发病至首次医疗接触时间对急性ST段抬高型心肌梗死患者预后影响的研究

发布时间：2018-05-14 07:30

本文选题：心肌梗死 + 发病至首次医疗接触　；参考：《安徽医科大学》2017年硕士论文

【摘要】：背景急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)起病急,并发症发生率及病死率高。研究表明缺血时间与STEMI患者预后强相关,STEMI患者总缺血时间每延长30分钟,其1年病死率增加7.5%[1]。再灌注时间是衡量急性心肌梗死尤其是STEMI早期救治能力和水平的主要指标。而这一时间包括了多个时间段,即患者发病至首次医疗接触、首次医疗接触至入门就诊、入门就诊至首次球囊扩张等。20余年来国外研究提出了很多救治时间点,比如“胸痛至球囊扩张(pain-to-balloon)时间、入门至球囊扩张(door-to-balloon,D2B/DTB)时间、首次医疗接触至球囊扩张(first medical contact-to-balloon,FMC-to-B)时间、发病至首次医疗接触(Symptom Onset-to-First Medical Contact,SO-to-FMC)时间、发病至首次球囊扩张(Symptom Onset-to-balloon,SO-to-B/S2B/STB)时间”等(见图1)。多年来国内外研究者就这些时间段与生存率进行了大量研究,证明这些救治时间点可影响STEMI患者的治疗和临床预后,目前较为推荐认可的是欧美指南提出的D2B和FMC-to-B这两大时间段。然而,目前针对STEMI患者的研究中,国内外一致将目光聚焦在患者FMC以后的急救工作上,极少关注STEMI患者从发病至首次医疗接触(SO-to-FMC)时间在整个急救体系中的意义。目的本研究探讨STEMI患者发病至首次医疗接触(SO-to-FMC)时间对各救治时间及预后的影响。方法回顾性研究2011年8月至2016年4月连续在我院急诊并符合入选标准的STEMI患者341例,根据SO-to-FMC时间分为≤90 min组(201例)和90 min组(140例),记录并分析主要救治时间,统计患者住院期间心肌损伤相关生物标志物、心肌组织灌注情况,定期随访心脏超声,并通过门诊、再住院以及电话等方式进行随访,统计其住院及随访期间的病死率、主要不良心脑血管事件(major adverse cardiac and cerebro-vascular events,MACCE)发生率。采用二分类Logistic回归模型分析术后1年病死率及出院后1年MACCE发生率的影响因素,并采用Cox比例风险回归模型分析PCI术后4.5年累计病死率及出院后4.5年无MACCE生存率的预测因素。结果1.SO-to-FMC时间≤90 min组患者的D2B时间[104(88,125)比111(92,144)min,P=0.023]、FMC-to-B时间[146(119,197)比177(125,237)min,P=0.005]、S2B时间[200(170,257)比338(270,474)min,P0.001]均短于SO-to-FMC时间90min组。2.SO-to-FMC时间≤90 min组患者术后30天病死率[2.99%(6/201)比7.86%(11/140),P=0.042]、1年病死率[2.89(5/173)比9.57(11/115),P=0.015]、4.5年累计病死率(3.00%比11.20%,P=0.007)及出院后1年MACCE发生率[1.16%(2/173)比6.96%(8/115),P=0.021]均低于SO-to-FMC时间90 min组,出院后4.5年无MACCE生存率高于SO-to-FMC时间90 min组(97.20%比88.80%,P=0.025);两组之间的院内病死率差异无统计学意义[2.49%(5/201)比6.43%(9/140),P=0.071];二分类Logistic回归分析显示SO-to-FMC时间90min是患者术后1年病死率及出院后1年MACCE发生率的独立危险因素(OR 2.90,95%CI 1.22~6.92,P=0.016;OR 5.19,95%CI 1.21~22.20,P=0.026);多因素COX回归分析显示SO-to-FMC时间90min是患者4.5年累计病死率的独立危险因素(HR 2.88,95%CI 1.10~7.53,P=0.031)。3.单因素分析显示,SO-to-FMC时间≤90min组患者CTFC值低于90min组[18(13,27)比23(16,33.5),P0.05],CTFC≤28达标率及MBG≥2级达标率均高于90min组[79.39(131/166)比63.64(77/121),P0.05;67.76(68/166)比46.78(81/121),P0.001],两组间killip≥Ⅱ级率及STR差异并无统计学意义(P0.05)。二分类Logistic回归分析结果显示,校正基线资料等混杂因素后,SO-to-FMC时间90min是STEMI患者CTFC28和killip≥Ⅱ级率的独立危险因素(OR 2.29,95%CI 1.33-3.93,P=0.003;OR=2.03,95%CI 1.08-3.82,P=0.029),然而SO-to-FMC时间90min并非MBG 0/1级的独立危险因素(OR 2.07,95%CI0.88-4.89,P=0.098)。结论1.SO-to-FMC时间越短,其相应D2B时间、FMC-to-B时间及S2B时间越短。2.SO-to-FMC时间≤90min可有效减少患者心肌组织灌注不良发生率,改善其心功能。3.SO-to-FMC时间≤90min可降低患者近远期病死率及出院后MACCE发生率。
[Abstract]:Background acute ST segment elevation myocardial infarction (ST-segment elevation myocardial infarction, STEMI) has an acute onset, a high incidence of complications and high mortality. The study showed that the ischemic time was strongly associated with the prognosis of STEMI patients. The total ischemic time of STEMI patients was prolonged by 30 minutes, and the 1 year fatality rate increased in 7.5%[1]. and reperfusion time was a measure of acute myocardial infarction. Death is especially the main indicator of the ability and level of early treatment of STEMI, which includes multiple time periods, namely, the onset of the first medical contact, the first medical contact to the entrance examination, the first medical treatment to the first balloon dilatation, and the other.20 years for the rest of the year, for example, "chest pain to balloon dilatation (pain-t)" O-balloon) time, entry to balloon dilatation (door-to-balloon, D2B/DTB) time, first medical contact to balloon dilatation (first medical contact-to-balloon, FMC-to-B) time, onset to first medical contact (Symptom Onset-to-First Medical Contact, SO-to-FMC) time, onset to the first balloon dilatation 2B/STB) time "et al. (see Figure 1). Over the years, researchers at home and abroad have conducted a large number of studies on these periods and survival rates, proving that these treatment time points can affect the treatment and clinical prognosis of STEMI patients. At present, it is recommended that the two periods of time, D2B and FMC-to-B, proposed by the European and American guidelines. However, at present, the STEMI patients are present. In the study, the first aid work after the patient's FMC was focused both at home and abroad, and little attention was paid to the significance of the time of STEMI patients from onset to first medical contact (SO-to-FMC) in the whole emergency system. The purpose of this study was to explore the effect of the onset of the onset of STEMI patients to the first medical contact (SO-to-FMC) on the treatment time and prognosis. A retrospective study was made to retrospective study 341 cases of STEMI patients in our hospital from August 2011 to April 2016. They were divided into 90 min groups (201 cases) and 90 min group (140 cases) according to SO-to-FMC time. The main treatment time was recorded and analyzed. Follow up echocardiography was followed up in outpatients, rehospitalization and telephone, and the mortality rate during hospitalization and follow-up, the incidence of major adverse cardiac and cerebrovascular events (major adverse cardiac and cerebro-vascular events, MACCE). The two classification Logistic regression model was used to analyze the mortality rate of 1 years after the operation and 1 year after discharge. The influencing factors of the incidence and the Cox proportional risk regression model were used to analyze the cumulative morbidity of 4.5 years after PCI and the predictive factors for no MACCE survival after 4.5 years after discharge. Results the D2B time of the patients with 1.SO-to-FMC time less than 90 min was [104 (88125), 111 (92144) min, P=0.023], FMC-to-B time [146 (119197) than 177 (125237) min. Time [200 (170257) was more than 338 (270474) min, P0.001] was shorter than SO-to-FMC time 90min group.2.SO-to-FMC time < 90 min > 30 days' mortality [2.99% (6/201) ratio 7.86% (11/140), P=0.042], 1 year fatality ratio 9.57 (3%), 4.5 years' cumulative mortality (3% / 11.20%,) and 1 years after discharge. .16% (2/173) ratio 6.96% (8/115), P=0.021] were lower than SO-to-FMC time 90 min group, 4.5 years after discharge, no MACCE survival rate was higher than SO-to-FMC time 90 min group (97.20% ratio 88.80%, P=0.025); the difference of hospital mortality between two groups was not statistically significant [2.49% (5/201) ratio 6.43% 90min was an independent risk factor (OR 2.90,95%CI 1.22~6.92, P=0.016; OR 5.19,95%CI 1.21~22.20, P=0.026) at 1 years postoperatively and 1 years after discharge (OR 5.19,95%CI 1.21~22.20, P=0.026). Multiple factor COX regression analysis showed that SO-to-FMC time was an independent risk factor for patients with 4.5 years' cumulative mortality. The analysis showed that the CTFC value of the patients with SO-to-FMC time less than 90min was lower than that of group 90min [18 (13,27) 23 (16,33.5), P0.05], CTFC < 28, and MBG > 2 level were higher than that of 90min group [79.39 (46.78), 67.76 (46.78), two groups had no statistical significance. Two classified Logistic regression analysis showed that SO-to-FMC time 90min was an independent risk factor for STEMI patients (OR 2.29,95%CI 1.33-3.93, P=0.003; OR=2.03,95%CI 1.08-3.82) after correction of baseline data and other confounding factors (OR 2.29,95%CI 1.33-3.93, P=0.003; OR=2.03,95%CI 1.08-3.82). 95%CI0.88-4.89, P=0.098). Conclusion the shorter the time of 1.SO-to-FMC, the corresponding D2B time, FMC-to-B time and the shorter S2B time,.2.SO-to-FMC time less than 90min can effectively reduce the incidence of poor myocardial perfusion, and improve the cardiac function.3.SO-to-FMC time less than 90min can reduce the mortality in the near and long term and the MACCE incidence after discharge.

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

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