急性ST段抬高型心肌梗死院前流程优化和非梗死相关血管治疗策略对预后的影响

发布时间：2018-05-25 18:37

本文选题：急救绿色通道 + 急性ST段抬高型心肌梗死　；参考：《苏州大学》2015年博士论文

【摘要】：第一部分:特色的优化的始自院前急救绿色通道对ST段抬高型心肌梗死抢救流程时间参数以及急诊冠脉介入治疗预后的影响目的:比较传统通道、绿色通道、优化的绿色通道这3种临床途径行直接经皮冠状动脉介入(PCI)治疗对急性ST段抬氋型心肌梗死(STEMI)患者抢救流程时间参数以及急诊PCI治疗预后的影响,验证本中心以派驻专科医生随诊120、自制的心梗抢救包等一系列措施为特色的优化的绿色通道模式在STEMI救治中的优势。方法:入选由救护车送入,发病12 h之内接受直接PCI的STEMI患者180例,分为传统通道组(由120急救系统→急诊室→CCU病房→导管室)45例、绿色通道组(120急救系统→急诊室→导管室)62例、优化的绿色通道组73例(简称优化通道组,在绿色通道基础上进一步优化,包括120救护车上由本中心派驻的随诊专科医生完成首份心电图→通过远程系统传输心电图和病人信息至急诊大厅→急诊内科医生接到信息→通知心内科值班医生(携带心梗抢救包)等待病人→通知PCI团队;或者120救护车随诊专科医生完成首份心电图→通过远程系统传输心电图和病人信息至急诊大厅(同时通知PCI团队)→急诊内科医生接到信息→通知心内科值班医生(携带心梗抢救包)等待病人),主要的研究指标为首次医疗接触至球囊扩张(FMC2B)时间、首次医疗接触至抗血小板治疗(FMC2A)时间、首次医疗接触至签署介入治疗同意书(FMC2S)时间、就诊至球囊扩张(D2B)时间、住院期间再次非致命性心梗、脑血管意外、心力衰竭发生、全因和心源性死亡及随访期间主要心血管事件发生率,比较三组无事件生存率,Logistic回归分析测定影响STEMI患者PCI术后住院和1年随访期间临床预后的相关因素。结果:1.三组患者基线特征无显著性差异(均P0.05)。FMC2B时间、FMC2A时间、FMC2S时间、D2B时间在传统通道组、绿色通道组、优化通道组依次缩短(除传统通道组与绿色通道组FMC2A时间、传统通道组与绿色通道组FMC2S时间比较外,均P0.05);首次医疗接触120min内完成球囊扩张的比例及D2B90 min的比例在传统通道组、绿色通道组、优化通道组依次增加(均P0.05)。2.三组住院期间再次非致命性心梗、脑血管意外、心力衰竭发生无显著差异(均P0.05),绿色通道组、优化通道组住院期间心血管疾病死亡及各种原因死亡率较传统通道组低(均P0.05),优化通道组住院期间心血管疾病死亡及各种原因死亡率较绿色通道组低,但无显著性差异(均P0.05);随访期间三组患者心绞痛复发率、再次非致命性心梗、靶血管再次的血管化、严重心律失常的发生均无差异(P0.05),但绿色通道组、优化通道组心力衰竭、再次因心源性疾病入院、全因死亡及心源性死亡率均明显低于传统通道组(P0.05)。3.通过对三组心血管事件相关危险因素的回归分析,发现年龄(P=0.025)、吸烟(P=0.013)、糖尿病(P=0.031)、双支病变(P=0.007)、三支病变(P=0.011)、FMC2B时间(P=0.034)、FMC2A时间(P=0.028),FMC2S时间(P=0.046),D2B时间(P=0.025)是心血管相关事件发生的危险因素,并进一步得出FMC2B时间、FMC2A时间、FMC2S时间、D2B时间、年龄是PCI后心血管相关事件发生的独立危险因素。结论:本中心以派驻专科医生随诊120、自制的心梗抢救包等一系列措施为特色的优化的绿色通道模式可显著缩短首次医疗接触至球囊扩张时间、首次医疗接触至抗血小板治疗时间、首次医疗接触至签署介入治疗同意书时间、就诊至球囊扩张时间,并改善急诊PCI术后住院和1年随访期间的临床预后。第二部分:急性ST段抬高型心肌梗死急诊PCI后非梗死相关血管不同治疗策略对血炎症因子、主要心血管事件的影响目的:急性ST段抬高型心肌梗死(STEMI)多支血管病变急诊经皮冠脉介入(PCI)治疗后非梗死相关血管采用标准药物或标准药物+PCI治疗后1年主要心血管事件发生率、血炎症因子(hs CRP、s CD40L、IL-6、TNF-a)变化以及冠脉造影结果的比较。方法:入选2011年6月至2014年6月接受急诊PCI的131例STEMI多支病变患者,根据对非梗死相关血管是否再次PCI治疗将患者分为两组,其中药物+PCI治疗组51例(占39%),药物治疗组80例(占61%)。随访两组1年的临床终点事件,术后一年复查冠脉造影,再次检测入选患者血中炎症因子(hs CRP、s CD40L、IL-6、TNF-α)水平。结果:1.两组患者性别、年龄、病因构成比、冠心病易患因素、冠心病家族史、心功能分级、肝肾功能指标、治疗用药、症状发作至球囊扩张时间、就诊至球囊扩张时间等在内的两组的基线特征以及急诊冠脉造影及直接PCI的相关数据均无显著差异(P0.05)。2.PCI组患者远期(3-12月)心绞痛复发率、再次因心源性疾病入院率均明显低于药物治疗组(P0.05)。两组心力衰竭、再发心梗、再次血运重建、严重心律失常的发生、全因死亡及心源性死亡率等均无差异(P0.05)。3.两亚组梗死相关血管支架内血栓发生率及支架内再狭窄发生率无显著性差异(P0.05),非梗死相关血管采用PCI治疗没有额外增加支架内再狭窄、节段性再狭窄、支架内血栓等事件。4.两组患者急诊PCI术后基线炎症因子、1年复查两亚组炎症因子水平比较无统计学差异(均P0.05),1年治疗后炎症因子水平较前均有所下降,具有显著的统计学差异(P0.05),但两亚组患者治疗前后炎症因子水平变化差值比较无统计学差异(P0.05)。5.hs CRP、s CD40L水平变化差值是随访期间心血管相关事件发生的独立危险因素。结论:1.STEMI多支病变患者急诊PCI治疗后非梗死相关血管采用标准药物+PCI治疗与单纯标准药物治疗比较,未能进一步降低心力衰竭、再发心梗、再次血运重建、严重心律失常、全因死亡及心源性死亡发生率,但是显著减少远期(3-12月)心绞痛复发、再次因心源性疾病入院率。2.STEMI多支病变患者急诊PCI治疗后非梗死相关血管采用标准药物+PCI治疗或单纯标准药物治疗,梗死相关血管支架内血栓发生率及支架内再狭窄发生率相似,非梗死相关血管采用PCI治疗没有额外增加支架内再狭窄、节段性再狭窄、支架内血栓等事件。3.STEMI多支病变患者急诊PCI治疗后非梗死相关血管采用标准药物+PCI治疗或单纯标准药物治疗,均可能降低STEMI后的炎症因子水平,但两种治疗方法降低炎症子水平比较无明显差异。4.STEMI多支病变患者急诊PCI治疗后检测hs CRP、s CD40L水平变化对患者PCI治疗后心血管相关事件的发生有一定的预测价值,有助于筛选相对高危患者。第三部分:急性ST段抬高型心肌梗死同期处理非梗死相关血管的小样本回顾性研究目的:急性ST段抬高型心肌梗死(STEMI)多支血管病变急诊经皮冠脉介入(PCI)治疗处理梗死相关血管后,非梗死相关血管采取急诊同期或择期PCI处理,比较两者1年的临床终点事件及血炎症因子水平。方法:入选2011年6月至2014年6月接受急诊PCI的74例STEMI多支病变患者,根据对非梗死相关血管是否同期PCI或择期PCI将患者分为两组,其中同期PCI组24例(占32%),择期(或称非同期)PCI组50例(占68%)。随访两组1年的临床终点事件,术后一年再次检测入选患者血中炎症因子(hs CRP、s CD40L、IL-6、TNF-α)水平。结果:1.两组患者性别、年龄、病因构成比、冠心病易患因素、冠心病家族史、心功能分级、肝肾功能指标、治疗用药、症状发作至球囊扩张时间、就诊至球囊扩张时间等在内的两组的基线特征以及急诊冠脉造影及直接PCI的相关数据均无显著差异(P0.05)。2.两组近期(1-3月)、远期(3-12月)、1年总的心血管事件发生率(心绞痛复发、再次因心源性疾病入院、心力衰竭、再发心梗、再次血运重建、严重心律失常、全因死亡及心源性死亡率)等均无差异(均P0.05)。3.两组患者急诊PCI术后基线炎症因子、1年复查两亚组炎症因子水平比较无统计学差异(均P0.05),1年治疗后炎症因子水平较前均有所下降,具有显著的统计学差异(P0.05),但两亚组患者治疗前后炎症因子水平变化差值比较无统计学差异(P0.05)。结论:1.急性ST段抬高型心肌梗死急诊PCI同期干预非梗死相关血管与择期干预非梗死相关血管比较,近期(1-3月)、远期(3-12月)、1年内总的心血管相关事件发生率(心绞痛、心源性疾病入院、心力衰竭、再发心梗、再次血运重建、严重心律失常、全因死亡及心源性死亡)相似。STEMI患者急诊PCI时同期干预非梗死相关血管是安全的,并没有额外增加心血管相关事件的发生。2.急性ST段抬高型心肌梗死急诊PCI同期干预非梗死相关血管与择期干预非梗死相关血管,均可能降低STEMI后的炎症因子水平,但降低炎症因子水平比较差异无统计学意义,进一步提示两种治疗方法对于此类患者远期预后的效果相当。
[Abstract]:The first part: the influence of pre hospital first aid green channel on the time parameters of ST segment elevation myocardial infarction and the prognosis of emergency coronary intervention: compare the traditional channel, green channel, and optimized green channel, the 3 clinical approaches of direct percutaneous coronary intervention (PCI) treatment for acute ST segment. The effect of the time parameters for the rescue process of STEMI patients and the prognosis of the emergency PCI treatment, the advantages of the optimized green channel model in the treatment of STEMI were verified by a series of measures, such as a series of specialist doctor follow-up and a series of self-made myocardial infarction rescue packages, and a series of measures for the treatment of STEMI. 180 cases of STEMI patients with direct PCI were divided into 45 cases of traditional channel group (120 first aid system, emergency room to CCU ward to catheter room), 62 cases of green channel group (120 first aid system, emergency room to catheter room), and 73 optimized green channel group (optimized channel group, further optimized on the basis of green color channel, including 120 ambulance by Ben. " The medical specialist stationed at the center completed the first electrocardiogram - the transmission of electrocardiogram and the patient information through the remote system to the emergency Hall - the emergency physician received the information - to notify the doctor on duty in the Department of Cardiology (carrying the myocardial infarction rescue package) to wait for the patient and notify the PCI team; or the 120 ambulance specialist completed the first electrocardiogram. The main research index is the first medical contact to the balloon dilatation (FMC2B), the first medical contact to the antiplatelet therapy (FM). The primary medical contact is the first medical contact to the balloon dilatation (FMC2B), and the first medical contact to the antiplatelet therapy (FM C2A) time, the first medical contact to sign the intervention therapy agreement (FMC2S) time, the time to visit the balloon dilatation (D2B), the non fatal myocardial infarction, cerebrovascular accident, heart failure, all cause and cardiogenic death and the incidence of major cardiovascular events during the period of hospitalization, and compare the three groups of non event survival rates and Logistic regression analysis. The related factors affecting the clinical prognosis of STEMI patients after PCI operation and 1 year follow-up were measured. Results there was no significant difference in baseline characteristics between 1. and three groups (P0.05).FMC2B time, FMC2A time, FMC2S time, and D2B time in the traditional channel group, green channel group, and optimized channel group shortened (except for the traditional channel group and the green channel group FMC2A). Between the traditional channel group and the green channel group FMC2S, P0.05); the proportion of balloon dilatation in the first medical contact with 120min and the proportion of D2B90 min in the traditional channel group, the green channel group, the optimized channel group increased (all P0.05) in the group.2. three, and the non fatal myocardial infarction, cerebrovascular accident, and heart failure occurred during the hospitalization. The significant difference (all P0.05), the green channel group, the mortality of cardiovascular disease and the mortality of various reasons in the optimal channel group were lower than that of the traditional channel group (P0.05). The mortality of cardiovascular disease and the mortality of various causes were lower in the optimal channel group than that in the green channel group, but there was no significant difference (all P0.05). During the follow-up period, three groups of patients were twisted. The rate of pain recurrence, again non fatal myocardial infarction, again the vascularization of the target vessel and the occurrence of serious arrhythmia (P0.05), but the green channel group, the optimal channel group heart failure, the cardiac disease again, all the death and cardiac mortality were lower than the traditional channel group (P0.05).3. through the three groups of cardiovascular events The regression analysis of risk factors showed that age (P=0.025), smoking (P=0.013), diabetes (P=0.031), double branch lesion (P=0.007), three lesions (P=0.011), FMC2B time (P=0.034), FMC2A time (P=0.028), FMC2S time (P=0.046), and D2B time were the risk factors of cardiovascular related events. Interval, FMC2S time, D2B time and age are independent risk factors for cardiovascular events after PCI. Conclusion: the optimal green channel model with a series of measures, such as 120, self-made myocardial infarction rescue package, and so on, can significantly shorten the first medical contact to the balloon dilatation time. The time of platelet therapy, the first medical contact to sign the agreement time of interventional therapy, the time of diagnosis to balloon dilatation, and the improvement of the clinical prognosis in the hospital after emergency PCI operation and 1 year follow-up. The second part: the different treatment strategies of non infarct related blood tube after acute ST segment elevation myocardial infarction in the emergency PCI The effects of tube events: acute ST segment elevation myocardial infarction (STEMI) multiple vascular lesions in emergency percutaneous coronary intervention (PCI) after percutaneous coronary intervention (PCI), the incidence of major cardiovascular events, changes in blood inflammatory factors (HS CRP, s CD40L, IL-6, TNF-a), and the results of coronary angiography after percutaneous coronary intervention (PCI) for non infarct related vessels were treated with standard drugs or standard drug +PCI Methods: 131 patients with STEMI multibranch disease received emergency PCI from June 2011 to June 2014 were divided into two groups according to the re PCI treatment of non infarct related vessels, of which 51 cases (39%) were treated with drug +PCI and 80 cases (61%) in the drug treatment group. The clinical endpoint events of the two group 1 years were reviewed and the coronary artery was reviewed one year after the operation. Results: the levels of HS CRP, s CD40L, IL-6, TNF- a in the blood of the selected patients were re examined. Results: 1. the sex, age, cause of cause of disease, family history of coronary heart disease, family history of coronary heart disease, heart function classification, liver and kidney function index, treatment medication, symptomatic attack to balloon dilatation time, treatment to balloon dilatation time, and so on were two in the two groups. The baseline characteristics of the group, the emergency coronary angiography and the related data of direct PCI were not significantly different (P0.05) the recurrence rate of angina pectoris in group.2.PCI patients (3-12 months), and the admission rate of cardiac disease was significantly lower than that of the drug treatment group (P0.05). The two groups of heart failure, re infarction, revascularization, serious arrhythmia, and all causes There was no difference in death and cardiac death rate (P0.05) in the.3. two subgroup, there was no significant difference in the incidence of thrombosis in the infarct related vascular stent and the incidence of restenosis in the stent (P0.05). The non infarct related blood vessels did not add to the stent restenosis, segmental restenosis, and stent thrombosis in the two group of patients with.4. in the emergency PCI. There was no statistical difference in the level of inflammatory factors in the 1 year reexamination of the two subgroup (all P0.05). The level of inflammatory factors decreased after 1 years of treatment, and there was a significant difference (P0.05), but there was no significant difference (P0.05).5.hs CRP, s CD40L water before and after treatment in the two subgroup. The difference is an independent risk factor for the occurrence of cardiovascular events during follow-up. Conclusion: the non infarct related blood vessels of 1.STEMI patients with multiple vessel diseases after emergency PCI treatment were compared with standard drug +PCI treatment and simple standard drug treatment, and failed to further reduce heart failure, re infarction, re revascularization, and serious arrhythmia. The incidence of all causes of death and cardiac death, but significantly reduced the recurrence of long term (3-12 months) angina pectoris, again due to the admission rate of cardiac disease.2.STEMI multiple disease patients after emergency PCI treatment of non infarct related blood vessels using standard drug +PCI treatment or simple standard drug treatment, infarct related vascular stent thrombosis and stent thrombosis The incidence of restenosis was similar. Non infarct related blood vessels were treated with PCI therapy without additional stent restenosis, segmental restenosis, stent thrombosis and other events in patients with.3.STEMI. Non infarct related blood vessels were treated with standard drug +PCI or simple standard drug treatment after PCI treatment, which could reduce the cause of inflammation after STEMI. Sublevel, but there is no significant difference between the two treatment methods to reduce the sublevel of inflammation, HS CRP was detected after emergency PCI treatment in patients with.4.STEMI multi branch lesions. The changes of s CD40L level have certain predictive value for the occurrence of cardiovascular related events after PCI treatment. It is helpful to screen relative high risk patients. The third part: acute ST segment elevation myocardium A retrospective study of non infarct related vessels for the simultaneous treatment of infarct Objective: acute ST segment elevation myocardial infarction (STEMI) multiple vascular lesions in emergency percutaneous coronary intervention (PCI) treatment of infarct related vessels. Non infarct related vessels were treated with emergency or elective PCI treatment, compared with 1 years of clinical endpoint events and blood inflammation Methods: 74 patients with STEMI multiple lesions from June 2011 to June 2014 were divided into two groups according to whether the non infarct related blood vessels were PCI or elective PCI, including 24 cases (32%) in group PCI and 50 cases (68%) in group PCI at elective (or non synchronous) period. The clinical endpoint events of the two groups and 1 years were followed up. The level of inflammatory factors (HS CRP, s CD40L, IL-6, TNF- alpha) in blood of the selected patients was re tested one year. Results: 1. the sex, age, etiology, family history of coronary heart disease, family history of coronary heart disease, heart function classification, liver and kidney function index, treatment medication, symptomatic attack to balloon dilatation time, and the time of balloon dilatation, and so on were two in the two groups. There were no significant differences in baseline characteristics, emergency coronary angiography and direct PCI (P0.05).2. two (1-3 months), long term (3-12 months), 1 years of total cardiovascular events (recrudescence of angina pectoris, relapse of heart disease, heart failure, re infarction, re revascularization, severe arrhythmia, all cause death and heart) There was no difference (P0.05) in the.3. two group with baseline inflammatory factors after emergency PCI operation, and there was no significant difference in the level of inflammatory factors in the 1 year reexamination two subgroups (all P0.05). The level of inflammatory factors decreased after 1 years of treatment, with significant statistical difference (P0.05), but the inflammatory factor water before and after treatment in the two subgroup There was no statistical difference (P0.05). Conclusion: 1. acute ST segment elevation myocardial infarction was compared with non infarct related blood vessels during the same period of emergency PCI intervention. The short-term (1-3 months), long term (3-12 months), 1 years of total cardiovascular related events (angina, cardiogenic disease admission, heart failure, recurrence) Myocardial infarction, revascularization, severe arrhythmias, all causes of death and cardiac death in.STEMI patients, non infarct related vessels were safe during the same period of emergency PCI, and no additional cardiovascular related events were added to.2. acute ST segment myocardial infarction in emergency PCI intervention for non infarct related vessels and selective intervention Infarct related blood vessels may reduce the level of inflammatory factors after STEMI, but there is no statistical difference in reducing the level of inflammatory factors. Further hints that the two treatments are effective for the long-term prognosis of these patients.
【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R542.22

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