昆明地区急性冠脉综合征流行现况及临床死亡病例的调查分析

发布时间：2018-04-28 00:11

本文选题：急性冠脉综合征 + 急性心肌梗死　；参考：《昆明医科大学》2017年硕士论文

【摘要】：[目的]描述和评价2013年下半年至2016年上半年昆明地区急性冠脉综合征(ACS)患者住院情况、临床特征、院内死亡率、死因构成和救治策略的差异及变化趋势,以此反映区域范围内疾病的流行现况、救治水平,总结死亡病例特点和区域医疗救治经验,从而为临床医生及时识别具有高死亡可能性的病患、作出更具特异性和精准性的医疗决策、避免死亡结局及进一步降低ACS患者的院内死亡率提供资料和依据。[方法]征得昆明地区10所具有冠心病介入诊疗资质医院的相关科室、研究生教学管理部门及病案管理部门的同意,通过各医院的病案信息管理系统检索并收集2013年07月01日至2016年06月30日期间出院诊断为ACS的患者的基础信息,并对其中从心脏内科出院、住院期间发生临床死亡且符合准入标准的死亡患者的病历资料进行回顾性调查分析。通过填写《昆明地区多中心急性冠脉综合征死亡病例临床研究病例报告表》,收集病例的社会人口学信息、临床特征、救治策略和终点死亡事件发生情况;采用Epidata 3.1软件,建立ACS死亡病例信息数据库,录入数据后进行统计分析。[结果]1.流行现况:(1)2013年07月01日至2016年06月30日期间昆明地区主要的10所具有冠心病介入诊疗资质医院的ACS患者出院总人次数为31 896人次,其中以男性患者为主,共21 692人次(占比68.0%),出院患者平均年龄为(64. 8±12. 3)岁,平均住院天数为(9. 4±5. 5)天,出院诊断以不稳定型心绞痛为主,比重为55. 3%,其余依次为ST段抬高型心肌梗死、非ST段抬高型心肌梗死、未详细划分的急性心肌梗死和未详细划分的ACS; (2) ACS院内死亡率为2. 2%,ACS的院内死亡率、男性院内死亡率和女性院内死亡率随年龄的增大而上升(各趋势P值均0.05),ACS的院内死亡率、男性院内死亡率、女性院内死亡率、女性患者的比例、急性心肌梗死的比例在各时间段中的变化无统计学意义(各趋势P值均0.05); (3)性别因素与ACS患者预后的差异无统计学意义(P0. 05),而年龄、住院天数、出院科室、出院诊断类型和出院时段的变化与ACS患者预后的差异具有统计学意义(P0. 01):过渡期组、老年组和高龄组相对中青年组ACS患者的预后差;2014年上半年、2014年下半年和2015年下半年相对2013年下半年ACS患者的预后好;住院2～3天、4～6天和7～14天相对≤1天的ACS患者的预后好;于非心内科住院的ACS患者较于心内科住院的ACS患者预后差;出院诊断为急性心肌梗死的患者较诊断为不稳定型心绞痛的患者预后差,出院诊断为未详细划分的ACS的患者较诊断为不稳定型心绞痛的患者预后好。2. ACS死亡病例分析:(1)昆明地区ACS住院患者死因前三位为心源性休克、机械并发症和院内合并症,占比78.1%、8. 4%和5. 8%; (2) ACS死亡患者的主诊断以急性心肌梗死为主,占比94. 2% (ST段抬高型心肌梗死占71.1%,非ST段抬高型心肌梗死占21. 4%),其次为不稳定型心绞痛和未详细划分的ACS; (3) ACS死亡患者发生的院内不良事件前三位为严重的心律失常、急性心力衰竭和心脏结构破坏,占比44. 3%、24. 5%和9. 7%; (4) ACS死亡患者中41. 0%接受了再灌注治疗,59.0%未接受任何再灌注治疗;(5) ACS死亡患者院内抗血小板、抗凝、他汀类、ACEI/ARB和β受体阻滞剂药物使用率分别为89. 5%、76. 0%、86. 5%、44.1%和46. 9%,其中β受体阻滞剂使用率随时间变化逐渐下降(趋势P值0. 05); (6)镁剂在ACS死亡患者中使用率为43.4%,在AMI死亡患者中为43. 1%,在STEMI死亡患者中此比例达43. 6%; (7)中药制剂在ACS死亡患者中使用率为71. 8%,在出现严重出血并发症的患者中,活血类中药制剂的使用率达68. 2%; (8) ACS死亡患者中49. 9%是通过急救医疗服务系统入院,50.1%采用了自行入院等其他方式求治;(9) ACS患者死亡日期趋近1月16日,标准差为1月9日(P0. 01 ),死亡昼夜时刻不存在集中趋势(P0. 05)。[结论]1.昆明地区ACS住院患者基本特征与全国基本一致,没有明显的区域异质性;2.昆明地区ACS住院患者主要以不稳定型心绞痛为主,其次为ST段抬高型心肌梗死和非ST段抬高型心肌梗死,疾病构成存在区域异质性;3.昆明地区ACS住院患者死因前三位为心源性休克、机械并发症和院内合并症,而死亡患者院内不良事件前三位为严重的心律失常、急性心力衰竭和心脏结构破坏;4.昆明地区ACS死亡患者再灌注率低;5.昆明地区ACS死亡患者药物使用不规范,镁剂和中药制剂的不规范使用情况尤为突出;6.昆明地区EMS系统有效使用率低;7.昆明地区ACS患者死亡日期存在集中趋势,死亡时间集中于1月中旬。
[Abstract]:[Objective] to describe and evaluate the hospitalization of the patients with acute coronary syndrome (ACS) from the second half of 2013 to the first half of 2016, the clinical characteristics, the hospital mortality, the difference of the cause of death and the strategy of treatment, which reflect the prevalence of the disease in the region, the level of treatment, the characteristics of the death cases and the regional medical treatment. In order to help clinicians identify patients with high risk of death in time, make more specific and accurate medical decisions, avoid death outcomes and further reduce the hospital mortality in ACS patients. [Methods] to obtain the relevant departments of 10 qualified hospitals with coronary intervention in the Kunming area. With the consent of the graduate students' teaching management department and the medical record management department, the basic information of the patients who were diagnosed as ACS was retrieved and collected through the medical record information management system of each hospital during the period from 01 to 2016 2013 to 06 months of 2016. The patients were discharged from the cardiology department and died in the hospital during the hospitalization period and were in accordance with the standard of admission. The medical records of the patients were reviewed and analyzed. By filling in the report table of the clinical study of the death cases of acute coronary syndrome in the Kunming area, the social demography information, clinical features, treatment strategies and end-point death events were collected, and the Epidata 3.1 software was used to establish the ACS information database of death cases. Statistical analysis was carried out after data entry. [results]1. epidemic status: (1) the number of total number of patients discharged from ACS patients with coronary artery disease intervention at 30 days from 01 to 2016 2013 to 06 months in 2016 was 31896 people, including male patients, 21692 people (68%), and the average age of discharged patients was ( 64.8 + 12.3 years old, the average days of hospitalization were (9.4 + 5.5) days, and the discharge diagnosis was mainly unstable angina pectoris, and the proportion was 55.3%. The rest were ST segment elevation myocardial infarction, non ST segment elevation myocardial infarction, undivided acute myocardial infarction and undetailed division ACS; (2) the mortality of ACS hospital was 2.2%, and the mortality rate of ACS was in the hospital. The mortality of male hospital and the mortality of women in hospital increased with age (the P value of each trend was 0.05). The rate of hospital mortality in ACS, the mortality of male hospital, the mortality of women in hospital, the proportion of female patients, the ratio of acute myocardial infarction in each time period were not statistically significant (all the values of P were 0.05), and (3) sex factors and A There was no statistically significant difference in the prognosis of CS patients (P0. 05), but the difference between age, hospital days, discharge section, discharge diagnosis type and discharge period and the prognosis of ACS patients was statistically significant (P0. 01): the prognosis of ACS patients in the elderly group and the elderly group relative to the middle age group was poor; in the first half of 2014, the second half and 2015 in the second half of 2014. The prognosis of ACS patients in the second half of the year was better than that in the second half of 2013; the prognosis of ACS patients with 2~3 days in hospital, 4~6 days and 7~14 days relatively less than 1 days was better; the ACS patients hospitalized in the non Department of Cardiology had a poor prognosis compared with those in the Department of Cardiology hospitalized patients; the patients with acute myocardial infarction diagnosed as acute myocardial infarction were worse than those in the diagnosis of unstable angina pectoris. Patients with undivided ACS were compared with.2. ACS mortality in patients diagnosed with unstable angina pectoris: (1) the first three cases of ACS hospitalized patients in Kunming were cardiogenic shock, mechanical complications and nosocomial complications were 78.1%, 8.4% and 5.8%, and (2) the main diagnosis of ACS death patients with acute myocardial infarction The majority was 94.2% (71.1% with ST elevation myocardial infarction, 21.4% for non ST segment elevation myocardial infarction), followed by unstable angina and undivided ACS, and (3) severe arrhythmia, acute heart failure and cardiac structural damage before hospital adverse events in ACS deaths, 44.3%, 24.5%, and 9.7%. (4) of the patients with ACS death, 41% received reperfusion therapy, and 59% did not receive any reperfusion therapy; (5) the use of antiplatelet, anticoagulant, statins, ACEI/ARB and beta blockers in patients with ACS death were 89.5%, 76%, 86.5%, 44.1% and 46.9%, respectively, and the use of beta blockers gradually decreased with time. The potential P value was 0.05); (6) the use rate of magnesium was 43.4% in patients with ACS death, 43.1% in AMI deaths and 43.6% in STEMI deaths; (7) the use rate of traditional Chinese medicine in ACS died patients was 71.8%, and in patients with severe bleeding complications, the use of traditional Chinese medicine preparation was 68.2%; (8) ACS death patients. 49.9% were hospitalized through the first aid medical service system, and 50.1% were treated by self admission. (9) the death date of ACS patients reached January 16th, the standard deviation was January 9th (P0. 01), and the day and night time of death did not exist (P0. 05). [conclusion the basic characteristics of ACS inpatients in]1. Kunming area were basically consistent with the country, and there was no obvious difference. 2. ACS inpatients in Kunming area were mainly unstable angina pectoris, followed by ST segment elevation myocardial infarction and non ST segment elevation myocardial infarction, the disease composition existed regional heterogeneity; 3. the first three cases of ACS hospitalized patients in Kunming area were cardiogenic Hugh, mechanical complication and hospital complication, and death patients Before the hospital adverse events, three were serious arrhythmia, acute heart failure and heart structural damage; 4. the rate of ACS death in Kunming was low; 5. in Kunming area, ACS death patients were unstandardized, and the unstandardized use of magnesium and traditional Chinese medicine preparations was particularly prominent; 6. in Kunming area, the effective use rate of EMS system was low; 7. Kunming land. The death date of ACS patients was concentrated in the middle of January.

【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R541.4

【参考文献】