急性ST段抬高心肌梗死患者非梗死血管慢性闭塞病变择期介入治疗的临床预后研究

发布时间：2018-04-26 06:17

本文选题：急性ST段抬高心肌梗死 + 慢性完全闭塞病变　；参考：《首都医科大学》2017年硕士论文

【摘要】：目的探讨对接受急诊介入治疗(percutaneous coronary intervention,PCI)的急性ST段抬高心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者非梗死相关血管慢性完全闭塞病变(non-infarct-related artery,non-IRA-CTO)择期血运重建对临床预后影响,并识别可能影响其临床预后的因素,以期为该类患者寻找一种安全、可行的血运重建策略,为临床提供进一步的循证医学依据。方法对我院急诊科2005年1月至2013年6月行急诊PCI的患者进行筛选,符合入组标准的STEMI合并non-IRA-CTO的共226例患者,择期non-IRA-CTO手术成功组82例患者,手术失败组36例患者,未行手术组108例患者。记录患者一般临床资料、药物使用情况、超声心动图及化验检查结果等,收集并阅读介入治疗光盘及手术记录等资料,电话随访3年内主要心血管事件(major adverse cardiac events,MACE)的发生情况,MACE事件包括心源性死亡,再次血运重建,心肌梗死,大出血,卒中。所有数据以均值±标准差(Mean±SD)表示,组间比较采用t检验或非参数检验。计数资料采用χ2检验。根据随访结果,临床终点通过Log-rank进行分析,生存分析应用Kaplan-Meier方法,并且通过多元Cox回归分析各组之间调整风险后的长期生存差异,P0.05为差异有显著统计学意义。结果择期non-IRA-CTO手术成功组,手术失败组及未手术组患者的基线资料、PCI相关指标差异无统计学意义。手术成功组患者术后1月超声结果提示射血分数较术前有改善(P0.05),手术失败组及未行手术组射血分数未见明显改善。3年内MACE事件手术成功组发生12例(14.6%),手术失败组15例(41.7%),未手术组为45例(41.7%),差异有显著统计学差异(P0.001);其中,心源性死亡发生分别为1例(1.2%)、3例(8.3%)、16例(14.8%),差异有统计学差异(P0.05);Kaplan-Meier生存分析发现:手术成功组心源性死亡(1.2%vs.8.3%,p=0.036)及主要MACE事件(14.6%vs.41.7%,p0.001)较手术失败组均明显降低;手术失败组与未行手术组在心源性死亡及主要MACE事件无差异;手术成功组心源性死亡(1.6%vs.13.6%,p=0.001)及主要MACE事件(14.6%vs.41.7%,p0.001)较未开通组(手术失败组及为未行手术组)均显著降低;多元Cox回归分析发现:手术成功是患者3年无心源性死亡(HR:0.035,95%CI:0.003-0.42,p=0.008)及无主要心血管事件(HR:0.344,95%CI:0.16-0.73,p=0.005)的独立预测因素。结论成功的non-IRA-CTO择期血运重建可以增加接受急诊PCI的STEMI患者择期手术后1个月的射血分数,减少患者3年的MACE事件,从而改善患者的临床预后。未来还需要更多的大规模、随机对照试验来全面衡量non-IRA-CTO择期血运重建在该类患者的临床预后价值。
[Abstract]:Objective to investigate the prognostic effects of selective revascularization of non-infraction related chronic total occlusive lesions in patients with ST-segment elevation myocardial infraction (ST-segment elevation myocardial inflexion) in patients with acute ST-segment elevation myocardial infarction (ST-segment elevation myocardial occlusion) undergoing emergency interventional therapy. In order to find a safe and feasible strategy of revascularization and provide further evidence-based medicine basis for clinical practice, we can identify the factors that may affect the clinical prognosis. Methods from January 2005 to June 2013, 226 patients with STEMI combined with non-IRA-CTO were selected from emergency department of our hospital, 82 patients were selected for successful non-IRA-CTO operation, 36 patients were failed operation group. 108 patients were treated without operation. To record patients' general clinical data, drug use, echocardiography and laboratory examination results, and to collect and read the data of interventional therapy CD and operation records, etc. The occurrence of major adverse cardiac events (Mace) during 3 years of telephone follow-up included cardiac death, re-revascularization, myocardial infarction, massive hemorrhage and stroke. All the data were expressed as mean 卤standard deviation (mean 卤SDN). T test or nonparametric test were used to compare the data between groups. The count data were analyzed by 蠂 2 test. According to the follow-up results, the clinical end point was analyzed by Log-rank, the survival analysis was performed by Kaplan-Meier method, and the long-term survival difference after adjusting risk was statistically significant by multivariate Cox regression analysis. Results there was no significant difference in baseline data between successful group, failed group and non-operative group. One month after operation, the ultrasonic results of successful operation group showed that the ejection fraction was improved compared with that before operation (P 0.05), but the ejection fraction in the failed operation group and the non-operation group was not significantly improved. Within 3 years, 12 patients in the successful MACE event group had 14. 6 and 12 patients in the failed operation group. There were significant differences between 15 cases (41.7%) and 45 cases (41.7%) in the unoperated group (P 0.001). The incidence of cardiac death in 1 case (1.2%) and 3 cases (8.3%) were significantly lower than that in the failed group (P 0.05). Kaplan-Meier survival analysis showed that the cardiac death rate of the successful group was 1.2vs.8.3% (0.036) and the main MACE events were 14.6vs.41.7p0.001) significantly lower than that of the failed group. There was no significant difference in cardiac death and major MACE events between the failed group and the non-operative group, the cardiac death score 1.6vs.13.6p0.001 and the main MACE event 14.6vs.41.7p0.001 in the successful group were significantly lower than those in the unopened group (the failed group and the non-operative group). Multivariate Cox regression analysis showed that the success of the operation was an independent predictor of the patient's 3-year non-cardiac death (HR: 0.035 / 95 CI: 0.003-0.42p0.008) and no major cardiovascular events (HR0.344 / 95CI0.16-0.73p0.005). Conclusion successful elective revascularization of non-IRA-CTO can increase ejection fraction of 1 month after elective operation in STEMI patients undergoing emergency PCI, reduce MACE events in 3 years, and improve the clinical prognosis of patients. In the future, more large-scale, randomized controlled trials are needed to evaluate the clinical prognostic value of elective revascularization of non-IRA-CTO in this group of patients.
【学位授予单位】：首都医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R542.22

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