急诊PCI术后TIMI血流Ⅲ级的STEMI患者冠脉内注射地尔硫卓的临床意义

发布时间：2018-01-07 15:33

  本文关键词：急诊PCI术后TIMI血流Ⅲ级的STEMI患者冠脉内注射地尔硫卓的临床意义　出处：《河北医科大学》2017年硕士论文　论文类型：学位论文

  更多相关文章： 直接经皮冠状动脉介入 急性ST段抬高型心肌梗死 TIMIⅢ级 冠脉微循环 地尔硫卓

【摘要】：目的:目前有指南明确指出急性ST段抬高型心肌梗死(acute STsegment elevation myocardial infarction,STEMI)的成功的标准之一为TIMI血流Ⅲ级,但是我们发现STEMI患者行急诊直接经皮冠状动脉介入治疗(primary percutaneous coronary intervention,PPCI)即使达TIMI血流Ⅲ级,仍有部分患者出现胸痛缓解不完全及ST段不能及时回落等,考虑与出现微循环障碍有关。本文是在STEMI患者行急诊PCI达到TIMI血流Ⅲ级后冠脉内继续应用地尔硫卓,尽量使微循环开放最大化,评估这一措施是否使恢复到TIMI血流Ⅲ级的STEMI患者获益更大,进一步探讨急诊PCI术后TIMI血流Ⅲ级的STEMI患者冠脉内注射地尔硫卓的临床意义。方法:入选2014年12月至2016年12月就诊于河北医科大学第三医院心血管内科,首次明确诊断为STEMI并行PPCI的78名患者,且行急诊PCI后TIMI血流达到Ⅲ级,同时排除影响观察指标的因素如低血压、严重心力衰竭及缓慢性心律失常等的患者。按随机数字表法原则将入选患者随机分为对照组(生理盐水组,n=37)和实验组(地尔硫卓组,n=41)。两组在梗死相关动脉(infarction related artery,IRA)病变处均置入药物涂层支架,待TIMI血流达Ⅲ级即刻给予相应的处理。实验组于冠状动脉内即刻给予地尔硫卓稀释液8ml(125ug/ml);对照组则给予8ml生理盐水,两组患者在给药过程中需要密切观察血压及心室率等相关指标。两组在支架植入后如出现冠脉无复流现象,术者可根据患者的具体情况选择硝普钠、替罗非班或地尔硫卓等相关药物进行缓解,直至TIMI血流分级达到Ⅲ级。观察指标:用药后10min心室率、用药后10min平均动脉血压、用药后TMPG分级,术后90min内ST段回落率(ST-segment resolution,STR),术后90min STR≥70%为ST段回落良好,STR70%表示ST段回落不良,术后1周、3个月的左心室射血分数(left ventricular ejection fraction,LVEF),用药后后TMPG及术后3个月主要心血管不良事件(major adverse events,MACEs)的发生率。结果:1基线资料:共入选了78名研究对象,其中对照组37例,实验组41例,其中男性共有49名(62.82%),两组间年龄、合并危险因素(高血压病、糖尿病、高脂血症、吸烟史)、术前平均动脉压、术前心率、体重指数、病变血管数量、置入支架数量、支架长度及直径、术前及术中用药、门-球时间及用药前TMPG等基础资料均无统计学差异(P均0.05)。2两组间用药后TMPG、术后90min STR、术后1周及3个月的LVEF比较:相比于对照组,用药后心肌灌注TMPG血流分级明显改善,两组之间有显著统计学差异(P=0.0440.05)。术后90min STR在两组间存在差异,相对于对照组(64.84±8.78%),实验组(69.17±7.74%,P=0.0230.05)明显改善。术后1周的LVEF在两组间无统计学差异(P0.05),但术后3个月,于对照组(55.89±6.00%)相比,实验组(61.27±7.42%)明显提高,有显著统计学差异(P=0.0010.05)。3两组间用药后10min心率、用药后10min平均动脉压、术后用药及术后3个月MACEs比较:相对于对照组(70.70±9.95次/分),实验组(70.46±8.96次/分)用药后10min心率有统计学差异(P=0.0010.05);用药后10min平均动脉压在实验组和对照组之间存在统计学差异(94.29±14.96vs102.38±14.13mm Hg,P=0.0350.05)。术后用药在两组间无统计学差异。术后3个月,实验组有2人出现急性心力衰竭,对照组有2人出现心衰,经药物保守治疗,症状好转;对照组有1人出现再发性心肌梗死,经急诊PCI好转,目前病情平稳。术后3个月的MACEs在两组间无明显统计学差异(P=0.9060.05)。结论:对STEMI患者行急诊PCI术后达到TIMI血流Ⅲ级水平后,继续在冠状动脉内应用地尔硫卓能够改善心肌灌注和增加梗死区域的血流供应,使患者术后3个月的左心室射血分数提高,明显改善患者的早期预后。由此可见,行PCI术后达到TIMI血流Ⅲ级水平对于STEMI患者来说是不足够的,还需要继续行改善微循环治疗。
[Abstract]:Objective: there are clear guidelines for acute ST elevation myocardial infarction (acute STsegment elevation myocardial infarction, STEMI) the success of one of the criteria for TIMI flow grade, but we found that STEMI patients underwent emergency percutaneous coronary intervention (primary percutaneous coronary intervention, PPCI TIMI) even if blood flow grade, still a part of patients with chest pain and ST segment can not completely fall, think about and microcirculation. This is in STEMI underwent emergency PCI to TIMI flow grade after intracoronary diltiazem application to open, try to make microcirculation maximization, to assess whether the measures to restore to the benefit of TIMI flow grade the STEMI were bigger, to further explore the clinical significance of TIMI blood flow grade STEMI patients with intracoronary diltiazem after emergency PCI. Methods: Selected From December 2014 to December 2016 in the cardiovascular department of the Third Hospital of Hebei Medical University, 78 patients first diagnosed as STEMI parallel PPCI, and after undergoing PCI TIMI flow reaching the third level, such as hypotension and eliminate the effect factors of observation index, serious heart failure and arrhythmia in the patients. Randomly selected patients principle were randomly divided into control group (saline group, n=37) and experimental group (diltiazem group, n=41). The two groups in the infarct related artery (infarction related, artery, IRA) lesions were implanted drug-eluting stents for the blood flow of TIMI was grade 3 was given corresponding treatment. The experimental group in the coronary artery was given diltiazem diluted 8ml (125ug/ml); the control group were given normal saline 8ml, two groups of patients need close observation of blood pressure and ventricular rate and other related indicators during administration. The two groups in the branch Frame after implantation as no reflow phenomenon, patients can choose sodium nitroprusside according to the specific circumstances of patients, for the Luo Fei class or diltiazem and other related drugs to ease, until the TIMI flow grade to grade. Observation index: 10min ventricular rate after treatment, after treatment 10min mean arterial pressure, after administration of TMPG classification. After 90min the rate of ST segment resolution (ST-segment, resolution, STR) after 90min STR = 70% for ST segment, STR70% said ST segment, 1 weeks after operation, left ventricular ejection fraction of 3 months (left ventricular, ejection fraction, LVEF), after TMPG and postoperative medication 3 months of major adverse cardiovascular events (major adverse, events, MACEs) incidence. Results: 1. Baseline data: a total of 78 subjects, including 37 cases in the control group, 41 cases in the experimental group, there were 49 males (62.82%), two groups of age, with risk factors (high blood 鍘嬬梾,绯栧翱鐥，

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