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Volume 45 Issue 10
Nov.  2020
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Analysis of the clinical and coronary lesion characteristics in different age patients with acute myocardial infarction

  • Received Date: 2020-01-01
    Accepted Date: 2020-06-05
  • ObjectiveTo investigate the clinical and coronary lesion characteristics in different age patients with acute myocardial infarction(AMI).MethodsTwo hundred and one AMI patients were detected using emergency coronary angiography, and divided into the young and middle-aged group(age < 60 years old, n=70) and elderly group(age ≥ 60 years old, n=131) according to their ages.The clinical data and coronary artery disease data were compared between two groups.ResultsElderly patients with AMI were more prone to have in-hospital death and heart failure compared with young and middle-aged patients(P < 0.05).The levels of red blood cell count, hemoglobin, hematocrit, reticulocyte count, lymphocyte count, eosinophil count, alanine aminotransferase, cholinesterase, total protein, albumin, uric acid, total cholesterol, low density lipoprotein and apolipoprotein B in young and middle-aged group were higher than those in elderly group(P < 0.05 to P < 0.01), and the level of lipoprotein a in young and middle-aged group was lower than that in elderly group(P < 0.05).In the young and middle-aged group, the single-vessel lesion and low Gensini score were the main performance, and the probability of no/slow reflow was low.In the elderly group, the coronary arteries were mainly composed of multiple vessels, calcification lesions and high Gensini score, and no/slow reflow was easy to occur during the operation.The difference of which between two groups was statistically significant(P < 0.05 to P < 0.01).ConclusionsThe levels of blood pressure, blood glucose and blood lipid in young and middle-aged patients are higher, and the coronary artery lesions are mainly single-branch and low Gesini score lesions.In the elderly patients, the coronary artery lesions are mainly diffused long lesions and calcificated lesions, and no/slow reflow is easy to occur during the operation.
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  • [1] 胡司淦, 陈耀, 卢冬雨, 等.中青年与老年男性冠心病患者的临床特征比较[J].中国老年学杂志, 2015, 35(6):1557.
    [2] 黄晖, 张国山, 马芸芸, 等.急诊PCI治疗急性心肌梗死患者的预后影响因素分析[J].宁夏医科大学学报, 2017, 39(12):1404.
    [3] 李智鹏.急性心肌梗死患者心血管内科的临床治疗效果分析[J].世界最新医学信息文摘, 2019, 19(65):82.
    [4] WICHMANN J, SJÖBERG K, TANG L, et al.The effect of secondary inorganic aerosols, soot and the geographical origin of air mass on acute myocardial infarction hospitalisations in Gothenburg, Sweden during 1985-2010:A case-crossover study[J].Environ Health, 2014, 13(1):61. doi: 10.1186/1476-069X-13-61
    [5] 中国医师协会急诊医师分会, 国家卫健委能力建设与继续教育中心急诊学专家委员会, 中国医疗保健国际交流促进会急诊急救分会, 等.急性冠脉综合征急诊快速诊治指南(2019)[J].中华急诊医学杂志, 2019, 28(4):421.
    [6] GENSINI GG.A more meaningful scoring system for determining the severity of coronary heart disease[J].Am J Cardiol, 1983, 51(3):606.
    [7] MUNIBARI AN, AL-MOTARREB A, ALANSI A, et al.Reperfusion therapy for ST elevation acute myocardial infarction in Yemen:Description of the current situation:Data from Gulf Registry of Acute Coronary Events (the Gulf RACE-I)[J].Int J Cardiol, 2015, 187:128. doi: 10.1016/j.ijcard.2015.03.348
    [8] PUYMIRAT E, AISSAOUI N, CAYLA G, et al.Changes in one-year mortality in elderly patients admitted with acute myocardial infarction in relation with early management[J].Am J Med, 2017, 130(5):555. doi: 10.1016/j.amjmed.2016.12.005
    [9] 国家卫生计生委合理用药专家委员会, 中国药师协会.冠心病合理用药指南(第2版)[J/CD].中国医学前沿杂志(电子版), 2018, 10(6):1.
    [10] GUPTA A, WANG Y, SPERTUS JA, et al.Trends in acute myocardial infarction in young patients and differences by sex and race, 2001 to 2010[J].J Am Coll Cardiol, 2014, 64(4):337. doi: 10.1016/j.jacc.2014.04.054
    [11] 韩全乐, 毛瑞英, 郁静, 等.中青年人群发生急性心肌梗死的危险因素分析[J].中国循环杂志, 2016, 31(7):632.
    [12] 马丽媛, 吴亚哲, 王文, 等.《中国心血管病报告2017》要点解读[J].中国心血管杂志, 2018, 23(1):3.
    [13] HONG X, BOSONG W, QINGMEI M, et al.Effectiveness and safety of recombinant human brain natriuretic peptide in the treatment of acute myocardial infarction in elderly in combination with cardiac failure[J].Pak J Med Sci, 2017, 33(3):540.
    [14] 袁晋青, 马元良.ST段抬高型心肌梗死伴多支冠状动脉病变患者的介入治疗策略[J].中国循环杂志, 2016, 31(10):954.
    [15] 杨茹, 邵素云, 胡司淦, 等.青年急性心肌梗死患者的临床特点及护理对策[J].蚌埠医学院学报, 2013, 38(1):105.
    [16] 李梦竹, 王震寰, 沈龙山, 等.急诊PCI与择期PCI对急性心肌梗死病人左心室功能的影响[J].蚌埠医学院学报, 2018, 43(4):437.
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Analysis of the clinical and coronary lesion characteristics in different age patients with acute myocardial infarction

  • 1. Department of Cardiovascular Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui 233004, China
  • 2. Department of Pharmacy, The First Affiliated Hospital of Bengbu Medical College, Bengbu Anhui 233004, China

Abstract: ObjectiveTo investigate the clinical and coronary lesion characteristics in different age patients with acute myocardial infarction(AMI).MethodsTwo hundred and one AMI patients were detected using emergency coronary angiography, and divided into the young and middle-aged group(age < 60 years old, n=70) and elderly group(age ≥ 60 years old, n=131) according to their ages.The clinical data and coronary artery disease data were compared between two groups.ResultsElderly patients with AMI were more prone to have in-hospital death and heart failure compared with young and middle-aged patients(P < 0.05).The levels of red blood cell count, hemoglobin, hematocrit, reticulocyte count, lymphocyte count, eosinophil count, alanine aminotransferase, cholinesterase, total protein, albumin, uric acid, total cholesterol, low density lipoprotein and apolipoprotein B in young and middle-aged group were higher than those in elderly group(P < 0.05 to P < 0.01), and the level of lipoprotein a in young and middle-aged group was lower than that in elderly group(P < 0.05).In the young and middle-aged group, the single-vessel lesion and low Gensini score were the main performance, and the probability of no/slow reflow was low.In the elderly group, the coronary arteries were mainly composed of multiple vessels, calcification lesions and high Gensini score, and no/slow reflow was easy to occur during the operation.The difference of which between two groups was statistically significant(P < 0.05 to P < 0.01).ConclusionsThe levels of blood pressure, blood glucose and blood lipid in young and middle-aged patients are higher, and the coronary artery lesions are mainly single-branch and low Gesini score lesions.In the elderly patients, the coronary artery lesions are mainly diffused long lesions and calcificated lesions, and no/slow reflow is easy to occur during the operation.

  • 环境和遗传的相互作用引起冠状动脉(冠脉)斑块破裂,血流突然中断,形成急性心肌梗死(acute myocardial infarction, AMI)[1-2],其发病急骤、进展迅速、临床并发症多样、致死致残率高[3]。近年来,中青年AMI的发病率一直在增加[4]。为了更好地防止中青年人发生AMI,本文回顾性分析AMI病人的临床和冠脉病变资料。现作报道。

1.   资料与方法
  • 选择2017年3月至2018年3月我院诊治并行急诊冠脉造影的201例AMI病人为研究对象。AMI诊断根据中国医师协会急诊医师分会制定的《急性冠脉综合征急诊快速诊治指南(2019)》[5]:(1)有胸痛或胸闷不适的临床表现;(2)至少两个相邻导联的ST段升高、新出现的完全性左束支传导阻滞或T波超急性改变;(3)血肌钙蛋白>99 th正常参考值或血肌酸激酶同工酶升高,至少满足上述标准中的两条。201例病人中男152例,女49例,年龄33~90岁。按年龄将病人分为中青年组(< 60岁,n=70)和老年组(≥60岁, n=131)。

  • 采用Judkins方法检查左右冠状动脉,选择多体位X线投照,由两名多年从事心血管介入治疗的医师判断和评分冠脉造影结果。根据美国心脏协会规定的冠脉血管图像分段评价标准,采用Gensini积分系统[6]对每支冠脉的狭窄程度进行积分。每支冠脉节段的病变分数等于狭窄程度积分乘以相应的位置系数,每支冠脉病变的积分之和等于冠状动脉疾病的总分,冠脉远端节段的总积分不超过近端段完全闭塞的总积分;左主干完全闭塞最多160分,右冠脉完全闭塞最多32点;左室后支完全闭塞最多为16分;冠脉血管直径狭窄超过50%定义为病变。根据受累病变的数量分为:单个病变和多处病变(2个或更多,包括左主干病变)。同时对冠脉病变特征进行分析,包括弥漫性长病变、血栓病变、钙化病变和侧支循环。

  • 采用t(或t′)检验和χ2检验。

2.   结果
  • 2组性别、年龄差异均有统计学意义(P < 0.01),AMI老年病人较中青年病人更容易发生院内死亡和心力衰竭(P < 0.05),2组病人在高血压病史、糖尿病病史、发生心律失常、入院时心率、血压水平方面差异均无统计学意义(P>0.05)(见表 1)。

    项目 中青年组(n=70) 老年组(n=131) χ2 P
    男女 63(90.0)7(10.0) 89(67.9)42(32.1) 71.70 < 0.01
    年龄/岁 50.3±6.1 70.4±7.0  20.30* < 0.01
    高血压病史 33(47.1) 66(50.4)  0.19 >0.05
    糖尿病病史 15(21.4) 29(22.1)  0.01 >0.05
    心力衰竭 13(18.6) 43(32.8)  4.61 < 0.05
    心律失常 14(20.0) 38(29.0)  1.93 >0.05
    院内死亡 0(0.0) 13(9.9)  5.88 < 0.05
    心率/(次/分) 73.8±16.1 78.5±20.6   1.65* >0.05
    收缩压/mmHg 125.6±24.7 122.9±22.9   0.79* >0.05
    舒张压/mmHg 78.6±17.4 74.7±13.5   1.63* >0.05
    *示t
  • 中青年组病人的红细胞计数(RBC)、血红蛋白(HGB)含量、红细胞压积(HCT)、网织红细胞计数(RET)、淋巴细胞计数(LY)、嗜酸细胞计数(EOS)均高于老年组(P < 0.05~P < 0.01);2组病人的白细胞计数(WBC)、中性粒细胞计数(NEUT)、血小板计数(PLT)差异均无统计学意义(P>0.05)(见表 2)。

    指标 中青年组(n=70) 老年组(n=131) t P
    WBC/(×109/L)   11.27±3.69     10.78±3.83   0.88 >0.05
    NEUT/(×109/L)     8.67±3.64       8.57±3.60   0.19 >0.05
    LY/(×109/L)     1.89±0.91       1.54±0.82   2.78 < 0.01
    EOS/(×109/L)     0.09±0.10       0.06±0.08   2.12 < 0.05
    RBC/(×1012/L)     4.87±0.48       4.46±0.52   5.49 < 0.01
    HGB/(g/L)   145.2±16.83 133.81±17.06 4.53 < 0.01
    HCT/(L/L)     0.44±0.05       0.41±0.05   4.19 < 0.01
    RET/(×1012/L)     0.06±0.02       0.05±0.02   2.57 < 0.05
    PLT/(×1012/L) 209.07±62.03 198.10±56.49 1.27 >0.05
  • 中青年组病人的丙氨酸氨基转移酶(ALT)、胆碱酯酶(CHE)、总蛋白(TP)、白蛋白(ALB)、血尿酸(UA)水平均高于老年组(P < 0.05~P < 0.01);2组病人的天门冬氨酸转移酶(AST)、碱性磷酸酶(ALP)、γ谷氨酰基转移酶(γ-GT)、总胆红素(TIBL)、球蛋白(GLB)、葡萄糖(GLU)、肌酐(CREA)、尿素(BUN)、钾(K+)、钠(Na+)、氯(Cl-)、钙(Ca2+)水平差异均无统计学意义(P>0.05)(见表 3)。

    指标 中青年组(n=70) 老年组(n=131) t P
    ALT/(U/L)      57.00±82.13           40.27±25.05      2.16 < 0.05
    AST/(U/L)    111.16±170.26         80.08±85.56      1.43 >0.05
    ALP/(U/L)      90.97±25.41           91.48±29.89      0.12 >0.05
    γ-GT/(U/L)      47.39±37.86           37.69±37.13      1.75 >0.05
    CHE/(U/L) 8 641.11±1 605.51 7 137.81±1 686.11 6.12 < 0.01
    TBIL/(μmol/L)      14.24±7.01             14.94±8.36        0.60 >0.05
    TP/(g/L)      72.92±7.85             69.84±7.22        2.79 < 0.01
    ALB/(g/L)      41.65±4.71             39.24±4.57        3.51 < 0.01
    GLB/(g/L)      31.27±4.76             30.60±4.82        0.95 >0.05
    GLU/(mmol/L)        8.93±4.63               9.35±4.53        0.63 >0.05
    UA/(μmol/L)    346.21±97.66         314.05±87.42      2.39 < 0.05
    CREA/(μmol/L)      70.60±19.15           70.13±21.16      0.16 >0.05
    BUN/(mmol/L)        5.88±1.86               6.24±1.58        1.43 >0.05
    K+/(mmol/L)        3.84±0.85               3.74±0.52        1.01 >0.05
    Na+/(mmol/L)    139.37±4.74           139.55±3.45        0.31 >0.05
    Cl-/(mmol/L)    101.71±3.99           101.51±3.91        0.35 >0.05
    Ca2+/(mmol/L)        2.22±0.18               2.18±0.14        1.30 >0.05
  • 检测中青年组中48例,老年组中86例血脂指标,中青年组病人的总胆固醇(TC)、低密度脂蛋白(LDL-C)、载脂蛋白B(Apo B)水平均明显高于老年组(P < 0.01), 脂蛋白a(Lpa)水平低于老年组(P < 0.05);2组病人的三酰甘油(TG)、高密度脂蛋白(HDL-C)、载脂蛋白A(Apo A)水平差异均无统计学意义(P>0.05)(见表 4)。

    指标 中青年组(n=48) 老年组(n=86) t P
    TC     4.45±1.1           3.93±1.02     2.77 < 0.01
    TG     1.81±0.93         1.53±1.24     1.37 >0.05
    HDL     0.98±0.24         0.98±0.29     0.10 >0.05
    LDL-C     2.68±1.04         2.25±0.75     2.78 < 0.01
    Apo A     1.12±0.23         1.09±0.24     0.76 >0.05
    Apo B     0.91±0.33         0.72±0.24     3.83 < 0.01
    Lpa 198.85±145.23 269.70±223.41  2.22* < 0.05
    *示t′值
  • AMI中青年病人的冠脉病变主要为单支血管病变,低Gensini积分,术中无/慢复流发生率低,老年病人冠脉病变主要为多支血管病变和钙化病变,高Gensini积分,术中容易出现无/慢流,2组比较差异有统计学意义(P < 0.05~P < 0.01),2组病人在靶血管位置、病变长度、侧支循环建立方面差异均无统计学意义(P>0.05)(见表 5)。

    项目 中青年组(n=70) 老年组(n=131) χ2 P
    靶血管位置
       左主干 2(2.9) 1(0.8)
       前降支 34(48.6) 68(51.9) 3.38 >0.05
       回旋支 6(8.6) 19(14.5)
       右冠 28(40) 43(32.8)
    病变支数
       单支 22(31.4) 25(19.1) 3.88 < 0.05
         多支 48(68.6) 106(80.9)
       钙化 0(0.0) 14(10.7) 6.48 < 0.01
       弥漫性长病变 46(65.7) 97(74.0) 1.54 >0.05
       侧支循环 3(4.3) 3(2.3) 0.13 >0.05
       Gensini积分 61.46±33.59 70.97±27.94  2.14* < 0.05
       术中无/慢复流 0(0.0) 14(10.7) 6.48 < 0.05
       最终3级血流 64(91.4) 118(90.1) 0.10 >0.05
    *示t
3.   讨论
  • 遗传、性别、年龄等不可控因素和吸烟、血脂异常、糖尿病、高血压、肥胖等可控因素的相互作用,启动和加重了动脉粥样硬化的进展。动脉粥样斑块是冠脉粥样硬化的最常见的原因。斑块不稳定,突然破裂,形成急性血栓,阻断血流,导致AMI。AMI起病急、进展快、预后差、病死率、致残率高[7-10]。管理和控制上述不良的可控因素,可以减缓冠脉粥样硬化的进展,防治AMI的发生和发展[11]

    本研究201例AMI病人中中青年组70例,男63例,女7例;老年组131例,男89例,女42例。年轻AMI病人以男性为主,可能与男性吸烟、饮酒率,工作压力大有关,可能与年轻女性拥有较高水平的雌激素,保护血管内皮细胞的功能有关,与韩全乐等[11]研究一致。中青年组院内死亡率0.0%,老年组院内死亡率9.9%,死亡13例(心源性休克4例、急性左心衰2例、心律失常2例、心脏破裂或穿孔3例、出血2例), 提示老年组病人病情重、合并症多,院内病死率高。

    高血压、糖尿病、血脂异常和吸烟等因素是冠心病主要的高危因素[12]。2组在高血压病史、糖尿病病史、发生心律失常方面差异均无统计学意义,提示中青年人更应该管理和控制血压、血糖和血脂水平。

    冠脉血流突然中断,发生AMI,诱发机体发生急性反应,血常规、血液生化等出现明显改变[13]。2组病人WBC、NEUT均升高,但2组病人的WBC、NEUT、PLT差异均无统计学意义,提示AMI诱发的机体急性反应与年龄无关。老年组病人RBC、HGB、HCT、RET、LY、EOS较低,提示与老年人的基础疾病有关。

    2组病人的ALT、ALP、γ-GT、TBIL、GLB、GLU、CREA、BUN、钾、钠、氯、、钙水平差异均无统计学意义。中青年组病人ALT、CHE、TP、ALB、UA、TC、LDL-C、Apo B水平高于老年组病人,而Lpa低于老年组病人。Apo B是LDL-C的主要组成部分,约占LDL-C总含量的97%,故Apo B可直接反应LDL-C水平,是心血管疾病的高危因素。

    本研究中中青年组AMI病人冠脉病变特点以单支病变为主,低Gensini积分,术中发生无/慢复流概率低,老年组以多支血管病变、钙化病变为主[14],高Gensini积分,术中易出现无/慢复流,2组比较差异有统计学意义。冠脉钙化筛査可以用于冠心病危险程度的分层,冠脉的钙化检测应作为冠心病早期预防指标。

    除了性别、年龄、遗传等不可控因素外,血压、血糖、血脂、UA也影响动脉粥样硬化的进展,上述可控因素也是中青年AMI病人重要的预防靶点。中青年AMI是可防可控的,中青年人应根据其自身特点,禁烟限酒,加强血压、血脂和UA等高危因素的控制,减少和控制中青年AMI发生[15],发生AMI时行急诊PCI术,能够改善并提高病人的生活质量,延长人均寿命[16]

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