中国省、市和县级医院急性ST段抬高型心肌梗死住院患者再灌注治疗和二级预防用药分析

摘要

目的：比较我国省级、市级及县级三个级别医院针对ST段抬高型急性心肌梗死（STEMI）患者进行再灌注治疗和住院期间二级预防药物的使用情况。　　方法：中国急性心肌梗死注册（CAMI）研究在2013-01-01至2014-09-30期间共登记覆盖全国31个省市、自治区和直辖市107家医院收治的18967例在发病7天内的STEMI患者，其中223例患者因住院结局等关键数据缺失而被排除，分析省、市和县级三个级别医院收治患者的人口统计学信息、再灌注治疗[包括急诊冠状动脉介入治疗（PCI）和溶栓治疗]和二级预防用药[包括阿司匹林、P2Y12抑制剂、他汀类药物、β受体阻滞剂、血管紧张素转化酶抑制剂（ACEI）/血管紧张素Ⅱ受体拮抗剂（ARB）]的使用情况。　　结果：在分析的18744例STEMI患者中，9885例（52.7%）接受了再灌注治疗，其中8038例（42.9%）接受了急诊PCI，1847例（9.9%）接受了溶栓治疗。省级医院再灌注治疗率明显高于地市级医院和县级医院，分别为4041例（61.8%）、4728例（49.1%）和1116例（43.2%），差异有统计学意义（P<0.001）；三个级别医院的再灌注治疗方式也存在明显差别，省级医院：急诊PCI 3840例（58.7%），溶栓201例（3.1%）；市级医院：急诊PCI 3753例（39.0%），溶栓975例（10.1%）；县级医院：急诊PCI 445例（17.2%），溶栓671例（26.0%）。发病12小时内到达医院的12502例患者中有8856例（70.8%）接受再灌注治疗，其中急诊PCI 7089例（56.7%），溶栓1746例（14.1%），省级医院3537例（80.0%），市级医院4274例（67.5%），县级医院1045例（59.8%），三个级别的医院依然差别明显（P<0.001）。在住院期间有16575例（90.9%）使用他汀、17963例（96.8%）使用阿司匹林，17922例（96.5%）例应用P2Y12抑制剂，12657例（68.2%）使用β受体阻滞剂，10541例（56.8%）使用ACEI/ARB。三个级别医院在应用上述几种二级预防用药比例相似。　　结论：CAMI研究中，在发病12小时内到达医院的患者中，有70.8%接受再灌注治疗。县级医院的再灌注治疗率明显较低。三个级别医院的二级预防用药情况相似，但β受体阻滞剂和ACEI/ARB使用比例偏低。% Objective:To investigate reperfusion and secondary preventive drug therapy for ST-segment elevation myocardial infarction (STEMI) patients in provincial, city and county levels hospitals of China. Methods:A total of 18,967 STEMI patients within 7 days of symptom onset from 2013-01-01 to 2014-09-30 were enrolled by China acute myocardial infarction (CAMI) registry study group from 107 hospitals covering 31 provinces/autonomous regions, cities and counties in China;223 patients were excluded for key information missing. Demographic data, reperfusion as primary percutaneous coronary intervention (pPCI), thrombolytic therapy (TT) and secondary preventive drug therapy as aspirin, P2Y12 inhibitors, statins,β-blockers, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor antagonist (ARB) were analyzed and compared among 3 levels of hospitals. Results:There were 9,885/18,744 (52.7%) patients received reperfusion including 8,038 (42.9%) pPCI and 1,847 (9.9%) TT. Reperfusion rate in provincial hospital (61.8%, 4041/6537) was higher than city hospital (49.1%, 4728/9625) and county hospital (43.2%, 1116/2582), P<0.001;reperfusion type was distinctive among 3 levels of hospitals, for provincial hospital:pPCI was performed in 3,840 (58.7%), TT in 201(3.07%) patients;for city hospital:pPCI in 3,753 (39.0%), TT in 975 (10.1%) patients;for county hospital:pPCI in 445 (17.2%), TT in 671 (26.0%) patients. 12,502 patients arrived hospital within 12 h of symptom onset and 8,835 (70.8%) of them received reperfusion including 7089 (56.7%) patients with pPCI and 1,746 (14.1%) with TT. 3537 (80%) patients received reperfusion in provincial hospital, 4272 (67.5%) in city hospital and 1045 (59.8%) in county hospital, P<0.001.The in-hospital application of statins was in 16,575 (90.9%) patients, aspirin was 17,963 (96.8%), P2Y12 inhibitors was 17,922 (96.5%),β-blockers was 12,657 (68.2%) and ACEI/ARB was 10,541 (56.8%) respectively;the therapeutic condition was similar among 3 levels of hospitals. Conclusion:In CAMI Registry, 70.8%arrived hospital within12 h of symptom onset had been treated by reperfusion therapy in China; the reperfusion rate in county hospital was obviously lower. The secondary preventive drug therapy condition was similar among 3 levels of hospitals.