中文摘要
心臟血管疾病；已成為物質文明進步下的重要產物，不管是在已開發國家、開發中國家，我們均可觀察到心血管疾病扮演威脅各國民眾生命的重要角色。根據我國衛生署的統計資料顯示，最近二十年國人十大死亡原因中，心臟病在排序上一路從第四位逐步竄升，從西元2007年起已經站穩第二位置。在西元2008年因心臟疾病而死亡者已達15,762人，佔總死亡人數的11.1%；僅次於惡性腫瘤的38,913人及27.3%。而在先進國家中，以美國為例，心血管疾病更是長期佔據主要死亡原因之首位。以西元2005年為例，從該國之NCHS (National Center for Health Statistics)以及NHLBI (National Heart, Lung and Blood Institute)的統計資料可知，該年在美國死於心血管疾病者有864,000人，遠遠超過死於癌症的559,000人，其他疾病則更難望其向背。由上述的代表性資料，我們不難理解，這是世界各國普遍存在的狀況；它代表的意義不僅僅是造成許多生命的消逝，因為罹病所帶來的相關問題，比如說醫療費用的支出(2007年我國民眾因心臟病住院醫療費用總支出為新台幣11,090,276元，依然僅次於惡性腫瘤的17,093,219元)、罹病後續問題的處置以及疾病的防治等都將會是影響家庭、社會以及國家的議題及帶來可能的負擔。
在各種心臟血管疾病中，以冠狀動脈心臟病最受人矚目。此類疾病簡稱冠心病，亦可稱為缺血性心臟病(Ischemic Heart Disease; IHD)或冠狀動脈疾病(Coronary Artery Disease; CAD)；這類疾病之所以受矚目，不僅有高的盛行率、高的發生率、高的死亡率，還常造成罹病個體合併許多合併症如心臟衰竭、心律不整等。以我國的資料為例，在西元2007年國人因缺血性心臟病(6,505)及急性心肌梗塞(3,502)死亡者共有10,067人，佔該年度因心臟病死亡人數13,003人之77.4%。而美國在西元2004年NHLBI的報告中指出有51.8%的心血管疾病死因為冠狀動脈心臟病；有78.9%的心臟病患者其死因為冠狀動脈心臟病及急性心肌梗塞。
急性心肌梗塞(Acute Myocardial Infarction; AMI)或急性冠心症(Acute Coronary Syndrome; ACS)乃為冠狀動脈心臟病的急性表現，在美國它已習慣被稱為心臟病發作(Heart attack)。此類病患發病後若未及時處置其死亡率更高，預後也更差，根據國內外有關心跳停止(Cardiac arrest)及院外心跳停止(Out of Hospital Cardiac Arrest; OHCA)之原因分析，最常見的病因就是急性心肌梗塞。由於它扮演如此關鍵生命之角色，因此目前醫學學術討論有關冠狀動脈疾病的的處置與防治的焦點總圍繞在這個主題上。
在冠狀動脈心臟病病患中，年紀被發現到與罹病率與死亡率息息相關。由衛生署的統計資料得知我國心臟病患死亡平均年齡已經從1997年的69.5歲增加到2007年的73.2歲，進一步分析年齡層死亡率，有超過70%的病患其死亡年齡超過65歲，此反映出罹患心臟病的老年人死亡率明顯高於非老年人。至於心臟病的盛行率或發生率，目前我國在此方面的資訊尚待有系統的建立，然從美國疾病管制局(Center of Disease Control; CDC)隸屬的National Health and Nutrition Examination Survey(NHANES)以及National Institute of Health(NIH)隸屬之National Heart, Lung and Blood Institute (NHLBI)等著名機構所執行的流行病學調查資料得知，高齡者不僅有顯著高比例罹患冠狀動脈心臟病及急性心肌梗塞，其罹病之預後，相較於非高齡者亦呈現顯著落差。
不同於惡性腫瘤疾病，冠狀動脈心臟病目前認為不僅可以預防，而且一旦罹病如果儘早就醫，在積極與適當的治療下，不僅能夠將病患之心臟損害減少到最低，而且能夠延長壽命及生活品質。上述特性當然普及於老年人，然而，現今國外流行病學調查報告顯示冠狀動脈心臟疾病之死亡率依然隨者年齡上升而顯著增加，究其原因，目前仍無法有效降低的罹病率當然是主因，然而是否存在其他因素足以左右預後值得我們進一步探究原因。著名的Framinhan Heart Study，以及GRACE(Global Registry of Acute Coronary Events)這兩個橫跨不同年代的大規模研究，皆具體陳述不典型的冠狀動脈心臟病或急性冠心症的病患及死亡率明顯高於典型症狀者，而且老年人之不典型症候比例顯著高於非老年人，這是個影響力大卻又是目前無法有效克服的問題，是否因同時罹患其他疾病比率多加上身體器官機能隨著老化而較為虛弱(frail)，以致難以對抗此兇猛疾病所帶來的衝擊，或者因較少接受完整治療等導致較差預後，是我們應該深入了解，集思廣益尋求因應之道。
絕大多數有關冠狀動脈心臟病以及急性冠心病的研究皆在歐美先進國家進行，以歐美民眾為主要研究對象，目前對於華人族群在這疾病相關的資訊還有不足之處；如罹病率如何，老年人在此疾病呈現出的特性與預後，不典型症狀比例如何等;這些資訊仍待有系統之建立，雖然從許多流行病學資料可知東西方民眾在心血管疾病的臨床表徵與預後有許多相似之處，然而，華人罹患心血管疾病的特性與相關指標是否就與歐美族群相近，值得研究並進一步完整陳述。於是，我們彙整中華民國國家衛生研究院的健保資料庫以及國立成功大學醫學中心的經驗，規劃”高齡者急性冠心症之特性與預後分析”這個主題的研究。從健保資料庫中我們發現從西元2002年至2007年享有全民健保的華人其罹患急性冠心症的人數為150,003人;平均年齡為65.8±13.4歲(平均值± 標準差);其男女性比例為1.8:1;其高齡者與非高齡者的比例為1.4:1;其治療盛行率(treated prevalence)在高齡者為670.2/100000;在整體族群為110/100000。高齡者在平均住院天數(Length of stay)、平均住院健保申報費用(Cost of hospitalization)、死亡率(In-hospital mortality)等三項指標與非高齡者比較起來皆呈現顯著統計學上的差異(P<0.001)。就死亡率分析，高齡者與非高齡者分別為13.1%:7%；其人數比為2.5:1。運用多變項邏輯回歸分析發現，罹患急性心肌梗塞者(OR=5.126; P<0.001)以及高齡者(OR=1.533；P<0.001)與死亡有顯著相關。然而若病患有接受介入性冠狀動脈治療者(OR=0.75; P<0.001)，病患的死亡率是顯著降低的。
就成大醫學中心的經驗而言，我們藉由病歷回顧西元2007年至2008年至成大醫院就醫的急性冠心症病患相關臨床特性與表徵，在405位資料完整的病患中，發現此以醫院為基礎的病患族群其平均年齡為64.9±13.4歲(平均值±標準差)；其男女性比例為2.5:1;其高齡者與非高齡者的比例為1.2:1;高齡者在不典型症狀 (Atypical presentation)、併發症(Complication)等二項指標與非高齡者比較起來皆呈現顯著統計學上的差異(P<0.001)。至於在住院死亡率(In-hospital mortality)與非高齡者比較起來亦呈現顯著統計學上的差異(P=0.002)。運用多變項邏輯回歸分析發現不典型症狀(OR=4.905; P=0.006)、ST波上升型心肌梗塞(OR=13.364; P=0.006)、高齡者(OR=4.354；P=0.034)等三特性與死亡有顯著相關。

Abstract

Cardiovascular disease (CVD) is the leading cause of death

worldwide. According to epidemiological survey by the

Department of Health, Executive Yuan, R.O.C. (Taiwan),

Chinese in Taiwan is also found to share the property, and

a trend in growing up of the situation is noticed.

Coronary heart disease (CHD), also to be called as

ischemic heart disease (IHD) or coronary artery disease

(CAD); is most common and popular among such diseases.

This kind ofcardiovascular disease deserves us to pay more

attention, not only it has critical impact on human health

condition, but also it might be probably avoided if the

preventive strategy could be implemented well.

Acute coronary syndrome(ACS), including unstable angina,

non-ST-segment-elevation myocardial infraction (NSTEMI)

and ST-segment-elevation myocardial infarction (STEMI)etc.

is an acute coronary event, caused mainly by a progressive

process of coronary atherosclerosis or rupture of the

atherosclerotic plaque. It has high mortality rate, and

may cause the affected peoples with high probability of

complication if immediate and optimal medical therapy and

intensive care could not be applied. This critically

medical problem currently is an important topic of medical

issue worldwide.

Findings of several observational studies that had been

carried out in western countries, including the

Framinhan’s Heart Study, the National Health and

Nutrition Examination Survey (NHANES), chart book of the

National Heart, Lung and Blood Institute (NHLBI) and

Global Registry of Acute Coronary Events (GRACE) etc. all

clearly show evidences that cardiovascular disease is more

popular in aged people than young. In addition, aged

persons with cardiovascular disease were noticed to have

poor outcome. However, the prevalence and demographic

characters of a Chinese population in Taiwan with acute

coronary syndrome remains not to be well clarified

at present.

Atypical presentations, is a common phenomenon in geriatric

patients with several types of medical disease. Elders with

acute coronary syndrome was also observed to own the

property. Atypical presentations of acute coronary syndrome

were reported to have poor outcome than the typical ones.

Such situation in the Chinese population in Taiwan also

remains unclearly.

Meanwhile, are there any undefined factors that have

impact on the high mortality of elders with acute coronary

syndrome deserve us to pay attention without any debates.

Could the “frail entity” be the only contributor to make

geriatricpatients with less defense in against heart

attack? We do not think so! Hence, we conduct a

descriptive study, base on analysis of the National Health

Insurance Research Database and review of the medical

records of acute coronary patients in

National Cheng Kung Medical Center, to realize the

characteristics and outcomes of our elderly patients with

acute coronary syndrome, and the impact of atypical

symptoms on outcome.

Based on the database of Bureau of National Health

Insurance, the total number of patients with acute

coronary syndrome in Chinese population from 2002 to 2007

was 150,003; their mean age at onset was 65.8±13.4 years

of age (Mean ± S.D.); the ratio between male and female

was 1.8:1; and the ratio between elder and non-elder was

1.4:1. The treated prevalence averagely was 670.2/100000

for elder, and 110/100000 for population, respectively.

Elder has statistical significantly in length of stay,

cost of hospitalization and in-hospital mortality in

comparison with non-elder (P<0.001). Multiple logistic

regression analysis revealed if patients with

AMI (OR=5.126; P<0.001), or if patients were elderly

(OR=1.533; P<0.001) may have strong association with

mortality. In contrast, if patients received percutaneous

coronary intervention while admission(OR=0.75; P<0.001),

their mortality rate would be reduced significantly.

In the study of a hospital-base population in National

Cheng Kung Medical Center, we retrospectively analysis the

patients with acute coronary syndrome in a two consecutive

years series from 2007 to 2008 by review the medical

records. Total number of the study subjects was 405; their

mean age at onset was 64.9±13.4 years of age(Mean ± S.D.);

the ratio between male and female was 2.5:1; and the ratio

between elder and non-elder was 1.2:1. Elder was noticed

to show statistical significantly in atypical

presentation, development of complication (P<0.001),

and in-hospital mortality (P=0.002). Multiple logistic

regression analysis revealed if patients manifested with

atypical presentation (OR=4.905; P=0.006), or if patients

developed STEMI (OR=13.364; P=0.006), or if patients were

elderly (OR=4.354; P=0.034), they may have strong

association with mortality.

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