急性ST段抬高型心肌梗死急诊PCI术前负荷剂量阿托伐他汀治疗长期疗效观察

发布时间：2018-06-19 10:27

本文选题：急性心肌梗死 + 阿托伐他汀　；参考：《河北医科大学》2013年硕士论文

【摘要】：目的：近年来，多个研究相继证实冠心病择期PCI术前给予大剂量阿托伐他汀治疗能够降低PCI围手术期心肌损伤，从而改善预后，降低短期内心脏不良事件发生率，尤其是对于稳定型心绞痛或急性冠脉综合征患者。然而对于急性ST段抬高型心肌梗死（STEMI）患者急诊PCI术前大剂量他汀治疗的相关研究却很少，因此本研究对STEMI患者急诊PCI术前给予负荷剂量的阿托伐他汀进行干预，旨在探讨STEMI患者急诊PCI围手术期强化阿托伐他汀治疗的长期临床疗效。方法：从2010年5月1日至2012年7月31日连续入选发病12小时内拟急诊行PCI治疗的STEMI患者，随机分为A、B、C组，A组（术前给予阿托伐他汀80mg，术后给予40mg/日，1月后改为20mg/日），B组（术前未服用阿托伐他汀，术后给予40mg/日，1月后改为20mg/日），C组（术前未服用阿托伐他汀，术后给予20mg/日），测定指标：1分别测定术前、术后7天、术后1个月、术后6月血清高敏C反应蛋白（hs-CRP）、基质金属蛋白酶9（MMP-9）及B型钠酸肽（BNP）水平。2分别测定术后2天、术后3个月及术后6月左室射血分数（LVEF）、左室舒张末期内径（LVEDD）。3观察术后1月及术后1年MACE事件(死亡、非致死性心肌梗死及靶血管血运重建)发生率。4药物安全性观察包括肝酶升高（超过正常值上限3倍），肌痛及横纹肌溶解，还包括胃肠道反应及皮疹等。结果：试验期间初步共筛选204例STEMI患者，符合入选标准的共181例，其中6例患者造影后未进一步行PCI治疗，12例患者拒绝参加临床试验，最终入组患者163例，其中A组54例，B组51例，C组58例。 1三组患者入院时一般情况无明显差异。 2三组患者hs-CRP比较:三组患者术前hs-CRP测定值两两比较均无统计学差异（P＞0.05）；术后7天hs-CRP测定值分别为6.21±1.31mg/L，7.37±1.74mg/L及7.24±1.70mg/L，A组明显低于B组、C组（P均＜0.05），B组较C组比较无统计学差异（P＞0.05）；术后1月hs-CRP测定值分别为3.06±1.49mg/L，4.14±1.40mg/L及4.95±1.43mg/L，三组间差别具有统计学意义（P＜0.05）。与C组相比较，A和B组的值明显降低（P均＜0.05），而A组又明显低于B组（P＜0.05）；术后6月hs-CRP测定值分别为1.96±0.98mg/L，2.10±0.82mg/L及2.54±0.71mg/L，三组间差别具有统计学意义（P＜0.05）。与C组相比较，A组和B组的值明显降低（P均＜0.05），而A组又明显低于B组（P＜0.05）。 3三组患者MMP-9比较：三组患者术前MMP-9两两比较均无统计学差异（P＞0.05）；术后7天MMP-9在三组分别为1.05±0.37ng/mL，1.13±0.62ng/mL及1.28±0.45ng/mL，A组明显低于C组（P＜0.05），而A组较B组、B组较C组无统计学差异（P＞0.05）；术后1月MMP-9在三组分别为0.86±0.34ng/mL，0.87±0.25ng/mL及1.05±0.35ng/mL，与C组相比较，A组和B组的值明显降低（P均＜0.05），而A组较B组无统计学差异（P＞0.05）；术后6月MMP-9在三组分别为0.63±0.28ng/mL，0.73±0.20ng/mL及0.93±0.26ng/mL，与C组相比较，A组和B组的值明显降低（P均＜0.05），而A组较B组无统计学差异（P＞0.05）。 4三组患者BNP比较:三组患者术前BNP两两比较均无统计学差异（P＞0.05）。术后7天BNP测定分别为555.62±122.82pg/mL,653.41±167.36pg/mL及658.03±206.47pg/mL， A组明显低于B组及C组（P＜0.05），，B组较C组无统计学差异（P＞0.05）。术后1月BNP测定值分别为397.71±87.98pg/mL，502.52±131.52pg/mL及579.59±182.42pg/mL，三组间差别具有统计学意义（P＜0.05）。与C组相比较，A和B组的值明显降低（P均＜0.05），而A组又明显低于B组（P＜0.05）；术后6月BNP测定值分别为320.72±47.45pg/mL，371.92±80.92pg/mL及433.95±124.23pg/mL，三组间差别具有统计学意义（P＜0.05）。与C组相比较，A和B组的值明显降低（P均＜0.05），而A组又明显低于B组（P＜0.05）。 5三组患者术后超声结果组间比较：三组患者术后2天、3个月LVEF组间比较无统计学差异（P＞0.05），术后6个月LVEF值分别54.95±6.50%，55.10±6.51%及50.95±5.67%,与C组相比，A组和B组值明显升高（P均＜0.05），A组较B组无统计学差异（P＞0.05）。三组患者术后2天、术后3月、术后6月LVEDD组间比较均无统计学差异（P＞0.05）。三组患者超声结果组内比较：A组术后3月及术后6个月LVEF显著高于术后2天（P＜0.05），而术后3个月与术后6个月比无统计学差异（P＞0.05）。B组术后6个月高于术后2天LVEF（47.15±7.84%vs55.10±6.50%）为差异有统计学意义（P＜0.05），术后2天与3月、术后3个月与6个月比无统计学差异（P＞0.05）。C组组间两两比较均无统计学差异（P＞0.05）。A组术后6个月LVEDD低于术后2天（51.05±7.38mmvs47.50±3.83mm），为差异有统计学意义（P＜0.05）。B组组内及C组组内自身前后对照比较均无统计学差异（P＞0.05）。 6术后MACE事件随访:住院及出院1月期间三组MACE事件发生率A、B、C三组分别是3.70%，5.88%，6.89%，P＞0.05无统计学差异；1年总体不良事件发生率在A、B、C三组分别为11.11%、25.49%、25.86%，P=0.098＞0.05无统计学差异，但是A组MACE事件发生率有下降的趋势。 7药物安全性观察：三组患者肝酶、肌酶比较：三组患者术前、术后7天、术后1月及术后6月谷丙转氨酶（ALT）、谷草转氨酶（AST）及肌酸激酶（CK）两两比较均无统计学差异（P＞0.05）。结论：STEMI患者急诊PCI术前80mg阿托伐他汀联合术后40mg阿托伐他汀治疗： 1可明显降低炎症反应程度，增加斑块的稳定性。 2可明显改善患者左室收缩功能，逆转心室重构。 3未显著降低术后1月及1年的MACE事件的发生率，但有降低术后1年MACE事件发生率的趋势。
[Abstract]:Objective: in recent years, a number of studies have confirmed that large doses of atorvastatin before PCI for coronary heart disease can reduce myocardial injury in the perioperative period of PCI, thus improving the prognosis and reducing the incidence of adverse cardiac events in the short term, especially for patients with stable angina or acute coronary syndrome. However, acute ST segment elevation There are few studies on the treatment of large dose statins in patients with acute myocardial infarction (STEMI) before the emergency PCI operation. Therefore, this study gave a load dose of atorvastatin before the emergency PCI operation in STEMI patients. The purpose of this study was to explore the long-term clinical efficacy of the intensive atorvastatin treatment in the emergency PCI perioperative period of the patients with STEMI.
Methods: from May 1, 2010 to July 31, 2012, STEMI patients were randomly selected for PCI treatment within 12 hours. They were randomly divided into A, B, C, A group (atorvastatin 80mg before operation, 40mg/ day after operation, January to 20mg/ day), B group (without atorvastatin before operation, 40mg/ day after operation, and 20mg/ day after January). Before operation, atorvastatin was not taken, and 20mg/ days were given after operation. 1 before operation, 7 days after operation, 1 months after operation, serum high sensitivity C reactive protein (hs-CRP), matrix metalloproteinase 9 (MMP-9) and B type natriuretic peptide (BNP) level.2 respectively for 2 days after operation, 3 months after operation and left ventricular ejection fraction (LVEF) and left ventricular systolic function after operation. The incidence of MACE events (death, non fatal myocardial infarction and target vessel blood revascularization) in January and 1 years after operation (death, nonfatal myocardial infarction and target vessel blood revascularization) was observed in the end of the end-stage internal diameter (LVEDD).3, including the elevation of the liver enzyme (over 3 times the upper limit of the normal value), myalgia and rhabdomyolysis, as well as the gastric and intestinal reactions and rashes.
Results: a total of 204 patients with STEMI were screened during the trial. 181 cases were in line with the standard of admission, of which 6 cases were not further treated with PCI, and 12 patients refused to participate in clinical trials, and 163 cases were finally enrolled, including 54 cases in group A, 51 in group B, and 58 in group C.
1 three groups of patients generally have no obvious difference.
2 three groups of patients with hs-CRP comparison: there was no statistical difference between the three groups before operation (P > 0.05), and the hs-CRP values were 6.21 + 1.31mg/L, 7.37 + 1.74mg/L and 7.24 + 1.70mg/L in the 7 days after the operation, A group was significantly lower than the B group, C group (P < 0.05), B group compared with the group (0.05) in January. The difference between the three groups was 3.06 + 1.49mg/L, 4.14 + 1.40mg/L and 4.95 + 1.43mg/L respectively (P < 0.05). Compared with the C group, the values of A and B groups were significantly lower (P < 0.05), and the A group was obviously lower than the B group (P < 0.05). In June, the hs-CRP measurement values were 1.96 +, 2.10 + and 2.54 +, respectively. There was statistical significance (P < 0.05). Compared with C group, A group and B group significantly decreased (P < 0.05), while the A group was significantly lower than that of group B (P < 0.05).
3 three groups of patients MMP-9 comparison: there was no statistical difference between the three groups before operation MMP-9 22 (P > 0.05), and 7 days after the operation, the three groups were 1.05 + 0.37ng/mL, 1.13 + 0.62ng/mL and 1.28 + 0.45ng/mL, A group was significantly lower than the C group (P < 0.05), while the A group was less than the B group. 0.86 + 0.34ng/mL, 0.87 + 0.25ng/mL and 1.05 + 0.35ng/mL, compared with group C, the value of A group and B group decreased significantly (P < 0.05), but there was no statistical difference between group A and B group (P > 0.05). The value of MMP-9 in the three groups in June was 0.63 + 0.28ng/mL, 0.73 and 0.93 +. ), and A group than in B group showed no significant difference (P > 0.05).
The comparison of BNP in the 4 three groups: there was no statistical difference between the three groups before operation (P > 0.05). The BNP determination was 555.62 + 122.82pg/mL, 653.41 + 167.36pg/mL and 658.03 + 206.47pg/mL in the 7 day postoperatively. The A group was significantly lower than the B group and C group (P < 0.05). The B group was less statistically significant than that of the group (0.05). The value of the determination in January was 397.71 + 87.. 98pg/mL, 502.52 + 131.52pg/mL and 579.59 + 182.42pg/mL, the difference between the three groups was statistically significant (P < 0.05). Compared with the C group, the values of the A and B groups were significantly lower (P < 0.05), and the A group was significantly lower than the B group (P < 0.05). In June, the BNP measurement values were 320.72, 371.92 and 433.95 +, respectively, and three groups were different. With statistical significance (P < 0.05). Compared with C, A and B were significantly decreased (P < 0.05), while the A group was significantly lower than that of group B (P < 0.05).
5 three groups of patients with postoperative ultrasound results group comparison: three groups of patients after 2 days, 3 months of LVEF group had no statistical difference (P > 0.05), 6 months after the operation, LVEF value 54.95 + 6.50%, 55.10 + 6.51% and 50.95 + 5.67%, compared with group C, A and B group values increased significantly (P < <), A group compared with the B group (P >). After 2 days, after March, after June LVEDD between two groups were not statistically significant (P > 0.05).
The comparison of ultrasound results in the three groups: LVEF in group A was significantly higher than that of 2 days after operation (P < 0.05) after operation in March and 6 months postoperatively (P < 0.05), but there was no statistical difference between 3 months after operation and 6 months after operation (P > 0.05), and 6 months after operation in.B group was higher than LVEF (47.15 + 7.84%vs55.10 + 7.84%vs55.10) after operation 2 days after operation (P < 0.05). Postoperative 2 days and March, postoperative 3 There was no statistical difference between 6 months and 6 months (P > 0.05) in group.C (P > 0.05). In group.A, LVEDD was lower than 2 days after operation (51.05 + 7.38mmvs47.50 + 3.83mm), and there was significant difference (P < 0.05) in group.B group and in C group, there was no statistical difference (P > 0.05).
6 postoperative follow-up of MACE events: the incidence of three groups of MACE events in the hospital and hospital in January was A, B, and C three groups were 3.70%, 5.88%, 6.89%, and P > 0.05, respectively. The incidence of 1 years' overall adverse events in A, B, and C three groups were 11.11%, 25.49%, 25.86%, P=0.098 > 0.05, but A group MACE events had a downward trend.
7 drug safety observation: three groups of patients with liver enzyme, muscle enzyme comparison: three groups of patients before operation, 7 days after operation, January and 6 months after the operation, ALT, AST and creatine kinase (CK) 22 compared to no statistical difference (P > 0.05).
Conclusion: STEMI patients before emergency PCI 80mg Atorvastatin Combined with atorvastatin in the treatment of postoperative 40mg:
1 can significantly reduce the degree of inflammatory reaction, increase the stability of the plaque.
2 can be significantly improved in patients with left ventricular systolic function, reverse ventricular remodeling.
3 without a significant reduction after January and 1 years in the MACE event rate, but reduce the postoperative MACE event 1 years incidence trend.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R542.22

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