手动血栓抽吸在老年STEMI患者PCI术中的临床实效性研究

发布时间：2018-05-27 12:17

本文选题：ST段抬高型心肌梗死 + 手动血栓抽吸　；参考：《中国人民解放军医学院》2016年博士论文

【摘要】：第一部分常规合用手动血栓抽吸术对行PCI术STEMI患者的有效性和安全性Meta分析更新目的：更新Meta分析是为了探究合用手动血栓抽吸术对行PCI术STEMI患者的有效性和安全性。方法：在该Meta分析中,一共纳入25个RCT试验,入组了21708名患者,其中10829名患者随机分配到手动血栓抽吸组,10902名患者随机分配到PCI-only组,根据不同的随访时间,我们做了临床结局的分析。时间框架按照从入院到30天为短期随访、6-9个月为中期随访、1年及1年以上为长期随访来界定。基于不同的随访时间计算反映心肌灌注终点的RR值,比如TIMI血流3级、心肌显色分级2-3、ST段回落率≥70%,以及临床结局终点,包括死亡率、MACE事件、再发心肌梗死、靶血管重建、支架内血栓和卒中。结果：观察到TA+PCI组术后TIMI血流3级增加,有统计学意义。[RR=1.05,95%CI(1.02,1.09), P=0.0004],与单纯PCI组相比。术后TA+PCI组MBG2-3级和STR比率明显增加,RR分别为[RR=1.68,95%CI(1.40,2.00),P0.001],[RR=1.24,95%CI(1.12,1.38),P0.001],没有发现在全因死亡率[RR=0.91,95%CI(0.80,1.02),P=0.11]、不同随访时期的死亡率方面存在差别。(RR值分别为[RR=0.85,95%CI(0.72,1.00),P=0.06], [RR=0.90, 95%CI(0.73,1.10),P=0.30]和[RR=0.90,95%CI(0.80,1.02),P=0.12]).在MACE事件复合终点方面短期和中长期的随访没有统计学差异。RR值分别为[RR=0.77,95%CI (0.56,1.07),P=0.12],[RR=0.94,95%CI(0.82,1.08),P=0.38]和[RR=0.92,95%CI (0.82,1.02), P=0.11].RI发生率短期随访在TA+PCI组比单纯PCI低[RR=0.60, 95%CI(0.38,0.96),P=0.03].中长期随访RI发生率两组之间差别无统计学意义分别[RR=1.00,95%CI(0.77,1.29),P=0.98]和[RR=0.96,95%CI(0.81,1.15),P=0.69]. TA+PCI治疗在不同时期都不能减少TVR的发生率,RR分别为[RR=0.82,95%CI(0.63,1.08), P=0.16],[RR=0.99,95%CI(0.84,1.18),P=0.94],[RR=0.98,95%CI(0.87,1.10),P=0.70].没有发现与单纯PCI组相比,TA+PCI组支架内血栓发生率下降。在中长期随访和总的卒中的发生率明显增加,有统计学意义,分别为[RR=1.60,95%CI(1.08,2.38), P=0.02],[RR=1.43,95%CI(1.03,1.98),P=0.03].结论：在所有STEMI患者中,常规血栓抽吸能够改善心外膜和心肌再灌注的参数。STEMI患者合并TA治疗会增加中长期卒中的风险,但短期影响仍存在争议。早期和中晚期随访在TA+PCI组和单纯PCI组之间,全因死亡率、死亡、MACE事件、靶血管重建、支架内血栓及中长期再发心肌梗死方面没有差别。TA+PCI可能和短期再发心肌梗死减少相关。第二部分老年STEMI患者行PCI术中合并手动血栓抽吸治疗对术后和30天临床结局的影响目的：研究目的是评估老年STEMI患者行PCI术中合并手动血栓抽吸治疗对术后和30天临床结局的影响。方法：从2012年11月1日到2014年10月31日一共连续入组了630名行PCI治疗的老年患者(年龄≥65岁,男性为387人,占61.6%；女性为243人,占38.6%,平均年龄为67.14±10.98)进行前瞻性队列研究。结果：高龄、最初入院行PCI之前血流动力学不稳定、血管管腔直径2.5mm,由资深心血管介入专家手术操作的患者接受TA治疗的可能性更大,在整个队列中行TA治疗的患者PCI术前TIMI血流0/1级而不是TIMI血流2/3级的情况更常见(95%vs5%,p0.001)。在倾向性分析中矫正混杂因素后,与单纯PCI治疗相比,TA能够显著改善术后TIMI血流3级水平(93.8%vs 84.3%,P=0.004),降低MACE和MACCE事件发生率(分别为1.7%vs5.6%,P=0.032;4.4%vs8.1%,p=0.034), TA+PCI治疗组大出血的风险增加,尽管没有统计学意义,TA+PCI台疗也不能改善30天的死亡率(2.8%vs 2.9%,P=0.94)。结论：该连续入组的老年STMI患者的观察性研究提示：PCI术中手动血栓抽吸治疗和术后TIMI血流3级和iSTR和MACE、MACCE事件发生率减少相关,但是不能改善30天死亡率。大出血风险在TA治疗组明显,尽管没有统计学差异。第三部分手动血栓抽吸治疗对行PCI术老年STEMI患者1年预后的影响目的：评估手动血栓抽吸治疗对行PCI术老年STEMI患者1年预后的影响方法：总共630名行PCI术的老年患者纳入观察性研究中,随访1年。通过倾向性评分矫正,TA+PCI组和单纯PCI组各纳入178名患者,记录分析全因死亡率和MACE事件。通过构建Cox比例风险模型,筛选1年全因死亡率的独立危险预测因子.结果：通过倾向性评分矫正后,TA+PCI组与单纯PCI组1年全因死亡率的分别为(5.6.%vs 6.7%,P=0.65),TA+PCI组与单纯PCI组1年MACE事件发生率分别为(7.3.%vs 8.4%，P=0.694),两组之间没有统计学差别。通过倾向性评分和其它协变量矫正,构建1年全因死亡率的COX比例风险模型,年龄做分类变量,截断值为75岁,1年的全因死亡率与高龄(≥75岁)密切相关(P0.001)。还和多支血管病变[HR:1.64,95%CI(1.42,1.89),P=0.02].心源性休克[HR:1.68,95%CI(1.45,2.46), P=0.01]、LVEF35%[HR:1.31,95%CI(1.02,2.99), P0.001]、HBG60g/L[HR: 1.07,95%CI(1.02,2.34), P=0.01]有关。结论：本研究提示：手动血栓抽吸合并PCI治疗和单纯PCI治疗相比,并没有改善老年STEMI患者1年的全因死亡率和MACE事件发生率。高龄(≥75岁)、多支血管病变、重度贫血、心源性休克、LVEF35%可以用来预测老年STEMI患者的1年全因死亡率结局。
[Abstract]:The first part is the efficacy and safety of routine combined manual thrombectomy for patients with PCI STEMI. Meta analysis is updated to update the Meta analysis to explore the effectiveness and safety of combined manual thrombectomy for patients with PCI STEMI. In this Meta analysis, a total of 25 RCT trials were included in a total of 21708 patients. 10829 patients were randomly assigned to the manual thrombus aspiration group, and 10902 patients were randomly assigned to the PCI-only group. According to the different follow-up time, we did the analysis of the clinical outcome. The time frame was followed up from admission to 30 days, 6-9 months was followed up, and 1 years and more than 1 years were defined for long-term follow-up. The follow-up time calculated the RR value of the endpoint of myocardial perfusion, such as the 3 level of TIMI blood flow, the color classification of the myocardium 2-3, the ST segment fall rate more than 70%, and the end point of the clinical outcome, including the mortality, the MACE event, the re infarction, the reconstruction of the target vessel, the stent thrombosis and the stroke. Results: the TIMI blood flow in the TA+PCI group was observed to be increased in 3 levels, and the statistical significance was observed. .[RR=1.05,95%CI (1.02,1.09), P=0.0004], compared with the simple PCI group. The MBG2-3 level and STR ratio in TA+PCI group increased significantly after the operation, RR was [RR=1.68,95%CI (1.40,2.00), P0.001], [RR=1.24,95%CI. (RR values are [RR=0.85,95%CI (0.72,1.00), P=0.06], [RR=0.90, 95%CI (0.73,1.10), P=0.30] and [RR=0.90,95%CI (0.80,1.02), P=0.12]). The incidence of 95%CI (0.82,1.02) and P=0.11].RI in the short-term follow-up of the TA+PCI group was lower than that of PCI, [RR=0.60, 95%CI (0.38,0.96), and P=0.03]. in the long term follow-up. There was no statistical difference between the two groups. The incidence of RR was [RR=0.82,95%CI (0.63,1.08), P=0.16], [RR=0.99,95%CI (0.84,1.18), P=0.94], [RR=0.98,95%CI (0.87,1.10). P=0.70]. did not find a decrease in the incidence of thrombus in the scaffold of TA+PCI group compared with that of the simple PCI group. CI (1.08,2.38), P=0.02], [RR=1.43,95%CI (1.03,1.98), P=0.03]. conclusion: in all STEMI patients, conventional thrombus aspiration can improve the parameters of the epicardium and myocardial reperfusion in patients with.STEMI patients combined with TA treatment to increase the risk of middle and long term stroke, but the short-term effects are still in dispute. Early and middle and late follow-up in TA+PCI and simple PCI groups There is no difference in mortality, death, death, MACE events, target vascular reconstruction, stent thrombosis, and middle and long term recurrent myocardial infarction, and there is no correlation between.TA+PCI and short term recurrent myocardial infarction. Second the effect of PCI combined with manual thrombus aspiration on postoperative and 30 day clinical outcomes in the second part of the elderly patients The objective was to assess the effect of PCI combined with manual thrombus aspiration on postoperative and 30 day clinical outcomes in elderly STEMI patients. Methods: from November 1, 2012 to October 31, 2014, a total of 630 elderly patients treated with PCI (age 65 years old, 387 men, 61.6%, 243 women, 38.6%, and average age 6) were evaluated. 7.14 + 10.98) prospective cohort study. Results: elderly patients were initially admitted to hospital with hemodynamic instability before PCI, 2.5mm of the vascular lumen, and more likely to receive TA for patients operated by senior cardiovascular interventional experts. In the whole cohort, TA patients were treated with TIMI blood flow 0/1 level before PCI instead of TIMI blood flow 2/3. The level of the situation was more common (95%vs5%, p0.001). Compared with the simple PCI treatment in the tendency analysis, TA significantly improved the level of TIMI blood flow 3 (93.8%vs 84.3%, P=0.004), and reduced the incidence of MACE and MACCE events (1.7%vs5.6%, P= 0.032, 4.4%vs8.1%,), and increased the risk of bleeding in the treatment group. Although there was no statistical significance, TA+PCI treatment could not improve the mortality rate of 30 days (2.8%vs 2.9%, P=0.94). Conclusion: the observational study of the elderly STMI patients in this continuous group suggests that manual thrombus aspiration and postoperative TIMI blood flow 3 in PCI are associated with a decrease in the iSTR and MACE, the decrease in the MACCE event rate, but can not improve the mortality rate of 30 days. The risk of massive hemorrhage in the TA treatment group, although there is no statistical difference. The effect of third part manual thrombus aspiration on the 1 year prognosis of elderly STEMI patients undergoing PCI surgery: evaluation of the effect of manual thrombus aspiration on the 1 year prognosis of the elderly STEMI patients undergoing PCI surgery: a total of 630 elderly patients with PCI In the study, 1 years were followed up. Through the tendency score correction, the TA+PCI group and the simple PCI group were included in 178 patients, and the total cause mortality and MACE events were recorded and analyzed. The independent risk predictors for the 1 year total cause of mortality were screened by constructing the Cox proportional hazard model. Results: after the correction of the tendency score, the TA+PCI group and the simple PCI group were all 1 years of cause. The mortality rate was (5.6.%vs 6.7%, P=0.65), and the incidence of MACE events in group TA+PCI and PCI group was respectively (7.3.%vs 8.4%, P=0.694), and there was no statistical difference between the two groups. Through the tendency score and other covariate correction, the COX ratio risk model of the 1 year all cause mortality was constructed, the age was classified as the classification variable, the truncated value was 75 years, 1 years. All cause mortality is closely related to older age (P0.001) (P0.001). It is also associated with multiple vascular lesions [HR:1.64,95%CI (1.42,1.89), P=0.02]. cardiogenic shock [HR:1.68,95%CI (1.45,2.46), P=0.01], LVEF35%[HR:1.31,95%CI (1.02,2.99), P0.001], HBG60g/L[HR: 1.07,95. Conclusion: This study suggests: manual thrombus extraction Compared with PCI therapy and simple PCI treatment, the total cause of mortality and the incidence of MACE events in the aged STEMI patients were not improved. Age (75 years old), multiple vessel disease, severe anemia, cardiogenic shock, and LVEF35% could be used to predict the 1 year total mortality outcome of elderly patients with STEMI.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R54

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