胸痛中心建设对急性ST段抬高型心肌梗死患者救治的影响
发布时间：2018-08-02 19:08
【摘要】：目的:本研究以本胸痛中心(Chest Pain Center,CPC)成立、改进流程实施为节点,评估CPC是否可以降低急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)的总缺血时间、主要不良心血管事件(major adverse cardiovascular events,MACE),同时缩短住院平均天数和降低住院平均费用,从而证实CPC在救治STEMI中的重要性以及社会效益。方法:本研究连续入选2015年10月1日-2016年11月30日就诊于天津医科大学第二医院且发病时间在12小时内的急性STEMI患者,纳入标准:发病12小时以内的急性STEMI患者,同时满足STEMI的诊断标准:1.胸痛症状持续时间超过20min且不大于12小时;2.两个或者两个以上的相邻导联出现ST段的抬高(胸导联≥0.2mV,肢体导联≥0.1mV)或者新发现的左束支传导阻滞(Left bundle branch block,LBBB);3.心肌损伤标志物(主要以肌钙蛋白(Cardiac troponin,CTn)证实诊断;排除标准:对抗血小板药物以及抗凝药物过敏者;活动性出血者。以天津医科大学第二医院CPC成立、胸痛中心流程证实实施的时间——2016年6月1日为节点,将STEMI患者分为CPC成立后组(简称成立后组)以及CPC成立前组(简称成立前组)。详细记录入选发病时间在12小时内的急诊STEMI患者的基本信息,包括就诊时间、年龄、性别、发病时间、到达大门时间、来院途径、既往病史等;以及住院后的时间节点,包括就诊-双联抗血小板药物时间(Door-double dual antiplatelet therapy,DDAPT);门-肝素时间(Door-Heparin,D-H);门-球时间(Door-to-Balloon,Dto-B);症状发作到医院大门时间(Symptom onset to Door,SO-Door)以及总缺血时间。所有病人根据中国2015年急性STEMI诊治和治疗指南进行诊断和治疗,其中急诊PCI是所有被入选的STEMI患者的最佳再灌注治疗方案,作为再灌注治疗的首选方案,同时预计D-to-B时间大于90min时实施溶栓治疗。CPC的成立后实现了自行来医院患者绕行CCU,网络医院和120系统来院患者绕行急诊观察室和CCU,从而减少D-to-B时间,为增加PCI术前血管再灌注率,在首次医疗接触、明确诊断后立即给予负荷剂量的抗血小板药物和抗凝药物,尽早实施抗栓预处理。同时记录造影结果,包括病变支数、病变节段数、罪犯病变、罪犯病变程度、是否有侧枝循环、是否存在慢性闭塞病变(Chronic total occlusion,CTO)、术前TIMI血流分级、血栓分级、血栓染色,以及PCI结果,包括术后TIMI血流分级、支架个数、长度等指标。同时住院期间记录患者心血管不良事件(Major adverse cardiovascular events,MACE)的发生情况,本文将MACE定义为一个临床不良心血管事件的复合体,包括急性心力衰竭、致死性和非致死性卒中、恶性心律失常、心绞痛复发、心源性死亡等。此外,记录出院前超声心动图的指标,包括左房内径大小、左室舒张末内径、左室收缩末内径以及左室的射血分数(Left ventricular ejection fraction,LVEF)。出院时记录平均住院天数以及平均住院费用。结果:1.与成立前组相比,成立后组的白细胞的总数、单核细胞绝对值、中性粒细胞百分比、术后CK-MB以及超敏-C反应蛋白的水平显著降低,具有显著性统计学意义(P0.05)。2.关于心功能分级方面,成立后组的KillipⅢ/Ⅳ级较成立前组比例显著减低(10.4%vs.23.6%,P=0.006)。两组间NT-proBNP的比较,成立前组高于成立后组(80.4(6.0,476.5)vs.18.3(5.0,128.4),P=0.012)。出院前超声心动图检查显示,成立后组的LVEF显著高于成立前组(55.38±7.79%VS.52.58±9.38%,P=0.029),具有显著性统计学差异。3.本研究中有249例STEMI患者接受急诊冠状动脉造影术,其中成立前组120人,成立后组129人。与成立前组相比较,成立后组的PCI术前再灌注比例显著增加(41.1%vs.25.8%,P=0.016),而PCI术后再灌注比例无显著性统计学差异。此外,在PCI术前TIMI血栓分级比较中,成立后组在0、1级比例显著高于成立前组(27.9%vs.16.7%,P=0.048;9.3%vs.1.7%,P=0.011),而在5级比例明显低于成立前组(55.5%vs.69.2%,P=0.036)。4.在时间节点方面,成立后组的D-DAPT(15.53±14.15 vs.45.11±36.98,P0.001)、D-to-B(80.15±31.74 vs.154.52±50.68,P0.001)、D-H(29.50±27.04 vs.138.40±84.92,P0.001)、SO-Door(45(90.0,241.0)vs.210.0(122.25,309.75),P=0.004)以及总缺血时间(266.21±224.31 vs.412.69±241.04,P0.001)均较短,存在显著性统计学差异。5.在住院期间的MACE的比较中,成立前组的MACE发生率显著高于成立后组(24.3%vs.12.7%,P=0.019)。其中,与成立后组相比,成立前组发生心源性死亡(10.0%vs.3.0%,P=0.026)、急性心力衰竭(19.3%vs.9.7%,P=0.027)均较高,均具有显著性统计学的差异。6.以是否发生MACE(否=0,是=1)为因变量,依次进行Logistic的回归分析最终以年龄、射血分数、D-to-B、SO-Door、总缺血时间为自变量带入Logistic回归方程,通过应用前向逐步回归分析,并校正混杂因素,最终结果得出,D-to-B、SO-Door、总缺血时间是MACE的独立危险因素。7.在预测住院期间MACE的ROC曲线分析中,D-to-B曲线下面积是0.631,95%可信区间是(0.540,0.722),SO-Door时间曲线下面积是0.661,95%可信区间是(0.575,0.747),总缺血时间曲线下面积是0.674,95%可信区间是(0.588,0.760),其用于预测住院期间MACE有显著性统计学差异。8.在住院天数以及费用方面,成立后组的住院天数从7.60±4.50天缩短6.08±1.96,平均缩短了20%;而住院期间费用从43517±23195元减少至35716±13465元,平均减少了17.9%,具有显著性统计学差异。结论:1.以胸痛中心成立为节点,胸痛中心成立后STEMI患者的D-DAPT、DH、D-to-B、SO-Door以及总缺血时间显著缩短,且PCI术前再灌注比例显著增加,TIMI血栓负荷显著降低。2.胸痛中心成立后时STEMI患者住院期间发生主要心血管不良事件显著减低,其中以急性心力衰竭以及心源性死亡事件降低为著。此外,D-to-B、SODoor、总缺血时间是STEMI患者住院期间发生MACE的独立危险因素。3.胸痛中心成立以后,STEMI患者显著缩短了平均住院天数,节约医疗资源,取得了更好的社会效益。
[Abstract]:Objective: This study was established with Chest Pain Center (CPC) and improved the process as a node to assess whether CPC could reduce the total ischemic time of acute ST segment elevation myocardial infarction (ST-segment elevation myocardial infarction, STEMI). The average days of short hospitalization and the decrease in the average cost of hospitalization confirmed the importance and social benefits of CPC in the treatment of STEMI. Methods: This study was continuously selected for the acute STEMI patients who were diagnosed with the Second Hospital Affiliated to Tianjin Medical University in November 30th, October 1, 2015 and within 12 hours of the onset of the disease, which were included in the standard: within 12 hours of the onset of disease. Acute STEMI patients met the diagnostic criteria for STEMI: 1. chest pain symptoms lasted longer than 20min and not more than 12 hours; 2. two or more than two adjacent lead appeared ST segment elevation (chest lead > 0.2mV, limb lead > 0.1mV) or newly found left bundle branch block (Left bundle branch block, LBBB); 3. myocardial injury markers The object (mainly Cardiac troponin, CTn) confirmed diagnosis; exclusion criteria: anti thrombotic drugs and anticoagulant drug allergy; active bleeding. Established in Second Hospital Affiliated to Tianjin Medical University CPC, the heart pain center process confirmed the implementation time - June 1, 2016 as the node, the STEMI patients were divided into the group after the establishment of CPC (abbreviation) After the establishment of the group) and the pre founded group of CPC (pre establishment group), the basic information of the emergency STEMI patients was recorded in 12 hours, including the time of treatment, age, sex, time of onset, the time of arrival at the gate, the way to the hospital, the past history, and so on; and the time nodes after the hospitalization, including the medical double antiplatelet drugs. Time (Door-double dual antiplatelet therapy, DDAPT); the door - heparin time (Door-Heparin, D-H); door - ball time (Door-to-Balloon, Dto-B); symptoms onset to the hospital gate time (Symptom onset to) and total ischemia time. All patients were diagnosed and treated according to China's 2015 acute guidelines and treatment guidelines. Middle and emergency PCI is the best reperfusion therapy for all selected STEMI patients. As the first choice for reperfusion therapy, it is expected that D-to-B time is greater than 90min when the thrombolytic treatment of.CPC is set up, and the hospital patients bypass CCU, network hospital and 120 system patients bypass emergency observation room and CCU, thus reducing the rate of thrombolytic therapy. Less D-to-B time, in order to increase the rate of preoperative vascular revasculature for PCI, in the first medical contact, immediately after the diagnosis was given a dose of antiplatelet drugs and anticoagulants, early implementation of antithrombotic preconditioning. And record the results of the contrast, including the number of lesions, the number of segments of the lesion, the pathological changes of the offender, the degree of the offender's pathological changes, and whether there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether there was collateral circulation, or not. There were chronic occlusion (Chronic total occlusion, CTO), preoperative TIMI blood flow classification, thrombus classification, thrombus staining, and PCI results, including postoperative TIMI flow classification, number of stents, length and other indicators. Meanwhile, the occurrence of cardiovascular adverse events (Major adverse cardiovascular events, MACE) in patients was recorded during hospitalization. It was defined as a complex of adverse cardiovascular events, including acute heart failure, fatal and non lethal stroke, malignant arrhythmia, recrudescence of angina pectoris, cardiac death, etc.. In addition, the parameters of echocardiography before discharge, including the size of the left atrium, the left ventricular end diastolic diameter, the left ventricular end systolic diameter, and the left ventricular ejection, were also recorded. Blood fraction (Left ventricular ejection fraction, LVEF). Recorded average hospitalization days and average hospitalization expenses. Results: 1. compared with the pre establishment group, the total number of leukocytes, the absolute value of monocyte, the percentage of neutrophils, the level of CK-MB and the hypersensitive -C reaction protein were significantly lower than those in the pre establishment group. Study significance (P0.05).2. on the classification of cardiac function, the proportion of Killip III / IV in the group after establishment was significantly lower than that of the pre establishment group (10.4%vs.23.6%, P=0.006). The comparison between the two groups was higher than that of the group after the establishment (80.4 (6.0476.5) vs.18.3 (5.0128.4), P=0.012). There were significant statistical differences in the pre establishment group (55.38 + 7.79%VS.52.58 + 9.38%, P=0.029). In this study, 249 cases of STEMI patients received emergency coronary angiography, of which 120 were in the pre establishment group and 129 in the post establishment group. Compared with the pre establishment group, the proportion of PCI before the establishment of PCI was significantly increased (41.1%vs.25.8%, P=0.01). 6), and there was no significant difference in the proportion of reperfusion after PCI. In addition, in the TIMI thrombotic classification before PCI, the proportion of the group at the 0,1 level was significantly higher than that in the pre establishment group (27.9%vs.16.7%, P=0.048; 9.3%vs.1.7%, P=0.011), but the proportion in the grade 5 was significantly lower than that in the pre establishment group (55.5%vs.69.2%, P=0.036).4. in the time node, and the post group was established. D-DAPT (15.53 + 14.15 vs.45.11 + 36.98, P0.001), D-to-B (80.15 + 31.74 vs.154.52 + 50.68, P0.001), D-H (29.50 + 27.04 vs.138.40 + 84.92, P0.001), SO-Door (45 (45) vs.210.0 (45) vs.210.0) and total ischemia time (266.21 + 224.31) In the comparison of MACE during the hospital, the incidence of MACE in the pre establishment group was significantly higher than that of the post establishment group (24.3%vs.12.7%, P=0.019). Among them, cardiac death (10.0%vs.3.0%, P=0.026) and acute heart failure (19.3%vs.9.7%, P=0.027) in the pre establishment group were higher than those after the establishment, and all had significant statistical differences in.6. to be MACE (P=0.026). =0, is =1) for the dependent variable, the regression analysis of Logistic in turn eventually takes age, ejection fraction, D-to-B, SO-Door, and total ischemia time as the independent variable into the Logistic regression equation. Through the application forward regression analysis, and correcting the confounding factors, the final result is that D-to-B, SO-Door, total ischemia time is an independent risk factor.7. of MACE.7.. In the ROC curve analysis of MACE during the period of hospitalization, the area under the D-to-B curve is 0.631,95% confidence interval (0.540,0.722), the area under the SO-Door time curve is 0.661,95% confidence interval (0.575,0.747), the area under the total ischemia time curve is 0.674,95% confidence interval (0.588,0.760), and it is used to predict the MACE in the period of hospitalization. The number of hospitalization days and cost of.8. in hospital was shortened from 7.60 + 4.50 days to 6.08 + 1.96, and the average decreased by 20%. The cost of hospitalization decreased from 43517 + 23195 yuan to 35716 + 13465 yuan, and the average decreased by 17.9%, with significant statistical difference. Conclusion: 1. with the center of chest pain, the center of chest pain was established. The D-DAPT, DH, D-to-B, SO-Door, and total ischemia time in the patients with STEMI were significantly shortened, and the proportion of pre PCI reperfusion was significantly increased, and the TIMI thrombus load significantly decreased the major cardiovascular adverse events during the hospitalization of STEMI patients at the time of.2. chest pain, which was reduced in acute heart failure and cardiac death. In addition, D-to-B, SODoor, total ischemia time was the independent risk factor of MACE in patients with STEMI during the hospitalization of.3., after the establishment of.3. chest pain center, STEMI patients significantly shortened the average number of days of hospitalization, saved medical resources, and achieved better social benefits.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R542.22
本文编号：2160442
[Abstract]:Objective: This study was established with Chest Pain Center (CPC) and improved the process as a node to assess whether CPC could reduce the total ischemic time of acute ST segment elevation myocardial infarction (ST-segment elevation myocardial infarction, STEMI). The average days of short hospitalization and the decrease in the average cost of hospitalization confirmed the importance and social benefits of CPC in the treatment of STEMI. Methods: This study was continuously selected for the acute STEMI patients who were diagnosed with the Second Hospital Affiliated to Tianjin Medical University in November 30th, October 1, 2015 and within 12 hours of the onset of the disease, which were included in the standard: within 12 hours of the onset of disease. Acute STEMI patients met the diagnostic criteria for STEMI: 1. chest pain symptoms lasted longer than 20min and not more than 12 hours; 2. two or more than two adjacent lead appeared ST segment elevation (chest lead > 0.2mV, limb lead > 0.1mV) or newly found left bundle branch block (Left bundle branch block, LBBB); 3. myocardial injury markers The object (mainly Cardiac troponin, CTn) confirmed diagnosis; exclusion criteria: anti thrombotic drugs and anticoagulant drug allergy; active bleeding. Established in Second Hospital Affiliated to Tianjin Medical University CPC, the heart pain center process confirmed the implementation time - June 1, 2016 as the node, the STEMI patients were divided into the group after the establishment of CPC (abbreviation) After the establishment of the group) and the pre founded group of CPC (pre establishment group), the basic information of the emergency STEMI patients was recorded in 12 hours, including the time of treatment, age, sex, time of onset, the time of arrival at the gate, the way to the hospital, the past history, and so on; and the time nodes after the hospitalization, including the medical double antiplatelet drugs. Time (Door-double dual antiplatelet therapy, DDAPT); the door - heparin time (Door-Heparin, D-H); door - ball time (Door-to-Balloon, Dto-B); symptoms onset to the hospital gate time (Symptom onset to) and total ischemia time. All patients were diagnosed and treated according to China's 2015 acute guidelines and treatment guidelines. Middle and emergency PCI is the best reperfusion therapy for all selected STEMI patients. As the first choice for reperfusion therapy, it is expected that D-to-B time is greater than 90min when the thrombolytic treatment of.CPC is set up, and the hospital patients bypass CCU, network hospital and 120 system patients bypass emergency observation room and CCU, thus reducing the rate of thrombolytic therapy. Less D-to-B time, in order to increase the rate of preoperative vascular revasculature for PCI, in the first medical contact, immediately after the diagnosis was given a dose of antiplatelet drugs and anticoagulants, early implementation of antithrombotic preconditioning. And record the results of the contrast, including the number of lesions, the number of segments of the lesion, the pathological changes of the offender, the degree of the offender's pathological changes, and whether there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether or not there was collateral circulation, whether there was collateral circulation, or not. There were chronic occlusion (Chronic total occlusion, CTO), preoperative TIMI blood flow classification, thrombus classification, thrombus staining, and PCI results, including postoperative TIMI flow classification, number of stents, length and other indicators. Meanwhile, the occurrence of cardiovascular adverse events (Major adverse cardiovascular events, MACE) in patients was recorded during hospitalization. It was defined as a complex of adverse cardiovascular events, including acute heart failure, fatal and non lethal stroke, malignant arrhythmia, recrudescence of angina pectoris, cardiac death, etc.. In addition, the parameters of echocardiography before discharge, including the size of the left atrium, the left ventricular end diastolic diameter, the left ventricular end systolic diameter, and the left ventricular ejection, were also recorded. Blood fraction (Left ventricular ejection fraction, LVEF). Recorded average hospitalization days and average hospitalization expenses. Results: 1. compared with the pre establishment group, the total number of leukocytes, the absolute value of monocyte, the percentage of neutrophils, the level of CK-MB and the hypersensitive -C reaction protein were significantly lower than those in the pre establishment group. Study significance (P0.05).2. on the classification of cardiac function, the proportion of Killip III / IV in the group after establishment was significantly lower than that of the pre establishment group (10.4%vs.23.6%, P=0.006). The comparison between the two groups was higher than that of the group after the establishment (80.4 (6.0476.5) vs.18.3 (5.0128.4), P=0.012). There were significant statistical differences in the pre establishment group (55.38 + 7.79%VS.52.58 + 9.38%, P=0.029). In this study, 249 cases of STEMI patients received emergency coronary angiography, of which 120 were in the pre establishment group and 129 in the post establishment group. Compared with the pre establishment group, the proportion of PCI before the establishment of PCI was significantly increased (41.1%vs.25.8%, P=0.01). 6), and there was no significant difference in the proportion of reperfusion after PCI. In addition, in the TIMI thrombotic classification before PCI, the proportion of the group at the 0,1 level was significantly higher than that in the pre establishment group (27.9%vs.16.7%, P=0.048; 9.3%vs.1.7%, P=0.011), but the proportion in the grade 5 was significantly lower than that in the pre establishment group (55.5%vs.69.2%, P=0.036).4. in the time node, and the post group was established. D-DAPT (15.53 + 14.15 vs.45.11 + 36.98, P0.001), D-to-B (80.15 + 31.74 vs.154.52 + 50.68, P0.001), D-H (29.50 + 27.04 vs.138.40 + 84.92, P0.001), SO-Door (45 (45) vs.210.0 (45) vs.210.0) and total ischemia time (266.21 + 224.31) In the comparison of MACE during the hospital, the incidence of MACE in the pre establishment group was significantly higher than that of the post establishment group (24.3%vs.12.7%, P=0.019). Among them, cardiac death (10.0%vs.3.0%, P=0.026) and acute heart failure (19.3%vs.9.7%, P=0.027) in the pre establishment group were higher than those after the establishment, and all had significant statistical differences in.6. to be MACE (P=0.026). =0, is =1) for the dependent variable, the regression analysis of Logistic in turn eventually takes age, ejection fraction, D-to-B, SO-Door, and total ischemia time as the independent variable into the Logistic regression equation. Through the application forward regression analysis, and correcting the confounding factors, the final result is that D-to-B, SO-Door, total ischemia time is an independent risk factor.7. of MACE.7.. In the ROC curve analysis of MACE during the period of hospitalization, the area under the D-to-B curve is 0.631,95% confidence interval (0.540,0.722), the area under the SO-Door time curve is 0.661,95% confidence interval (0.575,0.747), the area under the total ischemia time curve is 0.674,95% confidence interval (0.588,0.760), and it is used to predict the MACE in the period of hospitalization. The number of hospitalization days and cost of.8. in hospital was shortened from 7.60 + 4.50 days to 6.08 + 1.96, and the average decreased by 20%. The cost of hospitalization decreased from 43517 + 23195 yuan to 35716 + 13465 yuan, and the average decreased by 17.9%, with significant statistical difference. Conclusion: 1. with the center of chest pain, the center of chest pain was established. The D-DAPT, DH, D-to-B, SO-Door, and total ischemia time in the patients with STEMI were significantly shortened, and the proportion of pre PCI reperfusion was significantly increased, and the TIMI thrombus load significantly decreased the major cardiovascular adverse events during the hospitalization of STEMI patients at the time of.2. chest pain, which was reduced in acute heart failure and cardiac death. In addition, D-to-B, SODoor, total ischemia time was the independent risk factor of MACE in patients with STEMI during the hospitalization of.3., after the establishment of.3. chest pain center, STEMI patients significantly shortened the average number of days of hospitalization, saved medical resources, and achieved better social benefits.
【学位授予单位】：天津医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R542.22
【参考文献】
相关期刊论文 前4条
1 Geng QIAN;Chen WU;Yun-dai CHEN;Chen-chen TU;Jin-wen WANG;Yong-an QIAN;;急性ST段抬高型心肌梗死继发心脏破裂的预测因素分析(英文)[J];Journal of Zhejiang University-Science B(Biomedicine & Biotechnology);2014年12期
2 Rodrigo Estévez-Loureiro;ángela López-Sainz;Armo Pérez de Prado;Carlos Cuellas;Ramón Calvio Santos;Norberto Alonso-Orcajo;Jorge Salgado Fernández;Jose Manuel Vázquez-Rodríguez;Maria López-Benito;Felipe Fernández-Vázquez;;Timely reperfusion for ST-segment elevation myocardial infarction:Effect of direct transfer to primary angioplasty on time delays and clinical outcomes[J];World Journal of Cardiology;2014年06期
3 Sabine Vecchio;Elisabetta Varani;Tania Chechi;Marco Balducelli;Giuseppe Vecchi;Matteo Aquilina;Giulia Ricci Lucchi;Alessro Dal Monte;Massimo Margheri;;Coronary thrombus in patients undergoing primary PCI for STEMI:Prognostic significance and management[J];World Journal of Cardiology;2014年06期
4 Geng QIAN;Hong-bin LIU;Jin-wen WANG;Chen WU;Yun-dai CHEN;;Risk of cardiac rupture after acute myocardial infarction is related to a risk of hemorrhage[J];Journal of Zhejiang University-Science B(Biomedicine & Biotechnology);2013年08期
，本文编号：2160442
本文链接：https://www.wllwen.com/yixuelunwen/xxg/2160442.html
最近更新
教材专著
