不同年齡層次急性心肌梗死患者臨床特點(diǎn)對(duì)比觀察

李建華，程訓(xùn)民，杭　濤，王　璟，劉挺松，何松清，謝　亮，宮劍濱

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·論著·

不同年齡層次急性心肌梗死患者臨床特點(diǎn)對(duì)比觀察

李建華，程訓(xùn)民，杭濤，王璟，劉挺松，何松清，謝亮，宮劍濱

目的對(duì)比研究不同年齡層次急性心肌梗死(AMI)患者的臨床特點(diǎn)及冠脈病變特點(diǎn)。方法序貫入選AMI患者226例，按年齡層次分為青年組、中老年組及高齡組。比較3組人群的臨床特征及冠脈造影結(jié)果。結(jié)果兩兩比較3組患者高血壓病比例、總膽固醇、低密度脂蛋白、甘油三酯、高密度脂蛋白組間差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。青年組中年組吸煙比例較中老年組、高齡組明顯增高，與其比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。3組患者發(fā)病至入院時(shí)間、入院至導(dǎo)管室時(shí)間隨年齡增加，逐漸升高。高齡組糖尿病史、血肌酐、肌酸激酶、肌酸激酶同工酶MB、肌鈣蛋白I與青年組、中老年組相比差異均具有統(tǒng)計(jì)學(xué)意義(P<0.05)。比較高齡組患者與青年組、中老年組患者Gensini評(píng)分差異均具有統(tǒng)計(jì)學(xué)意義(P<0.05)。青年組與中老年組患者Gensini評(píng)分之間差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論急性心肌梗死在不同年齡層次患者中的臨床特點(diǎn)及病變程度不盡相同，其發(fā)病機(jī)制可能略有不同。不同年齡層次急性心肌梗死的特點(diǎn)對(duì)于臨床診療具有重要意義。

急性心肌梗死；冠狀動(dòng)脈造影；臨床特點(diǎn); Gensini評(píng)分

急性心肌梗死(acute myocardial infarction，AMI)是臨床常見(jiàn)的高風(fēng)險(xiǎn)疾病，指冠狀動(dòng)脈急性閉塞，血流中斷所引起的心肌缺血性壞死。主要表現(xiàn)為持續(xù)性的胸骨后疼痛、心律失常、休克及心力衰竭等，伴有血清心肌酶增高及心電圖改變，病死率極高。其患病率及死亡率隨著年齡的增加而增加。近年來(lái)急性心肌梗死的發(fā)病年齡有年輕化趨勢(shì)。本文回顧性分析226例臨床診斷為AMI患者的臨床資料，對(duì)不同年齡層次患者進(jìn)行對(duì)比研究。

1　對(duì)象與方法

1.1對(duì)象序貫入選2013-2015年入院的急性心肌梗死患者226例，按年齡分成青年組(男性<55歲，女性<65歲)、中老年組(55歲≤男性<80歲，65歲≤女性<80歲) 及高齡組(≥ 80歲)。診斷符合中華醫(yī)學(xué)會(huì)心血管分會(huì)《急性心肌梗死診斷和指南》標(biāo)準(zhǔn)。所有研究對(duì)象均知情同意。

1.2方法患者入院后首日采血，典型胸痛12 h內(nèi)或行急診經(jīng)皮冠狀動(dòng)脈介入(percutaneous transluminal coronary intervention,PCI)治療前采血，測(cè)定血清總膽固醇、低密度脂蛋白、甘油三酯、高密度脂蛋白、肌酐、肌酸激酶、肌酸激酶同工酶MB、肌鈣蛋白I。

表1　各組患者一般特點(diǎn)比較

指標(biāo)青年組(n=106)中老年組(n=81)高齡組(n=39)年齡(歲,x±s)53.66±7.7672.33±3.9282.38±2.54吸煙者[n(%)]80(75.4)43(53.1)20(51.3)高血壓病史者[n(%)]48(45.3)45(55.6)22(56.4)糖尿病史者[n(%)]20(18.9)40(49.4)21(53.4)發(fā)病至入院時(shí)間(min,x±s)42.14±22.4148.29±148.7864.69±49.10入院至導(dǎo)管室時(shí)間(min,x±s)190.65±72.78220.78±65.89367.61±107.62總膽固醇(mmol/L,x±s)4.64±1.174.17±0.884.43±1.00高密度脂蛋白(min,x±s)1.08±0.261.06±0.241.11±0.43低密度脂蛋白(mmol/L,x±s)3.06±1.022.73±0.732.80±0.93甘油三酯(min,x±s)1.61±1.221.31±0.631.27±0.56血肌酐(mmol/L,x±s)75.20±24.2497.56±54.37129.31±75.75肌酸激酶(mmol/L,x±s)1784.94±1917.101098.31±981.481365.30±1078.94肌酸激酶同工酶MB(mmol/L,x±s)119.20±112.62162.67±136.47198.64±143.992肌鈣蛋白I(μg/L,x±s)10.23±10.0811.92±15.4124.60±20.05

2　結(jié)　果

2.1一般特點(diǎn)比較青年組、中老年組、高齡組年齡分別為(53.66±7.76)歲、(72.33±3.92)歲、(82.38±2.54)歲。兩兩比較3組患者高血壓病比例、總膽固醇、低密度脂蛋白、甘油三酯、高密度脂蛋白組間差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。青年組、中年組吸煙比例較中老年組、高齡組明顯增高，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。3組患者發(fā)病至入院時(shí)間、入院至導(dǎo)管室時(shí)間隨年齡增加，逐漸升高。高齡組糖尿病史、血肌酐、肌酸激酶、肌酸激酶同工酶MB、肌鈣蛋白I與青年組、中老年組相比差異均具有統(tǒng)計(jì)學(xué)意義(P<0.05)。見(jiàn)表1。

2.2冠脈病變程度比較青年組、中老年組、高齡組Gensini評(píng)分分別為(55.20±33.84)、(53.95±34.62)、(73.29±34.47)。比較高齡組患者與青年組、中老年組患者Gensini評(píng)分差異均具有統(tǒng)計(jì)學(xué)意義(P<0.05)。青年組與中老年組患者Gensini評(píng)分之間差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。高齡組患者較青年組、中老年組患者Gensini評(píng)分明顯增加。

3　討　論

急性心肌梗死(AMI)是臨床常見(jiàn)的急、危、重病[1]。近年來(lái)，急性心肌梗死的發(fā)病率有逐年上升趨勢(shì)，發(fā)病年齡有年輕化趨勢(shì)，其發(fā)病急，來(lái)勢(shì)兇，病情進(jìn)展快而危重，并發(fā)癥較多，易發(fā)生猝死[2]。因此，深入了解和認(rèn)識(shí)不同年齡層次急性心肌梗死的臨床特點(diǎn)及病變程度對(duì)于防治急性心肌梗死具有重要意義。

吸煙、高血壓、高脂血癥、糖尿病及冠心病家族史是冠心病的獨(dú)立危險(xiǎn)因素[3]。我們的研究中，3組患者高血壓病比例、總膽固醇、低密度脂蛋白、甘油三酯、高密度脂蛋白無(wú)明顯差異。青年組中年組吸煙比例較中老年組、高齡組明顯增高，青年組吸煙率高達(dá)75.4%，為第一位危險(xiǎn)因素。目前認(rèn)為,吸煙導(dǎo)致AMI的可能機(jī)制是:① 促進(jìn)動(dòng)脈血栓形成及冠狀動(dòng)脈痙攣[4]；② 大量吸煙致血液中一氧化碳濃度升高,進(jìn)一步造成血管內(nèi)皮缺氧性損傷,長(zhǎng)期吸煙還可以使血小板聚集功能增強(qiáng)及冠狀動(dòng)脈緊張性增加[5]；③ 煙草中的尼古丁可引起冠狀動(dòng)脈痙攣和損傷冠狀動(dòng)脈內(nèi)膜。青年組預(yù)防冠心病，戒煙應(yīng)作為一級(jí)預(yù)防的首位措施。

3組患者發(fā)病至入院時(shí)間、入院至導(dǎo)管室時(shí)間隨年齡增加，逐漸升高。高齡組在救治過(guò)程中的時(shí)間明顯高于其余兩組，高齡患者往往由于胸痛癥狀不典型或合并其他病情等各種原因?qū)е氯朐汉笤\斷不明確，甚至掩蓋病情，從而耽誤了救治時(shí)間。因此，對(duì)于高齡患者應(yīng)盡早明確診斷，為進(jìn)一步治療贏取時(shí)間。

本研究可見(jiàn)高齡組患者中糖尿病比較較高，對(duì)于高齡糖尿病患者，控制血糖具有重要意義。高齡患者易出現(xiàn)腎功能不全，因此在進(jìn)一步介入治療時(shí)，造影劑使用應(yīng)謹(jǐn)慎，防止造影劑腎病[6]。本研究中肌酸激酶、肌酸激酶同工酶MB、肌鈣蛋白I與青年組、中老年組相比明顯增高。心肌酶譜作為胸痛患者的常規(guī)檢測(cè)項(xiàng)目在心肌梗死診斷中具有極其重要的地位[7-8]。心肌酶譜的峰值往往與心肌梗死的面積及程度呈正相關(guān)[9]。本研究發(fā)現(xiàn)，高齡組心肌梗死嚴(yán)重程度明顯升高。

本研究中高齡組患者較青年組、中老年組患者Gensini評(píng)分明顯增加。Gensini評(píng)分是冠狀動(dòng)脈造影病變?cè)u(píng)分方法[10]。Gensini 評(píng)分考慮了冠狀動(dòng)脈病變的數(shù)目部位狹窄程度，是較為客觀的冠狀動(dòng)脈評(píng)價(jià)標(biāo)準(zhǔn)[11]。Gensini評(píng)分是非常有效的對(duì)冠狀動(dòng)脈病變程度的評(píng)估方法，冠狀動(dòng)脈病變?cè)絿?yán)重，Gensini 評(píng)分越高，心功能越差[12]。說(shuō)明高齡組患者冠脈病變較青年組、中老年組更復(fù)雜，更嚴(yán)重。

綜上所述，急性心肌梗死在不同年齡層次患者中的臨床特點(diǎn)及病變程度不盡相同，其發(fā)病機(jī)制可能略有不同。高齡急性心肌梗死患者往往合并癥較多，病變彌散，程度較重; 而青年急性心肌梗死是環(huán)境與遺傳共同作用的結(jié)果，病變較局限，吸煙是首要危險(xiǎn)因素。對(duì)于不同年齡層次急性心肌梗死的對(duì)于臨床診療具有重要意義，并有待進(jìn)一步研究。

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(本文編輯：齊名；英文編輯：王建東)

Clinical characteristics in patients with acute myocardial infarction with different age levels

LI Jian-hua, CHENG Xun-min, HANG Tao,

WANGJing,LIUTing-song,HESong-qing,XIELiang,GONGJian-bin.JinlingHospital,NanjingUniversitySchoolofMedicine,Nanjing,Jiangsu210002,China

ObjectiveThe clinical characteristics of different age levels in patients with acute myocardial infarction and coronary artery lesion characteristics were studied comparatively. Methods226 cases of AMI patients, according to the ages were selected sequentially and divided into young group, elderly group and aged groups. clinical characteristics of three groups of people and the result of coronary angiography were compared. ResultsPairwise comparison of three groups of patients with hypertension disease percentage, total cholesterol, low-density lipoprotein cholesterol (LDL-C), triglycerides, high-density lipoprotein cholesterol (HDL-C) were not statistically significant (P>0.05). Young, middle-aged smoking rate was significantly higher than elderly group and aged group, and the difference was statistically significant (P<0.05); Three groups of patients with onset to admission time, admission to international time increased along with the age increasing. The differences of history of diabetes, serum creatinine, creatine kinase, creatine kinase isoenzyme MB, troponin I between elderly group and young group, were statistically significant (P<0.05). Gensini score between senile patients and young group, elderly group was significantly different (P<0.05). Gensini score between young patients and elderly group was significantly different (P>0.05). ConclusionThe clinical characteristics and pathological changes degree are not the same in patients with acute myocardial infarction (AMI) in different age groups, and its pathogenesis may be slightly different. Different age groups is of great significance for clinical diagnosis and treatment of acute myocardial infarction.

acute myocardial infarction; coronary angiography; clinical characteristics; gensini score

中國(guó)博士后科學(xué)基金特別資助(2012T50897)

210002江蘇南京，南京大學(xué)醫(yī)學(xué)院附屬金陵醫(yī)院，南京軍區(qū)南京總醫(yī)院心臟內(nèi)科

宮劍濱，E-mail: agong62@126.com

R541.4

A

10.3969/j.issn.1672-271X.2016.04.006

2016-02-14；

2016-02-26)

引用格式：李建華，程訓(xùn)民，杭濤，等.不同年齡層次急性心肌梗死患者臨床特點(diǎn)對(duì)比觀察[J].東南國(guó)防醫(yī)藥，2016,18(4):358-360.