【作者】 张健；

【导师】 林文华；

【作者基本信息】 天津医科大学 ， 临床医学（专业学位）， 2020， 硕士

【摘要】 研究目的坚持优化药物治疗是预防冠心病患者PCI术后动脉粥样硬化斑块进展的关键因素,如何识别PCI术后优化药物治疗依从性较差的人群非常重要,目前需要更多的证据来分析冠心病患者PCI术后应用优化药物治疗的预测因素。因此,我们通过本研究通过对我院确诊为ACS且行PCI的术者进行随访,记录冠心病患者PCI术后OMT的应用情况,分析其出院后非OMT的预测因素,通过识别出非OMT人群,从而为临床实践提供指导。研究方法本研究前瞻性收集2016.10-2017.09在泰达国际心血管病医院心内科确诊为ACS并接受PCI的患者共2240例,记录其入院时的基线资料及出院后1个月,6个月,12个月的OMT使用情况。根据患者出院后12个月的应用OMT的情况及基线危险因素进行分析,并建立Logistic回归模型计算非OMT的预测因素。应用SPSS 22.0进行数据统计分析,P<0.05差异有统计学意义。研究结果1、OMT应用现状:2132例PCI术后ACS患者住院期间阿司匹林片、P2Y12受体拮抗剂、他汀类降脂药物、β受体阻滞剂和ACEI/ARB的使用率分别为99.5%、100%、96.1%、76.7%和79.7%。随着时间的延长,OMT各组分药物的使用率均呈逐渐下降趋势,随访12个月时分别下降至96.2%、98.2%、84.0%、63.1%和64.5%,尤以ACEI/ARB类和β受体阻滞剂的下降幅度最大,但抗血小板药物使用比例仍超过90%。基线OMT比例为64.5%,随访12个月坚持OMT的患者有46.2%,下降幅度为28.4%。2、非OMT影响因素单因素分析筛选出基线OMT(P<0.001)、工作状况(P<0.05)、是否为多支病变(P<0.001)、吸烟情况(P<0.05)、既往PCI史(P<0.05)、高血压史(P<0.001)、2型糖尿病史(P<0.001)、高脂血症史(P<0.001)、合并疾病数量(P<0.001)、BMI值(P<0.05)对非OMT均有统计学差异,但是经多因素Logistic回归分析后发现基线非OMT(OR=1.520P<0.001),在岗职工(OR=1.443 P<0.05),单支血管病变(OR=1.259 P<0.05),无吸烟史(OR=1.283 P<0.05),首次接受PCI治疗(OR=1.304 P<0.05),无高血压(OR=4.330 P<0.001),高脂血症(OR=1.671 P<0.001),2型糖尿病病史(OR=1.493 P<0.05)是ACS患者PCI术后非OMT的预测因素。研究结论1、患者的住院期间及出院后OMT的使用率与循证指南推荐仍存在差距,并且随着出院时间的延长,OMT的使用率逐渐下降,其中ACEI/ARB、β受体阻滞剂的使用需要值得更加关注。2、基线非OMT,在岗职工,单支血管病变,无吸烟史,首次接受PCI治疗,无高血压,高脂血症,2型糖尿病病史是ACS患者PCI术后非OMT的预测因素。3、通过对ACS患者PCI术后非OMT的预测因素,识别并加强对非OMT的人群管理,提高术后OMT应用比例。更多还原

【Abstract】 ObjectiveAdherence to optimal medical therapy(OMT)is a key factor in preventing the progression of atherosclerotic plaque in patients with coronary heart disease after PCI.How to identify the population with poor compliance with optimal medical therapy after PCI is very important.At present,more evidence is needed to analyze the predictive factors of optimal medical therapy in acute coronary syndrome(ACS)patients after PCI.Therefore,in our study,we followed up the patients diagnosed with ACS and undergoing PCI in our hospital.Besides,we recorded the application of OMT in patients with coronary heart disease after PCI and analyzed the predictive factors of Non-OMT after discharge,and identified the Non-OMT population.Thus,we can provide guidance for clinical practice.MethodsThis study collected a total of 2240 patients diagnosed with ACS and undergoing PCI in the department of cardiology,TEDA international cardiovascular hospital from October 2016 to September 2017,and recorded their baseline data at admission and their OMT use at 1,6 and 12 months at discharge.According to the application of OMT during 12 months and baseline risk factors,a Logistic regression model was established to calculate the predictive factors of OMT.SPSS 22.0 was used for data statistical analysis,P<0.05 showed statistically significant differences.Results1.Application status of OMT: the utilization rates of aspirin tablets,P2Y12 receptor antagonists,statins,beta blockers and ACEI/ARB were 99.5%,100%,96.1%,76.7% and 79.7% respectively in 2132 ACS patients during the period of hospital after PCI.With the extension of discharge time,the utilization rate of each component of OMT showed a gradual decline,and decreased to 96.2%,98.2%,84.0%,63.1% and 64.5% at the 12 months of follow-up,with ACEI/ARB and beta blockers showing the greatest decrease,but the use rate of anti-platelet drugs still exceeded 90%.The proportion of baseline OMT was 64.5%,and 46.2% of patients who adhered to OMT after 12 months and showed a decrease of 28.4%.2.Single factor analysis of non-OMT influencing factors showed that Baseline OMT(P<0.001),Working status(P<0.05),Whether it was multi-vessel disease(P <0.001),Smoking status(P <0.05),Previous PCI history(P<0.05)),History of hypertension(P<0.001),History of type 2 diabetes(P<0.001),History of hyperlipidemia(P <0.001),Number of comorbidities(P<0.001),BMI value(P<0.05)Above all was statistical differences in OMT.But after multivariate logistic regression analysis,it was found that the baseline was non-OMT(OR=1.520 P<0.001),on-the-job workers(OR=1.443 P<0.05),and single vessel disease(OR=1.259 P<0.05),No smoking history(OR=1.283 P<0.05),first PCI treatment(OR=1.304 P<0.05),no hypertension(OR=4.330 P<0.001),hyperlipidemia(OR=1.671 P<0.001),A history of type 2 diabetes(OR=1.493 P<0.05)is a predictor of non-OMT after PCI in ACS patients.Conclusions1.There is still a gap between the utilization rate of OMT and the recommendation of evidence-based guidelines during the hospitalization and after the discharge,and the utilization rate of OMT gradually declines with the extension of discharge time.2.Baseline non-OMT,working staff,single vessel disease,no history of smoking,first PCI treatment,no hypertension,hyperlipidemia,and history of type 2 diabetes are non-OMT predictors of ACS patients after PCI.3.Identify and strengthen non-OMT population management by predicting factors for non-OMT after PCI in ACS patients,so we can increase the proportion of postoperative OMT application.更多还原