本文選題：急性冠脈綜合征 + 急性心肌梗死��； 參考：《昆明醫(yī)科大學(xué)》2017年碩士論文

【摘要】：[目的]描述和評(píng)價(jià)2013年下半年至2016年上半年昆明地區(qū)急性冠脈綜合征(ACS)患者住院情況、臨床特征、院內(nèi)死亡率、死因構(gòu)成和救治策略的差異及變化趨勢(shì),以此反映區(qū)域范圍內(nèi)疾病的流行現(xiàn)況、救治水平,總結(jié)死亡病例特點(diǎn)和區(qū)域醫(yī)療救治經(jīng)驗(yàn),從而為臨床醫(yī)生及時(shí)識(shí)別具有高死亡可能性的病患、作出更具特異性和精準(zhǔn)性的醫(yī)療決策、避免死亡結(jié)局及進(jìn)一步降低ACS患者的院內(nèi)死亡率提供資料和依據(jù)。[方法]征得昆明地區(qū)10所具有冠心病介入診療資質(zhì)醫(yī)院的相關(guān)科室、研究生教學(xué)管理部門(mén)及病案管理部門(mén)的同意,通過(guò)各醫(yī)院的病案信息管理系統(tǒng)檢索并收集2013年07月01日至2016年06月30日期間出院診斷為ACS的患者的基礎(chǔ)信息,并對(duì)其中從心臟內(nèi)科出院、住院期間發(fā)生臨床死亡且符合準(zhǔn)入標(biāo)準(zhǔn)的死亡患者的病歷資料進(jìn)行回顧性調(diào)查分析。通過(guò)填寫(xiě)《昆明地區(qū)多中心急性冠脈綜合征死亡病例臨床研究病例報(bào)告表》,收集病例的社會(huì)人口學(xué)信息、臨床特征、救治策略和終點(diǎn)死亡事件發(fā)生情況;采用Epidata 3.1軟件,建立ACS死亡病例信息數(shù)據(jù)庫(kù),錄入數(shù)據(jù)后進(jìn)行統(tǒng)計(jì)分析。[結(jié)果]1.流行現(xiàn)況:(1)2013年07月01日至2016年06月30日期間昆明地區(qū)主要的10所具有冠心病介入診療資質(zhì)醫(yī)院的ACS患者出院總?cè)舜螖?shù)為31 896人次,其中以男性患者為主,共21 692人次(占比68.0%),出院患者平均年齡為(64. 8±12. 3)歲,平均住院天數(shù)為(9. 4±5. 5)天,出院診斷以不穩(wěn)定型心絞痛為主,比重為55. 3%,其余依次為ST段抬高型心肌梗死、非ST段抬高型心肌梗死、未詳細(xì)劃分的急性心肌梗死和未詳細(xì)劃分的ACS; (2) ACS院內(nèi)死亡率為2. 2%,ACS的院內(nèi)死亡率、男性院內(nèi)死亡率和女性院內(nèi)死亡率隨年齡的增大而上升(各趨勢(shì)P值均0.05),ACS的院內(nèi)死亡率、男性院內(nèi)死亡率、女性院內(nèi)死亡率、女性患者的比例、急性心肌梗死的比例在各時(shí)間段中的變化無(wú)統(tǒng)計(jì)學(xué)意義(各趨勢(shì)P值均0.05); (3)性別因素與ACS患者預(yù)后的差異無(wú)統(tǒng)計(jì)學(xué)意義(P0. 05),而年齡、住院天數(shù)、出院科室、出院診斷類型和出院時(shí)段的變化與ACS患者預(yù)后的差異具有統(tǒng)計(jì)學(xué)意義(P0. 01):過(guò)渡期組、老年組和高齡組相對(duì)中青年組ACS患者的預(yù)后差;2014年上半年、2014年下半年和2015年下半年相對(duì)2013年下半年ACS患者的預(yù)后好;住院2～3天、4～6天和7～14天相對(duì)≤1天的ACS患者的預(yù)后好;于非心內(nèi)科住院的ACS患者較于心內(nèi)科住院的ACS患者預(yù)后差;出院診斷為急性心肌梗死的患者較診斷為不穩(wěn)定型心絞痛的患者預(yù)后差,出院診斷為未詳細(xì)劃分的ACS的患者較診斷為不穩(wěn)定型心絞痛的患者預(yù)后好。2. ACS死亡病例分析:(1)昆明地區(qū)ACS住院患者死因前三位為心源性休克、機(jī)械并發(fā)癥和院內(nèi)合并癥,占比78.1%、8. 4%和5. 8%; (2) ACS死亡患者的主診斷以急性心肌梗死為主,占比94. 2% (ST段抬高型心肌梗死占71.1%,非ST段抬高型心肌梗死占21. 4%),其次為不穩(wěn)定型心絞痛和未詳細(xì)劃分的ACS; (3) ACS死亡患者發(fā)生的院內(nèi)不良事件前三位為嚴(yán)重的心律失常、急性心力衰竭和心臟結(jié)構(gòu)破壞,占比44. 3%、24. 5%和9. 7%; (4) ACS死亡患者中41. 0%接受了再灌注治療,59.0%未接受任何再灌注治療;(5) ACS死亡患者院內(nèi)抗血小板、抗凝、他汀類、ACEI/ARB和β受體阻滯劑藥物使用率分別為89. 5%、76. 0%、86. 5%、44.1%和46. 9%,其中β受體阻滯劑使用率隨時(shí)間變化逐漸下降(趨勢(shì)P值0. 05); (6)鎂劑在ACS死亡患者中使用率為43.4%,在AMI死亡患者中為43. 1%,在STEMI死亡患者中此比例達(dá)43. 6%; (7)中藥制劑在ACS死亡患者中使用率為71. 8%,在出現(xiàn)嚴(yán)重出血并發(fā)癥的患者中,活血類中藥制劑的使用率達(dá)68. 2%; (8) ACS死亡患者中49. 9%是通過(guò)急救醫(yī)療服務(wù)系統(tǒng)入院,50.1%采用了自行入院等其他方式求治;(9) ACS患者死亡日期趨近1月16日,標(biāo)準(zhǔn)差為1月9日(P0. 01 ),死亡晝夜時(shí)刻不存在集中趨勢(shì)(P0. 05)。[結(jié)論]1.昆明地區(qū)ACS住院患者基本特征與全國(guó)基本一致,沒(méi)有明顯的區(qū)域異質(zhì)性;2.昆明地區(qū)ACS住院患者主要以不穩(wěn)定型心絞痛為主,其次為ST段抬高型心肌梗死和非ST段抬高型心肌梗死,疾病構(gòu)成存在區(qū)域異質(zhì)性;3.昆明地區(qū)ACS住院患者死因前三位為心源性休克、機(jī)械并發(fā)癥和院內(nèi)合并癥,而死亡患者院內(nèi)不良事件前三位為嚴(yán)重的心律失常、急性心力衰竭和心臟結(jié)構(gòu)破壞;4.昆明地區(qū)ACS死亡患者再灌注率低;5.昆明地區(qū)ACS死亡患者藥物使用不規(guī)范,鎂劑和中藥制劑的不規(guī)范使用情況尤為突出;6.昆明地區(qū)EMS系統(tǒng)有效使用率低;7.昆明地區(qū)ACS患者死亡日期存在集中趨勢(shì),死亡時(shí)間集中于1月中旬。
[Abstract]:[Objective] to describe and evaluate the hospitalization of the patients with acute coronary syndrome (ACS) from the second half of 2013 to the first half of 2016, the clinical characteristics, the hospital mortality, the difference of the cause of death and the strategy of treatment, which reflect the prevalence of the disease in the region, the level of treatment, the characteristics of the death cases and the regional medical treatment. In order to help clinicians identify patients with high risk of death in time, make more specific and accurate medical decisions, avoid death outcomes and further reduce the hospital mortality in ACS patients. [Methods] to obtain the relevant departments of 10 qualified hospitals with coronary intervention in the Kunming area. With the consent of the graduate students' teaching management department and the medical record management department, the basic information of the patients who were diagnosed as ACS was retrieved and collected through the medical record information management system of each hospital during the period from 01 to 2016 2013 to 06 months of 2016. The patients were discharged from the cardiology department and died in the hospital during the hospitalization period and were in accordance with the standard of admission. The medical records of the patients were reviewed and analyzed. By filling in the report table of the clinical study of the death cases of acute coronary syndrome in the Kunming area, the social demography information, clinical features, treatment strategies and end-point death events were collected, and the Epidata 3.1 software was used to establish the ACS information database of death cases. Statistical analysis was carried out after data entry. [results]1. epidemic status: (1) the number of total number of patients discharged from ACS patients with coronary artery disease intervention at 30 days from 01 to 2016 2013 to 06 months in 2016 was 31896 people, including male patients, 21692 people (68%), and the average age of discharged patients was ( 64.8 + 12.3 years old, the average days of hospitalization were (9.4 + 5.5) days, and the discharge diagnosis was mainly unstable angina pectoris, and the proportion was 55.3%. The rest were ST segment elevation myocardial infarction, non ST segment elevation myocardial infarction, undivided acute myocardial infarction and undetailed division ACS; (2) the mortality of ACS hospital was 2.2%, and the mortality rate of ACS was in the hospital. The mortality of male hospital and the mortality of women in hospital increased with age (the P value of each trend was 0.05). The rate of hospital mortality in ACS, the mortality of male hospital, the mortality of women in hospital, the proportion of female patients, the ratio of acute myocardial infarction in each time period were not statistically significant (all the values of P were 0.05), and (3) sex factors and A There was no statistically significant difference in the prognosis of CS patients (P0. 05), but the difference between age, hospital days, discharge section, discharge diagnosis type and discharge period and the prognosis of ACS patients was statistically significant (P0. 01): the prognosis of ACS patients in the elderly group and the elderly group relative to the middle age group was poor; in the first half of 2014, the second half and 2015 in the second half of 2014. The prognosis of ACS patients in the second half of the year was better than that in the second half of 2013; the prognosis of ACS patients with 2~3 days in hospital, 4~6 days and 7~14 days relatively less than 1 days was better; the ACS patients hospitalized in the non Department of Cardiology had a poor prognosis compared with those in the Department of Cardiology hospitalized patients; the patients with acute myocardial infarction diagnosed as acute myocardial infarction were worse than those in the diagnosis of unstable angina pectoris. Patients with undivided ACS were compared with.2. ACS mortality in patients diagnosed with unstable angina pectoris: (1) the first three cases of ACS hospitalized patients in Kunming were cardiogenic shock, mechanical complications and nosocomial complications were 78.1%, 8.4% and 5.8%, and (2) the main diagnosis of ACS death patients with acute myocardial infarction The majority was 94.2% (71.1% with ST elevation myocardial infarction, 21.4% for non ST segment elevation myocardial infarction), followed by unstable angina and undivided ACS, and (3) severe arrhythmia, acute heart failure and cardiac structural damage before hospital adverse events in ACS deaths, 44.3%, 24.5%, and 9.7%. (4) of the patients with ACS death, 41% received reperfusion therapy, and 59% did not receive any reperfusion therapy; (5) the use of antiplatelet, anticoagulant, statins, ACEI/ARB and beta blockers in patients with ACS death were 89.5%, 76%, 86.5%, 44.1% and 46.9%, respectively, and the use of beta blockers gradually decreased with time. The potential P value was 0.05); (6) the use rate of magnesium was 43.4% in patients with ACS death, 43.1% in AMI deaths and 43.6% in STEMI deaths; (7) the use rate of traditional Chinese medicine in ACS died patients was 71.8%, and in patients with severe bleeding complications, the use of traditional Chinese medicine preparation was 68.2%; (8) ACS death patients. 49.9% were hospitalized through the first aid medical service system, and 50.1% were treated by self admission. (9) the death date of ACS patients reached January 16th, the standard deviation was January 9th (P0. 01), and the day and night time of death did not exist (P0. 05). [conclusion the basic characteristics of ACS inpatients in]1. Kunming area were basically consistent with the country, and there was no obvious difference. 2. ACS inpatients in Kunming area were mainly unstable angina pectoris, followed by ST segment elevation myocardial infarction and non ST segment elevation myocardial infarction, the disease composition existed regional heterogeneity; 3. the first three cases of ACS hospitalized patients in Kunming area were cardiogenic Hugh, mechanical complication and hospital complication, and death patients Before the hospital adverse events, three were serious arrhythmia, acute heart failure and heart structural damage; 4. the rate of ACS death in Kunming was low; 5. in Kunming area, ACS death patients were unstandardized, and the unstandardized use of magnesium and traditional Chinese medicine preparations was particularly prominent; 6. in Kunming area, the effective use rate of EMS system was low; 7. Kunming land. The death date of ACS patients was concentrated in the middle of January.

【學(xué)位授予單位】：昆明醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.4

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