高龄老年患者冠状动脉介入治疗效果及风险评估

Evan Kurniawan　张瑞岩

200025 上海交通大学医学院附属瑞金医院心内科



高龄老年患者冠状动脉介入治疗效果及风险评估

Evan Kurniawan张瑞岩

200025 上海交通大学医学院附属瑞金医院心内科

【摘要】高龄老年冠状动脉粥样硬化性心脏病(冠心病)患者合并疾病多，冠状动脉病变复杂程度高，经皮冠状动脉介入治疗(PCI)并发症的发生率较高。对高龄老年患者PCI进行风险及预后评估非常重要。近年来，随着PCI操作技术及策略的改进，高龄老年患者PCI的成功率提高，相关并发症发生率也有所下降。该文对80岁以上的高龄老年冠心病患者接受PCI的疗效、手术风险、并发症及预后评估作一综述。

冠状动脉粥样硬化性心脏病(冠心病)是高龄老年人的首要死亡原因[1]，接受经皮冠状动脉介入治疗(PCI)的高龄老年冠心病患者比例逐年增高。80岁以上的冠心病患者行PCI手术风险增加，既往随机对照研究往往将该部分人群纳入排除标准[2-3]。本文介绍80岁以上的高龄老年冠心病人群PCI疗效、手术风险及并发症。

1高龄老年冠心病患者的临床特征

高龄老年冠心病患者往往合并肾功能不全、高血压、糖尿病、卒中等多种疾病[3-4]。研究发现，与年轻患者相比，高龄冠心病患者的高血压、脑血管疾病、外周血管疾病及肾功能衰竭发生率较高(高血压：61% 对 56%，脑血管疾病：14% 对 7.8%，外周血管疾病：15% 对 11%，肾功能衰竭：9.8%对4.8%；P<0.01)，且随着年龄的增长多支血管病变及复杂病变的发生率也明显升高[3]。另一项研究提示，年龄与冠状动脉钙化密切相关[5]。这些合并疾病及冠状动脉复杂病变导致高龄老年患者PCI的难度加大，并发症的发生率更高。

2高龄老年冠心病患者PCI的疗效

2.1PCI 与单纯药物治疗比较

TIME研究显示，稳定型心绞痛老年患者在药物治疗控制症状不佳时接受PCI，1年心血管不良事件发生率低于单纯药物治疗(19% 对49%，P= 0.0001)[6]。随访4年显示，接受PCI的高龄老年患者心血管不良事件发生率低于单纯药物治疗(37% 对68%，P< 0.001)[7]。这说明高龄老年冠心病患者接受PCI比单纯药物治疗效果更佳。

对高龄老年患者的临床疗效而言，维护及保留躯体功能是很重要的目标。接受PCI的高龄老年患者比单纯药物治疗患者的生活质量更好，且躯体功能及心绞痛症状改善比年龄较轻患者更明显。因此，高龄老年患者接受PCI获益更大[8]。

2.2PCI 与冠状动脉搭桥术(CABG)比较

目前，多支病变、左主干病变以及严重钙化病变是CABG的指征。近年来, 随着PCI操作技术的改进、桡动脉径路的普及、新一代药物支架的产生、新型双联抗血小板药物的出现及强化他汀类药物的使用，高龄冠心病患者PCI成功率升高(>90%)，同时PCI相关并发症显著减少[9]。一项荟萃分析收集了65 000余例高龄老年患者(>80岁)，结果显示，PCI组与CABG组30 d死亡率分别为5.4% 和7.3%，1年生存率分别为87%和86%，5年生存率分别为62% 和68%[10]。ASCERT研究显示，2支或3支血管稳定病变的高龄老年冠心病患者，上述两种血运重建策略的1年生存率无显著差异(6.5% 对6.2%)，但CABG组长期死亡率(随访4年)低于PCI组(16.4% 对20.8%)[11]。综合上述研究结果，对于高龄老年患者复杂病变，PCI与CABG的疗效相仿。

2.3特殊高龄老年患者PCI

研究提示，对于左主干病变患者，PCI与CABG的主要终点结果(死亡、心脑血管不良事件等)相仿。虽然PCI组再次血运重建比例较高，但CABG组脑卒中比例更高(1.5% 对4.3%，P= 0.03)[12]。Conrotto等[13]发现，左主干病变的高龄老年患者接受PCI及CABG术后远期死亡、脑血管意外及心肌梗死的发生率没有差异。

杂交手术是将左乳内动脉吻合于左前降支的旁路移植手术，并置入药物涂层支架处理非前降支病变，具有较高的远期通畅率[14]。高龄老年患者因多合并某些临床疾病难以耐受CABG术，可以考虑行杂交手术。

高龄老年非ST段抬高型心肌梗死(NSTEMI)患者应尽早接受血运重建治疗。Liistro等[15]发现，高龄NSTEMI患者未行早期血运重建治疗，死亡率及再次心肌梗死发生率均高于非高龄患者。GRACE 研究提示，高龄老年NSTEMI患者行PCI术后6个月的死亡率比保守治疗更低[16]。

目前临床上高龄老年ST段抬高型心肌梗死(STEMI)患者急性期PCI血运重建率较低，老年痴呆、急慢性肾衰竭是导致该结果的主要原因[17-18]。研究发现，高龄老年STEMI患者如在12 h内开通血管，超过90%的患者可恢复正常生活能力[19]。高龄老年患者在没有绝对禁忌证的情况下，应早期接受血运重建。

3围术期并发症

高龄冠心病患者病变更加复杂，临床合并症更多，并发症发生率也更高。研究显示，高龄老年冠心病患者PCI围术期并发症较年轻患者增加2～4倍[4]。这些围术期并发症包括死亡、心肌梗死、脑卒中、对比剂肾病及出血事件。

3.1对比剂肾病

PCI术后患者急性肾功能不全发生率达7%， 基线肾功能水平及造影剂用量是首要影响因素[20]。接受PCI的高龄老年患者，因基线肾功能较年轻患者差，其对比剂肾病的发生率较高，故需控制对比剂用量[21-22]。我国的专家共识推荐，术前6～12 h及术后4～12 h以100 mL/h的速度静脉输注生理盐水能降低对比剂肾病的发生率[23]。

3.2出血风险及抗血小板药物选择

高龄老年患者出血风险高于年轻患者[24]。研究发现，高龄老年患者凝血功能亢进，易引起急性支架内血栓形成，同时老年患者存在凝血调节功能退化，导致纤溶亢进，出血风险亦较高[25-27]。另外，高龄老年患者体质量偏轻，脂肪组织含量相对增加，对药物治疗的反应更敏感，进而放大不良反应。PCI后的抗血小板治疗是高龄老年患者出血的原因之一[28]。TRITON TIMI 38研究结果显示，虽然普拉格雷能降低19%的缺血事件发生率，但该药会导致出血风险上升32%，尤其是>75岁的老年患者出血风险更大，故不推荐>75岁的老年患者口服普拉格雷[29-30]。PLATO研究显示，对于年龄>80岁的患者，与氯吡格雷相比，替格瑞洛能降低心源性死亡、心肌梗死及中风等主要终点事件的发生率，且不增加出血风险。这提示替格瑞洛或许是老年患者PCI术后抗血小板的更佳药物[31]。

研究显示，与肝素相比，高龄老年患者应用比伐卢定能降低院内出血风险[32]。然而，一项随机对照试验的荟萃分析质疑了比伐卢定较肝素出血风险小的结论[33]。在绝大部分临床中心，肝素仍然是PCI术中抗血栓形成的基础药物之一。一项包括6个评估GP Ⅱb/Ⅲa受体拮抗剂疗效的大型临床试验荟萃分析表明，GP Ⅱb/Ⅲa受体拮抗剂的益处随着年龄的增加而下降，心血管净获益率下降<5%，但主要出血时间增加了70%[34]。因此，高龄老年患者应用此类药物时应酌情减量。

近年来，由于桡动脉穿刺并发症发生率较股动脉穿刺更低，介入医生倾向于选择桡动脉作为首选穿刺点。临床研究显示，高龄老年患者经桡动脉穿刺较经股动脉穿刺住院并发症发生率更低[35-37]。80岁以上患者经桡动脉穿刺行旋磨术治疗，手术成功率可达90%以上[38]。因此，高龄老年患者接受PCI治疗可以选择桡动脉穿刺途径。

4结语

对高龄老年冠心病患者，年龄不应该成为影响选择PCI治疗的决定因素。接受PCI的高龄老年患者需要根据其冠状动脉病变的严重程度、全身状态、血栓和出血风险，充分评估手术成功可能性、风险及预后。

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(收稿：2016-02-01修回：2016-02-25)

(本文编辑：梁英超)

doi:10.3969/j.issn.1673-6583.2016.02.005

通信作者：张瑞岩, Email: rjzhangruiyan@aliyun.com