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ENGLISH ABSTRACT
急性主动脉综合征强化保守治疗临床疗效研究
朱尹凡
戴路
吴昊天
李雅敏
李东杰
王世攀
梁嘉俊
严研
皋健钧
楼烨挺
陶震泽
鲁亦凡
杨智然
李嘉
陈思吉
刘创
张亚哲
米玉红
李海洋
姜文剑
张宏家
作者及单位信息
·
DOI： 10.3760/cma.j.cn112434-20250129-00027
Clinical efficacy of intensive conservative treatment for acute aortic syndrome
Zhu Yinfan
Dai Lu
Wu Haotian
Li Yamin
Li Dongjie
Wang Shipan
Liang Jiajun
Yan Yan
Gao Jianjun
Lou Yeting
Tao Zhenze
Lu Yifan
Yang Zhiran
Li Jia
Chen Siji
Liu Chuang
Zhang Yazhe
Mi Yuhong
Li Haiyang
Jiang Wenjian
Zhang Hongjia
Authors Info & Affiliations
Zhu Yinfan
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Dai Lu
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Wu Haotian
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Li Yamin
Department of Emergency Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Li Dongjie
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Wang Shipan
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Liang Jiajun
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Yan Yan
Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Gao Jianjun
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Lou Yeting
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Tao Zhenze
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Lu Yifan
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Yang Zhiran
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Li Jia
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Chen Siji
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Liu Chuang
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Zhang Yazhe
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Mi Yuhong
Department of Emergency Intensive Care Unit, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Li Haiyang
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Jiang Wenjian
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
Zhang Hongjia
Department of Cardiac Surgery Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
·
DOI： 10.3760/cma.j.cn112434-20250129-00027
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摘要

目的前瞻性观察研究评价强化保守治疗比常规保守治疗对急性主动脉综合征患者临床预后的影响。

方法前瞻性连续纳入2024年1月至2024年12月就诊于首都医科大学附属北京安贞医院、北京大望路急诊抢救医院的急性主动脉综合征患者，无法接受急诊手术或拒绝手术，行保守治疗。共纳入282例，排除数据缺失和未接受任何治疗死亡患者15例，最终纳入267例，其中94例强化保守治疗，173例常规保守治疗。通过逆概率加权校正基线数据，比较校正前后14、30天及随访结束时两组患者生存情况。

结果校正混杂因素后，就诊后14天强化保守治疗的急性主动脉综合征患者生存率显著高于常规保守治疗的患者(82.40%对53.20%， P<0.0001)，30天和276天中期随访时强化保守治疗患者生存率仍然显著高于常规保守治疗组(79.60%对51.60%， P<0.0001；78.50%对48.50%， P<0.0001)。在亚组分析中，与常规保守治疗组相比，A型主动脉夹层14、30和276天强化保守治疗组均有更高的生存率(63.46%对41.35%， P<0.05；52.17%对37.90%， P<0.05；50.00%对31.97%， P<0.05)，B型主动脉夹层虽强化保守治疗生存率亦高于常规保守治疗，但差异无统计学意义(96.29%对80.00%， P＝0.054；95.65%对78.37%， P＝0.067；94.12%对74.20%， P＝0.088)。

结论确诊为急性主动脉综合征的患者，若无法第一时间行急诊手术而选择保守治疗时，强化保守治疗策略比常规保守治疗能显著降低急性期死亡比例。中期随访强化保守治疗仍具有显著生存优势。

急性主动脉综合征;主动脉夹层;强化保守治疗
ABSTRACT

ObjectiveTo evaluate the outcomes of intensive conservative treatment compared to conventional conservative treatment in patients with acute aortic syndrome(AAS).

MethodsThe study prospectively enrolled consecutive patients with AAS who were admitted to Beijing Anzhen Hospital, affiliated with Capital Medical University, and Beijing Dawanglu Emergency Rescue Hospital from January 2024 to December 2024. These patients with surgical contraindications or refused surgery for various reasons opted for conservative treatment. A total of 282 patients were included, and 15 patients with missing data or those who died without any treatment were excluded. Finally, 267 patients were enrolled, of whom 94 received intensive conservative treatment, and 173 received conventional conservative treatment, the inverse probability of treatment weighting (IPTW) was used to reduce the influence of confoundings. After adjusting of baseline datas via IPTW, the survival outcomes of the two groups were compared at 14 days, 30 days, and at the end of follow-up.

ResultsThe results showed significant differences in acute phase survival rates between the enhanced conservative treatment group and the conventional conservative treatment group at 14 days(82.40%vs.53.20%, P<0.0001). Significant survival differences were also observed at 30 days and at 276-day mid-term follow-up (96.29% vs.51.60%, P<0.0001; 78.50% vs.48.50%, P<0.0001). In the subgroup analysis, for type A aortic dissection, the enhanced conservative treatment group had higher survival rates compared to the conventional conservative treatment group at 14, 30 and 276 days (63.46% vs.41.35%, P<0.05; 52.17% vs.37.90%, P<0.05; 50.00% vs. 31.97%, P<0.05). However, for type B aortic dissection, although the enhanced conservative treatment group had higher survival rates than the conventional conservative treatment group, no statistically significant differences were observed (96.29% vs. 80.00%, P=0.054; 95.65% vs.78.37%, P=0.067; 94.12% vs.74.20%, P=0.088).

ConclusionFor patients diagnosed with AAS are forced to choose conservative treatment if emergency surgery is not possible in the first place, intensive conservative treatment strategies can significantly reduce the mortality in the acute phase compared with conventional conservative treatment. Mid-term follow-up, intensive conservative treatment still has a significant survival advantage.

Acute aortic syndrome;Aortic dissection;Intensive conservative treatment
Jiang Wenjian Email: nc.defudabe.umccnaijnewgnaij
Zhang Hongjia nc.defudabe.umcc227aijgnohgnahz
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引用本文

朱尹凡,戴路,吴昊天,等. 急性主动脉综合征强化保守治疗临床疗效研究[J]. 中华胸心血管外科杂志,2025,41(03)：143-150.

DOI:10.3760/cma.j.cn112434-20250129-00027

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急性主动脉综合征(acute aortic syndrome，AAS)是指主动脉壁完整性受损的一组致命性疾病，主要包括主动脉夹层(aortic dissection，AD)、主动脉壁内血肿(intramural Hematoma，IMH)和主动脉穿通性溃疡(penetrating aortic ulcer，PAU)，或几种同时存在，可能导致主动脉破裂，每年发病率2.12～9.00/10万人 [ 1 , 2 , 3 , 4 , 5 , 6 ]，实际发病率可能更高。常见类型是急性AD，占62%～88% [ 7 ]，根据发病时间可分为急性期(≤14天)和慢性期(>14天) [ 8 ]。未经治疗的急性AD是高度致命的，症状出现后的早期死亡比例每小时1%～2% [ 9 ]。
急诊手术是急性AD首选治疗方案，此外指南建议AAS患者均应先进行药物治疗，包括积极的心率和血压管理及疼痛控制 [ 10 , 11 , 12 ]。然而，根据我国首个大规模AD登记注册队列研究(Sino-RAD)显示，急性A型AD手术率仅52.6% [ 13 ]，而AD国际注册登记研究(international registry of acute aortic dissection，IRAD)显示急性A型AD手术率92.5% [ 14 ]。这可能与地方医疗水平偏低、患者转运途中死亡、患者难以承担手术费用等因素相关 [ 5 ]。这些患者通常未能得到进一步的强化保守治疗及监测，亦缺乏长期的关注及随访。本研究聚焦未能接受急诊手术的AAS患者，拟探索强化保守治疗的临床效果。
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备注信息
A
姜文剑　Email: nc.defudabe.umccnaijnewgnaij
B
张宏家　 nc.defudabe.umcc227aijgnohgnahz
C

朱尹凡：酝酿和设计实验、实施研究、采集数据、分析/解释数据、起草文章、统计分析；戴路：酝酿和设计实验、实施研究、采集数据、分析/解释数据、对文章的知识性内容作批评性审阅、指导；吴昊天：实施研究、采集数据、分析/解释数据、起草文章、统计分析；李雅敏：实施研究、对文章的知识性内容作批评性审阅、支持性贡献；李东杰、严研：分析/解释数据、对文章的知识性内容作批评性审阅、统计分析、指导；王世攀：实施研究、分析/解释数据、对文章的知识性内容作批评性审阅、统计分析、支持性贡献；梁嘉俊、皋健钧、楼烨挺、陶震泽、鲁亦凡、杨智然、李嘉、陈思吉、刘创、张亚哲：实施研究、采集数据、对文章的知识性内容作批评性审阅、支持性贡献；米玉红：酝酿和设计实验、实施研究、对文章的知识性内容作批评性审阅、指导、支持性贡献；李海洋：酿和设计实验、对文章的知识性内容作批评性审阅、指导、支持性贡献；姜文剑、张宏家：酝酿和设计实验、实施研究、分析/解释数据、对文章的知识性内容作批评性审阅、统计分析、获取研究经费、行政、技术或材料支持、指导、支持性贡献

D
所有作者均声明不存在利益冲突
E
国家自然科学基金项目 (82241205，82422007，82170487，82400548)
北京市自然科学基金 (JQ24039)
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