急性心肌梗死患者药物治疗的疗效观察及选择药物治疗的原因分析

发布时间：2018-01-03 03:23

本文关键词：急性心肌梗死患者药物治疗的疗效观察及选择药物治疗的原因分析　出处：《广西医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:观察急性心肌梗死(Acute myocardial infarction,AMI)急诊患者药物治疗近期及远期临床疗效,分析急性心肌梗死急诊患者选择药物治疗的原因,并探讨影响药物治疗患者主要心血管不良事件(Major adverse cardiovascular event,MACE)发生的相关因素。方法:通过广西医科大学第一附属医院电子病历系统收集2013年1月至2016年9月期间确诊AMI—包括急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)和急性非ST段抬高型心肌梗死(Non-st-elevation myocardial infarction,NSTEMI)入住我院(包括院内急诊)的病例,分药物治疗组共126例,药物治疗组再分为单纯药物治疗组(115例)和单纯药物+静脉溶栓组(11例)两个亚组,选择同期在我院行急诊经皮冠脉介入治疗(Percutaneous coronary intervention,PCI)病例211例作为对照组。比较三组病人近期疗效及远期疗效—包括比较三组病人的全因死亡率、急性期或围术期急性左心衰或者心源性休克发生率、NT-proBNP的变化、心脏超声心动图各指标—包括左心室射血分数(Left ventricular ejection fraction,LVEF)、左心室舒张末期容积(Left ventricular end-diastolic volume,LVEDV)、左心室舒张末径(Left ventricular end-diastolic diameter,LVEDD)以及左心室收缩末径(Left ventricular end-systolic diameter,LVESD)以及MACE事件发生率等。简要分析影响AMI急诊患者坚持选择药物治疗的原因。根据药物治疗组是否发生MACE事件,分为MACE事件组和无MACE事件组,通过多因素logistic回归分析影响药物治疗组总MACE事件发生的相关因素。结果:1、药物治疗组总全因死亡例数为33例(占26.19%);急诊pci组全因死亡例数为18例(占8.53%),药物治疗组全因死亡率高于急诊pci组(26.19%vs8.53%,p0.05)。2、ami急性期内,单纯药物治疗组急性左心衰/心源性休克发生率明显高于急诊pci组(33.91%vs16.11,p0.05);药物治疗组两亚组与急诊pci组比较,心泵功能killip分级级别更高,提示药物治疗两亚组急性期心功能更差[秩均值比较分别为(194.49vs153.29)、(203.91vs153.29),p0.05]。3、单纯药物治疗组入院第一次nt-probnp水平中位值高于急诊pci组[(1120.50,1748.40)pg/mlvs(820.00,1591.30)pg/ml,p0.05],单纯药物+静脉溶栓组与急诊pci组入院第一次nt-probnp比较无差异[(572.60,2081)pg/mlvs(820.00,1591.30)pg/ml,p0.05]。经不同治疗方式后,出院前单纯药物组较急诊pci组nt-probnp水平更高[(448.50,401.30)pg/mlvs(98.00,130.00)pg/ml,p0.05]。与急诊pci组相比,单纯药物治疗组近期lvesd更大[(36.88±6.75)mmvs(34.94±6.39)mm,p0.05)、lvef值更低[(55.44±9.8)%vs(58.26±8.30)%,p0.05];单纯药物+静脉溶栓组与急诊pci组相比,出院前nt-probnp水平、lvef值、lvedv、lvedd、lvesd差异均无统计学意义[nt-probnp(189.00,229.75)pg/mlvs(98.00,130.00)pg/ml,lvef值(56.25±7.78)%vs(58.26±8.30)%,lvedv(134.37±25.83)mlvs(128.56±35.16)ml,lvedd(52.50±5.90)mmvs(51.56±5.87)mm,lvesd(37.25±3.86)mmvs,(34.94±6.39)mm,各p0.05]。单纯药物治疗组与急诊pci组相比,远期nt-probnp水平、lvef、lvedv、lvedd、lvesd差异明显[nt-probnp(653.20,984.50)pg/mlvs(109.00,49.50)pg/ml,lvef(55.65±8.66)%vs(62.78±7.27)%,lvedv(153.29±56.52)mlvs(131.08±33.44)ml,lvedd(56.01±7.15)mmvs(51.52±5.49)mm,lvesd(38.82±7.93)mmvs(33.58±5.81)mm,各p0.05]。单纯药物+静脉溶栓组远期nt-probnp高于急诊pci组[(567.30,1035.00)pg/mlvs(109.00,49.50)pg/ml,P0.05]。单纯药物治疗组与单纯药物+静脉溶栓组远期NYHA心功能分级级别均高于急诊PCI组(秩均值比较为180.04vs117.30、151.56vs117.30,P0.05);单纯药物治疗组与单纯药物+静脉溶栓组MACE事件发生率均高于急诊PCI组(66.96%vs19.91%、45.45%vs19.91%,P0.05)。4、药物治疗亚组组内配对比较,单纯药物治疗组入院时NT-proBNP明显高于远期NT-proBNP水平[(1641.50,4177.48)pg/mlvs(652.10,949.58)pg/ml,P0.05];单纯药物+静脉溶栓组入院时NT-pro BNP高于远期NT-proBNP水平[(445.00,264.40)pg/mlvs(142.60,100.00)pg/ml,P0.05]。单纯药物治疗组近期LVEDV、LVEDD均小于远期LVEDV、LVEDD[LVEDV(140.26±42.14)ml vs(153.26±58.50)ml、LVEDD(54.46±6.16)mm vs(56.18±7.28)mm,P0.05];单纯药物+静脉溶栓组近期LVEF值低于远期的LVEF值[(51.43±6.29)%vs(61.71±6.89)%,P0.05]。5、不能接受急诊手术风险、有急诊介入指征但已错过最佳手术时机、患者年龄太大不能耐受急诊手术、经济困难等是本地区AMI患者选择药物治疗的主要原因。6、通过多因素logistic回归分析发现年龄75岁、合并急性左心衰/心源性休克是AMI药物治疗患者MACE事件发生的独立危险因素。结论:1、虽然AMI急诊单纯药物或单纯药物+静脉溶栓治疗疗效尚可;但急诊PCI治疗死亡率更低、近期及远期心功能改善更优、疗效更佳。因此,在能够开展急诊PCI治疗的医院,建议将指南推荐的急诊PCI(I,A)作为AMI急诊患者首选的治疗手段。2、不能接受急诊手术风险、错过最佳手术时机、家属认为患者年龄大不能耐受急诊手术及家庭经济困难等是本地区AMI患者及家属选择药物治疗的主要原因。3、年龄75岁、合并急性左心衰或心源性休克是本地区AMI药物治疗患者MACE事件发生的独立危险因素。
[Abstract]:Objective: To observe the acute myocardial infarction (Acute myocardial, infarction, AMI) drug emergency treatment in patients with short-term and long-term clinical efficacy analysis of patients with acute myocardial infarction patients choose drug treatment, and the effect of drug treatment in patients with major cardiovascular adverse events (Major adverse cardiovascular event, MACE) related factors. Methods: the First Affiliated Hospital Guangxi Medical University of electronic medical records system from January 2013 to September 2016 during the diagnosis of AMI including acute ST elevation myocardial infarction (ST-segment elevation myocardial infarction, STEMI) and acute non ST elevation myocardial infarction (Non-st-elevation myocardial, infarction, NSTEMI) in our hospital (including hospital emergency) cases, drug treatment group of 126 cases. The drug treatment group were further divided into drug treatment group (115 cases) and single drug + intravenous thrombolysis group (11 Two cases) group, select the same period in our hospital for emergency percutaneous coronary intervention (Percutaneous coronary, intervention, PCI) of 211 cases as the control group. The three groups were compared, including short-term and long-term curative effect of the three groups were compared for all-cause mortality, acute or perioperative acute left heart failure or cardiac the incidence of shock, the change of NT-proBNP, echocardiography indexes including left ventricular ejection fraction (Left ventricular ejection fraction, LVEF), left ventricular end diastolic volume (Left ventricular end-diastolic volume, LVEDV), left ventricular end diastolic diameter (Left ventricular end-diastolic diameter, LVEDD) and left ventricular end systolic diameter (Left ventricular end-systolic diameter, LVESD) and the MACE event rate. A brief analysis of effect of AMI in emergency patients adhere to the reasons for choosing treatment. According to the drug treatment group The occurrence of MACE event, divided into MACE group and non MACE group event event, related factors by multivariate logistic regression analysis of influence of drug treatment group total MACE events. Results: 1, treatment group total all-cause deaths in 33 cases (26.19%); emergency PCI group all-cause death cases 18 cases (8.53%), drug treatment group was higher than that of all-cause mortality in emergency PCI group (26.19%vs8.53%, P0.05).2, AMI in the acute period, the group of drug treatment of acute left heart failure and cardiogenic shock was significantly higher than the rate of emergency PCI group (33.91%vs16.11, P0.05); treatment group two group and emergency PCI group comparison of cardiac pump function Killip levels higher, indicating that the drug treatment of cardiac function in two subgroups of acute worse [rank mean comparison respectively (194.49vs153.29), (203.91vs153.29, p0.05].3), single drug treatment group was the first time in a NT-proBNP level is higher than the value of emergency PCI Group [(1120. 501748.40) pg/mlvs (820.001591.30) pg/ml, p0.05], single drug + intravenous thrombolysis group and emergency admission of the PCI group had no significant difference between the first NT-proBNP [(572.602081) pg/mlvs (820.001591.30) pg/ml, p0.05]. after treatment before discharge, simple drug group than in the emergency PCI group higher level of NT-proBNP [(448.50401.30) pg/mlvs (98.00130.00 pg/ml, p0.05].) compared with the emergency PCI group, drug treatment group of more recent LVESD [(36.88 + 6.75) mmvs (34.94 + 6.39) mm, P0.05, LVEF) is low [(55.44 + 9.8)%vs (58.26 + 8.30)%, p0.05]; single drug + intravenous thrombolysis group and emergency PCI group compared to the level of NT-proBNP, LVEDV, LVEDd from LVEF, LVESD, there were no significant differences in [nt-probnp (189.00229.75) pg/mlvs (98.00130.00) pg/ml, LVEF (56.25 + 7.78)%vs (58.26 + 8.30)%, LVEDV (134.37 + 25.83) MLVs (128.56 + 35.16) ml, LVEDd (52.50 + 5.90 mmvs (5) 1.56 + 5.87) mm, LVESD (37.25 + 3.86) mmvs, (34.94 + 6.39) mm, compared to the p0.05]. group of drug treatment and emergency PCI group, the level of LVEF, LVEDV forward NT-proBNP, LVEDd, LVESD, [nt-probnp (653.20984.50) pg/mlvs significant difference (109.00,49.50) pg/ml, LVEF (55.65 + 8.66 (%vs) 62.78 + 7.27)%, LVEDV (153.29 + 56.52) MLVs (131.08 + 33.44) ml, LVEDd (56.01 + 7.15) mmvs (51.52 + 5.49) mm, LVESD (38.82 + 7.93) mmvs (33.58 + 5.81) mm, the p0.05]. drug + intravenous thrombolysis group was higher than that of long-term NT-proBNP emergency PCI Group [(567.301035.00) pg/mlvs (109.00,49.50) pg/ml, P0.05]. group of drug treatment and medication + intravenous thrombolysis group long-term NYHA cardiac functional grading level were higher than that of group PCI (mean rank of emergency was 180.04vs117.30151.56vs117.30, P0.05); group of drug treatment and medication + intravenous thrombolysis group MACE incidence rate was higher than that of group 66.96%v (emergency PCI S19.91%, 45.45%vs19.91%,.4, P0.05) drug treatment comparison of sub group matching, simple drug treatment group NT-proBNP on admission was significantly higher than that of long-term level of NT-proBNP [(1641.504177.48) pg/mlvs (652.10949.58) pg/ml, P0.05]; medication + intravenous thrombolysis group on admission NT-pro BNP higher than the long-term level of NT-proBNP [(445.00264.40) pg/mlvs (142.60100.00) pg/ml recently, P0.05]. drug treatment group LVEDV, LVEDD were less than the long-term LVEDV, LVEDD[LVEDV (140.26 + 42.14) ml vs (153.26 + 58.50) ml, LVEDD (54.46 + 6.16) mm vs (56.18 + 7.28) mm, P0.05]; medication + intravenous thrombolysis group in LVEF value is lower than the long-term value of LVEF [(51.43 + 6.29)%vs (61.71 + 6.89)%, P0.05].5, emergency operation risk can not accept emergency interventional indications but has missed the best timing of surgery, the age of patients can not tolerate too big emergency operation, economy is difficult with AMI local medicine The main reason for treating.6 by multivariate logistic regression analysis showed that age 75 years, combined with acute left heart failure or cardiogenic shock were independent risk factors for AMI drug treatment in patients with MACE events. Conclusion: 1, although AMI only emergency medicine or drug therapy + intravenous thrombolytic effect is acceptable; but the emergency treatment of PCI mortality lower short-term and long-term heart function improved better and better curative effect. Therefore, to carry out emergency PCI treatment in the hospital, recommended recommended guidelines for emergency PCI (I, A) as the AMI emergency treatment of choice for patients with.2, emergency operation risk can not be accepted, missed the best timing of surgery, patients older families that cannot the tolerance of emergency operation and family economic difficulties is patient and family AMI region main reason for choosing.3 medications, age 75 years, with acute left heart failure or cardiogenic shock is a local drug treatment AMI An independent risk factor for the occurrence of MACE events in a patient.

【学位授予单位】：广西医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R542.22

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