Single-center Research Of Prognosis And Relational Factors Of Coronary Heart Disease In PUMCH

【Objective】This retrospective cohort study is designed to analyse the effects of cardiovascular risk factors, blood biochemistry parameters, echocardiographic parameters on the prognosis of coronary heart disease (CHD)during long-term following-up in patients admitted to PUMC Hospital from 2000 to 2004; and to provide new information regarding secondary prevention of CHD in patients after hospital discharge.【Methods】1 Study patients: 2755 consequentive in-patients with definite diagnosis of CHD in PUMC Hospital from 2000 to 2004 were coded and randomized using computer randomization system. 918 patients were selected randomly and initially with the rule of one in every three patients. After review of inclusion and exclusion criteria, 634 patients satisfying both criteria were ultimately enrolled in this cohort study.2 Content: The data of demography, cardiovascular risk factors, blood biochemistry (inhospital, after hospital discharge, following-up, ending), echocardiographic measurements (inhospital), and the pharmacological treatment (inhospital and following-up) were collected and correlated with the cardiovascular events occurred in following-up period.3 Following-up methods: The following-up methods used in this study included: telephone consultation (51.1%) , clinic consultation (25.6%), family visit(8.8%) and letter communication (8.4%). The items of following-up included recurrence of cardiovascular events, times of hospital visits each year, blood biochemistry, cardiovascular events or death, treatment, etc. 4 The definition of end-points: The end-points used in this study include all cause deaths, cardiogenic deaths, non-fatal MI, congestive heart desease, unstable angina, revascularization (PCI or CABG) and stroke.5 Statistic method:In Logistic single variable analysis, nominal data were expressed with rate. Chi square test or fishers exact test were used to compare numeration data between groups. Scale data were expressed with mean±SD. T test was used to compare scale data between two groups. Multivariable regression analysis was performed usiung Logistic regression, survival analysis and COX regression. P＜0.05 was considered to be statistic significance.【Result】1. Demography data: The age of 610 CHD patients is 63.9±10.1 years old, the median age is 66 years old. 29% of the study patients were women. There was significant difference of cardiovascular events among groups of 18～40 years old, 40～60 years old and 60～80 years old during following-up. The group of 60～80 years old had the highest event rate of 33.6% during following-up period.1. 1,Types of coronary heart disease and complications inhospital: The clinical classfications of coronary heart disease in this cohort include stable angina, unstable angina /non-Q wave myocardial infarction (UA/NQWMI), and ST elevated myocardial infarction (STEMI). The in-hospital complication included congestive heart failure (20 cases), serious arrhythmia (13 cases), sudden cardiac death with successful resuscitation (2 cases). 35 patients with inhospital complication had 15 events during following-up period (43%), whereas 575 patients without inhospital complications had the event rate of 29% during following-up period (P=0.03). 75.6% of the study patients had their CHD established by coronary angiography. 1. 2,Risk factors: 90.4% male and 89% female patients had≥1 risk factors. The risk factors in this cohort patients included smoking(59.2%,361/610), hypertension (57.5%,351/610), diabetes mellitus(24.1%, 147/610) and lipid disorders(22.5%, 137/610) .The distributions of various risk factors including smoke, hypertension, diabetes mellitus were significantly different between the groups with and without cardiovascular events. The event rates of patients with heart rate＞80bpm and＜80bpm were 58.3% and 24%, respectively (P=0.001).2,Following up: The patients were followed for 1～73 months, with the mean following-up period of 32.6±20.0 months. The rate of following-up was 96.2%. 36.7% of the patients had hospital visits 1～3 times per year. 60% of the patients took aspirin,β-blocker and ACEI in following-up period. Whereas only 22.8% of the patients adhereed to statin treatment. There is significant difference between patient' s groups with and without events during following-up period in terms of the times of hospital visits each year and medical treatment.3,The clinic events during following-up: During following-up period, 182 of the 610 patients reached study end-points, 174 of which developed cardiovascular events. The cardiovascular event rate was 28.5%, with cardiogenic deaths (4.9%), non-fatal MI (6.2%), congestive heart desease (3.4%), unstable angina(12.1%), PCI or CABG (1%), stroke(0.82%) and non-cardiogenic deaths(1.3%). The total mortality rate was 6.2%.4,Echocardiographic findings inhospital: 27% of the patients with wall motion score index 1～1.5 developed cardiovascular events, whereas 32.4% of the patients with wall motion score index＞1.5(P=0.001). 35.1% of patients with AED＞39mm had cardiovascular events during following-up, whereas 26% of patients with AED≤39mm of AED(P=0.023). 42.6% of patients with LYESD＞40mm developed cardiovascular events, whereas 27.6% of patients with LVESD≤40mm(P=0.009). 45.8% of patients with LVEF＜ 50% developed events, whereas 29.3% of patients with LVEF≥50 %(P=0.009).5,Blood biochemical indicators : There were significant differencebetween groups with and without events during following-up in terms offollowing blood biochemical parameters of inhospital: TC,HDL-C,nonHDL-C,ApoA1,ApoB, Lp(a),TC/HDL-C,LDL/HDL-C,ApoB/ApoA1,hsCRP, UA, FBG; aswell as after hospital discharge: TC,LDL-C,nonHDL-C,ApoB, TC/HDL-C,LDL/HDL-C,ApoB/ApoA1,UA and FBG. as well as following-up: TC,HDL-C,nonHDL-C,ApoA1,ApoB,TC/HDL-C,LDL/HDL-C,ApoB/ApoA1 and FBG.6,Treatment : 409 patients (67.9%) experienced PCI inhospital. 96%patients of in hospital takes aspirin, 72.9%, statin medicine. All thepatients underwent coronary stent implantation used clopidegrel toprevent restenosis.7,Multi-factors analysis:7. 1,Many factors affect the type of regression analysis:Using Logisticmultiple analysis, 17 factors had independent predictive values forcardiovascular events occurring during following-up period: age, BMI,smoke amount per day, history of diabetes, moveless heart rate, TC, HDL-C,LDL/HDL-C, TC/HDL-C, APOB/A1, Lp (a), HsCRP, UA, cTnI, LAED, LVESD, LVEF.Factors with OR＞1 included: HDL-C, cTnI, LVESD, LVEF%.7. 2,COX regression was performed to investigate the relationship betweenCHD risk factors and the occurring of study end-points during following-up.After adjustment of related factors, the risk of cardiovascular eventsin patients smoking＞40, 20～40,＜20 cigarettes daily were3.00,1.88,1.23 times higher, repcectively when compared with nonsmokingpatients. The risks of cardiovascular events in patients with BMI 28～35,24～28 were 2.39, 1.27 times higher, repcectively when compared withthose,＜24. Heart rate of both acute and following-up period wellcorrelated with cardiovascular events during following-up, while heart rate of following-up had more predictively value than which of acute period. The risk of cardiovascular events in groups of LVEF＜20%, 20%～40%,＞40% were 1.98,1.82,1.34 times higher, respectively when compared with the group of LVEF＞60%. HDL-C have negative correlation with cardiovascular event rates. The risk of recurrence cardiovascular events in groups of HDL-C≤35mg/dl, 36～40mg/dl, 41～45mg/dl were 2.01, 1.83, 1.30 times higher, respectively when compared with the group,＞45mg/dl. With the increasing of serum LDL-C level from＜100mg/dl to＞160mg/dl, the risk of recurrence cardiovascular events increased 2.22 times(95%CI:1.3～3.7, P＜0. 05). The risk of recurrence cardiovascular events in groups of ApoB/ApoAl＞1.04, 0.84～1.04, 0.69～0.84 were 2.41,1.61,1.59 times higher than that,＜0.69.7.3,Survival analysis showed that from first to sixth year after discharge from hospital the cumulative survival rates were 85.3%, 79.8%, 75.9%, 73.8%, 73.1% and 72.3%, respectively, and the mortality rates were 15.8%, 6.61%, 5.02%, 2.87%, 0.91% and 1.15%, respectively.【Conclusion】1,Cardiovascular events reoccurrence has a high probability for patients discharged from hospital with the established diagnosis of CHD. Long-term and regular following-up and proper medical treatment may prevent the reoccurrence of these events. However, the proportion of patients being followed need to be further elevated.2,The patients with older age, obesity, smoking, hypertension , diabetes, and accelerated resting heart rate have relative poor prognosis. TC, HDL-C, LDL/HDL-C, TC/HDL-C, APOB/A1, Lp (a), HsCRP, cTnI, UA, LAED, LVESD and LVEF% are associated with cardiovascular events.3,Patients with CHD have the highest mortality rate during the first year after discharge from hospital. Then the mortality rates gradually reduce over time.4,For the secondary prevention of CHD, large hospital can not always satisfy the need of the society. It is urgent to make good use of other prevention and treatment system (for example, community intervention) to improve the prognosis of these patients further.