中国老年患者经桡动脉与股动脉介入治疗比较

doi:10.24920/J1001-9294.2017.023

摘要/Abstract

摘要：

目的从院内费用和临床结果两方面对65岁以上老年患者经桡动脉与股动脉路径行经皮冠状动脉介入治疗（percutaneous coronary intervention，PCI）进行比较和评价，为老年患者介入路径选择提供临床和卫生经济学依据。方法本研究为回顾性研究，共纳入阜外医院2010年1月1日至2010年12月31日收治的1229例年龄>65岁的PCI病例。其中，经桡动脉路径介入治疗（transradial intervention，TRI）1033例，经股动脉路径介入治疗（transfemoral intervention，TFI）196例。研究使用倾向性评分的逆概率加权法（inverse probability weighting，IPW）对两种路径的患者院内费用和临床结局进行了比较。依据出血学术研究联合会标准，对出血并发症及主要不良心血管事件（包括院内全因死亡、心肌梗死、住院期间再次血运重建及BARC分级≥3）进行了比较。结果与TFI组相比，TRI组患者平均年龄较低，女性患者所占比例较低，且既往心肌梗死、既往冠状动脉旁路移植术史、既往PCI及既往卒中病史均较少。造影结果提示TRI组患者单支病变比例较高，而开口病变比例则较低。IPW调整后，TRI组患者的院内费用明显低于TFI组，差值为CNY7495（95%CI：4419-10420，P<0.0001），造成住院费用差异的主要原因是TRI组患者PCI术中花费较低。IPW调整后TRI组患者住院时间较短（差值=1.9 d，95%CI：1.1-2.7，P<0.0001），且主要不良心血管事件较少（OR=0.47，95%CI：0.31-0.73，P<0.001）。IPW调整前后，两组患者出血并发症的差异在无统计学意义（P>0.05）。结论与股动脉路径PCI相比，桡动脉路径可降低65岁以上老年患者院内费用，缩短住院时间，减少主要不良心血管事件的发生。

关键词: 老年, 股动脉路径, 桡动脉路径, 经皮冠状动脉介入治疗, 费用

Abstract: Objective

To compare hospital costs and clinical outcomes between transradial intervention (TRI) and transfemoral intervention (TFI) in elderly patients aged over 65 years.

Methods

We identified 1229 patients aged over 65 years who underwent percutaneous coronary intervention (PCI) in Fuwai Hospital, Beijing, China, between January 1 and December 31, 2010. Total hospital costs and in-hospital outcomes were compared between TRI and TFI. An inverse probability weighting (IPW) model was introduced to control potential biases.

Results

Patients who underwent TRI were younger, less often female, more likely to receive PCI for single-vessel lesions, and less likely to undergo the procedure for ostial lesions. TRI was associated with a cost saving of CNY7495 (95%CI: CNY4419-10 420). Such differences were mainly driven by lower PCI-related costs. TRI patients had shorter length of stay (1.9 days, 95%CI: 1.1-2.7 days), shorter post-procedural stay (0.7 days, 95%CI: 0.3-1.1 days), and fewer major adverse cardiac events (adjusted odds ratio = 0.47, 95%CI: 0.31-0.73). There was no statistical significance in the incidence of post-PCI bleeding between TRI and TFI (P>0.05). Such differences remained consistent in clinically relevant subgroups of acute myocardial infarction, acute coronary syndrome, and stable angina.

Conclusion

The use of TRI in patients aged over 65 years was associated with significantly reduced hospital costs and more favorable clinical outcomes.

Key words: coronary artery disease, cost-benefit analysis, percutaneous coronary intervention, aged, transradial intervention, transfemoral intervention

Jin Chen, Xu Yi, Qiao Shu-bin, Tang Xin-ran, Wu Yong-jian, Yan Hong-bing, Dou Ke-fei, Xu Bo, Yang Jin-gang, Yang Yue-jin. Transradial Versus Transfemoral Approach for Percutaneous Coronary Intervention in Elderly Patients in China: A Retrospective Analysis[J].Chinese Medical Sciences Journal, 2017, 32(3): 161-170.

图/表 5

Items	TRI group	TFI group	Unadjusted OR (95%CI)	Adjusted OR (95%CI)	P value
Acute myocardial infarction
n	176	23
Total hospital costs [mean (95%CI), CNY]	64 002 (57 669-71 031)	79 265 (66 717-94 173)	-15 263 (-27 826, 368)^*	-9812 (-21 200, 4020)^*	0.153
MACE [n (%)]	6 (3.4)	1 (4.3)	0.78 (0.32, 1.86)	0.66 (0.26, 1.71)	0.396
BARC ≥2 bleeding [n (%)]	19 (10.8)	3 (13.0)	0.81 (0.31, 2.10)	1.51 (0.51, 4.51)	0.460
BARC ≥3 bleeding [n (%)]	4 (2.3)	1 (4.3)	0.51 (0.12, 2.23)	0.42 (0.09, 2.06)	0.284
Length of stay [mean (95%CI), d]	9.2 (8.2-10.3)	11.2 (9.2-13.6)	-2.0 (-4.0, 0.5)^*	-1.0 (-3.6, 2.5)^*	0.525
Postprocedural stay [mean (95%CI), d]	4.9 (4.1-6.0)	6.2 (4.8-8.0)	-1.3 (-2.7, 0.7)^*	-0.7 (-2.2, 1.4)^*	0.462
Acute coronary syndrome
n	730	133
Total hospital costs [mean (95%CI), CNY]	58 225 (54 095-62 671)	71 725 (66 068-77 866)	-13 500 (-17 101, -9661)^*	-12,508 (-17,524, -7023)^*	<0.001
MACE [n (%)]	20 (2.7)	8 (6.0)	0.44 (0.26, 0.74)	0.41 (0.25, 0.68)	<0.001
BARC ≥2 bleeding [n (%)]	60 (8.2)	12 (9.0)	0.90 (0.57, 1.44)	1.12 (0.68, 1.85)	0.657
BARC ≥3 bleeding [n (%)]	10 (1.4)	5 (3.8)	0.36 (0.15, 0.82)	0.30 (0.13, 0.74)	0.008
Length of stay [mean (95%CI), d]	6.9 (6.4-7.5)	9.4 (8.1-10.9)	-2.3 (-3.2, -1.7)^*	-2.6 (-3.5, -1.5)^*	<0.001
Post procedural stay [mean (95%CI), d]	3.7 (3.2-4.1)	4.4 (3.7-5.3)	-0.8 (-1.2, -0.2)^*	-1.0 (-1.5, -0.4)^*	0.001
Stable angina
n	274	56
Total hospital costs [ mean (95%CI), CNY]	61 039 (56 774-65 624)	63 460 (55 034-73 177)	-2422 (-8381, 4183)^*	3710 (-2818, 11 009)^*	0.277
MACE [n (%)]	10 (3.6)	3 (5.4)	0.67 (0.27, 1.69)	0.68 (0.24, 1.90)	0.462
BARC ≥2 bleeding [n (%)]	18 (6.6)	5 (8.9)	0.72 (0.28, 1.86)	0.66 (0.18, 2.41)	0.533
BARC ≥3 bleeding [n (%)]	2 (0.7)	1 (1.8)	0.40 (0.04, 3.95)	0.73 (0.07, 7.56)	0.791
Length of stay [mean (95%CI), d]	6.1 (5.5-6.7)	8.1 (6.8-9.6)	-2.0 (-2.7, -1.2)^*	-0.7 (-1.5, -0.2)^*	0.133
Post-procedural stay [mean (95%CI), d]	3.5 (2.9-4.1)	3.8 (3.0-4.7)	-0.3 (-0.7, 0.1)^*	-0.2 (-0.5, 0.2)^*	0.430

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Characteristics	TRI group	TFI group	Standardized difference
n	1033	96	18.5
Age^§ (yrs)	71.0±8.4	71.7±3.9
Female [n (%)]	361 (34.9)	98 (50.0)	30.8
Medical history
Myocardial infarction [n (%)]	174 (16.8)	44 (22.4)	14.1
Prior CABG [n (%)]	12 (1.2)	19 (9.7)	38.3
Prior PCI [n (%)]	179 (17.3)	56 (28.6)	27.0
Stroke [n (%)]	107 (10.4)	27 (13.8)	10.5
Diabetes mellitus [n (%)]	278 (26.9)	72 (36.7)	21.2
Hypertension [n (%)]	711 (68.8)	141 (71.9)	6.8
Hyperlipidemia [n (%)]	623 (60.3)	110 (59.2)	2.3
Diagnosis
STEMI [n (%)]	131 (12.7)	15 (7.7)	16.7
NSTEMI [n (%)]	45 (4.4)	8 (4.1)	1.4
Unstable angina [n (%)]	554 (53.6)	110 (56.1)	5.0
Stable angina [n (%)]	274 (26.5)	56 (28.6)	4.6
Vital signs
Heart rate^§ (bpm)	69.1±10.6	69.1±8.7	0.1
Systolic blood pressure^§ (mm Hg)	132.2±17.8	132.7±18.8	2.6
Diastolic blood pressure^§ (mm Hg)	77.3±24.0	76.2±9.9	6.0
LVEF^§ (%)	62.2±7.6	60.8±7.9	17.9
Creatinine^§ (μmol/L)	84.4±20.7	84.1±21.4	1.2

Characteristics	TRI group	TFI group	Standardized difference
n	1033	196
Artery sheath size^§(F)	6.0±0.2	6.1±0.3	33.5
Diseased coronary vessels	978	171
Single vessel [n (%)]	236 (24.1)	31 (18.1)	14.7
Double vessel [n (%)]	344 (35.2)	63 (36.8)	3.5
Triple vessel [n (%)]	398 (40.7)	77 (45.0)	8.8
Left main disease [n (%)]	69 (7.1)	15 (8.8)	6.4
Lesion type
De novo [n (%)]	1334 (98.4)	252 (95.8)	15.3
Intra stent [n (%)]	17 (1.3)	5 (1.9)	5.2
Restenosis [n (%)]	5 (0.4)	6 (2.3)	16.8
Lesion location
Ostial lesion [n (%)]	160 (11.6)	47 (17.6)	16.9
Bifurcation lesion [n (%)]	430 (31.4)	95 (35.4)	8.6
Number of treated lesion Median (IQR)	1 (1-2)	1 (1-2)	9.9
Number of stents used Median (IQR)	2 (1-2)	2 (1-2)	4.8
Stent type			9.1
Drug-eluting only [n (%)]	1030 (99.7)	194 (99.0)
Drug-eluting and bare metal [n (%)]	3 (0.3)	2 (1.0)
Domestic vs. imported stents			7.0
Domestic only [n (%)]	544 (52.7)	110 (56.1)
Imported only [n (%)]	462 (44.7)	81 (41.3)
Domestic and imported [n (%)]	27 (2.6)	5 (2.6)
Intravascular ultrasound [n (%)]	30 (2.9)	14 (5.3)	16.4
Vascular closure devices [n (%)]	0 (0)	141 (71.9)	226.4

Items	TRI group	TFI group	Unadjusted OR (95%CI)	Adjusted OR (95%CI)	P value
n	1033	196
Hospital costs [mean (95%CI), CNY]
Total cost	59 044 (54 995-63 392)	68 997 (63 172-75 359)	-9953 (-12 610 to -7171)^*	-7495 (-10 420 to -4419)^*	<0.0001
PCI-related costs	44 411 (41 604-47 407)	50 363 (46 865-54 122)	-5952 (-7770 to -4057)^*	-4067 (-6321 to -1693)^*	0.0010
Hospitalization costs	4950 (4241-5777)	6711 (5585-8062)	-1761 (-2344 to -1100)^*	-1394 (-2030 to -667)^*	0.0004
Medication costs	4653 (4273-5067)	6080 (5015-7372)	-1427 (-2015 to -754)^*	-1360 (-2003 to 614)^*	0.0007
Examination costs	5028 (4496-5622)	5833 (5144-6615)	-806 (-1243, -327)^*	-671 (-1146 to -147)^*	0.0133
Clinical outcomes [n (%)]
MACE	30 (2.9)	11 (5.6)	0.50 (0.35-0.73)	0.47 (0.31-0.73)	<0.001
BARC ≥2 bleeding	80 (7.7)	17 (8.7)	0.88 (0.59-1.33)	0.98 (0.64-1.52)	0.940
BARC ≥3 bleeding	12 (1.2)	6 (3.1)	0.37 (0.13-1.06)	0.34 (0.12-1.01)	0.051
Length of stay [mean (95%CI), d]	6.7 (6.2-7.3)	8.9 (7.6, 10.4)	-2.2 (-2.8 to -1.4)^*	-1.9 (-2.7 to -1.1)^*	<0.0001
Post-procedural stay [mean (95%CI), d]	3.6 (3.2-4.1)	4.2 (3.4, 5.1)	-0.6 (-1.0 to -0.1)^*	-0.7 (-1.1 to -0.3)^*	0.0017

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