本文選題：急性心肌梗死　切入點：冠狀動脈造影　出處：《大連醫(yī)科大學》2017年碩士論文　論文類型：學位論文

【摘要】：背景與目的:急性心肌梗死(AMI)而CAG檢查結(jié)果卻提示不存在血流受限性疾病,《2016ESC工作組意見書》將之定義為冠狀動脈非阻塞型心肌梗死(MINOCA)。指南中指出,MINOCA應(yīng)該被視為"初步診斷",需要通過完善相關(guān)檢查來鑒別導(dǎo)致患者臨床癥狀的潛在病因,進而明確診斷和治療。MINOCA的病因主要包括斑塊破裂或侵蝕、冠狀動脈痙攣等。MINOCA病因復(fù)雜,對于其預(yù)后的評估,不同的研究之間存有一定差異,但是多數(shù)研究認為MINOCA的遠期預(yù)后偏差。有研究顯示,非阻塞性CAD合并ACS患者隨訪26± 16個月死亡4.4%、ACS再入院3.8%,同阻塞性CAD合并ACS患者相比無明顯差異(P0.05),因此,非阻塞性CAD合并ACS患者的遠期心臟缺血事件再發(fā)風險偏高。最近一項研究也顯示,對126例MINOCA患者進行心臟磁共振(CMR)檢查,87%(109例)提示存在心臟結(jié)構(gòu)和/或心肌組織的異常改變,分別診斷為心肌炎、Takotsubo心肌病等。本研究的目的是希望通過觀察和分析本心血管病中心診斷為AMI而CAG檢查證實無明顯血管狹窄患者的基本特點、相關(guān)臨床指標和發(fā)病后1年的心血管事件發(fā)生后情況,進而改善MINOCA患者的預(yù)后提供依據(jù)及幫助。方法:回顧分析自2005年1月至2016年10月入住我院診斷為AMI且進一行CAG檢查證實冠狀動脈血管正�；颡M窄50%的患者。采集患者入院后臨床一般情況、檢驗指標、冠脈造影特點及治療用藥情況。研究終點為1年復(fù)合終點事件(包括全因死亡、再發(fā)心肌梗死和/或因胸痛發(fā)作再次入院),分析影響復(fù)合終點事件發(fā)生的相關(guān)因素。根據(jù)心電圖表現(xiàn),分為ST段抬高型心肌梗死(STEMI)和非ST段抬高型心肌梗死(NSTEMI),進行亞組分析。結(jié)果:1.MINOCA患者一般臨床特點:自2005年1月至2016年10月入住我院診斷為AMI并且進一步行CAG檢查的患者共有5474例,符合MINOCA診斷標準的患者占2.5%(139例),其中包括病因不明確64%(89例)、惡性心律失常15.8%(22例)、心肌橋10.8%(15例),Takotsubo心肌病2.9%(4例)、血管內(nèi)血栓影2.9%(4例)、血管瘤樣擴張2.2%(3例)、肥厚型心肌病1.4%(2例)、血管痙攣0.7%(1例)。MINOCA患者的平均年齡為55.80± 12.15歲;男性患者多于女性患者(69.1%比30.9%);易患因素依次為高血壓病史52.5%(73例)、吸煙史43.2%(60例)、糖尿病史9.4%(13例);既往腦血管病史5.8%(8例)、心肌梗死病史1.4%(2例);CAG結(jié)果顯示血管正常52.5%(73例),血管輕度狹窄(狹窄1-49%)47.5%(66例);入院后心功能不全(Killip≥II級)患者14.4%(20例);住院期間阿司匹林、ADP受體抑制劑、他汀類藥物及硝酸酯類藥物的應(yīng)用率達90%以上,出院后患者繼續(xù)應(yīng)用阿司匹林占90.6%、他汀類藥物占87.8%。2.MINOCA患者1年的終點事件及相關(guān)危險因素分析:隨訪1年復(fù)合終點事件的發(fā)生率為12.9%(18例),其中包括:死亡2.2%(3例)、非致死性再發(fā)心肌梗死2.2%(3例)、胸痛再入院8.6%(12例)。MINOCA患者復(fù)合終點事件COX模型多因素生存分析:年齡≥60歲(RR=3.676,9 95%CI:1.309～10.327,P=0.013)、入院時 CK-MB 最高水平(RR=1.010,9 95%CI:1.002～1.017,P=0.008)是MINOCA 患者 1 年內(nèi)發(fā)生復(fù)合終點事件的獨立危險因素,出院后應(yīng)用他汀類藥物(RR=0.301,95%CI:0.093～0.978,P=0.046)是復(fù)合終點事件的獨立保護因素。3.MINOCA患者ST段抬高型心肌梗死(STEMI)與非ST段抬高型心肌梗死(NSTEMI)的臨床特點及預(yù)后比較(亞組分析):MINOCA患者中NSTEMI的發(fā)生率51.8%(72例)略高于STEMI 48.2%(67例),而兩組患者的平均年齡大致相同(54.88±12.89vs56.65±11.45,P=0.392),男性患者和女性患者所占的比例也無明顯差異(P=0.528);與STEMI組患者相比,NSTEMI組患者多合并高脂血癥(27.1%vs12.5%,P=0.035),STEMI組患者中肌酐(Cre)、超敏C反映蛋白(hs-CRP)、肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、肌鈣蛋白I(TnI)峰值平均水平高于NSTEMI組患者(P0.05);CAG檢查結(jié)果顯示NSTEMI血管正常占51.4%(37例),血管狹窄1-49%占48.6%(35例),與STEMI組相比無明顯統(tǒng)計學差異(P=0.782);冠脈血流 TIMI≤Ⅱ 級 STEMI 組 7.5%(5 例)、NSTEMI 組 8.3%(6例),兩組差別(P=0.850);住院期間兩組治療用藥基本相似(P0.05),主要為阿司匹林、ADP受體抑制劑、他汀類及硝酸酯類藥物(應(yīng)用率90%),而出院后STEMI組患者他汀類藥物的應(yīng)用多于NSTEMI組患者(94%vs81.9%,P=0.03);隨訪1年,STEMI組發(fā)生復(fù)合終點事件14.9%(10例),包括:死亡1.5%(1例)、非致死性再發(fā)心肌梗死1.5%(1例)、胸痛再入院11.9%(8例),NSTEMI組發(fā)生復(fù)合終點事件11.1%(8例),包括:死亡2.8%(2例)、非致死性再發(fā)心肌梗死2.8%(2例)、胸痛再入院5.6%(4例),比較兩組復(fù)合終點事件無統(tǒng)計學差異(14.9%vs11.1%,P=0.505)。結(jié)論:1.MINOCA整體患病率偏低,MINOCA患者多較年輕,多發(fā)于男性,女性患者平均發(fā)病年齡高于男性患者,易患因素主要為高血壓和吸煙史,NSTEMI的發(fā)生率高于STEMI。2.經(jīng)COX模型多因素生存分析結(jié)果證實:年齡≥60歲和CK-MB水平是死亡、非致死性再發(fā)心肌梗死及胸痛再入院事件發(fā)生獨立危險因素,他汀類藥物可以預(yù)防上述不良事件發(fā)生的獨立保護因素。雖然MINOCA患者無明顯血管狹窄,但常常存在不同程度心肌損傷,并且長期預(yù)后偏差,應(yīng)予以重視。3.NSTEMI與STEMI亞組比較結(jié)果顯示:NSTEMI的發(fā)生率偏高,患者多合并高脂血癥,STEMI患者心肌壞死面積更多,炎性指標偏高,出院后應(yīng)用他汀類藥物的應(yīng)用更普遍;兩組1年復(fù)合終點事件的發(fā)生無明顯差異。4.MINOCA典型病例:一例NSTEMI患者,CAG結(jié)果僅顯示左前降支內(nèi)膜不整,然而CMR檢查結(jié)果提示:左心室前壁心肌略薄,中央部-基底部左心室前壁、前間壁心內(nèi)膜下條形灌注缺損。雖完善相關(guān)病因?qū)W檢查,AMI根本病因仍然未能明確。
[Abstract]:Background and objective: acute myocardial infarction (AMI) and CAG examination results is not restricted blood disease, <2016ESC working group opinions > will be defined as non obstructive coronary artery myocardial infarction (MINOCA). According to the guidelines, MINOCA should be considered as the initial diagnosis, need to identify the improvement check to the underlying cause of the patient's clinical symptoms, etiology and diagnosis and treatment of.MINOCA mainly include the rupture or erosion of plaque, coronary artery spasm, the etiology of.MINOCA is complicated, to evaluate the prognosis, there are certain differences between different studies, but most studies suggest that long-term prognosis. Studies have shown that the deviation of MINOCA, non blocking patients CAD with ACS 26 + 16 months and 4.4% died, 3.8% ACS readmission, with patients with obstructive CAD patients with ACS showed no significant difference (P0.05), therefore, the long-term prognosis of patients of CAD with non blocking ACS The high risk of recurrent ischemic events. A recent study also showed that the cardiac magnetic resonance in 126 patients with MINOCA (CMR), 87% (109 cases) indicates the presence of abnormal changes of cardiac structure and / or myocardial tissue, were diagnosed as myocarditis, cardiomyopathy and other Takotsubo. The purpose of this study is to observe the the center for cardiovascular disease diagnosis and analysis for AMI and CAG examination confirmed the basic characteristics of patients with no significant stenosis, cardiovascular events 1 years after the onset of clinical indicators and related conditions, and improve the prognosis of patients with MINOCA to provide a basis and help. Methods: a retrospective analysis from January 2005 to October 2016 in our hospital for diagnosis and AMI a CAG examination confirmed coronary artery stenosis in 50% patients with normal or collected. Patients admitted to the hospital after the clinical index, the general situation, the characteristics of coronary angiography and treatment of terminal conditions. For the composite end point event 1 years (including all-cause death, recurrent myocardial infarction and / or chest pain for readmission), analysis of factors affecting composite end point events. According to ECG, divided into ST segment elevation myocardial infarction (STEMI) and non ST segment elevation myocardial infarction (NSTEMI). Subgroup analysis. Results: the clinical features of patients with 1.MINOCA from January 2005 to October 2016 in our hospital diagnosed as AMI and further CAG examination of patients with a total of 5474 patients met the diagnostic criteria for MINOCA patients accounted for 2.5% (139 cases), including 64% unknown etiology (89 cases), malignant arrhythmia in 15.8% (22 cases), myocardial bridge 10.8% (15 cases), Takotsubo cardiomyopathy (4 cases), 2.9% intravascular thrombosis shadow 2.9% (4 cases), vascular ectasia 2.2% (3 cases), 1.4% patients with hypertrophic cardiomyopathy (2 cases), 0.7% vascular spasm (1 cases) with an average age of.MINOCA patients was 55.80 12.15 + years old; male Of patients than female patients (69.1% vs 30.9%); risk factors for hypertension were 52.5% (73 cases), smoking history 43.2% (60 cases), diabetic history 9.4% (13 cases); 5.8% case history of cerebrovascular disease (8 cases), history of myocardial infarction 1.4% (2 cases); CAG results showed that the blood of Guan Zhengchang 52.5% (73 cases), mild vascular stenosis (stenosis 1-49%) and 47.5% (66 cases); admission after heart failure (Killip = II) and 14.4% patients (20 cases); during hospitalization, aspirin, ADP receptor inhibitors, statins and nitrates in the rate of more than 90% patients continued after discharge aspirin accounted for 90.6%, 1 years of the event analysis of end point 87.8%.2.MINOCA patients and related risk factors for statins: 1 years follow-up composite end point events occurred in 12.9% (18 cases), including 2.2% deaths (3 cases), nonfatal recurrent myocardial infarction 2.2% (3 cases), chest pain and readmission 8.6% (12 cases) with.MINOCA complex Combined end point event COX model multivariate survival analysis: age greater than 60 years (RR=3.676,9 95%CI:1.309 ~ 10.327, P=0.013), the highest level of CK-MB on admission (RR=1.010,9 95%CI:1.002 ~ 1.017, P=0.008) were independent risk factors of MINOCA patients within 1 years of the composite end point events, use of statins after discharge (RR=0.301,95%CI:0.093 ~ 0.978, P=0.046) is an independent protective factor for.3.MINOCA patients with ST elevation myocardial infarction composite end point event (STEMI) and non ST segment elevation myocardial infarction (NSTEMI) clinical characteristics and prognosis of comparison (subgroup analysis: 51.8%) the incidence of NSTEMI in patients with MINOCA (n = 72) was slightly higher than that of STEMI 48.2% (67 cases). While the average age of patients in two groups were roughly the same as (54.88 + 12.89vs56.65 + 11.45, P=0.392), and no significant difference in male patients and the proportion of women (P=0.528); compared with group STEMI, group NSTEMI patients Combined hyperlipidemia (27.1%vs12.5%, P=0.035), creatinine of patients in group STEMI (Cre), high sensitive C protein (hs-CRP), reflecting the creatine kinase (CK), creatine kinase isoenzyme (CK-MB), troponin I (TnI) peak is higher than the average level of patients in the NSTEMI group (P0.05); CAG showed normal vascular NSTEMI accounted for 51.4% (37 cases), vascular stenosis 1-49% accounted for 48.6% (35 cases), compared with no significant difference between the STEMI group (P=0.782); coronary blood flow in TIMI is less than or equal to grade II and 7.5% in STEMI group (5 cases), 8.3% in NSTEMI group (6 cases), the difference between the two groups (P=0.850); the two groups during treatment in hospital similar to (P0.05), mainly for the ADP receptor inhibitor, aspirin, statins and nitrates (application rate 90%), and STEMI group of patients after discharge statin application more than patients in group NSTEMI (94%vs81.9%, P=0.03); 1 years of follow-up, STEMI group composite end point event 14.9% (10 cases), including 1.5%: death (1 cases), Nonfatal recurrent myocardial infarction 1.5% (1 cases), readmission 11.9% chest pain (8 cases), NSTEMI group composite end point event 11.1% (8 cases), including 2.8% deaths (2 cases), nonfatal recurrent myocardial infarction 2.8% (2 cases), readmission 5.6% chest pain (4 cases), no statistical difference between the two groups (14.9%vs11.1%, P=0.505, composite end point event). Conclusion: the overall prevalence rate of 1.MINOCA is low, MINOCA patients were younger, more than male, average age of female higher than male patients, the major risk factors for hypertension and smoking history, the incidence of NSTEMI is higher than STEMI.2. by COX model multivariate analysis results showed that: 60 years of age or older and the level of CK-MB death, non fatal risk factors for the occurrence of myocardial infarction and recurrent chest pain readmission events, statins can prevent the occurrence of adverse events independent protective factors. Although MINOCA patients without obvious vascular stenosis Narrow, but often there are different degree of myocardial injury, and long-term prognosis deviation, more attention should be paid to the.3.NSTEMI and STEMI sub groups showed: the incidence of high NSTEMI patients with hyperlipidemia, STEMI patients with myocardial necrosis area more inflammatory index is high, application of statins after hospital discharge is more common; there is no significant difference between.4.MINOCA group of 1 years and two typical cases: a composite end point events in NSTEMI patients, CAG results show only the left anterior descending artery intima is not the whole, but CMR results suggest that the left ventricular anterior wall myocardial slightly thin, Central - basal left ventricular anterior wall, anterior wall subendocardial strip although the improvement of perfusion defects. The etiology of AMI examination, the root cause is still not clear.

【學位授予單位】：大連醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R542.22
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本文編號：1603796