本文關(guān)鍵詞：急診PCI術(shù)后TIMI血流Ⅲ級的STEMI患者冠脈內(nèi)注射地爾硫卓的臨床意義　出處：《河北醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 直接經(jīng)皮冠狀動脈介入 急性ST段抬高型心肌梗死 TIMIⅢ級 冠脈微循環(huán) 地爾硫卓

【摘要】：目的:目前有指南明確指出急性ST段抬高型心肌梗死(acute STsegment elevation myocardial infarction,STEMI)的成功的標(biāo)準(zhǔn)之一為TIMI血流Ⅲ級,但是我們發(fā)現(xiàn)STEMI患者行急診直接經(jīng)皮冠狀動脈介入治療(primary percutaneous coronary intervention,PPCI)即使達(dá)TIMI血流Ⅲ級,仍有部分患者出現(xiàn)胸痛緩解不完全及ST段不能及時回落等,考慮與出現(xiàn)微循環(huán)障礙有關(guān)。本文是在STEMI患者行急診PCI達(dá)到TIMI血流Ⅲ級后冠脈內(nèi)繼續(xù)應(yīng)用地爾硫卓,盡量使微循環(huán)開放最大化,評估這一措施是否使恢復(fù)到TIMI血流Ⅲ級的STEMI患者獲益更大,進(jìn)一步探討急診PCI術(shù)后TIMI血流Ⅲ級的STEMI患者冠脈內(nèi)注射地爾硫卓的臨床意義。方法:入選2014年12月至2016年12月就診于河北醫(yī)科大學(xué)第三醫(yī)院心血管內(nèi)科,首次明確診斷為STEMI并行PPCI的78名患者,且行急診PCI后TIMI血流達(dá)到Ⅲ級,同時排除影響觀察指標(biāo)的因素如低血壓、嚴(yán)重心力衰竭及緩慢性心律失常等的患者。按隨機(jī)數(shù)字表法原則將入選患者隨機(jī)分為對照組(生理鹽水組,n=37)和實驗組(地爾硫卓組,n=41)。兩組在梗死相關(guān)動脈(infarction related artery,IRA)病變處均置入藥物涂層支架,待TIMI血流達(dá)Ⅲ級即刻給予相應(yīng)的處理。實驗組于冠狀動脈內(nèi)即刻給予地爾硫卓稀釋液8ml(125ug/ml);對照組則給予8ml生理鹽水,兩組患者在給藥過程中需要密切觀察血壓及心室率等相關(guān)指標(biāo)。兩組在支架植入后如出現(xiàn)冠脈無復(fù)流現(xiàn)象,術(shù)者可根據(jù)患者的具體情況選擇硝普鈉、替羅非班或地爾硫卓等相關(guān)藥物進(jìn)行緩解,直至TIMI血流分級達(dá)到Ⅲ級。觀察指標(biāo):用藥后10min心室率、用藥后10min平均動脈血壓、用藥后TMPG分級,術(shù)后90min內(nèi)ST段回落率(ST-segment resolution,STR),術(shù)后90min STR≥70%為ST段回落良好,STR70%表示ST段回落不良,術(shù)后1周、3個月的左心室射血分?jǐn)?shù)(left ventricular ejection fraction,LVEF),用藥后后TMPG及術(shù)后3個月主要心血管不良事件(major adverse events,MACEs)的發(fā)生率。結(jié)果:1基線資料:共入選了78名研究對象,其中對照組37例,實驗組41例,其中男性共有49名(62.82%),兩組間年齡、合并危險因素(高血壓病、糖尿病、高脂血癥、吸煙史)、術(shù)前平均動脈壓、術(shù)前心率、體重指數(shù)、病變血管數(shù)量、置入支架數(shù)量、支架長度及直徑、術(shù)前及術(shù)中用藥、門-球時間及用藥前TMPG等基礎(chǔ)資料均無統(tǒng)計學(xué)差異(P均0.05)。2兩組間用藥后TMPG、術(shù)后90min STR、術(shù)后1周及3個月的LVEF比較:相比于對照組,用藥后心肌灌注TMPG血流分級明顯改善,兩組之間有顯著統(tǒng)計學(xué)差異(P=0.0440.05)。術(shù)后90min STR在兩組間存在差異,相對于對照組(64.84±8.78%),實驗組(69.17±7.74%,P=0.0230.05)明顯改善。術(shù)后1周的LVEF在兩組間無統(tǒng)計學(xué)差異(P0.05),但術(shù)后3個月,于對照組(55.89±6.00%)相比,實驗組(61.27±7.42%)明顯提高,有顯著統(tǒng)計學(xué)差異(P=0.0010.05)。3兩組間用藥后10min心率、用藥后10min平均動脈壓、術(shù)后用藥及術(shù)后3個月MACEs比較:相對于對照組(70.70±9.95次/分),實驗組(70.46±8.96次/分)用藥后10min心率有統(tǒng)計學(xué)差異(P=0.0010.05);用藥后10min平均動脈壓在實驗組和對照組之間存在統(tǒng)計學(xué)差異(94.29±14.96vs102.38±14.13mm Hg,P=0.0350.05)。術(shù)后用藥在兩組間無統(tǒng)計學(xué)差異。術(shù)后3個月,實驗組有2人出現(xiàn)急性心力衰竭,對照組有2人出現(xiàn)心衰,經(jīng)藥物保守治療,癥狀好轉(zhuǎn);對照組有1人出現(xiàn)再發(fā)性心肌梗死,經(jīng)急診PCI好轉(zhuǎn),目前病情平穩(wěn)。術(shù)后3個月的MACEs在兩組間無明顯統(tǒng)計學(xué)差異(P=0.9060.05)。結(jié)論:對STEMI患者行急診PCI術(shù)后達(dá)到TIMI血流Ⅲ級水平后,繼續(xù)在冠狀動脈內(nèi)應(yīng)用地爾硫卓能夠改善心肌灌注和增加梗死區(qū)域的血流供應(yīng),使患者術(shù)后3個月的左心室射血分?jǐn)?shù)提高,明顯改善患者的早期預(yù)后。由此可見,行PCI術(shù)后達(dá)到TIMI血流Ⅲ級水平對于STEMI患者來說是不足夠的,還需要繼續(xù)行改善微循環(huán)治療。
[Abstract]:Objective: there are clear guidelines for acute ST elevation myocardial infarction (acute STsegment elevation myocardial infarction, STEMI) the success of one of the criteria for TIMI flow grade, but we found that STEMI patients underwent emergency percutaneous coronary intervention (primary percutaneous coronary intervention, PPCI TIMI) even if blood flow grade, still a part of patients with chest pain and ST segment can not completely fall, think about and microcirculation. This is in STEMI underwent emergency PCI to TIMI flow grade after intracoronary diltiazem application to open, try to make microcirculation maximization, to assess whether the measures to restore to the benefit of TIMI flow grade the STEMI were bigger, to further explore the clinical significance of TIMI blood flow grade STEMI patients with intracoronary diltiazem after emergency PCI. Methods: Selected From December 2014 to December 2016 in the cardiovascular department of the Third Hospital of Hebei Medical University, 78 patients first diagnosed as STEMI parallel PPCI, and after undergoing PCI TIMI flow reaching the third level, such as hypotension and eliminate the effect factors of observation index, serious heart failure and arrhythmia in the patients. Randomly selected patients principle were randomly divided into control group (saline group, n=37) and experimental group (diltiazem group, n=41). The two groups in the infarct related artery (infarction related, artery, IRA) lesions were implanted drug-eluting stents for the blood flow of TIMI was grade 3 was given corresponding treatment. The experimental group in the coronary artery was given diltiazem diluted 8ml (125ug/ml); the control group were given normal saline 8ml, two groups of patients need close observation of blood pressure and ventricular rate and other related indicators during administration. The two groups in the branch Frame after implantation as no reflow phenomenon, patients can choose sodium nitroprusside according to the specific circumstances of patients, for the Luo Fei class or diltiazem and other related drugs to ease, until the TIMI flow grade to grade. Observation index: 10min ventricular rate after treatment, after treatment 10min mean arterial pressure, after administration of TMPG classification. After 90min the rate of ST segment resolution (ST-segment, resolution, STR) after 90min STR = 70% for ST segment, STR70% said ST segment, 1 weeks after operation, left ventricular ejection fraction of 3 months (left ventricular, ejection fraction, LVEF), after TMPG and postoperative medication 3 months of major adverse cardiovascular events (major adverse, events, MACEs) incidence. Results: 1. Baseline data: a total of 78 subjects, including 37 cases in the control group, 41 cases in the experimental group, there were 49 males (62.82%), two groups of age, with risk factors (high blood 鍘嬬梾,緋栧翱鐥，

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