静脉应用重组人脑利钠肽对老年患者急性前壁心肌梗死直接PCI术后心功能的影响

发布时间：2018-03-18 13:16

  本文选题：重组人脑利钠肽　切入点：老年　出处：《河北医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：目的:研究重组人脑利钠肽(recombinant human brain natriuretic peptide,rh BNP)对老年患者急性前壁心肌梗死直接PCI术后患者心功能的影响。方法:连续选取2015年1月-2016年12月在我院心血管内五科住院治疗的符合急性前壁心肌梗死诊断标准且接受急诊PCI的老年患者63例为研究对象,年龄≥65岁,平均年龄为69.09±2.93岁。依据数字化随机表随机分为静脉应用重组人脑利钠肽(rh BNP)组32例(男性25例,女性7例)和硝酸甘油治疗组(nitroglycerin,NIT组)31例(男性25例,女性6例)。两组患者在术前均给予阿司匹林片300mg、硫酸氢氯吡格雷300mg嚼服,阿托伐他汀钙片40mg口服,行急诊PCI后继续常规应用抗凝、抗血小板聚集、降脂、血管紧张素转换酶抑制剂(Angoitensin converting enzyme inhibitor,ACEI)或血管紧张素受体拮抗剂(angiotensin receptor blocker,ARB)、β受体阻滞剂等药物治疗。rh BNP组在常规治疗的基础上,PCI术后血流动力学稳定、血压允许(收缩压≥90mm Hg)的情况下给予rh BNP(新活素,康哲药业)负荷量1.5ug/kg静脉注射,以0.0075ug/kg/min为起始剂量静脉泵入,用药期间保证收缩压≥85mm Hg,平均动脉压≥65mm Hg,根据患者临床症状及血压情况,调整rh BNP剂量范围(0.0075ug/kg/min-0.03ug/kg/min),并在6小时内调至患者能耐受的合适剂量,共维持72小时静脉泵点。NIT组在基础治疗的前提下,PCI术后血流动力学稳定、血压允许(收缩压≥90mm Hg)的情况下给予硝酸甘油10ug/min静脉泵点,用药期间保证收缩压≥85mm Hg,平均动脉压≥65mm Hg,根据患者临床症状及血压情况,调整硝酸甘油的用量(10ug/min-100ug/min泵入),并在6小时内调至患者可耐受的合适剂量,共维持72小时静脉泵入。通过观察两组患者在治疗前后心率、呼吸频率、收缩压、血NT-pro BNP水平、24小时出入量差值、肌酸激酶同工酶(CK-MB)和肌钙蛋白I(c Tn I)峰值、左室射血分数(left ventricular ejection fraction,LVEF)、二尖瓣舒张早期血流峰值(E)与二尖瓣环舒张早期运动速度(e,)比值(E/e,)、左室舒张末内径(left ventricular end diastolic diameter,LVEDD),左室收缩末内径(left ventricular end systolic diameter,LVESD),探讨rh BNP对老年患者急性前壁心肌梗死直接PCI治疗术后心功能的影响。通过观察应用过程中低血压、过敏、头痛、急性肾功能异常、恶性心律失常等不良事件发生率及主要心血管不良事件(MACE事件)(包括:梗死后心绞痛、院外心衰加重、恶性室性心律失常、心源性猝死),来评价rh BNP在老年患者急性前壁心肌梗死直接PCI术后应用的有效性及安全性。两组患者均应用SPSS 20.0统计软件对数据进行统计分析。统计结果将P0.05(双侧)作为有差异并具有统计学意义。结果:1两组患者基线资料:年龄、性别、吸烟、高血压、高血脂、糖尿病、收缩压、舒张压、呼吸频率、心率、首次医疗接触时间(first medical contact time,FMC)、发病至血管开通时间、血浆NT-pro BNP浓度、肾肌酐清除率、Killip分级上均无统计学差异(P0.05)。两组患者在应用盐酸替罗非班治疗及常规药物治疗上均无统计学差异(P0.05)。2两组患者呼吸频率在治疗后24h、72h呼吸情况较前有所降低(P0.05),且rh BNP组较NIT组降低更显著(P0.05)[(22.92±1.31)次/分vs(24.86±1.38)次/分,P0.01;(17.25±1.09)次/分vs(22.75±1.48)次/分,P0.01];两组患者的心率在治疗后24h、72h较治疗前均降低(P0.05),且rh BNP组较NIT组降低更为显著[(80.79±5.15)次/分vs(85.26±4.83)次/分,P=0.001;(65.25±4.28)次/分vs(71.97±5.93)次/分,P0.01];两组患者收缩压在治疗24h、72h后较前均明显降低(P0.05),且rh BNP组较NIT组降低更为明显[(120.45±9.93)mm Hg vs(126.94±10.04)mm Hg,P=0.012;(104.12±5.45)mm Hg vs(111.09±5.75)mm Hg,P0.01]。两组患者治疗后第一个、第三个24小时出入量差值均有统计学差异(P0.05),且rh BNP组较NIT组升高明显[(731.55±124.51)ml vs(657.14±155.01)ml,P=0.04;(964.06±189.51)mlvs(799.83±146.91)ml,P0.01]。3通过对两组CK-MB、c Tn I峰值的测定,rh BNP组较NIT组减低,有统计学意义(P0.05)[CK-MB(195.30±89.71)u/L vs(227.06±88.27)u/L,P0.01;c Tn I(55.29±15.36)ng/ml vs(66.76±16.45)ng/ml,P=0.006]。4两组患者在治疗72h、7天后血NT-pro BNP水平较治疗前明显降低,且rh BNP组较NIT降低更为明显,有统计学意义(P0.05)[(1391.09±50.62)pg/ml vs(1505.72±60.69)pg/ml,P0.01;(849.01±50.96)pg/ml vs(947.04±47.12)pg/ml,P0.01]。在治疗1个月时再次测定两组患者血NT-pro BNP水平,无明显差异[(474.84±46.45)pg/ml vs(481.76±64.58)pg/ml,P=0.626]。5两组患者在治疗7天后LVEDD值与LVESD值,rh BNP组与NIT组相比较无统计学差异[LVEDD:(53.70±3.99)mm vs(54.13±4.21)mm,P=0.405];[LVESD:(40.64±4.29)mm vs(40.79±4.35)mm,P=0.888];rh BNP组LVEF值与NIT组相比较,无统计学意义[(46.11±3.41)%vs(45.04±3.21)%,P=0.205];在治疗1个月时,LVEDD值、LVESD值rh BNP组与NIT组均比原来缩小,且rh BNP组较NIT组缩小较为明显,[LVEDD:(49.06±4.37)mm vs(52.68±3.74)mm,P0.01];[LVESD:(36.32±3.66)mm vs(38.74±4.03)mm,P0.01]。LVEF值rh BNP组、NIT组较治疗7天时均有升高,且rh BNP组较NIT组升高明显,有统计学差异[(51.98±3.03)%vs(47.73±3.71)%,P0.01]。两组患者E/e,值,在治疗7天和1个月时,rh BNP组均比NIT组改善明显[(13.55±3.45)vs(15.81±4.18),P=0.023;(10.24±2.31)vs(13.04±2.43),P0.01]。6两组患者在治疗过程中均未发现过敏现象。rh BNP组发现1例患者出现低血压现象(收缩压85mm Hg),NIT组发现2例,在调整药物的剂量后低血压现象没有再发生,两组患者在发生低血压现象上无统计学差异(P0.05);rh BNP组患者中未出现头痛病例,NIT组则出现5例,后患者耐受,继续给予硝酸甘油静脉泵点,在头痛发生情况上,NIT组较rh BNP组明显,有统计学意义(P0.05);在出现室性心律失常上,rh BNP组未出现,NIT组出现2例频发室性早搏,给予盐酸利多卡因抗心律失常治疗后,未再发生,两组相比无统计学差异(P0.05);两组患者在治疗期间均未发现急性肾损伤。7两组患者在出院后1周、1个月、3个月时均行动态心电图检查,通过随访在3个月时,rh BNP组出现1例室性心律失常者,NIT组出现2例室性心律失常者,通过比较,两组患者在室性恶性心律失常发生率上无统计学差异(P=0.613)。rh BNP组1例患者出现梗死后心绞痛,NIT组出现3例,两组再发心绞痛发生率无统计学差异(P=0.286)。出院后rh BNP组无患者再次发生心衰加重情况,NIT组出现2例患者,在院外心衰发生上,两组发生率无统计学差异(P=0.238)。两组患者均未出现心源性猝死事件。结论:对于急性前壁心肌梗死直接PCI治疗的老年患者,静脉应用rh BNP,可明显缓解临床症状、稳定血流动力学状态并显著改善心功能。
[Abstract]:Objective: To study the effects of recombinant human brain natriuretic peptide (recombinant human brain natriuretic peptide, Rh BNP) effects on cardiac function in elderly patients with acute anterior myocardial infarction after primary PCI. Methods: from January 2015 December -2016 in our hospital in five hospitalized cardiovascular treatment with acute anterior wall myocardial infarction diagnostic criteria and received emergency PCI of 63 cases of elderly patients as the research object, 65 years of age or older. The average age was 69.09 + 2.93 years. On the basis of the digital random table were randomly divided into intravenous recombinant human brain natriuretic peptide (RH BNP) group of 32 cases (25 cases, male 7 cases of female) and nitroglycerin group (nitroglycerin NIT group) 31 cases (25 cases, male 6 cases of female). Two groups of patients were treated with Aspirin Tablets 300mg in the preoperative, clopidogrel 300mg chawing, Atorvastatin Calcium Tablets 40mg orally after undergoing PCI to conventional anticoagulation, antiplatelet poly Set, lipid-lowering, angiotensin converting enzyme inhibitors (Angoitensin converting, enzyme inhibitor, ACEI) or angiotensin receptor antagonist (angiotensin receptor, blocker, ARB), beta blockers and other drugs for the treatment of.Rh BNP group on the basis of conventional treatment, stable hemodynamics after PCI, blood pressure (systolic blood pressure was 90mm Hg allowed under the condition of given RH BNP) (Xinhuosu, kangzhe pharmaceutical) load 1.5ug/kg intravenous injection with 0.0075ug/kg/min as initial dose of intravenous infusion, medication period guarantee systolic blood pressure more than 85mm Hg, mean arterial pressure was 65mm Hg, according to the clinical symptoms and blood pressure in patients with the situation, adjust the RH BNP dose range (0.0075ug/kg/min-0.03ug/kg/min). And within 6 hours to the patient can appropriate dose tolerance, were maintained for 72 hours intravenous.NIT group based on the basic treatment, stable hemodynamics after PCI, blood pressure (systolic blood pressure was allowed 90mm Hg) under the condition of given nitroglycerin intravenous medication during 10ug/min, ensure systolic blood pressure than 85mm Hg, mean arterial pressure was 65mm Hg, according to the clinical symptoms and blood pressure, adjust the dosage of nitroglycerin (10ug/min-100ug/min pump), and in 6 hours to patients with appropriate dose tolerance, total maintenance 72 hour intravenous infusion. Through the observation of two groups of patients before and after treatment, heart rate, respiratory rate, systolic blood pressure, serum NT-pro BNP levels, 24 hours of quantity difference, creatine kinase isoenzyme (CK-MB) and troponin I (C Tn I) peak, left ventricular ejection fraction (left ventricular ejection fraction, LVEF), mitral valve the early diastolic peak (E) and early diastolic velocity of mitral annulus (E) ratio (E/e), left ventricular end diastolic diameter (left ventricular end diastolic diameter, LVEDD), left ventricular end systolic diameter (left ventricular end systolic DIAM Eter, LVESD, RH) to investigate the effects of BNP on cardiac function in elderly patients with PCI in acute anterior myocardial infarction after treatment. The blood pressure, the observation in the application process of allergy, headache, acute renal dysfunction, arrhythmia and other adverse events and the incidence of major cardiovascular adverse events (event MACE) (including: outside the hospital after infarction angina, heart failure, malignant ventricular arrhythmia and sudden cardiac death), to evaluate the efficacy and safety of the application of RH BNP direct PCI in elderly patients with acute anterior myocardial infarction after operation. Two patients were used SPSS 20 statistical software for statistical analysis of data. The statistical results of the P0.05 (as there are differences in bilateral) and had statistical significance. Results: 1 patients in two groups: age, gender, baseline smoking, hypertension, hyperlipidemia, diabetes, systolic blood pressure, diastolic blood pressure, respiratory rate, heart rate, the first medical contact time (first medical contact time,FMC),鍙戠梾鑷宠��绠″紑閫氭椂闂，

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