发病至首次医疗接触在3-6小时急性ST段抬高心肌梗死患者静脉溶栓和转诊PCI的预后分析

发布时间：2018-03-23 13:56

本文选题：首次医疗接触　切入点：急性ST段抬高型心肌梗死　出处：《郑州大学》2017年博士论文

【摘要】：目的明确郑州周边县市内发病至首次医疗接触在3-6小时的急性ST段抬高心肌梗死静脉溶栓和转诊PCI患者的临床特点、30天和1年的预后及其影响因素。材料与方法收集2013年1月至2014年1月隶属于郑州市的6家县级医院确诊为急性ST段抬高心肌梗死的患者999例,排除发病至首次医疗接触在3小时内或6小时以上者共653例,346例发病至首次医疗接触在3-6小时内患者符合入选标准,排除有溶栓禁忌症者6例、既不接受溶栓也不接受转诊PPCI者7例后,最终接受在当地县医院急诊静脉溶栓者192例,拒绝溶栓要求转诊至我院行PCI者141例。对192例当地静脉溶栓及141例转诊PPCI患者的临床资料和特征进行分析,分别记录两组患者从症状发作至溶栓或转诊行PPCI治疗期间各时间点(段)的时间,分析影响各时间点(段)的因素,并对两组患者30天和1年的预后进行对比分析,同时分析其影响因素。结果1.转运PCI组较溶栓组患者年龄偏大、男性居多,且既往有短暂性脑缺血发作或脑卒中的比例偏高,但无明显统计学差异;两组患者在吸烟史、高血压、糖尿病、血脂异常、心血管疾病史、心肌梗死部位、病变血管支数、发生心脏骤停、充血性心力衰竭和心源性休克例数等方面均无明显差异。2.两组患者整个救治过程都有不同程度的时间延搁,但发病至首次院内医疗接触时间、疾病诊断时间和总缺血时间无明显差别。3.就地溶栓治疗组和转运PCI治疗组患者30天全因死亡率无明显差异,而1年的预后分析显示转运PCI组患者明显好于就地溶栓治疗组。4.单因素分析显示:心源性休克及需要通气支持的心脏骤停是30天和1年死亡的两个强力预测因子。既往短暂性脑缺血发作(TIA)和(或)卒中史始终与患者30天和1年死亡有明显相关性。左心室射血分数40%、前壁心肌梗死、糖尿病、既往心肌梗死病史、高血压及年龄均与患者30天的全因死亡明显相关。外周动脉疾病影响患者1年的预后。多因素回归分析显示:既往TIA或卒中史,需要通气支持的心脏骤停、心源性休克、LVEF0.40、多支病变或主干病变与30天和1年死亡均相关。经多因素校正后结果显示:糖尿病与30天死亡相关,而转运PPCI明显提高患者1年的生存率且转运PCI时间是PPCI组生存的独立预测因素。结论1.基层医院院内溶栓治疗仍然是目前较为安全有效的再灌注治疗手段之一,但整个溶栓过程有不同程度的时间延迟。2.发病至首次医疗接触在3-6小时内的STEMI患者,尽管转运PCI时间大于2小时,但其总的预后明显好于就地静脉溶栓患者。3.尽管转诊PCI组患者转运时间有较长的延迟,两组患者最终的总缺血时间无明显统计学差异,转诊PCI的最终获益明显抵消了其转运时间超过2小时的时间延迟。
[Abstract]:Objective to determine the clinical features of patients with acute ST-segment elevation myocardial infarction (ST-elevation) treated with intravenous thrombolytic therapy and referral to PCI for 30 days and 1 year from onset to first medical exposure in Zhengzhou surrounding counties and cities. Materials and methods were used to study the prognostic factors of patients with acute ST-segment elevation myocardial infarction for 30 days and 1 year. From January 2013 to January 2014, 999 patients with acute ST-segment elevation myocardial infarction in 6 county-level hospitals affiliated to Zhengzhou were collected. The total of 653 patients who were excluded from the first medical exposure within 3 hours or more or more than 6 hours from the onset of the disease to the first medical exposure within 3 to 6 hours met the inclusion criteria, and 6 patients with thrombolytic contraindications were excluded. After neither thrombolytic therapy nor referral of PPCI was accepted in 7 patients, 192 patients received intravenous thrombolysis in the emergency department of the local county hospital. There were 141 patients who refused to be referred to our hospital for PCI. The clinical data and characteristics of 192 local venous thrombolytic patients and 141 referrals to PPCI were analyzed. The time from symptom onset to thrombolytic therapy or referral to PPCI treatment was recorded, and the factors affecting each time point (segment) were analyzed, and the prognosis of 30 days and 1 year were compared between the two groups. At the same time, the influencing factors were analyzed. 1. The patients in PCI group were older than those in thrombolytic group, and the proportion of patients with transient ischemic attack or stroke was higher than that of thrombolytic group, but there was no significant difference between the two groups. 2. Hypertension, diabetes, dyslipidemia, history of cardiovascular disease, location of myocardial infarction, number of diseased vessels, cardiac arrest, There was no significant difference in the number of cases of congestive heart failure and cardiogenic shock. 2. The whole treatment process of the two groups was delayed in varying degrees, but the time from onset to first in-hospital medical contact was delayed. There was no significant difference between the time of diagnosis and the time of total ischemia. 3. There was no significant difference in the 30-day all-cause mortality between the thrombolytic therapy group and the PCI transport treatment group. One-year prognostic analysis showed that patients in the PCI group were significantly better than those in the in-situ thrombolytic therapy group .4. univariate analysis showed that cardiogenic shock and cardiac arrest requiring ventilation support were two powerful predictors of 30-day and 1-year mortality. There was a significant correlation between TIA and / or stroke history in 30 days and 1 year of death in patients with transient ischemic attack. Left ventricular ejection fraction (LVEF), anterior wall myocardial infarction, left ventricular ejection fraction (LVEF), left ventricular ejection fraction (LVEF), anterior wall myocardial infarction (AMI), Diabetes mellitus, myocardial infarction history, hypertension and age were significantly associated with 30 days of all-cause death. Peripheral artery disease affected the prognosis of patients for one year. Multivariate regression analysis showed that: previous TIA or stroke history. For cardiac arrest requiring ventilation support, LVEF 0.40 for cardiogenic shock, multivessel lesions or trunk lesions were associated with 30 days and 1 year of death. The results of multifactorial adjustment showed that diabetes was associated with 30 days of death. The transport of PPCI significantly improved the 1-year survival rate of patients and the time of transporting PCI was an independent predictor of survival in PPCI group. Conclusion 1.Inhospital thrombolytic therapy in primary hospitals is still one of the more safe and effective methods of reperfusion therapy at present. However, the whole thrombolytic process was delayed in varying degrees. 2.The onset of thrombolysis occurred in patients with STEMI within 3-6 hours of initial medical exposure, although the PCI transport time was longer than 2 hours. However, the overall prognosis was significantly better than that of intravenous thrombolytic patients in situ .3.Although there was a long delay in the transit time of the patients in the referred PCI group, there was no significant difference in the final total ischemic time between the two groups. The ultimate benefit of referral PCI significantly offset the delay of more than 2 hours of transit time.
【学位授予单位】：郑州大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R542.22

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