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系統識別號 U0026-2508201414100400
論文名稱(中文) 性別差異對急性心肌梗塞病患臨床表徵診療處置之影響:以台灣某醫學中心為例之研究
論文名稱(英文) Impact of sex difference in clinical presentations, therapeutic characteristics in patients with acute myocardial infarction
校院名稱 成功大學
系所名稱(中) 公共衛生研究所
系所名稱(英) Graduate Institute of Public Health
學年度 102
學期 2
出版年 103
研究生(中文) 林怡慧
研究生(英文) Yi-Hui Lin
學號 T86011028
學位類別 碩士
語文別 中文
論文頁數 107頁
口試委員 共同指導教授-謝棟漢
指導教授-陳國東
口試委員-王亮懿
中文關鍵字 急性心肌梗塞  性別  胸痛  非典型症狀  住院死亡率 
英文關鍵字 acute myocardial infarction  sex  chest pain  atypical symptoms  hospital case-fatality 
學科別分類
中文摘要 研究背景
據世界衛生組織2011年Global Atlas on Cardiovascular Disease Prevention and Control報告指出,心血管疾病為全球的主要死因,且占所有疾病死因的1/3,即每年約有17,300,000人死於此疾病;其中又以缺血性心臟病為首要死因,在男、女間各占46%與38%,當中死於急性心肌梗塞(Acute myocardial infarction, 簡稱AMI)更高達7,300,000人,占有重要地位。研究指出,在先進國家中急性心肌梗塞在不同性別間存在許多差異,包括不同的罹病率、不同的臨床表徵、以及不同的預後等,而台灣地區在這個議題的研究尚相當稀少。
研究目的
探討台灣地區不同性別急性心肌梗塞病患之流行病學特性、臨床特徵以及診療特性。
材料與方法
本研究採取病歷回顧方式進行回溯性研究,研究對象為南部某醫學中心從2007至2010年間因急性心肌梗塞就醫病人;病歷擷取條件為住院診斷碼ICD-9-CM為410之病人,蒐集方法為使用已設計好之病歷登錄表登錄研究所需之相關病歷資訊。研究分析架構,將針對性別、疾病之典型與非典型表徵進行分層分析;類別變項使用卡方檢定與費雪檢定,連續變項則使用獨立樣本t檢定進行分析。
結果
從2007至2009年間本研究共蒐集216位因急性心肌梗塞住院病人,男性有157人,占72.7%;女性有59人,占27.3%。其中,女性急性心肌梗塞病人在平均年齡71.14歲顯著高於男性病人平均年齡62.34歲,且女性病人有糖尿病史比例顯著高於男性病人(52.5% vs. 33.1%),並多以非典型症狀表現(47.5% vs. 21.7%)。進一步控制疾病表徵之分層分析,發現無論在典型胸痛組或非典型症狀組之下,女性病人有腎臟病病史比例、發生併發症比例,特別是心臟衰竭、肺炎或其他感染、急性腎衰竭以及發生住院死亡比例皆顯著高於男性病人。在多變量邏輯斯迴歸分析當中,控制了年齡、性別、非典型症狀、無使用Aspirin後,未進行PCI手術者,則為急性心肌梗塞病人的住院死亡風險因子。
結論
女性病人多以非典型症狀表現居多、年齡較長、有糖尿病史及腎臟病史較多、發生併發症比例與住院死亡比例等皆顯著高於男性病人。在多變量邏輯斯迴歸分析中,沒有做超音波檢查與有併發症之病人,其住院死亡風險較高。建議未來面對女性急性心肌梗塞病人之醫護人員,透過加強管控、早期辨識併發症之發生(如:肺炎)與及早進行PCI手術,可望能減少急性心肌梗塞病人之住院死亡比例。

關鍵字:急性心肌梗塞、性別、胸痛、非典型症狀、住院死亡率
英文摘要 Impact of sex difference in clinical presentations, therapeutic characteristics and in-hospital outcome in patients with acute myocardial infarction

Lin Yi-Hui
Chen Kow-Tong
Hsieh Tung-Han
Department of Public Health College of Medicine National Cheng Kung University

SUMMARY
This study was based on hospital-base population at a medical center in the south of Taiwan from 2007 to 2010,for patients with discharge diagnosis of acute myocardial infarction ICD-9-CM codes 410. The aim of this study was to determine the characteristics of AMI by sex. We used chart review and chi-square test, fisher’s exact test, independent sample t test, logictic regression for statistic anlyzing. Females were more likely to have atypical symtroms, older age, history of diabetes mellitus and chronic kidney disease, higher incidence of complications and hospital fatality than males.

Key words: acute myocardial infarction, sex, chest pain, atypical symptoms, hospital case-fatality





INTRODUTION
Cardiovascular diseases (CVDs) remain the biggest cause of deaths worldwide, account for 1/3 of all cause of deaths and it is responsible for 17.3 million of the cardiovascular deaths. Of the cardiovascular deaths, in the ischaemic heart diseases, there were up to 7.3million people died with acute myocardial infarction (AMI) which was remained the most important cause of deaths. In the developed countries, gender plays a major role of different morbidities, clinic presentations and prognosesof AMI. However, few studies wad done in Taiwan. The aim of this study was to determine the characteristics of AMI by sex.

MATERIALS AND METHODS
This study was based on hospital-base population at a medical center in the south of Taiwan from 2007 to 2010. Patients with discharge diagnosis of acute myocardial infarction ICD-9-CM codes 410 were enrolled in our study. For the categorical variables, we used chi-square test and fisher’s exact test and for the countiunable variables we used independent sample t test to analyze the variables.

RESULTS AND DISCUSSION
A total of 216 patients was erolled in our study. Among them, 157 cases were male (72.7%) and 59 cases were female (27.3%). Women were older than men with average age 71.14 years vs. 62.34 years. Females had significantly higher proportion of history of diabetes mellitus than that of males had (52.5% vs. 33.1%) and more likely to present with atypical symtroms than males had (47.5% vs. 21.7%). In multiple analyzing showed, females were more likely to had chronic kidney disease history, complications which especially were heart failure, pneumonia/other infections, acute renal failure and also had significantly higher proportion of hospital case-fatality. Finally, in logistic regresstion models we found out that sex, not do PCI surgery will have higher risk of hospital case-fatality.

CONCLUSION
Females were more likely to have atypical symtroms, older age, history of diabetes mellitus and chronic kidney disease, higher incidence of complications and hospital fatality than males. Patients who were without echocardiography and had complications had higher risks to have hospital fatality. In the future, early diagnosis or detecting the complications (ex. pneumonia) and doing PCI surgery are important to decrease the hospital case-fatality.
論文目次 目錄
第一章 緒論5
第一節 研究背景5
第二節 研究動機8
第三節 研究目的9
第二章 文獻探討10
第一節 急性心肌梗塞定義10
第二節 急性心肌梗塞流行病學與危險因子概述14
第三節 急性心肌梗塞之性別差異24
第四節 非典型症狀在性別間之差異30
第三章 研究方法33
第一節 資料來源33
第二節 研究對象與資料蒐集33
第三節 研究架構與操作型定義34
第四節 分析方法35
第四章 研究結果37
第一節 急性心肌梗塞病人描述性流行病學特徵37
第二節 男、女性急性心肌梗塞病人之單變量分析39
第三節 急性心肌梗塞病人依疾病表徵與性別分層之單變量分析41
第四節 急性心肌梗塞病人住院死亡之危險因子46
第五章 討論47
第六章 結論與建議54
第七章 參考文獻55
附錄 62

表目錄
表1-台灣某醫學中心急性心肌梗塞病人基本人口學特質之描述 66
表2-台灣某醫學中心急性心肌梗塞病人臨床表現與到院後診療特性 68
表3-台灣某醫學中心男、女性急性心肌梗塞病人基本人口學特質之單變量分析 70
表4-台灣某醫學中心男、女性急性心肌梗塞病人臨床表現與到院後診療特性 72
表5-台灣某醫學中心典型胸痛症狀之男、女性急性心肌梗塞病人基本人口學特質單變量分析 76
表6-台灣某醫學中典型胸痛症狀之男、女性急性心肌梗塞病人臨床特性與到院後診療特性 78
表7-台灣某醫學中心非典型症狀之男、女性急性心肌梗塞病人基本人口學特質單變量分析 82
表8-台灣某醫學中非典型胸痛症狀之男、女性急性心肌梗塞病人臨床特性與到院後診療特性 84
表9-台灣某醫學中心男性典型、非典型心肌梗塞病人之基本人口學特質單變量分析 88
表10-台灣某醫學中男性典型、非典型之心肌梗塞病人臨床特性與到院後診療特性 90
表11-台灣某醫學中心女性典型、非典型心肌梗塞病人之基本人口學特質單變量分析 95
表12-台灣某醫學中女性典型、非典型之心肌梗塞病人臨床特性與到院後診療特性 97
表13-台灣某醫學中急性心肌梗塞病人出院結果之基本人口學特質之單變量分析 101
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