rank}=0.005;HR=0.54,95...     

二级综合性医院内科住院患者肺栓塞临床分析

目的分析二级综合性医院内科住院患者急性肺栓塞的临床特点,以提高早期诊断和对高危患者预防性治疗的观念。方法对上海浦东新区公利医院2005年1月-2010年1月间22例内科住院肺栓塞患者的临床表现、高危因素、预防性治疗、诊断等进行回顾性分析。结果 22例患者中,存在高危因素占100%,进行预防性治疗2例（9.1%）。临床表现中最常见是呼吸困难15例（68.2%）,晕厥7例（31.8%）;血气分析提示低碳酸血症,PaCO2小于45 mmHg 14例（63.6%）,低氧血症15例（68.2%）;血浆D-二聚体阳性率72.7%。心电图ST-T改变占9例（40.9%）,SIQⅢTⅢ型4例（18.2%）;超声心动图检查右室扩大8例（36.4%）,肺动脉高压12例（54.5%）;下肢静脉彩超示下肢静脉血栓形成6例（27.3%）;CT肺动脉造影确诊8例（36.4%）。结论肺血栓栓塞症（PTE）的漏诊率及病死率高,不少患者由于未能及时正确诊断和恰当治疗而死亡。因此,提高对PTE的诊断意识和诊断水平,增强我国内科VTE高危者的预防性治疗有重要意义。     

The incidence of venous thromboembolism following stroke and its risk factors in eastern China

Few studies have documented the prevalence of venous thromboembolism (VTE) in the Chinese population. We aimed to investigate the incidence of VTE following stroke and to determine the potential risk factors for the onset of VTE in patients of eastern China. A prospective multi-center study was conducted. A total of 1,380 patients with acute stroke received venous duplex ultrasound (VDU) examination on both lower limbs. The National Institutes of Health Stroke Scale (NIHSS), Barthel index (BI), Wells, and modified Rankin scale scores were determined. Among 1,380 cases of acute stroke, 4.49 % (62 cases) had deep venous thrombosis (DVT) and 0.80 % (11 cases) had pulmonary thromboembolism (PTE). In the cases of DVT, 48.4 % had no clinical symptoms. The independent risk factors for the incidence of DVT, following the acute stage of stroke, were an age ≥ 70 years, bed-ridden, a Wells score ≥ 2, an NIHSS score of lower limbs ≥ 3, a low BI score, and an elevated concentration of D: -dimer. Rehabilitative and anti-coagulant therapy prevented the incidence of DVT following stroke. Moreover, an age ≥ 70 years, bed-ridden and having DVT were the independent risk factors for the incidence of PTE among stroke patients during the acute stage. Finally, 1.51 % of the patients had DVT whereas no PTE occurred during the period of the follow-up study. VDU examination is recommended for patients with acute stroke, which may help to diagnose and treat asymptomatic DVT early as well as prevent the subsequent incidence of PTE.     

急性脑卒中患者静脉血栓栓塞症调查及危险因素探讨

<正>静脉血栓栓塞症(venous thromboembolism,VTE)包括深静脉血栓形成(deep venous thrombosis,DVT)和肺血栓栓塞症(pulmonary thromboembolism,PTE)。脑卒中患者是VTE发生的高危人群,如果不给予任何干预措施,30%~40%的脑卒中患者会发生DVT,严重     

The Swiss cohort of elderly patients with venous thromboembolism (SWITCO65+): rationale and methodology

Venous thromboembolism (VTE) is common and has a high impact on morbidity, mortality, and costs of care. Although most of the patients with VTE are aged ≥65 years, there is little data about the medical outcomes in the elderly with VTE. The Swiss Cohort of Elderly Patients with VTE (SWITCO65+) is a prospective multicenter cohort study of in- and outpatients aged ≥65 years with acute VTE from all five Swiss university and four high-volume non-university hospitals. The goal is to examine which clinical and biological factors and processes of care drive short- and long-term medical outcomes, health-related quality of life, and medical resource utilization in elderly patients with acute VTE. The cohort also includes a large biobank with biological material from each participant. From September 2009 to March 2012, 1,863 elderly patients with VTE were screened and 1003 (53.8 %) were enrolled in the cohort. Overall, 51.7 % of patients were aged ≥75 years and 52.7 % were men. By October 16, 2012, after an average follow-up time of 512 days, 799 (79.7 %) patients were still actively participating. SWITCO65+ is a unique opportunity to study short- and long-term outcomes in elderly patients with VTE. The Steering Committee encourages national and international collaborative research projects related to SWITCO65+, including sharing anonymized data and biological samples.     

Pulmonary thromboembolism associated with air travel in Japan.

BACKGROUND: A link between venous thromboembolism (VTE) and air travel has been recently discussed, so the present study aimed to clarify the characteristics of acute pulmonary thromboembolism (PTE) associated with air travel in Japan. METHODS AND RESULTS: The study group comprised 36 patients with acute PTE associated with air travel. Patients' characteristics, clinical risk factors for VTE and coagulation abnormalities were investigated, and compared with a group of PTE not associated with travel. Of the 36 cases, 30 cases were female, 34 were over 40 years of age and all had flown more than 6 h. Two-thirds of all cases did not leave their seats during the flight. Of the patients, 44% had no clinical risk factors for VTE or coagulation abnormalities. Idiopathic PTE (ie, PTE without clinical risk factors or coagulation abnormalities) was significantly more common in the air travel group. CONCLUSION: Acute PTE associated with air travel in Japan is common in elderly women and may occur without any clinical risk factors for VTE or coagulation abnormalities. Remaining seated throughout the flight increases the risk.     

Risk factors for venous thromboembolism in hospitalized patients with acute medical illness: analysis of the MEDENOX Study

BACKGROUND: There is limited information about risk factors for venous thromboembolism (VTE) in acutely ill hospitalized general medical patients. METHODS: An international, randomized, double-masked, placebo-controlled trial (MEDENOX) has previously been conducted in 1102 acutely ill, immobilized general medical patients and has shown the efficacy of using a low-molecular-weight heparin, enoxaparin sodium, in preventing thrombosis. We performed logistic regression analysis to evaluate the independent nature of different types of acute medical illness (heart failure, respiratory failure, infection, rheumatic disorder, and inflammatory bowel disease) and predefined factors (chronic heart and respiratory failure, age, previous VTE, and cancer) as risk factors for VTE. RESULTS: The primary univariate analysis showed that the presence of an acute infectious disease, age older than 75 years, cancer, and a history of VTE were statistically significantly associated with an increased VTE risk. Multiple logistic regression analysis indicated that these factors were independently associated with VTE. CONCLUSIONS: Several independent risk factors for VTE were identified. These findings allow recognition of individuals at increased risk of VTE and will contribute to the formulation of an evidence-based risk assessment model for thromboprophylaxis in hospitalized general medical patients.     

Emerging strategies in the prevention of venous thromboembolism in hospitalized medical patients

Venous thromboembolism (VTE) remains a significant cause of morbidity and mortality in hospitalized patients with acute medical illness. The high prevalence of VTE in this patient population, its clinically silent nature, and associated morbidity and mortality indicate that prophylactic therapy is appropriate in those determined to be at increased risk. Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) have been shown to reduce the incidence of VTE and are the primary therapies used for prophylaxis in these patients. Although both UFH and LMWH have received grade 1A recommendations for the prevention of VTE in at-risk medical patients in the 2004 American College of Chest Physicians consensus conference statements, LMWH has advantages over UFH in its once-daily dosing scheme, reduced incidence of major and minor bleeding events, and reduced incidence of heparin-induced thrombocytopenia. Fondaparinux is a novel antithrombotic agent characterized by specificity for factor Xa and a lack of platelet interaction. A recent clinical trial in hospitalized patients with acute medical illness found that fondaparinux significantly reduced the incidence of both VTE and fatal pulmonary embolism compared with placebo, without increased major bleeding. Despite the availability of effective thromboprophylactic therapies, VTE prophylaxis continues to be underutilized in hospitalized medical patients.     

Double trouble for 2,609 hospitalized medical patients who developed deep vein thrombosis: prophylaxis omitted more often and pulmonary embolism more frequent

BACKGROUND: Hospitalized patients with medical illness are especially susceptible to the development of venous thromboembolism (VTE). METHODS: To improve our understanding of the demographics, comorbidities, risk factors, clinical presentation, prophylaxis, and treatment of hospitalized medical patients with deep vein thrombosis (DVT), we evaluated hospitalized medical patients in a prospective registry of 5,451 consecutive ultrasound-confirmed DVT patients at 183 institutions in the United States. RESULTS: Of those patients who participated in the registry, 2,609 (48%) were hospitalized medical patients. Compared with 1,953 hospitalized nonmedical patients with DVT, medical patients with DVT experienced pulmonary embolism (PE) more often (22.2% vs 15.5%, respectively; p < 0.0001). However, medical patients in whom DVT developed had received VTE prophylaxis far less frequently than nonmedical patients (25.4% vs 53.8%, respectively; p < 0.0001). The underutilization of VTE prophylaxis among hospitalized medical patients extended to both pharmacologic and mechanical modalities. In a multivariable logistic regression analysis of all hospitalized VTE patients, status as a medical patient was negatively associated with receiving prophylaxis (adjusted odds ratio, 0.47; 95% confidence interval, 0.28 to 0.78). CONCLUSIONS: Hospitalized medical patients face "double trouble." First, during hospitalization for a reason other than VTE, VTE prophylaxis is omitted in medical patients more often than in nonmedical patients. Second, when VTE develops as a complication of hospitalization, hospitalized medical patients experience PE more often. Further studies should focus on understanding why prophylaxis is often omitted in hospitalized medical patients and on improving its implementation in this vulnerable population.     

Venous thromboembolism prophylaxis in hospitalized elderly patients： Time to consider a ＇MUST＇ strategy

Venous thromboembolism (VTE) is the commonest cause of preventable death in hospitalized patients. Elderly patients have higher risk of VTE because of the high prevalence of predisposing co-morbidities and acute illnesses. Clinical diagnosis of VTE in the elderly patient is particularly difficult and, as such, adequate VTE prophylaxis is of pivotal importance in reducing the mortality and morbidities of VTE. Omission of VTE prophylaxis is, however, very common despite continuous education. A simple way to overcome this problem is to implement universal VTE prophylaxis for all hospitalized elderly patients instead of selective prophylaxis for some patients only according to individual’s risk of VTE. Although pharmacological VTE prophylaxis is effective for most patients, a high prevalence of renal impairment and drug interactions in the hospitalized elderly patients suggests that a multimodality approach may be more appropriate. Mechanical VTE prophylaxis, including calf and thigh compression devices and/or an inferior vena cava filter, are often underutilized in hospitalized elderly patients who are at high-risk of bleeding and VTE. Because pneumatic compression devices and thigh length stockings are virtually risk free, mechanical VTE prophylaxis may allow early or immediate implementation of VTE prophylaxis for all hospitalized elderly patients, regardless of their bleeding and VTE risk. Although the cost-effectiveness of this Multimodality Universal STat (‘MUST’) VTE prophylaxis approach for hospitalized elderly patients remains uncertain, this strategy appears to offer some advantages over the traditional ‘selective and single-modal’ VTE prophylaxis approach, which often becomes ‘hit or miss’ or not implemented promptly in many hospitalized elderly patients. A large clustered randomized controlled trial is, however, needed to assess whether early, multimodality, universal VTE prophylaxis can improve important clinical outcomes of hospitalized elderly patients.     

Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients. A retrospective multicenter study

ObjectiveTo analyze the incidence of VTE in hospitalized medical patients and prophylaxis applied in accordance with the 8th ACCP guidelines and the National PRETEMED guide for thromboprophylaxis.MethodsDischarge lists were reviewed to select the first consecutive 20 patients, aged ≥ 40 years and admitted ≥ 4 days to the Internal Medicine Departments of 79 Spanish hospitals. Exclusion criteria were: admission for diagnostic procedures, VTE or surgical illness, or care during hospitalization provided by the local investigator.ResultsFrom September 2011 to July 2012, 2845 discharge reports were evaluated and 1623 were considered eligible for the study. Overall 930 (57.3%) patients of this group were at risk of VTE according to the ACCP guidelines, 759 (81.6%) received VTE prophylaxis (mechanical or pharmacological) and 159 (17.1%) had at least one risk factor that might contraindicate anticoagulant use. The proportion of patients at VTE risk according to the ACCP and National PRETEMED guidelines with no risk factors of bleeding that did not receive prophylaxis was 16.3% and 17.2%, respectively. During hospitalization, there were 14 (0.9%) episodes of symptomatic VTE, 12 (86%) of which occurred in patients receiving prophylaxis. VTE rate was 1.3% among patients with VTE risk that received prophylaxis and 3.5% in patients that also had one risk factor that might contraindicate anticoagulant use.ConclusionsIn a setting characterized by high thromboprophylaxis compliance most of the episodes occurred in patients receiving pharmacological prophylaxis. Patients with combined VTE and bleeding risk factors showed the highest rate of both symptomatic VTE and prophylaxis failure.