摘要目的 总结60岁及以上老年冠心病病例的心脏病理特点,分析老年急性心肌梗死(AMI)死亡病例的心脏病理特点及相关危险因素.方法 回顾性分析北京医院病理科资料库1969年4月至2013年10月的尸检病理资料,纳入60 ～ 100岁老年冠心病病例,共471例,以尸检病理报告结论为依据,AMI是引起死亡的主要原因者,为AMI组(共128例),其余病例(343例)为对照组,比较两组的心脏病理特点,用冠状动脉积分反映冠状动脉整体动脉粥样硬化程度,对AMI死亡的相关危险因素进行多因素logistic回归分析.结果 老年冠心病病例中,严重冠状动脉狭窄230例(48.8％),三支病变88例(18.7％),左前降支狭窄达Ⅲ级及以上338例(71.8％),左前降支狭窄Ⅳ级141例(29.9％),左主干狭窄达Ⅲ级及以上122例(25.9％),左主干狭窄Ⅳ级45例(9.6％),发生AMI 128例(27.1％),其中39.1％ (50/128)为首发AMI,60.9％(78/128)为合并陈旧性心肌梗死的病理改变.与对照组比较,AMI组年龄更小[(77.1±11.6)岁比(83.2±9.1)岁,P＜0.01],严重冠状动脉狭窄更多[77.3％ (99/128)比38.2％ (131/343),P＜0.01],三支病变更多[30.3％(43/128)比13.7％(45/343),P＜0.01],冠状动脉积分更高(9.9±2.8比8.0±2.5,P＜0.01),心脏质量更重[(447.8 ±90.6)g比(426.6 ±99.1)g,P＜0.05],肺瘀血或肺水肿比例更多[57.8％ (74/128)比39.9％(137/343),P＜0.01].AMI组中有23例(18.0％)发生心脏破裂.logistic回归分析显示,左前降支狭窄Ⅳ级(OR=3.55,95％CI 2.05 ～ 6.17,P＜0.01)、三支病变(OR=2.47,95％ CI 1.30～4.67,P＜0.01)是老年冠心病病例发生AMI死亡的独立危险因素.结论 老年冠心病中严重冠状动脉狭窄多见,左前降支为常见的病变血管.AMI死亡病例的冠状动脉粥样硬化程度更严重,心脏质量更重,心脏破裂并不少见.左前降支严重狭窄和三支病变是AMI死亡的独立危险因素.

abstractsObjective To analyze the cardiac pathological features of elderly coronary artery disease (CAD) patients (60 years and over) and evaluate the pathological features at autopsy and risk factors of patients with acute myocardial infarction (AMI).Methods Data from 471 elderly patients (aged from 60 to 100 years old) with CAD confirmed by autopsy hospitalized in our hospital from April 1969 to October 2013 were retrospectively reviewed.Patients were divided into 2 groups:AMI group(n =128) with AMI as the primary cause of death and the rest served as control group (n =343).The pathological features of coronary lesion and related risk factors of AMI were analyzed.Results In patients aged 60 and over with CAD,48.8％ (230/471) had severe coronary stenosis,18.7％ (88/471) had three-vessel disease,71.8％cases (338/471) had left anterior descending artery(LAD)grade Ⅲ and over stenosis,29.9％ (141/471) had LAD grade Ⅳ stenosis,25.9％ (122/471) had left main coronary artery (LM) grade Ⅲ and over stenosis,9.6％ (45/471) had LM grade Ⅳ stenosis,27.1％ (128/471) had AMI.The first AMI accounts for 39.1％ (50/128),and 60.9％ (78/128) had both AMI and old MI.Compared with the control group,AMI group were younger ((77.1 ±11.6) years vs.(83.2±9.1) years,P＜0.01),had more severe coronary artery stenosis lesion (77.3％ (99/128) vs.38.2％ (131/343),P ＜ 0.01),higher coronary index which reflects the overall arteriosclerosis (9.9 ± 2.8 vs.8.0 ± 2.5,P ＜ 0.01),more three-vessel disease (30.3％ (43/128) vs.13.7％ (45/343),P ＜0.01),heavier heart weight ((447.8 ±90.6)g vs.(426.6 ± 99.1) g,P ＜ 0.05),higher prevlence of pulmonary congestion or edema (57.8％ (74/128) vs.39.9％ (137/343),P ＜ 0.01).Twenty-three cardiac ruptures (23/128,18.0％) were observed in AMI group.Logistic regression analysis showed that grade Ⅳ LAD stenosis (OR =3.55,95％ CI 2.05-6.17,P ＜ 0.01),three-vessel disease (OR =2.47,95％ CI 1.30-4.67,P ＜ 0.01) were the independent risk factors of AMI in elderly patients with CAD.Conclusions Severe coronary stenosis is common in CAD patients aged 60 and over.Patients aged 60 and over with AMI have more severe coronary artery stenosis lesion and heavier heart weight.Cardiac rupture is not uncommon in elderly patients with AMI.Severe LAD stenosis and three-vessel disease are the independent risk factors of AMI in the elderly.