急诊PCI术前高负荷他汀对急性心肌梗死患者介入术中无复流预防及短期心功能的影响

发布时间：2018-09-04 16:37

【摘要】：目的：研究急性心肌梗死（Acute myocardial infarction，AMI）患者直接经皮冠状动脉介入术（Percutaneous coronary intervention，PCI）前高负荷阿托伐他汀80mg对PCI术中无复流的预防作用及短期心功能的影响。方法：选取2012年9月到2013年12月期间于河北医科大学第三医院心血管二科住院，首次诊断为急性心肌梗死并成功行冠脉介入治疗的72名患者（年龄在32~79岁）作为研究对象，排除急性心梗合并急性左心衰、心源性休克、活动性肝脏疾病及严重肝肾功能不全等影响观察指标患者，其中包括ST段抬高型心肌梗死（ST segment elevation myocardialinfarction，STEIM）54例，非ST段抬高型心肌梗死（Non-ST segment eleva-tion myocardial infarction，NSTIM）患者18例，按随机数字表法随机分为两组，负荷组（38例），急诊PCI术前嚼服阿托伐他汀（立普妥，20mg/片，辉瑞制药）80mg，术后给予20mg每晚一次口服；常规组（34例）仅术后给予阿托伐他汀20mg每晚一次，两组患者术前均给予嚼服阿司匹林300mg，氯吡格雷600mg；术后住院期间两组均给予阿司匹林、氯吡格雷及低分子肝素，根据患者情况给予IIb/Ⅲa受体拮抗剂、血管紧张素转化酶抑制剂/血管紧张素受体拮抗剂（ACEI/ARB）及β－受体阻滞剂等冠心病基础药物治疗。记录所有患者一般情况：性别、年龄、吸烟、饮酒、基础疾病（包括高血压、糖尿病、血脂代谢异常）及病变血管数、梗死相关动脉、胸痛持续时间等临床特点，所有患者在签署知情同意书后90min内开通梗死相关动脉，成功的PCI术后即刻由两名有经验验的介入医师对梗死相关动脉进行TIMI（thrombolysis in myocardial infarction）血流分级评估梗死相关动脉心外膜冠脉血流，记录无复流发生率；根据TIMI心肌灌注分级（TIMI myocardial perfusion grade，TMPG），评估微循环、心肌灌注情况；记录入院即刻及术后第一天空腹血浆BNP（脑利钠肽，BrainNatriuretic Peptide，BNP）水平，及术后一个月心脏彩超心脏左室射血分数（Left ventricular ejection fraction，LVEF）值，评估短期心功能受损及恢复情况。实验主要研究终点：两组术中无复流发生率及心肌灌注水平，次要终点是急诊PCI术前阿托伐他汀高负荷对患者短期心功能的影响。结果：1两组参数的比较两组患者性别、年龄、吸烟史、饮酒史、高血压病史、糖尿病病史、血脂代谢异常病史、入院时BNP水平、发病时间、梗死相关动脉、冠脉病变数等均无统计学差异，两组有可比性。 2TIMI血流结果将梗死相关动脉开通后TIMI血流≤II级定义为无复流，无复流总发生率25%，与资料统计10~30%相符；负荷组发生无复流7例，无复流发生率18.4%；常规组发生无复流11例，无复流发生率32.3%，负荷组较常规组无复流发生率低但差异无统计学意义（18.4%vs32.3%，P＞0.05）； 3TIMI心肌灌注比较负荷组TMPG血流＜3级患者10例，占负荷组26.3%，常规组18例，比例52.9%，负荷组TMPG血流＜3级患者比例显著低于常规组（26.3%vs52.9%，P＜0.05），差异有统计学意义。 4心功能评价结果两组患者入院即刻BNP水平，负荷组101±33pg/ml，常规组89±45pg/ml，两组比较（101±33pg/ml vs89±45pg/ml，P＞0.05），差异无统计学意义；术后第一天BNP水平，负荷组275±212pg/ml，常规组389±157pg/ml，两组比较（275±212pg/ml vs389±157pg/ml，P＜0.05）差异有统计学意义；术后1个月心脏彩超左室射血分数（LVEF）：负荷组（54±12）%，明显好于常规组（49±8）%，两组比较差异有统计学意义（P0.05）。住院及随访期间监测患者肝酶及肌酸激酶水平，，无一例出现严重肝毒性及肌毒性。结论： 1急性心肌梗死患者直接PCI术前高负荷他汀能有效改善缺血心肌再灌注，对术中无复流现象有一定预防作用。 2急诊PCI术前高负荷他汀能减轻缺血、PCI及再灌注等对心肌的损伤，保护心肌细胞功能，改善AMI患者心功能。
[Abstract]:AIM: To investigate the effects of high-load atorvastatin 80 mg before percutaneous coronary intervention (PCI) on no-reflow and short-term cardiac function in patients with acute myocardial infarction (AMI).
METHODS: Seventy-two patients (aged 32-79 years) with first acute myocardial infarction and successful coronary intervention were enrolled in the Department of Cardiovascular Disease, Third Hospital of Hebei Medical University from September 2012 to December 2013. All patients were excluded from acute myocardial infarction complicated with acute left heart failure, cardiogenic shock, active liver disease and coronary intervention. Severe hepatorenal insufficiency, including 54 patients with ST-segment Eleva tion myocardial infarction (STEIM) and 18 patients with non-ST-segment Eleva tion myocardial infarction (NSTIM), were randomly divided into two groups according to the random number table method. Atorvastatin was given 80 mg before PCI and 20 mg once a night after PCI. Atorvastatin was given to 34 patients in routine group only 20 mg every night after PCI. Both groups were given 300 mg aspirin and 600 mg clopidogrel before PCI. Both groups were given aspirin and clopidogrel during hospitalization. Gray and low molecular weight heparin were given basic medications for coronary heart disease, such as IIb/III a receptor antagonist, angiotensin-converting enzyme inhibitor/angiotensin receptor antagonist (ACEI/ARB) and beta-blocker, according to the patient's condition. Infarction-related arteries were opened in all patients within 90 minutes after signing informed consent. Two experienced interventional physicians performed TIMI (thrombolysis in myocardial infarction) immediately after successful PCI. Blood flow grading was used to assess the epicardial coronary flow of infarct-related artery and record the incidence of no-reflow; microcirculation and myocardial perfusion were assessed according to TIMI myocardial perfusion grading (TMPG); abdominal plasma BNP (brain natriuretic peptide, BNP) levels were recorded immediately after admission and the first day after surgery; and after surgery. One-month echocardiographic left ventricular ejection fraction (LVEF) was used to assess the short-term impairment and recovery of cardiac function.
Results: 1 Comparison of two groups of parameters
There were no significant differences in gender, age, smoking history, drinking history, hypertension history, diabetes history, abnormal blood lipid metabolism history, BNP level at admission, onset time, infarction-related artery, coronary artery lesions between the two groups.
2TIMI blood flow results
TIMI blood flow (< II) was defined as no-reflow, the total incidence of no-reflow was 25%, which was consistent with the statistical data of 10-30%. No-reflow occurred in 7 cases in load group and the incidence of no-reflow was 18.4%. No-reflow occurred in 11 cases in routine group and the incidence of no-reflow was 32.3%. The incidence of no-reflow in load group was lower than that in routine group, but the difference was not statistically significant. Meaning (18.4%vs32.3%, P > 0.05);
Comparison of 3TIMI myocardial perfusion
Ten patients (26.3%) in load group and 18 patients (52.9%) in routine group, whose TMPG blood flow was less than grade 3 in load group were significantly lower than those in routine group (26.3% vs 52.9%, P < 0.05).
4 cardiac function evaluation results
There was no significant difference in BNP level between the two groups immediately after admission. The BNP level in the load group was 101 + 33pg / ml and that in the routine group was 89 + 45pg / ml. There was no significant difference between the two groups (101 + 33pg / ml vs 89 + 45pg / ml, P > 0.05). The left ventricular ejection fraction (LVEF) of cardiac color Doppler echocardiography at 1 month after operation was significantly better than that of routine echocardiography group (54 65507
Conclusion:
High-load statin before PCI can effectively improve myocardial ischemia-reperfusion in patients with acute myocardial infarction.
High-load statin before emergency PCI can alleviate myocardial injury such as ischemia, PCI and reperfusion, protect myocardial cell function and improve cardiac function in patients with AMI.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R542.22

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