急性ST段抬高心肌梗死患者签署直接经皮冠状动脉介入治疗知情同意书的影响因素

摘要

Objective To determine the influencing factors on informed consent associated with decline or delay of primary percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction(STEMI).Methods This study was conducted in Peking University People′s Hospital from 1 August, 2014 to 31 March, 2016, with 229 consecutive cases of acute STEMI enrolled in the study.Data were collected by reviewing medical records and STEMI treatment time records.180 patients with ischemic symptoms ≤12 hours were included in the final analysis.Patients were divided into the consent group and the refusal group according to the final decision.For patients who received primary PCI, they were further categorized into two groups based on the 30min cut-off time.Results Among the 180 STEMI patients reviewed, 139 patients agreed to primary PCI and the remaining 41 patients refused primary PCI.Multivariate logistic analysis showed that symptom relief (OR 5.532, 95% CI 1.165-26.278, P=0.031) and history of chronic kidney disease (OR 4.786, 95% CI 1.346-17.011, P=0.016) were predictors of dissent of primary PCI.Self-rated symptoms severity (OR 0.094, 95% CI 0.034-0.260, P<0.001)was predictor of consent to primary PCI.106 patients had complete time point records of informed consent in the consent group (n=139).Among these patients, the median informed consent delay was 24 min.64 patients made a decision within 30 minutes, and the other 42 patients had their decision made beyond 30 minutes.Symptom-to-door time ≥4 hours (OR 4.563,95% CI 1.682-12.385, P=0.003) was independent predictor of informed consent delay.Conclusions Patients with resolved symptoms, self-rated mild symptoms or renal insufficiency were more inclined to refuse primary PCI.For patients who eventually received primary PCI, symptom-to-door time ≥4 hours was the independent predictor of informed consent delay.%目的 探讨急性ST段抬高心肌梗死(ST-segment elevation myocardial infarction, STEMI)患者拒绝或延迟签署直接经皮冠状动脉介入治疗(percutaneous coronary intervention, PCI)知情同意书的影响因素.方法 连续入选2014年8月至2016年3月经北京大学人民医院急/门诊初诊的急性STEMI患者229例.查阅病历和STEMI救治时间记录表并收集资料,将发病时间≤12 h的180例患者纳入最终研究对象,依据决策结果分为接受直接行PCI组和拒绝直接行PCI组,依据决策时间分为知情同意时间<30 min组和知情同意时间≥30 min组.采用单因素和多因素分析识别拒绝或延迟签署直接行PCI知情同意书的相关因素.结果 接受直接行PCI组139例,拒绝直接行PCI组41例.多因素logistic回归分析显示,症状缓解(OR 5.532, 95% CI 1.165~26.278, P=0.031)、症状剧烈(OR 0.094, 95%CI 0.034~0.260, P<0.001)、慢性肾病史(OR 4.786, 95%CI 1.346~17.011, P=0.016)是影响患者或亲属签署直接行PCI知情同意书的重要因素.接受直接行PCI组中救治时间点记录完整者106例,知情同意中位时间为24 min,其中知情同意时间<30 min者64例,知情同意时间≥30 min者42例.多因素logistic回归分析显示,症状至就诊时间≥4 h(OR 4.563,95%CI 1.682~12.385, P=0.003)是患者或亲属延迟签署直接行PCI知情同意书的影响因素.结论 发现症状缓解及合并慢性肾病患者更容易拒绝签署直接行PCI知情同意书,但症状剧烈的患者更易接受签署直接行PCI知情同意书,而对于最终接受直接行PCI的患者,症状至就诊时间≥4 h是直接行PCI知情同意书签署延迟的影响因素.