衰弱对住院老年冠心病患者短期预后的影响:前瞻性队列研究Impact of Frailty on the Short-term Prognosis of Hospitalized Elderly Patients with Coronary Heart Disease:A Prospective Cohort Study
张宁;朱文玲;刘晓红;陈伟;康军仁;朱鸣雷;田然;
ZHANG Ning;ZHU Wen-ling;LIU Xiao-hong;CHEN Wei;KANG Jun-ren;ZHU Ming-lei;TIAN Ran;Department of Geriatrics,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;Department of Cardiology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;Department of Clinical Nutrition,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;
摘要(Abstract):
目的探讨衰弱对住院老年冠心病患者短期预后的影响。方法前瞻性收集并分析2017年12月至2018年11月在北京协和医院住院治疗的老年冠心病患者临床资料。根据是否合并衰弱,将患者分为衰弱组和非衰弱组。对两组患者随访,终点事件包括非常规就诊、主要不良心脑血管事件(major adverse cardiac and cerebral events,MACCE)、全因死亡。采用多因素Cox回归分析衰弱与冠心病患者预后的关系。绘制两组无MACCE的Kaplan-Meier生存曲线,并采用Log-Rank检验进行比较。结果共345例符合纳入和排除标准的老年冠心病患者入选本研究,包括稳定性冠心病250例,急性冠状动脉综合征95例。衰弱组74例(21.4%),其中轻度衰弱38例、中度衰弱36例,非衰弱组271例(78.6%)。中位随访时间351(300, 394)d,失访3例。与非衰弱组比较,衰弱组非常规就诊发生率(36.1%比21.5%)、全因死亡率(11.1%比4.1%)均升高(P均<0.05),MACCE发生率(9.7%比4.8%)无显著差异(P>0.05)。多因素Cox回归分析结果显示,轻度和中度衰弱是稳定性冠心病患者全因死亡的危险因素(HR=4.169,95%CI:1.055~16.474,P=0.042),对其非常规就诊(HR=1.704,95%CI:0.947~3.066,P=0.075)、MACCE(HR=1.268,95%CI:0.331~4.863,P=0.729)无显著影响。在急性冠状动脉综合征患者中,轻度和中度衰弱对其非常规就诊(HR=1.159,95%CI:0.342~3.924,P=0.812)、MACCE(HR=0.822,95%CI:0.092~7.369,P=0.861)及全因死亡(HR=1.445,95%CI:0.210~9.964,P=0.708)均无显著影响。Kaplan-Meier生存曲线显示,衰弱组和非衰弱组患者的无MACCE生存曲线无显著差异(P>0.05)。结论住院老年冠心病患者合并轻中度衰弱的比率较高,其可能增加稳定性冠心病患者近期死亡风险。
Objective To analyze the effect of frailty on the short-term prognosis of hospitalized older patients with coronary heart disease. Methods The clinical data were prospectively collected and analyzed in elderly patients with coronary heart disease that were hospitalized in Peking Union Medical College Hospital from December 2017 to November 2018. According to whether they were combined with frailty, the patients were divided into frailty group and non-frailty group.All the patients were followed up, and endpoint events included unscheduled return visits, major adverse cardiac and cerebral events(MACCE), and death from all causes. Multivariate Cox regression was used to analyze the relationship between frailty and the prognosisof patients with coronary heart disease. The Kaplan-Meier method and Log-Rank test were used to compare the MACCE-free survival curves between patients with and without frailty. Results A total of 345 elderly patients with coronary heart disease who met the inclusion and exclusion criteria were selected for this study, including 250 cases of stable coronary heart disease and 95 cases of acute coronary syndrome. There were 74 cases(21.4%) in the frailty group including 38 cases of mild frailty and 36 cases of moderate frailty, and 271 cases(78.6%) in the non-frailty group. The median follow-up time was 351(300, 394) days, and 3 cases were lost to follow-up. Compared with the non-frailty group, the incidence of unscheduled return visits(36.1% vs. 21.5%) and all-cause mortality(11.1% vs. 4.1%) in the frailty group increased(all P<0.05), and there is no significant difference in the incidence of MACCE(9.7 % vs. 4.8%) between the two groups(P>0.05). The results of multivariate Cox regression analysis showed that mild and moderate frailty were risk factors for all causes of death in patients with stable coronary heart disease(HR=4.169, 95% CI: 1.055-16.474, P=0.042), but had no significant effect on unscheduled return visits(HR=1.704, 95% CI: 0.947-3.066, P=0.075) and MACCE(HR=1.268, 95% CI: 0.331-4.863, P=0.729). In patients with acute coronary syndrome, mild and moderate frailty had no significant effect on unscheduled return visits(HR=1.159, 95% CI: 0.342-3.924, P=0.812), MACCE(HR=0.822, 95% CI: 0.092-7.369, P=0.861) and death from all causes(HR=1.445, 95% CI: 0.210-9.964, P=0.708). The Kaplan-Meier curve showed that there was no significant in the MACCE-free survival curve between the two groups(P>0.05). Conclusions The prevalence of mild and moderate frailty in hospitalized older patients with coronary heart disease is high, which may increase the risk of short-term mortality for those with stable coronary heart disease.
关键词(KeyWords):
老年;冠心病;衰弱;预后
elderly;coronary heart disease;frailty;prognosis
基金项目(Foundation): 中国医学科学院医学与健康科技创新工程(2018-I2M-1-002)~~
作者(Author):
张宁;朱文玲;刘晓红;陈伟;康军仁;朱鸣雷;田然;
ZHANG Ning;ZHU Wen-ling;LIU Xiao-hong;CHEN Wei;KANG Jun-ren;ZHU Ming-lei;TIAN Ran;Department of Geriatrics,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;Department of Cardiology,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;Department of Clinical Nutrition,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences & Peking Union Medical College;
Email:
DOI:
参考文献(References):
- [1]Nú1ez J,Palau P,Sastre C,et al.Sex-differential effect of frailty on long-term mortality in elderly patients after an acute coronary syndrome[J].Int J Cardiol,2020,302:30-33.
- [2]陈旭娇,严静,王建业,等.老年综合评估技术应用中国专家共识[J].中华老年医学杂志,2017,36:471-477.[2]Chen XJ,Yan J,Wang JY,et al.Chinese experts consensus on application of comprehensive geriatric assessment[J].Zhonghua Lao Nian Yi Xue Za Zhi,2017,36:471-477.
- [3]李杰,程秀丽,关向荣,等.住院患者老年综合征发生率及评估分析[J].中华老年医学杂志,2017,36:266-268.[3]Li J,Cheng XL,Guan XR,et al.Incidence and evaluation of geriatric syndromes in hospitalized patients[J].Zhonghua Lao Nian Yi Xue Za Zhi,2017,36:266-268.
- [4]Arik G,Varan HD,Yavuz BB,et al.Validation of Katz index of independence in activities of daily living in Turkish older adults[J].Arch Gerontol Geriatr,2015,61:344-350.
- [5]Bier N,Belchior Pda C,Paquette G,et al.The Instru-mental Activity of Daily Living Profile in Aging:A Feasibility Study[J].J Alzheimers Dis,2016,52:1361-1371.
- [6]Charlson ME,Pompei P,Ales KL,et al.A new method of classifying prognostic comorbidity in longitudinal studies:development and validation[J].J Chronic Dis,1987,40:373-383.
- [7]陈阳希,史兆荣,朱小蔚,等.共病状态评估工具的临床应用及研究进展[J].中华老年多器官疾病杂志,2017,16:147-151.[7]Chen YX,Shi ZR,Zhu XW,et al.Clinical application and progress of testing and assessments for comorbidity[J].Zhonghua Lao Nian Duo Qi Guan Ji Bing Za Zhi,2017,16:147-151.
- [8]Koren-Hakim T,Weiss A,Hershkovitz A,et al.Comparing the adequacy of the MNA-SF,NRS-2002 and MUST nutritional tools in assessing malnutrition in hip fracture operated elderly patients[J].Clin Nutr,2016,35:1053-1058.
- [9]Rockwood K,Song X,Mac Knight C,et al.A global clinical measure of fitness and frailty in elderly people[J].CMAJ,2005,173:489-495.
- [10]Chen TY,Janke MC.Predictors of falls among communitydwelling older adults with cancer:results from the health and retirement study[J].Support Care Cancer,2014,22:479-485.
- [11]Singh M,Rihal CS,Lennon RJ,et al.Influence of Frailty and Health Status on Outcomes in Patients with Coronary Disease Undergoing Percutaneous Revascularization[J].Circ Cardiovasc Qual Outcomes,2011,4:496-502.
- [12]Bariani GM,de Celis Ferrari AC,Precivale M,et al.Sample Size Calculation in Oncology Trials:Quality of Reporting and Implications for Clinical Cancer Research[J].Am J Clin Oncol,2014,38:570-574.
- [13]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性ST段抬高型心肌梗死诊断和治疗指南[J].中华心血管病杂志,2015,43:380-393.[13]Cardiovascular Society of Chinese Medical Association.Guidelines for diagnosis and treatment of acute ST segment elevation myocardial infarction[J].Zhonghua Xin Xue Guan Bing Za Zhi,2015,43:380-393.
- [14]中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组.中国急性缺血性脑卒中诊治指南2014[J].中华神经科杂志,2015,48:246-257.[14]Neurology Society of Chinese Medical Association.Guidelines for diagnosis and treatment of Acute Ischemic Stroke in China 2014[J].Zhonghua Shen Jing Ke Za Zhi,2015,48:246-257.
- [15]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.急性心力衰竭诊断和治疗指南[J].中华心血管病杂志,2010,38:195-208.[15]Cardiovascular Society of Chinese Medical Association.Guidelines for diagnosis and treatment of acute heart failure[J].Zhonghua Xin Xue Guan Bing Za Zhi,2010,38:195-208.
- [16]Tse G,Gong M,TNunez J,et al.Frailty and Mortality Outcomes After Percutaneous Coronary Intervention:ASystematic Review and Meta-Analysis[J].J Am Med Dir Assoc,2017,18:1097.e1-1097.e10.
- [17]Veronese N,Cereda E,Stubbs B,et al.Risk of cardiovascular disease morbidity and mortality in frail and pre-frail older adults:Results from a meta-analysis and exploratory meta-regression analysis[J].Ageing Res Rev,2017,35:63-73.
- [18]Ekerstad N,Swahn E,Janzon M,et al.Frailty is independently associated with short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction[J].Circulation,2011,124:2397-2404.
- [19]Ekerstad N,Swahn E,Janzon M,et al.Frailty is independently associated with 1-year mortality for elderly patients with non-ST-segment elevation myocardial infarction[J].Eur JPrev Cardiol,2014,21:1216-1224.
- [20]康琳,朱鸣雷,刘晓红,等.衰弱与老年人冠状动脉粥样硬化性心脏病的相关性研究[J].中华老年医学杂志,2015,34:951-955.[20]Kang L,Zhu ML,Liu XH,et al.Correlation between frailty and coronary heart disease in the elderly[J].Zhonghua Lao Nian Yi Xue Za Zhi,2015,34:951-955.
- [21]Kang L,Zhang SY,Zhu WL,et al.Is frailty associated with short-term outcomes for elderly patients with acute coronary syndrome?[J].J Geriatr Cardiol,2015,12:662-667.
- [22]苏琳凡,张宁,王倩,等.皮疹,心力衰竭,肾功能不全,嗜酸性粒细胞增多:一例高龄衰弱老年患者[J].协和医学杂志,2020,11:479-485.[22]Su LF,Zhang N,Wang Q,et al.Rash,Heart Failure,Renal Insufficiency,and Hypereosinophilia in an Elderly Frail Male[J].Xie He Yi Xue Za Zhi,2020,11:479-485.
- [23]Kang L,Gao Y,Liu XH,et al.Effects of whey protein nutritional supplement on muscle function among communitydwelling frail older people:A multicenter study in China[J].Arch Gerontol Geriatr,2019,83:7-12.
- 张宁
- 朱文玲
- 刘晓红
- 陈伟
- 康军仁
- 朱鸣雷
- 田然
ZHANG Ning- ZHU Wen-ling
- LIU Xiao-hong
- CHEN Wei
- KANG Jun-ren
- ZHU Ming-lei
- TIAN Ran
- Department of Geriatrics
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College
- Department of Cardiology
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College
- Department of Clinical Nutrition
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College
- 张宁
- 朱文玲
- 刘晓红
- 陈伟
- 康军仁
- 朱鸣雷
- 田然
ZHANG Ning- ZHU Wen-ling
- LIU Xiao-hong
- CHEN Wei
- KANG Jun-ren
- ZHU Ming-lei
- TIAN Ran
- Department of Geriatrics
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College
- Department of Cardiology
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College
- Department of Clinical Nutrition
- Peking Union Medical College Hospital
- Chinese Academy of Medical Sciences & Peking Union Medical College