中国ST段抬高急性冠状动脉综合征诊疗现况调查

目的 了解目前我国ST段抬高急性冠状动脉综合征(ACS)临床治疗及二级预防措施的实施状况.方法 在中国31个省市自治区选择33家三级医院和32家二级医院,每家医院选择住院患者50例,共计3323例,其中1304例(39.2%)为ST段抬高的ACS.采用问卷回顾形式收集住院患者临床治疗及二级预防信息.结果 (1)三级医院在人员及设备方面均优于二级医院,仅33.3%的二级医院拥有心脏导管检查设备;患者的年龄、性别、既往医疗史及心血管病危险因素水平在不同级别的医院间差异无统计学意义.(2)50.3%(656/1304)的ST段抬高ACS患者接受了再灌注治疗.三级医院再灌注治疗率高于二级医院[57.9%(380/668)比42.3%(267/636),P=0.000],二级医院的溶栓治疗率[37.4%(237/636)]高于三级医院[14.5%(97/668)];患者从症状出现到就诊间的平均时间(中位数)为240 min,从就诊到溶栓的时间(中位数)为60 min,从就诊到直接经皮冠状动脉介入治疗(PCI)的时间(中位数)为110 min.(3)阿司匹林、血管紧张素转换酶抑制剂(ACEI)及β受体阻滞剂在不同医院中应用均较为普遍(P0.05),二级医院极化液和中药的使用率(分别为37.6%和70.0%)高于三级医院(分别为30.2%和44.0%,P=0.013),三级医院使用低分子肝素(80.5%)、血小板膜糖蛋白Ⅲa/Ⅱb受体拮抗剂(7.6%)、氯吡格雷(73.8%)及他汀药物(82.8%)高于二级医院(分别为72.3%,0.3%,25.8%和69.3%,P<0.01).相似的使用趋势同样存在于患者的出院带药中;二级医院住院期间主要事件的发生率以及死亡或再发心肌梗死联合事件发生率均高于三级医院.(4)多因素分析结果 表明,年龄、高血压、糖尿病、再灌注治疗、使用阿司匹林、β受体阻滞剂及ACEI和(或)血管紧张素受体阻滞剂与住院期间病死率有独立的联系.结论 在ST段抬高ACS的临床治疗阶段及二级预防用药方面各级医院均存在很大的提升空间,应加大力度推动指南在心血管病临床实践中的实施.

Current clinical practice patterns and outcome for acute coronary syndromes in China: results of BRIG project

Objective To analyze current clinical management patterns and outcome of inpatients with ST segment elevation acute coronary syndromes (ACS) in China. Methods Totally 1304 in-patients with ST segment elevation ACS from 64 hospitals across China were recruited and a standard questionnaire was used to get information of the patients including demographic, treatments and in-hospital outcomes. Results (1) There were no significant differences in baseline characteristics between the patients from tertiary hospitals and that from the secondary hospitals. (2) Reperfusion therapy was applied more often in tertiary hospitals (57.9%) than in secondary hospitals (42.3%). Thrombolysis was more often used in secondary hospitals than that in tertiary hospitals (37.4% vs. 14.5%). The median time from pain onset to hospital was 240 min, the median time from admission to reperfusion was 60 min for thromhalysis and 110 min for PCI. (3) Statias and glycoprotein Ⅱb/Ⅲa antagonists were given more frequently in tertiary hospitals. (4) Major in-hospital events and death rates were significantly higher in secondary hospitals than in tertiary hospitals. Multivariate logistic regression analysis showed that age ≥ 75 years, hypertension, diabetes, reperfusion, aspirin, β-blocker and ACE/ARB inhibitor use were associated independently with in-hospital mortality. Conclusions There is a big gap between guidelines and current management of ST segment elevation ACS in China, especially in secondary hospitals.