冠状动脉非阻塞型心肌梗死的临床特点及预后分析—单中心回顾性研究

发布时间：2018-03-12 23:24

  本文选题：急性心肌梗死　切入点：冠状动脉造影　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景与目的:急性心肌梗死(AMI)而CAG检查结果却提示不存在血流受限性疾病,《2016ESC工作组意见书》将之定义为冠状动脉非阻塞型心肌梗死(MINOCA)。指南中指出,MINOCA应该被视为"初步诊断",需要通过完善相关检查来鉴别导致患者临床症状的潜在病因,进而明确诊断和治疗。MINOCA的病因主要包括斑块破裂或侵蚀、冠状动脉痉挛等。MINOCA病因复杂,对于其预后的评估,不同的研究之间存有一定差异,但是多数研究认为MINOCA的远期预后偏差。有研究显示,非阻塞性CAD合并ACS患者随访26± 16个月死亡4.4%、ACS再入院3.8%,同阻塞性CAD合并ACS患者相比无明显差异(P0.05),因此,非阻塞性CAD合并ACS患者的远期心脏缺血事件再发风险偏高。最近一项研究也显示,对126例MINOCA患者进行心脏磁共振(CMR)检查,87%(109例)提示存在心脏结构和/或心肌组织的异常改变,分别诊断为心肌炎、Takotsubo心肌病等。本研究的目的是希望通过观察和分析本心血管病中心诊断为AMI而CAG检查证实无明显血管狭窄患者的基本特点、相关临床指标和发病后1年的心血管事件发生后情况,进而改善MINOCA患者的预后提供依据及帮助。方法:回顾分析自2005年1月至2016年10月入住我院诊断为AMI且进一行CAG检查证实冠状动脉血管正常或狭窄50%的患者。采集患者入院后临床一般情况、检验指标、冠脉造影特点及治疗用药情况。研究终点为1年复合终点事件(包括全因死亡、再发心肌梗死和/或因胸痛发作再次入院),分析影响复合终点事件发生的相关因素。根据心电图表现,分为ST段抬高型心肌梗死(STEMI)和非ST段抬高型心肌梗死(NSTEMI),进行亚组分析。结果:1.MINOCA患者一般临床特点:自2005年1月至2016年10月入住我院诊断为AMI并且进一步行CAG检查的患者共有5474例,符合MINOCA诊断标准的患者占2.5%(139例),其中包括病因不明确64%(89例)、恶性心律失常15.8%(22例)、心肌桥10.8%(15例),Takotsubo心肌病2.9%(4例)、血管内血栓影2.9%(4例)、血管瘤样扩张2.2%(3例)、肥厚型心肌病1.4%(2例)、血管痉挛0.7%(1例)。MINOCA患者的平均年龄为55.80± 12.15岁;男性患者多于女性患者(69.1%比30.9%);易患因素依次为高血压病史52.5%(73例)、吸烟史43.2%(60例)、糖尿病史9.4%(13例);既往脑血管病史5.8%(8例)、心肌梗死病史1.4%(2例);CAG结果显示血管正常52.5%(73例),血管轻度狭窄(狭窄1-49%)47.5%(66例);入院后心功能不全(Killip≥II级)患者14.4%(20例);住院期间阿司匹林、ADP受体抑制剂、他汀类药物及硝酸酯类药物的应用率达90%以上,出院后患者继续应用阿司匹林占90.6%、他汀类药物占87.8%。2.MINOCA患者1年的终点事件及相关危险因素分析:随访1年复合终点事件的发生率为12.9%(18例),其中包括:死亡2.2%(3例)、非致死性再发心肌梗死2.2%(3例)、胸痛再入院8.6%(12例)。MINOCA患者复合终点事件COX模型多因素生存分析:年龄≥60岁(RR=3.676,9 95%CI:1.309～10.327,P=0.013)、入院时 CK-MB 最高水平(RR=1.010,9 95%CI:1.002～1.017,P=0.008)是MINOCA 患者 1 年内发生复合终点事件的独立危险因素,出院后应用他汀类药物(RR=0.301,95%CI:0.093～0.978,P=0.046)是复合终点事件的独立保护因素。3.MINOCA患者ST段抬高型心肌梗死(STEMI)与非ST段抬高型心肌梗死(NSTEMI)的临床特点及预后比较(亚组分析):MINOCA患者中NSTEMI的发生率51.8%(72例)略高于STEMI 48.2%(67例),而两组患者的平均年龄大致相同(54.88±12.89vs56.65±11.45,P=0.392),男性患者和女性患者所占的比例也无明显差异(P=0.528);与STEMI组患者相比,NSTEMI组患者多合并高脂血症(27.1%vs12.5%,P=0.035),STEMI组患者中肌酐(Cre)、超敏C反映蛋白(hs-CRP)、肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、肌钙蛋白I(TnI)峰值平均水平高于NSTEMI组患者(P0.05);CAG检查结果显示NSTEMI血管正常占51.4%(37例),血管狭窄1-49%占48.6%(35例),与STEMI组相比无明显统计学差异(P=0.782);冠脉血流 TIMI≤Ⅱ 级 STEMI 组 7.5%(5 例)、NSTEMI 组 8.3%(6例),两组差别(P=0.850);住院期间两组治疗用药基本相似(P0.05),主要为阿司匹林、ADP受体抑制剂、他汀类及硝酸酯类药物(应用率90%),而出院后STEMI组患者他汀类药物的应用多于NSTEMI组患者(94%vs81.9%,P=0.03);随访1年,STEMI组发生复合终点事件14.9%(10例),包括:死亡1.5%(1例)、非致死性再发心肌梗死1.5%(1例)、胸痛再入院11.9%(8例),NSTEMI组发生复合终点事件11.1%(8例),包括:死亡2.8%(2例)、非致死性再发心肌梗死2.8%(2例)、胸痛再入院5.6%(4例),比较两组复合终点事件无统计学差异(14.9%vs11.1%,P=0.505)。结论:1.MINOCA整体患病率偏低,MINOCA患者多较年轻,多发于男性,女性患者平均发病年龄高于男性患者,易患因素主要为高血压和吸烟史,NSTEMI的发生率高于STEMI。2.经COX模型多因素生存分析结果证实:年龄≥60岁和CK-MB水平是死亡、非致死性再发心肌梗死及胸痛再入院事件发生独立危险因素,他汀类药物可以预防上述不良事件发生的独立保护因素。虽然MINOCA患者无明显血管狭窄,但常常存在不同程度心肌损伤,并且长期预后偏差,应予以重视。3.NSTEMI与STEMI亚组比较结果显示:NSTEMI的发生率偏高,患者多合并高脂血症,STEMI患者心肌坏死面积更多,炎性指标偏高,出院后应用他汀类药物的应用更普遍;两组1年复合终点事件的发生无明显差异。4.MINOCA典型病例:一例NSTEMI患者,CAG结果仅显示左前降支内膜不整,然而CMR检查结果提示:左心室前壁心肌略薄,中央部-基底部左心室前壁、前间壁心内膜下条形灌注缺损。虽完善相关病因学检查,AMI根本病因仍然未能明确。
[Abstract]:Background and objective: acute myocardial infarction (AMI) and CAG examination results is not restricted blood disease, <2016ESC working group opinions > will be defined as non obstructive coronary artery myocardial infarction (MINOCA). According to the guidelines, MINOCA should be considered as the initial diagnosis, need to identify the improvement check to the underlying cause of the patient's clinical symptoms, etiology and diagnosis and treatment of.MINOCA mainly include the rupture or erosion of plaque, coronary artery spasm, the etiology of.MINOCA is complicated, to evaluate the prognosis, there are certain differences between different studies, but most studies suggest that long-term prognosis. Studies have shown that the deviation of MINOCA, non blocking patients CAD with ACS 26 + 16 months and 4.4% died, 3.8% ACS readmission, with patients with obstructive CAD patients with ACS showed no significant difference (P0.05), therefore, the long-term prognosis of patients of CAD with non blocking ACS The high risk of recurrent ischemic events. A recent study also showed that the cardiac magnetic resonance in 126 patients with MINOCA (CMR), 87% (109 cases) indicates the presence of abnormal changes of cardiac structure and / or myocardial tissue, were diagnosed as myocarditis, cardiomyopathy and other Takotsubo. The purpose of this study is to observe the the center for cardiovascular disease diagnosis and analysis for AMI and CAG examination confirmed the basic characteristics of patients with no significant stenosis, cardiovascular events 1 years after the onset of clinical indicators and related conditions, and improve the prognosis of patients with MINOCA to provide a basis and help. Methods: a retrospective analysis from January 2005 to October 2016 in our hospital for diagnosis and AMI a CAG examination confirmed coronary artery stenosis in 50% patients with normal or collected. Patients admitted to the hospital after the clinical index, the general situation, the characteristics of coronary angiography and treatment of terminal conditions. For the composite end point event 1 years (including all-cause death, recurrent myocardial infarction and / or chest pain for readmission), analysis of factors affecting composite end point events. According to ECG, divided into ST segment elevation myocardial infarction (STEMI) and non ST segment elevation myocardial infarction (NSTEMI). Subgroup analysis. Results: the clinical features of patients with 1.MINOCA from January 2005 to October 2016 in our hospital diagnosed as AMI and further CAG examination of patients with a total of 5474 patients met the diagnostic criteria for MINOCA patients accounted for 2.5% (139 cases), including 64% unknown etiology (89 cases), malignant arrhythmia in 15.8% (22 cases), myocardial bridge 10.8% (15 cases), Takotsubo cardiomyopathy (4 cases), 2.9% intravascular thrombosis shadow 2.9% (4 cases), vascular ectasia 2.2% (3 cases), 1.4% patients with hypertrophic cardiomyopathy (2 cases), 0.7% vascular spasm (1 cases) with an average age of.MINOCA patients was 55.80 12.15 + years old; male Of patients than female patients (69.1% vs 30.9%); risk factors for hypertension were 52.5% (73 cases), smoking history 43.2% (60 cases), diabetic history 9.4% (13 cases); 5.8% case history of cerebrovascular disease (8 cases), history of myocardial infarction 1.4% (2 cases); CAG results showed that the blood of Guan Zhengchang 52.5% (73 cases), mild vascular stenosis (stenosis 1-49%) and 47.5% (66 cases); admission after heart failure (Killip = II) and 14.4% patients (20 cases); during hospitalization, aspirin, ADP receptor inhibitors, statins and nitrates in the rate of more than 90% patients continued after discharge aspirin accounted for 90.6%, 1 years of the event analysis of end point 87.8%.2.MINOCA patients and related risk factors for statins: 1 years follow-up composite end point events occurred in 12.9% (18 cases), including 2.2% deaths (3 cases), nonfatal recurrent myocardial infarction 2.2% (3 cases), chest pain and readmission 8.6% (12 cases) with.MINOCA complex Combined end point event COX model multivariate survival analysis: age greater than 60 years (RR=3.676,9 95%CI:1.309 ~ 10.327, P=0.013), the highest level of CK-MB on admission (RR=1.010,9 95%CI:1.002 ~ 1.017, P=0.008) were independent risk factors of MINOCA patients within 1 years of the composite end point events, use of statins after discharge (RR=0.301,95%CI:0.093 ~ 0.978, P=0.046) is an independent protective factor for.3.MINOCA patients with ST elevation myocardial infarction composite end point event (STEMI) and non ST segment elevation myocardial infarction (NSTEMI) clinical characteristics and prognosis of comparison (subgroup analysis: 51.8%) the incidence of NSTEMI in patients with MINOCA (n = 72) was slightly higher than that of STEMI 48.2% (67 cases). While the average age of patients in two groups were roughly the same as (54.88 + 12.89vs56.65 + 11.45, P=0.392), and no significant difference in male patients and the proportion of women (P=0.528); compared with group STEMI, group NSTEMI patients Combined hyperlipidemia (27.1%vs12.5%, P=0.035), creatinine of patients in group STEMI (Cre), high sensitive C protein (hs-CRP), reflecting the creatine kinase (CK), creatine kinase isoenzyme (CK-MB), troponin I (TnI) peak is higher than the average level of patients in the NSTEMI group (P0.05); CAG showed normal vascular NSTEMI accounted for 51.4% (37 cases), vascular stenosis 1-49% accounted for 48.6% (35 cases), compared with no significant difference between the STEMI group (P=0.782); coronary blood flow in TIMI is less than or equal to grade II and 7.5% in STEMI group (5 cases), 8.3% in NSTEMI group (6 cases), the difference between the two groups (P=0.850); the two groups during treatment in hospital similar to (P0.05), mainly for the ADP receptor inhibitor, aspirin, statins and nitrates (application rate 90%), and STEMI group of patients after discharge statin application more than patients in group NSTEMI (94%vs81.9%, P=0.03); 1 years of follow-up, STEMI group composite end point event 14.9% (10 cases), including 1.5%: death (1 cases), Nonfatal recurrent myocardial infarction 1.5% (1 cases), readmission 11.9% chest pain (8 cases), NSTEMI group composite end point event 11.1% (8 cases), including 2.8% deaths (2 cases), nonfatal recurrent myocardial infarction 2.8% (2 cases), readmission 5.6% chest pain (4 cases), no statistical difference between the two groups (14.9%vs11.1%, P=0.505, composite end point event). Conclusion: the overall prevalence rate of 1.MINOCA is low, MINOCA patients were younger, more than male, average age of female higher than male patients, the major risk factors for hypertension and smoking history, the incidence of NSTEMI is higher than STEMI.2. by COX model multivariate analysis results showed that: 60 years of age or older and the level of CK-MB death, non fatal risk factors for the occurrence of myocardial infarction and recurrent chest pain readmission events, statins can prevent the occurrence of adverse events independent protective factors. Although MINOCA patients without obvious vascular stenosis Narrow, but often there are different degree of myocardial injury, and long-term prognosis deviation, more attention should be paid to the.3.NSTEMI and STEMI sub groups showed: the incidence of high NSTEMI patients with hyperlipidemia, STEMI patients with myocardial necrosis area more inflammatory index is high, application of statins after hospital discharge is more common; there is no significant difference between.4.MINOCA group of 1 years and two typical cases: a composite end point events in NSTEMI patients, CAG results show only the left anterior descending artery intima is not the whole, but CMR results suggest that the left ventricular anterior wall myocardial slightly thin, Central - basal left ventricular anterior wall, anterior wall subendocardial strip although the improvement of perfusion defects. The etiology of AMI examination, the root cause is still not clear.

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