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澳大利亚悉尼大学Gemma A Figtree团队研究了没有标准可调危险因素的ST段抬高型心肌梗死患者的死亡率。2021年3月10日，该研究发表在《柳叶刀》杂志上。

在心血管疾病中，针对标准可改变的心血管危险因素（SMuRFs，包括高血压、糖尿病、高胆固醇血症和吸烟）的预防策略至关重要。然而，在没有SMuRFs的情况下心肌梗死并不少见，但这些患者的预后并不为人所知。

研究组根据瑞典心肌梗死登记处的数据，回顾性分析了首次出现ST段抬高型心肌梗死（STEMI）的成人患者，对有或无SMuRFs的成年患者（年龄≥18岁）的临床特征和预后进行全面和性别分析。排除有冠心病病史的患者。主要结局是ST段抬高型心肌梗死后30天的全因死亡率。次要结局包括30天时的心血管死亡、心力衰竭和心肌梗死。

2005年1月1日至2018年5月25日，62 048例STEMI患者中，9228例（14.9%）无SMuRFs的患者达到诊断阈值。有或无SMuRFs患者的中位年龄分别为68岁和69岁，相差不大。无SMuRFs的患者经皮冠脉介入治疗的发生率与至少有一种可改变危险因素的患者相似，但出院时接受他汀类药物、血管紧张素转换酶抑制剂（ACEIs）或血管紧张素受体阻断剂（ARB）或β受体阻断剂的可能性显著降低。

在发病后30天，无SMuRFs患者的全因死亡率显著高于有SMuRFs患者，风险比为1.47。无SMuRFs女性的30天死亡率最高（17.6%），其次是有SMuRFs女性（11.1%），无SMuRFs男性（9.3%）和有SMuRFs男性（6.1%）。在对年龄、性别、左室射血分数、肌酐和血压进行校正后，无SMuRFs患者30天全因死亡率的增加风险仍然显著，但在出院时纳入药物治疗处方（ACEI或ARB、β受体阻滞剂或他汀类药物）后，风险有所降低。

此外，无SMuRFs患者的院内全因死亡率显著高于有一个或多个SMuRFs的患者，分别为9.6%和6.5%。无SMuRFs患者30天时的心肌梗死和心力衰竭发生率较低。无SMuRFs组的全因死亡率在男性中连续8年以上，在女性中连续12年以上持续上升。

研究结果表明，与至少有一个SMuRFs的个体相比，在没有SMuRFs的情况下出现STEMI的个体全因死亡的风险显著增加，这在女性中尤为明显。

附：英文原文

Title: Mortality in STEMI patients without standard modifiable risk factors: a sex-disaggregated analysis of SWEDEHEART registry data

Author: Gemma A Figtree, Stephen T Vernon, Nermin Hadziosmanovic, Johan Sundstrm, Joakim Alfredsson, Clare Arnott, Vincent Delatour, Margrét Leósdóttir, Emil Hagstrm

Issue&Volume: 2021-03-10

Abstract:

Background

In cardiovascular disease, prevention strategies targeting standard modifiable cardiovascular risk factors (SMuRFs; hypertension, diabetes, hypercholesterolaemia, and smoking) are crucial; however, myocardial infarction in the absence of SMuRFs is not infrequent. The outcomes of individuals without SMuRFs are not well known.

Methods

We retrospectively analysed adult patients with first-presentation ST-elevation myocardial infarction (STEMI) using data from the Swedish myocardial infarction registry SWEDEHEART. Clinical characteristics and outcomes of adult patients (age ≥18 years) with and without SMuRFs were examined overall and by sex. Patients with a known history of coronary artery disease were excluded. The primary outcome was all-cause mortality at 30 days after STEMI presentation. Secondary outcomes included cardiovascular mortality, heart failure, and myocardial infarction at30 days. Endpoints were also examined up to discharge, and to the end of a 12-year follow-up. Multivariable logistic regression models were used to compare in-hospital mortality, and Cox-proportional hazard models and Kaplan-Meier analysis for long-term outcomes.

Findings

Between Jan 1, 2005, and May 25, 2018, 9228 (14·9%) of 62048 patients with STEMI had no SMuRFs reaching diagnostic thresholds. Median age was similar between patients with SMuRFs and patients without SMuRFs (68 years [IQR 59–78]) vs 69 years [60–78], p<0·0001). SMuRF-less patients had a similar rate of percutaneous coronary intervention to those with at least one modifiable risk factor, but were significantly less likely to receive statins, angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockade (ARB), or β-blockers at discharge. By 30 days after presentation, all-cause mortality was significantly higher in SMuRF-less patients (hazard ratio 1·47 [95% CI 1·37–1·57], p<0·0001). SMuRF-less women had the highest 30-day mortality (381 [17·6%] of 2164), followed by women with SMuRFs (2032 [11·1%] of 18220), SMuRF-less men (660 [9·3%] of 7064), and men with SMuRFs (2117 [6·1%] of 34600). The increased risk of 30-day all-cause mortality in SMuRF-less patients remained significant after adjusting for age, sex, left ventricular ejection fraction, creatinine, and blood pressure, but was attenuated on inclusion of pharmacotherapy prescription (ACEI or ARB, β-blocker, or statin) at discharge. Additionally, SMuRF-less patients had a significantly higher rate of in-hospital all-cause mortality than patients with one or more SMuRF (883 [9·6%] vs 3411 [6·5%], p<0·0001). Myocardial infarction and heart failure at 30 days were lower in SMuRF-less patients. All-cause mortality remained increased in the SMuRF-less group for more than 8 years in men and up to the 12-year endpoint in women.

Interpretation

Individuals who present with STEMI in the absence of SMuRFs have a significantly increased risk of all-cause mortality, compared with those with at least one SMuRF, which was particularly evident in women. The increased early mortality rates are attenuated after adjustment for use of guideline-indicated treatments, highlighting the need for evidence-based pharmacotherapy during the immediate post-infarct period irrespective of perceived low risk.

DOI: 10.1016/S0140-6736(21)00272-5

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00272-5/fulltext

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