NEJM：院内心脏停搏或不影响老年生存者的远期转归

对于院内心脏停搏的老年生存者的远期转归我们所知甚少。日前，美国心脏学会遵循心肺复苏指南研究者，以及来自美国密苏里州堪萨斯城圣路加中美心脏研究所的研究人员明确了院内心脏停搏生存者的长期生存率和再入院率，并且对这些转归是否根据人口学统计学特征和出院时的神经功能状态而产生变化进行了研究。

临床医生通常认为院内心脏猝死幸存者，尤其是其中的老年人远期预后不良。该项新研究对这种看法提出了质疑，显示65岁以上院内心脏停搏幸存者1年生存率接近60%。研究结果3月13日发表于New England Journal of Medicine，首席研究员Paul Chan博士（美国中部心脏研究所）说“我们的发现令人感到一些安心，患者1年后死亡率曲线趋于平稳，老年院内心脏停搏幸存者的生存率和其他常见心脏疾病如心力衰竭相比没有区别。”

研究人员结合有医保档案的心脏停搏住院患者国家注册数据，共鉴别出6972例于2000～2008年间发生院内心脏停搏后得以幸存的、年龄不小于65岁的成人出院患者。研究人员对其1年生存率和再入院的预测因素进行了检验。

结果显示，出院后1年时，有58.5%的患者生存，34.4%的患者未再次入院。年龄较大患者校正危险后的1年生存率比年龄较小的患者低（年龄为65～74、75～84和≥85岁分别为63.7%、58.6%和49.7%，P＜0.001）、男性低于女性（58.6% VS 60.9%，P＝0.03）、黑人患者低于白人患者（52.5% VS 60.4%，P＝0.001）。研究者发现，有轻度或无神经功能失能的患者出院时校正危险后的1年生存率为72.8%，相比之下，有中度神经功能失能的患者为61.1%，有重度神经功能失能的患者为42.2%，处于昏迷或植物人状态的患者为10.2%（所有比较P值均＜0.001）。此外，黑人、女性和有重度神经功能失能患者的1年内再入院率较高（所有比较P值均＜0.05）。第2年时，生存率和再入院率的差异均持续存在。第3年时，院内心脏停搏生存者的生存率与因心衰住院并生存出院的患者相似（分别为43.5% 和44.9%，风险比0.98，95%置信区间0.95～1.02，P＝0.35）。

研究人员由此得出结论：老年院内心脏停搏生存者在第1年时其生存率接近60%，第3年生存率与心衰患者相似。生存率和再入院率根据患者的人口统计学特征和出院时神经功能状态的不同而出现差异。

Long-Term Outcomes in Elderly Survivors of In-Hospital Cardiac Arrest
Background
Little is known about the long-term outcomes in elderly survivors of in-hospital cardiac arrest. We determined rates of long-term survival and readmission among survivors of in-hospital cardiac arrest and examined whether these outcomes differed according to demographic characteristics and neurologic status at discharge.
Methods
We linked data from a national registry of inpatient cardiac arrests with Medicare files and identified 6972 adults, 65 years of age or older, who were discharged from the hospital after surviving an in-hospital cardiac arrest between 2000 and 2008. Predictors of 1-year survival and of readmission to the hospital were examined.
Results
One year after hospital discharge, 58.5% of the patients were alive, and 34.4% had not been readmitted to the hospital. The risk-adjusted rate of 1-year survival was lower among older patients than among younger patients (63.7%, 58.6%, and 49.7% among patients 65 to 74, 75 to 84, and ≥85 years of age, respectively; P<0.001), among men than among women (58.6% vs. 60.9%, P=0.03), and among black patients than among white patients (52.5% vs. 60.4%, P=0.001). The risk-adjusted rate of 1-year survival was 72.8% among patients with mild or no neurologic disability at discharge, as compared with 61.1% among patients with moderate neurologic disability, 42.2% among those with severe neurologic disability, and 10.2% among those in a coma or vegetative state (P<0.001 for all comparisons). Moreover, 1-year readmission rates were higher among patients who were black, those who were women, and those who had substantial neurologic disability (P<0.05 for all comparisons). These differences in survival and readmission rates persisted at 2 years. At 3 years, the rate of survival among survivors of in-hospital cardiac arrest was similar to that of patients who had been hospitalized with heart failure and were discharged alive (43.5% and 44.9%, respectively; risk ratio, 0.98; 95% confidence interval, 0.95 to 1.02; P=0.35).
Conclusions
Among elderly survivors of in-hospital cardiac arrest, nearly 60% were alive at 1 year, and the rate of 3-year survival was similar to that among patients with heart failure. Survival and readmission rates differed according to the demographic characteristics of the patients and neurologic status at discharge. (Funded by the American Heart Association and the National Heart, Lung, and Blood Institute.)