红细胞体积分布宽度与血小板计数比值对STEMI行直接PCI术患者心肌灌注水平的预测意义

发布时间：2018-06-27 01:17

本文选题：红细胞体积分布宽度 + 血小板计数　；参考：《河北医科大学》2016年硕士论文

【摘要】：目的:本研究旨在评估红细胞体积分布宽度(Red Cell Distribution Width,PDW)与血小板计数(Platelet Count,PLT)的比值(Red Cell Distribution Width to Platelet ratio,RPR)对急性ST段抬高性型心肌梗死(ST-segment Elevation Myocardial Infarction,STEMI)行直接经皮冠状动脉介入治疗(Percutaneous Coronary Intervention,PCI)患者心肌灌注水平的预测意义及其与无复流现象(No-Reflow Phenomenon,NR)发生的相关性。方法:本研究前瞻性入组2013年9月-2015年12月明确诊断为STEMI、就诊于河北省邢台市第一医院心血管内并接受急诊PCI的患者。患者入选标准:(1)符合2015年中华医学会心血管病学分会《急性ST段抬高型心肌梗死诊断和治疗指南》中关于STEMI的诊断标准;(2)患者于发病12小时内就诊入院;(3)患者接受急诊PCI术治疗;(4)患者及其家属同意手术,并签署手术知情同意书。患者排除标准:(1)对麻醉剂或对比剂过敏;(2)严重肝功能不全(谷丙转氨酶或谷草转氨酶水平大于正常值上限2倍);(3)严重肾功能不全,需行血液或腹部透析治疗;(4)主动脉夹层;(5)既往曾有心肌梗死病史,曾行冠脉支架置入或冠脉搭桥手术;(6)合并室速、室颤等恶性心律失常,急性心力衰竭或机械性并发症;(7)心原性休克,需应用主动脉内球囊反搏(Intra-Aortic Balloon Pump,IABP);(8)合并抗凝、抗血小板聚集药物禁忌症;(9)合并血液系统疾病、自身免疫性疾病、严重创伤及肿瘤;(10)已行溶栓治疗;(11)患者或其家属拒绝参加本研究。所有入组患者均经充分的术前准备(吸氧、心电监护、镇静止痛和抗凝、抗血小板聚集等治疗),行冠状动脉造影(Coronary Angiography,CAG)明确梗死相关动脉(Infarction Related Artery,IRA),并予以直接PCI治疗。术中记录患者症状发作至球囊扩张的时间、心肌梗死溶栓试验血流(Thrombolysis In Myocardial Infarction,TIMI)分级,校正的TIMI血流帧数(Corrected TIMI Frame Count,CTFC)、TIMI心肌灌注分级(TIMI myocardial perfusion grade,TMPG)。根据TMPG结果,将入组患者分为两组:A组为无复流组,即术后TMPG分级为0-2级;B组为正常血流组,即术后达到TMPG3级。两组患者术后均给予抗凝、抗血小板聚集治疗,同时应用β受体阻滞剂、硝酸酯类、血管紧张素转换酶抑制剂(Angiotension Converting Enzyme Inhibitors,ACEI)/血管紧张素Ⅱ受体阻滞剂(AngiotensionⅡReceptor Blocker,ARB)、钙通道阻滞剂(Calcium Channel Blocker,CCB)、调脂等常规药物治疗。比较两组患者一般基线资料,相关实验室指标如血常规、D-Dimer、心肌损伤标志物(hs-CRP、心肌酶、肌钙蛋白I(c Tn I))、随机血糖、电解质、低密度脂蛋白(LDL-C)、血浆BNP等,术后病情稳定及30天行心脏彩超明确左室射血分数(Left Ventricular Ejection Fraction,LVEF),随访比较30天内主要心脏不良事件(Major Adverse Cardiac Events,MACEs)的差异,记录患者心原性再入院情况。所有数据均使用统计软件SPSS 23.0行数据处理分析,将双侧P0.05定义为有统计学意义。结果:本研究共入选80例患者,其中男性59例,女性21例;A组共入组患者27例(男性20例,平均年龄64.39±11.87岁),B组53例(男性43例,平均年龄57.84±12.44岁);1一般基线资料两组患者在性别、家族史、吸烟史、高血压病史、血脂异常、BMI、CRUSADE评分等方面均无统计学差异(P0.05);A组患者的平均年龄为64.39±11.87岁,B组为57.84±12.44岁,两组患者年龄差异具有统计学意义(P0.001);A组中有10例患者既往有梗死性心绞痛发作(37.0%),B组中有33例患者曾有梗死性心绞痛发作(62.3%),两组数据具有统计学差异(P=0.032);A组患者TIMI评分显著高于B组(10.65±2.98 vs.8.37±3.18,P=0.027),A组患者的GRACE评分高于B组(144.56±34.78 vs.129.48±30.56,P=0.037);2 PCI治疗资料A组患者自胸痛发作至球囊扩张的平均为6.4±2.1h,而B组的再灌注时间为5.1±2.3h,两组患者再灌注时间有差异(P=0.018);行冠脉介入治疗时,两组患者IRA分布比例、置入支架平均直径和长度、术前TIMI3级血流的比例均无明显统计学差异(P0.05);术后A组三支冠脉LAD、LCX、RCA的CTFC大于B组,且差异有统计学意义(25.29±5.59 vs.19.81±6.00,P=0.0002;23.50±6.53 vs.18.86±6.67,P=0.004;24.00±6.00 vs.19.88±3.72,P=0.0003);A组术中预扩张扩张比例高于B组(P0.001),而两组在后扩张比例、术中球囊释放压力、血栓抽吸比例、术中应用替罗非班比例方面均无统计学差异(P0.05);3入院后实验室检查结果PCI术前两组患者行实验室检查,其中,两组患者在红细胞计数、血小板计数、血肌酐水平、c Tn I、CK-MB、低密度脂蛋白-C、随机血糖等指标方面均无统计学差异;A组患者的白细胞计数虽然高于B组患者,然而差异并无统计学意义(P=0.067);中性粒细胞百分比(%)方面A组高于B组,具有显著差异(78.30±14.38 vs.67.44±14.73,P=0.002);红细胞体积分布宽度(fl)方面A组高于B组,具有统计学意义(6.68±1.19 vs.5.38±1.45,P0.001);A组患者红细胞分布宽度与血小板计数的比值和B组患者相比,有统计学意义(6.68±1.19 vs.5.38±1.45,P0.001);A组患者的肾小球滤过率(ml/min/1.73m2)高于B组,有统计学意义(89.08±12.22 vs.103.94±18.91,P0.001);A组患者的hs-CRP(mg/L)高于B组,具有显著差异(8.58±1.98 vs.5.11±1.27,P0.001);A组BNP(pg/ml)水平高于B组,具有显著差异(254.80±87.70 vs.216.03±72.18,P=0.038);A组D-dimer(ug/ml)水平高于B组,具有显著差异(0.79±0.40 vs.0.60±0.38,P=0.041);4心功能结果患者术后基线及术后30天通过心脏彩超测量LVEF。A组基线资料明显低于B组(44.29±4.14 vs.47.55±3.67,P=0.006);两组患者术后30天较入院时LVEF(%)均有升高,且组间比较差异具有统计学意义(44.29±4.14 vs.47.87±8.30,P0.05;47.55±3.67 vs.51.63±4.99,P0.05;47.87±8.3 vs.51.63±4.99,P=0.002);5随访MACEs的发生率术后随访30天内,A组有4例患者出现心原性死亡,6例患者出现恶性心律失常,14例患者出现不同程度的心力衰竭,2例患者出现非致死性再发性心梗,1例患者行靶血管重建,4例患者心原性再入院治疗。B组有1例患者出现心原性死亡,1例患者出现恶性心律失常,8例患者出现心力衰竭,无患者出现非致死性再发性心梗及靶血管重建,2例患者出现心原性再入院治疗。两组MACEs的发生率均有统计学意义(P0.05),两组患者心原性再入院率无差异;6多因素logistic回归分析综合以上结果,A组患者年龄、既往心绞痛病史、再灌注时间、术前TIMI评分、GRACE评分、糖尿病史、中性粒细胞比例、红细胞分布宽度、其与血小板计数的比值、hs-CRP、肾小球滤过率、BNP水平等方面的指标和B组患者具有较为明显的差异。将既往心绞痛病史、再灌注时间、中性粒细胞比例、红细胞分布宽度与血小板计数的比值、hs-CRP、肾小球滤过率等作为自变量,将NR作为因变量,行多因素logistic回归分析,结果发现,红细胞分布宽度与血小板计数的比值是STEMI患者直接PCI术后NR发生的独立危险因素(OR=2.104,95%CI=1.343-3.297,P=0.001)。结论:1.对于STEMI行急诊PCI术的患者,高龄、合并糖尿病病史、无梗死性心绞痛发作、延迟开通梗死相关动脉、术前中性粒细胞比例升高、红细胞体积分布宽度增加、红细胞体积分布宽度与血小板计数比值升高、高敏C反应蛋白计数升高、肾小球滤过率下降、BNP等指标提示无复流发生的可能性较高;2.红细胞体积分布宽度与血小板计数比值对STEMI行直接PCI术患者的心肌灌注具有预测价值,是无复流发生的独立危险因素,需要广大临床工作者予以重视。
[Abstract]:Objective: To evaluate the ratio of the Red Cell Distribution Width (PDW) to the platelet count (Platelet Count, PLT) (Red Cell Distribution Width) (Red Cell Distribution Width) for acute segment elevation myocardial infarction. Predictive significance of myocardial perfusion level in patients with Percutaneous Coronary Intervention (PCI) and the correlation with non reflow phenomenon (No-Reflow Phenomenon, NR). Methods: This prospective study was clearly diagnosed as STEMI in December -2015 year September 2013, in the cardiovascular and reception of Xingtai First Hospital in Hebei province. Emergency PCI patients. Patient admission criteria: (1) compliance with the diagnostic and therapeutic guidelines for acute ST elevation myocardial infarction in the Chinese Medical Association of China in 2015; (2) patients were hospitalized within 12 hours of onset; (3) patients received acute PCI surgery; (4) patients and their families agreed to operate, and signed hands. Patient's informed consent. Patient exclusion criteria: (1) allergies to anesthetics or contrast agents; (2) severe liver dysfunction (alanine aminotransferase or cereal transaminase level is 2 times greater than the upper limit of normal value); (3) severe renal insufficiency, need for blood or abdominal dialysis treatment; (4) aortic dissection; (5) previously had a history of myocardial infarction, had coronary stent implantation Or coronary artery bypass surgery; (6) combined ventricular tachycardia, ventricular fibrillation and other malignant arrhythmia, acute heart failure or mechanical complications; (7) cardiogenic shock, Intra-Aortic Balloon Pump, IABP; (8) combined anticoagulant, antiplatelet aggregation drug contraindication; (9) combined blood system disease, autoimmune disease, serious Trauma and tumor; (10) thrombolytic therapy; (11) patients or their families refused to participate in this study. All the patients received adequate preoperative preparation (oxygen inhalation, electrocardiographic monitoring, sedative analgesic and anticoagulant, anti platelet aggregation), and Coronary Angiography (CAG) (Infarction Related Artery, I). RA) and direct PCI treatment. During the operation, the time of symptom onset to balloon dilatation was recorded, the blood flow (Thrombolysis In Myocardial Infarction, TIMI) classification of myocardial infarction thrombolytic test, the number of corrected TIMI flow frames (Corrected TIMI Frame Count), cardiac muscle perfusion classification. The patients were divided into two groups: the group A was no reflow group, that is, the post operation TMPG classification was grade 0-2, and the group B was the normal blood flow group, that is, the TMPG3 level was reached after the operation. The two groups were treated with anticoagulant, antiplatelet aggregation, and the use of beta blockers, nitrates, angiotensin converting enzyme inhibitors (Angiotension Converting Enzyme Inhi). Bitors, ACEI) / angiotensin II receptor blocker (Angiotension II Receptor Blocker, ARB), calcium channel blocker (Calcium Channel Blocker, CCB), and lipid modulation. Compare the general baseline data of two groups of patients, related laboratory indicators such as blood routine, D-Dimer, myocardial damage markers (hs-CRP, myocardial enzymes, troponin proteins) ) random blood sugar, electrolytes, low density lipoprotein (LDL-C), plasma BNP and so on. After operation, the condition was stable and the left ventricular ejection fraction (Left Ventricular Ejection Fraction, LVEF) was determined by color Doppler ultrasound (LVEF) on 30 days. The difference of the major adverse events (Major Adverse Cardiac Events, MACEs) in 30 days was compared, and the cardiogenic readmission of the patients was recorded. All data were analyzed with statistical software SPSS 23 lines. Results: bilateral P0.05 was defined as statistically significant. Results: 80 patients were enrolled in this study, including 59 males and 21 females, 27 cases in group A (20 men, 64.39 + 11.87 years old), 53 in group B (43 males, 57.84, 12.44 years of age); 1 General There were no significant differences in gender, family history, smoking history, hypertension history, dyslipidemia, BMI, CRUSADE score in the two groups of patients (P0.05). The average age of the A group was 64.39 + 11.87 years, the B group was 57.84 + 12.44 years, and the two groups had statistical significance (P0.001); 10 patients in the A group had previous infarct sex. Angina pectoris (37%), 33 patients in group B had infarct angina (62.3%), and the two groups had statistical difference (P=0.032). The TIMI score in group A was significantly higher than that in group B (10.65 + 2.98 vs.8.37 + 3.18, P=0.027), and the GRACE score of group A was higher than that of B group (144.56 + 34.78 vs.129.48 + 30.56, P=0.037). The averages from the onset of chest pain to balloon dilatation were 6.4 2.1h, while the reperfusion time of group B was 5.1 2.3h, and the time of reperfusion was different in the two groups (P=0.018). The proportion of IRA distribution in the two groups, the average diameter and length of the stent, and the proportion of the TIMI3 grade blood flow before operation were not significantly different (P0.05), and A group after operation (P0.05). The CTFC of LAD, LCX and RCA in three coronary arteries was greater than that in group B, and the difference was statistically significant (25.29 + 5.59 vs.19.81 + 6, P=0.0002; 23.50 + 6.53 vs.18.86 + 6.67, P=0.004; 24 + 6 vs.19.88 + 3.72, P=0.0003); the proportion of predilatation in the A group was higher than that in the posterior expansion ratio, the pressure of balloon release, the ratio of thrombus aspiration, There was no statistical difference in the proportion of tirofiban in the operation (P0.05); 3 the results of laboratory examination in the two groups before the admission were performed in the laboratory. Among the two groups, there were no significant differences in red blood cell count, platelet count, serum creatinine, C Tn I, CK-MB, low density lipoprotein -C, and random blood sugar, and A patients. Although the white blood cell count was higher than the B group, the difference was not statistically significant (P=0.067); the percentage of neutrophils (%) in A group was higher than that in group B (78.30 + 14.38 vs.67.44 + 14.73, P=0.002); A group of erythrocyte volume distribution width (FL) was higher than that of B group, and had statistical significance (6.68 + 1.19 vs.5.38 + 1.45, P0.001); A Compared with the B group, the ratio of erythrocyte distribution width to platelet count was statistically significant (6.68 + 1.19 vs.5.38 + 1.45, P0.001), and the glomerular filtration rate (ml/min/1.73m2) in group A was higher than that in group B (89.08 + 12.22 vs.103.94 + 18.91, P0.001), and hs-CRP (mg/L) in group A was higher than that in B group, 8 (8). .58 + 1.98 vs.5.11 + 1.27, P0.001); BNP (pg/ml) level in group A was higher than that in B group (254.80 + 87.70 vs.216.03 + 72.18, P=0.038); D-dimer (ug/ml) level in A group was higher than that in the group (0.79 + 0.40 + 0.38,); 4 cardiac function results were measured after baseline and 30 days after operation by cardiac color Doppler ultrasound The data were significantly lower than that of the B group (44.29 + 4.14 vs.47.55 + 3.67, P=0.006), and the two groups were higher than the admission LVEF (%) after 30 days of operation, and the difference between the groups was statistically significant (44.29 + 4.14 vs.47.87 + 8.30, P0.05; 47.55 + 3.67 vs.51.63 + 4.99, P0.05; 47.87 + 8.3 vs.51.63 +, P=0.002). In group A, there were 4 patients with cardiogenic death, 6 patients with malignant arrhythmia, 14 patients with different degrees of heart failure, 2 patients with non fatal recurrent myocardial infarction, 1 patients with target vascular reconstruction, 4 patients with cardiogenic readmission and 1 patients with cardiogenic death in group.B, and 1 patients with malignant heart rhythm. Abnormal, 8 cases of patients with heart failure, no patients with non fatal recurrent myocardial infarction and target vascular reconstruction, 2 cases of cardiogenic readmission. The two groups of MACEs were statistically significant (P0.05), two groups of patients with cardiogenic readmission rate of no difference; 6 multifactorin logistic regression analysis of the comprehensive results, the A group of patients age, The history of angina, the time of reperfusion, the preoperative TIMI score, the GRACE score, the diabetes history, the ratio of neutrophils, the width of the red blood cell, the ratio of the platelet count, the hs-CRP, the glomerular filtration rate, the BNP level, and the B group were significantly different. The history of angina, reperfusion time, neutrophils The ratio of cells, the ratio of red blood cell width to platelet count, hs-CRP and glomerular filtration rate were used as independent variables, and NR was used as a dependent variable, and multiple factor Logistic regression analysis was performed. The results showed that the ratio of red blood cell width to platelet count was an independent risk factor for NR in STEMI patients after direct PCI (OR=2.104,95%CI=1.34). 3-3.297, P=0.001) conclusion: 1. for the patients with STEMI for emergency PCI, the age of the elderly, the history of the diabetes, the onset of the infarction, the delayed opening of the infarct related artery, the increase in the proportion of neutrophils before the operation, the increase in the width of the red blood cell volume, the increase of the volume distribution width of the red blood cell and the ratio of the platelet count, and the high sensitive C reaction protein meter The rate of glomerular filtration rate decreased, BNP and other indicators suggested that the possibility of no reflow was higher, and the ratio of 2. red cell volume distribution width to platelet count was of predictive value for myocardial perfusion in patients with STEMI direct PCI, which was an independent risk factor for no reflow. It is necessary for clinical workers to pay attention to it.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R542.22

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