高龄急性脑梗死静脉溶栓治疗的有效性和安全性分析
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摘要
目的探讨高龄急性脑梗死患者静脉溶栓治疗的有效性和安全性。方法将337例发病4.5h内接受重组组织型纤溶酶原激活物静脉溶栓治疗的急性脑梗死患者分为高龄(≥80岁)溶栓组75例和非高龄溶栓组262例。并将211例高龄急性脑梗死非溶栓治疗的患者作为高龄非溶栓组,予抗血小板聚集治疗。比较高龄溶栓组与高龄非溶栓组、非高龄溶栓组的基线资料和治疗效果,分析高龄急性脑梗死患者静脉溶栓治疗的有效性和安全性。结果高龄溶栓组患者基线NIHSS评分、症状性脑出血发生率均高于高龄非溶栓组,差异均有统计学意义(均P<0.05),两组患者90d良好预后、病死率比较差异均无统计学意义(均P>0.05)。NIHSS评分≥10分组中,高龄溶栓组患者90d良好预后优于高龄非溶栓组,差异有统计学意义(P<0.01),但两组患者症状性脑出血、病死率比较差异均无统计学意义(均P>0.05)。高龄溶栓组患者90d良好预后劣于非高龄溶栓组,且病死率高于非高龄溶栓组,差异均有统计学意义(均P<0.01),两组症状性脑出血发生率比较差异无统计学意义(P>0.05)。多因素logistic回归分析显示,高龄并非静脉溶栓90d良好预后的影响因素(OR=0.562,95%CI:0.301～1.047,P>0.05)。结论高龄不影响急性脑梗死静脉溶栓预后,神经功能缺损较重的高龄急性脑梗死患者可能从静脉溶栓中获益,且并不一定会增加症状性脑出血的发生。
Objective To explore the efficacy and safety of intravenous thrombolysis(IVT) in elderly ischemic stroke patients. Methods A total of 337 acute ischemic stroke(AIS) patients were treated with IVT. Patients were categorized into two groups according to age: those aged ≥80 years(n=75) and <80 years(n=262), 211 non-IVT elderly AIS patients receiving platelet aggregation therapy served as control group. The baseline characteristics and prognosis were compared among those groups, and the efficacy and safety of IVT in elderly AIS patients were evaluated. Results In patients aged ≥80 years, the IVT subgroup had higher National Institutes of Health Stroke Scale score(NIHSS) and symptomatic intracranial hemorrhage(sICH) than the non-IVT subgroup(both P<0.05). There were no significant differences in 90 d favorable outcome and mortality between two groups(both P >0.05). The 90 d favorable outcome was superior in elderly IVT patients with NIHSS≥10(P<0.01). Among all IVT patients, the elderly subgroup had lower 90 d favorable outcome and higher mortality than the non-elderly subgroup(both P<0.01). The sICH was not significantly different in the two groups(P >0.05). Logistic regression analysis revealed that age ≥80 years was not an independent influencing factor for 90 d favorable outcome rate(OR=0.562, 95%CI:0.301～1.047, P>0.05). Conclusion Age≥80 years does not affect the prognosis of AIS patients receiving IVT. The elderly AIS patients with severe neurologic deficits could still benefit from IVT,and may not increase the risk of sICH.
Objective To explore the efficacy and safety of intravenous thrombolysis(IVT) in elderly ischemic stroke patients. Methods A total of 337 acute ischemic stroke(AIS) patients were treated with IVT. Patients were categorized into two groups according to age: those aged ≥80 years(n=75) and <80 years(n=262), 211 non-IVT elderly AIS patients receiving platelet aggregation therapy served as control group. The baseline characteristics and prognosis were compared among those groups, and the efficacy and safety of IVT in elderly AIS patients were evaluated. Results In patients aged ≥80 years, the IVT subgroup had higher National Institutes of Health Stroke Scale score(NIHSS) and symptomatic intracranial hemorrhage(sICH) than the non-IVT subgroup(both P<0.05). There were no significant differences in 90 d favorable outcome and mortality between two groups(both P >0.05). The 90 d favorable outcome was superior in elderly IVT patients with NIHSS≥10(P<0.01). Among all IVT patients, the elderly subgroup had lower 90 d favorable outcome and higher mortality than the non-elderly subgroup(both P<0.01). The sICH was not significantly different in the two groups(P >0.05). Logistic regression analysis revealed that age ≥80 years was not an independent influencing factor for 90 d favorable outcome rate(OR=0.562, 95%CI:0.301～1.047, P>0.05). Conclusion Age≥80 years does not affect the prognosis of AIS patients receiving IVT. The elderly AIS patients with severe neurologic deficits could still benefit from IVT,and may not increase the risk of sICH.
引文
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[12]Chen Y,Li CH,Wang YX,et al.Safety and effectiveness of intravenous thrombolysis with recombinant tissue plasminogen activator in eighty years and older acute ischemic stroke patients[J].Eur Rev Med Pharmacol Sci,2015,19(10):1852-1858.
[13]Matsuo R,Kamouchi M,Ago T,et al.Thrombolytic therapy with intravenous recombinant tissue plasminogen activator in Japanese older patients with acute ischemic stroke:Fukuoka Stroke Registry[J].Geriatr Gerontol Int,2014,14(4):954-959.DOI:10.1111/ggi.12205.
[14]Sarikaya H.Safety and efficacy of thrombolysis with intravenous alteplase in older stroke patients[J].Drugs Aging,2013,30(4):227-234.DOI:10.1007/s40266-013-0052-5.
[15]Kammersgaard LP,Jorgensen HS,Reith J,et al.Short-and long-term prognosis for very old stroke patients.The Copenhagen Stroke Study[J].Age Ageing,2004,33(2):149-154.DOI:10.1093/ageing/afh052.
[16]Olindo S,Cabre P,Deschamps R,et al.Acute stroke in the very elderly:epidemiological features,stroke subtypes,management,and outcome in Martinique,French West Indies[J].Stroke,2003,34(7):1593-1597.DOI:10.1161/01.STR.0000077924.71088.02.
[2]Russo T,Felzani G,Marini C.Stroke in the very old:a systematic review of studies on incidence,outcome,and resource use[J].JAging Res,2011,2011:108785.DOI:10.4061/2011/108785.
[3]Rojas JI,Zurru MC,Romano M,et al.Acute ischemic stroke and transient ischemic attack in the very old--risk factor profile and stroke subtype between patients older than 80 years and patients aged less than 80 years[J].Eur J Neurol,2007,14(8):895-899.DOI:10.1111/j.1468-1331.2007.01841.x.
[4]Engelter ST,Bonati LH,Lyrer PA.Intravenous thrombolysis in stroke patients of>or=80 versus<80 years of age--a systematic review across cohort studies[J].Age Ageing,2006,35(6):572-580.DOI:10.1093/ageing/afl104.
[5]中华医学会神经病学分会脑血管病学组脑血管病学组.中国急性缺血性脑卒中诊治指南2014[J].中华神经科杂志,2014,48(4):246-257.DOI:10.3760/cma.j.issn.1006-7876.2015.04.002.
[6]Hacke W,Kaste M,Bluhmki E,et al.Thrombolysis with alteplase 3to 4.5 hours after acute ischemic stroke[J].N Engl J Med,2008,359(13):1317-1329.DOI:10.1056/NEJMoa0804656.
[7]Feigin VL,Lawes CM,Bennett DA,et al.Stroke epidemiology:a review of population-based studies of incidence,prevalence,and case-fatality in the late 20th century[J].Lancet Neurol,2003,2(1):43-53.
[8]Rosamond W,Flegal K,Furie K,et al.Heart disease and stroke statistics--2008 update:a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee[J].Circulation,2008,117(4):125-146.DOI:10.1161/CIRCULA-TIONAHA.107.187998.
[9]Mishra NK,Ahmed N,Andersen G,et al.Thrombolysis in very elderly people:controlled comparison of SITS International Stroke Thrombolysis Registry and Virtual International Stroke Trials Archive[J].BMJ,2010,341:c6046.DOI:10.1136/bmj.c6046.
[10]Sagnier S,Galli P,Poli M,et al.The impact of intravenous thrombolysis on outcome of patients with acute ischemic stroke after90 years old[J].BMC Geriatr,2016,16:156.DOI:10.1186/s12877-016-0331-1.
[11]Pundik S,McWilliams-Dunnigan L,Blackham KL,et al.Older age does not increase risk of hemorrhagic complications after intravenous and/or intra-arterial thrombolysis for acute stroke[J].JStroke Cerebrovasc Dis,2008,17(5):266-272.DOI:10.1016/j.jstrokecerebrovasdis.2008.03.003.
[12]Chen Y,Li CH,Wang YX,et al.Safety and effectiveness of intravenous thrombolysis with recombinant tissue plasminogen activator in eighty years and older acute ischemic stroke patients[J].Eur Rev Med Pharmacol Sci,2015,19(10):1852-1858.
[13]Matsuo R,Kamouchi M,Ago T,et al.Thrombolytic therapy with intravenous recombinant tissue plasminogen activator in Japanese older patients with acute ischemic stroke:Fukuoka Stroke Registry[J].Geriatr Gerontol Int,2014,14(4):954-959.DOI:10.1111/ggi.12205.
[14]Sarikaya H.Safety and efficacy of thrombolysis with intravenous alteplase in older stroke patients[J].Drugs Aging,2013,30(4):227-234.DOI:10.1007/s40266-013-0052-5.
[15]Kammersgaard LP,Jorgensen HS,Reith J,et al.Short-and long-term prognosis for very old stroke patients.The Copenhagen Stroke Study[J].Age Ageing,2004,33(2):149-154.DOI:10.1093/ageing/afh052.
[16]Olindo S,Cabre P,Deschamps R,et al.Acute stroke in the very elderly:epidemiological features,stroke subtypes,management,and outcome in Martinique,French West Indies[J].Stroke,2003,34(7):1593-1597.DOI:10.1161/01.STR.0000077924.71088.02.