急性心肌梗死患者直接PCI不同阶段发生无复流的临床意义及强化他汀治疗的临床观察

发布时间：2018-02-22 16:30

本文关键词： 急性心肌梗死无复流临床特点预后直接PCI 强化他汀治疗无复流预后　出处：《安徽医科大学》2015年博士论文　论文类型：学位论文

【摘要】：第一部分急性心肌梗死患者直接PCI不同阶段发生无复流的临床意义背景:直接经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)是恢复急性心肌梗死(acute myocardial infarction,AMI)患者冠状动脉前向血流的最有效策略之一。然而,随之而来的无复流(No-reflow,NR)现象,降低了PCI的疗效以及给患者带来不良的临床预后,当前已经引起临床介入医师的广泛重视。对发生NR患者临床特征的分析,可以筛选出高危病人;进一步对发生在直接PCI的不同阶段(包括支架植入术后阶段和发生在球囊预扩张后至支架植入前的阶段)的NR患者临床特征的分析,可以为心血管介入医师提供更多有价值的临床信息。然而,在PCI术中不同阶段的发生NR的临床意义尚未见相关研究与报道。我们的研究分析比较NR发生在直接PCI的两个阶段(支架植入术后阶段和发生在球囊预扩张后至支架植入前的阶段)的AMI患者的临床和血管造影特征,随访上述两个阶段各自的临床预后,并探讨早期阶段无复流发生的预测因素。方法:连续收集2009年1月至2013年12月在安徽医科大学第一附属医院心内科接受直接PCI的420例ST段抬高心肌梗死患者。其中63例(15%)患者发生NR构成我们的研究对象。根据患者在直接PCI期间发生无复流的时间不同分为早期NR组和随后NR组。比较两组之间的临床特征和血管造影结果。运用Logistic多变量逐步回归分析确定早期NR的预测因素,并分析两组PCI术后长期的临床结果。应用SPASS17.0统计软件对上述资料进行分析。结果:在直接PCI期间63例无复流中,早期NR组28例,随后NR组35例。两组使用手动血栓抽吸导管的比例没有明显差异(53.6%vs 37.1%,P=0.192)。通过与随后NR组的基线特征比较,我们发现早期NR组有更高的糖尿病的比例(42.9%vs20%)、更低的入院时SBP(102.2±8.3mm Hg vs 110.5±7.6mm Hg)、更高的Killip分级III级比例(71.4%vs45.7%)和更长的再灌注时间(7.1±2.3 h vs 5.88±2.2 h),差异有统计学意义(P均0.05)。血管造影特征比较,两组初始TIMI血流0/1百分比(64.3%vs37.1%)、目标病变长度(31.4±13.6mm vs13.6±17.3mm)及血栓积分≥4(67.9%vs 42.9%)有显著的统计学差异(P均0.05)。多重Logistc逐步回归分析表明,入院时SBP100mm Hg(OR=4.580;95%可信区间1.385-15.150;P=0.0130)、再灌注时间≥6 h(OR=4.978;95%可信区间1.468-16.882;P=0.010)和血栓评分≥4(OR=2.708;95%可信区间0.833-8.799;P=0.008)是早期NR发生的独立危险因素。在1年的随访期间,早期的NR组出现心源性死亡6例和由于出血并发症与严重肾功能衰竭所致的非心源性死亡2例,导致全因死亡率28.6%(n=8),随后NR组的全因死亡率为5.7%(心源性死亡2例)。与随后NR组比较,早期NR组心源性死亡有增加的趋势,但是差异无统计学意义(21.4%比5.7%,P=0.063)。早期NR组的全因死亡率和MACE发生率显著高于随后NR组(分别为28.6%vs 5.7%、35.7%vs 14.3%,P均0.05)。上述两组分别与基线比较,在1年随访结束时LVEF减少(42.5±4.7mm vs 48.6±3.7mm,48.6±3.7mm vs 50.2±2.9mm,P均0.001),LVEDD增加(56.0±4.0mm vs 49.6±2.8mm,49.6±2.8mm vs 48.3±3.7mm,P均0.001)。此外,在1年随访结束时,早期NR组LVEF明显低于随后NR组(42.5±4.7 vs 47.8±3.5,P0.001),而LVEDD显著高于随后NR组(56.0±4.0 vs51.5±4.7,P0.001)。结论:AMI直接PCI患者早期NR组有更严重的基线临床和血管造影特点以及更差的长期预后。第二部分直接PCI患者术前强化他汀治疗的临床观察目的:强化他汀药物治疗能否改善直接PCI患者术中无复流现象当前临床上还存在很大的争议。我们的研究进一步验证直接PCI术前强化阿托伐他汀治疗是否减少患者无复流发生,并探讨其对术中处理无复流药物使用情况的影响。方法:收集施行直接PCI的STEMI患者130例,随机分为负荷剂量治疗组和对照组。负荷剂量治疗组60例,在PCI术前给予80mg首剂负荷剂量阿托伐他汀嚼服,术后20mg/天口服维持;对照组70例,给予阿托伐他汀20mg/天的标准剂量口服维持治疗。记录患者的基线临床资料、LVEF、LVEDD及术中处理无复流药物(地尔硫罩、硝普钠、腺苷、替罗非班)的使用情况。术中采用心肌梗死溶栓分级(TIMI)血流分级与校正的TIMI血流帧数(CTFC)评价心肌微循环灌注,收集冠状动脉造影及PCI影像资料。随访记录术后1个月内主要不良心脏事件(major adverse cardiovascular events,MACE)发生;测量1个月时LVEF、LVEDD并检测hs-CRP水平。结果:负荷剂量治疗组术中发生无复流13例(21.7%),对照组18例(25.7%),两组间比较,差异无统计学意义(P=0.589)。前组手术结束前无复流者持续存在2例(3.3%),对照组4例(5.7%)(P=0.976)。负荷剂量治疗组术中地尔硫罩重复使用率、硝普钠重复使用率、腺苷重复使用率均分别低于对照组(8.3%vs21.4%,5%vs18.6%,5%vs 17.1%,P均0.05),两组替罗非班使用率比较,差异无统计学意义(3.3%vs 11.4%,P=0.084)。前组1个月内MACE事件发生率低于后组(8.3%vs 22.9%,P=0.023)。负荷剂量治疗组LVEF略高于对照组,LVEDD略低于对照组,但差异无统计学意义(P均0.05)。与对照组比较,在1个月的随访时负荷剂量治疗组hs-CRP水平显著下降[7.8(6.2-18.3)vs 10.3(8.6-20.6),P0.05]。与基线比较,负荷剂量治疗组明显下降[7.8(6.2-18.3)vs16.5(13.4-25.4),P0.05];对照组明显下降[10.3(8.6-20.6)vs15.9(12.5-24.3),P均0.05]。结论:尽管术前强化他汀治疗未能显示改善直接PCI患者术中无复流的发生率,但是其可以减少术中血管扩张剂的使用,改善患者术后近期临床预后,并进一步下调hs-CRP水平。
[Abstract]:The first part of the direct PCI in patients with acute myocardial infarction in different stages of background and clinical significance of no reflow: direct percutaneous coronary intervention (percutaneous coronary, intervention, PCI) is the recovery of acute myocardial infarction (acute myocardial, infarction, AMI) of coronary artery in patients with anterior to the one of the most effective strategies for blood flow. However, it no longer flow (No-reflow, NR), reduced the efficacy of PCI as well as to patients with poor clinical prognosis, the current has attracted wide attention of interventional cardiologist. Analysis of the clinical features of NR patients, selected high-risk patients; further to occur in different stages of PCI (including direct stent implantation and stage in balloon dilation after stent implantation before the stage) analysis of the clinical characteristics of patients with NR, can provide more valuable for clinical interventional cardiologists The information in the PCI. However, during different stages of the clinical significance of NR has been studied and reported. The two stage of comparative analysis we NR occurred in PCI (direct stenting and balloon dilation occurred in the stage to the stage before stent implantation) clinical and angiographic characteristics of AMI patients the clinical prognosis of the above two stages respectively, and to explore the early stages of no reflow predictors of the occurrence. Methods: from January 2009 to December 2013 to accept direct PCI in the Department of Cardiology of the First Affiliated Hospital of Medical University Of Anhui, 420 cases of patients with ST elevation myocardial infarction. 63 cases (15%) patients with NR constitute the object of our study according to the patients. No reflow time were divided into early NR group and NR group in PCI during the subsequent direct comparison between the two groups. The clinical characteristics and angiographic results using Logistic. Multivariate stepwise regression analysis to determine predictors of early NR, and to analyze the long term results of PCI two groups after operation. The data were analyzed by SPASS17.0 statistical software. Results: in 63 cases of direct PCI during no reflow, NR group of 28 cases of early, and 35 cases in NR group. There was no significant difference between two groups the use of manual thrombus aspiration catheter ratio (53.6%vs 37.1%, P=0.192). By comparing with the baseline characteristics of subsequent NR group, we found that the early NR group had a higher proportion of diabetes mellitus (42.9%vs20%), lower admission SBP (102.2 + 8.3mm Hg vs + 7.6mm 110.5 Hg), higher Killip class III the ratio (71.4%vs45.7%) and the longer time of reperfusion (7.1 H + 2.3 vs 5.88 + 2.2 h), the difference was statistically significant (P < 0.05). Angiographic features comparison, two groups of initial TIMI blood 0/1 (64.3%vs37.1%), the percentage of target lesion length (31.4 + 13.6mm and vs13.6 + 17.3mm) The thrombus integral is greater than or equal to 4 (67.9%vs 42.9%) there is a statistically significant difference (P < 0.05). Multiple Logistc regression analysis showed that admission SBP100mm Hg (OR=4.580; 95% CI 1.385-15.150; P=0.0130), reperfusion time was greater than 6 h (OR=4.978; 95% Ci, 1.468-16.882; P=0.010 = 4) and thrombus score (OR=2.708 95% confidence interval; 0.833-8.799; P=0.008) is an independent risk factor for early NR. During 1 years of follow-up, the early NR group appeared 6 cases of cardiac death and 2 cases with non cardiac complications of hemorrhage and severe renal failure caused by death, resulting in all-cause mortality 28.6% (n=8), and NR group the all-cause mortality was 5.7% (2 cases of cardiac death). And then compared with NR group, NR group had an increasing trend of early cardiac death, but the difference was not statistically significant (21.4% vs 5.7%, P=0.063). Early NR group of all-cause mortality and the incidence of MACE significantly Then higher than NR group (28.6%vs 5.7%, 35.7%vs 14.3%, P 0.05). The two groups were compared with the baseline, LVEF decreased after 1 years of follow-up (42.5 + 4.7MM vs 48.6 + 3.7mm, 48.6 + 3.7mm vs 50.2 + 2.9mm, P 0.001), LVEDD (56 + 4.0mm vs 49.6 + 2.8mm, 49.6 + 2.8mm vs 48.3 + 3.7mm, P 0.001). In addition, at the end of the 1 years of follow-up, early NR group LVEF was significantly lower than that of the NR group (42.5 + 4.7 vs 47.8 + 3.5, P0.001), while LVEDD was significantly higher than that of group NR (56 + 4 and vs51.5 + 4.7, P0.001). Conclusion: AMI PCI patients in NR group with baseline clinical and angiographic characteristics of more serious and long-term prognosis. The second part of PCI patients before intensive statin therapy clinical observation Objective: intensive statin therapy can improve PCI directly in patients with no reflow phenomenon in the clinic is still controversial our study. To further verify the direct PCI preoperative atorvastatin treatment is reduced in patients with no reflow, and investigate the effect of no reflow on drug use during treatment. Methods: 130 patients with STEMI were collected for direct PCI patients were randomly divided into treatment group and control group loading dose. Loading dose of 60 cases in the treatment group give first dose, 80mg loading dose of atorvastatin chewing before PCI, maintain 20mg/ orally days after operation; 70 cases in control group were given standard oral dose of atorvastatin 20mg/ day maintenance therapy. Clinical data, patients with baseline LVEF, LVEDD and the operative treatment of no reflow (diltiazem drug cover. Sodium nitroprusside, adenosine, tirofiban). The use of intraoperative use of thrombolysis in myocardial infarction (TIMI) grading flow classification and correction TIMI frame (CTFC) in evaluation of myocardial microcirculation perfusion, collecting coronary angiography and PCI images were recorded. After 1 months of major adverse cardiac events (major adverse cardiovascular events, MACE); measured at 1 months of LVEF, LVEDD and hs-CRP level detection. Results: loading dose treated group was no reflow in 13 cases (21.7%), the control group of 18 cases (25.7%), were compared between the two groups. There was no statistically significant difference (P=0.589). The former group before the end of surgery, no reflow were persistent in 2 cases (3.3%), 4 cases in the control group (5.7%) (P=0.976). The treatment group was loading dose of diltiazem cover repeated use rate, rate of repeated use of sodium nitroprusside, adenosine repeated use rate were significantly lower than those of control group (8.3%vs21.4% 17.1%, 5%vs18.6%, 5%vs, P 0.05), two groups of tirofiban use rate comparison, the difference was not statistically significant (3.3%vs 11.4%, P=0.084). The MACE group before the event occurred within 1 months after the rate is lower than the group (8.3%vs 22.9%, P=0.023). Loading dose LVEF in treatment group was slightly higher than the control group, LVEDD but lower than that of control group There was no statistically significant difference (P < 0.05). Compared with the control group, after 1 months of follow-up loading dose hs-CRP in treatment group was significantly decreased by [7.8 (6.2-18.3) vs 10.3 (8.6-20.6), P0.05]. compared with the baseline, the loading dose treatment group significantly decreased [7.8 (6.2-18.3) vs16.5 (13.4-25.4), P0.05] control group; decreased [10.3 (8.6-20.6) vs15.9 (12.5-24.3), P was 0.05]. conclusion: Although preoperative intensive statin therapy failed to show improvement in patients with direct PCI incidence of no reflow, but it can reduce the use of vasodilators in patients, improve the postoperative prognosis, and further lowered the level of hs-CRP.

【学位授予单位】：安徽医科大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R542.22

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