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系統識別號 U0026-1308201317101800
論文名稱(中文) 初次急性心肌梗塞病患新發生心衰竭之危險因子分析
論文名稱(英文) Risk Factors of Incident Heart Failure in Patients with Acute Myocardial Infarction
校院名稱 成功大學
系所名稱(中) 臨床藥學與藥物科技研究所
系所名稱(英) Institute of Clinical Pharmacy and Pharmaceutical sciences
學年度 101
學期 2
出版年 102
研究生(中文) 林于雅
研究生(英文) Yu-Ya Lin
學號 s66004018
學位類別 碩士
語文別 中文
論文頁數 137頁
口試委員 指導教授-高雅慧
口試委員-鄭靜蘭
口試委員-李貽恆
口試委員-李政翰
口試委員-許美英
中文關鍵字 心肌梗塞  心衰竭  發生率  危險因子 
英文關鍵字 myocardial infarction  heart failure  incidence  risk factors 
學科別分類
中文摘要 研究背景
隨著醫療進步,急性心肌梗塞病患的預後已逐漸改善。然而,心肌梗塞造成心肌受損,使得存活的病患有較高的風險發生心衰竭。發生心衰竭會顯著增加心肌梗塞病患的死亡率。
過去文獻指出,心肌梗塞後約有13~76%病患發生心衰竭,此差異可能是來自於研究期間、納入族群及研究設計上的不同所導致。台灣缺乏相關研究,且許多文獻的研究期間在2000年以前,而近十幾年來治療一直持續進步。因此,若能了解台灣目前心肌梗塞病患的心衰竭發生率以及找出發生心衰竭的危險因子,將有助於提升心肌梗塞病患的照護。

研究方法
本研究為回溯性世代研究,利用1999~2009年全民健康保險資料庫,篩選年齡≧18歲,過去無心衰竭病史,於2002年1月1日至2008年12月31日期間首次因急性心肌梗塞住院之病患,並追蹤1年。
主要研究結果變項為心衰竭,次要研究結果變項為心衰竭或死亡。心衰竭定義分別包含「HF」與「Severe HF」,前者定義為門、急診及住院出現心衰竭診斷(ICD-9 428、402.01、402.11、402.91、404.01、404.03、404.11、404.13、404.91、404.93),後者則以住院出現心衰竭診斷且使用loop類利尿劑或注射劑型強心劑定義。
本研究主要目的有二。首先,分別計算病患於心肌梗塞住院期間、出院後30天、6個月及1年內心衰竭發生率;接著,利用Cox proportional hazard model校正病患基本特性、共病症、治療及其他變項,分析心衰竭危險因子。


研究結果
本研究共納入42,011位病患為研究對象,經排除死亡人數後,住院期間 「HF」及「Severe HF」發生率分別為14.83%與12.78%。出院後,30天、6個月及1年內「HF」累積發生率分別為9.59%、14.21%及16.76%;「Severe HF」累積發生率則分別是1.59%、3.83%及4.84%。
心衰竭危險因子分析中,年齡≧65歲、糖尿病或缺血性中風病史、出院30天內使用loop類利尿劑及追蹤期間心肌梗塞復發為最主要與心衰竭有關的因子。依據此5項因子數將病患分為低、中及高危險群3組。中、高危險群患1年內發生心衰竭的風險是低危險群病患的3.37及5.99倍。使用statins (HR 0.85, 95% CI 0.78-0.92)及其他降血脂藥品(HR 0.61, 95% CI 0.48-0.78)可顯著降低「HF」發生風險。另外,使用beta-blockers (HR 0.86, 95% CI 0.76-0.98)及statins (HR 0.82, 95% CI 0.72-0.94)可顯著降低「Severe HF」發生風險。

研究結論
台灣心肌梗塞病患仍有相當高比例發生心衰竭,且大部分是發生在心肌梗塞住院期間以及出院幾個月內。本研究找出5個與心衰竭發生有關的重要因子,可以應用於病患危險分級。使用beta-blockers及降血脂藥品與降低心衰竭風險相關。
英文摘要 Background
Due to the medical improvements in the past decades, the survival of acute myocardial infarction (AMI) patients has improved. However, with the damaged myocardium from infarction, survivors of AMI are at higher risk of developing heart failure (HF). The development of HF is associated with a significantly elevated risk of death.
Previous studies indicated that about 13~76% patients would develop HF after AMI. The variability in the incidence of post-MI HF may be explained by heterogeneity in study periods, study populations and study design. There is a paucity of information regarding this issue in Taiwan. In addition, the time periods of most studies were before 2000 and therapies have continued to evolve. A better understanding of the incidence of post-MI HF in Taiwan and the factors involved in HF development would help to improve care of AMI patients.

Methods
We conducted a retrospective cohort study by using 1999~2009 National Health Insurance Research Database (NHIRD). Patients aged≧18 years, with no history of HF, who hospitalized with a first AMI between January 1, 2002 and December 31, 2008 were identified and followed up for 1 year. The primary outcomes were HF and severe HF, and secondary outcome was HF or death. HF was defined as an outpatient visit or hospitalization for HF (ICD-9 428, 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93). Severe HF was defined as a hospitalization for HF and prescription of loop diuretics or intravenous inotropic agents.
We evaluated the incidence of HF during AMI hospitalization, 30 days, 6 months and 1 year after discharge. Further, we estimated factors related to HF by using Cox proportional hazard model with adjusting baseline characteristics, comorbidities, medical interventions and other covariates.

Results
A total of 42,011 patients were identified. After excluding those who died, 14.83% had HF and 12.78% had severe HF during AMI hospitalization. After discharge, the cumulative incidence of HF at 30 days, 6 months and 1 year was 9.59%, 14.21% and 16.76%. The cumulative incidence of severe HF was 1.59%, 3.83% and 4.84%, respectively.
The most important factors related of HF were age≧65 years, history of DM and ischemic stroke, use of loop diuretics within 30 days after discharge and recurrent MI. Patients can be classified into low-, intermediate-, and high-risk groups according to the numbers of above factors. The risk of developing HF was 3.37 fold and 5.99 fold higher in the intermediate- and high-risk groups compared with low-risk group. The use of statins (HR 0.85, 95% CI 0.78-0.92) and other lipid-lowering agents (HR 0.61, 95% CI 0.48-0.78) significantly reduced the risk of HF. The use of beta-blockers (HR 0.86, 95% CI 0.76-0.98) and statins (HR 0.82, 95% CI 0.72-0.94) significantly reduced the risk of severe HF.

Conclusions
Survivors of AMI without prior HF remain at risk of developing HF in Taiwan and most episodes occur early after AMI. We identified 5 most important factors related to HF which may help to stratify risk level. The use of beta-blockers and lipid-lowering agents is associated with a reduced risk of HF.
論文目次 中文摘要I
AbstractIII
誌謝V
目錄VII
表目錄IX
圖目錄XI
縮寫與全名對照表XII
第一篇、 初次急性心肌梗塞病患新發生心衰竭之危險因子分析1
第一章、 研究背景1
第二章、 文獻回顧2
第一節、 急性心肌梗塞2
第二節、 心衰竭7
第三節、 急性心肌梗塞與心衰竭之相關性15
第四節、 總結23
第三章、 研究目的及重要性24
第四章、 研究方法25
第一節、 研究設計25
第二節、 研究變項與操作定義31
第三節、 研究變項校正與排除條件之操作定義35
第四節、 研究結果變項之操作定義38
第五節、 資料處理流程39
第六節、 統計方法40
第七節、 敏感性分析 42
第五章、 研究結果44
第一節、 研究對象I44
第二節、 心肌梗塞後心衰竭發生率分析48
第三節、 研究對象II51
第四節、 心肌梗塞出院後發生心衰竭之危險因子分析55
第五節、 心肌梗塞出院後發生心衰竭或死亡之危險因子分析64
第六節、 病患危險分級73
第七節、 敏感性分析 76
第六章、 研究討論84
第一節、 研究對象之納入、排除條件分析84
第二節、 心衰竭發生率分析87
第三節、 心衰竭危險因子分析93
第四節、 心衰竭危險分級100
第五節、 研究限制102
第七章、 結論與建議 104
第八章、 未來研究方向105

第二篇、 臨床藥事服務107
第一章、 服務緣起107
第二章、 服務目的與方法109
第一節、 目的109
第二節、 方法109
第三章、 結果113
第一節、 服務對象基本特性113
第二節、 服藥順從性 114
第三節、 藥品知識115
第四章、 衛教感想117
第五章、 建議119

參考文獻121
附錄130


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