缺血后处理减轻急性心肌梗死患者再灌注损伤

发布时间：2018-07-11 14:16

本文选题：缺血后处理 + 急性心肌梗死　；参考：《天津医科大学》2013年硕士论文

【摘要】：背景：以溶栓疗法和经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)为代表的早期再灌注治疗(Reperfusion therapy, RT)能及时开通梗死相关动脉(infarction related artery, IRA),限制梗死面积(infarct size, IS),是急性心肌梗死(acute myocardial infarction, AMI)的主要救治措施。然而,RT又可以矛盾性的造成新的心肌损伤,这称之为缺血再灌注损伤(ischemia reperfusion injury,IRI)。在接受成功血运重建治疗的AMI患者中,有40%的心肌IS来源于IRI。如何减少RT过程中的IRI是近几十年来的研究重点。 1986年,Murry等提出缺血预处理(ischemic preconditioning, IPreC)的概念并指出IPreC可以减轻IRI,限制IS,这一效应先后在多种缺血再灌注动物模型上得到证实,心外科医生在择期的心脏手术中也观察到了IPreC的保护作用。然而,由于AMI事件的不可预知性限制了IPreC的临床应用。在2000年和2003年,陶凌和Zhao等先后提出了缺血后处理(Ischemic postconditioning, IPostC)的概念并发现IPostC同样可以减轻再灌注治疗时的IRI,限制IS。此后,大量的基础研究证实IPostC可以减轻不同动物心肌缺血再灌注模型的IRI并对其心肌保护作用机制进行了深入而广泛的探讨。由于IPostC可以很容易的在AMI患者的直接PCI治疗中实现,人们对其临床效果寄予厚望。小样本的“概念证明研究”表明IPostC可以缩小接受直接PCI治疗的AMI患者的IS,但IPostC在临床应用中的心肌保护作用仍存在争议。目的：观察IPostC对接受直接PCI治疗的AMI患者再灌注心律失常(reperfusion arrhythmia, RA)、冠状动脉及心肌灌注、IS、左室结构和功能改变以及临床事件和炎症标志物水平的影响,探索预防心肌IRI的方法。方法：自2010年6月至2012年6月,于天津医科大学宝坻临床学院心血管内科住院,发病12小时内且接受直接PCI治疗的急性ST段抬高型心肌梗死患者106例,随机进入对照组(56例)或IPostC组(50例)。两组均接受规范的药物治疗,再此基础上对照组以标准技术行PCI治疗,IPostC组于IRA开通后30秒内给予3轮30秒／次的IPostC后再给予持续再灌注治疗并继续完成PCI治疗操作。记录PCI过程中RA发生情况,测定术中、术后冠状动脉TIMI血流、校正的TIMI血流帧数计数(corrected TIMI frame count, cTFC)、心肌染色显影分级(myocardial blush grade, MBG)和术后即刻ST段回落率(ST segment recovery,STR),并于入院即刻和发病8小时、10小时、12小时、14小时、16小时、18小时、24小时、48小时取静脉血1次,分别测定血清肌酸激酶同工酶MB(creatine kinase isoenzyme-MB, CK-MB)、高敏肌钙蛋白T (high sensitivity troponin T,hs-TnT)和高敏C反应蛋白(high sensitivity C reactive protein, hs-CRP)水平,于发病90天时行经胸二维超声心动图检查,测定左室舒张末期内径(left ventricular end diastolic diameter, LVED), Simpson法测定左室射血分数(Left Ventricular Ejection Fractions, LVEF),检测并计算室壁节段运动指数(wall motion score index, WMSI),同时观察90天时死亡、再梗死、脑卒中、梗死后心绞痛及心力衰竭等临床事件发生率。结果：两组患者基线临床情况、冠脉病变及PCI治疗情况一致,术中IPostC组频发室性期前收缩、室性心动过速等室性RA发生率少于对照组(24.0%vs42.9%,P=0.041;2.0%vs14.3%,P=0.034)；IPostC组术中冠脉无复流(no reflow, NRF)发生率低于对照组(8.0%vs23.2%,P=0.033)：术后ST段完全回落率高于对照组(96.0%vs83.9%,P=0.042)；尽管术毕时IRA的TIMI血流无差异,但cTFC及MBG优于对照组(P0.05);IPostC组术后CK-MB和Hs-TnT均低于对照组(258.3±87.8U/L vs306.6±94.4U/L,P=0.008；3582.08±1731.40ng/L vs4501.34±1554.4ng/L,.P=0.005)同样,术后IPostC组的hs-CRP水平亦低于对照组(13.65(4.36,32.76) mg/Lvs17.25(9.58,36.35) mg/L, P=0.048);90天时IPostC组LVED小于对照组(52.02±3.28mm vs55.11±4.08mm, P0.0001), LVEF高于对照组(55.92%±2.87%vs48.96%±3.19%,P0.0001),WMSI低于对照组(1.34±0.21vs1.49±0.24,P=0.0001);两组患者90天时心力衰竭发生率在IPostC组低于对照组(10.0%vs25.0%,P=0.044)。结论：在标准PCI操作基础上,3轮30秒/次的IPostC操作可以减轻急性ST段抬高型心肌梗死患者的IRI,降低术中RA和冠状动脉NRF发生率及术后心肌坏死标志物水平,限制IS,减轻AMI后心室重塑,改善室壁运动,提高LVEF和心脏泵血能力,从而改善临床预后。
[Abstract]:Background:
Early reperfusion therapy (Reperfusion therapy, RT), represented by thrombolytic therapy and percutaneous coronary intervention (percutaneous coronary intervention, PCI), can open the infarct related artery (infarction related artery, IRA) in time, and limit the infarct area (infarct), which is acute myocardial infarction. AMI) major treatment. However, RT can also create a contradictory new myocardial injury, which is called ischemia reperfusion injury (IRI). In AMI patients receiving successful revascularization, 40% of cardiac IS originates from how IRI. reduces RT process, and is the focus of recent research.
In 1986, Murry and so on proposed the concept of ischemic preconditioning (IPreC) and pointed out that IPreC could reduce IRI and restrict IS. This effect has been confirmed in a variety of ischemic reperfusion animal models, and the cardiac surgeon also observed the protection of IPreC during elective cardiac surgery. However, because of the inability of AMI events Predictability restricts the clinical application of IPreC. In 2000 and 2003, Tao and Zhao proposed the concept of Ischemic postconditioning (IPostC) successively and found that IPostC also alleviated IRI during reperfusion treatment, limiting IS., and a large number of basic studies confirmed that IPostC could reduce myocardial ischemia and reperfusion in different animals. IRI and the mechanism of myocardial protection are extensively discussed. Since IPostC can be easily implemented in the direct PCI treatment of AMI patients, people have great expectations for its clinical effects. The "conceptual proof study" of small samples shows that IPostC can reduce the IS of AMI patients receiving direct PCI treatment, but IPostC The myocardial protective effect in clinical application is still controversial.
Objective:
To observe the effect of IPostC on reperfusion arrhythmia (reperfusion arrhythmia, RA), coronary artery and myocardial perfusion, IS, left ventricular structure and function changes, the level of clinical events and inflammatory markers in AMI patients receiving direct PCI treatment, and to explore the methods of preventing cardiac IRI.
Method:
From June 2010 to June 2012, 106 patients with acute ST segment myocardial infarction (56 cases) or group IPostC (56 cases) or IPostC (50 cases) were hospitalized in the cardiovascular medicine department of the Baodi Clinical College of Medical University Of Tianjin and received direct PCI treatment. The two groups were treated with standardized drug treatment, and then the control group was based on the standard. The technique was treated with PCI, and group IPostC was given 3 rounds of 30 seconds / times of IPostC in 30 seconds after the opening of IRA, and followed by continuous reperfusion therapy and continuing to complete PCI treatment. Record the occurrence of RA in the PCI process, determine the coronary artery TIMI blood flow in the operation, the corrected number of TIMI blood flow frames (corrected TIMI frame), and myocardial staining Myocardial blush grade (MBG) and immediate ST segment drop rate (ST segment recovery, STR) after operation, and 8 hours, 10 hours, 12 hours, 12 hours, 14 hours, 16 hours, 18 hours, 24 hours and 48 hours for 1, respectively, to determine the serum creatine kinase isoenzyme MB (creatine kinase), Gao Minji. The T (high sensitivity troponin T, hs-TnT) and the high sensitive C reactive protein (high sensitivity C reactive protein) were measured at the 90 day of the onset, and the left ventricular end diastolic diameter was measured. Icular Ejection Fractions, LVEF), detect and calculate the ventricular wall segment motion index (wall motion score index, WMSI), and observe the incidence of death, re infarction, stroke, post infarction angina and heart failure at the same time in 90 days.
Result:
The baseline clinical conditions, coronary lesions and PCI treatment in the two groups were consistent. The incidence of ventricular RA in IPostC group was less than that in the control group (24.0%vs42.9%, P=0.041; 2.0%vs14.3%, P=0.034), and the incidence of coronary artery free flow (no reflow, NRF) in group IPostC was lower than that of the control group (8.0%vs23.2%,) After the operation, the total fall rate of ST segment was higher than that of the control group (96.0%vs83.9%, P=0.042), although the TIMI blood flow of IRA was no difference at the time of operation, but cTFC and MBG were superior to the control group (P0.05), and the CK-MB and Hs-TnT in group IPostC were lower than those of the control group (258.3 +). The level of hs-CRP in the post IPostC group was also lower than that of the control group (13.65 (4.36,32.76) mg/Lvs17.25 (9.58,36.35) mg/L, P=0.048), and at the 90 day IPostC group LVED was less than the control group (52.02 + 3.28mm vs55.11 + 4.08mm,), which was higher than that of the control group (55.92% + 3.19% + 3.19%, 1.34 + 0.24, 1.34); The incidence of heart failure was lower in the IPostC group than in the control group on the 90 day (10.0%vs25.0%, P=0.044).
Conclusion:
On the basis of standard PCI operation, 3 rounds of 30 seconds / 30 seconds can reduce the IRI in patients with acute ST segment elevation myocardial infarction, reduce the incidence of RA and coronary NRF in operation and the level of postoperative myocardial necrosis markers, restrict IS, reduce ventricular remodeling after AMI, improve ventricular wall movement, improve LVEF and cardiac pump blood ability, thus improving clinical preclinical. After.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R542.22

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