大连地区急性ST段抬高型心肌梗死直接PCI患者住院期间的诊治现状及预后分析

发布时间：2018-09-09 10:01

【摘要】：目的:了解大连地区急性ST段抬高型心肌梗死患者的发病特点、直接经皮冠状动脉介入术(PCI)治疗现状、住院期间主要不良事件及预后情况,为大连地区优化STEMI救治提供理论依据。方法:前瞻性分析2015年10月1日至2016年10月30日在大连市6家医院收治的、发病后行直接PCI并住院的902例STEMI患者。医院:选择大连市首诊STEMI能行直接PCI中的6家医院(其中1家二甲医院和5家三甲医院)。收集并记录研究对象的临床基线资料、冠脉造影结果、PCI冠脉开通策略、药物辅助治疗情况及住院期间主要不良事件及预后情况。住院期间不良事件包括:住院期间的死亡(包括心源性和非心源性死亡)及MACE事件(住院期间的死亡、非致死性再发心肌梗死、新发脑卒中、出血事件)。结果:1.STEMI直接PCI患者入院基线资料:共连续入选902例STEMI患者,平均年龄(62.4± 12.5岁),其中男性715例(79.3%)、女性187例(20.1%)。冠心病危险因素,其中合并高血压51.6%、糖尿病27.7%、高脂血症26.5%、吸烟52.2%。发病后91.4%主要表现为胸闷、胸痛,其它症状(呼吸困难、晕厥、上腹不适)占8.6%。发病后呼叫120救护车比例为47.5%,选择出租车或其他方式来院占52.5%。中位"症状入门时间"为3.5(2-6)h。2.STEMI直接PCI患者手术情况:直接PCI前口服抗血小板药物负荷量阿司匹林99.0%、氯吡格雷/替格瑞洛98.7%。直接PCI时经桡动脉路径791例(87.7%)、经股动脉111例(12.3%),应用血栓抽吸导管288例(31.9%),应用IABP 12例(1.3%)。术中抗凝药物比伐卢定580例(64.3%)、普通肝素钠322例(35.7%);应用GPⅡb/Ⅲa受体拮抗剂458例(50.8%)。直接PCI术中98.5%患者植入支架,中位"入门球囊扩张时间" 76.50(60.00-90.00)min,造影剂用量150.0±48.1ml。梗死相关动脉前降支占44.2%、右冠状动脉占41.6%、回旋支13.0%、左主干1.2%。住院期间平均植入支架1.41 ±0.67个,平均支架长度29(21-43)mm。STEMI合并冠脉多支病变494/902(54.8%),多支病变直接PCI治疗时血运重建策略:①仅干预罪犯血管:421例(85.2%)选择Culprit-only PCI;②完全血运重建:73例(14.8%),其中35例(7.1%)选择Single-setting PCI,38例(7.7%)选择Staged PCI。对于STEMI患者住院期间完全血运重建平均植入支架2.51 ±0.80个、支架平均长度62.76±24.89mm。3.STEMI直接PCI患者住院期间用药及平均住院日:住院期间药物使用情况:阿司匹林98.1%、氯吡格雷/替格瑞洛99.2%、他汀97.8%、β受体阻滞剂70.1%、ACEI/ARB68.5%、CCB 类 9.8%。平均住院日 7±3 天。4.STEMI患者直接PCI术后住院期间不良事件:住院期间病死率为4.2%(38例),再发心肌梗死0.4%(4例)、新发脑卒中0.9%(8例)、出血事件1.0(9例),MACE事件5.3%(51例)。多因素Binary Logistic回归分析显示年龄(OR=1.069,95%CI:1.036～1.114,P0.01),既往脑卒中病史(OR=3.014,95%CI:1.331～6.824,P0.01)为STEMI直接PCI患者住院期间死亡独立危险因素。同时在校正其他因素后年龄(OR=1.062,95%CI:1.033～1.091,P0.01),既往脑卒中病史(OR=3.105,95%CI:1.512～6.378,P0.01)仍是 STEMI 直接PCI患者住院期间MACE的独立危险因素。结论:大连地区STEMI患者发病后仍有较高的院前延迟,男性STEMI直接PCI比例、心血管疾病危险因素远高于女性,直接PCI早期再灌注治疗以及住院期间药物治疗与目前指南仍有差距,STEMI直接PCI患者住院期间病死率低于国内相关研究。通过本次研究,初步了解了大连地区STEMI患者行直接PCI治疗的现状和住院病死率的相关危险因素。年龄、既往脑卒中病史是STEMI直接PCI患者住院期间MACE的独立危险因素。
[Abstract]:Objective: To investigate the characteristics of acute ST-segment elevation myocardial infarction (STEMI) in Dalian, the current status of direct percutaneous coronary intervention (PCI), major adverse events and prognosis during hospitalization, and to provide theoretical basis for optimizing the treatment of STEMI in Dalian. Ninety-two STEMI patients received direct PCI and were hospitalized after the onset of the disease. Hospitals: Six hospitals (one second-grade hospital and five third-class hospitals) in Dalian were selected for the first time to undergo direct PCI. Clinical baseline data, coronary angiography results, PCI coronary artery patency strategy, drug-assisted therapy and residence were collected and recorded. Main adverse events and prognosis during hospitalization. Adverse events during hospitalization included death during hospitalization (including cardiogenic and non-cardiogenic deaths) and MACE events (death during hospitalization, non-fatal recurrent myocardial infarction, new stroke, hemorrhagic events). Results: 1. Baseline admission data of STEMI patients with direct PCI: 902 consecutive patients were enrolled. The average age of STEMI patients was 62.4 (+ 12.5 years), 715 males (79.3%) and 187 females (20.1%). The risk factors of coronary heart disease were hypertension 51.6%, diabetes 27.7%, hyperlipidemia 26.5%, smoking 52.2%. 91.4% of the patients were mainly manifested as chest tightness, chest pain, and other symptoms (dyspnea, syncope, epigastric discomfort) 8.6%. The median "symptom entry time" was 3.5 (2-6) h.2. STEMI for direct PCI: oral antiplatelet drug loading aspirin 99.0%, clopidogrel / tigrilol 98.7% before direct PCI; radial route 791 (87.7%) during direct PCI; femoral artery 111 (12.7%). Among them, 288 (31.9%) were treated with thrombus aspiration catheter, 12 (1.3%) with IABP, 580 (64.3%) with bivalirudin, 322 (35.7%) with heparin sodium, 458 (50.8%) with GP II b/III a receptor antagonist, 98.5% with stent implantation during direct PCI, and the median "entry balloon dilation time" of 76.50 (60.00-90.00) minutes with contrast agent dosage of 150.0%. 44.2% of the patients had anterior descending branch of infarction-related artery, 41.6% of the right coronary artery, 13.0% of the circumflex coronary artery and 1.2% of the left main coronary artery. Culprit-only PCI was selected in 5.2%. Complete revascularization was performed in 73 patients (14.8%). Single-set PCI was used in 35 patients (7.1%) and Staged PCI was used in 38 patients (7.7%). Hospital Days: Drug Use: Aspirin 98.1%, Clopidogrel / Tigrilol 99.2%, Statin 97.8%, Beta-blockers 70.1%, ACEI / ARB 68.5%, CCB class 9.8%. Average length of stay: Adverse events after direct PCI in STEMI patients: In-hospital mortality was 4.2% (38 cases), recurrent myocardial infarction 0.4% (4 cases), new onset Multivariate Binary Logistic regression analysis showed that age (OR = 1.069, 95% CI: 1.036-1.114, P 0.01) and previous stroke history (OR = 3.014, 95% CI: 1.331-6.824, P 0.01) were independent risk factors for death in STEMI patients with direct PCI. Age (OR = 1.062, 95% CI: 1.033-1.091, P 0.01) and previous stroke history (OR = 3.105, 95% CI: 1.512-6.378, P 0.01) were still independent risk factors for MACE in STEMI patients during hospitalization. The mortality of STEMI patients during hospitalization was lower than that of domestic related studies. Through this study, we preliminarily understood the current status of direct PCI in Dalian area and the related risk factors of hospitalization mortality. Intermediate history is an independent risk factor for MACE in patients with STEMI direct PCI.
【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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