曲美他嗪对冠脉介入治疗急性心肌梗死患者的影响

发布时间：2018-05-08 06:26

本文选题：经皮冠脉介入治疗术 + 曲美他嗪　；参考：《延安大学》2014年硕士论文

【摘要】：背景经皮冠状动脉介入治疗术(percutaneous coronary intervention，PCI)是治疗急性心肌梗死（acute myocardial infarction，AMI）患者当前最为直接有效的治疗方法，它可以及时恢复梗死相关冠状动脉的血流灌注，挽救受损或濒临坏死的心肌细胞，缩少梗死面积和恢复心脏功能，改善患者的远期预后，提高生活质量。但某些患者并未从中受益，术后的心肌损伤和不良心血管事件仍较常见，这考虑与PCI术后心肌微循环障碍所致的心肌缺血损伤紧密相关。本研究旨在PCI术前及术后给予改善心肌能量代谢的药物干预，从而改善心肌微循环灌注，减少缺血心肌的损伤和术后不良心血管事件的发生，最终改善患者的临床预后。目的对AMI患者行PCI术前30min口服曲美他嗪（trimetazidine，TMZ）负荷剂量60mg，术后长期服用TMZ（20mg，tid），通过观察PCI术中冠脉TIMI血流分级及靶血管无复流现象（no-reflow phenomenon，NR)的发生，PCI前后血清肌钙蛋白I (cardiac troponin I，cTnI)、高敏C反应蛋白(high sensitive C-reactive protein，hs-CRP)、左室射血分数（left ventricular ejection fraction，LVEF）和左室短轴缩短率(left ventricular fraction shortening，LVFS)的变化，并通过电话随访观察PCI术后再发心绞痛症状和主要不良心脏事件（MajorAdverse Cardiovascular Events，MACE，包括再入院、心肌梗死、死亡等），从而探讨TMZ对PCI术后心肌缺血损伤的影响和可能的作用机制。方法选择我科2013年10月至2014年1月期间择期行PCI治疗的AMI患者35例，其中男性24例，女性11例。采用平行对照研究，所入选的病例被随机分成2组：TMZ组和对照组。TMZ组18例，对照组17例。对照组仅接受常规治疗；而TMZ组除接受常规治疗外，于术前30min口服TMZ负荷剂量60mg，术后长期服用TMZ（20mg，tid）治疗。两组均采用相同的常规治疗如抗血小板聚集、抗凝、β-受体阻滞剂、ACEI类、降脂、硝酸酯类等常规药物。观察并记录术中TIMI血流分级及NR的发生，并分别测定PCI术前后cTnI、hs-CRP水平，于PCI前后行心脏超声检查，测定LVEF和LVFS。并通过电话随访并记录两组患者PCI后3月再发心绞痛及MACE发生率。结果cTnI水平测定示：TMZ组与对照组患者在PCI术前无明显差异且P0.05；PCI术后24h、48h，两组患者较术前均明显升高（P0.05），但对照组cTnI水平明显高于TMZ组（P0.05）。hs-CRP浓度测定示：TMZ组与对照组患者在PCI术前无显著性差异且P0.05；PCI术后48h，两组患者较PCI术前均明显升高（P0.05），但对照组hs-CRP明显高于TMZ组（P0.05）。冠脉TIMI血流分级及NR示：TMZ组患者PCI术中Ⅲ级血流的比例较对照组高，但无显著性差异（P0.05）；TMZ组患者NR的发生率低于对照组，两组比较亦无显著性差异（P0.05）。心脏超声测定示：TMZ组患者术后3月LVEF和LVFS均较PCI术前升高（P0.05）；而对照组未显示出显著性差异（P0.05），术后TMZ组LVEF和LVFS值均高于对照组(P0.05)。PCI术后平均随访观察3个月后示：TMZ组同对照组患者比较，再发心绞痛患者的比例明显减少（P0.05），TMZ组患者的MACE发生率低于对照组，但无显著性差异（P0.05）。结论1.对于行PCI治疗的AMI患者，TMZ可降低术后cTnI及hs-CRP升高的幅度，改善冠脉血流情况，使患者LVEF和LVFS值升高，提示TMZ可减轻PCI术后的炎性反应，减轻氧自由基引起的脂质过氧化引发的缺血心肌损伤，并可能具有改善心肌微循环及提高左心功能的作用，为PCI术后患者提供心肌保护。2.术后长期服用TMZ则可通过改善心肌细胞代谢等方式，明显降低PCI术后患者再发心绞痛症状及比率，改善患者的远期预后，提高PCI术后患者生活质量。
[Abstract]:Background percutaneous coronary intervention (percutaneous coronary intervention, PCI) is the most direct and effective treatment for patients with acute myocardial infarction (acute myocardial infarction, AMI). It can restore the infarct related coronary artery blood perfusion in time to save the damaged or near necrotic myocardial cells and reduce the infarction. The dead area and the recovery of heart function improve the long-term prognosis and improve the quality of life. However, some patients have not benefited from it. Myocardial injury and adverse cardiovascular events are still more common after the operation, which is closely related to myocardial ischemia injury caused by myocardial microcirculation after PCI. This study aims to improve the pre and post operation of PCI. Drug intervention of myocardial energy metabolism improves myocardial microcirculation perfusion, reduces ischemic myocardium injury and postoperative adverse cardiovascular events, and ultimately improves the patient's clinical prognosis.
Objective to perform 30min (trimetazidine, TMZ) loading dose 60mg before PCI for AMI patients, and to take TMZ (20mg, TID) for a long time after operation, and to observe the incidence of TIMI blood flow in the operation of the coronary artery and the occurrence of no reflow of the target vessels in PCI. High sensitive C-reactive protein (hs-CRP), the left ventricular ejection fraction (left ventricular ejection fraction, LVEF), and the short axis shortening of the left ventricle (left ventricular) were observed and followed up by telephone follow-up to observe the symptoms of angina and the major adverse cardiac events TS, MACE, including readmission, myocardial infarction, death, etc., to explore the effect of TMZ on myocardial ischemic injury after PCI and the possible mechanism.
Methods 35 patients with AMI from October 2013 to January 2014, including 24 male and 11 female, were randomly divided into 2 groups: group TMZ and control group, group.TMZ 18, control group 17. The control group received routine treatment, and the TMZ group received routine treatment, and the TMZ group was treated with routine treatment, in the TMZ group in addition to conventional treatment, in the TMZ group, in addition to conventional treatment, in the control group. Preoperative 30min oral TMZ load dose 60mg, long-term use of TMZ (20mg, TID) treatment. The two groups of the same routine treatment such as anti platelet aggregation, anticoagulant, beta blocker, ACEI class, lipid lowering, nitrate and other conventional drugs. Observe and record the incidence of TIMI blood flow grade and NR, and determine the cTnI, hs-CRP level before and after PCI, respectively. Echocardiography was performed before and after PCI, LVEF and LVFS. were measured, and the incidence of recurrent angina pectoris and MACE in two groups of patients after March were recorded by telephone follow-up and PCI.
Results the cTnI level showed that there was no significant difference between the TMZ group and the control group before PCI and P0.05; after PCI, 24h, 48h, and two groups were significantly higher than before operation (P0.05), but the level of cTnI in the control group was significantly higher than that in the TMZ group (P0.05). H, the two groups were significantly higher than the preoperative PCI (P0.05), but the control group was significantly higher than the TMZ group (P0.05). The coronary TIMI flow classification and NR showed that the proportion of grade III blood flow in the TMZ group was higher than the control group, but there was no significant difference (P0.05), and the incidence rate of the TMZ group was lower than that of the control group, and there was no significant difference between the two groups. Echocardiography showed that in group TMZ, LVEF and LVFS were higher in March than before PCI (P0.05), but there was no significant difference in the control group (P0.05). The LVEF and LVFS values in the TMZ group were higher than those of the control group (P0.05).PCI after 3 months after operation: the TMZ group was compared with the control group and the proportion of the patients with recurrent angina pectoris was obvious. Decrease (P0.05), the incidence of MACE in group TMZ was lower than that in control group, but there was no significant difference (P0.05).
Conclusion 1. for AMI patients treated with PCI, TMZ can reduce the elevation of cTnI and hs-CRP after operation, improve the blood flow of coronary artery and increase the value of LVEF and LVFS, suggesting that TMZ can reduce the inflammatory response after PCI operation, reduce the myocardial injury caused by lipid peroxidation induced by oxygen free radicals, and may improve myocardial microcirculation and improve the myocardial microcirculation. The function of left heart function, for patients after PCI, the long-term use of TMZ after the operation of myocardial protection.2. can improve the symptom and rate of re angina after PCI, improve the long-term prognosis of patients and improve the quality of life after PCI.

【学位授予单位】：延安大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R542.22

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