醫院上下班時間與心肌梗塞死亡率之關聯

中文摘要研究目的：本研究旨在研究關於緊急ST波段上升心肌梗塞患者，在上班時間及下班時間，到院接受心導管治療的三十天內死亡率及死亡原因分析，並探討相關導致死亡因素。研究方法及資料：本研究工具採事後回溯研究法，主要統計在中部單一醫學中心，自民國101年1月至民國103年12月，共三年期間，合計兩百五十三名急性ST波段上升心肌梗塞並接受心導管治療患者，進行臨床檢查，包含病史詢問，理學檢查，心電圖，抽血分析低密度膽固醇及腎功能。將患者依照到院時間，分成上班時間跟下班時間兩組，就死亡率跟臨床數據進行統計分析，並探討相關導致死亡因素。研究結果：在上、下班時間到院後接受心導管手術(Door-to-Balloon Time)的時間分別為(72.62±26.81分鐘 vs 79.46±35.6分鐘 p=0.102)，導管時間，並無顯著差異。而在三十天內死亡率方面分別為(10% vs 6% p=0.151)，並無顯著差異 (log-rank p=0.226)。在死亡風險分析方面：身體質量指數越高(HR 0.88　p=0.035)，吸菸(HR 0.115　p=0.04) ，低密度膽固醇越高(HR 0.984　p=0.022)，帶藥支架(HR 0.357　p=0.048)會減少死亡風險；女性(HR 3.656 p=0.005)，腎功能不全(HR 4.740 p=0.001 )，洗腎(HR 5.544　p=0.022 )，年齡較大(HR 1.066 p<0.001)等會增加死亡風險。經由矯正以上所有顯著影響死亡風險的因素，未抽煙為獨立死亡風險因子(HR 4.950 p=0.046)。結論與建議：在台灣都會區，急性ST波段上升心肌梗塞患者，於下班時間到院執行心導管手術，並不會增加心導管時間以及患者死亡率。雖然未抽煙會影響(減低)死亡風險，但抽煙會造成更多的心肌梗塞。

AbstractObjective :Previous studies have shown patients with ST-segment elevation myocardial infarction (STEMI) who received primary percutaneous coronary intervention (pPCI) during office hours versus off-hours.Those studies reported door to balloon time increase during off-hours and had worse clinical outcome.In Taiwan, door to balloon time was no different between office hours and off-hours. We evaluated the mortality rate between office-hours and off-hours in Taiwan.Methods and Materials:This study population comprised 253 STEMI patients treated with primary PCI in a medical center during 2012–2014.We evaluate the relationship between treatment during office-hours (Monday-Friday, 8.00 am-6.00 pm) versus off-hours (Monday-Friday, 6.00 pm-8.00 pm, Saturday and Sunday) and the incidence of all-cause mortality at 30-day . After the data collection, all samples were processed and analyzed by multiple analysis of variance, hazard ratio, Cox proportional hazard model and Kaplan-Meier curve, by SPSS for windows 18.0.Results:Total of 101 patients (40%) were treated during office-hours and 152 patients(60%) during off-hours. With the exception of diabetes mellitus, smoking, low-density lipoprotein, use of glycoprotein IIb/IIIa antagonists, no major differences in baseline characteristics were observed between the groups. Patients with STEMI presenting during off-hours who receive percutaneous coronary intervention time (door to balloon time) were similar to office-hours (72.62±26.81 minutes vs 79.46±35.60 p=0.102). Mortality at 30-day follow-up was similar in patients treated during office-hours and those treated during off-hours (10% vs 6% p=0.151)(log-rank p=0.226). Higher BMI (HR 0.88 p=0.035), Smoking (HR 0.115 p=0.04), higher LDL (HR 0.984　p=0.022), Drug-eluting stent (HR 0.357　p=0.048) will decrease mortality risk.Female (HR 3.656 p=0.005), renal insufficiency (HR 4.740 p=0.001), uremia (HR 5.544 p=0.022), higher age (HR 1.066 p<0.001) will increase mortality risk. After adjustment with age, sex, smoking and LDL by multivariable Cox proportional hazards regression, no smoking is a independent factor (adjusted HR 4.950 p=0.046).Conclusion and Suggestion:In acute ST elevation myocardial Infarction patients who treated during off-hours in a medical center in Taiwan, primary PCI provides similar door to balloon time and survival as patients who were treated during office hours.